September is Pain Awareness Month in the United States. One important reality of chronic pain that is rarely acknowledged is this: chronic pain doesn’t just result in suffering in the body. 

Beyond the aching muscles, flaring nerves, and cracking joints, there are other wounds: reduced livelihood, lost opportunities, changed relationships, confused identities, altered plans, and a fading sense of purpose and hope. 

These experiences beyond the physical pain itself are often overlooked by the healthcare teams of people who live with chronic pain. Research clearly demonstrates that living with chronic pain can have profound impacts on almost every aspect of life, including physical, mental, social, professional, and even spiritual experiences. These experiences are real, they matter, and they deserve evidence-based, trauma-informed care. 

Fortunately, psychotherapy for chronic pain exists—and psychological science tells us is safe, effective, and reduces both physical and psychological suffering for those with chronic pain. Aviva Psychology Services offers a specialty Chronic Pain Clinic, and we’ve written before about how we can help you Live Well With Chronic Pain. In this article, we’ll explore the impacts of chronic pain and three approaches to therapy that can help. 

What Is Chronic Pain? 

Chronic pain is one of two types of pain we experience. The other type of pain, acute pain, is something that all humans experience throughout life. 

Acute pain is the pain of every illness and injuries. If you’ve ever had a sunburn, stubbed your toe, felt a little achy when you had the flu, broken a bone, or dealt with pain during recovery from a surgery, you have experienced acute pain. By definition, acute pain is short term. It lasts only until we have healed, either naturally or with the help of medical treatment. When the illness or injury is gone, acute pain is gone, too. 

Chronic pain is different: it persists. Chronic pain may persist even after receiving medical treatment, even after we’ve had adequate time to heal, or when there is no treatment available for a particular medical condition. Chronic pain may develop as part of a medical condition like arthritis, lupus, or endometriosis. It may also develop after an injury, even one that appears resolved based on imaging like X-rays or MRIs. Some chronic pain has an unknown cause. 

Chronic pain is also extremely variable across people and may vary for one person over time. For example, chronic pain may be:

• Mild, moderate, or severe—even incapacitating 
• Localized to certain body parts or spread throughout the body 
• Consistent and predicable 
• Fluctuating in response to known triggers 
• Fluctuating without clear, identifiable triggers 
• Of any quality: aching, burning, pins-and-needles, stabbing, etc. 

Unfortunately, chronic pain is very common. Research to date suggests it impacts between 1 in 5 to 1 in 4 Americans. However, it does not impact all people equally. Chronic pain is more common among:

• Women than men
• Military veterans than civilians 
• Indigenous Americans and Alaskan Natives than other racial/ethnic groups 
• Disabled people than non-disabled people 
• Chronically ill people than those without chronic health conditions 
• People who work manual labor jobs, including athletes 

How Can Therapy Help? 

Chronic pain is a physical problem, but it has profound impacts on our mental health by impacting our physical, psychological, social, professional, and even spiritual experiences. People living with chronic pain are at higher risk of psychological conditions like depression and anxiety, frequently lack financial resources to support a sense of stability in society, and are often subjected to social isolation as a result of their limitations and needs. 

For most people living with chronic pain, their treatment plans will be complex, ever-changing, and multifaceted. They are likely to include a mix of interventions, such as: 

• Lifestyle changes, like modifying physical activity, diet, or substance use 
• Medications, such as NSAIDs, muscle relaxers, and opioids 
• Medical procedures such as surgeries and injections 
• Physical or occupational therapy
• Assistive devices like canes, wheelchairs, braces, and heating pads
• Psychological interventions, including therapy 

Most people who experience chronic pain develop a unique pain management plan that integrates multiple forms of the interventions above. There is no “one size fits all” approach to chronic pain management. 

Broadly speaking, the therapy with the strongest research support for helping with chronic pain is cognitive behavioral therapy, for CBT for short. Cognitive Behavioral Therapy, also called CBT, is a broad category of therapy that involves understanding and leveraging the relationship between our thoughts, feelings, and behaviors. 

CBT recognizes that we develop our habits of thought and habits of behavior for understandable reasons, including our culture, education, trauma history, relationship history, and our medical history—which includes chronic pain! 

CBT does not suggest that these learned thoughts and behaviors are wrong. In fact, CBT honors them as evidence of our incredible ability to adapt and survive. However, CBT also recognizes that habits shaped by our past may not always serve us well in our present. Sometimes we want to live differently than we did in the past, such as learning new ways to navigate the world after developing chronic pain. 

At Aviva Psychology Services, there are multiple forms of CBT available to help people learn to live well with chronic pain. Each offers unique benefits, has a slightly different style, and can be custom-tailored to fit individual needs. 

What To Expect in CBT for Chronic Pain (CBT-CP)

The type of CBT with the strongest research evidence is simply called CBT for chronic pain or CBT-CP for short. 

CBT is a highly structured program of therapy, typically involving 10-15 weekly appointments. In CBT-CP, you and your psychologist will progress through a series of modules designed to help you learn practical, effective ways of managing chronic pain. 

CBT-CP focuses on helping you understand how our thoughts, emotions, and behaviors are related to our experiences of chronic pain. For example, you’ll learn how the brain uses overlapping regions for both emotional and physical pain, meaning the presence of one can intensify the experience of the other. Using biology, psychology, and neuroscience, CBT-CP teaches strategies for working with your body—both the physical and psychological aspects—to reduce the impact of chronic pain on your daily life. 

CBT-CP teaches strategies like relaxation training, pacing techniques to reduce recurrent experiences of “overdoing it,” and methods of improving mood and sleep. CBT-CP offers practical, specific strategies you can implement right away rather than a focus on the past.

Overall, CBT-CP is a great fit for clients who prefer structured, short-term, evidence-based, action-oriented, and highly practical approaches to therapy. While customized to each individual client, it is a less flexible therapy than ACT or DAT (both described below) and tends to feel more “brisk” in pace. 

What To Expect in Acceptance and Commitment Therapy (ACT) for Chronic Pain 

Acceptance and Commitment Therapy, called ACT for short, is another form of CBT. Like CBT-CP, ACT has robust research support for managing chronic pain, but it uses a very different approach. ACT focuses on building a rich, meaningful life even while chronic pain is present. 

ACT theorizes that when we try to control our internal experiences, like thoughts and emotions, we actually become more entangled in them. Like quicksand, the more we struggle, the faster we sink. To help us break free of this suffering, ACT teaches several ways to increase our psychological flexibility rather than increase our control strategies. 

In ACT, you will learn about concepts like radical acceptance, which means honoring our experience by acknowledging it fully, without judging it, regardless of whether our experience is wanted or unwanted, pleasant or painful. In this way, we experience freedom from struggling with our own mind. ACT also teaches mindfulness and defusion,  both of which allow us to “step back” from thoughts, emotions, and sensations rather than be swept away by them. 

ACT also pays close attention to your personal values, which will be used to customize ACT to fit you as an individual and will guide the therapeutic process. In ACT, values are considered different from goals. Goals are specific to-do list items, like going to the gym. Values are the reasons behind our goals, like health or independence, which can be pursued in a multitude of ways, including but not limited to going to the gym. 

Ultimately, ACT for chronic pain is about learning to step out of the struggle with our mind, to fully accept the reality of our body, and committing to make values-consistent choices. Some of the choices we have are big, and some are very small, but ACT says they all matter.

Overall, ACT is a great fit for clients who prefer evidence-based therapy that is highly flexible, explores internal experiences without asking you to change them, and that focuses on building a rich, meaningful life even while chronic pain is present. ACT can be both fairly short-term (such as six months or so) or support long-term therapy. 

What To Expect in Disability Affirmative Therapy (D-AT) for Chronic Pain

Unlike CBT-CP and more like ACT, Disability Affirmative Therapy (D-AT) is a framework for therapy rather than a specific therapeutic program. Because many people with chronic pain consider themselves disabled by the chronic pain or by other health conditions, D-AT can be an appealing and enriching therapeutic style. 

D-AT is an approach to therapy that integrates a client’s disability into therapy without hyperfocusing it on it and making it “the only thing that matters” and without dismissing its profound impacts. D-AT is highly sensitive to context, such as how disability interacts with other aspects of client identity like race, gender, or sexual orientation. 

In D-AT, there is explicit space and support to develop a sense of identity and empowerment as a disabled person. Topics like ableism and microaggressions aren’t taboo; they’re a given. D-AT creates a collaborative space to explore your personal history—medical, educational, political, relational, trauma, and more—and to build insight and meaning about these experiences and the narrative you tell about it. 

Overall, D-AT is a great fit for clients who identify as disabled, whether by chronic pain or secondary to another experience. It is a highly-flexible approach to therapy that can easily integrate other forms of therapy, such as CBT-CP, ACT, or Narrative Therapy. Simply put, other forms of therapy can be applied in a D-AT manner. Because D-AT is so flexible and can be combined with other styles of therapy, it supports both short-term and long-term therapy. 

Starting Therapy for Chronic Pain

Chronic pain can be life-altering, isolating, and overwhelming. You don’t have to face it alone, and medical interventions aren’t the only option! 

Psychologists at Aviva Psychology Services are trained in evidence-based, trauma-informed therapies for chronic pain. In addition to the treatment plan you’ve developed with your medical team, therapy can improve your pain management plan, enrich your quality of life, and help the journey feel a little less lonely. 

You can get connected with a psychologist who has expertise in chronic pain by filling out the Request an Appointment form.

Selected References and Additional Reading:

Bogart, K. R. (2023). Disability is a social identity. It's time for therapy to affirm it. Developmental Medicine & Child Neurology, 65(3).

Conner, K. J., Acosta, V. M., Nouri, R., Tyler von Wrangel, M., Gramillo, E., & Conner, A. (2023). Psychotherapy experiences of US adults with physical disabilities: Recommendations for affirmative practice. The Counseling Psychologist, 51(7), 970-1004. 

McCracken, L. M., Yu, L., & Vowles, K. E. (2022). New generation psychological treatments in chronic pain. The BMJ, 376, Article e057212. https://doi.org/10.1136/bmj-2021-057212 

Olkin, R. (2017). Disability-affirmative therapy: A case formulation template for clients with disabilities. Oxford University Press.

Perry G. Fine, Long-Term Consequences of Chronic Pain: Mounting Evidence for Pain as a Neurological Disease and Parallels with Other Chronic Disease States, Pain Medicine, Volume 12, Issue 7, July 2011, Pages 996–1004, https://doi.org/10.1111/j.1526-4637.2011.01187.x

Wall, D. (2021, February 28). Chronic Pain | Fact Sheet - ABCT - Association for Behavioral and Cognitive Therapies. ABCT - Association for Behavioral and Cognitive Therapies. https://www.abct.org/fact-sheets/chronic-pain/ 

Ward, A. (Host). (2022, November 10). Dolorology (PAIN) with Dr. Rachel Zoffness. Episode 228. Ologies with Allie Ward. https://www.alieward.com/ologies/dolorology 

Wetherell, J. L., Afari, N., Rutledge, T., Sorrell, J. T., Stoddard, J. A., Petkus, A. J., ... & Atkinson, J. H. (2011). A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain, 152(9), 2098-2107.