“Are you going to tell me it is in my head?”

Author: Sarah Walsh, Axis Clinical Lead & Health Psychologist

Pain Psychologists work with people experiencing pain past normal healing times. The suffering is often unpredictable, inconsistent, intense and relentless. It starts to impact every part of a person’s existence.  

The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to walk through water without getting wetRachel Naomi Remen, Kitchen Table Wisdom 1996 

When experiencing persistent pain, the things people used to take for granted aren’t possible. Things like taking a shower require problem solving and planning. It is mentally and physically exhausting. When pain doesn’t ease in expected time frames the most normal, human, common sense response is to feel like there something “seriously wrong”.  

This feeling is often compounded by seeing numerous health professionals and not receiving any satisfying explanations. Or perhaps being told “it’s all in your head”, “you’re fine to go back to your normal life”.  

Often, there is also personal and financial stress, extreme sleep disturbance and confusing experiences with compensation or insurance processes. This results in a chronically tense, highly distressed patient, who generally avoids doing anything they used to love, for fear of harming or re-injuring themselves. This is the most normal response to unexplained pain that won’t go away.  

This patient has a strong sense of hopelessness and often distrust of health professionals, especially psychologists. It can be hard to join the dots as to why would you see a mental health professional for a physical injury? There are many reasons for this, the fear comes from the stigma around mental health, not wanting to be considered crazy and the concern that they will receive the message that there is some kind of conscious control over their pain, and they aren’t trying hard enough. The reality is not that simple.  

It’s true that psychologists work a lot with cognitions, everyday people don’t always think about their thinking. Most of the time we don’t have to and our autopilot mode works just fine. However, the automatic cognitive and physiological responses to pain, particularly pain that lasts a long time, are often out of proportion to the amount of threat that exists. This is when our autopilot stops being helpful.  

Pain is a complex experience, produced by the brain, as a result of many systems in our body working together to try and protect. It is a very powerful behaviour change system. Think how quickly we take our hand away from something that is hot.  

To assist with recovery from persistent pain it is important to understand how patients perceive their pain, their level of health literacy and any misconceptions they may have about their pain. The knowledge someone has about pain contributes to how they think about pain, how they feel about it and how they respond. Thoughts are nerve impulses in the brain and can contribute to how protective the brain thinks it needs to be, and therefore how much pain is produced.  

This does not mean thinking differently will turn pain off like a switch. However, we know that our conscious mind can retrain automatic responses to help decrease the intensity of a pain experience. This comes in the form of helping patients to feel supported and safe, and helping them to access their higher order problem solving brain over their “fight or flight” survival brain.  

So no it’s not “all in your head”, but bringing conscious awareness to unconscious protective systems can be a good place to start.