By Paul Frysh
December 7, 2023
Pictured: Shelly Spears
Our 'Fundamental Misunderstanding' of Pain
The surprising power of behavioral interventions
"Let's do it," Shelly Spears told her doctor. "I can no longer live like this."
The "it" in this case was a procedure in which doctors would anesthetize an area of her back and then burn off a chunk of nerve where it was pushing on her spine. But it was risky and there was no guarantee that it would even work.
It had been several months since the pain arrived unannounced and decided to stay — a pain "like someone punched me in the back and then left their fist there."
That was June 2020. Since then, Spears, 54, had lost her job, her house, her independence, her mobility, and her confidence. She was in near constant pain and unable even to pick up her grandchildren. Several weeks of grueling physical therapy had no effect. Medications didn't help much either.
Surgery seemed the logical next step. But her doctor wanted her to try something else first. She referred Spears to a mental health professional to learn about "behavioral interventions."
Spears was dumbfounded.
"I was not able to take care of myself. I couldn't lift, I couldn't bend, I couldn't sit more than 5 minutes. I couldn't stand more than 5 minutes."
"And you're gonna send me to talk to somebody?"
More Than Just Talk
That's how Spears met Amanda Green, a licensed clinical social worker, who treats people with chronic pain. Green sees this kind of resistance all the time in her practice as a behavioral health specialist.
Amanda Green, LCSW
"The truth is, all pain is processed in the brain. And I think there is a natural tendency for people's immediate response to be defensive about that as if we are saying the pain is 'all in their head.' But that is not the case," says Green, who teaches behavioral interventions to her clients at Lehigh Valley Health Network in Allentown, PA.
Decades of clinical science show certain behavioral interventions — which aim to redirect the anxiety, stress, fear, and cycles of negative thought that naturally accompany pain — can lessen pain levels, reduce need for some medications, increase mobility, and even improve medical outcomes, typically with no known risks or side effects.
Several studies show that cognitive behavioral therapy (CBT), the gold standard for these types of interventions, can lead to lasting reductions in pain at 6, 12, and even 24 months after treatment. And the results are strong enough that the U.S. Department of Health and Human Services 2019 Pain Management Best Practices Task Force Report calls for the integration of behavioral interventions into short-term (acute), long-term (chronic), and post-surgical pain management.
So why is there such resistance to these proven behavioral interventions?
Pain: A 'Fundamental Misunderstanding'
One of the primary reasons is a "fundamental misunderstanding" of the nature of pain, says Sean Mackey, MD, PhD, professor of pain medicine and director of the Systems Neuroscience and Pain Laboratory at Stanford University.
Most people, Mackey says, think of pain as a straightforward calculus: A physical stimulus — say a pinprick — causes a physiological response: pain. The doctor in this scenario is like a treasure hunter looking to find and block the pain pathway.
"But it's far more complex than that," Mackey says.
Physical stimulus travels up nerves into the spinal cord where it is shaped in different ways and may be turned up (amplified) or down (dulled) depending on your genes and other factors. Only then does it travel to your brain where "different brain circuits responsible for our emotions, beliefs about pain, prior experiences with pain, expectations of pain, all shape those signals coming in from our body into a unique, individual experience of pain."
There is huge variation between different people in this process, Mackey says.
Sean Mackey, MD, PhD
This "biopsychosocial model" — widely accepted by pain experts but largely absent from the practice of pain treatment — divides into biological, psychological, and sociological factors.
The obvious biological factor is the stimulation of the nerve and its perception in the brain. A typical psychological factor might be the anxiety due to questions like: Where did it come from? Am I sick? Am I injuring myself? Sociological factors might include social isolation or a weak social support system or poor health care access.
But, says Mackey, it's a mistake to think of any single factor by itself. They're so interwoven and interact in such complex ways, it's almost impossible to pull them apart.
A simple mistake of fact can have a huge effect. For example, one day a man in his 40s came to see Mackey about chronic foot pain due to Morton's Neuroma — a thickening of the tissue around the nerves between his toes. A former Masters level amateur tennis player, the man was distraught at being in pain and on crutches for 2 years.
He felt every pang of pain as a sign that his foot was worsening.
But once Mackey explained to the man that his pain didn't signify anything more than a sensation — that it wasn't a sign of further damage to his foot — the man brightened considerably.
"Wait, are you saying I can play tennis?"
"Yeah. You can play tennis all you want. It's gonna hurt, but you're not gonna harm yourself," Mackey told the man.
Within a few weeks the man was back on the tennis court and had left his crutches behind for good. At a later consult, the man told Mackey that he still felt the pain, he just didn't care that much about it anymore.
This was not a simple factual clarification, says Mackey. Emotions — fear, anxiety, anger, sadness — were inextricably linked to the man's understanding of his pain and its effects on his life.
"And when we talk about [emotions], we're talking about brain circuits, and those circuits overlap and converge with the circuits involved with the experience of pain ... amplifying his overall experience of pain," Mackey says.
Clearly, people — Shelly Spears is just one example — often struggle with far more complex, intractable, and intense long-term pain.
Beth Darnall, PhD
That's where a full program of behavioral interventions can really help, says Beth Darnall, PhD, professor of anesthesiology and pain medicine at Stanford University and director of the Stanford Pain Relief Innovations Lab.
At Stanford, Darnall developed a 2-hour program called Empowered Relief that teaches pain relief skills. Already in use in a number of clinics and hospitals, Empowered Relief requires less time and resources than multi-session approaches, like CBT or MBSR, and some studies show it may work as well for certain types of pain up to 6 months later.
And there are encouraging new developments in virtual reality and artificial intelligence that show real promise in treating pain with behavioral interventions in the comfort of your own home.
Virtual reality technology shows real promise in the treatment of pain.
Like other experts in this piece, Darnall made clear that behavioral interventions are not psychotherapies for people with mental illness or imagined pain. Nor are they necessarily a replacement for other effective tools for pain management, like surgery and medications. They are proven treatments designed to integrate into a complete pain management program in order to help people — any people — manage chronic pain.
"Pain is real," Darnall says. "It has a medical basis, sometimes in very serious illness or injury — cancer, ankylosing spondylitis, rheumatoid arthritis, degenerative diseases with no cure that get worse over time.
"And within that context, evidence-based behavioral interventions can lessen suffering, pain, and related symptoms."
A Nervous System 'Reset'
One night, unable to sleep from a pain flareup and already maxed on her medication, Spears decided to try a simple breathing exercise Green had taught her: Eyes closed, breathing deeply, she concentrated on her breath and imagined her spine opening up, her muscles relaxing.
"We're trying to turn off that fight or flight response," Green had told her.
To her surprise, says Spears, it helped enough to get her to fall asleep. Perhaps more importantly, she says, it started her on a journey to discover more about other "behavioral interventions" that might help her.
Over the coming months, Spears practiced strategies for stopping the spiraling negative thoughts about her pain. Extensive research shows that interrupting such thought patterns can ease the experience of pain.
She learned more about the likely physiology of her pain and the difference between "hurt" and "harm." Studies show that mere knowledge of how your pain works in your body can change your experience of it. That led her back to her gym workouts, an activity she enjoyed — which is good, because, as you may have guessed, both physical movement and positive emotion can help lessen the experience of pain, studies show.
She began adding other interventions like changes in sleep, diet, and even socializing habits — each one carefully crafted to help those with chronic pain. Learning these strategies doesn't have to be overly complex or time-consuming. For example, Green guided Spears to Empowered Relief for tools she could explore, even on her own.
And over time, says Spears, she began to feel better.
That's no surprise to Darnall.
Studies show that the most effective behavioral intervention programs combine pain education with skills education that help people regulate their emotions, thought patterns, activity levels, stress responses, sleep behaviors around pain — even diet and exercise, says Darnall.
"What we're doing, at a very basic level, is help people reset how their nervous system responds to pain, which changes their experience of pain," Darnall says.
A Culture Shift: Toward a New Model of Pain Treatment
Conventional pain management can resemble a never-ending game of whack-a-mole that frustrates both the doctor and the patient and finds success only about 30% of the time.
It often involves prescription medications with well-known risks and side effects. And this includes opioids, despite an opioid misuse epidemic that has killed more than 280,000 people since 1999 — 17,000 in 2021 alone. A growing body of evidence shows opioids don't even work very well for many types of pain.
This is a serious problem for the 50 million people in the U.S. who live with chronic pain.
Part of the problem is the current culture of medicine, says Robert Kerns, PhD, professor emeritus and senior research scientist at the Yale University School of Medicine and a director of the NIH-DOD-VA Pain Management Collaboratory Coordinating Center.
"Our culture reinforces and incentivizes the use of passive approaches such as medications, procedures, and surgeries and generally does not support active, learning-based approaches that support behavior change and lifestyle modification," Kerns says.
And this goes for doctors as well as those they treat.
"Clinicians were historically not educated about pain and pain management to any significant extent, including the importance of using a biopsychosocial framework to develop an effective treatment plan," says Kerns.
Robert Kerns, PhD
This combined with the persistent myth that pain always signals an underlying physical problem that needs to be "fixed" can lead to feelings of helplessness and hopelessness that can further exacerbate symptoms both in people with chronic pain and in the doctors that treat them, he says.
Even messaging can be an issue.
Patients and clinicians without proper training often reject references to "psychological" treatment or referral to a psychologist that often happen in discussion of behavioral interventions due to concerns that this is somehow dismissive of "real pain."
The result is that most people simply don't have access to effective behavioral interventions for pain.
Spears was lucky. She happened to be part of one of the few health systems in the nation — Lehigh Valley Health Network in eastern Pennsylvania — that, like Cleveland Clinic, fully integrates behavioral interventions into pain treatment programs.
Not only that, but her insurance was willing to pay for the cost — insurance reimbursement can be a real problem for many behavioral interventions.
Other providers are trying to integrate more behavioral interventions. Allegheny Health Network, Humana, and various other Veterans Health Medical Centers in the U.S. offer Empowered Relief to treat chronic or postoperative pain. And the Veterans Health Administration, the largest integrated health system in the U.S., provides access to cognitive-behavioral therapy for chronic pain across the nation.
But it is still just a drop in the bucket, says Kerns.
Getting Past the Barriers
These barriers aren't insurmountable, says Sara Davin, PsyD, director of the Comprehensive Pain Recovery Program at Cleveland Clinic's Neurological Institute.
Take the common resistance of doctors. "Physicians respond well to facts. Once they know about efficacy for behavioral interventions, most clinicians are on board with the idea," says Davin, who has helped integrate multiple behavioral intervention protocols for pain management at Cleveland Clinic.
Sara Davin, PsyD
The bigger problem, says Davin, is integration of these programs into already stuffed treatment pathways. "We have to make it as easy as possible for all the clinicians, already swamped with paperwork, patient interaction, labs, and other tasks, not only to speak to their patients about the benefits of these programs, but also to schedule them and to implement them."
Davin saw this at work in Cleveland Clinic's spine surgery group where already overloaded nurses were understandably apprehensive about more work, Davin says.
"The idea of having to talk to a chronic pain patient about going to a pain psychology class worried them initially because they were anticipating all this resistance. They thought it would take hours to explain."
But in the end, with a clear playbook of talking points and a clear guide for the "treatment pathway," the whole group was happily surprised at just how easy — and effective — it was, Davin says.
It helped that this intervention was a lighter lift than most — the single-session 2-hour Empowered Relief program, delivered online if necessary. (CBT typically requires 8 to 10 1-hour sessions at up to $200 per session.)
"One-session behavioral pain treatment is a huge shift and it suddenly makes it possible for people to receive this evidence-based care in a scalable way, especially in a surgical context, where longer behavioral interventions are often impractical," says Davin.
It also makes it easier to integrate at the beginning of a pain treatment program, rather than as a "treatment of last resort" after many medical treatments have failed, where they are often less effective, she says.
"It's not that complicated. It's all about just making a simple point and really emphasizing that this is best practice. It's the standard of care. We have to emphasize that there is science supporting this. These are highly effective interventions that can help with serious pain."
Feeling at Peace
For Shelly Spears, these behavioral interventions have been "life-changing," she says.
Today, she is back at work and back to picking up her grandchildren. Her medication use is a fraction of what it once was, and for now, she has decided against the nerve ablation.
She continues to use behavioral interventions to manage her pain, and she consults regularly with Green to keep her on track.
"It's not a magic bullet. I have to work at it every day," says Spears. But slowly, incrementally, her pain levels have gone down and her mobility and quality of life have gone up.
And for now, says Spears, that's more than good enough.