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Your Invitation
What is this booklet based on and what does it invite me into?
The content of this invitation, understanding pain through psychology, has been developed in collaboration with the psychological community practice "Psychologists Gera," based on scientific findings from pain therapy. This can provide you with an even better understanding of psychological backgrounds and allow easier access to knowledge in dealing with pain. All exercises, content, and applications that you wish to use for your personal pain management are used solely at your own responsibility.
We invite you to take on this responsibility. We understand that understanding alone cannot address your worries. However, we still believe that you can set things in motion if you approach the information, methods, and exercises openly and persistently use your knowledge and application spectrum.
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The Painful Stress
What does stress have to do with pain, anyway?
Stress and chronic pain interact with each other. A stressful life, for example, increases the risk of chronic illnesses. At the same time, chronic pain can contribute to psychosocial stress (e.g., being overwhelmed, conflicts, fear, isolation, or anger over trivial matters).
Moreover, persistent physical and mental stress results in changes to biological processes and promotes pain.
However, individual perception and behaviors strongly influence these events. Optimism and hope, for example, are factors that facilitate problem-solving and can therefore alleviate pain.
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One stress function of the body is particularly noteworthy, namely the release of the hormone cortisol, which is partially responsible for the stress response. This hormone is produced in the adrenal cortex and also regulates metabolism and the immune system. Cortisol levels vary throughout the day, but short-term or unexpected stress stimulates an additional increase.
As a result, persistent stress is the starting point for a malfunction. This misregulation of cortisol in the body can eventually contribute to inflammation ①. Inflammation contributes to more pain and a vicious circle is created.
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A New Understanding of Pain
What else is there to understand about pain?
A distinction is made between acute pain and chronic pain. For both, predispositions play a decisive role. This calls for a change in perspective, revealing that it is not always pain that makes life unbearable, but often the other way around, life makes the pain unbearable.
In this more holistic perspective, a reassessment of pain is sought, as adequate pain management is clearly superior to the traditional concept of pain elimination.In summary, humans are not just viewed at the biological level, but also at the mental level. At the same time, efforts are made to make coping as positive as possible ②.
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The goal is to reprocess pain and re-evaluate it. In recent years, remarkable results have been found regarding "pain reprocessing therapy". For many people, the pain does not originate where it is felt, but mostly in the brain. From a research perspective, there are countless pieces of evidence that for many people (e.g., with back pain), no cause for specific pain impulses could be found in the back. This does not mean that the pain is not felt. On the contrary, the pain is real and is felt nonetheless ③.
Pain is often not only caused at the site of pain.
Even if pain is caused in the brain, it is noticeable. For a better understanding of the holistic approach, a re-evaluation is necessary.
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In an experiment with a group A of test subjects, where sham operations were performed on the pain sites, and a group B of test subjects, where real operations were carried out, it was found that both groups felt less pain in the long run. With the difference that group A felt less pain overall and initially recovered more quickly from the pain. Possibly because they didn't really have to recover from interventions afterward.
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A Tale of Work Focus
How can I apply the new understanding of pain in everyday life?
A man sits on a hard wooden chair and notices that after 30 min his lower back hurts and feels twisted. The man remembers"Two days ago I was already sitting on this chair and noticed no pain after 90 min of sitting. I remember that the day was relatively relaxed and I sat next to my favorite colleague and chatted with him."
However, on this day, the man sat next to his boss, and a very important meeting was about to start, in which the man also wanted to contribute. This was not the first meeting of its kind and should not be the last either.
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The man remembered a friend who was a psychologist, who once explained to him that stress and pain sensations can be very quickly learned and associated by the brain, linking them to places or certain situations.
He explained that the brain sometimes even learns on its own to deliberately use pain in the background to protect the owner from certain "dangers," difficult situations, or problems.
Unfortunately, the owner sometimes disagrees with the brain, and both have to readjust to each other to avoid too often misunderstandings. The man understood that if he behaves as usual in this situation, i.e., maintains the same thinking and behavioral patterns, he will get the same result.
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Normally, the man pays very close attention to his pain and tries to logically explain and interpret the pain in order to soothe himself (stress). For some reason, this didn't work for the man in the past, and he noticed more and more tension in his body, interpreting it further and becoming even more stressed and tense (overinterpretation and additional stress).
The pain seemed to intensify and made the man doubt himself. This time, the man wanted to do things differently. He decided to think about his doctor and psychologist friends and not necessarily attribute his pain to physical malice or long-standing injuries and overinterpretation, even though he usually quickly comes to this idea.
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Instead of focusing inward, the man directed his attention to external things, opportunities, and colleagues in his environment. He broke the cycle of his behavior (attention redirection). He became creative and deliberately sought out situations that were beneficial for him (situation selection).
He reevaluated the events and shifted his focus outward. Instead of evaluating and overinterpreting the pain as he usually did (evaluation).
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He didn't let his emotional reaction depend on it, but instead he positioned his body positively (upright posture, "power posing"), as he once learned in a training. He smiled more and more (which also changed his mood, the man once learned) and began to feel more stable and self-assured (emotional response). As a result, the man felt significantly better in his difficult situation and noticed afterwards that he experienced much less pain than usual during that time.
It is not always the pain that makes life unbearable, but often the other way around, life makes the pain unbearable.
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The 5 Phases of Emotion Regulation
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Study on Pain Processing Therapy
How does research know about the new understanding of pain?
This pain-reducing understanding was explored in a highly published study. A pain processing therapy group with 50 participants was informed about the new "holistic" approach to pain treatment and introduced to a new understanding of pain.
In this study, medical analyses ensured that the pain was largely not physiologically caused and could actually be generated in the brain. Among other things, it was analyzed whether the pain, for example, could move around the pain site and not consistently appear in the same exact location. Furthermore, it was checked whether the intensity of the pain remains the same or if it can also partially disappear.
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If, for example, the pain varies or is completely absent in similar events, it is likely that stress situations or difficult life events can change it. With solely a physical cause, one would expect the pain to occur consistently in a specific situation.
Keep in mind: Overinterpretations of pain increase the alertness in the brain and body. The brain becomes even more vigilant and overinterprets various tensions in the body or other unpleasant sensations. These overinterpretations lead to more stress and therefore more pain.
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The theory teaches us that we can change pain by changing our evaluation and break the cycle. By not focusing on the pain, but looking at external factors from a bird's-eye perspective and reacting differently, we can alleviate the pain through this understanding. Surprisingly, pain can be reduced in the long term and sustainably.
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As a result of the study, it was found that 66% of the pain processing group had no or almost no pain in the medium and long term.
This means that the pain processing group was able to reduce pain with the help of additional information and largely through a new understanding of pain. No study that achieved such results through cognitive behavioral therapy has been published so far. In this regard, these findings are the best that current research has to offer.
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What is important to you?
What is my well-being worth to me?
Motivation is often hindered in many clients due to unrealistic ideas and expectations regarding their own bodies. It is advantageous to formulate expectations in advance. Ask yourself, "What needs to change in your daily life within six months for you to say that the therapy was successful ④?"
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Physical Measures
Therapeutic techniques like ultrasound therapy or exposing the body to stimuli such as pressure, tension, electric currents, temperatures, etc., support pain treatment. When combined with exercise, improved effects can be noticed ④.
The Ultraease ultrasound device generates and utilizes heat generated by ultrasound in deeper layers of tissue. Heat, on the other hand, reduces the sensation of pain. For this reason, relaxation exercises also include aspects related to heat and circulation.
Approximately 95% of people find heat to be pain-reducing, while approximately 5% prefer cold. This can be deliberately used in everyday life.④
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Conscious Pain Processing
What could a successful pain therapy look like, for example?
Read the following case study to get a better sense of a potential pain therapy. The case study takes place in a clinical setting and consists of various combined therapy components that can largely be applied on an outpatient or home basis.
"Case study: Frau L. has been coming to our rheumatology and pain outpatient clinic regularly and happily for about a year now. A crucial factor for a good working relationship was the fact that she could talk extensively about her pain and other complaints and felt taken seriously.
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Through working together to determine which measures are beneficial to her personally, she learned to become self-active and to use relieving measures more frequently and intentionally. As a result, the patient now does light gymnastics daily, goes swimming once a week on designated warm bath days, and uses a heated blanket to fall asleep in the evenings. Occasionally, she also takes mild pain medication (Paracetamol).
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She married at a very young age against her parents' wishes to a man who later developed alcohol problems. "I could never talk about it with my mother, I always had to maintain the facade, so as not to admit that maybe he was the wrong one after all." Even today, her relationship with her mother is strained. Every time she has to visit her mother, she gets sick beforehand, feels physically very bad, and usually only goes out of a sense of duty. During group therapy, the patient realized that she is still trying to please everyone based on this biographically learned pattern. "I have realized that I don't love myself enough. In the future, I want to take better care of myself and learn to say no." She began to do more for her own well-being, went for a stroll in the city before the group session, and treated herself to a coffee, something she had never dared to do alone before. Since she noticed the connection between her sleep disorders and her husband's restless sleep, she set up a separate bedroom after 30 years of marriage.
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Although this was met with incomprehension in the C family. Are you getting cranky in your old age? 😊), it improved her sleep. For heavy housework that regularly worsened her pain, she learned to delegate and asked her husband for help.
He now vacuums the apartment once a week and takes on other heavy tasks. Through bodywork in the group (Feldenkrais), Mrs. L became more aware of her body and was able to improve her mobility as well. She noticed that she was unconsciously very tense, often shrugged her shoulders or clenched her teeth. She came up with the good idea of placing yellow tennis balls everywhere in her apartment. "Every time I see one of the yellow tennis balls, I try to let go, to relax." Mrs. L showed a very positive development during group therapy. She became more self-confident, learned to better sense herself and her own needs, and set boundaries against the wishes of her family."
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I have always lived for others, I also want to have something of my own life!" Overall, the pain has become more bearable due to a more considerate approach to herself and respecting her own limits. Some of the accompanying symptoms have also been reduced through further symptom-oriented measures. Mrs. L now feels that she can live well with her condition and influence the symptoms herself (self-efficacy).
When her symptoms become stronger than usual, she has a plan for how to help herself. The stress management in this case study could be complemented with other techniques such as hypnosis, progressive muscle relaxation, imagination exercises, or autogenic training ④.
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Psychosocial Risk Factors
What could be pain-maintaining factors for me?
There is so-called "feed for the pain" (psychosocial risk factors) according to Waddell 1998, such as:
- Attitudes and beliefs, e.g. "The pain must be completely gone before I can do what I used to do." "Pain cannot be influenced."
- Behavior, e.g. extensive periods of rest and relaxation in daily routine.
- Incapacity for work, e.g. personal history of prolonged periods of incapacity for work.
- No financial incentive to take up work, e.g. living too frugally and avoiding leisure expenses.
- Diagnosis and treatment, e.g. experience with contradictory diagnoses and resulting loss of trust.
- Dramatization of pain due to unsatisfactory treatment experiences.
- Emotional stress, e.g. fear of pain worsening due to activity, irritability, and depressive mood.
- Family, e.g. overprotective partner or lack of social support.
- Work, e.g. frequent job changes, dissatisfaction with the workplace ④.
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Physical Balance
I need a lot of rest... How can I maintain balance despite the pain?
Balancing activity and rest periods is of great importance in pain treatment. This, along with a realistic goal outlook, provides a significantly higher probability of success in reducing pain and building new activities, which in turn desensitizes pain-related fears and reduces pain further. It becomes clear that rest is apparently more dangerous than movement, gradually dispelling the original myth. Nevertheless, many people believe that they cannot perform certain exercises due to their pain. Do you have such concerns as well? Movement is essential, and sometimes progress is not without pain. Do not see episodes of pain as setbacks but as "feedback." Additional information that your body sends you so that you can reassess it and effectively use it against the pain ④.
Continue to learn to maintain balance, even if you sometimes stumble.
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Balancing activity and rest periods is of great importance in pain treatment. This, along with a realistic goal outlook, provides a significantly higher probability of success in reducing pain and building new activities, which in turn desensitizes pain-related fears and reduces pain further. It becomes clear that rest is apparently more dangerous than movement, gradually dispelling the original myth. Nevertheless, many people believe that they cannot perform certain exercises due to their pain. Do you have such concerns as well? Movement is essential, and sometimes progress is not without pain. Do not see episodes of pain as setbacks but as "feedback." Additional information that your body sends you so that you can reassess it and effectively use it against the pain ④.
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Pain and Relaxation Techniques
What exactly can I achieve with relaxation when it's actually about pain?
It has been experimentally proven that pain also acts as a physical stressor, which can lead to an increase in blood pressure and heart rate, resulting in long-term sleep disorders, stomach problems, headaches, and restlessness. As we already know, these types of stress factors worsen pain. With the help of learned relaxation techniques, you can reduce the stress reactions of your body. This means that you are not helpless against pain; on the contrary, you are able to counteract it independently. Relaxation techniques lead to a faster perception of your body and muscle tensions, allowing you to learn to interrupt the tensions more quickly and avoid them in a helpful way.
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Muscle tension leads to more pain. It can be prevented and addressed proactively and situationally.
Mental perception of stress-related tensions can also be improved by these techniques.
It is important to know that all relaxation techniques may not work fully at first and require a longer time to master. Lasting effects can only be achieved through persistent practice ④.
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There are a number of accompanying phenomena that can occur during the practice of relaxation techniques. These are mostly due to the initially prevailing tension and disappear with more practice time. However, they are positive indications of a shift in the nervous system and an emerging change, even if you may initially find them uncomfortable.
As an additional effect, Ader et al. (1991) have shown that the immune system can produce new natural "killer cells" as a result of relaxation and this effect can be further enhanced with increasing frequency of application. Relaxation techniques therefore alter several immune parameters and strengthen the immune system, which can also better protect you against viruses such as COVID-19.
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These may include vegetative, motor, and cognitive reactions, such as:
- Twitches in smaller muscle groups or a brief jerk throughout the body
- Increased salivation
- Inner restlessness
- Disturbing images and thoughts
- Distorted body perception
- Sweating
- Hot flashes
- Dizziness
- Heightened perception of existing pain
These effects occur because the focus is then directed to the body and thoughts. You observe and initially focus on your body sensations.
Usually, these effects disappear on their own. It is usually better to continue practicing relaxation to eventually achieve the desired effect ④.
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Your Sources of Strength and Living with Pain
How do I find what is beneficial for me and my pain management?
For everything in life, there is a suitable measuring device, such as a ruler, a scale, and a thermometer.
Try to assess certain phases of your life with a "feeling meter". The scale ranges from green to red and represents your well-being. Green stands for feeling good. Red stands for little well-being (e.g., due to a lot of pain or anxiety).
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Are You Seeking Green or Red?
Now consider when in your everyday life you tend to have the green phase on the feeling meter, when you feel good, and when you have few symptoms and little pain.
What sources of strength/resources surround you during the "green" time? What do you do during the "green" time? What brings you into your personal "green" zone?
"Many pain coping programs nurture the illusion that you can overcome the pain - as the name suggests pain coping. I believe that "coping" in the context of chronic pain is the wrong expression and that it is not about the question "How do I cope with the pain?", but about the question "How do I live with the pain, how do I stay alive with it ⑤?"
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"There is no one 'big' answer to this question, at most various small answers - depending on the person's personality, depending on the intensity of the pain, depending on the situation. Certain answers do not help equally every day - and not all possibilities help equally for all people. For me, staying alive means that I don't want to make the pain my life's content ⑤."
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The disease largely determines the external form of my life - I cannot prevent that. But I try to determine the content of my life as much as possible.
For example, by thinking as little as possible about the pain. The pain is there. I don't sugarcoat it, I don't repress it. But I also don't dwell on it. When I do my exercises (for relaxation, muscle building, mobility, etc.), it's not to fight against the pain but to do something for my body, to use my range of motion and expand it if possible.
Because staying alive also means to me to view my situation as a kind of challenge that life presents to me ⑤.
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In this case, it is a particularly great challenge, at least greater than all previous challenges.
What matters is not whether I meet this challenge, what matters is only that I try!
And that includes the joy of every small step forward, as well as the longing for further steps and the sorrow over what is probably lost forever ⑤."
Sources
(1) Mickle et al., 2020. See Appendix 1.1.
(2) Krankenkasse, T. (2016). Entspann dich, Deutschland. TK-Stressstudie 2016. https://www.tk.de/centaurus/servlet/contentblob/921466/Datei/3654/TK-Stressstudie_2016_PDF_barrierefrei.pdf. (Accessed on April 4, 2018)
(3) Ashar, Y. K., Gordon, A., Schubiner, H., Uipi, C., Knight, K., Anderson, Z., ... & Wager, T. D. (2021). Effect of pain reprocessing therapy vs placebo and usual care for patients with chronic back pain: A randomized clinical trial. JAMA psychiatry.
(4) Psychologische Schmerztherapie by Prof. Dr. Dr. Heinz-Dieter Basler, Dipl.-Psych. Carmen Franz, Prof. Dr. Birgit Kröner-Herwig, Dipl.-Psych. Hans-Peter Rehfisch.
(5) Psychologische Schmerztherapie by Prof. Dr. Dr. Heinz-Dieter Basler, Dipl.-Psych. Carmen Franz, Prof. Dr. Birgit Kröner-Herwig, Dipl.-Psych. Hans-Peter Rehfisch, pp. 637-638.