The Role of Psychology in Pain Management
Scene: A psychologist’s office during an initial evaluation of an individual with chronic pain; the patient shifts uncomfortably in his chair, visibly distressed, slightly confused.
Patient: “I’m in pain, I’m not crazy!” (Alternate dialogue: “If I’m seeing you, does this mean my doctor thinks my pain is all in my head?”)
Psychologist: Reassures patient that he is not crazy and that his pain experience is indeed real. Explains that psychosocial factors can contribute to the maintenance or exacerbation of the pain problem and that emotional distress can develop as a consequence of chronic pain.
This scenario repeats itself in various forms during most initial encounters between psychologists working in pain management and the patients in their care. Individuals with pain seldom spontaneously seek assistance from psychologists; the encounters nearly always involve consultation with third-party referral sources. Referring clinicians may understand that collaboration with a psychologist can be a valuable part of comprehensive pain management but may not be comfortable explaining the recommendation or psychology referral to the patient. It is evident from the concern expressed by such patients that the role of the psychologist in pain management is not always well understood. This article will attempt to familiarize the reader with the various functions a psychologist can serve in pain management within a variety of settings, and will attempt to demystify the psychological evaluation and treatment process of a patient with chronic pain.
Comprehensive Pain Models Include the Psychologist
The scope of the psychologist’s role has evolved in parallel with our expanding understanding of the pain experience. In the early days when pain was approached solely from a biomedical model, the realm of the “mind’ was considered irrelevant. The psychologist’s part in pain management was nonexistent. Although the concept of a direct correlation between specific organic pathology and pain report tended to explain acute pain fairly well, using purely physiological evidence failed to predict or adequately explain the experience of chronic pain. Clinical observations also indicated that many patients complained of persistent pain refractory to medical and surgical treatments and that functional disability often appeared in excess of what might be expected based on physical pathology alone. Specifically, the biomedical model was inadequate in situations when a patient complained of pain which was not commensurate with the degree of observable pathology. This ‘disconnect’ is common in such chronic pain conditions as back pain, headache, fibromyalgia, ‘pelvic pain,’ and temporomandibular disorders. It became obvious that other factors must contribute to the pain experience and treatment outcome. Likely contributors included psychological and social factors.
The evolution of comprehensive pain models incorporating a biopsychosocial approach has developed over decades but a thorough description of the systematic attempts to produce these models is beyond the scope of this article. It is sufficient to note that more recent pain models have been constructed to incorporate multiple dimensions of the pain experience, acknowledging that pain does not exist in a social vacuum, and that non-physiological factors such as personality, cognitions, beliefs, socio-cultural variables, learning and emotional reactivity all contribute significantly to a patient’s perception of pain. One recent model1 characterizes pain along three distinct, interrelated dimensions:
- sensory/discriminative, which acknowledges underlying physical pathology and incorporates nervous system pathways
- affective-motivational, which reflects emotional responses to pain
- cognitive-evaluative, which takes into account individual beliefs and ascribes meaning to the pain experience
In like fashion, Price2,3 described the experience of pain as involving:
- primary pain affect
- secondary pain emotion
- behavioral response
Treatment based on such biopsychosocial perspectives must not only address the biological basis of symptoms, it must also incorporate the full range of social and psychological factors that are affecting the individual patient’s pain, distress, and disability. The role of the psychologist in comprehensive pain management depends, in part, on the strength of one’s acceptance of, and adherence to, a truly biopsychosocial approach to pain conceptualization and management. A therapeutic intervention that focuses predominately or solely on physiological (or social/ psychological, for that matter) factors ignores the complex and dynamic interactions among these variables at a given point in time, as well as over time, and is therefore incomplete. This approach will also likely be ineffective in the long run. Clearly, the psychologist can play an important role in working with clinicians to evaluate, identify, monitor and treat non-physiological factors contributing to a patient’s complaints.
Psychologists Fill Multiple Roles
The psychologist involvement does not have to be limited to the role of ‘last resort’ for patients with physical complaints or with disability exceeding pathophysiological explanations. Although mental health involvement can be helpful for these suspected ‘psychogenic’ or somatoform disorders, a psychologist can be involved in many other aspects of pain management of any pain condition.
Typical roles for a psychologist include:
- evaluator/consultant, including screener, compliance monitor, cognitive fitness judge
- therapist/ counselor, including pre-intervention educator, pre-intervention counselor, pain psychologist
- outcomes analyst
A comprehensive psychological evaluation of a patient with chronic pain can serve several functions as a complement to a medical evaluation.
The psychologist in the role of consultant or evaluator can:
- collect additional data regarding the patient’s pain complaints
- complete the ‘big picture’ psychosocial and medical history
- use this information to guide the establishment of individual treatment goals and algorithms
- suggest appropriate outcome measurement of treatment gains
Further, the psychologist in the role of evaluator or consultant can prove helpful during several critical points within a comprehensive pain management program. The following sections elaborate on various roles in this category.
Patients can be evaluated pre-treatment, including prior to surgery; before an implant trial; pre-implantation of spinal cord stimulator or drug administration system; before beginning pharmacological treatment (especially chronic opioid therapy); or prior to participation in a multidisciplinary pain management program.4
The initial patient evaluation can: