Chronic Pain 


Psychoeducation is an important component of mindfulness-based pain therapy (MBPT) according to Dr. Peter Tamme. Patients should become experts on their problems, which is why communicating the important fundamentals about pain is indispensible. Pain cannot be objectified – it is a subjective phenomenon. The reason for this is that the extent of the suffering that a person feels due to pain does not directly correlate with the frequency of pain impulses delivered to the brain; instead, it represents a composite product for which the electrical impulse rate just represents an unfinished blank at best.


This blank is modified, modulated, intensified, weakened, and colored many times over up to the point of its graphic depiction in the cerebral cortex. Together with additional sensations, it is tied into a data package so that the extent of the physical pain can only be deduced indirectly.


Many therapists would really like to use a “pain monitor” in order to objectively assess the initial findings and the course of therapy. The pain scales that have been overrated in pain therapy are a naive attempt to create objectification. Instead, it is important for the treating professional to mindfully capture and synthesize all of the information that can be acquired through interaction with the patient when recording the pain. A working hypothesis must be produced and validated in every additional contact.


Pain cannot be objectified.


In addition, it is important to note that chronic pain can have very much or very little in common with acute pain, similar to diabetes with a high blood sugar level or asthma with difficulty in breathing. In order to be chronic, pain must meet a large number of conditions; however, it is more than just the sum of these conditions.


Chronic pain is not comparable with acute pain.


When acute pain is not treated appropriately, it becomes chronified due to neuroplastic changes in the central nervous system (brain and spinal cord). These always lead to a pain-processing disorder.


Acute pain is a symptom. Chronic pain is a separate disease (comparable with diabetes, asthma, and high blood pressure).


More precisely: Chronic pain is a secondary illness.


If chronic pain is a secondary illness, we should not be surprised that it must also be treated in a completely different way. This is a trap for doctors and patients because the methods, treatment goals, and prognosis change. Also – and this is especially important – the diagnosis of “chronified pain” makes it unnecessary to keep searching for additional causes. Whenever possible, diagnoses that are expensive, unnecessary, and sometimes harmful to health should be avoided.

Another consequence of this is that the therapy – as opposed to acute pain – will usually be for life instead of just temporary and the therapy goal cannot be “healing in the sense of getting rid of something”; instead, it can only be “helping and relieving.”

As soon as the pain has become chronic, is everything suddenly different? Yes, but: The determination of whether pain is chronic is just as important as the altered way of dealing with pain. As we already know, neuroplastic changes of the central nervous system are the organic correlate for chronification. However, this perception is not useful for making a diagnosis. The conclusion about the extent of the chronification is only possible through the recording of the consequences of chronification with the help of the standardized questionnaire. These questionnaires are used at every pain facility for this purpose.


A further definition says that chronic pain is always a bio-psycho-social phenomenon. This means that just recording the physical complaints do not do justice to the disease. Physical, psychological, and social factors are always involved in the overall process. However, the weighting of these three factors varies from person to person and must be reflected in the proportions of the therapeutic measures.



Chronic pain is bio-psycho-social.


In the initial therapeutic conversation, the pain therapist prepares a working hypothesis on the weighting of the individual components. Is the distribution of bio:psycho:social = 33:33:33, 50:25:25, or even10:60:30? And this already takes us to the next problem. Does it make sense to actually use opioids for a strong weighting of psychological factors (such as in a somatized depression), such as 15:70:15? This would only be capable of influencing a maximum of 15% of the overall illness (the biological portion). The necessary consequence of this would be that a psychological emphasis of the therapy must be developed.


Not only the disorder of “chronic pain” is bio-psycho-social. The therapy also must take the physical, psychological, and social aspects into consideration.


A variety of emotional states and conditions is responsible for why people experience chronified pain as so distressing. The clinical variation of the historic mindfulness practice makes almost unbelievable successes possible with regard to the tolerance of such suffering.


Specific mindfulness deproblemizes chronic pain.


The emphasis here is on “specific.” For mindfulness to be helpful, the focus must be on the pain-associated aspects. We think that it is very important to emphasize this point. Especially in spiritual circles, the opinion is propagated – often without any justification – that mindfulness and/or meditation helps against all kinds of things. This is nonsense. It helps just as little as a non-specific psychotherapy or general relaxation techniques. To the contrary: When the indication is incorrect and the work is done without a concrete plan, the applied energy is squandered and the invested time is wasted. The reputation of something that certainly is valuable suffers, and an inundation with pain stimuli may occur in the low-stimulus atmosphere of a meditation. Such highly efficient methods must be used in a targeted manner and should “not just be added to the drinking water.” An appropriate analogy would be the insane idea of wanting to eliminate infectious diseases in general through a blanket distribution of antibiotics.



social issues


And what does the “social” pain-therapy component look like? Just like “bio” and “psycho,” there are many misunderstandings regarding the topic of “support in social issues.” And this applies to patients, as well as therapists who send the patients to pain-therapy facilities.


Misunderstanding No. 1: “Pain doctors promote early retirement.” In a pain facility, financially rewarding work is seen as a means of self-determination. If a person gives it up, the chances are greater for the disease to get worse instead of improving. Instead of being awarded, applicants are punished by the approval of early retirement: They receive written notification that they will no longer be allowed to participate in one of the most important social aspects of life: “I am no longer permitted to work (perhaps for my entire lifetime).” Experience shows that in contrast to the expectation of most applicants, the extent of pain-associated suffering tends to be intensified with a “positive” award of early retirement benefits.


Misunderstanding No. 2: Filling out the disability attestations and forms for social security insurance, social welfare courts, health insurance companies, requests for expert assessments, and other insurances is part of the social assistance.” Not true. Pain is neither a reason for disability nor early retirement or incapacity to work. The basic principle is to maintain the ability to work as long as possible (see MisunderstandingNo. 1).


Misunderstanding No. 3: Pain is a reason for early retirement.” Definitely not. Pain is not currently recognized as a reason for early retirement, and it will never be. Pain does not justify taking a basic right away from a person.


Misunderstanding No. 4: “Treating doctors have a direct influence on the further professional development of their patients with regard to the so-called ‘relief measures.’” Not true. Since they are treating doctors and therefore “on the side” of the patients, they are automatically disqualified as evaluators. Pain therapists are usually asked to send their findings to the decision-makers for approval. Other doctors are entrusted with the assessment. Patients are frequently disappointed about their encounters with evaluators because they do not display the otherwise accustomed empathetic basic attitude of the doctor. The reason for this is that evaluators are obligated by profession to not be empathetic but impartial as they stand between the applicants and institution to which the application is addressed.


Misunderstanding No. 5: Highly effective medications cannot be reconciled with paid work.” This is not true. Although an impairment of the ability to work (and fitness for driving) may occur in the discontinuation or dosage-finding phase, it is usually even possible for professional truck drivers to continue their work with a careful increase in dosage and a stable attitude.


Misunderstanding No. 6: “Serious disorders cannot be compatible with work.” Wrong. If a dispute goes to trial at the social welfare court, both parties to the dispute usually agree on the diagnosis. It is acknowledged that the applicant is suffering from the stated disorder. Even in view of the professional capacity, the two parties are not so very far apart: it is acknowledged that the applicant can no longer perform as before. But here comes the catch: Quite (very) frequently, the court believes that the disorder allows the patient to continue working in his/her profession with a decreased intensity, less exertion in terms of hours, and under certain restrictions (no bending, no drafts, etc.). The applicant can then be instructed to accept such an occupational activity (even though such jobs may not even be offered). The result: no early retirement, no employment, and social impoverishment.

As a result, this is the motto of the pain therapist: Stay at the job under all circumstances, do not take sick leave, and definitely do not have any inappropriate expectations of early retirement.

One current type of support in the social sense is clarification of the above-mentioned issues and placement in socio-therapy or partner therapy, but primarily in a pain therapy that maintains the social ability to function.


Copyright Dr. Peter Tamme and Dr. Iris Tamme

Last update: September 9, 2012