Behavioral Health Approaches to Pain Management

Pain is a multidimensional problem ranging from discomfort to agony and affecting physical, emotional, and cognitive function as well as interpersonal relationships and social roles. In this section you will learn more about pain, its causes, evaluation and treatment utilizing behavioral health interventions.

Behavioral health interventions can be effective in improving clinical outcomes for pain, but treatment should be tailored to address patient preferences and needs. This tailoring requires careful assessment of patients’ pain perceptions, cognitive and emotional responses, coping skills, and social and environmental status. It also requires accurate diagnosis of comorbid psychosocial concerns.

Effective pain management, particularly for chronic pain, is best achieved using a patient-centered, multidisciplinary, multimodal, integrated approach that may include behavioral health approaches .

Behavioral therapy (BT) for pain treatment focuses largely on applying the principles of operant conditioning to identify and reduce maladaptive pain behaviors (e.g., fear avoidance) and increase adaptive or “well” behaviors. This improvement is achieved by minimizing reinforcement of maladaptive behaviors, providing reinforcement of well behaviors, and reducing avoidance behaviors through gradual exposure to the fear-provoking stimuli (e.g., exercise).

Cognitive behavioral therapy (CBT) aims to reduce maladaptive behavior and improve overall functioning. However, in addition to focusing on altering behavioral responses to pain, CBT focuses on shifting cognitions and improving pain coping skills.

Acceptance and commitment therapy (ACT) is a form of CBT that emphasizes observing and accepting thoughts and feelings, living in the present moment, and behaving in a manner that serves an individual’s chosen values. Unlike traditional CBT approaches, ACT focuses on creating psychological flexibility through acceptance of psychological and physical experiences rather than by challenging them.

Mindfulness-based stress reduction (MBSR) is a mind-body treatment developed by Jon Kabat-Zinn typically delivered in a group format that focuses on improving patients’ awareness and acceptance of their physical and psychological experiences through intensive training in mindfulness meditation. Mindfulness meditation teaches patients to self-regulate their pain and pain-related comorbidities by developing nonjudgmental awareness and acceptance of present moment sensations, emotions, and thoughts.

Emotional awareness and expression therapy (EAET) is an emotion-focused therapy for patients with a history of trauma or psychosocial adversity who suffer from centralized pain conditions. In this approach, patients are taught to understand that their pain is exacerbated or maintained by unresolved emotional experiences that influence neural pathways involved in pain. Patients are taught to become aware of these unresolved experiences, which include suppressed or avoided trauma, adversity, and conflict, and to adaptively express their emotions related to these experiences. Patients learn that control over pain can be achieved through emotional awareness and expression. Enhancing the patient’s capacity to approach and experience rather than inhibit or avoid important emotions and interpersonal interactions leads to increased engagement in life activities.

Self-regulatory or psychophysiological approaches include treatments such as biofeedback, relaxation training, and hypnotherapy. These approaches use the mind-body connection to help patients with pain develop control over their physiologic and psychological responses to pain.

Biofeedback entails monitoring and providing real-time feedback about physiologic functions associated with the pain experience (e.g., heart rate, muscle tension, skin conductance). The overall goal of biofeedback is to improve awareness and voluntary control over bodily reactions associated with pain exacerbations.286 The use of biofeedback training has been shown effective for chronic headache and migraine in adults and children.287

Relaxation training and hypnotherapy involve altering attentional processes and heightening the experience of physical and psychological relaxation. Relaxation training is often used in conjunction with biofeedback to increase physiological awareness and enhance relaxation skills. Both of these approaches have empirical support in pain management.