Understanding Chronic Pain

About this resource

Chronic pain, usually defined as pain lasting more than three months, affects around one in five adults and is one of the most common reasons people are referred to psychological services. Many arrive believing that psychology has been offered because someone thinks the pain is imaginary. The first task is to explain, credibly and without condescension, that pain is always real, that it is produced by the nervous system rather than the injured tissue alone, and that in chronic pain the nervous system itself has often become the main driver.

This handout presents the biopsychosocial model of pain in plain language. It explains central sensitisation, the way the nervous system can turn up its volume so that pain persists after healing or arises from ordinary signals. It then introduces the fear-avoidance model described by Vlaeyen and Linton, in which catastrophic interpretations of pain lead to fear of movement, avoidance, deconditioning and low mood, all of which increase pain and disability over time. This sets up the rationale for graded activity, pacing and values-based engagement used in both CBT and ACT approaches.

The handout is written to be read before pacing or activity work begins. It does not promise that pain will go away; the aim is to help the person see that a different relationship with pain is possible and that what they do day to day influences the pain system. The professional version adds guidance on introducing the material to people who feel dismissed by the medical system, common objections and how to respond to them, and notes on when to involve the treating physician.

How to use it

1. Introduce this early, ideally in the first or second session, and read it together. Ask the client at the outset what they have been told about their pain and what they make of being referred to a psychologist or counsellor.
2. Explain the sensitised alarm idea using an example from the client's own life, such as pain that flares with stress or poor sleep rather than with activity.
3. Draw out the client's own fear-avoidance loop. Ask what they have stopped doing because of pain, what they fear would happen if they did it, and how their fitness, mood and confidence have changed as a result.
4. Use the final reflection section to capture what the client wants back: activities, roles, relationships. This feeds directly into pacing and goal setting (see Pacing Activity with Chronic Pain).
5. Where the client has an unresolved medical question, encourage them to raise it with their physician rather than trying to answer it yourself. Psychological work runs alongside medical care, not instead of it.

References

• Vlaeyen, J. W. S., & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art. Pain, 85(3), 317-332.
• Butler, D. S., & Moseley, G. L. (2013). Explain Pain (2nd ed.). Noigroup Publications.
• Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133(4), 581-624.
• Dahl, J., Wilson, K. G., Luciano, C., & Hayes, S. C. (2005). Acceptance and Commitment Therapy for Chronic Pain. Context Press.