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Chronic pain is experienced differently by every individual in terms of location, intensity, frequency and duration of the pain, as well as the impact on the individual psychologically. Psycho-physiological pain, or physically expressed pain with emotional bases, can be treated successfully with ISTDP.

What is chronic pain?

Chronic pain is ongoing pain that usually lasts beyond the typical healing time of a few months, where the word ‘chronic’ means ongoing or persistant. Around one in five Australians suffer from what we know as chronic pain, but the experience of chronic pain is different for every individual in terms of the severity/intensity and also the impact on the individual’s well being and life in general.

When seeing an individual who is presenting with chronic pain the first important step is to investigate what is causing it, and to explore whether the pain is organic/medical or psycho-physiological/somatic in nature. 

Most pain conditions have some sort of psychological component,  including pain due to organic tissue damage. The reason for this is that pain is a scary and frustrating experience to be living with, and the distress caused by living with pain only aggravates its intensity. Depending on the nature of the pain, the treatment of choice can either be medical or surgical, or it can be a combination of medical, physiological and behavioural therapies (i.e., classic chronic pain management), or in many cases pain can also be successfully treated with psychotherapy. The outcomes of all types of treatment can be further boosted with lifestyle, relationship and mindfulness coaching.

The information below will be focused on psycho-physiological pain which can be successfully treated (fully eliminated) by emotion focused experiential psychological treatment.

What is psycho-physiological pain and how does it occur?

First of all, psychophysiological pain is real and it is experienced in the body physically. The following conditions may be psycho-physiological in nature:

Headaches, chest pain, back pain, neck pain, foot pain, stomach aches and nausea, fibromyalgia, chronic fatigue syndrome, muscle weakness, hyperventilation, vulvodynia, vaginismus, erectile dysfunction, irritable bowel syndrome, abdominal cramps/pains, nausea, irritable bladder/bladder spasms, coronary artery spasm, hypertension, migraine, inappropriate sinus tachycardia, hives, chronic tendinitis.

The most commonly observed type of pain is chronic pain due to prolonged or high bodily tension. Bodily tension can be either a fearful activation or an attempt to control internal experiences and we consider this type of physical tension to be anxiety driven. 

Note that conditions that are caused by organic changes in the body are not psycho-physiological. They should be treated medically, but can be better managed with psychological support.

Quick check: Can you recognise any signs of fear or nervousness in your body? Notice how you experience it, without trying to do anything about having it.   
Chronic tension in the body can have a negative impact on the regulation of many bodily systems. For example, chronic tension can interfere with the oxygen supply in different parts of the body and the resulting oxygen deprivation is known to be associated with increased pain (and holding your breath can similarly affect the intensity of pain as well as the frequency and duration. Our internal regulatory processes – respiratory, cardiovascular, gastrointestinal, musculoskeletal, neurological and dermatological bodily systems, can all be affected by chronic tension in our bodies.

Quick check: How tense are you right now? Where and how much tension are you experiencing in your body right now? Try not to control it, because when you try to control tension with tension, you will only feel worse. 

In addition to high bodily tension, pain can also be caused by internal avoidance mechanisms. As the name suggests, avoidance mechanisms allow individuals to avoid experiencing pain, discomfort and conflicting emotions. Although necessary for our ancestors, these avoidance mechanisms unfortunately do not have a beneficial effect for us in this day and age and cause more physical and psychological suffering long term, because they prevent our body from recovery. You can read more about these mechanisms and how they impact recovery in our post of disturbed sleep and night-terrors here. 

Quick check: How present or detached are you feeling right now within your body (not your head)? Pay attention to what is going on inside of you without doing anything about it. Try to let go of any desire to control your internal experience listening to it instead.

Last but not least, pain can be caused when our anger, guilt and grief are suppressed or repressed and turned inwards instead of being constructively processed and expressed. In my personal experience, most of the clients who suffer somatic pains are nice people and it is precisely because of that that many of them develop this problem. To briefly explain, when we are hurt, it activates emotions of anger and this anger comes with impulses to fight back. These impulses can be a distressing experience for many people –  especially when in our childhood we learned that having anger has negative consequences. 

In this situation, where a person has a violent impulse but does not want to hurt another person, they frequently turn those impulses and distress onto themselves i.e. internalising their anger. Feelings of guilt about the anger and impulses surface and as a result the person experiences painful symptoms that mirror what their anger wanted them to do, for example, stomach pains because their anger made them want to punch someone in the stomach.

I want to highlight a very important message here – the intensity of the impulses to hurt another person is a reflection of how much the person is hurting themselves, not an indication of how bad they are as a human being and it is the person’s actions, not their impulses, that provide information about their character. 

People who suffer this kind of problem are usually quite critical of themselves, they frequently feel very bad as if they did something terribly wrong and often receive subconscious punishment for the crimes they actually did not commit in reality. This is a tricky concept to grasp, but I hope the information here gives you a little bit of clarity. 

Quick check: What reactions or emotions are you having reading this information? How is it for you to have those reactions – okay or uncomfortable? Notice how you experience your reactions (without trying to do anything about having them).

The triggering emotions can originate from painful experience(s) with other people, or from painful loss or traumatic experience as a natural disaster. See if you can establish a link between psychologically important events and your pain problems.

How do you determine whether it is psycho-physiological pain or not?

In order to know whether your pain is psycho-physiological or not, you should first consult with your doctor. If there is no obvious medical reason then the doctor might recommend that you undergo a psychological assessment. 

When I perform psychological assessment of chronic pain together with the client I test whether pain triggers are emotional or psychological in nature. When the pain is psycho-physiological,  the pain symptoms will start changing in the moments when we put the pressure on avoided emotional material and if yes, then together we explore the relationship between avoided emotions and the symptoms, and work towards constructive processing of the feelings underlying pain.   

Ideally, we then want to help the client to address the core psychological issues causing the pain or fatigue. If there is no physiological response to the experience of feelings throughout the whole assessment, then it is possible that the pain is medical in nature and further medical or psychological investigation might be required.

How do you do this assessment? What are the indicators?

I use a highly structured experiential treatment modality called Intensive Short-Term Dynamic Psychotherapy (ISTDP), which allows for discovery of all types of the psycho-physiological or somatic pain outlined below. Together with the client we explore whether there is a connection between their pain and emotionally charged experiences in their life. This work is most effective when we can explore clients’ emotions and fears. However, some clients benefit from initially exploring what is happening inside their important relationships, what they consider challenging and how they are coping with their difficulties.

In the process of evaluation I am paying close attention to my clients feelings and emotions, how they experience them physically, their level or tension or fear/anxiety, and their emotional avoidance mechanisms. If any of these are in operation during our work – then the pain is likely psycho-physiological and together with the client we go on exploring it further.

If there are none of the above-mentioned responses, and both clients and myself agree that our work does not bring any results, the client is referred back to their treating doctor with this information.

If you have somatic pain your treatment plan will depend on what your goals are. You can start your work by yourself independently or with the help of a therapist. I personally think that it is better to have a few initial sessions with  a therapist and then to decide whether to continue working together or doing work on your own, only seeing a therapist when you decide it is needed. 

As part of your treatment, working on a good relationship with yourself is crucial, as the quality of your relationship with yourself greatly affects your health in general and psycho-physiological pain in particular. Know and accept your limits, because it is only when you know the reality of your problems you can start changing.

Let us know if you have any specific questions and, as always, we will do our best to answer them.

Valeria Zoteyeva, Health Psychologist, registrar program in Chronic pain management
This post is an intellectual property of the Melbourne Health Psychology Centre

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