NEWS BRIEFING and EXPERT REACTION: Retraining the brain for chronic pain

Australians are desperately in need of accessible and effective pain care that treats the whole person, not just injured body parts. At least one in five people live with daily, persistent pain which takes a huge toll physically, mentally and socially. Being in pain makes it hard to do the things you love so it’s very common to develop emotional problems like anxiety and depression. More than half of those living with chronic pain also have an anxiety or mood disorder. Research shows that pain and distress bounce off each other – they have reciprocal effects. Gold standard treatments for chronic pain have long tried to target emotional distress and there’s lots of evidence that different psychological therapies help, including cognitive behaviour therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based therapies (e.g. MBCT, MBSR). However these aren’t a silver bullet, generally showing modest effects that alleviate the symptoms rather than curing the problem.

The study recently published by Dr Norman-Nott and Prof Gustin in JAMA this week is a promising development in the effort to help people struggling with the emotional fallout of living with unremitting pain. It is based on a well-established psychological therapy originally developed to help people with borderline personality disorder - Dialectical Behavioral Therapy (DBT). A key feature of DBT is helping people to understand and express their emotions better. There are several other clinical trials showing DBT is promising for people with pain, so this isn’t entirely novel. Because pain activates both sensory and affective networks in the brain, reducing negative emotion helps turn down the volume on pain, especially the “bothersomeness” of pain. Instead of bottling emotions up, lashing out when angry, or  avoiding things that feel scary, we want people in pain to get better at processing their feelings, calming their nervous system, and solving everyday problems.

This is actually a core feature of most pain psychology interventions, so the iDBT-Pain intervention is not novel in this respect. However, there is probably a bigger “dose” of emotion regulation content than we see in pain-focused CBT, the most common and well-validated psychological pain therapy.

The effect sizes found in this study were mostly modest, much like other pain therapies. However, there was a large effect size in reducing depression in the short term (9 weeks), and pain intensity in the medium term (21 weeks).

Most of the improvements (e.g. emotion regulation, anxiety, stress, trauma symptoms, general wellbeing) were short-term, disappearing after people stopped the treatment. This is disappointing because the central aim of pain management interventions is long-term change. Previous research mirrors this, showing most interventions wear off within a year.

Encouragingly, improvements in pain intensity and depression were felt at the 5 month mark, or about 3 months after people stopped the treatment. Hopefully this is because people kept using the skills they learnt in the program. But we need more research to understand this.

iDBT-pain did not improve pain interference in the short or medium term. This is disappointing because, aside from alleviating pain, helping people to function better in their lives is the holy grail of all pain management programs.

A novel and valuable feature of iDBT-pain is the way it’s delivered in hybrid form, using written materials, an app with multimedia content, and online group sessions to teach people the emotion regulation skills.This blended format encourages people to practice these skills at home, while still giving them exposure to psychologists and other people struggling with pain. This hybrid approach is promising because it is more efficient than traditional one-on-one psychological therapy, so more people could potentially access it.

Overall, this study shows that iDBT-pain seems to be about as good as existing pain psychology treatments. It may be especially helpful for people in pain who struggle with emotional distress and are able to navigate technology to practice skills like meditation at home.

More research is needed to show that this is helpful in the long term.

As always, the best outcomes in pain management come from person-centred care that targets all aspects of a person’s pain experience, often with input from different health professionals. While improving emotion regulation is important, something like iDBT-pain won’t replace the need for interdisciplinary care, for example from physiotherapists, pain specialists, nurses and occupational therapists, and psychologists working together.

A good resource on pain management is the painHEALTH website: https://painhealth.csse.uwa.edu.au

Chronic pain - pain on most days for three months or more - can be brutal and take a significant toll on those who experience it. It is one of the most challenging and burdensome health problems we face. If you or a loved one has significant chronic pain, you will know that the constant and unpleasant nature of it can make it hard to regulate how you feel in response to a wide array of situations.

This clinical trial shows that psychological treatment can help, just as it can help people without chronic pain. That’s not very surprising. It also raises the possibility - but does not prove it - that treating emotional dysregulation can also improve pain levels. Old ideas of how pain works can’t explain that, but modern ideas can - our pain system is extraordinarily complex and the sensitivity of our pain system can be modified moment to moment and gradually over time through a wide range of strategies.

The best treatments we have for chronic pain are grounded in high quality education and active and psychological strategies that gradually reduce pain system hypersensitivity. We don’t know if this psychological intervention offers any benefit over any other intervention, but it raises the possibility that it might.

This study by Norman-Nott and colleagues offers evidence that targeting emotion regulation is a viable intervention for chronic pain. While emotion dysregulation has long been linked to chronic pain, this is one of the first trials to show that teaching emotion regulation skills is helpful for individuals suffering from chronic pain— and do so effectively online and in group settings.This is a game changer for people with limited access to in-person care, such as those in rural and remote communities.

The study's methodological rigour is strong, with a pre-registered sample size of 90 determined via power analysis, aligning with gold-standard clinical trial protocols. Most importantly, the intervention outperformed treatment as usual — a critical benchmark. Chronic pain is typically managed with a mix of physiotherapy, medications, and psychological support, and while those are helpful, this study shows emotion regulation training can offer more. Thus, this research marks a major step forward in pain care — not just treating symptoms, but empowering people to better manage the emotional challenges that control their pain experience.