‘Courage doesn’t always roar. Sometimes courage is the little voice at the end of the day that says I’ll try again tomorrow.’ —Mary Anne Radmacher

It all began with the numbing of my hands. Too much time was spent holding my smartphone, I surmised. I went to my doctor after the tingling began to keep me up at night. Carpal tunnel. Wear a brace at night, and it should resolve. If not, a simple surgical procedure would fix the problem.

A year later, the numbing was replaced with swollen, painful joints that now included my shoulders and feet. Mornings were the worst — it took me twice as long to get anything done because of the stiffness and pain. As a self-proclaimed gym rat and former aerobics instructor, I was forced to modify my daily workouts, as I was committed to keeping a routine. Moving helped, and by midmorning, I was able to function relatively well most days. Still, something was terribly wrong, and it was impacting every aspect of my life.

The blood work continued to come back negative for an autoimmune disease, but my family history and presenting concerns all pointed to rheumatoid arthritis. I was immediately placed on a disease-modifying antirheumatic drug that carried its own side effects, including fatigue, which I was already experiencing from a lack of sleep.

There were many days that I questioned how I was going to manage a private practice and a demanding academic career, while just barely having the energy to feed the dog, get dressed and eat breakfast. But there were even more mornings that I put on a smile, cringed through the pain and focused on the possibilities of the new day ahead.

Chronic pain

According to R. Jason Yong and colleagues, in their 2022 article published in the journal Pain, 1 in 5 adults in the United States experience chronic pain. Using data from the National Health Interview Survey, the researchers found that the experience of chronic pain negatively impacted the participants’ quality of life. Previously enjoyed activities were forfeited due to restrictions in mobility.

In addition to physical discomfort, there were psychological effects to living with chronic pain and illness. These included an increase in anxiety and depressive symptoms. Let’s face it — pain can sabotage even the best of days. I knew that from my own experiences. Therefore, imagine my excitement when I found research that completely changed my understanding of pain and offered real tools to cope.

Neuroscience advancements

Over the past decade, the science regarding the etiology of pain has evolved to a biopsychosocial model. This approach examines not only physical injuries but also the role that our thoughts and beliefs about pain and injury play in our overall experience of pain. Therefore, most models are antiquated in that they dismiss the brain’s function in assessing and moderating pain. Additionally, newer pain science research examines individual histories around trauma and childhood experiences as they have been found to be associated with a decrease in pain threshold and more frequent bouts of pain. In addition to the roles of trauma, childhood experiences and cognitive appraisals, pain science has also adopted the following tenets.

Pain is not purely physical. While pain is designed to protect the body, it is not purely physical. According to Robert Edwards and colleagues, in a study published in The Journal of Pain in 2016, pain is a “multidimensional, dynamic interaction among physiological, psychological, and social factors that reciprocally influence one another.” We often think that pain is related to an injury or tissue damage, but research indicates that chronic pain is often unrelated to physical injury. There are neurological changes that occur to create the sensation of pain even when there is no physical damage to the body. Therefore, when we focus solely on the physical aspect of pain, we miss so many other elements that contribute to coping and recovery.

Pain is processed in the brain. The brain sends biochemical messages to the cells in the body, and they in turn provide the brain with a status report. While injury can certainly be read by this process, stress also accounts for changes in the body that can register as pain (e.g., nerve pain or migraines). When activated, the body’s own analgesics (e.g., endorphins) are released to attempt to address the symptoms.

Everyone’s nervous system response is unique and can be altered. Additionally, with chronic pain, individuals can become sensitive to the possibility of pain. For example, initially, I experienced tremendous pain in my hands and wrists — so much so that even after my swelling and pain had significantly subsided, I was fearful of trying to do a pushup or yoga poses such as downward dog. I would cringe just thinking about it.

Neurologically, the brain keeps track of our pain threats, and it begins to anticipate the threat to the point of significantly decreasing the pain threshold. It is like a hypersensitive alert system that may even “sound the alarm” prematurely. This should sound familiar. It is a conditioned response. My brain became conditioned to anticipate pain in my wrists and hands, and anything that might pose a threat was received with a pain rating that exceeded that actual discomfort (if any). The good news is that anything learned can be unlearned.

Neural pathways can be reprogrammed. Individuals with chronic pain are prone to hypersensitivity. They have learned to expect pain, and their neurology is now wired to react even when the injury or stimulus no longer exists. In addition to the reactive neural pathways, the brain interprets each experience with cognitive appraisals of the pain sensation and situation. For example, a person may avoid activities that previously triggered pain or discomfort with the appraisal “I can’t do this activity without feeling pain.” However, David Seminowicz and colleagues’ study, published in The Journal of Pain in 2013, found that using cognitive behavioral tools to confront and reframe thoughts and beliefs around pain changed the brain and reprogrammed neural pathways, resulting in a decrease of pain sensation.

Implications for counselors

Counselors can play an instrumental role on a pain management team. Utilizing cognitive and meaning-centered approaches, counselors can help clients recognize the thoughts and meaning they ascribe to pain and illness that maintain or even increase the pain sensation. Conversely, challenging and changing those thoughts and beliefs can alter the neuroprocessing that results in the reduction of the experience of pain. Here are a few techniques for your toolbox when working with clients with chronic pain:

• Word swapping (reframing). Language matters. It conjures images, and the brain (in particular, the amygdala) responds to these images. Swap out words that conjure fear with words that are more comfortable. Substitute the word “pain” for “sensation” or “pressure.” Use phrases such as “not as cool” or “not as loose” when describing the experience of heat or tightening sensations. This will reduce the amygdala’s engagement and help the brain create new neural pathways.
• Meditation. Meditation can help retrain the brain and nervous system to process pain sensations. There are numerous guided meditations that specifically address chronic pain.
• Positive self-talk. Often, we succumb to our fear of the pain and catastrophize the scenario. This increases the amygdala and stress response. Try talking to the pain. Whether it’s with a determined voice (e.g., “OK, I’m not going to miss out on this event because you [pain] are presenting. You are just going to have to leave me alone today.”) or a softer approach (e.g., “I know we can feel better. I’m going to make tea and do a brief meditation, and we will feel much better.”), be intentional and empowered in your self-talk.
• Journaling or expressive writing. First pick a situation and write down your feelings and thoughts about it. Don’t hold back. For example, the first time I had to ask my husband for help opening a container during a flare-up was horrific. I hold the belief that I am independent, strong and capable. This is part of my identity; I see myself as Wonder Woman! So I hated asking for help. I felt vulnerable and scared. Now write another version of the narrative. In this scenario, my rewrite would be that after many years (decades) of believing that I had to be strong, I was shown that I have support and do not need to be physically strong. It is wonderful to be cared for, and opening jars also allows my husband opportunities to feel needed.

Courage

In her 2019 Netflix special The Call to Courage, Brené Brown says, “Courage starts with showing up … and letting ourselves be seen.” As counselors, we know that it is no small feat to show up and face the uncomfortable. It can be scary to be vulnerable and shed that superhero mask. We can validate and normalize the challenges of living with chronic pain, and we can bring our Adlerian pom-poms and cheer on our clients’ bravery. We can remind clients that not only can they live satisfying lives with chronic pain, but as they engage in the work of pain management, they are doing it.

 

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Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and associate professor for Alliant International University California School of Professional Psychology’s online master’s in clinical counseling program. Her research interests include examining sexuality and spirituality in young women with advanced breast cancer, nature-informed therapy and geek therapy. Contact her at cyfisherphd@gmail.com.

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