What is pain?
Pain… pain is something we all know well, but how could we define it? Put simply, pain is an unpleasant feeling caused by an averse or damaging stimuli. Pain can be both physical and/or psychological. Pain can be vaguely distinguished into two different types: acute and chronic. Acute pain can last anywhere from a millisecond to roughly 3 months, and tends to subside when the averse stimuli subsides. Chronic pain lasts from 3 to over 6 months and often persists even when the averse stimuli subsides. Psychological pain is often chronic in nature (Treede et al., 2015) and often requires psychological techniques to mitigate it. Here are 3 such techniques:
1. Cognitive Behavioural Therapy
CBT has been shown to be an effective psychological technique for alleviating pain. This is because it focuses on changing two different areas of a person’s being, namely their cognition and behaviour. CBT’s founder Dr. Aaron T. Beck (1967) originally devised CBT as an approach to treating clinical depression, but CBT’s applications have turned out to be much broader than this. The CBT approach argues that life’s misfortunes are out of our control, and this understandably makes us feel angry, depressed, resentful, upset etc. However, we can control our thoughts about what happens to us and we can control our behaviour; in turn, our thoughts and behaviours can influence our feelings and we can gradually feel better about things. The diagram below displays this cycle nicely:
The centre triangle signifies 3 beliefs each person has about themselves - are they a good person, are others good and are their future prospects good?
Image sourced from https://it.wikipedia.org/wiki/File:Cognitive_behavioral_therapy_-_basic_tenets.svg
This method of changing a person’s thoughts about and behaviours surrounding pain can help alleviate pain. This seems to apply to acute, chronic, physical and psychological pain, although research into and meta-analysis on physical pain is very complex and not well documented. What is better documented is CBT’s effectiveness at alleviating chronic physical pain. Turner & Clancy (1988) showed that CBT had a significant effect on improving symptoms of lower back pain in patients – this included after a 12 month check-up period. A potential design flaw in this study was operant conditioning also seemed to work just as effectively as CBT, which calls into question issues with a between-subject design or CBT’s effectiveness. Nevertheless, it is an insightful finding that’s not to be sniffed at.
CBT’s effectiveness at alleviating psychological pain is much more well documented and has been shown to improve symptoms of depression, anxiety disorders, substance abuse disorders, eating disorders and impulse disorders (Agras & Bohon, 2021; McKay et al., 2015.) This is a particularly interesting finding considering clinical depression is sometimes conceptualised as a ‘pain’ state (Overview - Clinical Depression, 2019.)
Some argue that psychological pain is as real as physical pain. This is hauntingly captured by Vincent van Gogh in his illustration 'Sorrow.' (1882)
Image sourced from https://commons.wikimedia.org/wiki/File:Vincent_van_Gogh_-_Sorrow_-_F929_JH129.jpg
2. Mindfulness
Mindfulness is another useful way of mitigating pain that has scientific backing behind it. Mindfulness is the ability to view things from a mindful perspective – it involves being aware of the present moment, of one’s own body, thoughts, feelings, emotions and aware of one’s daily activities. Another way of conceptualising mindfulness is it’s the opposite of autopilot or automatic processes. Instead of brushing your teeth without really thinking about it, being mindful would mean paying attention to how you’re brushing your teeth, the taste of the toothpaste, the sound of brushing, noticing the thoughts that enter your mind etc. In other words, being fully in the present moment, no matter how mundane. From my experience, life can become unusually dynamic and interesting when one lives mindfully.
The Buddha is attributed with saying:
“If we could see the miracle of a single flower clearly our whole life would change.”
Image sourced from https://pixnio.com/flora-plants/flowers/wildflowers-pictures/detailed-image-of-the-interior-of-a-pink-flower
Mindfulness’ emphasis on accepting every stimulus in the present without judgement or aversion but with pure awareness can help untie the natural negative reactions we have to pain. A meta-analysis of 16 studies concluded that mindfulness reduces the intensity of chronic pain over a sustained period of time (Reiner, Tibi and Lipsitz, 2013.) However, another literature review showed that mindfulness interventions are not as effective on a short-term basis (McClintock et al., 2019.) These researchers concluded that short-term mindfulness interventions should not be recommended as a first-line treatment for acute or chronic pain conditions.
Some would argue that McClintock’s et al. (2019) study does not account for individual differences well because it is a broad-based literature review of mainly quantitative studies. Mindfulness is an individual journey for every person to undertake and its benefits will benefit each and every person differently. To hammer this point further, mindfulness-based pain management (MBPM) is a mindfulness program catered to people with acute and chronic pain conditions. Its efficacy has been demonstrated by several clinical studies (Long et al., 2016; Lopes et al., 2019; Mehan & Morris, 2018.)
3. Hypnosis
Hypnosis is the most controversial of the 3 techniques here. Despite its controversial nature there is compelling evidence that it’s a very useful psychological tool for pain relief. Put simply, hypnosis is a psychological state where a person is intently focused, has reduced peripheral awareness and is more open to suggestion. This can be a powerful way of reappraising pain for a sufferer.
James Coates demonstrating Braid's 'upwards and inwards squint' method. It is a way to divert somebody's attention to a single thing, in this case a pendant, which seems to make the subject more open to suggestion.
Image sourced from https://en.wikipedia.org/wiki/Hypnosis#/media/File:Braid's_ %22upwards_and_inwards_squint%22_induction_method.tif
Hypnosis seems to be effective at mitigating some painful physiological issues, including menopause symptoms and IBS (Elkins et al., 2013; Peters et al., 2016.) It’s also helped reduce the symptoms of pain experienced during harmful medical procedures performed on children and adolescents (Accardi & Milling, 2009.) These are compelling findings, but it’d be wise to keep in mind some limitations these studies have. A literature review on this topic pointed out some shortcomings these studies have, including small sample sizes, skewed power calculations and a lack of credible control subjects (Elkins, Jensen and Patterson, 2007.) However, this review concluded that there is strong evidence that hypnosis does help mitigate pain, but more research is needed to clarify how it achieves this and how effective it is on different pain conditions. To me, this critical literature review concedes that hypnosis has a beneficial effect on people, despite trying to show the opposite to be true. It’s compelling evidence that hypnosis is a useful tool for mitigating pain, albeit not a well understood one yet.
These psychological techniques demonstrate that pain relief is not just a neurological or biological problem, but there is also a huge psychological dimension at play. Pain management requires not only discipline, self-compassion and medicine when necessary, but also requires one’s own resources, wits and willpower to overcome it.
References
Accardi M.C. & Milling L.S. (August 2009). The effectiveness of hypnosis for reducing procedure-related pain in children and adolescents: a comprehensive methodological review. Journal of Behavioral Medicine 32(4). 328–39. doi: 10.1007/s10865-009-9207-6
Agras, W.S. & Bohon, C. (7 May 2021). Cognitive Behavioral Therapy for the Eating Disorders. Annual Review of Clinical Psychology 17(1). 417–438. doi: 10.1146/annurev-clinpsy-081219-110907
Beck, A.T. (1967). The diagnosis and management of depression. University of Pennsylvania Press.
Elkins G., Jensen M.P., Patterson D.R. (July 2007). Hypnotherapy for the management of chronic pain. The International Journal of Clinical and Experimental Hypnosis 55(3). 275–87. doi: 10.1080/00207140701338621
Elkins G.R., Fisher W.I., Johnson, A.K., Carpenter J.S. and Keith T.Z. (March 2013). Clinical Hypnosis in the Treatment of Post-Menopausal Hot Flashes: A Randomized Controlled Trial. Menopause 20(3). 291–298. doi: 10.1097/GME.0b013e31826ce3ed
Long J., Briggs M., Long A. and Astin, F. (2016). Starting Where I Am: A Grounded Theory Exploration of Mindfulness as a Facilitator of Transition in Living With a Long-Term Condition. Journal of Advanced Nursing 72(10). 2445–56. doi: 10.1111/jan.12998
Lopes, S.A., Vannucchi, B.P., Demarzo M., Cunha Â., Geraldo J. and Nunes M.D.P.T. (2019). Effectiveness of a Mindfulness-Based Intervention in the Management of Musculoskeletal Pain in Nursing Workers. Pain Management Nursing 20(1). 32–38. doi: 10.1016/j.pmn.2018.02.065
McClintock A.S., McCarrick S.M., Garland E.L., Zeidan F. and Zgierska A.E. (March 2019). Brief Mindfulness-Based Interventions for Acute and Chronic Pain: A Systematic Review. Journal of Alternative and Complementary Medicine 25(3). 265–278. doi: 10.1089/acm.2018.0351
McKay D., Sookman D., Neziroglu F., Wilhelm S., Stein D.J., Kyrios M., et al. (February 2015). Efficacy of cognitive-behavioral therapy for obsessive-compulsive disorder. Psychiatry Research 225(3). 236–46. doi: 10.1016/j.psychres.2014.11.058
Mehan S. & Morris J. (2018). A literature review of Breathworks and mindfulness intervention. British Journal of Healthcare Management 24(5). 235–241. doi: 10.12968/bjhc.2018.24.5.235
Overview - Clinical depression. (December 10 2019). NHS. Retrieved May 13, 2022, from https://www.nhs.uk/mental-health/conditions/clinical-depression/overview/
Peters, S.L., Yao, C.K., Philpott, H., Yelland, G.W., Muir, J.G. and Gibson, P.R. (2016). Randomised clinical trial: the efficacy of gut-directed hypnotherapy is similar to that of the low FODMAP diet for the treatment of irritable bowel syndrome. Alimentary Pharmacology & Therapeutics 44(5). 447–459. doi: 10.1111/apt.13706
Reiner K., Tibi L, and Lipsitz J.D. (February 2013). Do mindfulness-based interventions reduce pain intensity? A critical review of the literature. Pain Medicine 14(2). 230–42. doi: 10.1111/pme.12006
Treede R.D., Rief W., Barke A., Aziz Q., Bennett M.I., Benoliel R. et al. (June 2015). A classification of chronic pain for ICD-11. Pain 156(6). 1003–1007. doi: 10.1097/j.pain.0000000000000160
Turner J.A. & Clancy S. (April 1988). Comparison of operant behavioral and cognitive-behavioral group treatment for chronic low back pain. Journal of Consulting and Clinical Psychology 56(2). 261–6. doi: 10.1037/0022-006x.56.2.261