Over the past two decades, as the opioid crisis has shaken the public’s view of painkillers and pharmaceutical companies have come under fire for their marketing practices, many patients are looking for alternatives. One of the leading contenders has become treating pain with talk therapy.
Psychologists, therapists and social workers have quietly become a crucial part of pain treatment programs, proving to be as effective or more so than medication. In 2018, the medical journal The Lancet went so far as to recommend education and psychological treatment as first-line interventions for chronic low back pain, before pharmacological treatment.
A spokesman for the American Psychological Association said they have only recently started tracking pain psychology and in 2021 found that nearly 40 percent of its members report their patients frequently have chronic pain. The organization is currently drafting guidelines for chronic pain treatment, a sign, according to Lynn Buska, a Maryland psychologist and a senior director at the A.P.A., that it’s an important and growing field with science-based solutions.
Still, finding the right pain counseling can take a bit of effort on the part of the patient. Here are a few things to consider before you get started.
What does a pain psychologist do?
Many pain psychologists treat chronic pain with cognitive behavior therapy, or C.B.T., which focuses on reframing thoughts to positively affect behavior and emotions, or mindfulness, which involves learning to become conscious of feelings without reacting to them. Acceptance and commitment therapy combines mindfulness and C.B.T. to help patients accept their emotions and respond to them.
Another method psychologists use to treat pain is biofeedback, which monitors a person’s muscle tension, heart rate, brain activity or other functions in real time to make patients aware of their stress and learn to control it. Lastly, some clinicians use hypnosis, which can be effective at managing pain for some people.
What unifies all these treatments is a focus on teaching patients how they can use their minds to manage their pain.
How do you find a pain psychologist?
Finding a pain psychologist can be tough. Large medical centers and boutique practices are more likely to have comprehensive pain treatment but also tend to be in urban areas. People in rural areas or those who can’t afford the services get left out, said Rachel Aaron, an assistant professor of physical medicine and rehabilitation at Johns Hopkins Medicine. But even in urban areas, not all large medical networks have pain services.
“It’s definitely a challenge to get from the initial pain diagnosis to psychological care no matter what system you’re in,” said Dr. Aaron.
There are no specific certifications for pain management therapists, said Eric Garland, director of the Center on Mindfulness and Integrative Health Intervention Development at the University of Utah, nor does the American Psychological Association track their numbers. But most experts agree there is a shortage of pain-focused psychologists, just as with other mental health professionals.
If you are interested in trying a pain therapist, Dr. Aaron said, the first stop is your primary care doctor. Some insurance plans cover pain psychology, but others do not. It’s important to talk to a mental health provider first about how to get treatment covered.
After that, look for specialized pain clinics by calling hospitals in your area or use the Find a Therapist function on the Psychology Today website. Search for a provider who either treats your specific condition, be it fibromyalgia or migraines, or who treats chronic pain more broadly, a specialty often referred to as behavioral medicine or health psychology. There are also online programs that are evidence-based and freely available; Dr. Aaron recommends PainTRAINER and Pain Course.
Some experts recommend working with licensed professionals with doctorates or master’s degrees in psychology or clinical social work with additional training in chronic pain, and to interview them about their training and approach before getting started.
“If they can’t give a clear answer on their approach or how they would treat your specific pain issue, they probably don’t have good training,” Dr. Garland said.
Most importantly, you should feel comfortable enough to open up with them.
What should you expect?
Most pain therapy programs start with six to eight weekly sessions, said Dr. Zeidan. Often the first session is an evaluation to learn about the pain problem and the emotional issues it may be causing. You might then learn mindfulness techniques to separate the physical and emotional aspects of pain, train yourself to reframe negative thought patterns or practice paying more attention to pleasant sensations.
One recent paper in JAMA Psychiatry found that two-thirds of chronic back pain patients who underwent four weeks of psychological treatment were pain-free, or nearly so, afterward. However, most studies show a more modest effect — about one-third of participants see a significant decrease in pain.
To put this in perspective, this is about the same as opioids’ effect on chronic pain, but those benefits diminish over time (and they come with risks). The effectiveness of psychological pain management skills, on the other hand, can increase with practice.
Dr. Zeidan recommended trying different methods at once — individualized therapy, pain management courses and group therapy. “We don’t actually know what the silver bullet is because there likely isn’t one to cure pain. So testing, validating and optimizing multiple approaches is a critical step.”
What if you can’t see a psychologist in person?
The definitions insurance companies use for chronic pain are rapidly changing — with pain being increasingly seen as its own disease — but for now it’s hard to get a trip to a pain psychologist covered. That can put one-on-one treatment out of reach for many.
“We do not have enough trained psychologists to address all of the need,” said Beth Darnall, the director of the Stanford Pain Relief Innovations Lab. “We really have to look beyond what we are doing now.”
Dr. Darnell said that technology could provide new alternatives, since many of the psychological tools shown to diminish pain can be learned and shared with minimal training. She has created a program, based on C.B.T. and other models, called Empowered Relief, which is affordable and can be done from your own home.
Patients can sign up, often for free, for a single two-hour online class delivered by her or one of 300 instructors, all health care professionals, who offer simple skills to calm the nervous system, reframe pain and change how your brain processes it. It’s been integrated into the Cleveland Clinic for chronic pain and spine surgery patients, as well as several insurance companies. In one trial, a single class was comparable to eight sessions of C.B.T. She’s also currently working on an app and even virtual reality platforms.
“You can live on a ranch in Idaho and get quality access to evidence-driven pain care,” she said.
Dr. Darnell stressed that psychological counseling is just one component of a treatment program for chronic pain, which can also include medication or lifestyle changes.
“It’s not psychological treatments or medication,” Dr. Darnall said. “It’s a menu, and patients might land on two or three different options that offer a good formula for them.”
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