Pain is more than just a physiological phenomenon; the human experience of pain has behavioral, cognitive, and emotional dimensions (Andrasik, 2005). In pain management for individuals with chronic pain, research suggests that psychological factors are even more essential to consider, since most medical treatments seem no longer effective (Jensen et al., 2001). The American Psychological Association published a book written by Turk and Winter (2006) that advices people with pain to reclaim their lives and become their own pain managers. Research shows that perceived self-efficacy and control are associated with better coping (e.g., Bandura, 1987). In retrospect, I realize that pain management is far too vast and complex a subject for a term paper. However, I am glad that I took this opportunity to do some research into this intriguing subject that certainly deserves the attention of a student in counseling health psychology.

Pain

Marks et al. (2005) defined pain as primarily adaptive, a biological warning mechanism that signals that something is out of balance in the body. Pain is a sensory and often emotional sensation of discomfort, mostly a symptom of an underlying physical disorder. Pain serves as a signal to take protective action and in that, pain is critical for survival (Pinel, 2009). However, pain is also a very personal and subjective experience that affects many areas in a person’s life and is influenced by many factors like culture, learning, and context (Dixon, Keefe, Scipio, Perri, & Abernethy, 2007). Brannon and Feist (2007) define chronic pain as pain that persists for six months or more and pain that does not respond to pharmacological treatment.

The experience of pain is the most important medical complaint, heard from patients in almost 80 % of their visits to physicians (Lebovits, 2001). Pain dominates the life of the people living with it because it often impairs functioning and has many effects on somebody’s social relationships (Turk & Winter, 2006).

Pain syndromes are symptoms that occur together and characterize a condition. Migraines, low back pain, arthritis, and phantom limb pain are examples of pain syndromes. Often pain is not only caused by the disease itself, for instance in cancer pain by the growth and progression of a tumor, but pain can also be triggered by the treatments that are meant to cure the disease (Allard, Maunsall, Labbe, & Dorval, 2001).

There are many types of pain and pain varies in sensation, intensity, and duration. Acute pain, for example, causes high levels of anxiety, where chronic pain can cause other problems like depression and sleeping problems (Keefe, 1982). More often than not, the experience of pain is an interplay of pain sensations due to tissue damage, physical disease, or injury with pain due to psychological causes (psychogenic pain). When the condition is long lasting, the psychological factors (e.g. anxiety, depression) normally increase (Turk, 2001).

Research suggests that women experience pain differently than men do. Fillingim (2003) confirmed that gender-related factors influence pain responses and responses to pain treatment, and emphasized the need to adapt treatment according to the personal needs of the person receiving it. This researcher found for instance, that interventions increasing the sense of self-efficacy seem to be more effective for women, where interventions to reduce anxiety might be more helpful for men (Fillingim, 2003). These examples suggest that qualitative gender differences might have substantial treatment (pain management) implications.

Eccleston and Malleson (2003) warned that chronic pain is not a uniquely adult problem, but that many children and adolescents suffer from chronic and recurrent pain. Chronic pain in children affects people around them and can cause distress and family disruption; in this situation, a multidimensional approach with a focus on the whole patient is called for (Eccleston, Bruce, & Carter, 2006). An intervention should focus not only the child itself, but also, for example, look at how the parents might encourage their child to exercise, or what the school could do to inspire the child to become socially involved with peers.

Studies did not show ethnic differences in the perception of pain, the experience of pain, or the impact of pain. Even though variations were found in coping strategies (e.g., prayer among African Americans and Hispanics), adaptive coping interventions were expected to be effective across ethnic groups (Edwards, Moric, Husfeldt, Buvanendran, & Ivankovich, 2005).  

Physiological Aspects of Chronic Pain

Chronic pain never has a biological benefit (Brannon & Feist, p. 166). Pain is a sensation evoked by noxious stimuli, external or internal. Pain perception however, is not entirely similar to other sensory experiences (e.g., vision or hearing) in that it operates more like the  bodies motivational systems such as hunger or thirst: it triggers certain response patterns such as withdrawal movements or recuperative behaviors (Janssen, 2002). The sense of pain has three unique properties: (1) there are no (known) specific pain receptor cells, (2) pain is experienced in response to various types of noxious stimuli, and (3) the perception of pain is often accompanied by a strong emotional response.

Nociception is defined as the reception of signals in the central nervous system evoked by activation of nociceptor, sensory receptors that provide information about tissue damage (Janssen, 2002, p. 131). Long lasting and/or intense noxious stimulation or damage sensitizes the nervous system and implies a risk for alterations in transmitters, receptors and neural connectivity (Jensen et al., 2001). The neurologic responsiveness can change when the receptor cells become hyper-excitable and when even stimuli that are normally below the threshold trigger a response. Another example is an expansion of the activated area in the neocortex, or a heightened sensitivity of the nociceptive neurons (Jensen et al., 2001). These changes can cause the pain to develop into chronic pain and persisting pain-related interference with functioning.

The discovery of opiate receptors in the brain led to the search for naturally occurring chemicals in the brain that effect pain perception. According to Jensen et al. (2001) opiate like neurochemicals (e.g. endorphins) lessen pain, but some neurotransmitter seem also to produce pain (e.g. glutamate). Placebos relieve pain by causing the release of endogenous opioids (Breedlove, Rosenzweig, & Watson, 2007). Petrovic, Kalso, Peterson, and Ingvar (2002) seemed to confirm this when they discovered that opioids and placebo’s reduced the pain response in the same areas in the brain.

Psychological aspects of Chronic Pain

Pain is a complex and multidimensional phenomenon. The biomedical model failed to explain pain in the absence of unidentifiable pathology (e.g., phantom pain) and pathology without pain. It also could not explain the variations between individual experiences (e.g., between people with the same pathology) and the variations in responses to treatments (e.g., the efficacy of pain medication). The biopsychosocial model of health regards pain as a result of an interaction between biological, psychological, and sociocultural factors (Andrasic, Flor, & Turk, 2005).

Gate-Control Theory of Pain and the Neuromatrix

           In 1965, Melzack and Wall introduced the Gate-control theory of pain that revolutionized the conceptualization of pain (Turk, 2005). According to this theory, the perception of pain is subject to modulations of the original sensory input. Structures located in the spinal cord act as a neural gate for the sensory input that the brain records and then interprets as pain. Psychological factors, which scientists interpreted as reaction to pain before, were now demonstrated to be an integral part of the processing of pain (Melzack & Wall, 1965). This theory invited the medical science to regard the brain as an active dynamic system that not only filters and selects the input from the sensory nerves, but also modulates it. From this perspective, physiology could explain sensory and psychological dynamics of pain perception (Turk, 2005). According to the gate control theory, pain has not only sensory components, but also motivational and emotional ones.

           The reality of painful phantom limbs suggests that the brain generates experiences like pain also without the explicit external inputs (Melzack, 2008). In 1999, Melzack proposed a new supraspinal theory: the neuromatrix theory. He explained pain as a multidimensional experience generated by patterns of nerve impulses produced by a complex and widely distributed neural network: the body-self neuromatrix (Melzack, 2008, p. 629). With this new view, phantom limbs became more comprehensible: the brain generates the experience of pain. When the active matrix is no longer receiving input from the limb it produces an abnormal response (firing of neurons) as a substitute (Woodhouse, 2005). The output pattern of the neuromatrix is determined by multiple influences, the somatic sensory inputs representing only part of the picture. In chronic pain, often characterized by severe pain that is not associated with discernible pathology or injury, other influences (psychological, environmental) are independent from sensory inputs that interact with the neuromatrix (Melzack, 2008).

Pain Management

According to Turk and Winter (2006), the body does not protest without a reason: pain is an important messenger and pain management the critical skill an individual needs to understand the message and live life optimally.

Physiological Approaches to Pain Management

Medical treatments

Turk and Winter (2006) considered surgical methods relatively radical and not likely to be effective for chronic pain. The most commonly used medical approach for treating pain involves pharmaceuticals. Four types of chemical treatments are common: (1) peripherally active analgesics reduce pain by inhibiting neurochemicals that act on the nociceptors (e.g., acetaminophen, aspirin, and ibuprofen), (2) centrally acting analgesics, narcotics (opioids) inhibit nociceptor transmission or perception of stimuli (e.g., codeine, morphine, and heroin),  (3) local anesthetics block nerve cells from generating impulses (e.g., novocaine, lidocaine, and bupivacaine), and (4) indirectly acting drugs, including tranquilizers, sedatives and antidepressants (Sarafino, 2008).

Antidepressants (especially the newer classes) and second-generation antiepileptic drugs are also often given to chronic pain patients and seem to modulate (neuropathic) pain by acting on specific neurotransmitters (Maizels & McCarberg, 2005).

Limitations for long use of drug are tolerance and dependency (addiction), and the many side effects that can seriously affect the functioning of patients. Breedlove et al. (2007) suggested that an early and aggressive treatment with narcotic analgesics is often appropriate, since once developed, chronic pain is extremely hard to treat.

Even the most potent pharmacological treatment however, will not be effective when the medication is not properly taken; personalized medication options and adherence consultation are behavioral strategies that can optimize drug treatments when necessary (Andrasik, 2005).

Physical manipulation, biofeedback, movement, and relaxation

Manipulation techniques like massage, relaxation, chiropractic manipulation, and  are often used as an alternative approach to pain management. Movement bases therapy (e.g., Chinese qigong, martial arts, and Pilatus), nutritional, or herbal therapies can also have beneficial effects on chronic pain. Although physical interventions are not the focus of this research project, they merit some brief remarks.

Bassman and Uellendahl (2003) explored complementary alternative medicine (CAM) modalities and suggested a shift toward a greater understanding of mind-body processes could expand the willingness of physicians and patients to explore the efficacy of CAM approaches. Interesting is the suggestion made by Godfrey and Dugan (2009) that the moderate effectiveness of acupuncture could be elicited by human touch and the power of suggestion/expectation; according to these researchers, primarily physiological approaches contain psychological elements that might influence the pain-related outcomes of the treatment. The simple “intervention” of giving personal and compassionate attention to an individual seeking help for chronic pain seems to be of help (Turk & Winter, 2006).

Another often-used tool with chronic pain is biofeedback. Biofeedback therapy helps individuals in training them to become aware of and gain voluntary control over physiological responses (e.g., muscle tension) that contribute to the experience of pain (Dixon et al., 2007). The most common biofeedback methods are electromyogram (EMC-biofeedback) and thermal biofeedback (Andrasik, 2005). Extensive research has shown that relaxation, often induced with guided imagery, meditation, or self-hypnosis, brings patients relief from pain and pain-related discomfort (e.g., Pavlek, 2008; Roelofs et al., 2002).

Psychological Approaches to Pain Management

The biopsychosocial perspective assumes that people’s experience of pain is not only determined by the underlying pathology, but also by environmental and psychological factors (Roelofs, Boissevain, Peters, Jong, & Vlaeyen, 2002). In this section, I focus on the psychological aspects of pain, and roughly divide the major psychological pain management interventions into behavioral, cognitive, cognitive-behavioral, affective, and integrative approaches.

Behavioral approaches                               

Behavioral approaches can be subdivided into three types of learning: (a) non-associative learning (e.g., habituation and sensitization), (b) associative learning, for instance operant and respondent conditioning, and (c) social learning (Andrasik, Flor & Turk, 2005).

Stressful experiences predispose us to experience anxiety in situations that are similar; pain expected or experienced in the present triggers responses from earlier pain experiences and influences the way we perceive pain (Turk & Winter, 2006). This is an example of non-associative learning. Stress management training can help patients to self-monitor their stress, and respond to it with coping techniques that range from relaxation, breathing to distraction and goal setting (Dixon et al., 2007). Imagery, often in combination with relaxation can also be used to help individuals, especially children, to alleviate the pain by distraction (Sarafino, 2008).

Montgomery et al. (2010) suggested that hypnosis was a successful tool to change expectancies and lessen distress and claimed that levels of expectancy for pain and suffering and emotional distress predict levels of pain and suffering. Hypnotherapy uses relaxation techniques and suggestions designed to transform affective and cognitive response to stimuli and thus modulating pain perception through mechanisms such as distraction, dissociation, and reinterpretation; altering the way individuals internally deal with pain (Mazzola et al., 2009). An hypnosis intervention invites patients (a) to transform former interpretations of disease and pain sensations into more positive constructs (b) and to divert attention to more healing thoughts. Both strategies are meant to reduce the brain’s response to the nociceptive stimuli (Butler et al., 2009).

Hadjistavropoulos, Hunter, and Dever Fitzgerald (2009), researched associative learning and the beneficial results from the reinforcing of coping mechanisms that are likely to lessen the pain (e.g., physical activity) and the refraining from pain behaviors that are likely to prolong the pain (e.g., complaining). These researchers proposed to identify the components and processes of the pain experience to be able to create appropriate interventions.

On the other hand, there are also patients who suffer from persistent pain but show resistance to express signs of pain (Wall & Melzack, 2000). Leventhal (1992) discussed the individual differences in reactivity and concluded that the way an individual pays attention to and copes with noxious stimuli influences this person’s pain threshold and pain tolerance. Distraction and suppression seem also effective ways to alter to intensity of pain. Christenfeld (1997) suggested after research that the attention a distraction is demanding and the hedonic value of the distraction itself have an important impact. 

Studies using functional magnetic resonance imaging (fMRI) showed that when an individual focused his/her attention on the pain certain areas (involved with pain regulation) in the periaqueductal grey region were activated, whereas when the same individual is distracted,  decreased activity in these areas were registered (Andrasik et al., 2005). Turk and Winter (2006) agree, they suggested that distraction can be one’s most useful ally.

An example of social learning occurs in situations where and individual feels that he or she is rewarded for pain behaviors by attention, sympathy, relief from responsibility, or disability compensations. Fordyce (2001) claimed that episodic pain could develop into chronic pain in patients who were reinforced in their (negative) pain behaviors by solicitous significant others. According to Martire, Schultz, Keefe, Rudy, and Starz (2008), spouses and partners play an important role in how individuals with chronic pain learn to cope with their emotions, and psychosocial interventions that include spouses and partners can be highly beneficial in pain management. Newton-John (2002) proposed further research into couples-based chronic pain interventions that seek to benefit optimally from this supportive relationship with a solicitous partner.  

Cognitive approaches

Cognitive therapy, working on the principle that our thought constructs about our pain can be changed, has a beneficial effect, especially in adults (Marks et al., 2005). Beliefs, appraisals, and expectancies held by patients can affect pain severity (Andrasik et al., 2005).

Educational interventions about pain management, clearly explaining the process and possible outcome of pain-related interventions have shown to be successful. Brief counseling sessions in which the patient is informed about pain management (e.g., information about analgesic care) and taught to monitor and report the pain intensity in daily pain diaries, seem to improve knowledge about and attitude towards pain (Allard et al., 2001). With knowledge about their pain coping processes and a way to measure their progress, patients seem to feel more in control and gain a sense of self-efficacy in relation to their coping skills.

Chronic pain patients do not expect to be completely relieved from the pain, the pain-related fatigue, or the emotional distress of the interference of pain with daily functioning by their pain treatment (Robinson et al., 2005). Patients do however, expect a significant higher pain reduction (the patient criteria for success) than clinical definitions of treatment success predict. Robinson et al. (2005, p. 236) speculated that the discrepancy between what the patient expects from the treatment and his or her personal “success criteria” (e.g., seeing the intervention as meaningful) might result in dissatisfaction and frustration.

Lebovits (2001) suggested that the inherent difficulty with chronic pain is that both practitioners and patients have trouble accepting that there is no cure. He confirms that false patient expectations can lead to further distress. The result of a misinterpretation of the curability of the pain can be a difficult physician/patient relationship that is characterized by frustration and possibly anger. The patient might not be taken seriously (e.g., the pain is his/her head), or the physician might treat overly aggressive medically. Clear and personalized communication and patient education are essential interventions to prevent additional suffering for chronic pain patients (Lebovits, 2001).

Individuals with persisting pain often turn to spirituality in an effort to better cope with the pain. Religious practice can help managing pain: it can be a way to find comfort and support from a community (and higher power), can engender feelings of acceptance, hope and relaxation (negative/absent higher power produces feelings of being punished or abandoned), and can also distract from pain (Wachhholtz & Keefe, 2006).

Spirituality seems to have a definite influence on how people cope with chronic pain (Wachholtz & Keefe, 2006). According to Wachholtz and Keefe (2006) positive religious coping has beneficial effects beyond what can be expected from an individuals’ adjustments to pain. These researchers found decreased levels of pain and depressive moods and increased levels of social support in chronic pain patients who reported positive spiritual coping strategies.

Rippentrop, Altmaier, Chen, Found, and Keffala (2005) reported that although positive religious coping techniques seemed to have a positive effect on mental health, they found no direct relation between these practices and reduced pain levels. According to Rippentrop and colleagues, chronic pain patients often feel alone and abandoned by God, and this could be the reason why religious activities (e.g., prayer and meditation) were in their research findings associated with poor health measures.

Cognitive-behavioral approaches

The primary aim of cognitive-behavioral therapy (CBT) is to alleviate the pain, distress, and disability by transforming maladaptive perceptions of the pain experience and unsuccessful coping with chronic pain (Burns, Kubilus, Bruel, Harden, & Lofland, 2002). Traditionally, CBT consist of three steps: (1) an educational phase: patients learn about the biopsychosocial aspects of their pain, (2) a training phase: patients receive the actual training in skills that help them coping, an (3) the application phase: patients practice the new skills in real life situations (Dixon et al., 2007). CBT seems to have a direct and positive impact on the sense of control and perceived self-efficacy, which in turn has shown beneficial effects on coping with chronic pain (Bandura, O’Leary, Taylor, Gauthier, & Gossard, 1987). 

Cognitive-behavioral therapy has shown to be beneficial in the treatment of chronic pain: approaches that promote acceptance of pain and its negative consequences like anxiety and fatigue prove to be helpful; they increase functionality and life satisfaction and decrease fear, depression, and psychological inflexibility (Wicksell, Ahlqvist, Bring, Melin & Olsson, 2008). Especially therapies emphasizing on valued-based exposure and acceptance strategies seemed to be effective (Wicksell et al., 2008).

McCracken and Vowles (2008) researched contextual methods that included the use of acceptance, mindfulness, and values and found that acceptance of pain and values-based action correlated positively with emotional, physical, and social functioning in patients with chronic pain. Values-based action means than an individual’s goals and desires determine his or her actions. A relative new approach to cognitive strategy is the Acceptance and Commitment Therapy (ACT), an approach that seeks to transcend the differences between behavioral and cognitive therapy (a third generation/wave intervention). It emphasizes the need of building flexible and positive behavior patterns that integrate the pain rather than working on the elimination of (the symptoms of) the pain.

ACT follows a functional and contextual philosophy and uses experimental methods of behavioral change (Hayes, 2008). ACT theorists, like Hayes, suggest that thoughts and feelings do not cause behavior, but that they are of critical importance in many social/verbal contexts. ACT-based treatments have proven effective in patients with chronic pain (Vowles, McCracken, Eccleston, 2008). Its three major components acceptance, mindfulness and values-related action are all significantly associated with pain severity, pain-related distress, anxiety, and avoidance, depression, depression-related interference with functioning, physical disability, and psychosocial disability (McCracken & Vowles, 2008).

Mindfulness-based stress reduction (MBSR) is a cognitive-behavioral approach that originates from the Buddhist tradition and was (re)introduced by Kabat-Zinn in 1996 as a treatment method for psychological and chronic disorders (Vowles, McCracken, & Eccleston, 2008). It emphasized nonjudgmental acceptance, focused here-and-now attention, and proposes a strict regime of daily practice. Research shows promising results: individuals with pain report to cope more successfully with their persisting symptoms (Majumdar, Grossman, Dietz-Waschkowski, Kersig, & Walach, 2002).

Affective approaches

According to Andrasik et al. (2005), not only the behavioral and cognitive, but also the affective aspects of pain need to be addressed in pain management. These authors suggested that because pain is an unpleasant experience, it is also an emotional experience; pain and negative affectivity (e.g., anxiety, depression, and fear) are connected. Vowles, McNeil, Sorell, and Lawrence (2006) for instance, studied the interaction between fear and pain and concluded that for chronic pain patients, in order to find the appropriate pain intervention, it is essential to determine which  is perceived as the most aversive. These authors pointed to the importance to address the emotional difficulties for patients with chronic pain in order to avoid and alleviate the additional suffering of pain-related distress and depression.

One way to improve the awareness of affective processes in individuals with chronic pain is psychotherapy. Emotional disclosure sessions, in which the client has the opportunity to talk about traumatic events or situations and the emotions surrounding these, and psychodynamic interventions, uncovering underlying processes that contribute to the experience of pain, are important aspects of any pain management therapy (Dixon et al., 2007).
           Depression and depressive moods are common among chronic pain patients (Asghari & Nicholas, 1999). Epping-Jordan et al. (1998) found that pain-related interference with functioning (disability) is directly associated with depressive symptoms, which are, when the pain becomes chronic, in turn directly associated with persisting pain intensity and continued disability. These authors suggest that these findings clarify the development from acute to chronic pain-related symptoms, which should emphasize the importance of disability in predicting pain outcomes (p.426).

Pain related negative affect (e.g., fear and pain-related anxiety) has a sensitizing and disabling effect (Janssen, 2002). The emotional response to pain is an essential part of the pain experience and a powerful determinant of the continuing and often destructive pain roller coaster; individuals with an anxious, worried, negative outlook on life experience pain and the emotional response to it, both leading to sympathic arousal with similar response patterns (Janssen, 2002).

Integrative approaches

Multidisciplinary chronic pain programs seek to combine elements of various pain management approaches: cognitive-behavioral therapy is incorporated in programs that use physical and occupational therapies, often in addition to medical treatments (Burns et al., 2002).

Seeking support is and active coping mechanism (Walker, Smith, Garber, & Claar, 2005). Support groups are now widely employed for people with chronic illnesses; research suggests positive benefits for pain patients range from reductions in mood disturbances and depression, to reduced suffering from trauma symptoms, loss of emotional control, and other forms of maladaptive coping.

Butler and colleagues (2009) studied the effects of a Supportive-Expressive group Therapy (SET) with self-hypnosis training for women with metastatic breast cancer (MBC). They found that the SET intervention (combined with hypnosis) significantly reduced the experience of pain and suffering for MBC patients (Butler et al., 2009). In a SET group patients are encouraged to share and confront their emotional distress, engage in supportive relationships with others, and find enhanced meaning in their changed lives. Themes that are openly discussed in a SET group are for instance (a) the fear of death and dying (b) life priorities, (c) communication with family and friends, (d) new concepts of self and body image, and (e) communication with health professionals.

Another example of an integrative approach is the Communications Program of Pain (CPM). The CMP recognizes the importance of physiological, psychological (cognitive and affective), behavioral, and sociocultural factors in the pain experience and seeks to provide appropriate assessment methodologies and interventions. It focuses on how the pain is encoded in behavior and how this behavior is decoded by observers (Hadjistavropoulos, Hunter, & Dever Fitzgerald, 2009). CMP is consistent with the gate-control theory of pain and recognizes that effective and cognitive processes can modulate the gating mechanism.        

Eye movements desensitization (EMDR), yet another integrative psychotherapeutic approach, in which the clients reprocesses dysfunctional thoughts, emotions and perceptions by a rapid information-processing method. EMRD has been successfully used with phantom limp pain and migraine headaches. Mazzola et al. (2009) found statistically significant improvements in all pain-related measures from pain severity to anxiety and depression. These researchers suggested that the right-hemisphere’s role is highly involved when experiencing negative emotions such as pain and that when the left hemisphere is activated; more coping resources seem to become available. In chronic pain patients, the constant feeling of pain, fatigue, and distress can become a traumatic experience in itself. Like in post-traumatic stress disorders, the traumatic memories trigger pain sensations, and EMRD treatment seeks to desensitize both the automatic emotional response to pain and the somatic component of the stored memories related to prior pain (etiology; Mazzola et al., 2009).

Discussion

Why “something as maladaptive to an organism as chronic pain could have ever evolved?” asked Sufka (2000, p. 156) when he discusses the similarities between chronic pain and other forms of neuroplasticity like learning and memory. One of the major difficulties in developing effective interventions and treatments for chronic pain is our limited understanding of the pain mechanisms and underlying neurobiology (Pietrobon & Striessnig, 2003). According to Melzack (2008), the future of the field of pain lies in the understanding of the brain. Combining findings from research in epidemiology, medical genetics, and sociological and cultural studies has the potential to reveal more about the functions of the brain, and could lead to new ways to relieve pain. The development of new imaging techniques makes it progressively possible to study the physiological events in a brain, even while the owner of the brain reports his or her experience. Advanced knowledge of cognitive neuroscience and surgical skills create possibilities for further research into the structures of the brain (Melzack, 2008).

The nociceptive system has plasticity and experience can modify pain (Sufka, 2000). Neuroplasticity is an interesting field of research for counseling health professionals who work with individuals with chronic pain. When we realize that the plasticity of the brain may play a causal role in the therapeutic effectiveness of psychosocial interventions (Garland & Howard, 2009), and find prove that humans can actually change their physical body by altering the way they think and feel, the importance of psychological interventions becomes more evident.

At the end of this paper, I must conclude that I barely scratched the surface of this overwhelming subject. This brief research project however, has awakened my interest in pain management and its possible applications in my own work as a counselor.    

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