Expanding the boundaries of chronic pain care

Page Haviland, PhD, is a clinical psychologist at two outpatient comprehensive pain and spine clinics with Saint Alphonsus Regional Medical Center in Boise and Nampa Idaho. Working alongside physicians, nurse practitioners, and physician assistants, she treats adult and geriatric patients with chronic pain conditions, from traumatic injuries to degenerative neurological diseases.

Haviland is also one of a growing number of psychologists with prescriptive authority—a privilege that only exists in a small number of states and requires a master’s degree in psychopharmacology, state prescribing psychologist licensure, and federal DEA licensure.

During her tenure as president of the Idaho Psychological Association in 2017, Haviland and fellow advocates worked hard to pass a state bill allowing properly trained psychologists to prescribe psychotropic drugs and medications that treat their side effects. In 2022, she earned her master’s degree from Idaho State University’s clinical pharmacology program, completed 2 years of collaborative prescribing with a psychiatrist, and has since provided independent psychotropic management along with psychotherapy in her practice. “This combined expertise creates a more seamless experience for patients and, often, better medical and mental health outcomes,” she said.

We talked to Haviland about the relationship between pain and mental illness, how psychological treatment can improve pain symptoms, and how clinical psychologists can better serve patients with chronic pain.

Most of the referrals I get are chronic pain patients who need nonpharmacological interventions for pain management. Physicians typically want patients taking the least amount of prescription pain medication possible. Psychotherapy can help reduce patients’ perception of pain and minimize how it affects their daily functioning.

It’s not uncommon for me to diagnose patients with mental health conditions, such as posttraumatic stress disorder, depression, or anxiety. For both pain and mental health conditions, I use cognitive behavioral therapy, acceptance and commitment therapy, biofeedback techniques, and relaxation tools like deep breathing, progressive muscle relaxation, and mindfulness interventions to help with pain perception.

I also evaluate patients for medical interventions. For example, I do presurgical evaluations for spinal cord stimulator implants, which when placed under the skin near the spinal cord can interfere with pain signals. If a patient has a disqualifying mental illness, substance use disorder or recent suicidal ideation, I work with the physician to find alternative management strategies.

Even though many of my patients have pain symptoms from incurable, progressive diseases, I can help them learn to cope and function better in daily life with less suffering. Patients with chronic health and pain conditions are also dealing with identity crises such as job loss, financial hardships, housing and transportation needs, or marital and family strain that contribute to anxiety and depression, so their physical pain and mental suffering become intertwined.

Psychologists are uniquely trained in the assessment and treatment of mental health disorders, navigating life transitions, and teaching patients how to self-manage symptoms with and without the use of medications. We collaborate with patients to understand links between their history and current symptoms, encourage trials of various treatment modalities, and celebrate successes in self-management. Working with a prescribing psychologist like me saves patients time, copays, and inconvenience by seeing only one provider for both their therapy and psychotropic medication needs.

When needed, I augment psychotherapy with psychotropic drugs that serve to calm patients’ nervous systems and reactivity to physical and emotional distress. For many patients, adding antidepressants, sleep aids, or anxiolytics can bolster their resilience and motivation for physical therapy and use of the coping skills learned in psychotherapy.

A lot of what I do is deprescribe. It’s not uncommon for a patient to come to me on three different antidepressants, a benzodiazepine for anxiety, a sleep drug, and an antipsychotic. Very rarely are all of these necessary, and they can also cause unwanted side effects and even worsen pain. I go through the patient’s history to determine the best fit and help them taper off any medications that aren’t helping them. If we start new drugs, we do it slowly, so we can determine what’s helping and what isn’t, then make incremental adjustments.

From your first visit, set the expectation that self-management of our health and pain conditions is a collaborative journey that includes both medical and nonmedicinal therapies.  Normalize the importance of seeing a pain psychologist to learn coping skills as part of their treatment plan and not implying that the “pain is all in your head.”

We have robust literature showing that medication and therapy are better than either one alone for both mental illness and pain conditions. Educate yourself on the bidirectional relationship between mental illness and therapeutic modalities that help with both. APA’s Division 38 (Health Psychology) is a great resource.

And whenever possible, collaborate with the patient’s physician to ensure you’re aligned on a treatment plan. Many medical providers are grateful for the chance to better support their patients.