Chronic Pain: Behavioral Management

A biopsychosocial framework for pain treatment is increasingly valued, as healthcare professionals are encouraged to engage in shared decision making to adequately understand individuals’ unique experiences and support their active management of chronic pain.^1,2 Interest in incorporating behavioral approaches into pain care has grown in recent years, in part because of the shifting emphasis on evidence-based nonpharmacologic approaches. Unfortunately, much of the literature on behavioral pain management remains overly specific to mental health clinicians and places too much emphasis on relationships between psychopathology and comorbid pain symptoms. Few resources provide accessible information for medical providers on strategies that, if implemented early, provide a foundation for more successful pain management. The purpose of this article is to provide guidance for how to add core behavioral approaches into routine care that can concurrently address complex symptoms related to pain and mood, enhance motivation to engage in meaningful activities, and improve pain treatment outcomes.

When pain persists over time, the system becomes overly sensitive, and pain is more likely to be debilitating, negatively impacting overall function and mood. Although there are various behavioral approaches for pain, cognitive behavioral therapy (CBT) is the gold standard^3-5 and recommended as a first-line treatment.^6,7 The use of cognitive behavioral principles emphasizes a person changing their response to and relationship with pain.⁸ Treatment with CBT includes focused skill-building and basic pain psychoeducation, often incorporating details of neurophysiologic pain processing by the nervous system (See Understanding Pain in this issue). These approaches are useful when discussing the complex pain experience that includes how mood, stress and autonomic responses, and pain-related intensity interact.^9,10 The goal of behavioral pain management is to empower patients with a better understanding of pain and a skill set to minimize and manage related symptoms. Importantly, these techniques can be implemented by a diverse variety of healthcare professionals across different care settings. We present 2 scenarios for how behavioral strategies can be used in a variety of real-world interactions between a person with pain and their physician (Case 1 and Case 2).

The Complexity of Pain

People who seek care for chronic pain often do so with the expectation and hope that clinicians can deliver a treatment that will eliminate their pain symptoms. This stems from a biomechanical reductionistic view of pain that does not reflect its complexity. The pain experience is much more than sensory descriptors, significantly interacting with mood, behaviors, and beliefs. Chronic pain is not merely a physical symptom of underlying tissue pathology, but a condition in and of itself,¹⁵ requiring a whole-person assessment and behavioral prescriptions. By acknowledging the association between pain, psychosocial stress, and mood symptoms, we may more effectively communicate that their pain experience is both valid and valued. Although comprehensive care can be delivered by multiple disciplines working together collaboratively,¹⁶ these messages can and should be delivered by all providers early and often to establish the biopsychosocial framework as the prevailing approach for successful chronic pain management. This approach empowers those seeking care by underscoring the complex nature of chronic pain while appreciating the role of behavior in response to pain and the value of self-management skills. Education about the physiologic and psychologic relationships relevant to pain and mood assist with expectations, allowing more reasonable goals to improve overall function, and enhance motivation necessary to take charge of pain.

The cases provided show how skills can be incorporated seamlessly into care. For Mr. Shockley, his provider shared that behavioral change is necessary for him to return to valued activities despite his pain, which helped him adjust his expectations. His frustration with unsuccessful attempts to return to important activities was acknowledged, facilitating collaboration on a specific plan for how he might safely reengage. Furthermore, the role of mood and emotion was acknowledged and normalized. Similarly, Ms. Chen’s provider focused on being empathic and highlighting the empowering role of self-managed techniques. Despite her skepticism, Ms. Chen learned a valuable skill to manage pain and stress, and the message about its ability to calm the nervous system was received.

Biopsychosocial Approaches Are Needed

At the heart of effective pain management is the biopsychosocial approach, in which we not only examine physical pathology but also actively address pain-related thoughts and behaviors. Too often, individuals are sent to a mental health provider with expertise in pain management only after years of suffering. Rather than adopting a “referral only” approach, medical providers can include core behavioral strategies for managing pain and stress as a foundation for most encounters addressing pain. It is important to note, in instances where mental health symptoms are severe or there is concern for patient safety, general mental health referrals are often necessary. In general, however, all providers should include the suggested approaches early in treatment or when taking over care for those who live with chronic pain. Resistance to beneficial behavioral changes is likely to be encountered, as patients may expect “silver bullet” solutions to come in the form of prescription medications or interventional procedures. Yet, when physicians promote investing energy into behavior change—by discussing pain from a biopsychosocial model that is complex and requires collaboration—patients are more likely to “buy-in” and be more willing to engage in self-care. This reduces the burden for people with pain and those who care for them.