The “Why”and “How” of Therapy and Pain Management

Clients are sometimes confused about why they are referred to therapy for pain management because pain is generally not thought of as a mental health concern. Some clients feel that the medical professional making the referral believes the pain is all in their “head”; as a result they may resist treatment.

Therapy can be helpful in managing pain, to understand how we first need to understand the connection between our thoughts, emotions, activity, social supports and pain. The Gate Control Theory (Melzack and Wall) posits that there is a gate of sorts in the spinal cord that controls how much pain a person feels. This gate opens and closes based on the type of information that gets to the brain. If the gate is open pain is perceived to be more intense; if it’s closed pain information is blocked.

To explain why thoughts and emotions influence pain perception, Ronald Melzack and Patrick Wall proposed that a gating mechanism exists within the dorsal horn of the spinal cord. Small nerve fibers (pain receptors) and large nerve fibers (“normal” receptors) synapse on projection cells (P), which go up the spinothalamic tract to the brain, and inhibitory interneurons (I) within the dorsal horn. The interplay among these connections determines when painful stimuli go to the brain: link

There are several factors that open and close the gate (From “Managing Chronic Pain, A Cognitive Behavioral Therapy Approach”, Otis 2007):

Factors that open that Gate (increase pain perception):
Cognitive- Attention to pain, thoughts about uncontrallability of pain, beliefs about pain as a mysterious, terrible thing
Emotions- Depression, Fear, Anxiety
Activity- To much or too little activity, poor diet and other health behaviors, imbalance between work, social and recreational activity
Social-Little support for family and friends, others focusing too much on your pain, others trying to protect you too much

Factors that close the Gate (reduce pain perception):
Cognitive- Distraction or external focus of attention, thoughts of control over pain, beliefs about pain as predictable and manageable
Emotions- Emotional stability, relaxation, and calm positive mood
Activity- Appropriate pacing of activity, positive health habits, balance between work, recreation, rest and social activity
Social-Support from others, reasonable involvement from family and friends, encouragement from others to maintain moderate activity

Therapy for pain, from a skills perspective, is similar to therapy for other issues which makes sense. Symptoms of anxiety and depression are many times described as painful by clients. Much like pain medications, anti-depressants and mood stabilizers do not take all of “it” away. Cognitive restructuring, behavioral exercises, distraction/attentional skills, distress tolerance skills, problem solving, interpersonal effectiveness training, family and couples counseling can help clients who struggle with pain become more effective at closing the “gate” by changing their thinking, reactions and landscape.

Hard to believe?

Although CBT can be used in managing acute pain (Jay, Elliot, Ozolins, & Pruitt, 1985), the treatment procedures described above are those that are most commonly used in the management of persistent pain. Randomized, controlled studies have been carried out with a number of patient populations. Turner and Clancy (1988) demonstrated the usefulness of CBT in the management of chronic low back pain. CBT produced significant decreases in physical and psychosocial disability when compared to a waiting list control condition. The improvements reported by patients receiving CBT were maintained up to 12 months following treatment. Bradley, Young, Anderson et al. (1987) conducted a study of CBT in patients having rheumatoid arthritis and found that CBT was superior to both a social support control and no treatment control group in reducing pain behavior, disease activity, and trait anxiety. In our own lab we have evaluated the efficacy of CBT in managing osteoarthritic knee pain (Keefe, Caldwell, Williams et al., 1990). At post-treatment, CBT produced significant reductions in pain and psychological disability relative to an arthritis education and standard care control conditions. Syrjala, Donaldson, Davis et al. (1995) have recently demonstrated the efficacy of CBT in managing cancer-related pain. Thus, evidence suggests that CBT is effective in treating both chronic pain conditions such as back pain and persistent disease-related pain conditions such as arthritis or cancer. link

Of course, therapy is not a panacea and the field as a whole still struggles with a coherent approach to different types of pain issues. Despite the amount of work that still needs to be done, therapy can be an effective part of an overall strategy in managing pain. Medical professionals, when referring clients to therapy, should explain why the referral is being made. It should be explained that therapy does not mean that the pain the client is experiencing is not real; therapy is one part of an approach to help the client manage the pain more effectively and improve their overall quality of life.