David Cosio, PhD, ABPP
Jesse Brown VA Medical Center
An understanding of the role of health psychology in chronic pain management is fundamental in improving its assessment and treatment. The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience.1 Living with chronic pain can be disheartening, so fear, anxiety, and depression is expected. 2 In terms of fear, heightened attention and vigilance to pain is associated with high levels of disability and distress. The consequences of attention and vigilance to pain may be the development of catastrophic thinking and/or avoidance of pain-inducing behaviors. The experience of pain and the threat of pain can lead to negative affect, or depression, which includes anger and low self-esteem. Anger in chronic pain patients is often an attempt to claim self-esteem. Patients who do not address these unpleasant emotional experiences may in fact experience more physical pain because parts of the brain that are responsible for pain are also responsible for emotions. Health psychologists can help patients learn better ways to manage difficult emotions connected to their pain through psychotherapy, assessment, education, consultation, and/or administrative tasks/leadership.
Health psychologists have a unique knowledge base, skill set, and role on the health care team.3 One role is to provide psychotherapy to chronic pain patients. Acceptance & commitment therapy (ACT) and traditional CBT are among the most utilized interventions for chronic pain. Past research has shown that ACT compares favorably with CBT for chronic pain treatment among different populations.4 Due to the high frequency of patients with comorbid PTSD and chronic pain, I also decided to offer an integrated CBT/cognitive-processing therapy group. This is based on the notion that patients who suffer from PTSD and chronic pain may engage in avoidance behaviors for both conditions regardless if they have the same activating event. In this intervention, patients learn to confront and engage with activity and the fear related to their pain. Health psychologists can also use technology-based methods to address this disease with patients in distant communities. There are many changes chronic pain patients can actively make in their lifestyle to help their pain and emotional state, and health psychologists bring considerable unique expertise in health promotion and disease prevention.
Assessment requires integration of bio-psycho-social information because chronic pain is a complex, multidimensional, personal experience.5 Often times, health psychologists perform psychological assessments to determine a chronic pain patient’s appropriateness for invasive medical procedures, such as a spinal cord stimulator (SCS). Such assessments are based on the notion that patients with certain psychosocial profiles may respond poorly to invasive procedures.6 SCS psychological evaluations assess 1) the patient’s psychological stability; 2) informed consent of the risks and benefits of the procedure; 3) psychological factors that might limit or undermine long-term benefits from the SCS; 4) engagement in other interventions leading to decreases in pain, lasting relief, and increase function; and 5) factors leading to bad outcome, costly removal of the device, and potential increases in pain. Thus, familiarity and experience with certain instruments can help the health psychologists fulfill these requests from physicians with whom they consult in their practice.7 For example, I tend to use a mental health/addictions integrated intake assessment; a measure of pain intensity (Numeric Rating Scale); two measures of mood (Beck Depression Inventory-II and the Beck Anxiety Inventory); a measure of personality (Minnesota Multiphasic Personality Inventory-2); and two measures of cognitive functioning (Mini-Mental State Examination and the Neurobehavioral Cognitive Status Examination).
Another important role for health psychologists working in pain is patient education – one strategy used to enhance patient motivation.8 Health psychologists can provide effective instruction in psychological concepts to patients and to team members across professions.3 Health psychologists may be requested to develop and implement patient pain education programs. Such an education-focused, professionally driven program assumes that if individuals are provided with adequate education, they will be empowered and thus more likely to self-manage chronic pain. For example, I was charged with developing my facility’s Pain Education School program. The goals of the program are to share basic principles of pain relief and prevention, provide education about pharmacologic interventions, and introduce services offering nonpharmacological interventions for relief of chronic, noncancer pain. The program consists of an introduction class followed by twelve weekly one-hour classes that are led by guest speakers from over 20 different disciplines within the facility. The introduction class covers the ground rules, schedule of classes, and basic principles of the bio–psycho–social approach to pain self-management. A menu of treatment modalities is then scheduled on a rotating basis. Past research has shown that this formal patient pain education program improved patient readiness to adopt a self-management approach, improved experience of pain, and decreased depressive symptoms.9 Patients should at the very least learn what causes their pain, their treatment options, and the rationale for therapy. Health psychologists can also help patients set realistic goals and expectations for improvement of their pain.
Pain physicians recognize that chronic pain is real, and will at times refer patients to psychology for a consultation. Referring a patient to a health psychologist is important because there are limits to what traditional medical treatments can accomplish with chronic pain. A health psychologist may be consulted to help the provider and the patient create a better multidisciplinary, self-management plan to address the chronic pain, and with use of more effective communication strategies. They can assist by adding psychological approaches and complementary and alternative medicine modalities (CAM), such as biofeedback, hypnosis, relaxation, and mindfulness-based interventions, aimed to modify the overall pain experience, help restore functioning, and improve the quality of life of chronic pain patients. There is promising scientific evidence to support the use of CAM for chronic, non-cancer pain conditions.10
Health psychologists may also take on administrative tasks and leadership roles in pain clinics. They may be responsible for training different trainees from a variety of disciplines other than psychology in chronic pain management. They are integral members of interdisciplinary staff meetings and can make considerable contributions to case conferences. Additionally, health psychologists can conduct research in pain treatment settings to help fill the gaps in knowledge regarding pain evaluation and treatment.
The role of psychology has the potential to grow in the areas of policy development and in the legislative process. As the health care system continues to prioritize cost containment, health psychologists must educate stakeholders about the importance of psychology’s role in chronic pain management. Due to the absence of graduate training in business skills, I often teach my trainees five steps on how to improve their sales pitch. The first step is to make sure to do preliminary research about the question being presented. Second, one must demonstrate command of the research and provide reports or other visuals to the stakeholders. Nowadays, health care facilities are concerned about their customers’ satisfaction. The psychologist needs to determine how to address these concerns. One must also highlight past successes and sell the benefits of psychotherapeutic interventions. Of course, the most important skill is having confidence and enthusiasm during delivery. Using these skills, health psychologists can continue to maintain a strong presence in the field of chronic pain management.
- International Association for the Study of Pain (1994). Part III: Pain terms, a current list with definitions and notes on usage. Classification of Chronic Pain. Seattle, WA.
- Eccleston, C. (2001). Role of psychology in pain management. British Journal of Anesthesia, 87, 144-152.
- France, C., Masters, K., Belar, C., et al. (2008). Application of the competency model to clinical health psychology. Professional Psychology: Research & Practice, 39, 573-580.
- Wetherell, J., Afari, N., Rutledge, T., et al. (2011). A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain, 152, 2098–2107.
- Rudy, T., Turk, D., & Brena, S. (1988). Differential utility of medical procedures in the assessment of chronic pain patients. Pain, 34, 53-60.
- Fillingim, R. (1997). The Future of Psychology in Pain Management. Journal of Clinical Psychology in Medical Settings, 4, 207-218.
- Doleys, D. & Olson, K. (2001). Psychological assessment and intervention in implantable pain therapies (Medtronic Pamphlet).
- Jensen, M. (1996). Enhancing motivation to change in pain treatment. In R. Gatchel & D. Turk (Eds), Psychological approaches to pain management: A practitioner’s handbook, New York: Guilford Press.
- Cosio, D., Hugo, E., Roberts, S., & Schaefer, D. (2012). A pain education school for veterans with chronic non-cancer pain: Putting prevention into VA practice. Federal Practitioner, 29, 23–29.
- National Center for Complementary & Alternative Medicine (NCCAM). (2013). Chronic pain and complementary health practices. Available at: https://nccih.nih.gov/health/providers/digest/chronic-pain. Accessed February 5, 2014.