Pain management, somatic pain & chronic pain

Common sense would say that pain is in the realm of the physical (the body), and psychotherapy deals with the mind. So how could you expect psychotherapy to deal with very real pain?

Pain management therapy is based on an emerging theory of what creates the sensation of pain, and, in a broader way, what creates our perceptions in general. This theory goes against the grain of common sense - much the same way that thinking of the earth as a sphere goes against our common sense perception that it is flat.

Our commonsense understanding of perception is that our brain functions much the way a telephone or a television does: It receives some signals from the outside and "plays" them. These signals contain all the information necessary to create the visual or the sound, or other perception.

Neuroscience findings have been leading us to a more complex understanding of how we perceive. Essentially, perceptions come from a mixture of external data (similar to the commonsense signals described above), and a lot of interpolation done by the brain. Think of it as some kind of "connect the dot" method: It is not necessary for the brain to be sent a whole line of dots when two dots are enough to reconstruct that line. This is what makes it possible for movies to work: We actually see a series of still images, and our brain interprets this as continuous movement.

A paragraph from an article by Dr. Atul Gawande sums this up very powerfully:
"So the mind fills in most of the picture. You can get a sense of this from brain-anatomy studies. If visual sensations were primarily received rather than constructed by the brain, you’d expect that most of the fibres going to the brain’s primary visual cortex would come from the retina. Instead, scientists have found that only twenty per cent do; eighty per cent come downward from regions of the brain governing functions like memory. Richard Gregory, a prominent British neuropsychologist, estimates that visual perception is more than ninety per cent memory and less than ten per cent sensory nerve signals."
(Atul Gawande, M.D., The Itch, The New Yorker, 6/30/08)

Perception is a constructed reality, very much influenced by such functions as memory. According to this theory, so it is with the perception of pain. Of course, this doesn't mean that pain is imaginary. This would be just about as absurd as saying that the outside world that we see and hear is all a figment of our imagination. Pain is very real. What this means is that our experience of pain includes a sizable component that is constructed by our emotions and memories... as well as by "default" functions in our brain that will automatically "connect dots", whether this is warranted or not in a specific situation.

So managing pain is neither a feat of superhuman willpower (gritting teeth to willfully ignore the pain)... Nor is it about magically making pain disappear. Pain management operates within the context of a sophisticated theory of what causes our perceptions. We pay attention to the internal factors that contribute to constructing the experience of pain, and we work on them.

In other words: Going to counseling does not mean that the pain is "all in your mind". It means finding a better way to understand it and deal with it. It can also mean finding some underlying emotional problems (e.g. Dr Sarno's approach to back pain).

See also: Somatic psychotherapy