Overcoming suffering and pain is difficult—sometimes it even seems impossible. Pain can isolate you from family and friends, causing you to feel alone in the world. Chronic pain takes a serious toll on your mental health, your self-esteem and your ability to cope with the changes that have occurred because of your chronic pain condition.

Chronic pain conditions not only change how your body functions, but also the way the brain works. Overcoming isolation and opening your mind to psychological help are two ways you can start on the path to healing. Support groups and psychological intervention are important tools available to people living with chronic pain.

Sarah M. Whitman, MD, is a psychiatrist in private practice in Pennsylvania and Clinical Assistant Professor in the Department of Psychiatry at Drexel University College of Medicine, Philadelphia. After her own experience with a chronic pain condition, Dr. Whitman began focusing her practice on treating people with pain conditions. She also runs a series of support groups for people with chronic pain, a web site, www.howtocopewithpain.org, and recently published a handout for family members of those suffering from chronic pain with her colleague, psychologist David Kannerstein, Ph.D., titled Surviving a Loved One's Chronic Pain.

How did you become interested in working with people with chronic pain?

It's actually from my own experience. I had developed a chronic pain condition, and started to get very interested in the biology of pain and understanding the difference between acute pain and chronic pain. I began to look at the research and to understand what happens to the brain in pain. I'm a psychiatrist — I've always liked that interface between psychology and people's stories, and biology. After my own experience, I was interested in treating people with chronic pain both from an understanding of medicine and what happens in the brain, as well as listening to people's own stories, which is really important.

Can you describe how chronic pain changes the brain?

It depends on the type of chronic pain. One of the areas that I am particularly interested in is neurological chronic pain — for example, RSD or central pain which is pain developed from a brain lesion itself. Some of things I find really interesting are, in RSD for example, if you have pain in your hand, there are changes in your hand, changes in the nerves that run up to the spinal cord, in spinal cord itself, and finally there are changes in the brain.

Some of these changes happen within a couple of days of experiencing pain. We used to think these changes happened slowly over months, but we've found that these changes happen very quickly. The part of the brain that's allotted to pay attention to your pain increases fairly quickly.

Your brain is set up in a way that if you're in pain, more and more of your brain gets taken over by paying attention to these pain signals — they're very important signals for you to attend to from an evolutionary perspective.

In the past 10 years, we've begun to understand more about what happens in the brain, and some of the treatments that are coming out are more advanced and exciting than, say, taking medications and or having an epidural injection. For example, some of the functional magnetic resonance imaging (fMRI)1 work that is coming out of California helps people look at their own brain signals — by neuromodulating those brain signals, some patients can decrease their pain.

Why are support groups important?

I think they're important because, while most people know what acute pain is like, I think chronic pain is very different. If you haven't had that experience, it's hard to imagine what it's like to be in pain most days or constantly.

In my experience in treating patients, having a chance to talk with other people who have been through a similar experience, is really helpful. It's helpful to have someone else say, "Oh, I know what it's like to always be in severe pain." Or, in some of the conditions like RSD that have some unusual features, to have someone else say "Oh, I know what mirror image spread of pain is," it helps people know they're not imagining it.

When their families get tired of hearing about the pain, they have someone else who knows what that experience is like. Having a peer support group lets people have one other place to talk about not only the disability associated with chronic pain, but also what they've found helpful, how they deal with the loss of work or how they deal with the impact on their whole family system.

I think chronic pain is a traumatic life experience to go through. Just like with a cancer support group or other difficult chronic diseases, to be able to talk to other people who have gone through it is very helpful.

What happens during a support group?

I run eight-week support groups. I call them Coping with Pain groups rather than just pain support groups. About four of the sessions are devoted to learning skills, such as breathing exercises, relaxation exercises, visualization, or guided imagery — all ways to decrease the pain and cope with the pain levels that people have.

The other sessions, and even some of the skill-building sessions, are a chance to talk about specific topics, such as how to cope with the loss of work or loss of friendships and hobbies. One of the things I emphasize in my groups is not just describing the difficulties or pain they have, but also the ways to cope with those difficulties or pain.

Another topic during the support group is discussing what types of coping skills are helpful, such as how to use pacing. Pacing is keeping track of your pain levels across a day or a week and not going over a point that's going to leave you in more pain in the long run. You may go out and garden — in the past you could do the whole yard in a morning, but now you plant for 15 minutes and then come in and take a break or do some breathing exercises. Then you go out again later and do another 15 minutes. Pacing involves trying to do some of the same activities but managing your pain as you go along.

Sometimes people have to really change their lives from what they used to do, either by modifying activities or sometimes by completely giving up some of things they've done in the past. Part of the support group is helping people identify how they can go about replacing some of those things they've given up with things they can do now. Again with our gardening example, perhaps you can't do the whole yard anymore, but container gardens still let you dig in the dirt and see plants grow. Or perhaps you do need to find a whole new hobby, so try swimming instead. It's a gradual process — it's challenging and difficult for a lot of people to really have to change their lives.

What's the best way to find a group in your area or to evaluate whether it's the right group for you?

One way to do so is to consult national pain organizations or talk with your pain management physician. Both may know what groups or other resources may be in the area.

What I suggest people look for in groups is a focus on how to cope with their disorder, not just discussing how much pain they're in or who has the most pain — living with pain rather than just talking about pain. I'd certainly encourage people to try one - it's better to go to a support group and find out that it's the wrong one and keep looking, than to be fearful about going to one.

Many of the national pain organizations also have good online chat groups or online groups — sometimes people are limited in how much they can travel or go out, or there isn't one in their area. Many of the online groups sponsored by national organizations are moderated, which I think is a good idea.

What can people do to get the best out of their treatment?

What I think is important is a willingness to try to learn about what's going to help them. One point that I try to get across throughout the treatment process is that, for many people, this is a chronic disorder or at least this is a disorder that's going to take a while to treat. If things aren't fixed in the first month, that doesn't mean you give up or start looking for a new doctor.

One treatment or approach is usually not going to work alone — it does take time and different approaches all put together. It's a lot to ask of people who are in significant pain to wait, but that's often the way pain conditions heal or get better. It can be very slow.

It helps when patients are willing to look at functioning, instead of just what their pain levels are. The goal may not be to have your pain at zero on a scale of 1 to 10 — that may not be realistic. It's important to look at what your pain level is, certainly, but also at what ways you have to cope with that pain level. You need to look at how you are functioning. Are you able to go back to work even with some pain? Are you able to do your hobbies? Are you able to go out and socialize or spend time with your family? You need to look at a broader picture of what is getting better.

Patients need to be willing to look beyond just taking medication to treat their pain. I tend to look at the bio-psycho-social model. What is going to help biologically in terms of medication or injections? They need to be willing to look at the psychological piece in terms of dealing with what's causing stress in addition to the pain disorder, or looking at psychological ways to cope with the pain, such as putting some effort and time into breathing, relaxation, and guided imagery exercises.

The social part of a bio-psycho-social approach is trying to go back to work or changing work so they can do something meaningful. I think the most challenging thing is to come up against the fact that they may have to change their life. They like their old life, but they need to be willing to take a look at a different future — maybe you can't go back, so how can you go forward. I think that's an ongoing process for people. I don't think that changes immediately.

Is eight weeks the norm for support groups? Would people benefit from a longer running group? Do people repeat the experience?

Some patients like to come in and learn skills and then move on. I do encourage people to exchange e-mails and phone numbers to continue contact after the group. Some people will come in for therapy and work more intensively for a period of time and then follow as needed. Some people have gone through the group more than once — some for a skills refresher and some to have contact with other people with pain disorders.

What about people who go to a support group indefinitely? Is there a benefit for that sort of model?

About 25% of the people I see continue in psychotherapy or will come back for a second support group session or even a third group. I think for some people, especially if their pain becomes more manageable over time, they come to a point where they can they resume their life in some sense. They go back to work or some other fulfilling activity. They socialize with their family and friends. Many of those people don't continue, which I think is positive. Therapy has helped them cope with their pain condition and they've moved on.

The people that I tend to see that continue therapy over time have more severe pain or pain that starts to get worse. In those cases, I believe it often is helpful to continue in therapy for support, to continue to learn skills, and to modify the guided imagery that we do. I also do hypnosis, which I think is helpful for certain people and we may continue to work on that.

For some people with chronic pain, how their condition effects their life changes over time. For example, I may discuss certain issues with someone if she starts to see me when her kids are 8 and 10. But when her kids get into their teenage years, there may be new issues that come up for this family because of her chronic pain problem. There are new challenges to deal with as things around patients change or as their own pain condition changes. At times, it is helpful to the patient to revisit therapy.

Why do you think there's such resistance to therapy?

I think in general, people are resistant to therapy — not just patients with pain. For example, many people with anxiety want to take a pill and not go to a therapist. Therapy results are often slower than taking a pill for depression or anxiety. Our society focuses on a quick fix rather than working on more permanent changes or the underlying problem. I also think mental health certainly has a stigma. The fear people have when their neurologist or anesthesiologist refers them to a psychiatrist is that their doctor thinks it's all in their head rather than a "true" medical problem.

As a society, we're used to treating things biologically rather than looking at what is happening psychologically that contributes to disorders. It's the same thing if someone has diabetes. It's easier to take an insulin shot than the harder work of changing your exercise habits and diet, or losing weight over time. I think that's true of pain disorders as well. You hope that one injection will be the cure or one medication will get the pain down to zero.

Hopefully, people realize that if you add to your medical treatment --- with guided imagery and hypnosis, with changing the way you sit at the computer — all these types of things can help with pain disorders. Some people are more amenable to looking at things from a broader perspective and are interested right away in going to a psychiatrist or pain management therapist to learn anything that's going to help. They're very interested in trying to help themselves.

Editor's Note —
A significant roadblock to psychological treatment is funding — people who are uninsured or whose health plans do not support psychological treatment may have a difficult time getting professional help. Free support groups, in these instances, may be helpful but caution is advised. If the group experience results in increased functionality and a sense of healing, then it is probably good. If the opposite occurs, it is probably not worth pursuing.
Richard Stieg, MD, MHS

1. Mackey S. Functional MRI for pain. Program and abstracts of the 22nd Annual Meeting of the American Academy of Pain Medicine; February 22-25, 2006; San Diego, California; Baron, R et al. Brain processing of capsaicin-induced secondary hyperalgesia: A functional MRI study. Neurology, vol 53, no 3, Aug 11, 1999, 548-557.