The psychological treatment of pain is important for a number of reasons. Firstly, psychological factors play a crucial role in the onset and course of chronic pain. People with psychological problems are more at risk of injury and pain (Tunks, 1996). The author has observed for example, that poor people who get hurt at work {particularly repetitive strain  injuries] often do not report the injury for fear of losing their job, leading to delayed access to medical treatment and aggravation of injury.

People with pain are also more likely to develop anxiety and depression - some studies have found up to 60% of chronic pain sufferers have either  clinical anxiety or depression (Tunks, ibid). Although anxiety and depression are effects of pain, they can also undermine a person's ability to cope as well as increasing their perception of the intensity of the pain. A kind of pain-stress feedback loop is created.

Chronic pain also presents a number of diagnostic dilemmas, as the physical cause is often unclear. This presents the clinician with a dilemma, is it  psychogenic (e.g.; a somatization disorder) or a medical problem of  unknown origin? Treating a somatization disorder as a real medical problem can lead to unnecessary treatment, while treating a medical disorder as 'psychological' can lead to withholding of treatment and cause added suffering and complications.

In addition, chronic pain is often poorly managed, not because of lack of know-how, but because of psychological factors. For example, one study {of cancer patients} found that over 50% were under-medicated. The reason was poor communication between doctor and patient. Other  studies indicate underreporting of pain by patients is a major problem. Cultural factors such as macho attitudes may also predispose people to "putting up with it."

Thus although chronic pain may start out with physical injury, it quickly develops into a major psychological problem. Psychological factors play a part in the whole course of the development of chronic pain, including diagnosis and management. Clearly, psychological treatment is an essential part of any treatment approach. Given the difficult nature of the disorder, a preventative approach founded on early intervention is indicated.

Psychological treatment can help by:

• Education - many people with chronic pain are ignorant about the causes of pain, or their rights and responsibilities as a patient, or even just how to deal with the effects of pain on their relationships. Education in the form of information about pain, communication skills, and the treatment process can empower the chronic pain sufferer and enable them to benefit more from treatment.
• Provision of adequate support - adequate psychological support is known to be an essential prerequisite for coping with life stressors, including chronic pain.
• Reduce anxiety and depression - this is largely achieved through changing negative feelings, thoughts and behaviors associate with pain. Once a person knows what is going on and has some ability to control things, their confidence increases and anxiety and depression are less.
• Case management - the pain management psychologist is the best-qualified person to identify any psychological obstacles to recovery, and advise other treating professionals.

Probably one of the most important and overlooked needs is for people to be educated and supported to learn to recognize the signs of pain and injury and seek medical help as soon as possible. It is the author's belief that this  single thing could do much towards avoiding chronic pain before it starts.

As a general principle, the psychologist plays a complimentary role to the medical practitioner and each needs the help of the other in understanding and managing this
condition.

In the past, there has been a trend, both in the professional literature and among the general population, to make negative attributions about chronic pain sufferers. They are malingerers, lazy or weak. An ethical and effective approach must always incorporate compassion, validate the persons experience and avoid judgment. As  someone once said, "pain is whatever the patient says it is."

For more information about the psychological management of pain, visit www.overcomingpain.com

References:

Tunks, Eldon (1996) Comorbidity of Psychiatric Disorder and Chronic Pain.

Pain 1996 - an updated review. IASP Committee of Refresher Courses. Editor: James N. Campbell. IASP Press, Seattle, USA.