Chronic pain: psychological treatment, step by step

She walks in with a folder and eighteen months of reports. Lumbar MRI: mild disc bulge, nothing that explains what she describes. Blood work normal. Two rounds of physiotherapy, an anti-inflammatory that stopped helping months ago, and a sentence she was given at her last appointment: «you'll have to learn to live with it». She sleeps badly, she stopped swimming and she has been off work for three months. That is how chronic pain arrives at a psychology practice: once the medical system has done what it could and life has shrunk around the symptom.

This article goes through what we know about the psychological treatment of chronic pain: what it is and what it isn't, why pain can persist with no injury to justify it, how to assess it without the patient feeling they're being told «it's all in your head», and which interventions actually have evidence behind them. It is written from the consulting room, for clinicians, although it will also help if you landed here trying to understand your own pain.

What chronic pain is

We talk about chronic pain when pain persists or recurs for more than three months. That is the threshold used by the eleventh revision of the international classification of diseases, and by almost every clinical guideline. It is not acute pain that has dragged on: it is a different thing, with a different mechanism and a different treatment. The APA dictionary defines it along those lines, as pain that outlasts the expected healing time of a tissue.

The prevalence figure most often quoted in Europe is around one adult in five, more common in women, with low back pain, neck pain and osteoarthritis at the top of the list. Translated into your diary: if you see thirty people, a sizeable share of them live with persistent pain, even when that is not what brought them in.

ICD-11 introduced a distinction worth knowing, because it changes the conversation with the doctor. There is secondary chronic pain, where an underlying disease explains it (arthritis, diabetic neuropathy, cancer), and there is primary chronic pain, where the pain is the problem itself rather than a symptom of something else. Fibromyalgia, irritable bowel syndrome and non-specific chronic low back pain belong here. MedlinePlus has a plain-language page on chronic pain that works well as reading to send home after the first session.

Why it still hurts when «there's nothing there»

Here is the piece almost nobody has explained to the patient, and the one that holds up all the work that follows. Pain is not measured in the tissue: it is produced by the nervous system. Nociceptors send signals, and the brain decides, using that information plus a great deal more (context, memory, fear, what the pain means to you), whether to generate pain and how intense it should be. That is why a sprained ankle mid-match doesn't hurt until the final whistle, and why a back with a normal MRI can hurt every single day.

When the system has spent months on alert it gets better at its job, which is to warn. The threshold drops, signals that used to go unnoticed get amplified, and eventually harmless input produces pain: leaning on a hand, a bedsheet brushing the skin, sitting for twenty minutes. This is central sensitisation. It is not imagination or exaggeration; it is an alarm system well calibrated for an emergency that is already over.

Nociceptive, neuropathic and nociplastic

Telling the mechanisms apart helps you set expectations and talk to the rest of the team:

• Nociceptive: there is real tissue damage or inflammation. It hurts where the problem is and responds reasonably well to anti-inflammatories.
• Neuropathic: there is injury or disease of the nervous system itself. It burns, stabs, gives electric shocks, follows the path of a nerve.
• Nociplastic: no tissue damage explains it and no nerve lesion can be demonstrated, but pain processing is altered. Fibromyalgia sits here, and so does much of the persistent pain that reaches psychology. This is the scenario where psychological intervention carries the most weight.

All three can coexist in the same person, and usually do. Knee osteoarthritis (nociceptive) with two years of history, poor sleep and fear of moving almost always has a nociplastic layer on top.

What chronic pain is not

The fact that psychology has something to offer does not make the pain «psychological». That confusion is the number one reason a patient with chronic pain never comes back for a second session.

It is not a matter of willpower either, nor depression in disguise, nor secondary gain by default. Some cases do involve a workplace dispute or an ongoing disability claim, and that has to be explored without prejudice, but starting from suspicion wrecks the alliance before you begin. And it is not the same as somatization, even though they share mechanisms of attention and amplification: in chronic pain there is a localised, persistent pain that organises a whole life.

The goal is not to make the pain stop

This needs saying early and gently, because if you don't say it, it says itself two months later in the form of a dropout. The realistic goal of the psychological treatment of chronic pain is not zero. It is getting back the life the pain has taken: returning to work, going out again, sleeping through the night, stopping the habit of measuring intensity all day. The pain often does come down along the way, but it comes down later, and it is almost never the first thing that shifts.

In session it sounds like this: «I don't know whether we'll get it to hurt less. I do know we can get you doing more things with the pain you have, and that usually brings the intensity down in the end». It is honest, it is what the data say, and it hands the patient back something they had lost: a goal that partly depends on them.

Assessment: what to ask in the first session

The first session decides whether there will be a second. This is not about collecting an intensity rating and moving on to technique; it is about the person leaving with the feeling that somebody has finally understood the whole picture.

Map the day, not the pain scale

Ask about a whole day, from waking up to falling asleep. What they do, what they have stopped doing, when in the day it is worst, what they do when a flare hits, how long they spend lying down, how many times they get up at night. Interference matters more than intensity: two people reporting a seven out of ten can be living completely different lives.

Write down the history of the pain in the patient's own words, too. «It digs in», «like carrying a stone», «it's a live wire». Those metaphors become working material, and if you record them verbatim in the file you can use them six months later. A session notes template with a fixed slot for function and sleep saves a lot of time across long follow-ups.

What gets referred, no discussion

Psychology does not replace medical assessment at any point in the process. Refer again whenever a change of pattern shows up: new pain in a different location, loss of strength, bladder or bowel changes, fever, unexplained weight loss, night pain that wakes them in a way it didn't before. And if you pick up suicidal ideation, persistent pain is a recognised risk factor: apply your protocol, don't play it down by attributing it to the pain condition.

The psychological treatment that has evidence

The UK's NICE reviewed the evidence in depth for its guideline on chronic primary pain and left a message that surprised a lot of people: it recommends supervised exercise and psychological therapies (cognitive behavioural therapy and acceptance and commitment therapy), while recommending against starting most of the usual analgesics for primary pain. Psychology is not a pleasant add-on here: in that scenario it is first-line treatment.

Pain neuroscience education

It is the first piece and the best value for time. Explaining how pain works, what sensitisation is and why a normal scan doesn't mean «there's nothing wrong with you» reduces fear, and with it part of the pain. It works better with drawings and with your own metaphors than with a lecture. The most useful one is usually the alarm: if the smoke detector goes off every time you make toast, the problem isn't the toast, it's the detector's sensitivity. Nobody argues that the alarm is really sounding.

Cognitive behavioural therapy for pain

Cognitive behavioural therapy applied to pain works on catastrophising («this is going to get worse», «I'll end up in a wheelchair»), excessive guarding behaviours, the relationship between activity and flares, and the gradual return of what had been given up. The central piece is activity pacing: moving from the all-or-nothing pattern (a good day means doing everything, the next three are spent in bed) to small, sustained amounts set by time or repetitions rather than by how the pain feels that day.

Acceptance, values and flexibility

When pain doesn't go away, fighting it eats up a whole life. Acceptance and commitment therapy shifts the target: instead of controlling the sensation, widen what the person can do while the sensation is still there. You work on willingness to feel the pain without organising life around it, distance from thoughts about it and, above all, values: what they want back, and what the smallest possible step in that direction is this week.

Present-moment practices fit well here, with one important caveat: don't sell them as a painkiller. If the patient understands that mindfulness is there to bring the pain down, and it doesn't, they drop it within two weeks and walk away with one more piece of evidence that nothing works.

Graded exposure to movement

A large part of persistent pain is maintained by avoidance. The person has been ruling out movements that hurt once, and the repertoire narrows until almost everything feels risky. Kinesiophobia (fear of movement) predicts a worse outcome better than pain intensity itself. The work is classic exposure: a hierarchy of feared movements, an explicit prediction of what will happen, exposure, and then checking what actually happened. It goes much better alongside a physiotherapist doing the same job from the other side.

Pain, sleep and mood: the loop that feeds itself

Sleeping badly lowers the pain threshold the next day, and pain breaks up sleep. It is a loop, and treating it often produces results sooner than attacking the pain head-on. Where there is insomnia, cognitive behavioural therapy for insomnia is indicated just as it is anywhere else; time-in-bed restriction is a harder sell in this group, because the bed has turned into a refuge.

Mood works the same way. Comorbidity with depression and anxiety is high, and it is not always clear which came first. You don't need to settle that order to get to work: behavioural activation and emotion regulation serve both fronts at once.

Partners and family: helping without reinforcing

The people around the patient do what they can, and sometimes what they can works against them. Two patterns are worth exploring. The first is overprotection: the partner takes over everything, removes tasks, speaks for the person in meetings. With the best intentions, it confirms that the pain is disabling and shrinks activity further. The second is attrition: after two years of pain, distrust and resentment appear, and the patient starts overplaying the signs so as to be believed.

One session with the partner, without turning it into couples therapy, changes quite a lot. The agreement usually goes like this: help with what the person cannot do today, not with what they are afraid to do; and ask how the day went, not how the pain is.

Working with the doctor and the physiotherapist

Chronic pain is interdisciplinary territory by definition, and one contradictory message brings the whole thing down. If physiotherapy says «you need to move» and the specialist says «careful with that back», the patient keeps the second sentence. Fifteen minutes on a phone call or a short report is time well spent, always with the patient's written informed consent, to agree three things: the functional goal for the quarter, who owns the activity plan and what happens when a flare hits.

On medication, your role is supportive, not prescriptive. High as-needed analgesic use is common, sometimes opioids prescribed years ago. Tapering is the doctor's call; what you can work on is adherence to the regimen they have set and the «only when I can't take it any more» pattern of use, which reinforces the circuit.

How a long case holds together in practice

A chronic pain treatment runs for months and has its ups and downs. The difference between a process that moves forward and one that fizzles out is nearly always the record-keeping. Three things worth writing down from the first session:

• A measure of function, not just of pain. Minutes walking, flights of stairs, hours worked, times they went out with friends. That is what shifts first and what sustains motivation when intensity refuses to budge.
• The agreed goal for the month, in one sentence and with numbers. «Swim twenty minutes, twice a week» can be reviewed; «feel better» cannot.
• Flares and what preceded them. Without obsessing over a pain diary (which sometimes worsens attention to the symptom), it is enough to note the two or three episodes the patient brings to session.

With that, a three-month review stops being an impression and becomes a comparison. And if the case gets complicated, you have the traceability you need to reformulate it or to write a report for the doctor.

Mistakes that stop the patient coming back

• Opening with a relaxation technique in the first session, before the person has felt believed.
• Promising the pain will disappear. When it doesn't, you are the one who loses credibility.
• Using «psychosomatic», «functional» or «central» without translating them.
• Measuring intensity only. If the single indicator is a number from 0 to 10, treatment looks stuck even while life is getting better.
• Working with your back turned to the doctor and the physiotherapist.
• Confusing acceptance with resignation, and letting the patient hear it as «you'll just have to put up with it».

Running these cases without admin eating the session

A chronic pain process is twenty or thirty sessions spread over a year, with reports to the doctor, follow-up scales, consent forms and stretches of better and worse. It is exactly the kind of case where paper goes missing and things get forgotten.

My Psico Agenda is built for that: encrypted digital clinical records with the full thread of each patient session by session, files and reports stored in their file, automatic WhatsApp reminders so a bad day doesn't turn into a missed appointment, consent forms signed from a phone and numbered invoicing with its PDF. It works on phone, tablet and computer, GDPR-compliant and hosted in the European Union.