Article summary:
- Around 5 million Australians live with chronic pain; half experience disabling levels that impact daily functioning.
- Chronic pain is not a disease to ‘fix’. It is a personal, multifactorial experience requiring individualised care.
- Psychologists play a crucial role by using behaviour change methods, drawing out patient perspectives and fostering self-efficacy.
- A biopsychosocial approach is essential, integrating psychological, physical and social dimensions of pain.
- CBT-based interventions, when tailored and delivered by interdisciplinary teams, are more effective than medication or invasive physical procedures.
- Interdisciplinary collaboration improves outcomes and reduces burden on individual clinicians.
- Self-management is the end goal, with psychologists helping people build skills to manage pain long-term.
- APS has a range of useful resources for upskilling in this space, including a pain management in practice online workshop in November and Introduction to pain management CPD-approved short course.
APS sat down with prominent chronic pain management researcher and psychologist Professor Michael Nicholas MAPS, who has more than 40 years' experience in this space, to explore the many ways psychologists support people in managing chronic pain.
Chronic pain – defined as pain experienced for at least three months – is an often-silent epidemic impacting approximately 20 per cent of the population. That’s around five million people in Australia alone.
Of that 20 per cent, roughly half live with pain that would be considered disabling, meaning it significantly interferes with their daily functioning, says Professor Michael Nicholas MAPS, a clinical psychologist and Director of Pain Education at the Pain Management Research Institute – Kolling Institute, Sydney Medical School – Northern, at the Royal North Shore Hospital.
“It’s not a thing, it’s an experience”
One of Nicholas’s greatest frustrations is the persistent misunderstanding of what chronic pain is.
“Both professionals and lay people are usually convinced that if you’ve got a chronic pain and it hasn’t resolved with treatment, that means they just haven’t found the problem yet and that they’ve got to keep searching with more scans to find the cause. That’s not true,” he says.
“Chronic pain is not a ‘thing’. It’s not something you can see on a scan. It’s an experience that affects people to varying degrees.”
“Its features can be categorised or diagnosed – that’s true – but it must always be thought of in terms of the person with the problem. We don't treat chronic pain itself. Rather, we treat a person with chronic pain."
Unless the pain stems from a specific disease, such as arthritis or cancer, Nicholas says most chronic pain doesn't have a clear biological basis.
“That doesn’t mean it’s not real. It’s a condition in its own right called Chronic Primary Pain,” he says.
"Pain is a very personal experience. You can’t determine how much of a problem it is for a particular person just from an X-ray or a scan. That doesn’t tell you much about the pain problems experienced by the person.”
Psychology’s role in chronic pain management
In 1980, Nicholas was appointed as one of two psychologists at Westmead Hospital in Sydney.
“They’d never had a psychologist working there before, so we were appointed to provide a service to the whole hospital. One of the groups who showed the most interest in us was the pain clinic. I didn’t know anything about pain – no more than anyone else out on the street.
“They explained to us that the medications weren’t very effective at treating persistent chronic pain. Psychologists were increasingly working in this space in the US, but it wasn’t happening in Australia. So I treated this as both a matter of interest and a challenge.”
For many, chronic pain can be accompanied by co-occurring mental health challenges, including depression, anxiety, drug dependence, unhelpful beliefs and behaviours, and dependency on others.
“Psychologists need to be able to draw out the perspectives of the person in pain, not simply make a diagnosis, which is often not very helpful by itself,” says Nicholas.
“In addition to that, they should encourage or guide other disciplines – doctors, physiotherapists, nurses and so on – in the utilisation of psychological principles and behaviour change methods.”
“It has to be personalised, and that’s where we get to this concept now called person-centred care, which psychologists have always used, but other professions are now catching on to. Psychologists can assist in that process.”
Low pain self-efficacy beliefs are another common barrier to improvement.
“This is one of my areas of research. If you don’t think you can do things in pain, then you probably won’t. That belief becomes the barrier. Psychologists should be able to help people change those beliefs.”
Following a biopsychosocial framework
After listening to patients’ experiences, Nicholas recognised the urgent need for psychological interventions in pain management – especially for people not well served by a purely medical model.
Pain is influenced by multiple factors. While it may originate in physical injury, it’s also shaped by psychological and social contexts.
“I’ve become increasingly convinced of the importance of the biopsychosocial model of pain and the role of psychology and psychologists in helping people [understand that model], usually in conjunction with other healthcare providers.
“Psychologists have been trained in what we might broadly call ‘behaviour change processes’, that is: helping people to change their behaviours and mood. The most obvious approach is cognitive behavioural therapy, but of course, it doesn’t come in a box.”
“You approach the person in pain and learn about their experiences and contributing factors, develop a case formulation with that person – and their other healthcare providers, such as doctors and physiotherapists – then you need to look at the context in which it’s occurring. For example, do you need to include family members or employers?
Consistency is so important. If one healthcare professional is doing one thing and another is doing something completely at odds with that, it’s going to be chaos. There needs to be an agreed approach.”
Understanding the context that a client’s pain exists within is critical.
“Rather than asking if a treatment ‘works’, a better way of thinking about it is: which treatment for which people and under what circumstances? The circumstances will influence what works.
“For example, if someone’s got pain and they’re depressed, then the treatments for pain will be harder and the outcomes won’t be as good – unless you treat both the depression and the pain."
Despite these complexities, Nicholas says international evidence suggests that versions of CBT, tailored to the client, are effective when used as part of a multidisciplinary approach.
“When delivered in combination with exercises and education about pain, and delivered by a multidisciplinary team, that’s the gold standard.
“These combined treatments are generally more effective than drug-based treatments or procedures like nerve blocks and spinal cord stimulators. They also have a much lower potential harms profile, which is very important – and they’re much cheaper. But they’re not supported by Medicare at present, unless you’re in a public hospital.”
Register for APS's online workshop Pain Management in Practice on 12 November. Early-bird prices end 12 October 2025. Secure your spot today.
Why interdisciplinary approaches matter
Nicholas is a strong advocate for interdisciplinary collaboration.
“Consistency is so important. If one healthcare professional is doing one thing and another is doing something completely at odds with that, it’s going to be chaos. There needs to be an agreed approach.”
“We need to help the person in chronic pain understand that we’ll be taking a collaborative approach to their care. They may not be used to that. They may be used to going to a health professional and being told: 'You’ve got this, and this is the treatment.'”
As a result, psychologists often need to take time to educate clients about the importance of an interdisciplinary approach, including how this can help them reach their goals faster and maintain them more sustainably.
He notes that psychologists often seem to work in silos, which can hinder progress, unless they collaborate with other healthcare providers, like the GP and physiotherapist, involved in a case.
“We need to be much more open about what we’re doing and explore how we can work with other healthcare providers like members of a multidisciplinary team, whether it’s virtual or actual.
“But one of the advantages [of collaborative care plans] is that it takes the load off the individual provider trying to solve all the client’s problems. Working in a collaborative way enables us to share the load and do what we’re good at.
“In our health system, it’s usually the medical practitioner who is regarded as the leader of informal teams. But it doesn’t have to be. With good communication skills and a willingness to collaborate, psychologists, GPs, nurses, and physiotherapists can work out ways of working in an interdisciplinary manner with shared roles and responsibilities.”
Self-management tools
After developing a treatment plan with the person in pain and their other providers (where possible), psychologists can apply relevant elements of CBT and self-management skills in conjunction with the other providers involved.
Whatever the components of the treatment plan, it is essential the person in pain understands them and their own role in its implementation, says Nicholas.
“The self-management skills we might have to teach them include things like activity pacing, self-calming methods, and ways of dealing with stressors and setbacks.
“You might also use aids like written or electronic materials that provide relevant information and facilitate recording of home practice of exercises, applied relation, and agreed tasks.”
Ensuring adherence to the plan by all involved is important. This applies as much to the person in pain as it does to the healthcare providers involved.
“A critical role of the psychologist is to make sure that a sense of engagement and partnership is established with the person in pain and the other providers involved. This will help them stay on track. Of course, this means we need to liaise regularly with the other healthcare providers involved.”
There should always be an endpoint to treatment, he adds. This is especially important with a chronic condition as there can be “a temptation to go on forever”.
“It can’t go on forever. We’re trying to equip the person in pain so they can self-manage. I say to them, ‘My goal is to get to a point where you don’t need me.’”
Critical training
Nicholas believes many psychologists need more training in chronic pain management.
“I think some psychologists believe pain is best treated by doctors and physios. But psychologists can play a really important role. They just need to make sure they are well-prepared and confident.
"They may not realise it, but they’ve already got many of the necessary skills, they just need the confidence and the knowledge to use them.”
He argues this kind of upskilling across the entire health workforce is essential because everyone in the health workforce will encounter people in pain.
“If 20 per cent of the population are living with pain, that means all healthcare professionals will have a touchpoint with someone at some point in their career.
“It’s critical that we go beyond specialised services to having all healthcare providers able to help people in pain. A bit like how, if you work at a hospital, you’re supposed to be able to do CPR.
“If all health professionals had a basic understanding of pain and how to help people manage it, I think we’d see far less pain-related disability, and more people returning to work and meaningful lives after injury.”
Putting insights into practice
Psychologists looking to upskill in supporting clients to manage their chronic pain can utilise the following APS resources: