Kristen Slater, PsyD
Clinical Assistant Professor
Stanford University School of Medicine
What do you hear from patients living with chronic pain conditions?
When I ask patients: “What is it like living with chronic pain?” the most common answers are descriptors such as “depressing, frustrating, isolating, exhausting, stressful, debilitating,” and other words that interestingly, do not depict the physical sensation of pain, but rather, highlight the emotional component of living with a chronic pain condition. While experiencing chronic pain is relatively common, living with chronic pain can feel extremely isolating. Functionally, it may be difficult to participate in life activities which can lead to physical isolation. It is also critical to recognize the degree of emotional isolation and distress experienced by many. All of this can lead to a sense of grief or loss. Numerous pain conditions may be “invisible” and many feel that others do not understand the intense physical and emotional impacts of chronic pain. This is one reason why those with chronic pain are four times more likely to experience depression and anxiety compared to the general population. Recognition, support, and treatment pertaining to the various ways chronic pain can infiltrate numerous aspects of one’s life are imperative.
What resources are available to help with chronic pain?
Pain psychologists are specifically trained to improve one’s quality of life in the context of chronic pain. Evidence-based interventions designed to address the suffering experience of pain are well established and include treatments such as: Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), Mindfulness Based Stress Reduction (MBSR), Emotions Focused Therapy (EFT), Pain Reprocessing Therapy (PRT), Biofeedback, and Empowered Relief (ER).
How do Empowered Relief sessions fit into the larger landscape of chronic pain? Is it a standalone system or does it work alongside other mental health tools?
While evidence-based pain psychology treatments are apparent and effective, access to treatments can be challenging. Finding a pain psychologist in and of itself can be difficult. Further, many interventions are delivered by pain psychologists over the course of multiple (often 8-12) sessions, and participation in numerous sessions often requires considerable financial resources, time, and availability.
Empowered Relief (ER) is an evidence-based pain management program developed by FPA Medical Advisory Board member, Dr. Beth Darnall at Stanford University, that is uniquely designed to improve access to care in a single session. The ER session includes aspects of pain neuroscience education, cognitive behavioral therapy, and mindfulness to help individuals develop effective pain coping skills. Research suggests ER promotes improvements in pain intensity, pain interference and pain distress after just one 2-hour class. Further, ER is often delivered online and is not restricted to (the small number of) pain psychologists; any health care provider can become certified to offer ER, considerably expanding availability options.
ER can be effective as a stand-alone treatment; however, it does not replace the need for other and, often times, more intensive treatments. ER can be a complement to, or even function as a gateway to other interventions. For example, the minimalburden design of ER can facilitate a willingness to engage in pain psychology for those that may otherwise be hesitant to do so. Participation in ER can provide exposure and insights into how beneficial psychological therapies may be. The corrective experience of ER may promote motivation to participate in other types of psychological treatments that may be advantageous.
While the brevity of ER has made pain psychology skills reachable to more individuals, it is impossible to address all pain psychology strategies with this approach. Longer term therapies delivered by those with dedicated mental health training may have superior outcomes, including enhanced opportunities for greater depth of interpersonal connectivity and expansion of the breadth of relevant treatment targets. The various pain psychology intervention options should not be viewed in isolation but as unique tools that make up a more comprehensive toolkit designed to alleviate suffering and promote vitality in those with chronic pain.
Why is it important for physicians who are not mental health professionals to either refer patients or at least impart the importance of taking mental health into consideration?
The International Association for the Study of Pain (IASP) defines pain as both an emotional and sensory experience. If we focus solely on the sensory pain experience rather than the whole person, we are only addressing a portion of the pain experience. An approach that does not address emotional suffering is not only less effective, but a disservice to those experiencing both pain and suffering.
Further, more objective findings by physical examination or imaging studies may not accurately account for one’s experience of pain. This can be frustrating and confusing for both patients and providers. It is important to recognize that all pain is real. Imaging or other tangible medical tests may not reflect the experience of one’s pain because pain perception is influenced by a variety of contextual factors that span biological, psychological, and social domains, making pain a complex and highly individualized experience.
Pain psychologists are uniquely positioned to evaluate biopsychosocial factors that may be contributing to one’s pain experience and make recommendations that can target underlying causes regarding pain generation or exacerbation. For example, research shows that factors such as sleep disturbance and trauma can enhance or even trigger chronic pain due to overlapping biological and psychological pathways. Treating these underlying issues offers relief of emotional distress and significant improvements in physical symptoms, including pain.
Addressing psychological factors can alleviate pain independently and can even improve one’s response to other pain treatments. Depression and anxiety can overstimulate the nervous system, leading to a state of “central sensitization” where the brain amplifies pain signals. Treating mood symptoms helps calm these pathways, allowing pain treatments to work more effectively. Mood optimization may also promote adherence to various pain treatments, such as physical therapy, enhancing long-term outcomes.
It is imperative we consider psychological therapies for optimal outcomes in those with chronic pain as they offer a pathway to pain resilience, pain relief and enriched quality of life.
