Novel psychotherapy approaches for patients with chronic noncancer pain

Case description

Mandeep is a 32-year-old PhD student with a long-standing history of migraine headaches that started after a car accident in her adolescence. She saw a neurologist a few years ago, had normal findings on magnetic resonance imaging of the brain, and has since been taking propranolol for prophylaxis and a triptan for abortive treatment. Her headaches have been manageable and fairly infrequent since that time. She presents to your office concerned about an increasing frequency of headaches within the past few months. You complete a thorough history and physical examination. There are no focal neurological abnormalities or other findings on the examination to suggest a serious underlying cause. Mandeep wonders what else she can do to manage her headaches. She is hesitant about taking more medication.

After reassuring Mandeep that her headaches are likely a transient worsening of her usual migraines rather than a serious medical problem requiring urgent attention, you gently ask whether there might be added stress in her life that could be a factor. Mandeep tearfully relates that she has been having more disagreements with her long-term partner recently. You suggest booking a dedicated appointment to collaboratively look into whether this might be the cause of her worsening headaches and whether a psychological approach might help her.

Quality of evidence

The prospect of reversing chronic pain conditions is tantalizing, and many physicians may rightly be sceptical that talk therapy alone can provide substantial relief. In truth, only in the past few years has high-quality evidence for a robust treatment effect emerged, as standardized methods of providing these therapies have been developed and tested in randomized controlled trials (RCTs). There is now level I evidence for the effectiveness of nociplastic psychotherapy approaches based on RCTs, systematic reviews, and meta-analyses.

Main message

Family physicians should be familiar with several effective evidence-based types of psychotherapy they can recommend to patients living with chronic pain once a structural or inflammatory cause for pain has been ruled out: pain reprocessing therapy (PRT), emotional awareness and expression therapy (EAET), and intensive short-term dynamic psychotherapy (ISTDP).

PRT. The main therapeutic approach of PRT shifts the typical perspective of pain from being an indicator of tissue damage to a “brain-generated false alarm” that leads to avoidance of benign activities that have become associated with the onset or worsening of pain.⁶ The patient is provided with pain neuroscience education and is taken through a series of exercises to demonstrate that the pain can be reliably triggered by benign stimuli (such as imagining a painful activity). Patients are then encouraged to reattribute their pain symptoms to their brain as the symptoms occur, and to develop a sense of safety and positive self-regard instead of anxiety and pessimism, using self-talk and brief meditation practices called somatic tracking. An RCT of PRT published in 2022 showed a statistically significant and durable positive effect in patients with chronic back pain.⁷ Those who succeeded in reattributing the source of their pain from their backs to their brains appeared to benefit the most from treatment.⁶

In our experience, PRT can be provided by trained therapists but also lends itself well to self-treatment in the form of books and online video courses (Box 1). It can also be delivered through peer coaching from those who have recovered from chronic pain.

EAET. The premise of EAET is that chronic pain and other symptoms without clear physical causes can be manifestations of internal emotional conflicts, which are often related to adverse experiences in early life.^8,9 A developmentally acquired avoidance of complex mixed feelings toward important attachment figures from both the past and present appears to be the driving force behind many patients’ symptoms; becoming aware of and giving expression to these hidden feelings can often result in substantial improvement.

A trial of EAET versus CBT for chronic musculoskeletal pain published in 2024 showed statistically significant benefits of EAET over CBT on measures of pain, as well as for measures of anxiety and depression.¹⁰ EAET has also shown benefit compared with CBT in the treatment of patients with irritable bowel syndrome and fibromyalgia.^11,12 EAET can be provided either as individual or group treatment, and there is some evidence suggestive of benefit when it is administered virtually in a self-guided, asynchronous format.¹³

Because of its emphasis on the expression of strong emotions, EAET may not be an optimal treatment choice for patients with substantial emotional dysregulation or defensiveness about their emotions.

ISTDP. When patients’ symptoms are more complex or recalcitrant, a more intensive approach may be helpful. ISTDP is a modality that is part of the greater family of experiential dynamic therapy, an umbrella term that includes similar approaches (eg, accelerated experiential dynamic psychotherapy, affect phobia therapy).

ISTDP offers the advantage of a personalized approach to each patient, wherein the therapist carefully monitors the patient’s conscious and unconscious responses to each verbal intervention and responds accordingly.¹⁴ The goal, as with EAET, is to uncover hidden emotional conflicts that patients avoid through automatic defence mechanisms; these conflicts and defences often drive physical symptoms.^15,16 Compared with EAET, ISTDP generally involves a closer examination of the relationship between patient and therapist and how this may mirror the dysfunctional aspects of relationships with other key figures in the patient’s life outside the therapy setting. This specific process may help patients overcome barriers to engagement, such as intense anxiety, ambivalence about treatment, or emotional detachment.¹⁴ Positive effects of ISTDP on pain and other physical symptoms,^15,17 including functional neurologic disorders,¹⁸ have been reported in multiple meta-analyses and reviews.

Access to ISTDP in Canada is currently limited compared with other more common types of psychotherapy due to the extensive training and experience needed to deliver treatment in this modality properly.

Recommending psychotherapy to patients: practical issues. Time constraints of a busy family practice may make it difficult for physicians to engage personally in psychotherapy, but providing education about nociplastic pain and referrals or resources for patients to explore on their own time can still be worthwhile. In this situation it can be helpful to provide the patient with documentation that a serious medical cause has been ruled out so their therapist may safely commence treatment. Arranging a follow-up visit to check on the patient’s progress and to ensure that no concerning new symptoms have arisen can provide reassurance.

Novel psychotherapy for chronic pain may be difficult to access outside large urban centres in Canada. Some patients may also benefit from mind-body therapies that have less published evidence backing them but are more widely available, such as internal family systems psychotherapy.¹⁹

Box 1 presents a number of resources and self-treatment options available to patients who are interested in exploring the modalities described here. Clinicians familiar with the books and programs we have recommended may choose to assign reading to patients and review the content with them at future appointments to gauge whether the approaches in question are suitable and effective.

Some patients may react negatively to the suggestion their symptoms are related to altered neural circuits rather than to a specific structural diagnosis. In our experience, patients with chronic pain have often been made to feel discounted or ignored by health care professionals in the past, which may trigger feelings associated with emotional neglect from their primary caregivers. This may be of particular concern in populations that have historically faced discrimination and neglect within the health care system (eg, women, sexual and gender minorities, racialized people). Any discussion about recommending psychotherapy to patients for chronic pain must be conducted with the utmost sensitivity and compassion, emphasizing that all pain is real and the patient is being believed and taken seriously.²⁰ Our personal experience is that it can be eye-opening and empowering, for both patients and clinicians, to be able to elicit consistent links between emotions and symptoms in real time, and some patients may have symptomatic improvement with just a single brief intervention.

Case resolution

At Mandeep’s next appointment you conduct a brief emotion-focused interview (as described in Box 2).^8,9,16,20 The discussion leads you both to agree that her headaches seem to be related to a tendency to avoid and suppress angry feelings and healthy assertion toward others, including her partner and her PhD supervisor. She is relieved there could be a specific trigger for her headaches. You provide Mandeep with contact information for therapists and online programs that can help her build capacity to tolerate the powerful feelings that drive some of her headaches. You provide a note for her prospective therapist indicating that Mandeep is medically clear to engage in psychotherapy for pain symptoms. You also suggest booking a follow-up visit in 4 to 6 weeks to check on her progress and to ensure that no new warning signs arise to suggest a need for more urgent medical intervention.