Pain psychology: what Veterans can expect

Before your appointment

For Veterans, a useful starting point is to ask your VA team what the referral is meant to help with and how the clinician will coordinate with the rest of your care.

What does a pain psychologist do?

A pain psychologist works with the difficulties that accompany persistent pain, such as worries about activity, distress, or disruption to routines. Treatment may include cognitive behavioral therapy for chronic pain, often shortened to CBT-CP. Some services also offer other approaches. WashU Medicine describes CBT, acceptance and commitment therapy, and self-management skills among its pain-psychology services. What a particular clinic provides will vary. WashU’s overview.

Ask which approach is being offered, what you will practice, and how it connects to a goal that matters to you. You might want help returning to a hobby or handling the worry that comes before a necessary trip. You and the clinician should agree on a goal you can recognize in daily life.

Why talk about thoughts when the pain is physical?

Pain is a personal experience influenced by biological, psychological, and social factors. Those influences can coexist with an injury or disease. The International Association for the Study of Pain also distinguishes pain from nociception, the nervous system’s processing of potentially harmful stimuli, and emphasizes respecting a person’s report of pain. IASP terminology.

In his 2017 lecture, Dr. Shehzad Khalid moves from nerve pathways to pain-related fear. He explains how avoiding activity can make sense to someone who has been told their back is damaged or vulnerable. That gives clinicians a reason to understand the person’s concern and explain their assessment clearly. Watch the discussion at about 8:45.

The practical question is specific: what are you worried will happen during an activity, and what does the clinical assessment tell you about that risk? A fear-avoidance model cannot establish that your symptoms are harmless. Restrictions after surgery, new symptoms, and other medical concerns still belong in the plan.

What might CBT for chronic pain involve?

VA describes CBT-CP as an active approach to solving problems associated with chronic pain. Its goals include participation in meaningful activities, managing flares, and reducing worries about pain or injury. Ask a member of your VA health care team how to access it. VA’s CBT-CP information.

For example, if you have stopped attending a weekly gathering because you expect a difficult evening afterward, bring that concern to the appointment. Discuss what has happened before, what your medical team recommends, and whether a different plan could make participation more manageable. This is a conversation example, not an instruction to push through symptoms.

If you also receive treatment for PTSD, depression, or another condition, ask how the plans will fit together. A pain-focused referral should have a clear purpose rather than leaving you to sort out several sets of instructions alone.

How much improvement is realistic?

Benefits vary. A 2020 Cochrane review found that CBT produced small or very small average improvements in pain, disability, and distress, depending on the comparison. It covered chronic pain other than headache and migraine. Limited reporting of adverse events also restricted conclusions about harms. This supports a realistic discussion of possible benefit, not a promise of pain relief. Read the review.

Ask when you and the clinician will review progress, what counts as a useful change, and what happens if treatment is not helping. Improvement in an activity or coping with a flare can matter even when pain remains, but you should have a say in which outcomes matter most.

Questions to bring to a referral appointment

• Why are you recommending this service for me now?
• Which concerns need medical assessment or rehabilitation as well?
• What training does the treating clinician have in chronic pain?
• Are appointments individual, group-based, remote, or in person?
• How will the plan be adapted if concentration, fatigue, travel, or scheduling is difficult?
• Who will coordinate with my other clinicians?

The Valor chronic-pain care guide can help you organize referral questions. If care outside VA is proposed, use the Community Care guide to discuss authorization before arranging treatment. A provider’s availability does not establish VA coverage.

What about Valor’s home-based program?

If you are exploring broader chronic pain support, ask Valor for program information to review with your treating clinician. Ask what services and staff are included, whether the program fits your current care, and how availability and payment are determined. Do not assume that coaching or pain education is the same service as psychotherapy from a licensed clinician. The research above does not establish outcomes for Valor’s program.

About the source

This guide draws on “Neuroanatomy Neuropsychology of Pain,” presented by Shehzad Khalid, MD, published by Seattle Science Foundation on July 28, 2017. Review covered the complete available automatic transcript and selected slide frames, not a full audiovisual review. The referral questions are an editorial adaptation for Veterans. Current clinical resources are linked separately. This is educational information; no clinician review has been recorded.