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17 Articles in Volume 20, Issue #3
20/20 with Dr. Suzanne Amato Nesbit: Clinical Pharmacy Roles and Disparities
A Clinician’s Guide to Treating Chronic Overuse Injuries
Adhesive Arachnoiditis: No Longer a Rare Disease
Analgesics of the Future: Cebranopadol as an Opioid Alternative
Ask the PharmD: What role do vitamin D supplements play in treating dysmenorrhea?
Behavioral Pain Medicine: Managing the Affective Components of Pain
Chronic Fatigue Syndrome: Naltrexone as an Alternative Treatment
Chronic Pain and Coronavirus
Connecting the Dots: How Adverse Childhood Experiences Predispose to Chronic Pain
Editorial: Why Are ER Opioids Out of Favor?
Fibromyalgia as a Neuropathic Pain Disorder: The Link to Small Fiber Neuropathy
How the COVID-19 Pandemic Is Transforming Pain Care
Hydroxychloroquine Use and Risk in the Management of Systemic Lupus Erythematosus
Management of Trigeminal Neuralgia in Multiple Sclerosis
Optimizing Care Using a Trauma-Informed Approach
Pediatric Pain Management: A Review of Clinical Diagnosis and Management
The Use of Low Dose Naltrexone in the Management of Chronic Pain

Behavioral Pain Medicine: Managing the Affective Components of Pain

Psychological techniques and strategies for helping pain patients who live with related stress and distress.
Pages 14-18

The classification of psychological techniques for the treatment of pain was first developed in 2007, and is based on which component of pain the treatment is focusing on, be it affective, cognitive, behavioral, or sensory.1 Numerous studies have been conducted in the area of pain and emotion, including stress and pain, negative emotional states and pain, emotional regulation processes and pain, the effects of enhancing emotional regulation on pain, and the relation of emotional distress to treatment-seeking in persons having pain.2

Various treatments focus on these related effects but they seem to have limited effect on overall pain management.3 The notion that accessing and exploring painful emotions in a therapeutic relationship makes one better is a widely held belief among several schools of psychotherapy.4 This paper focuses on the psychological techniques available to address the affective component of pain, starting with supportive therapy.

Supportive therapy techniques include comforting, advising, encouraging, reassuring, and listening attentively and sympathetically. (Image: iStock)

Supportive Therapy

Supportive therapy is a practical approach that can be used in pain care to help patients cope with their emotional distress and problems of living with chronic pain. Techniques include comforting, advising, encouraging, reassuring, and listening attentively and sympathetically. Supportive therapy offers an emotional catharsis for the patient. It may also include education about the patient’s illness and directive coping strategies. The therapist appeals to the patient’s conscious mind rather than interpreting their unconscious. The therapist might also serve as a case manager, interceding on a patient’s behalf with various authorities with whom the patient may be contending. In supportive therapy, the therapist serves as a role model of appropriate behavior, including healthy emotional regulation, and consequently conveys implicitly an adaptive ideology about the way that life ought to be led.5

Target Patients: Supportive therapy is often included as a condition in clinical trials to provide a rigorous comparison group that controls for nonspecific factors in therapy (such as treatment alliance, time, and frequency of visits) and allows researchers to evaluate any unique benefits of other psychotherapies (eg, cognitive-behavioral therapy).

Humanistic Psychotherapy

The inclusion of a humanistic section diverges from Kreitler and Kreitler’s original psychotherapy classification system for the treatment of pain.1 For example, in the original taxonomy, existential and gestalt therapies are considered to be dynamic therapies. Herein, these therapies are organized under a humanistic heading, along with the person-centered approach, due to shared assumptions, including the belief that people tend to move toward positive growth. These approaches are phenomenological, in that they are interested in the patient’s subjective report of their life experiences.

All three approaches emphasize the therapeutic relationship and see nonjudgmental regard as a curative factor. Lastly, the person-of-the-therapist is considered a vital change mechanism. This requires the therapist to use their whole, authentic self to role model healthy interpersonal relationships, including healthy boundaries, distress tolerance, and emotional regulation.

Person-Centered Therapy

This process-oriented, humanistic approach to therapy was developed by psychologist Carl Rogers in the 1940s. This treatment seeks to facilitate a patient’s self-actualizing tendency, or an inbuilt proclivity toward growth and fulfillment, using communication micro-skills to develop and convey an understanding of the patient without judgment or opinion. The therapist does this via acceptance (unconditional positive regard), congruence (genuineness), and an empathic understanding. Rogers believed that these three core conditions help liberate the patient so they may confidently express their true feelings without fear of judgment. The therapist therefore creates a nonjudgmental environment wherein patients may explore their true selves without the personal input of others. This judgment and directive free space then allows the patient to discover their values independent of others.6

Existential Therapy

Existential therapy is informed by the existential tradition of European philosophers, such as Kierkegaard and Nietzsche, but it was Rollo May, a psychologist, who brought existential therapy into the mainstream in the middle of the 20th century. Existential therapy is a process-oriented approach rooted in the humanistic tradition. It assumes that people are inherently driven to self-actualize. Like other humanistic psychotherapies, this approach is focused on the here-and-now as opposed to past childhood experiences.

Existential theory assumes that anxiety is a normal part of the human condition. It aims to help people cope with macro-level existential issues, such as finding meaning in life and cultivating courage in the face of death anxiety. The goal of the therapy is to promote responsibility in the patient through awareness of thoughts, feelings, and choices in order to live an aware, authentic life. There is limited research on the effectiveness of existential therapy with non-oncology populations.

Gestalt Therapy

This therapy was developed by Fritz Perls and his wife Laura Perls in the mid-1900s. Like person-centered and existential approaches, Gestalt therapy is a humanistic, process-oriented approach. It promotes the relationship between the patient and the therapist as its most vital intervention. The therapist uses their whole, authentic self to cultivate biopsychosocial awareness in the patient. A distinct component of Gestalt therapy, compared to other theories, is a focus on physical body awareness. Gestalt therapists encourage their patients to notice bodily sensations in order to access patterns of feelings, thoughts, and ultimately behaviors. In Gestalt therapy, patients are challenged to identify introjections – value systems that come from outside themselves – rather than from their own self-concept.

In Gestalt therapy, patients gain exposure to authentic interpersonal contact (with the therapist). Because of this, the person-of-the-therapist serves as an important change mechanism. Further, because of the important role of the therapist’s personhood in treatment, Gestalt therapists should complete their own Gestalt therapy to ensure they are able to effectively role model characteristics of healthy interpersonal interactions. The objective of Gestalt therapy is to enable the patient to shed the incongruent values of others while integrating parts of the self that had been cut off. An increase in self-regulation and authenticity are the ultimate desired outcomes.

Emotional Awareness and Expression Therapy (EAET)

This intervention is based on the principle that life stress accompanied by emotional suppression can lead to chronic over-arousal, dysregulate the brain, and trigger or exacerbate pain symptoms related to fibromyalgia. EAET seeks to reduce stress and improve health by helping patients recognize their own stress‐pain links and recognize that the avoidance of emotionally difficult interpersonal experiences is a key stressor.
Therefore, this approach teaches patients to identify, experience, and express their emotions related to stressful experiences, and encourages them to engage in emotionally honest and direct interpersonal communication. EAET uses techniques such as writing about stress, role-playing how to handle difficult relationships, recognizing and expressing anger and other feelings, and being more open with others.7

Target Patients: Recent clinical trials have found that home-based, telephone-delivered supportive care (using person-centered therapy) and cognitive-behavioral treatments help with back pain severity and disability.8,9 While existential therapy outcomes have been investigated, these studies have predominantly included oncology patients. The impact of existential and Gestalt therapies on well-being and pain experiences needs to be studied in more diverse pain patient populations.

Meaning-Based Control of Negative Emotion

Kreitler and Kreitler (1985) posed that pain control may be a pattern of cognitive-based, meaning assignment tendencies of the patient. They further asserted that changes in these tendencies facilitate changes in the experience of suffering from chronic pain, which may help to reduce anxiety and increase coping abilities in pain patients.10

Cognition is the processing system that identifies, transforms, retrieves, elaborates, stores, and produces meanings. Meaning itself consists of what is often called cognitive contents, or verbal and nonverbal representations that relate to an input, or an external stimulus, situation, signal from the autonomic system, or thought. These inputs are called “referents” when they serve as anchors for meaning assignment. The content items assigned to a particular referent are called “meaning values.” Accordingly, a unit of meaning consists of a referent (eg, “pain”) and a meaning value (eg, “is depressing, difficult, and reminiscent of crises”).10

The manipulations of meaning consist of changing the strength of the negative meaning values of the referent by assigning specific, well-defined attributes or comparatives, such as “Pain is a normal feature of the human experience;” expressing interpersonally-shared meanings; and emphasizing actions and sensory-qualities of the referent, such as “Pain is an alarm of a threat which interferes with normal life functioning.”

Target Patients: Kreitler and Kreitler have used a structured protocol (one to two brief sessions) to train individuals in adequate cognitive styles that help them deal with anxiety and trauma.1,10

Dynamic Psychotherapy

Studies investigating dynamic approaches have shown that emotional changes often accompany severe and persistent pain.11  Dynamic psychotherapy is typically used when psychosocial risk factors play a role in pain symptoms, and the goals include long-term adaptation to pain and symptom relief.11 Evidence suggests that emotional factors, defense mechanisms often measured by the Minnesota Multiphasic Personality Inventory, and personality traits can modulate the subjective pain experience.12

Dynamic psychotherapy aims to enable insight into the unconscious processes (eg, one’s motivations, conflict resolutions, overcoming trauma, and catharsis) as liberation from one’s emotional suffering, which impacts pain and its psychological components.3  This type of psychotherapy serves as an umbrella concept for psychotherapeutic treatments that operate on an interpretive/expressive-supportive continuum (eg, psychoanalysis, Adlerian, and more contemporary approaches, such as interpersonal psychotherapy.) 13


Rooted in the theory of evolution, this therapeutic approach was established in the early 1890s by Sigmund Freud. Psychoanalytic approaches emphasize early childhood experiences and caregiver relationships. Its therapeutic techniques aim to explore the unconscious mind and bring repressed fears and conflicts from infancy and childhood into the conscious mind. Intervention techniques are used, such as dream interpretation and free association.

Traditional psychoanalysis is a lengthy process that involves many sessions with a psychoanalyst. It is an example of global therapy, which aims to help the patient bring about a major change in their whole perspective on life rather than symptom reduction.

Interpersonal Psychotherapy

This therapy differs from traditional psychoanalytic approaches in that it examines current rather than past relationships and recognizes internal conflicts without focusing on them. The main goal of interpersonal psychotherapy is to improve the quality of a patient’s interpersonal relationships and social functioning to help reduce their distress. The therapy provides strategies to resolve problems within four key areas, including interpersonal deficits, unresolved grief, difficult life transitions, and interpersonal disputes.

Adlerian Therapy

Alfred Adler, a contemporary of Freud, developed this therapeutic approach during the early 20th century. Similar to Freud, Adler was interested in the impact of early childhood experiences. Different from Freud, who emphasized sex and aggression instincts, Adler emphasized the importance of social interest and belonging. He also assumed that children experienced inherent feelings of inferiority and that a crucial developmental goal was to transform feelings of inferiority into social interests aimed at helping the greater good.

Therefore, Adlerian therapists explore factors such as sibling birth order, lifestyle, and parenting. Therapists assist patients in uncovering their private logic, including distorted thinking, and style of life in order to help them develop insights, skills, and behaviors. The objective is to identify and reframe basic mistakes and private logic across four phases of treatment: engagement, assessment, insight, and reorientation.

Target Patients: Past research has shown that short-term dynamic psychotherapy is indicated for patients with psychiatric comorbidity and those with somatoform pain disorder.12,14-16 A systematic review of the literature has shown a range of studies that have investigated the use of short-term dynamic psychotherapy for the treatment of somatic conditions, including idiopathic, chronic pain conditions,17,18 severely physically ill with mostly chronic pain,19 chronic headaches,20,21 rheumatoid arthritis,22 chronic back pain,23 and pelvic pain or urethral syndrome.24 In addition, there are some randomized controlled trials that have reported dynamic psychotherapy outperforming mindfulness-based stress reduction and cognitive behavioral therapy on measures of chronic pain.15

There also has been preliminary evidence to support the use of interpersonal psychotherapy as a treatment for patients with chronic pain and depression.25 While some research supports Adlerian therapy, more testing is needed to back the benefits of the approach. 

Creative art – including dance or movement-based expression, story and poetry writing, acting, and visual arts – can be part of the therapeutic process. (Image: iStock)

Creative Arts Therapy

Creative art – including dance or movement-based expression, story and poetry writing, acting, and visual arts – can be part of the therapeutic process.3,26
While the art-making process has been found to be therapeutic as a stand-alone treatment, it is more often used as a complementary alternative intervention under one of the aforementioned therapies.27 The purpose of art therapy is essentially one of healing.

Visual Arts Therapy

In visual arts therapy, any type of two- or three-dimensional visual art project is conceptualized and executed as a means to express oneself and gain insights into thoughts, feelings, and behaviors. Visual arts projects might include painting, drawing, photography, sculpting, and/or digital art.3,26 Art therapy can be facilitated using studio-based art therapy, group art therapy, and/or individual art therapy.Creative arts therapists tend to make these media accessible for all types of patients. There are various reasons for the integration of these forms of therapy in complementary, supportive pain management programs, including their stimulation of a positive emotional experience.28


Psychodrama was originally developed by Jacob L. Moreno and includes elements of theater. It is a type of group psychotherapy where dramatic expression, theatric plays, or body movement are applied to re-enact real-life, past situations (or inner mental processes) by acting them out in present time. Participants then evaluate their behavior, reflect on how the past incident played out in the present, and work to more deeply understand particular situations in their lives. Psychodrama aims to improve patient’s relationships with others and, reciprocally, their self-confidence.

Play Therapy

Play therapy is a supportive, process-based psychotherapeutic approach used primarily with children 3 to 12 years of age. This type of therapy is used to help patients explore their lives and freely express repressed thoughts and emotions through play. The goal is to help children learn to express themselves in healthier ways, become more self-compassionate and empathic, and discover new and more positive ways to solve problems.

Target Patients: More studies are needed to better understand the effectiveness of creative art therapy in patients living with chronic pain conditions.3 However, one rigorous study examined the meaning of chronic pain using visual art interventions and  found that patients reported greater introspection, and, as a result, a greater understanding of their patterns of thoughts, feelings, and behaviors.29 Further, there is evidence to support the effectiveness of psychodrama on the expression of suppressed feelings in a sample of cancer patients.30


The treatments discussed herein capitalize on the research findings demonstrating the importance of positive emotion expression on the alleviation of pain experiences. Each approach is unique in its conceptualization of the causes of distress and negative mood states. Moreover, each technique is unique in its proposed curative factors – humanistic approaches emphasize the importance of a nonjudgmental therapeutic condition; meaning-based techniques transform maladaptive patterns of meaning assignment; dynamic psychotherapies promote insight and resolution of emotional conflicts; and creative art therapies facilitate emotional expression and awareness.

Last updated on: June 18, 2020
Continue Reading:
The Sensory Component of Pain: Modifying Its Emotional and Cognitive Meaning
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