Behavioral Medicine

Volume 23, Issue 2

Chronic Pain: How to Guide Patients through Processing Change

The ability to recognize, express, tolerate, and take responsibility for emotions, including pain, can improve self-treatment outcomes. CITE THIS ARTICLE

Demyan A, Cosio D. Chronic Pain: How to Guide Patients through Processing Change. Pract Pain Manag. 2023 March/April;23(2).

Mar 1, 2023

Amy Demyan, PhD, RYT

Professor of Psychology

David Cosio, PhD, ABPP

Psychologist, Interdisciplinary Pain Program

An elderly man sits on a couch next to his wife while touching his side, showing a female physician where his pain is.
Getty Image/milan2099

Individuals with chronic pain must not only manage their medical care but also their pain’s impact on daily functioning, and how these changes affect their family and community.¹ The ability to self-manage these domains has been identified as an important factor in chronic pain treatment outcomes. However, not everyone has the skills or readiness to navigate such changes and related challenges. Therefore, it is important to not only assess a patient’s chronic pain symptoms and related treatment needs, but also the patient’s capacity and emotional readiness to engage, comply, and adhere to treatment plans.

Herein, we describe a person-centered approach to meeting these challenges, including a deep look at the seven stages of the change process.² With this process, clinicians can better assess patients’ emotional readiness for self-management programs and guide them toward interventions that match their skill level.


Emotional Intelligence as Part of Treatment Plans

Emotional intelligence refers partly to the ability to recognize and name one’s own emotions.³ Emotional intelligence plays an important role in the treatment of chronic pain⁴ and can act as a buffer against the adverse impacts of chronic pain.⁵ Shepard further argues that pain is an emotion – in that the emotion cannot be separated from the pain experience.⁶ Consequently, it makes sense to explore patients’ ability to recognize, communicate, and take responsibility for their emotions, affective expression, and behavior as these skills are important to the success of self-care.⁷

One guiding framework to increase patient self-awareness, and thus emotional intelligence, is the psychotherapeutic person-centered theory.

Person-Centered Theory

Person-centered theory is a humanistic psychotherapeutic treatment approach whose outcomes rely on the relationship between patient and provider. Carl Rogers, PhD, developed this approach, moving beyond the question, “What treatment is needed to address this symptom?” to “How can I create a relationship with this person, which this person may use for personal growth?”⁸ Overall, Rogers highlighted three provider relational conditions to facilitate the assessment and development of emotional intelligence:

  1. provider genuineness
  2. unconditional positive regard (caring/prizing of the patient
  3. empathic understanding

While it is beyond the scope of this article, it is vital that we, as clinicians, develop our own self-awareness and emotional intelligence to meet provider-relational conditions.


Seven Stages of the Change Process

To address chronic pain, one must be able to communicate. The seven stages of the change process, outlined by Rogers, focus on improving understanding and communication of one’s emotions, which ultimately helps patients living with pain engage in self-management of that pain. The stages guide a clinician’s assessment of patient awareness and emotional intelligence as well as treatment goals and tasks for the individual patient. For example, it would not be appropriate to refer someone with low awareness to an interdisciplinary self-management program without first referring them to resources that will help them develop foundational self-awareness and emotional intelligence to navigate the challenges of engaging in such multifaceted treatment.

The stages include:

  • Stage 1: The patient is unlikely to identify and express emotions; they have difficulty being in the here and now. Note that it is rare to see a patient at this stage voluntarily attend psychotherapy.
  • Stage 2: The patient can talk about past emotions and distressing emotions with an external locus of control (ie, an individual’s perception about the underlying main causes of events in their life). They are likely to describe things as happening to them. For example, “He made me so mad” as opposed to “I got really mad.”
  • Stage 3: The patient can describe feeling states but lacks the acceptance of emotions and has difficulty being in the here and now. They are past-focused with an external locus of control – they will describe things as happening to them. This is a common stage to enter psychotherapy.
  • Stage 4: The patient begins to describe their own here-and-now feelings but tends to be critical of themselves for having them. This stage is marked by the burgeoning development of an internal locus of control/responsibility for self.
  • Stage 5: The patient can somewhat express emotions and tolerate distressing emotions, and they are close to taking some responsibility for emotions. The provider is likely to see the patient take action in this stage.
  • Stage 6: The patient is able to experience and accept present distressing emotions. At this stage, the patient is unlikely to regress. They are now able to treat themselves with self-care and love.
  • Stage 7: The patient can readily identify and freely discuss their emotions, even distressing ones, in the here and now with an internal locus of control. At this stage, the patient is a fluid, self-accepting person who is open to the changes that life presents.


Emotional Recognition and Expression

Clinicians can benefit from being curious about a patient’s capacity for emotional recognition, expression, and ability to tolerate distressing emotions. When conducting evaluations, consider asking: “Can you talk about your feelings?”

If they are unable to talk about their feelings or talk about emotions in a detached way that focuses on the past, it is likely appropriate to refer these patients to treatment interventions that help build emotional awareness and emotional communication skills prior to self-management programs.⁹ Such programs include humanistic-based psychotherapies, including a person-centered approach.⁸

It is also important to assess a patient’s ability to be mindfully aware in the present moment. Providers can assess patient communication patterns that demonstrate whether the patient is preoccupied with the past or the future, and whether they are able to experience and sit in the present. To assess mindful awareness, consider asking: “Are you running on autopilot without paying much attention to what you are doing? Are you often in a rush? Do you have trouble remembering brief instructions right after they are given?”

Patients who have difficulty being present may benefit from mindfulness-based psychotherapeutic approaches such as Acceptance & Commitment Therapy (ACT)¹⁰ and Mindfulness-Based Stress Reduction (MBSR).¹¹

To assess responsibility taking (ie, external versus internal locus of control), clinicians can listen for “I” versus “other” talk. Does the patient talk more about other people or about themselves and their own experiences? Further, do they own their feelings or blame others for making them mad, hurt, etc. Again, referral to a humanistic-based psychotherapy such as the person-centered approach8 would be helpful for a patient who does not yet have a sense of personal responsibility.


Practical Takeaways

Through the seven stages of the change process, patients can move from a then and there to a here and now perspective. They increase their ability to recognize, express, experience, and tolerate emotions in the present moment. Further, patients in the final stages can readily take responsibility for their emotions.

Together, these skills improve a patient’s ability to fully participate and adhere to self-management treatment programs, which require patient self-care across interdisciplinary treatment domains.¹² Patients with low self-awareness, difficulty identifying and expressing emotions, and difficulty taking responsibility can benefit from humanistic and behavioral psychotherapies that enhance present-moment awareness, emotional intelligence, and personal responsibility for emotions and behaviors before entering self-care.