When Chronic Pain Enters the Therapy Room

It was 2015, and I was amidst the grueling pace and teachings of my counseling program. As a single mom of two young children, working as a personal assistant and interning at a community mental health clinic, I thought the general pain and fatigue I felt were part of the stress I was under.

However, after months of tests and continual, increasing pain, I was finally diagnosed with fibromyalgia. I had crossed the threshold into chronic pain, as my pain exceeded a normal recovery period. I became depressed and anxious, not wanting to do much. The medications I tried had horrible side effects or were ineffective at best. I felt alone on a horrible roller coaster of emotions and pain, unable to exit when the ride ended. Worst of all, I felt I was letting my children down. I didn’t know much about the best ways to treat chronic pain, so I started researching.

About 50.2 million people in the United States suffer from chronic pain. It is one of the most costly diagnoses, estimated between $560 and $635 billion annually.

For clients experiencing chronic pain, you will often see that their pain causes a ripple effect into all areas of their life. A majority of those with chronic pain often also have a diagnosis of anxiety, depression, substance abuse, or PTSD, and they are twice as likely to die by suicide. And yet, this is not something most of us learn about in our graduate programs. 

The physical experience and mental experience of pain have a reciprocal relationship, and both must be addressed. 

Pain and Anxiety

People experiencing chronic pain typically experience a lot of fear and anxiety – the individual is in fear of pain-related cues in their body and can become anxious and hypersensitive to body sensations. Because of this, clients may avoid physical activity, leading to a weakened physical state and reinforcing the fear. It can be very difficult to break this cycle of avoidance and find positive coping mechanisms because cognitive and emotional resources are already at their limits. 

Pain and Social Support

The experience of pain and distress can also begin to affect an individual’s support system. Clients often report feeling rejected and misunderstood by the medical community, friends, and family. Those around them may imply symptoms are all psychological and blame the individual, resulting in them feeling “crazy” and eliciting feelings of shame. This can lead to strain in marriages, family relationships, and friendships. 

Clients also may need to make changes in familial, social, and workplace roles because of the physical and cognitive impacts of chronic pain. All of this can affect one's sense of self, evoking depression, anxiety, and overall emotional dysregulation.

Pain and Mood

Studies show that those with chronic pain have decreased levels of serotonin, dopamine, and norepinephrine, and there is a lot of overlap between mood disorders and the experience of chronic pain in the brain. Like with any mood disorder, it can be very difficult to break the cycle of negative thinking when there is less positive emotion to work with, and it can be hard for the client to cope. This can also lead to difficulties with: affect regulation and monitoring; working memory, problem resolution, and hypothesis generation; attention, organizing, and planning; decision-making and judgment; motivation; abstract thought; and cognitive flexibility.  

As a therapist, it is important to consider that those with chronic pain are desperately trying to fight or flee from something they cannot. Though there is overlap with many other mental health diagnoses, you may find that your typical therapeutic approach is not as effective in this population. To address the complex connections between mental health and chronic pain, it is important to consider an integrative holistic treatment modality, giving consideration to other areas that may not be a part of typical psychotherapy.

Teaching self-compassion, acceptance, positive psychological concepts, mindfulness, and integrating family support should be part of conventional treatment. However, finding creative and individualized ways to manage cognitive dysfunction, expand social interactions, improve nutrition, increase movement, integrate self-care, and explore nature can greatly decrease symptoms and increase life satisfaction. 

If you want to learn more, here are some great places to start:

Evidence-based Treatments for Chronic Pain

Chronic Pain Anonymous

Pain Connection Support Groups

The Pain Management Workbook by Rachel Zoffness

The Way Out by Alan Gordon

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