Pain as a Perception, Not a Sensation: An Interview With Beverly Thorn

Pain psychologist Beverly Thorn discusses her career and the interacting factors that contribute to chronic pain. Image credit: get4net/123RF Stock Photo.

Editor’s note: This interview originally appeared on the IASP Pain Research Forum and has been lightly edited for RELIEF.

At the International Association for the Study of Pain (IASP) 2021 Virtual World Congress on Pain, to take place June 9-11 and June 16-18, IASP will present awards to honor the achievements of up-and-coming as well as more established investigators (these awards were originally to be presented at the 2020 World Congress on Pain in Amsterdam, which was canceled due to the COVID-19 pandemic). In advance of the meeting, we spoke with each of the winners. Here, in this interview, we chat with Beverly Thorn, PhD, winner of the Ronald Melzack Lecture Award. Read more about the award here.

Thorn is professor emerita of psychology at the University of Alabama, where she was on the faculty for 30 years, including serving as director of the Clinical Psychology PhD program for 15 years and chair of the Department of Psychology for five years. Her research has focused on investigating the important components of cognitive-behavioral therapy (CBT) for chronic pain conditions. Since retiring in 2016, she has remained actively involved in dissemination and implementation of CBT for chronic pain with low-income, multiply disadvantaged populations. She also consults in healthcare settings to help train behavioral health providers to implement CBT for pain management, and is a consultant on federally funded research programs.

Here, Thorn speaks with freelance writer Kayt Sukel about the filters of pain perception, why CBT is effective as part of an interdisciplinary approach to pain management, and why doctors’ offices need a specialized pain education expert to help patients learn about the brain’s role in pain.

How did you first become involved with pain research?

I was earning a dual degree in clinical psychology and neuroscience. Today, they’d call that clinical health psychology, but they didn’t have that track back then. My primary mentor did animal research on the mechanisms of opiate withdrawal. I didn’t want to go into that area, so I decided to go into pain. It’s ironic when you think about it, in this day and age, because there are a lot of overlaps, especially when you consider the opiate crisis and chronic pain, but I certainly didn’t see that coming at the time.

For the first 10 years of my career, I did animal neuroscience research looking at the brain mechanisms of opiate-related pain responsivity. Then I moved into human experimental research, investigating pain responsivity using the cold pressor test, a paradigm where people have to hold their arm in very cold water for a period of time. Some people could tolerate that for five minutes and stay there even after their arm went completely numb. Others were in there for 10 seconds and would start to freak out.

Beverly Thorn

The individual variability really interested me. I started recognizing that a lot of individual variability had to do with people’s cognition – what they were thinking and telling themselves. That led to me getting more training in cognitive-behavioral therapy [CBT], where you ask people to focus on their thoughts so they can recognize how their thoughts impact their emotions and behaviors. I quickly realized this was an avenue that could help people work through chronic pain, or even acute pain. So often, you don’t think about what you are telling yourself; so many thoughts are just automatic. But those negative thoughts can make a big difference in how we feel and what we do next. I thought this had great relevance for the management of chronic pain.

The evidence really supports the biopsychosocial model of pain [the idea that pain has biological, psychological and social contributors]. What does that mean for chronic pain treatment?

It means we have to move away from purely biomedical ways of treating the sensation of pain – because pain isn’t really a sensation. It’s a perception. Thinking about pain as a perception, you have to look at what the brain is doing. It’s not a passive recipient of sensory information; sensory information is going through all kinds of different filters, including your memory of experiences you’ve had in the past, experiences that your family has had, what you’ve observed, your emotional state, what you tell yourself about pain. There’s a lot there that can influence what you end up perceiving. So if all we’re doing is trying to slice out the pure sensory phenomenon associated with pain, we’re never going to be able to effectively treat pain. Yet, ironically, that’s what we keep doing, mostly because that’s what the healthcare system will recognize and reimburse.

What are some of the biggest misconceptions people have about interventions that target those filters – treatments that focus more on the biopsychosocial factors of the pain experience?

The biggest misconception is that people think that, when you raise attention to the biopsychosocial model of pain, you are telling them that their pain is all in their head. I hear this all the time: “My real doctor sent me to a psychologist because they don’t think my pain is real.” That seems to be how we always start out.

Before I retired, when I was seeing patients for pain management, I had to tell them that, in a sense, your pain is in your head because it’s in your brain. That doesn’t mean it’s not real. It’s real pain, but where you’re feeling it, where you are sensing it, is actually in your brain, not your back or knee. Then we would spend some time talking about the way the brain actually processes pain information. I think this lends itself beautifully to an explanation that tells patients that this is why we really need to dive into your emotions, your thoughts, your experiences, and other factors so we can speak to this holistic perception.

We’re not ignoring the organic components. Yes, you broke your leg, and it didn’t heal properly. Yes, you have chronic pain associated with that tissue damage. But it isn’t the whole story. If we keep breaking and resetting your leg, we may fix the tissue pathology, but when your sensory information is going through all those filters, that may not do the trick to manage that pain. We need to do more than just address the damaged tissue because pain, so often, comes down to so much more than that.

How can CBT help?

CBT is effective as part of an interdisciplinary approach to pain management. When it comes to chronic pain, when we do one thing, it tends to be moderately effective. That’s good, and CBT, for example, can have lasting effects on its own; that’s good, too. But when we can pair CBT with other interventions, it tends to work even better.

In the 1980s, we had pain management programs where an interdisciplinary team of providers would work together on the tissue damage, physical therapy, rehab, and CBT parts of treatment, just to name a few. The results from those programs weren’t just modestly effective – they were very effective. We have very few interdisciplinary pain management programs available now, not because they don’t work, but because they are expensive to run and insurance companies aren’t really that interested in reimbursing for them when they could just pay for a medication.

But you were asking me how CBT can help. One reason it’s effective is that it validates patients and tells them that their pain is real – that they’re not “crazy” or faking. The brain just has a problem that we can manage in a number of different ways. We do that by recognizing what you’re telling yourself, and how that may be impacting your feelings and behaviors. We work to interrupt that often automatic cycle of unconscious, or even preconscious, negative thoughts that are constantly running in our heads. When bad things happen, that negative self-concept gets really revved up. There are exercises you can do to make yourself more conscious of those negative thoughts and find ways to effectively manage them.

CBT also works well, especially in group settings, because it helps people living with chronic pain realize that they are not alone. That, universally, is one of the first things that people say to a CBT therapist: “I thought I was the only one in the world dealing with something like this.” Knowing you’re not alone is huge. Then, second, to realize there are other people who are learning things that can be useful to you, and that you might be learning things that can help them – that’s powerful, too.

Taking a step back even further, it’s also important to recognize that most people aren’t taught how the brain processes pain. It’s an important piece of the puzzle that needs to be an important part of our treatment rationale. When you discuss the brain and pain early on in treatment, patients are often surprised; they don’t know why their doctors had never explained it to them. CBT is often a good way to help educate patients about pain.

How do we implement more interdisciplinary care?

Quite frankly, we need a different reimbursement system in our healthcare. We’re reimbursing for medical interventions but not for hands-on time with patients. In fact, we’re probably getting worse when it comes to getting the time we need to really sit down and just communicate with patients. With all these fancy new diagnostic and interventional procedures, it may seem like we don’t need that face time. But we need to have these conversations about how pain really works.

We’re doing better in terms of medical education – we are finding ways to help physicians understand the biopsychosocial model of pain a bit better. But we’re still compartmentalizing everything. Doctors tend to say, “Okay, I don’t know how to do anything but cut it out or fuse it. If it’s psychological, I need to send this patient to someone else.” We’re missing the opportunity to consult and interact with other physicians and psychologists to come up with those interdisciplinary interventions that we know work. That’s disappointing.

What can we do to improve the educational component?

Medical students are now exposed to the biopsychosocial model of pain. They know what it is, but they aren’t taught how to integrate it into their practice, nor do they feel like they have the time to integrate it. That can be partially explained by the way medical education happens now. Today, you get your general training and then you go into some kind of specialty. As soon as you start to specialize, you are taught the things you need for that specific practice, and it doesn’t pay for you to look beyond those skills to seek out more interactive, integrative ways of pain management. You refer to a specialist.

Certainly, I’m talking in generalities here. I know plenty of physicians and surgeons who have been very receptive to CBT and other forms of treatment; they want to refer patients to get it. But we all remain, largely, in our own silos, which is problematic in terms of helping patients.

We’re still sort of in the dark ages when it comes to providing effective interventions. So if I were the queen and had the power to make changes, I’d say there ought to be pain management education specialists in every doctor’s office. That way, patients can come to the physician, who will look for tissue damage, but there will also be someone there who can teach that patient about how the brain processes pain and some of the things the patient can do to manage pain that they may never have heard about before.

How do you feel about receiving the IASP Ronald Melzack Lecture Award?

To be honest, I’m flabbergasted. I’ve been retired for six years now and feel, in some ways, a bit out of the game even though I’m still publishing and still interacting with students and other professionals. So I have to admit, winning was a big surprise to me. But I’m absolutely thrilled.

What’s also funny is that I remember meeting Ronald Melzack early in my career at a workshop he was giving. He was always very interested in the researchers and clinicians who came to those events. He wanted to know more about me and what I was about. I told him about my dual training and he told me, “Oh, with that background, you can do anything! You can do anything you want to do because you have the human side of things and you have the neuroscience. So go out and do anything!”

And that’s really what I’ve tried to do.

Kayt Sukel is a freelance writer based outside Houston, Texas.