The Seven (Difficult) Conversations I often have with clients during Chronic Pain sessions
For the skim-readers, this article includes:
A brief introduction into my experience working with Chronic Pain clients
A concise definition of what chronic pain involves
Seven common conversations including:
“I didn’t have that much pain at the time… but afterwards it hit me like a ton of bricks.”
“I haven’t been able to do anything - even resting hurts.”
“I’m taking my medication… but I’m still in pain”
“I feel like I’m about to snap.”
“I don’t feel like anyone believes me.”
“I’ve been recommended to have surgery… but it scares the **** out of me.”
“I don’t know if this will ever go away… I feel like I’ve tried everything.”
Across approximately eight years of practice as a Clinical Psychologist, chronic pain has been one of the most common presenting problems across multiple settings and organisations I have been a part of. While this makes sense based on the high prevalence of chronic pain (approximately 20% of the general adult population), the complexity, long-term nature, and challenges that surround the treatment of chronic pain initially took me by surprise.
Perhaps this was due to the relative lack of early training in this area (compared to the extensive training my cohort received on most mental health conditions). Over time, my naivety has faded. The number of clients who have presented for support with chronic pain would be too many to count. At the same time, I have navigated my own chronic pain journey, resulting from a knee injury that has lingered for almost three years. This has left me with some of the same challenges, dilemmas, and emotions that many of my clients have described.
Accordingly, I have found myself thinking about, talking about, and researching chronic pain with more reverence than earlier in my career.
This article seeks to explore some of the conversations that continue to occur with regularity, and hopefully shed some light on the common struggles, misconceptions, and barriers to recovery for anyone struggling with chronic pain.
This article is for educational purposes, and does not seek to offer professional advice or replace psychological or medical support.
What is Chronic Pain?
Pain could be thought of as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Chronic pain typically lasts for three months or longer, and well beyond the expected healing time for the injury or diagnosis thought to underlie the pain.
In brief, it can be helpful to think of pain as one of our body and brain’s many protective mechanisms for danger. Pain signals that something is imminently unsafe - to the point where our physical body has been (or is about to be) seriously injured. This typically leads to self-preservation behaviours, protecting us from further harm. It is crucial to recognise that self-preservation is the number one priority for all living organisms. In simple terms, your body and brain take pain very, very seriously - hence why it can be so difficult to override or reduce.
While not the purpose of this article, it’s important to mention that complex systems in the body and brain are involved in the perception of pain. The brain has the tremendously complicated task of interpreting signals from the body and processing the pain “message”, as well as integrating a huge array of external signals, past memories and experiences, and your own psychological belief system into the experience of pain.
The important lesson… pain is not simply the result of tissue damage. There are innumerable factors that can influence pain levels - for better or worse.
Continue reading for the common conversations I still find myself having in sessions focused on Chronic pain.
“I didn’t have that much pain at the time… but afterwards it hit me like a ton of bricks.”
Many people will experience injuries that (for a variety of reasons) may not be painful at the time, but get significantly worse in the hours or days afterwards. This can be common for back injuries: “I felt something pop or slip and got a bit of a twinge…but the next day it was 100x worse.”
A number of factors can play into this. The situational demands (e.g., a sports match, or being at work) can influence how your brain perceives pain. An altered internal state (e.g., adrenaline, or being “in shock”) can also influence pain perception.
A significant issue that can arise from this common injury and pain experience is that people may feel like they aren’t believed about how an injury occurred. Especially if an incident has occurred at work (and is the focus of an insurance claim), there can potentially be greater scrutiny and investigation into the cause of pain if a person didn’t seem distressed or in agony at the time. More on this below.
This can often cause increased stress, fear, self-doubt, and emotional distress, which inadvertently can increase dysfunction and pain levels. As such, education around how pain states can vary, and how the brain processes information and pain stimuli, can be invaluable.
“I haven’t been able to do anything - even resting hurts.”
The above statement will normally result either from a serious acute injury that is still in the healing phase, or chronic pain and a highly sensitised pain system. Either way, it means the person is likely getting minimal or no relief from their pain. This is often extremely threatening and stressful for the individual - and a huge warning sign for health practitioners. This experience may indicate a high risk for over-reliance on medication, or other potentially harmful methods to ease pain and get relief.
If you are reading this and are in a situation where there is minimal or no escape from pain, this is not normal beyond a short period after an injury, and may suggest that specialist rehabilitation services and pain management support are necessary.
Unfortunately, sometimes having more rest does not equate to more recovery - and getting expert guidance on this can help kickstart progress. The common cliche “Motion is Lotion!” is a good guiding principle for most recovery plans (but there are exceptions).
“I’m taking my medication… but I’m still in pain”
It is common to be prescribed some form of analgesic medication following an injury or if experiencing chronic pain.
Importantly, I am not trained or qualified to comment on the suitability of any given medication for Chronic Pain, and this is not part of my day-to-day role as a Clinical Psychologist. Medication decisions should always be made in consultation with your prescribing doctor. With that being said…
Medication can be an invaluable form of treatment, and may even be an ongoing component of treatment for chronic pain sufferers. Medication is practical, oftentimes effective at reducing pain, and relatively low-cost. It can have powerful psychological benefits (due to a sense of reassurance). Medication and the subsequent pain relief can enhance or speed up recovery if it allows for greater activity levels and engagement in rehabilitation exercises and activities (within safe limits).
Medication will also have some challenges and limitations. Importantly, medication may help with dampening pain signalling and sensation - but it will not heal and strengthen the body directly. Many pain medications also affect emotions, sleep, and other biological processes peripheral to pain. Like all substances, our bodies can develop tolerance, which can lead to over-medicating to achieve the desired effect. Some medications can impact the gut, stomach lining, and other internal organs. And, some medications will impact concentration and thinking, or cause fatigue and tiredness.
One of the biggest concerns is when an individual is over-relying on medication and not engaging in a physical rehabilitation plan or graded exposure process to help with improving strength, functioning, and/or self-efficacy.
Medication can be a valuable solution when it is embedded within a broader recovery plan that includes education, physical rehabilitation, nervous system retraining, and psychological strategies.
“I feel like I’m about to snap.”
It’s no secret that living in constant pain can drain patience, tolerance, and emotional wellbeing.
Many of my clients have shared their frustration and anger with their circumstances surrounding chronic pain. This could be directed at any one or a number of factors, including:
An organisation, person, or the subject of “blame” for an accident or injury
The medical system (if a person feels they haven’t accessed appropriate treatment)
An insurer, or other funding body that manages financial decisions, and approval for treatment providers
Specific treatment providers (including myself at times - despite my best efforts)
Friends, family, or the community - especially if feeling under-supported or invisible
A serious injury and chronic pain may also cause PTSD, and associated changes in how a person views themselves, others, and the world.
In essence, living in pain often causes severe emotional distress for which there is no easy outlet. Even people with fantastic support systems, positive resilience, and good emotional intelligence are not immune to this.
Psychological support to manage anger, frustration, stress, or PTSD that co-occurs with chronic pain can be invaluable in limiting the flow-on effect and damage caused by pain. Furthermore, support to manage the impact of pain/mental health on relationships and social life can also assist with lessening the total harm and disability associated with chronic pain.
“I don’t feel like anyone believes me.”
Pain can feel like an invisible burden - and is abstract to everyone but the beholder. Even with incredible advancements in technology (e.g., fMRI and other brain scanning techniques), which provide deeper understanding of the “brain map” and processes involved in pain perception, we still cannot fully appreciate what the experience of pain is like for another individual.
While an injury can be tested or examined with an xray, ultrasound, or other techniques, this is not an exact science! Furthermore, it is possible for nervous system changes to occur that can affect how pain is experienced - and these changes are extremely difficult to test for or validate. As such, we do not have a perfect test that can tell us “at 4:30pm, Jim had 7.6/10 pain in his left leg”.
Because of this, it is crucial to have a support team that takes time to ask good questions, listen, and understand your lived experience of pain. Feeling seen, believed, and having agreement on what solutions will help is a key foundation to any good treatment plan.
Sometimes, psychological support can also include strategies and communication tips to help people in situations where they feel unheard and unsupported.
“I’ve been recommended to have surgery… but it scares the **** out of me.”
The decision to undergo specialist surgery to alleviate pain can be a difficult choice. There can be a range of surgical options and approaches depending on the injury or presentation, and some are more invasive or carry more risks than others.
Seeking support and having the opportunity to discuss the pros, cons, and expected outcomes of a given surgery will help guide your decision-making. Asking medical specialists about the typical success rates, recovery timelines, and adjunctive rehabilitation approaches to complement surgery will also help with feeling more in control of the process.
Over the years, the clients I have worked with who appear to achieve better outcomes are those who follow their treatment plan prior to surgery. This may include medication usage, physical rehabilitation, holistic and lifestyle factors (including limiting alcohol intake and managing diet), and utilising other pain management strategies. These individuals often build a comprehensive understanding of holistic health principles, and can then continue with evidence-based rehabilitation in the aftermath of surgery.
Lastly, surgery may not be right for everyone, and if this is you, it is crucial to talk to your treating providers and discuss alternative rehabilitation options that seek to build strength, mobility, and endurance in the surrounding muscle groups and structures, and explore viable pain management strategies that have good outcomes and long-term sustainability.
“I don’t know if this will ever go away… I feel like I’ve tried everything.”
Waking up in pain, day after day, will inevitably get exhausting.
Hopelessness can be an understandable experience for anyone who feels they have tried everything to manage their pain, but to no avail. However, hopelessness can also be one of the biggest barriers to recovery, and lead to complex challenges that maintain or even exacerbate pain.
This is probably the most taboo topic of the whole article - but it is important to address. When pain gets overwhelming, life is falling apart, and nothing seems to help, it is extremely common for people to use substances or engage in behaviours that help to escape pain, even temporarily, at the expense of long-term recovery. Alcohol, cannabis, over-medicating, over-sleeping, or over-resting are understandable protective solutions when desperation sets in. Addictions can creep up, or emerge suddenly, when pain is severe and long-lasting, and mental health challenges are taking their toll.
Many people will experience a sense of shame or embarrassment around this. It is especially common for people to feel like they should be “stronger than pain” and be able to manage it - and this can lead to trying to hide some of the ways in which a person has learned to cope.
Years of clinical experience, and sitting with some very distressed, confused, and defeated clients, has taught me a lot about the challenges of chronic pain, as well as the difficulties of being vulnerable and asking for help when it feels like everything is falling apart.
It’s a repetitive theme —- but hopefully a reassuring one. Support is available for anyone who is struggling with managing pain, the emotional drain, hopelessness, or any one of many possible complications that can occur when pain is severe.
In Summary…
Each of the conversation points listed above is immensely complex - and takes time to talk through. Chronic pain is a really challenging experience to navigate, and can throw even the most resilient, upbeat, and emotionally stable person into deep water.
It is also complex enough that even well-trained, experienced clinicians still have a lot to learn and many skills to develop when working with people who experience chronic pain. It is important, at times, to give your clinician grace and understand that we also get stuck, and sometimes need time and further supervision, research, or training to clarify a suitable plan.
If you, or someone you know, is struggling with chronic pain and needs support to move forward in recovery and life, please feel free to reach out.
If you are experiencing a mental health crisis or are at risk of harm:
Call 000 or attend your nearest hospital emergency department
Lifeline: 13 11 14 (24 hours)
NSW Mental Health Access Line: 1800 011 511 (24 hours)
