Chronic Pain,Chronic Demoralization,and the Role of Psychotherapy

This article discusses demoralization in patients with chronic pain and the role of psychotherapy at combating chronic demoralization associated with chronic pain. The advantages of the biopsychosocial conceptual framework for the understanding of chronic pain are highlighted. Demoralization may be viewed as a combination of distress and subjective incompetence. While the distress experienced by the patient may be understandable and commensurate to the predicament, the co-occurrence of subjective incompetence (the polar opposite of resilience) and its escalation to helplessness, and hopelessness may result in suicidal attempts, demands for euthanasia, or death by suicide. The complexity of chronic pain and its relationship to demoralization may be examined from multiple perspectives. Biological, psychological, social and cultural variables play varying roles depending on the observer’s perspective and the context of the observation. The role of psychotherapy in chronic pain may be viewed in terms of multiple pathways through which language, cognitive style, behavior, relationships, attitude towards pain, and awareness of the body modify the relative influences of top-down and bottom-up processing of information within the pain neuromatrix. Various psychotherapeutic interventions developed for patients with chronic pain are reviewed and recommendations are made for future research.