Robert Kerns, PhD, has been studying the psychology of pain for 30 years. He’s an associate professor of psychiatry at Yale University and the national program director for pain management at the Veterans Health Administration. When Kerns was in graduate school in the late 1970s, he treated a patient with terrible back pain as a result of kidney disease. Even though this patient had a serious physical condition, Kerns noticed that psychological therapy helped her cope with the pain. “That’s when I realized that a person’s thinking could affect his or her pain experience,” he says. “Chronic pain isn’t beyond our control.”
At the time, there was little hard evidence to support such mental interventions. Treating chronic pain with psychological therapy was like treating cancer with a poem: The best thing most doctors could say about it was that it would do no harm, but few expected it to actually help. Pain, after all, was a medical condition. Therapy was just words. But the words are working. Kerns’s most recent study, published in January 2007 in
Health Psychology, is also his most definitive. It’s a meta-analysis of 22 trials that looked at the effectiveness of psychological treatments for patients with chronic lower-back pain. The statistics were complicated, but the results were clear: Psychological treatments made the pain go away. Patients with chronic back pain could reduce their suffering by learning how to think differently about their pain. Benson Hoffman, PhD, an associate professor at Duke University and first author on the study, was surprised by the robustness of the data. “Going into the study,” says Hoffman, “I thought that psychological interventions would probably increase the patients’ quality of life, but not actually reduce their pain. But my hypothesis was wrong. These psychological treatments reduced the pain more than anything else did.”
Think for a moment about what this means: These patients received routine medical care that failed to provide substantial relief. And yet, after just a few psychological treatment sessions, their pain started to subside. According to the meta-analysis, the two particularly effective psychological interventions were cognitive behavioral therapy and “self-regulatory therapies” such as biofeedback. Cognitive behavioral therapy is a popular form of talk therapy that teaches patients how to adopt a problem-solving approach to their pain. The simple premise of the treatment is that we are capable of controlling our own thoughts, emotions, and experiences. Therapists teach patients specific mental exercises, such as keeping a journal or practicing relaxation techniques, that help them manage their negative feelings and alleviate their suffering. Self-regulatory therapies show people how to take back control of their bodies. By giving patients information about their own internal processes (e.g., readouts of their blood pressure and brain waves), the therapy teaches them how to modulate these processes. The mind needn’t be a slave to the flesh.
“Many patients with chronic back pain develop a sense of hopelessness,” says Kerns. “These therapies show them that they can develop everyday strategies that make them feel better. I think one of the things that modern medicine has forgotten is that it’s important to treat the whole person, and this means addressing both the physical and psychological aspects of the pain. When it comes to back pain, just fixing a ‘broken’ body part often isn’t enough.”
One of the first studies to demonstrate the importance of psychological factors for back pain came from an investigation of 3,020 employees at Boeing in the 1980s. Over a four-year period, about 10 percent of these employees reported chronic back pain. When doctors analyzed the factors that predicted the onset of this pain, they were surprised to learn that structural back problems played a negligible role. Factory workers who often lifted heavy objects were no more likely to experience disabling pain than office workers. Instead, the best predictor of chronic pain was emotional distress: Employees suffering from depression or stress were much more likely to suffer from back pain.
A study more recently published in
Spine made a similar point. Eugene Carragee, MD, a professor and vice chairman of orthopedic surgery at Stanford University School of Medicine, was the lead author. He tracked nearly 200 patients over five years, attempting to better understand the specific structural ailments that cause chronic back pain. The researchers imaged people in MRI machines and used discographies to assess the possible structural sources of back pain. They also conducted regular psychological evaluations.
Dr. Carragee’s results, like earlier studies, showed that neither discographies nor MRIs were reliable predictors of severe back pain. While two-thirds of patients with chronic pain had small cracks in their disks, so did 24 percent of patients with no pain at all. “The real issue,” he says, “is, Why do some people have a mild backache and some have crippling pain?”
