Psychological, Behavioral, and Rehabilitation Approaches
Mechanisms
Pain is modulated by attention, appraisal, mood, sleep, and learning. Cognitive behavioral therapy targets unhelpful beliefs and teaches coping skills. Acceptance and commitment therapy builds willingness to engage in valued activity despite pain. Operant programs reinforce well behavior and reduce pain behavior. Graded activity and exercise reverse deconditioning and fear-avoidance. Relaxation, biofeedback, and sleep hygiene address arousal. These are active treatments, not evidence that pain is imaginary.
Rehabilitation
Set functional goals: walking tolerance, sitting, lifting, sleep, and return to work. Pace activity rather than boom-bust cycles. Use graded exposure for fear of movement. Coordinate physical therapy with psychological care. Screen for depression, anxiety, trauma, and substance use because they affect engagement and outcomes. Motivational interviewing improves adherence better than confrontation.
Traps
Questions may suggest that psychological treatment is only for patients whose pain has no physical cause. That is false. Another trap is blaming the patient for catastrophizing; catastrophizing is a modifiable process, not a character flaw. Do not push exercise beyond tolerability or ignore flares. Also avoid using a single screening score to deny care.
Worked example
A patient with chronic low back pain avoids walking because she fears re-injury. Instead of saying there is nothing wrong, the clinician explains central sensitization, sets a baseline walk of five minutes, and increases by two minutes every few days. Rule of thumb: start below the flare threshold, progress by time, and reinforce function rather than pain score.