Why do they want me to see a psychologist – I’m not nuts, I just have pain!

Explaining to someone that seeing a psychologist about chronic pain might be helpful can be a bit like this:

Yup, brick wall – hard object!

I can see it from the person’s point of view – it’s taken a long time (usually) for medical and other people to recognise that this pain isn’t simply going away, and isn’t about the person being ‘pathetic-why-don’t-you-just-pull-yourself-together’, so when someone suggests that psychology might be helpful it’s like saying ‘You’re nuts, you’re just losing it’ – or worse, ‘you’re a hypochondriac’.

I thought it might be helpful to review some ways to introduce the idea of seeing a psychologist (or other allied health person), or using a CBT perspective in pain management.

The first approach might be to explain, using examples that the person has already given you from your assessment, what a cognitive behavioural approach can offer. Yesterday’s post about the distinction between cognitive behavioural therapy and a cognitive behavioural approach can be a useful guide: a CBT approach is about learning how to take control again rather than simply a set of techniques. It’s much less about who delivers the approach and much more about the philosophy of it.

The key points I think for a person to hear are

  • that this is about changing what you understand about pain (not simply being educated or getting more information)
  • once you’ve begun to think about your pain differently, you’ll find your feelings and actions are more able to change
  • that changing actions is difficult to start and maintain
  • but means you’re in charge of the process
  • this approach means you are more aware of the choices you have to be able to do things differently

I think it helps to draw from examples the person has already given you about their situation.  For example

‘You mentioned that when you’re trying to exercise, you’re worried that your knee is going to give out on you.  I’m guessing that when you walk somewhere, you’re probably looking at what you’re walking on and never completely relax, just in case.

I wonder if you’ve started to anticipate that it ‘might’ let go and perhaps get a bit worried about going somewhere where the ground is uneven?

You can see how quickly you learn not to do things ‘just in case’ something happens.  So your pain starts to decide what you can and can’t do.

If we can help you be a bit more confident about what is going on in your knee (changing what you understand about pain), it might be easier for you to start testing it out gradually in different situations.

This might help you anticipate problems a bit less.

And at the same time you might find if you learn how to relax your body and mind, you might find it easier to cope with the pain if it does happen.

Then you’ll be in a better position to decide what you want to do rather than letting pain be in charge.

Pain is a strong and unpleasant experience. It brings out immediate ‘automatic’ thoughts and emotions that we’ve probably used since we were young. Although these thoughts and emotions are often real, they’re not very helpful, so it’s useful to review them and replace them with more helpful thoughts.

While you’re learning how to manage pain, you’re often introduced to new ways of going about activities – like working to quota (‘pacing’), or asking for help. And by using these new ways of doing things, it can bring up thoughts or judgements about yourself and your situation that don’t help you keep on using the new skills (or at least make it feel unpleasant).
At the same time it’s difficult to change what you do when the rewards are a little way in the future.  We often use things like recording sheets or quota to help you achieve things and see your successes.  This helps you during the hard times, and can keep you focused.’

I don’t know whether it’s a good thing to reaffirm that you believe the person’s pain is real and that we don’t think of pain as a ‘mental health problem’.  I wonder sometimes whether saying that ‘we believe the pain is real’ can be experienced as a negative thing, as if other people don’t believe the person! And I am not happy with any suggestion that having a mental health problem is any better or worse than having a ‘physical’ problem.  I personally don’t say anything specific about the pain, except to listen and reflect empathically.

The second point is to reflect, using good listening skills, that the person is concerned about seeing someone ‘psychological’ or from a non-medical perspective.  Things that might help to say are:

‘I can see you’re not very comfortable with the idea of this new approach.  Can you tell me what’s going through your mind when I make that suggestion?’

‘It sounds like you’re worried that we might think you’re having trouble coping, or that your pain isn’t real.  Can I spend a little while just going through why we use this approach in our service?’

I do think it’s opportune to talk to the person about the effect of being told their pain is not likely to go.  I’m not sure whether this is ever really discussed with people, to ask what is going through their mind at that time, and it might be helpful to do so.

And lastly, is it imperative that the person see a psychologist at all? One of the other health professionals may be in a better position to work with someone who’s not keen on ‘shrinks’, for example occupational therapists, nurses, social workers.  You may be able to circumvent the reluctance by suggesting one of these health professionals, who can then discuss the person’s reservations about ‘psychology’ and review the beliefs and concerns underlying their resistance.

A CBT perspective doesn’t need to be introduced as ‘psychological’: it’s simply ‘self help’, using ‘no drugs’, living a healthy life.


  1. Nice post! As a practitioner spending lots of time with chronic pain patients, I know that how they think and feel about their pain is a huge factor.

    And we know the longer they have pain the more likely they are to become depressed, which invites even more pain.

    Pain may not be in her head, but once someone is afflicted with chronic pain (longer than 3 mos), it is often in the head where pain relief gains can be made.


  2. Oh well put Dr M!! Even if pain isn’t chronic, lots of gains can be made by addressing thoughts and beliefs. In fact, if you think about it, that’s what ‘reassurance’ is in the acute low back pain situation!
    Thanks for stopping by, and taking the time to make a comment, I hope to see you again soon!

  3. I’m a pain management psychiatrist, and people who refer to me describe me as that to patients – the important part being to include “pain management” in front of “psychiatrist.” I fin dthat most people are more than willing to go – wanting to try anything to help.

    Here’s an article I wrote on How to Cope with Pain that reviews what people can get out of seeing someone in mental health for their pain.
    Should I See a Pain Management Psychiatrist?

  4. What a great link – thanks for that!
    I wonder whether there are cultural differences with regard to seeing a mental health professional depending on the country the person is living in?
    I also wonder whether there are differences between people of varying socioeconomic backgrounds.
    It’s the stigma that people associate with ‘having a mental illness’ that really bothers me I suppose. At some point in the future I’d love to see people recognise that having a health problem is simply a health problem, and it doesn’t matter whether it’s ‘mental’ or ‘physical’ – it will affect a whole person!

  5. If only more people prepared patients as you suggest. Most people that come to me have no idea why, usually don’t want to be there (because they’re not adequately prepared) and are quite resistant (understandable really because most feel their pain is getting dismissed).

    Oh, and I have significantly more empathy for my pain patients now….have done something nasty to my own back!

  6. HP you really are in the wars! Thanks for that comment, I think most people who are referred for pain management as opposed to pain reduction have been inadequately prepared. Perhaps its partly about medical practitioners not wanting to acknowledge (a) that they can’t ‘cure’ and/or (b) that they don’t really know what we do!

  7. I believe most doctors would fall into (b) they have no idea what you do.

    Over the years I have sent chronically painful or patients who I thought might have emotional or psychological issues related to their pain, to psychiatrists who specialized in pain mgt. It’s been especially helpful for personal injury and worker’s compensation cases when the patient needs not only to manage their pain, but also have someone explain to everyone else why they have their pain.

    Sometimes it would be a hard sell to get the attorney to understand why and insurance companies would often fuss, but many cases would not have progressed without it.

    And hey, lets be honest here, sometimes you need proof from an expert that someone is not “crazy,” but are instead actually in pain!

    Do you know how often my patients are insulted by the insurance company and their own attorney who ask me if they’re “nuts” (their word not mine) just because their pain doesn’t go away in a timely manner? It’s maddening (unfortunate pun there).

  8. In NZ we don’t have quite the litigious environment that happens in the US, so I find it’s often the medical profession who inadvertently suggest that because the pain is not going away ‘normally’ the person must be either ‘pathetic’ or ‘depressed’. And of course the family members and colleagues – and if you’re a bloke in NZ and play rugby, well ‘just get on with it’!
    Again I’m not sure that people necessarily NEED psychological or psychiatric input – rather they need to have the biopsychosocial model applied from word go, and all of us in the health care field could use it all the time.

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