Doxa Deconstructed: Chronic Pain is Not What You Think, Is What you Believe

by Clark Miller

August 15, 2018

Chronic pain and its treatment have played central roles in runaway over-prescription of opioid pain medications and the lethal opioid crisis.

As documented in a preceding post, the inappropriate over-prescription of opioids proceeded in the face of longstanding research and lines of evidence invalidating the practice:

1) opioids not supported by evidence as being effective long-term

2) hyperalgesia – increased sensitivity to pain

3) the addictive potential of opioids

4) the psychogenic (psychological) nature of centralized chronic pain, and

5) cognitive behavioral therapies (CBT) as the indicated treatment for chronic pain – all evidenced decades prior to emergence of runaway misuse of opioids and the current crisis.

Pain is complex

and in a meaningful way “all pain is in the brain” that is, the experience of the inner state of pain, like all experience, is managed by the brain. For one generalized type of pain – centralized chronic pain – mental and emotional states, not physical or biological, are the basis for its understanding and treatment. Centralized chronic pain, or “brain pain” is understood primarily as distinguished from peripheral pain, pain that is best understood as caused by adaptive (important, useful) signals from non-brain tissues that are inflamed, damaged, or physically impacted (cancer pain) – the experience of pain serves as a useful signal to the organism that an area of the body is injured or impacted, with the potential for responsive behaviors to manage harm and promote healing.

It’s worth thinking about the adaptive (evolutionary), value and function of pain – a signal to the animal to start behaviors likely to increase survival: slow down, stop, get away from potential harm, stop moving, isolate in protective, safe settings, restrict body movement and demands on the body, guard body areas, communicate in ways to get help and protection from others. Perception of pain is complex: modified by mood, stress, beliefs, setting, circumstances, use of substances – tobacco use, for example, heightening perception of chronic pain. Understanding the complexity gives us more angles to use in treatment.

Understanding how we got off track with chronic pain is crucial considering the costs that include: medically mismanaged pain causing the opioid crisis with projected deaths and illness and, for example, an estimated $90 billion annually in wasted healthcare expenditures for inappropriate biomedical treatments just for lower back pain.

Opioid Crisis, ineffective treatments, $billions wasted yearly –

how do we understand chronic pain and treat it more effectively?

Consider the placebo effect – the well-known and common (so common it is supported as possibly accounting for the perceived positive effect of antidepressant medications) experience of a desired change or benefit in wellness, mood, health, often described for depressed mood, caused by getting a fake pill, a sham treatment, often a pill – the physical, chemical, or biomedical nature of that placebo “treatment” without any action or properties to provide such relief or benefit.

There are various explanations for placebo effect. And yet what is common to clinical trials with placebo is the impossibility of achieving an experimental design that truly “controls” (factors out) all relevant factors in the healing process, making it hard to figure out what’s going on, causing the effect.

Or not –

It turns out the factor that can’t be eliminated from placebo trials is the most likely explanation of effect.

In trials with medication placebo it is essentially impossible to factor out (“control”) for the well-established and little known therapeutic factor (subject of Upcoming Posts) already established by decades of research to predict the largest share of benefit in all mental health therapy interactions that provide benefit – the common factors approach or Contextual Model of Psychotherapy – describing the large positive therapeutic (healing) effect due to the quality of the therapist-patient (or professional-patient) interaction in sustained individual therapy. Those effective factors, determined by research, are not techniques or therapy procedures, instead intangible factors that “come across” to the patient: like non-judgmental attitude, authenticity (being real), empathic responding, respect for patient integrity and autonomy, collaborative interaction, sense of being heard and understood, sense of safety and trustworthiness of the therapist – factors contributing to patient confidence in and hope for benefit and change, leading to investment in change, working to change.

Those are factors likely to be present to some extent generally in healthcare visits whether the “treatment” is real or sham, an antidepressant or sugar pill, to the extent that the professionals interacted with transmit those intangible supportive factors.

That understanding of placebo effect fits well with and is supported by decades of strong research establishing effectiveness of Cognitive Behavioral Therapy (CBT) which works on the basis of mental or psychological states, specifically held beliefs and belief systems (with or without conscious awareness of them), generating and associated with mood states, inclinations, states of motivation, also physical sensations and experiences, and behaviors including choices.

Check it out: when I’m frightened by a harmless noise, the physical and emotional sensations I have, generated by my false belief, or interpretation, of the noise are as real as if the noise represented danger, the responses driven by beliefs about the noise, not the noise itself. The extensive, reinforced evidence for effectiveness of CBT and about placebo effect tell us something important: that beliefs are themselves powerful forces driving our experience of inner states including mood, physical sensations, inclinations, 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.

That is, they mistakenly link their experience of pain – which is real – to tissue damage or lasting  injury, when medical imaging and testing demonstrate no such lasting damage, because physical healing has occurred.

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.

This is why CBT is the indicated treatment for centralized chronic pain, providing lasting relief, and why the most effective form of CBT for chronic pain is behavioral activation – 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, a threat to the very integrity of the body. CBT works by challenging and changing distorted, self-defeating beliefs, and the most effective way to change beliefs is through experience.

For example, if I have the distorted belief and associated fear that I can never learn to surf then accessing CBT in a therapy office setting, where I am encouraged to express and mentally process other physically challenging skills I’ve learned or mastered will be beneficial, helping me to correct the distorted belief.
But even more effective will be using therapy to overcome barriers to “activating” behaviors to go out and try it – to sequentially experience repeatedly and step-by-step, through direct experience, success-by-success, the progressive steps of learning to surf in the real world, in the water, each experience of progress without injury or harm or catastrophe helping to correct the distorted beliefs generating fear and/or avoidance.

It’s the same with chronic pain, and that’s why the seemingly paradoxical therapy of increasing physical activity, using the body believed to be “broken” and vulnerable, works.

Once prior, false beliefs that parts of the body are broken, weak, fragile, vulnerable to catastrophic injury are corrected through progressive use – through therapies focused on CBT and behavioral activation – then there is no adaptive value, no “reason” for pain – the functional signal for the organism to behave in ways to protect vulnerable parts of the body – to be generated.

Decades of mutually-reinforcing 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. Yet current practices for chronic pain (like those for treatment of compulsive substance use) are stuck in doxa: misinformation constructed to serve the interests of industries with the cultural capital to fabricate and establish the misinformation as accepted.

Chronic pain remains treated as if it were a medical, biophysical condition, patients encouraged and trained by what they see on TV and other mass media to access a medical visit, then most often referred to surgeons, or for steroid injections, to medical pain clinics, for massage, chiropractic fixes, other biophysical interventions without support for effectiveness.

Against efforts for change, 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 and costly barrier to change, 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, into Bourdieu’s Doxa.

Also in SCIENCE at A Critical Discourse – What does the most current research say about retained doxa that treats chronic pain as a medical condition, with visits to medical professionals and continued referrals to biophysical interventions, versus therapies including CBT and Behavioral Activation?