Complex pain management

By the time you look for psychotherapy for pain, you have usually had years of appointments behind you. Scans, blood tests, medication changes, physiotherapy, injections, referrals, waiting lists. Advice that helped a little, advice that made things worse, and long stretches where nothing much moved at all.

The pain is still there. It is there when you wake, when you try to settle at night, when you have sat too long or stood too long or planned more than the day would allow. It reaches past the painful place and into how far ahead you dare to look, whether you say yes to things, and what you are afraid you will pay for tomorrow.

When pain has outlasted its cause

Persistent pain is not the same problem as acute pain, and it does not always behave like an injury. In chronic and complex pain, including fibromyalgia and other persistent pain conditions, the nervous system becomes more sensitive over time. It amplifies the signals it carries, so pain can continue long after tissue has healed, or without any ongoing damage to explain how much it hurts. This is a real, physical process. It is not a sign that you are imagining it or making too much of it.

Around that central fact, patterns build up that keep pain in charge of the week. Boom and bust is one of the most common. On a better day, or when something matters enough, you push through and do far more than usual. The flare follows, and the days after are spent recovering, regretting, and trying to work out what set it off. Over time the safe range shrinks. Fear of a flare narrows what you attempt, activity drops, the body deconditions, and ordinary movement starts to feel more threatening than it is. Sleep, mood, worry and pain begin to feed one another, so that a bad night raises the pain, and the pain wrecks the next night.

Attention plays its part too. Pain pulls the mind towards the body and towards checking, and the more closely a sensation is watched, the louder it tends to become. None of this is a character flaw. It is how a sensitised system and a frightened, exhausted person keep each other going.

How I work with pain

Much of what I understand about persistent pain I learned while working as a Consultant Cognitive Behavioural Psychotherapist in an NHS specialist unit, working with complex pain, fibromyalgia and chronic fatigue. That is where I saw how often the boom and bust cycle gets mistaken for a lack of willpower, and how much changes once pacing stops being a punishment and starts being a plan you can actually live inside.

NICE guidelines list acceptance and commitment therapy (ACT) and cognitive behavioural therapy (CBT) for pain among the treatments to consider for people aged 16 and over with chronic primary pain, alongside a supervised exercise programme, while advising that paracetamol, anti-inflammatories and opioids should not be started for this kind of pain. The aim is not to argue you out of pain, and not to tell you it is in your mind. It is to loosen the patterns that have grown up around it, so that more of your life becomes possible while the pain is still present.

In practice, that often means building pacing that is realistic rather than punitive, so activity is planned around what you can sustain instead of what a good day tempts you into. It means planning for flares before they take over, and rebuilding confidence in movement where fear has quietly narrowed things. It means working with the thoughts that arrive at three in the morning. What if this is my life now. What if I cannot cope. Where pain has changed your work, your relationships, your independence or your sense of the future, Acceptance and Commitment Therapy can help you find ways to make life matter again without waiting for the pain to leave first.

If part of you is reading this on guard, braced to be told that the answer is simply to think differently, that is a fair thing to expect after the appointments you have had. It is not what happens here.

Therapy is not a substitute for medical assessment or treatment. I do not diagnose pain conditions and I do not prescribe medication. I work with the emotional, behavioural and psychological weight of living with pain, alongside your medical care.

Sessions are fifty minutes, online, and usually weekly to begin with. I work with adults and adolescents.

Online work matters most when the journey, the waiting room and the trip home would use up the very energy you were trying to protect.