Speaking of Psychology: Understanding and treating chronic pain, with Rachel V. Aaron, PhD

Each year, more than 50 million U.S. adults experience chronic pain. Increasingly, researchers and patients are finding that behavioral treatments and therapies can be an important part of pain treatment. Pain psychologist Rachel V. Aaron, PhD, discusses what effective treatments are available, the link between chronic pain and mental health, how our emotions and life experiences affect pain, and what promising pain treatments may be on the horizon.

Rachel V. Aaron, PhD, is an assistant professor of physical medicine and rehabilitation at Johns Hopkins Medicine. She is a clinical psychologist who specializes in chronic pain within a rehabilitation psychology setting. She treats patients with acute and chronic pain, illness, and injury in outpatient settings. She also researches psychosocial factors that contribute to the experience of chronic pain, particularly the role of emotional factors in the development and maintenance of chronic pain. She applies this research to develop novel approaches to improve treatment outcomes in individuals living with chronic pain.

Kim Mills: Each year, more than 50 million adults in the U.S. experience chronic pain. Whether it’s caused by arthritis, injury or something else, chronic pain can affect every aspect of a person’s life and significantly limit their daily activities. Many people turn first to medications for pain, but in recent years, researchers and patients have found that behavioral approaches and therapies can play an important role in pain treatment and management.

Today I’m going to talk to a pain psychologist about what effective treatments are available for chronic pain. We’ll also discuss the link between chronic pain and mental health. How does pain interact with anxiety, depression, and stress? How does emotion affect our experience of pain? What promising new pain treatments may be on the horizon? And if you’re living with chronic pain, where can you go for help?

Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association that examines the links between psychological science and everyday life. I’m Kim Mills.

My guest today is Dr. Rachel Aaron, an assistant professor of physical medicine and rehabilitation at the Johns Hopkins School of Medicine. She’s a clinical psychologist who specializes in treating patients with chronic pain, illness, and injury. She also studies the psychosocial factors that contribute to chronic pain, especially the role of emotion in pain. She’s authored more than 60 peer-reviewed journal articles on the experience and treatment of chronic pain in children and adults. 

Dr. Aaron, thank you for joining me today.

Rachel V. Aaron, PhD: Hi, Kim. Thank you so much for having me. It’s really an honor to be here and to speak to such a large body of people interested in psychology.

Mills: Let’s start with a basic question, which we often do, which is: How do you define chronic pain?

Aaron: So typically chronic pain is described as pain that has persisted for three months or longer past the point of expected healing. So acute pain is a part of life. Acute pain is adaptive. It tells us that something’s wrong in our body. It tells us to seek help or to slow down if we’re healing. But when that pain persists for more than three months after the body has healed from injury or acute pain, then we typically think of that as chronic.

Mills: And is pain a physical experience, a mental experience, or both?

Aaron: What we know today is that pain is -- the sort of fancy term for this is biopsychosocial. So pain is a combination of biological experiences, psychological experiences, and social experiences. And that is true of all pain, whether it’s acute or whether it’s chronic. Our psychological state, our psychological experiences, the context in which the pain occurs all affect the way that our brain processes and generates physical pain.

Mills: What are the most common causes of chronic pain?

Aaron: Causes is an interesting question. It’s easier to speak to common types of pain diagnoses or conditions. Actually, about half the time, we don’t know what caused the chronic pain. So often chronic pain develops after an injury or after a surgery, sometimes after an illness or it’s a symptom of some sort of illness or disease or condition. But in most cases, we actually can’t pinpoint a specific cause of chronic pain. And speaking of the psychological experiences, that’s a real source of distress for a lot of people -- to be experiencing very severe pain and not understand where that pain is coming from or why.

Mills: What are the most common treatments for chronic pain and which are the most effective?

Aaron: There’s all sorts of treatments for chronic pain, and depending on the type of chronic pain, there are different types of medications that can be used. There are different types of medical interventions, things like nerve blocks that can be used. People use all sorts of complementary treatments like yoga, massage, and acupuncture, things like this. My area of expertise is in psychological interventions for pain. So we also, after several decades of research and anecdotes from clinical care now understand that psychological treatments are considered a frontline treatment for chronic pain.

Mills: And what are those psychotherapeutic treatments for pain that are effective? I mean, if I come to you and I say, my back is killing me and I’ve been treating it with drugs and I can’t get around, what can I possibly do psychologically that might help me deal with the pain and lessen it?

Aaron: So historically, the most extensively studied psychological treatment for chronic pain is called cognitive behavioral therapy, or CBT, which I’m sure this audience is quite familiar with, and fortunately seems to be a sort of a household word these days. CBT was developed to treat depression and anxiety, and it’s been adapted to help people cope with chronic pain.

So the goal of cognitive behavioral therapy for chronic pain is to help people examine the types of thoughts that they have about pain -- thoughts like, my pain will never go away, or my life is over, or I can never be the mother, father, spouse, friend, professional that I was when I live with this pain. So a core piece of CBT is helping people identify those thoughts and work with them to be a little bit more neutral or realistic. That’s sort of the C of CBT.

The B or the behavioral part is helping people be active despite pain. So working together a patient and the clinician to set very specific goals around activity, physical activities or pleasant activities, helping people pace their activity to avoid overdoing or underdoing activity. So those are some of the core components of CBT. And again, that’s sort of been the most extensively studied.

There are several related treatments. There is a group of treatments that take a mindfulness-based approach to pain, and there are treatments that take something called an Acceptance and Commitment Therapy, ACT. Again, this audience is familiar. So helping people learn to live a valued life despite pain, learn to accept the experience of pain. And then there’s also a new class of psychological treatments that have come about in recent years that focus more on the affective or emotional components of pain.

Mills: It sounds like these are all treatments that are helping you manage and live with the pain but not alleviating the pain. So what are the most effective treatments for alleviating pain?

Aaron: Great question. So CBT and CBT based treatments came around at a time when we thought of chronic pain as a chronic condition that could not necessarily be altered, in the same way that you might think of other types of physical disabilities. And CBT was developed to help people cope with that pain. So the sort of initial framework of CBT was, you know what? You’ve seen all these doctors and you’ve had all these evaluations, and you know what? It looks like your pain’s not going to go away, so let’s figure out how you can cope with it better. Let’s figure out how it can cause you less distress, and let’s figure out how you can be more physically active. So CBT and related treatments really came out of this idea that we were helping people manage pain, and the goal of those treatments is actually not necessarily pain reduction.

And in fact, in the early days, the idea was that you might sort of coach someone on this pain might never change, your pain might never go away. We need to help you accept that. So there’s been a lot of research in recent years to understand the neuroscience of chronic pain. And what we’re learning is that pain is not always chronic for all people. There are many instances where chronic pain can be reversed. And so we’ve seen a huge shift in treatment, in psychological treatment towards how can we actually help people’s pain get better now that we know what we know about the neuroscience of pain and we know that there are some psychological factors that might lead to or maintain pain, how can we actually help pain go away? And that’s where that class of more emotion-focused interventions come in. So one thing that is really unique about these particular treatments, one example is emotional awareness and expression therapy, which was developed by Mark Lumley, who is a psychologist at Wayne State University, who had sort of over the course of decades built up towards this amazing intervention.

And it has gone a bit of a medical direction in terms of how we treat pain. And one thing that it’s done that’s very different is it addresses trauma. It addresses historical experiences of life, trauma, adverse life events, even experiences of discrimination or stigma. So whereas some of the CCBT and the CCBT- based treatments came in saying, well, let’s talk about what’s going on in your life now, the past isn’t important because we want to kind of stay symptom focused and focused on the here and now, EAET pulled in some more of those historical themes around let’s actually talk about your childhood and talk about difficult things that happened to you. And by the way, connect that to pain. So you sort of help people understand the link between stress or trauma and pain, and that treatment is resulting in improved pain for people with particular types of pain conditions. So it’s a great question that signals actually this shift in the psychology of pain treatment.

Mills: You’ve studied the link between pain and anxiety and depression. What have you found? How are these three situations related to each other?

Aaron: What we know is that people who have chronic pain are more likely than people in the average population or in the general public to have depression and anxiety. So my colleagues and I actually just completed a systematic review of the last 10 years of research studies measuring depression and anxiety and chronic pain. So we identified hundreds of studies, hundreds of thousands of participants, and we found that number to be around 40%. So around 40% of people who have chronic pain also have depression or have anxiety. So we know that rates are high. So we know that this co-occurrence is common, the co-occurrence of pain and depression or pain and anxiety is common, but some other things we now know is that not everybody has these co-occurring conditions, right? Many people live really high functioning lives with chronic pain and it doesn’t affect their mood. But for a lot of people with pain, depression is high and we’re still trying to figure out how to treat that particular comorbidity.

But I can tell you more about what we don’t know. So we know that the prevalence is high. What we don’t know are how pain and depression or anxiety develop over time. So sort of the old way of thinking many decades ago before the surge of research and before the surge of understanding the neuroscience of pain was, well, if you have chronic pain, you must be depressed because having chronic pain is depressing. That’s a very ableist narrative by the way, to assume that someone with a chronic condition must be depressed. So we used to think that sort of pain led to depression or anxiety, but what the literature, there haven’t been too many studies really trying to parse this relationship. But what we can see from the studies that we do have is that those relationships are bidirectional. So sometimes chronic pain precedes depression and anxiety and sometimes depression and anxiety precedes chronic pain. And I think that where we will go next is understanding how that might be different for different types of chronic pain conditions.

Mills: So one of the reasons I became interested in this topic myself was experiencing chronic pain, and you just talked about the link between depression and pain. Now I was not depressed, but one of the treatments that was prescribed for me was an antidepressant. Duloxetine was given to me, and I have to say it didn’t do anything for me. I wasn’t depressed, so I didn’t feel happier, but it did nothing for my pain. So what is going on with these antidepressants and pain? How are they changing people’s experience of pain?

Aaron: Yeah, thank you for sharing that. And I’m sorry to hear that you were sort of prescribed something that came with plenty of side effects and wasn’t helpful to you in the end. So in general, we don’t know a lot about the best course of treatment. So we have these treatments, it’s a laundry list of treatments, but the science is not at a state that we know that this particular treatment works best for this particular pain condition in this particular type of person. So it’s a bit like throwing a dart on a dart board. You kind of try what you can. So antidepressant medications are considered a frontline treatment for some types of chronic pain conditions, and the idea is that antidepressants, acknowledging I’m not a physician, but the idea is that antidepressants can operate on different sorts of channels that could reduce inflammation, that could reduce the central sensitization of pain in the body, so it could slow down those pain signals or turn them down a little bit. They work for some people, but not for everybody, and we don’t know why.

Mills: Interesting. And we tried a bunch of things. I’m going to ask you about another couple of therapies that I went through. So I went to acupuncture for a while and I’ve had acupuncture for other pain that has been transient and it’s been very effective. For this particular pain, didn’t do a thing. How effective is acupuncture in treating chronic pain?

Aaron: The evidence is quite mixed, and partly that’s because there haven’t been a ton of high quality research studies in this area. But I think overall we could say minimally effective, but important caveat, compared to active control. So if you give one group of people acupuncture and you give one group of people nothing, people who get acupuncture will feel better than the people who got nothing. If you compare real acupuncture to sham acupuncture, so you sort of took some needles, but not necessarily the way that acupuncture is supposed to be delivered. We don’t see huge treatment effects. And again, there’s a lot of treatments out there. A placebo control is powerful. Expectations matter a whole lot. And so if someone came to me in my pain clinic and said, I really want to try acupuncture, I think that could really help me, then I would say, absolutely, go for it. If you think something’s going to help you and you believe something’s going to help you, then it probably will.

Mills: Yeah, because it had worked before, I thought it was going to do it, but it didn’t this case. So then we stopped doing that and the acupuncturist suggested that I try red light therapy. Now is that totally woo woo or does that really work?

Aaron: I think we could probably put that on a list of a lot of things that maybe totally woo, certainly haven’t been subjected to randomized control trials. But I think that because we don’t know exactly how to treat chronic pain and because in most cases we don’t know exactly where that chronic pain came from, when people are living with chronic pain or treating people with chronic pain or interested in this topic, it’s just sort of easy to sort of cast a wide net and think, well, maybe this will help me or maybe this will help me. And I’ll say that that is also fueled by the biomedical model of pain. So we talked about the bio-psychosocial model of pain that replaced the biomedical model of pain, which is the idea that pain is, the experience of pain is perfectly correlated with some degree of injury or pathology in the body. So the idea that we should just be able to identify the source of the pain and identify the best treatment for that pain is very rooted in that biomedical model, which unfortunately, as of yet is not helping us explain pain. And that’s why those psychological pieces are so important for so many people.

Mills: Well, we were definitely throwing darts at this for a while, I have to say. And so for our listeners, any of you who are experiencing this, you may go through a lot of different treatments before you find something that works, which I finally did. It was actually an epidural and it has helped a lot, but cortisone injections are a fairly common treatment for pain and can be effective as I have learned. I want to ask you though about how you create a pain plan. I mean, I think, as I said, we were throwing darts at things. If somebody were to come into your clinic and say, this is I’ve been having pain for the last two years and I really can’t deal with this anymore. How do you set them up to determine what is the best course of treatment?

Aaron: Yeah, so I’ll address that, but I want to back up a little and talk about throwing the darts at the dartboard. And I just want to say for people who are listening who might have personal experience, so that is some degree of seeking treatment for chronic pain is throwing darts at dartboard. That is sort of an inherent part of it. I think that there are some potential pitfalls for people to be aware of. And I think the biggest one is just how collaborative you feel with your providers, because sometimes providers get frustrated when they’re not throwing the right dart at the right place on the dartboard, and that’s where we get, again, some of that ableism or some of that bias saying, well, this must be a you problem, right? We’ve tried 10 different biomedical things and nothing’s working, so this must be a you problem.

So I would say, and that reaction’s unfortunately quite common. It used to be I only saw people in my chronic pain psychology clinic because of that reason, because of a sort of a physician saying, well, this is a you problem, so go see a psychologist. This has changed so much in recent years with greater adoption of the biopsychosocial model, and now people are incorporating mental health perspectives from sort of the beginning. But I just want to kind of highlight that that throwing darts in a dartboard is part of the process, and it’s important that you feel collaborative with your provider and you feel like you have their respect and that they view your pain is valid, which fortunately it seems like you had supportive providers in your case.

Mills: Yeah, I mean, I was willing to try what they suggested and when that didn’t work, okay, let’s go to plan C. Let’s go to plan F. We just kept working our way through.

Aaron: So in terms of what I do, one of the most important things is just understanding what the person’s goal is. And so sometimes people have very specific goals around return to work or engagement in physical activity or just finding more joy in their life. So knowing exactly what their goal is is always going to be an important part of that treatment design. Well, I’ll always get a detailed history including understanding what sort of traumatic experiences someone might have had or experienced in their life. And that’s also used to inform what kind of treatment we go through together. We do a lot of different types of start off treatment with some questionnaires to understand what is depression, what is anxiety, are these symptoms that we’re also going to be addressing in treatment? And then to get at that CBT model, we ask some questions about thoughts around pain, ability to physically function, things like that. So all of that type of information is going to be useful. So sort of someone’s symptom profile, their history and their treatment goals.

Mills: What role, if any, does hypnosis play in pain management?

Aaron: Hypnosis for pain is another evidence-based approach to pain. So there have been numerous clinical trials that have shown that hypnosis can have a small effect on pain. I’ll say this is not as widely practiced as some of the other treatments. It requires really specialized training that not everyone has. I think the goal of hypnosis, one important thing to state would be people learn to apply these practices to themselves. So it’s almost like there’s a lot of similarities with a mindfulness meditation. So sometimes people think standing on a stage and clucking like a chicken. So there’s a lot of stereotypes about what that is, but indeed that is a respected and evidence-based treatment or a chronic pain.

Mills: Another treatment that’s out there that seems to be applied to almost anything you can think of today is psychedelics. And I’m just wondering where we are with the use of all kinds of psychedelics and chronic pain and not even psychedelics, even things like marijuana, CBD.

Aaron: The evidence for cannabis-based products is very mixed and very political. It’s subject to a lot of hot debate in field and people having sort of all sorts of different vested interests in sort of what outcome comes out. I will say that right now, like acupuncture, we don’t see cannabis-based treatments having big effects when they’re compared to a good control condition. But I’ll again say that expectations matter so much what people think or believe is going to help them. And with that comes a sense of control, right? Oh, here’s something I can do. Here’s something I can try. I feel like this pain is totally out of my hands. Here’s something. And certainly that’s important to have something that you feel like you have some control over. And if someone feels like something works for them, then in most cases, I’m not going to dissuade them from that. In terms of psychedelics, that’s a very new area of research. There are a number of ongoing studies right now, and I don’t know that the results are out there yet. There’s still ongoing sort of recruiting participants. So TBD.

Mills: Let’s talk for a moment about emotion regulation and pain management. I know that’s an area where you’ve done some work. What does that mean? I mean, how do you apply emotion regulation to managing your pain?

Aaron: Emotion regulation refers to one’s ability to sort of change or alter their emotional state in a more desired direction. So living with pain can be very distressing. Experiencing pain can feel very distressing. And so the extent that someone is able to manage the distress that comes up around that is going to affect how they’re able to live with pain. So someone who is very skilled at feeling like their life, some of these thoughts that I called out earlier, these very negative thoughts about pain, my life is over, or I can’t be the mother that I want to be to my children. So people differ and how well they’re able to take that thought and do something about it. So we see that people who struggle to sort of manage that distress have poor outcomes. They have worse pain over time. And just as important as sort of feeling better when you feel bad is also just the ability to experience and express emotion. So sometimes people might not be as tuned into their emotional experiences or they might be really trying to tamp something down, really don’t want to talk about that. And so when people have a real tendency to sort of push that down and to avoid that emotion, avoid talking about that emotion, that can also lead to poor outcomes. That’s where some of those emotion focused treatments come in are really trying to help people dial up those feelings and express those feelings and learn and heal from those feelings.

Mills: And you’ve also looked at chronic pain in children and adolescents. Can you talk about what your research found in just treating chronic pain in kids differ from the way that you treat chronic pain in adults?

Aaron: It’s been a while since I’ve done too much with pediatric populations in terms of psychological interventions, they are similar, that new category of emotion-focused treatments that I can’t stop talking about have not yet been tested in kids. And I think that there are some real questions about how to do that safely and ethically. With adults you might talk about trauma from childhood that is in the past, or you might talk about ongoing stressors that adult has some control over. So I’m not exactly sure how that applies to pediatric populations. I think taking themes from that treatment is so important, but it hasn’t been done yet. So I’m curious to see what that looks like. But otherwise, CBT like an adult is the most well-studied treatment for children and adolescents. One real advantage of treating pain well, there are several advantages of treating pain in children and adolescents.

One is you can often get their people in their environment involved so you can get their parents or caregivers involved. You can even get the school involved so you can make some real changes to their environment that you can’t really make with adults. People have done research studies incorporating the spouses of people with chronic pain and they’ve kind of tried to get a social environment in that way, but it’s really great to have those other people involved change. You can talk to caregivers about the way that they’re talking about pain, and so you can kind of make some good behavioral changes in that way. The other thing is that kids are more likely to get better, and there’s a lot of reasons why that might be, but one is probably that chronic pain isn’t as instantiated, that their brains are still more malleable and that they might be more likely to get pain relief from treatment for that reason compared to say, an adult that’s had a chronic pain condition for decades. It’s going to be a lot different. It’s going to be a lot harder to sort of change the way that the brain’s responding to that pain or generating that pain.

Mills: Let me ask you this for our listeners in particular. How do you know when you need some professional help to manage your chronic pain? And if you decide that you need help, where do you start?

Aaron: Most people who have chronic pain are doing just fine. They’re functioning in the world, they’re achieving their goals. They’re not depressed or anxious. They’re doing okay, and that’s great, and that should be reinforced. That’s resilience and that’s wonderful. So not everyone with chronic pain needs specialized mental health healthcare treatment. Most people with chronic pain are doing okay. I think that reasons why you might seek treatment are if you start to have some of those really negative beliefs or thoughts about pain. So it’s really getting you down. You’re really starting to feel like you can’t live in this world with the pain that you have or you can’t be the person that you want to be and this is stressing or these thoughts are frequent or common or hard to turn off. These are all reasons why getting some help to deal with that might be helpful for people who have had maybe significant traumas or stressful events in their life that they haven’t had the chance to fully heal from or process in the context of a therapeutic relationship or just with the passing of time.

That might also be a reason to seek out therapy because those experiences can link to chronic pain. So finding someone that can help you sort of understand that link, so not just sort of resolving the trauma, but how might that link to pain that you’re having today. Otherwise, I think if you have physical goals or life goals that you’re not able to achieve and that is a source of distress, then you might want to work with someone to figure out either how can I achieve these goals or how can I adapt this goal to the way that my body is functioning now? So those are some reasons why someone might seek treatment. Those might be some flags, and there are not a lot of mental health care providers who are specialized in chronic pain. There are very few graduate pipelines for this area of specialty training.

And so hopefully that’s changing and shifting as there is more attention to this biopsychosocial model of pain. But it doesn’t change the fact that today there are sort of a dearth of providers. So most providers are found in academic medical centers, I can say, or many are found in academic medical centers. I can say that now that telehealth is so much more accessible, it’s easier to find somebody. There are also several great self-paced programs online. So a great one that I like to recommend is called Pain Trainer, so people can look up pain trainer online and get access to this treatment. There’s another one out of Australia that people worldwide can access called the Pain Center, and that’s out of Macquarie University in Sydney. So that’s another one of those self-paced programs that people can access and work through on their own. So there are some great resources available online.

Mills: So to wrap up, let me ask you, what are some of the new and most promising treatments that are on the horizon?

Aaron: I’m so excited about this new wave of treatments that is saying that we can reverse pain by addressing historical trauma or changing the way that the brain is processing pain. So we talked about emotional awareness and expression therapy. Another new treatment is called pain reprocessing therapy treatment. And the EAT has components of PRT within it. So these treatments have a lot in common, and they’re both based on the idea that in part, pain is part of an overactive threat response. So pain is your body’s way of saying something’s wrong. What you’re doing, look around, something’s wrong. These treatments just again, take a very different view of pain and sort of conceptualizing it as a brain generated response that’s telling you that you’re not safe. And so through a variety different practices, you learn how to rewire that sequence. So you learn to tell yourself that you’re safe and that your pain is either coming from your brain or being amplified by your brain.

It’s like, thank you brain for trying to keep me safe, but I don’t need that right now. My injury has healed. I know you’re trying to keep me sane, but I got this. It’s okay. And that’s sort of a very sort of simplified notion, but I think we can all relate to this idea that our bodies respond in a certain way when we’re in a heightened state of distress. So these treatments have sort of conceptualizing pain for some people as one of those symptoms, which is positive because we can change the way that our body responds to stress. This is a very new thing. It, again, has had really big effects in select types of chronic pain conditions, specifically those types of chronic pain conditions that can’t be pinpointed in the body, so they’re not specifically related to a particular injury or disease process or something like that. And so we’re learning how to translate those same findings to all types of pain conditions. So I’m really excited about that and excited to see where it goes from here.

Mills: Well, Dr. Aaron, I want to thank you for joining me today. I think you’ve imparted a lot of useful information. Thank you.

Aaron: Thank you so much for having me, Kim. Again, such an honor to speak to this audience. And yeah, my favorite topic.

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Thank you for listening. For the American Psychological Association, I’m Kim Mills.