Is "Therapy Nixes Pain" The New "It's All In Your Head"?
By Katarina Zulak
Every chronic pain patient has their version of this story—the one where a health practitioner tells you that the pain is "all in your head." For me, the first time occurred when a doctor told me that fibromyalgia was not a real disease, but the product of thinking wrong and "having a negative mental attitude toward your body." Fix your mind, fix your pain. I only wish it was that easy!
A recent study on treating chronic pain out of Boulder, Colorado received a lot of coverage in recent weeks. The headline for the article I first read was: "Psychological Treatment, Not Drugs, Provides Long-Lasting Relief to Chronic Pain." A press release for the study summarised the findings:
We found that two-thirds of chronic back pain patients who underwent a four-week psychological treatment called Pain Reprocessing Therapy (PRT) were pain-free or nearly pain-free post-treatment. And most maintained relief for one year. They also showed changes in pain-generating brain regions after therapy.[1]
The study proves that, in a small sample of 151 people with mild back pain, Pain Reprocessing Therapy (PRT) reduced pain intensity. PRT claims to shift your beliefs about the cause and threat value of chronic pain by framing pain as a "false alarm" rather than something dangerous. In helping patients to re-conceptualise their pain as a "reversible, brain-generated phenomenon," not ongoing physical damage, the study authors concluded PRT provides significant, durable pain relief.[2]
What Significance Do These Findings Actually Have For Pain Management?
This study opens the door to further investigation on how pain perceptions held by individuals with low back pain affect pain intensity, and how learning to reappraise pain sensations as safe may help reduce pain levels. However, this is a far cry from the 'revolution in how we understand and treat all forms of chronic pain' proclaimed in articles reporting on the study. We would need a sample size of thousands in different settings to confirm the findings that PRT can reduce mild low back pain. It is impossible to draw conclusions about how PRT would work for people with different pain conditions, like fibromyalgia, until a study is repeated in those populations.
It is valid to say that certain types of pain are not due to damaged tissue, but are disorders of the pain processing system. This is called 'central nervous system sensitisation' (you can think of it as saying pain is "all in the central nervous system") and it describes a process whereby nerve endings send more frequent or intense pain signals, in the absence of injury or inflammation, which are prioritised and amplified in the spinal cord, and finally interpreted as a significant, dangerous threat in the brain. However, this does not mean that thoughts or emotions solely cause physical pain sensations, or that pain is a psychological problem. That being said, teaching patients not to fear pain as a sign of bodily damage and degeneration, but as a misfiring alarm system, may reduce the threat and fear associated with pain sensations, and thus, the pain intensity.
Is 'Therapy Can Nix Chronic Pain' The New 'It's All In Your Head'?
People living with chronic pain spend 5 to 7 years being dismissed and disbelieved before they get an accurate diagnosis. This occurs in spite of the fact that an explosion of recent research confirms the very real physiological (bodily) dysfunction in patients with conditions like fibromyalgia, compared with healthy individuals. The primary way that chronic pain is explained away is as a "psychosomatic" disorder, occurring in depressed hypochondriacs—"it's all in your head." Health writers need to be very careful that their headlines don't dismiss chronic pain patients, and undo recent gains in validating these conditions as real, physical pathologies.
In addition, in the era of the opioid epidemic, people living with chronic pain have been stigmatised as drug-seekers. Effective medications are becoming harder to access for people living with intense pain, even for responsible, long-term prescription recipients with no sign of substance misuse, and even for non-addictive pain medications. Publishing headlines that suggest pain patients don't need medication, only therapy, is dangerous. It contributes to a narrative that directly leads to policies which are increasing the suffering of pain patients and worsening levels of disability, as daily functioning decreases.
Pain & Psychology
The researchers argue their results prove that psychological intervention directly reverses physical pain sensations. In this study, fMRI brain scans showed changed activity in brain regions associated with processing pain. Despite this, the researchers state further research is needed to accurately interpret the brain changes, because the impact of the changes is unclear.
We need to distinguish between the emotional dimension of pain, governed by brain regions responsible for emotional processing, and the physical sensations of pain, sent via the central nervous system to sensory processing brain regions. Emotions and pain have a reciprocal relationship.[3] For example, we know emotions affect the perception of pain (positive emotions reduce pain and negative emotions amplify pain). Similarly, the cognitive dimension of pain–our expectations of it, how we compare it to memories of past pain–also colour how we perceive our physical pain sensations, particularly if the threat detection brain regions, like the amygdala, are activated. But the mechanisms underlying the interrelationship between emotion and pain are poorly understood, and the PRT study does not add new understanding, or prove that psychology alone can 'fix' pain.
I think it is misleading and potentially harmful to suggest that psychological interventions can fix or cure chronic pain, as some recent health headlines do (ex. "How therapy, not pills, can nix chronic pain"). After all, fibromyalgia has been discredited as a fake, "all in your head" illness for years, which "unduly lead[s] to a 'psychologisation' of physical complaints."[4] This occurs despite an exploding body of research to the contrary, such as that fibromyalgia causes small fibre neuropathy,[5] and immune dysregulation.[6] The body-wide changes observed in fibromyalgia directly contradict any hypothesis that this chronic pain disorder is purely a "reversible brain-generated phenomenon."
How Media Stereotypes Shape the 'Realness' of Pain
The health headline for one medical news website stated "Psychology, not Pills Provide Long-lasting Pain Relief", setting it up as one or the other, psychology vs. drugs, whereas the research article had the much tamer name "Effect of Pain Reprocessing Therapy vs. Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial" (albeit, in a psychiatry journal).[7] As you can clearly see, the health website jumped to an extreme interpretation of the findings, from PRT to all psychology, from low-back pain to all chronic pain, and from saying PRT was more effective than usual care or placebo, to saying psychology 'nixes' all pain and pills do absolutely nothing.
If you wrote a headline proclaiming 'New Study Shows Essential Oils, Not Pills, Provide Pain Relief,' the response would be a raised eyebrow. Yet, a similarly designed placebo-controlled study found that applying lavender essential oil while doing acupressure point therapy on participants with low back pain significantly reduced pain levels.[8] It included 131 participants, divided into a treatment and control group, who received eight acupressure sessions over four weeks. Regardless of how effective lavender oil acupressure is for pain relief, no one would suggest throwing out science-backed medications in favour of essential oils.
I make this comparison only to show how narratives about the 'realness' of chronic pain, and the stereotype of the drug-addicted hypochondriac shape how we talk about psychology, medications, and pain, especially in the media. We need to be clear-eyed about the limitations of all studies, and maintain a healthy dose of scepticism about all findings.
A Critical Reading Of Scientific Research
As critical readers, it is useful to check at the bottom of the journal article for conflict of interest disclosures. The lead authors of this study, Dr. Ashar and Alan Gordon, receive personal fees from the Pain Reprocessing Therapy Centre, which offers for profit US workshops to train healthcare professionals in PRT. To my mind, it was also rather gimmicky and unscientific that the first patient fMRI was televised on an American medical talk show called The Doctors.[9]
There is no conflict of interest regarding funding or publication of the study, or suggestion that the results are inaccurate in any way. However, when a study is designed and conducted by researchers who have a financial stake in the medical intervention being tested, we need to have the findings confirmed by repeating the study. Replication, an established part of the scientific method, means: "the repetition of a research study, generally with different situations and different subjects, to determine if the basic findings of the original study can be applied to other participants and circumstances."[10] For context, in 2015, researchers attempted to repeat 100 psychology studies to see if they could obtain the same results as the originals, but 61% of the studies could not replicate the findings of the original studies.[11] Thus, although this research opens the door to further investigation on the role of psychology in pain management, it is clear that this is only a preliminary finding, not a paradigm shift in pain medicine, as described in many recent media articles.
[1] https://www.colorado.edu/today/2021/09/29/how-therapy-not-pills-can-nix-chronic-pain-and-change-brain
[2] ibid.
[3] Vadivelu, Nalini et al. “Pain and Psychology-A Reciprocal Relationship.” The Ochsner journal vol. 17,2 (2017): 173-180.
[4] Crombez, Geert et al. “The unbearable lightness of somatisation: a systematic review of the concept of somatisation in empirical studies of pain.” Pain vol. 145,1-2 (2009): 31-5. doi:10.1016/j.pain.2009.04.006
[5] https://www.verywellhealth.com/small-fiber-neuropathy-may-cause-fibromyalgia-pain-3972935#:~:text=A%20small%20study%20has%20linked,not%20to%20actual%20nerve%20damage.
[6] https://skillfullywell.com/2021/07/09/fibromyalgia-as-an-autoimmune-disorder-the-new-study-changing-everything-we-thought-we-knew/
[7] Ashar YK, Gordon A, Schubiner H, et al. Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial. JAMA Psychiatry. Published online September 29, 2021. doi:10.1001/jamapsychiatry.2021.2669
[8] Yip, Y B, and S H M Tse. “The effectiveness of relaxation acupoint stimulation and acupressure with aromatic lavender essential oil for non-specific low back pain in Hong Kong: a randomised controlled trial.” Complementary therapies in medicine vol. 12,1 (2004): 28-37
[9] https://www.painpsychologycenter.com/our-team.html
[10] https://www.verywellmind.com/what-is-replication-2795802#:~:text=When%20studies%20are%20replicated%20and,generalized%20to%20the%20larger%20population.
[11] ibid.