CHRONIC PAIN: THE RESEARCH SAYS FIND A THERAPIST
by Clark Miller
Published August 15, 2018
Updated April 4, 2021
The best available research on effectiveness of treatments for the most common chronic pain, pain that is “centralized” (not cancer pain or due to acute inflammation or tissue damage) – like lower back pain and fibromyalgia – affirms decades of mutually-confirming lines of research and understanding pointing to basic, widely-available psychotherapies like Cognitive Behavioral Therapy and Behavioral Activation as the effective and durable treatments, yet patient care remains driven by current, ineffective practices with enormous costs in healthcare resources wasted on inappropriate medical/biophysical interventions.
Chronic pain and its treatment have played central roles in runaway over-prescription of opioid pain medications and the opioid crisis. Understanding how we got off track with chronic pain is crucial considering the costs that include: key role in etiology of the opioid crisis and projected mortality and morbidity and, for example, an estimated $90 billion annually in wasted healthcare expenditures for inappropriate biomedical treatments just for lower back pain.
While inappropriate biophysical interventions continue to suck healthcare funds down that black hole, decades of strong research have established durable effectiveness of Cognitive Behavioral Therapy (CBT) for chronic pain. CBT works with mental or psychological states, specifically held beliefs and belief systems with or without conscious awareness, generating and associated with mood states, inclinations, states of volition, physical sensations and experiences, and behaviors including choices. When I’m frightened by a harmless noise, those sensations generated by my false beliefs about, or interpretation of, the noise are as real as if the noise represented danger, the responses driven by beliefs about something. The extensive, congruent evidence around effectiveness of CBT and other phenomena, like placebo effect, tell us that beliefs are themselves potent forces driving our experience of inner states including mood, physical sensations, inclinations, impetus for behaviors.
In clinical practice, patients experiencing centralized chronic pain, provided a supportive and inviting setting, reliably express beliefs, clearly distorted yet firmly held, about their pain experiences and associated physical conditions of their bodies, in the context of describing, for example, surgeries and injuries occurring months to years past and in spite of medical imaging and other medical evaluations with no indication of continued pathology or damage. The cognitions (thoughts) are of the type: I’m broken . . . my spine is disintegrating . . . I can’t do anything . . . my foot is destroyed . . . and commonly with themes of acute vulnerability for catastrophic harm: I’ll be in a wheelchair the rest of my life if I move my body the wrong way, or fall, etc. due to distorted beliefs about the fragility of their physical conditions. The congruent inner states integrated with those distorted beliefs include fear, anxiety, vulnerability, anger, hopelessness, and chronic pain, along with anxious desperation for a medical fix and medical relief from the distressing set of inner experiences.
Enter Cognitive Behavioral Therapy – CBT :
The Paradoxical, Indicated, Effective and Durable Treatment for Chronic Pain
That is why CBT is the indicated treatment for centralized chronic pain, providing durable relief, and why the most effective form of CBT for chronic pain is Behavioral Activation integrated with other CBT approaches – in this case the paradoxical therapy of encouraging use, more and more use, of the very physical activities/body areas/physical movements that are believed to be broken, fragile, vulnerable, unusable. CBT works by challenging and changing distorted, self-defeating beliefs, and the most effective way to change beliefs is through experience.
What does the most current research say about the nature of chronic pain and its effective treatment?
See this companion post for a more thorough discussion of psychotherapies for centralized chronic pain (CCP).
Discrepant results –
Interventions provided to produce benefit through biophysical changes/manipulation (“Biophysical therapies” targeting, for example, relaxed musculature, reduced inflammation) lack strong evidence and long-term benefit with one exception: keeping active, regular physical exercise, return to physical functioning. That result generates useful hypotheses allowing additional evaluation.
1) Prediction under hypothesis of biophysical nature and effective medical therapies for CCP:
Interventions that target and predict biophysical changes (Type 1) will, as a group, be effective.
2) Prediction under hypothesis of psychogenic/psychosocial/behavioral nature and effective therapies for CCP:
Interventions that target and predict change in pain-related, self-defeating cognitions (e.g. “I’m broken”, “I can’t”, “I’m fragile, injured”) and associated mood states (fearfulness, anxiety, helplessness, etc.) will, as a group, be effective (Type 2).
Status of The Evidence:
Look at the table. Interventions that predict Type 2 factors (CBT mediated by talk therapy and structured experience through behavioral activation) are supported strongly by evidence for significant long-term effects.
Interventions that predict Type 1 factors are not supported as effective and durable.
Evidence-based indicated treatments:
Based on longstanding evidence and understanding, affirmed by the most current research, chronic centralized pain is psychogenic and psychosocial in nature and etiology. Congruently, the indicated evidence-based, effective, durable treatment is CBT with cognitive restructuring including experiential disputation through behavioral activation (by paradoxical and successful return to use of the protected body parts believed to be fragile, unusable) – of maladaptive, self-defeating cognitions e.g. “I’m broken”, “I’m fragile, injured, “I can’t”.
Congruently, biophysical interventions that are passive and do not predict experientially-mediated cognitive restructuring (e.g. massage, acupuncture), do not predict durable gains in pain moderation measures.
Chronic pain continues to be treated as biophysical in nature and etiology, patients trained over decades to access visits to medical professionals for a non-medical problem (generating the opioid crisis) where they typically are still referred to invalidated and ineffective biophysical interventions, at enormous cost in wasted healthcare resources. Entitlement industries providing services like physical therapy, massage, acupuncture, and steroid injections for chronic pain continue to thrive.
Decades of mutually-supporting research and understanding – of the psychogenic nature of chronic pain; of placebo effect and its meaning; of why CBT works and provides durable relief for chronic pain – establish that centralized chronic pain should never have been treated as a medical condition.
Current practices for chronic pain (like those for treatment of problem substance use) are stuck in doxa: misinformation constructed to serve the interests of industries generating the misinformation.
Chronic pain remains treated as if it were a medical, biophysical condition, patients referred by medical providers and trained by what they see on TV and other mass media to access a medical visit.
Then they are most often referred to surgeons, or for steroid injections, to medical pain clinics, for massage, chiropractic fixes, other ineffective and invalidated biophysical interventions.
Continuation of scheduling of patients with chronic pain complaints with their PCP or a medical provider makes as much sense as prescribing opioid medications for chronic pain, both predicting waste and harm.
Standing against efforts for change and reduced harm, the burden of decades of a nation of patients trained to access medical care for non-medical problems, with the expectation of a pill or other physical intervention as a fix, has created a formidable barrier to change that threatens multibillion dollar industries. That domestication, training, for quick medical fixes – for everything from addiction, smoking, to chronic pain, to depressed mood – is woven solidly into our Matrix, is Bourdieu’s Doxa, forms of social pathology.
“Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.”
– Pierre Bourdieu Outline of a Theory of Practice (1972)
In Bourdieu’s Theory of Practice, heterodoxy is dissent, challenge to what “goes without saying” – the accepted, constructed doxa, “knowledge”, reality, that goes without saying precisely because it “comes without saying”, without real scrutiny, untested, unquestioned. The function of doxa is not knowledge or truth or promotion of the collective good, but to protect and serve the interests of those with the power, the cultural capital, to create it.
- Cherkin DC, Anderson ML, Sherman KJ, Balderson BH, Cook AJ, Hansen KE, Turner JA. Two-Year Follow-up of a Randomized Clinical Trial of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care for Chronic Low Back Pain. JAMA. 2017;317(6):642–644. doi:10.1001/jama.2016.17814
- Richmond H, Hall AM, Copsey B, et al. The Effectiveness of Cognitive Behavioural Treatment for Non-Specific Low Back Pain: A Systematic Review and Meta-Analysis. Bencharit S, ed. PLoS ONE. 2015;10(8): e0134192. doi:10.1371/journal.pone.0134192.
- Hofmann SG, Asnaani A, Vonk IJJ, Sawyer AT, Fang A. The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive therapy and research. 2012;36(5):427-440.
2017 review by American College of Physicians:
- Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, et al. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017; 166:493–505. doi: 10.7326/M16-2459
- van Middelkoop, M., Rubinstein, S.M., Kuijpers, T. et al. A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. Eur Spine J (2011) 20: 19. https://doi.org/10.1007/s00586-010-1518-3
Current compilation of Cochrane, other reviews of primary research: