The overlap of the symptoms of chronic pain and the symptoms of depression is well documented.
Up to 85% of people with chronic pain suffer from depression. This can make therapy hard, particularly if it means setting goals which involve some kind of activity. If we are to manage low mood and pain it will help by defining what we mean. Pain, as defined by the International Association for the Study of Pain, is the “unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”.
This tells us that pain is a response to threat.
Pain may be keeping us safe from threat
In Cognitive Behavioural Therapy (CBT) many of the symptoms of depression such as avoidance are also ways that we try to keep ourselves safe from threat. In this sense, pain and depression are outputs to triggers. Physical pain is the output to a trigger such as standing on a nail. Low mood will be the output to the trigger such as loss or bereavement. How well we deal with depression and pain is about the balance between safety and threat.
Our personal attributes, support system, and coping abilities keep us safe and allow us to deal with potential or actual threats. These factors regulate the balance between safety and threat. In the physiology of pain this is described as a regulated nervous system. If there are less of these positive modulating factors and a greater perception of threat then our nervous system is dysregulated. An illness such as fibromyalgia is understood by some as a dysregulated nervous system disorder. In situations, we become overloaded and experience pain.
One of the family of CBT interventions is Acceptance and Commitment Therapy or ACT. ACT has proved useful in the management of pain.
I recently met with CBT therapist and pain practitioner Caroline Neal who works for Primary Integrated Community Services, a community pain pathway in Nottingham. Here's what she shared with me about how ACT can be used to manage pain:
How can ACT help people who are experiencing chronic pain as well as depression?
For many people there is not a cure for their pain, it is fuelled and maintained by multiple factors: biological (the sensitised nervous system), psychological (impact upon mood), and social (impact in wider life context). This often results in people moving further away from things that matter to them, giving up important activities and roles in their lives. This causes secondary suffering and further impacts upon mood.
ACT is a psychological flexibility model bringing us back in to contact with important values in our lives, making room for pain and suffering while we move towards what matters. In pain services this involves learning and applying practical and psychological skills including mindfulness.
I have a few practices that help me to work effectively with people to reconnect with their values and make room for pain in their lives. Values work is fundamental in setting our intentions for therapy work.
- See more: Acceptance and commitment therapy: ‘How to find – and live – your personal values’
- See more: What is CBT+? The therapy combining traditional and third-wave approaches
In ACT we also learn to develop an observer perspective and relate differently to the activity of the mind rather than getting caught up in the content. To be open - and willing even - to experience pain in the service of values. The other really powerful aspect of ACT is its behavioural focus, committing to move towards your values even in small ways and learn skills to manage difficulty as it arises.
I am also an advocate of Compassion Focused Therapy. It offers so much to people in pain in terms of understanding the activity of the mind, and is very de-shaming for people who treat themselves harshly.
Buy Michael's book "A Practical Guide to Working with Depression: A cognitive behavioural approach for mental health workers" here