Week 1: Understanding chronic pain

Week 4: Healthy thinking, healthy self

Week 5: Balancing your activity patterns

Week 6: Maintaining your gains and staying well

The biopsychosocial model of pain

The biopsychosocial model of chronic pain is a helpful way of understanding the relevant factors involved in the pain experience. This model suggests that biological, psychological, and social factors all play a role in the development and maintenance of chronic pain. These three factors can overlap and influence each other. The many different ways that biopsychosocial factors interact can help us understand why people experience pain differently.

Examples of biological factors include genetics, physical health and response to medication. Examples of psychological factors include self-esteem, coping skills and personality. Examples of social factors include cultural influences, family relationships, and social support. Based on this model, treatment for chronic pain can only be effective if all dimensions (biological, psychological and social) are taken into account. This is why psychological therapies play a role in pain management, in addition to medication and physical therapies. 

Below, we discuss some of the psychological factors that impact pain. We also briefly touch on some key behavioural and social factors that can worsen pain. Whilst biological factors are important, they are not directly targeted in CBT and therefore won’t be discussed in depth here. 

Important psychological factors involved in the chronic pain experience include:

  • Thoughts about pain. Unhelpful thoughts about pain can result in unhelpful ways of coping with it. They can also worsen the severity of your pain, increase your suffering and lead to greater disability. 
  • Catastrophic assumptions. Assuming the worst is common amongst people with chronic pain. When you frequently assume the worst case scenario (e.g., “my pain will never get better” or “I won’t be able to cope”), tension increases in the body and your pain can get worse. This type of thinking is also likely to prevent you from engaging in helpful coping techniques. 
  • Seeking answers. Whilst it is essential to be well educated about chronic pain, information seeking can go too far. Some people fail to accept their diagnosis and/or continue to look for medical explanations and solutions for their pain. This can interfere with effective treatment.   
  • Fearing further damage. When pain is thought to signal further damage to the body, people are more likely to be distressed by it. However, in chronic pain, the pain itself does not signal this kind of damage. It is more helpful to think of chronic pain as a continuing, but stable, problem that can improve over time.  
  • Negative emotions. Pain is closely related to negative emotions, including depression and anxiety. Negative emotions can worsen pain and vice versa. As such, addressing difficult emotions and treating comorbid mental health conditions is an essential part of chronic pain management.
  • Pain self-efficacy. Pain self-efficacy refers to your belief in your ability to cope with your pain. Many people with chronic pain have low pain self-efficacy. In other words, they have little confidence that they can manage their pain or change it in any way. Increases in pain self-efficacy often result in use of better coping strategies and pain reduction.

It is also important to briefly note some important behavioural and social factors that impact the chronic pain experience. People with chronic pain often adapt their behaviour to cope with their pain. Some people tend to ‘guard’ their injury by changing the way they move around (e.g., limping, bracing, using walking aids). This guarding behaviour often continues beyond the point of healing and can cause secondary injury, as other parts of the body have to work harder to compensate for the guarded area. In addition to guarding, many people with chronic pain become underactive and rely too heavily on resting as a coping strategy. 

In contrast, other people tend to become overactive and may overwork the painful area. These people may believe that they can “push through” the pain or that the activity will help “loosen up” the body and reduce their pain. However, overactivity often leads to inflammation and an increase in pain. Whilst these forms of coping are understandable, they are also unhelpful in the long run. Later in this course, we will introduce you to some more helpful behaviours for pain management.

Lastly, the people around you can significantly impact your experience of pain. Having at least one person in your life who knows about and understands your pain is important. Not only can others provide practical and physical aid, they can also provide emotional support and a shoulder to cry on when needed. Importantly, good sources of social support should also be a welcome distraction from pain. They should be able to help you focus your attention away from your problems and onto different topics or activities for a period of time.

However, although well meaning, some support people can be unhelpful. Supporting people who are highly focussed on or overly responsive to your pain may actually make it worse. Similarly, supporting people who rush in and do things for you, rather than allowing you to manage them alone, may keep you feeling more ‘disabled’ than you actually are. Unfortunately, there are also people who are unsupportive and punishing in their response to others’ pain. Angry or dismissive responses to your pain by others is also likely to make it worse.