Help! I’ve been referred to a psychologist for my pain!

If psychology input has been suggested as part of your pain management and/or rehabilitation, it’s normal to have questions.

Psychology isn’t the first profession people default to when considering treatment. Pain is a physical problem, so what do thoughts and feelings have to do with it?

To make matters more complicated, if you’re accessing treatment through a funding scheme, it can be common for referrals to be made with little information provided in advance. Plenty of people come to their initial session not realising they’re speaking to a psychologist (or why they are even sitting in the consult room in the first place).

As a health psychologist with a special interest area in persistent pain, I want to assure you that I fully believe your pain is real, just as you describe it, and that it has a significant negative impact on your life. Having worked in the rehab space for some time, I’ve made friends with scepticism and even come to welcome questions about the role of a psychologist in treating pain. If you’re someone who has been recommended psychology in your pain treatment plan and want to know before you go, this article is for you.

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Myth: Psychologists are only for mental health issues, not physical pain.

Fact: Many people know psychologists help with mental health, but they also have knowledge about the things that affect how we act, our thoughts, feelings, and automatic reactions to situations. They can offer guidance and support in these areas, which can be helpful for rehabilitation from persistent pain.

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Myth: If I see a psychologist, they’ll think pain is all in my head.

Fact: A psychologist’s role is not to question the reality of your pain, but to explore with you how to manage it. When pain persists past expected healing times, it is normal for it to start to encroach on many parts of our lives. We tend to pull away from the things we care about, becoming less engaged in work and feeling less productive. This often leads us to feel lower, disengaged, and withdrawn from the people and activities we’d usually find joyful or meaningful. Additionally, pain is a warning signal that our body normally responds to by activating our threat or survival mechanisms. When switched on all the time, these ultra-protective responses can backfire, causing tension and stress, anxiety, and sleep issues. These are common responses to persistent pain, but that doesn’t mean there aren’t strategies we can introduce to minimise them.

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Myth: Seeing a psychologist means I’m weak or can’t handle my pain.

Fact: Despite huge strides forward in mental health awareness in recent years, there is still lots of stigma around seeking psychological support. This is especially true for pain, especially if your condition is not clearly visible (i.e., a broken leg in a cast). This can lead people to feel they should be able to "tough it out." This a common stuck point for people who set exceptionally high standards for themselves or use self-criticism to motivate themselves to get things done.

Rehabilitation from persistent pain involves us doing things a different way in the short-term so we can recover better in the long-term. It feels like we are doing things in a way that is going against our survival mechanisms. We are naturally inclined to take the path of least resistance, opting for what brings us the most ease in the moment (e.g., stopping what we are doing if there is pain, withdrawing from social activities, pushing through then paying for it the next day, or relying solely on treatments that don’t require active participation like massage or medications). However, making the choice to approach things in a new way, rather than sticking with what has always been done, is often the tougher decision – but it's also the one that leads to better recovery. Research shows that active strategies for pain are more likely to predict better long-term outcomes (Ambrose & Golightly, 2015), demonstrating that although it's a challenging route, it’s ultimately a more effective one.

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Myth: A psychologist can’t do anything to help reduce the actual pain.

Fact: Previously, scientists used to think that the amount of pain we felt was directly related to how severe the tissue damage was (e.g., a broken arm should cause more pain than a jarred finger). But updated pain science now tells us that pain is not simply due to the severity of your injury, tissue damage, or a certain amount of ‘wear and tear’. It is variable, depending on your nervous system and immune system, your personal context and environment, as well as your thoughts, mood, sleep, stress and fears. When people have persistent, unhelpful internal dialogue (like constantly worrying or expecting the worst), difficult emotions (like anger or anxiety), or unhelpful behaviours (like resting too much because of pain or avoiding activities), these can make pain feel worse over time. This happens because the brain and nervous system become more sensitive, setting off a danger alarm during activities or situations that are not damaging or harming us. This means we become more hypervigilant and may limp, guard, or resist movement, creating a cycle that makes the pain harder to manage. In other words, pain is your body’s way of protecting you, and sometimes it does this too much.

You can teach your body to gradually move using a structured approach to operate safely again (even with an old injury). In doing so, you can retrain your pain system to adjust and “wind down”, producing less pain. Approaches to rehabilitation which involve the thinking and feeling parts of the brain have been shown to alter pain perception, reduce pain intensity, and increase ability to do more before pain stops you (Day, 2016; McKracken, Yu, & Vowles, 2022; Seminowicz et al., 2013). Attention training, paced activity, challenging unhelpful thought patterns around pain, and other active self-management strategies can help people to experience less pain and improve their day-to-day functioning. But just like taking medication for it to work, you need to practise these exercises to harness the nervous system’s ability to retrain itself. While they may not necessarily provide immediate pain relief, they can help reduce how much pain interferes with our daily lives, restore our confidence to move, and over time can decrease the intensity of our pain experience.

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Myth: If I’m prescribed medication, I don’t need psychological support.

Fact: Medication can be helpful, but it often doesn’t address the other impacts of dealing with ongoing pain, such as changes to your self-esteem, mood, pain thoughts, or relationships. Combining medical with psychological support can lead to better outcomes, as psychologists can provide tailored ways of managing difficulties such as anxiety and depression, along with emotional reactions like stress, fear, and frustration that often accompany persistent pain.

Additionally, research comparing opioids with non-medical treatments suggests that while opioids might offer short-term relief, alternatives like physical therapy and cognitive-behavioural therapies (ideally alongside each other) may provide more sustainable gains towards functioning with fewer risks (Day, 2016; Nadeau, Wu, & Lawhern, 2021).

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Myth: I’ll have to talk about my childhood or other unrelated issues.

Fact: Pain psychology focuses on the present experience of pain and ways to manage it. While background might be discussed for context, sessions typically focus on actionable steps for managing pain, like building a greater understanding of your pain, active behavioural strategies, relaxation and stress-management, and cognitive techniques specific to your experience of pain.

Reference list

Ambrose, K.R. and Golightly, Y.M. (2015). Physical exercise as non-pharmacological treatment of chronic pain: Why and when. Best Practice & Research Clinical Rheumatology, [online] 29(1), pp.120–130. doi:https://doi.org/10.1016/j.berh.2015.04.022.

Day, M. (2016). Reversing maladaptive plasticity in chronic pain | APS. [online] psychology.org.au. Available at: https://psychology.org.au/inpsych/2016/august/day.

Khera, T. and Rangasamy, V. (2021). Cognition and Pain: A Review. Frontiers in Psychology, [online] 12(673962). doi:https://doi.org/10.3389/fpsyg.2021.673962.

McCracken, L.M., Yu, L. and Vowles, K.E. (2022). New generation psychological treatments in chronic pain. BMJ, [online] 376, p.e057212. doi:https://doi.org/10.1136/bmj-2021-057212.

Nadeau, S.E., Wu, J.K. and Lawhern, R.A. (2021). Opioids and Chronic Pain: An Analytic Review of the Clinical Evidence. Frontiers in Pain Research, 2(721357). doi:https://doi.org/10.3389/fpain.2021.721357.

Seminowicz, D.A., Shpaner, M., Keaser, M.L., Krauthamer, G.M., Mantegna, J., Dumas, J.A., Newhouse, P.A., Filippi, C.G., Keefe, F.J. and Naylor, M.R. (2013). Cognitive-Behavioral Therapy Increases Prefrontal Cortex Gray Matter in Patients With Chronic Pain. The Journal of Pain, 14(12), pp.1573–1584. doi:https://doi.org/10.1016/j.jpain.2013.07.020.