Article summary:
- Research on women in Victoria found that 40% of participants reported living with chronic pain, yet women are less likely to receive treatment for it.
- Research indicates that women are more likely to be challenged about whether their pain is real. Nearly one-third of Australian adults with severe or very severe pain experience high levels of psychological distress.
- Women experiencing pain can present with a range of psychological conditions, including depression, anxiety, PTSD and trauma.
- APS calls on the Government to increase funding to support regular case conferences among health professional teams, as well as shared electronic health records to improve communication among providers.
- APS also calls for the Government to fund public campaigns promoting the importance of comprehensive care to empower women to advocate for their needs.
In a survey of more than 1,750 women in Victoria, 40% of participants reported living with chronic pain. Yet, women are less likely to receive treatment.
These research findings led the Victorian Government to initiate a first-of-its-kind Inquiry into Women’s Pain.
The APS welcomes the inquiry and has made a submission advocating for the important role of psychologists in the management of women’s pain.
Our submission puts forward eight recommendations:
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Patient education and empowerment
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Evidence-based guidelines for health professionals
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Improved access to multidisciplinary pain care for women and girls
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Increased access to psychologists and psychological care
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Greater focus on prevention and early intervention
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Recognition of the importance of stigma reduction
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Workforce development, and
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Public awareness campaigns.
In this article, we speak with Professor Anne Burke, clinical and health psychologist, and APS member; Dr Genesta Nicolson, clinical psychologist; and Carmen Stewart, psychology clinical educator, empowered relief facilitator and health psychologist, to learn more about how psychologists can help women experiencing chronic pain.
The relationship between women’s pain and mental health
Nearly one-third of Australian adults with severe or very severe pain experience high levels of psychological distress, according to Pain Australia.
This is around three times the rate of those with mild pain and six times the rate of those with no pain.
“Pain can affect all aspects of a person’s life,” says Professor Burke.
It can impact their mood, energy, concentration, movement and activity, relationships, sex drive and sleep, she says.
“It does so to different degrees and in different ways for different people, and the relationship is usually bidirectional. For example, we know that pain impacts sleep, and sleep impacts pain, but the data seems to be suggesting that sleep impacts pain more than the other way around.”
Women experiencing pain may also present with a range of conditions, including depression, anxiety, PTSD, trauma history and suicide ideation.
According to Professor Burke, it’s important to take a holistic approach.
“We need to consider the whole person and their social environment, not just their physical symptoms,” she says.
How psychologists can help women with pain management
Given the comorbidities of pain with mental health, the APS advocates for women experiencing pain to be given greater access to psychologists.
“Pain is really complex – it includes physical, psychological and social components,” says Professor Burke. “Given all these components are involved in the person’s pain experience, it follows that they should all be considered in the treatment.
“Psychologists can help people identify their patterns of interpreting and responding to pain – and to evaluate how well, or otherwise, these responses are working for them.
“Where things aren’t working quite so well, we help people set goals for things they’d like to change and empower them to achieve these goals by helping them learn skills to support behaviour change.”
For both Dr Nicolson and Stewart, the foundation for treatment is a trauma-informed approach.
“[This is] not only because we know rates of trauma are much higher in this group, but also because it’s the centre of creating safety within the therapeutic relationship and the patient’s nervous system,” says Dr Nicolson.
The main intervention – regardless of theoretical framework – should be calming the nervous system.
“Starting with a solid understanding of how the central nervous system changes and rewires when living with pain is important.
“I think words like ‘nociceptive’, ‘neuropathic’ and ‘nociplastic drivers’ of pain put people off. But really, if you know how to treat trauma, create safety and help people come back to living with, listening to and caring for their bodies, you already have so many useful skills.”
Evidence-based, multi-disciplinary approach
The APS advocates for psychologists to be one element in an evidence-based, multi-disciplinary approach, which, the research shows, is more effective than the use of pharmaceuticals and more invasive strategies.
This brings together psychologists, GPs, specialists and allied health professionals to collaborate on individualised treatment plans.
However, multidisciplinary care “doesn’t have to happen in the same building,” says Professor Burke.
“If you’re in a community setting, it might be all about building a virtual team. The important thing is connection and collaboration among care providers.”
Dr Nicolson and Stewart recommend psychologists develop relationships with other allied health practitioners.
“Join a [professional body] such as APS, or an interest group, and refer patients to online pain management programs,” says Stewart.
Whichever way a team is formed, it’s important that all practitioners agree.
“[This means the client] is getting a consistent message,” says Professor Burke.
Often, psychologists might be in the best position to ensure agreement, by taking on a leadership role.
“Psychologists are well-placed to supervise, and provide containment for, teams that may not be as experienced in managing distressed and distressing patients,” says Dr Nicolson.
The APS calls on the Victorian Government to increase funding to support regular case conferences among health professional teams, as well as shared electronic health records. These two tactics would drastically improve communication among providers.
Prevention and early intervention
"Once pain becomes chronic, treatment can become more challenging and achieving a level of recovery is more difficult – not impossible, but harder,” says Professor Burke.
“The earlier we can intervene, the less entrenched any unhelpful cycles become, and the more quickly people can get back to the business of living.”
Ideally, GPs and allied health professionals would screen clients for psychological risk factors, and, upon identifying a risk for pain-related disability, would facilitate a timely referral to a psychologist.
However, even with early referrals, APS has found that accessing psychological services can be difficult for many who are already contending with cost-of-living challenges.
“Right now, people can access only five sessions a year under a Chronic Disease Management Plan to cover all allied health requirements – for someone with pain that runs out really quickly,” says Professor Burke.
“There is very limited access to publicly funded psychology services. So for many people with pain, their only option might be to see a private psychologist and that can be extra tricky for females given their often lower wages and tendency towards underemployment.”
On top of this, clients only have access to 10 Medicare-subsidised psychology sessions per calendar year, which, again, limits the amount of support psychologists can offer.
Breaking down the stigma
There’s a culture of disbelief and disenfranchisement around women’s pain.
Research indicates that women are more likely to be challenged about whether their pain is real. The suggestion being that women’s pain is exaggerated or results from emotional and psychosomatic causes.
For example, middle-aged women with chest pain are twice as likely to be misdiagnosed with mental health issues compared to men with the same symptoms.
“The tendency to dismiss women’s symptoms as psychological is really concerning – it invalidates their experience,” says Professor Burke. “The first step in quality care is to recognise that the person’s pain is real.”
Dr Nicolson and Stewart add that psychologists shouldn’t be afraid to admit uncertainty.
“Ask questions if you don't know, be honest when you don't, and be realistic and kind,” says Stewart. “This will speak volumes to bridge the gender divide and knowledge gap.
“If you’re not confident in treating pain, do [specific training] about persistent pain, read ‘Explain Pain' [a book that explains how pain experiences are constructed], and learn more about pain because it’s common. You’ll see it in your practice, and it happens across the entire lifespan.”
Building education and public awareness
“For me, education underpins everything from a pain management perspective,” says Professor Burke.
“We need to make sure that women with pain understand that it is not just something they have to put up with – that things can be different.”
For psychologists, this could mean helping clients understand the science behind pain.
“The more I understand what’s happening in my body, the more I’m able to interpret it in an appropriate way,” says Professor Burke. “This can reduce catastrophising and misperceptions, which, in turn, can change how people manage their condition, as well as how they seek and engage with health care.
“Sometimes that might mean [people] advocating more strongly for a referral when [they] feel [their] pain is being dismissed. Other times it might be learning self-management strategies so [they] feel empowered to manage things for [themselves].”
Just as important is the education of GPs and community health professionals.
“It’s vital that clinicians understand the messaging they’re conveying to women,” says Professor Burke. “Words matter – statements like “crumbling spines” and “weak backs” can be terrifying to patients and lead to poorer outcomes. They are also typically inaccurate.
“Clinicians should make sure they’re up to date with pain science, so they can share a contemporary understanding which demystifies pain and normalises a broad range of experiences.”
The community has a role to play, too.
“If I have a daughter, partner or friend with pain, the better I understand it, the better equipped I am to support them,” says Professor Burke.
The APS calls on the government to fund public campaigns promoting the importance of comprehensive care to empower women to advocate for their needs and raising awareness about gender disparities in pain management.
“We’ve been calling for change for years,” says Professor Burke. “2008 was the International Association for the Study of Pain’s global year against pain in women, and this year, the focus is on sex and gender disparity in pain management.
“There’s a strong need to raise awareness of the disparity in pain recognition, management and research between men and women – and to highlight the need for more effective care.”