1. The programme at a glance
Indication. The programme is intended for an adult whose pain has lasted or kept coming back for more than three months, has been assessed by a doctor, and whose impact — on activity, work, sleep, mood, relationships — is at the forefront of the request. The most frequent presentations are chronic low back pain, fibromyalgia, widespread or regional musculoskeletal pain, chronic headache, and pain that persists after surgery. The programme is also suitable when an identified disease partly explains the pain, such as osteoarthritis or nerve damage, provided that the treatment of that disease is conducted elsewhere.
Reference model. The programme rests on cognitive behavioural therapy for chronic pain, which remains the most studied psychological approach (Williams et al., 2020), and enriches it with acceptance and commitment therapy, which targets psychological flexibility (McCracken & Morley, 2014). The programme rests on three models, presented in section 6: the biopsychosocial model, which describes pain as the product of biological, psychological and social factors; the fear-avoidance model, which explains how pain interpreted as dangerous leads to avoidance, then to disability (Vlaeyen & Linton, 2000, 2012); and the psychological flexibility model, which describes what allows a person to go on living according to their values with pain that does not give way (McCracken & Morley, 2014).
Format. The programme consists of twelve weekly sessions, individual or in a group. Individually, they last 50 to 60 minutes; the first lasts 75 minutes. In a group of six to ten people, they last 90 to 120 minutes, and session 1 is held as an individual interview with each participant before the first meeting. Three booster sessions follow, at one, three and six months. Section 14 justifies this format.
Targeted mechanism. The programme does not seek to make the pain disappear, which the manual does not promise, but to bring about four changes: that the person understands their pain without believing it dangerous at every sensation; that they set their activity according to a plan rather than the pain of the moment, and increase it in steps; that they resume the movements and activities they avoid out of fear; and that they stop making the fight against pain the only project of their life, to come back to what matters to them.
| Session |
Focus |
Session deliverable |
| 1 |
Assess, triage, link with the doctor |
Red flags checked, risk assessed, baseline measures, diary handed over |
| 2 |
Understanding one's pain |
Explanation of the pain restated by the person |
| 3 |
The cycle, and what matters |
Cycle drawn, values and goals written |
| 4 |
Pacing activity |
Baselines calculated, first quotas set |
| 5 |
Moving again |
Graded activity programme written |
| 6 |
Feared movements |
Hierarchy built, first exposure done, mid-point measures |
| 7 |
Facing, and thinking more accurately |
Exposures continued, catastrophic thoughts examined |
| 8 |
Making room |
One acceptance exercise done in session, distancing sentence written |
| 9 |
Sleeping despite the pain |
Sleep plan written |
| 10 |
Mood, other people, work |
One request prepared, one adjustment considered |
| 11 |
Flare-ups and care |
Flare-up plan written, consultation prepared |
| 12 |
Review, plan, relapse |
Measures repeated, plan for what comes next written |
What the person takes away. They leave with ten printable worksheets, listed in section 39: my pain and activity diary, understanding my pain, what matters to me, pacing my activities, the movements I fear, my thoughts and making room, my nights, my flare-up plan and my consultation, the corner for those close to you, my plan for what comes next.
What distinguishes this programme from general psychological support. Three things set it apart. It starts by checking that the doctor has done their job and stays in the loop, because chronic pain can change in nature. It judges the outcome on what the person does with their life, not on the pain score, which is often the last thing to move. And it works on the body in motion: sessions include exercises that are actually done, not only conversations about pain.
2. Before you begin
The five preliminary decisions
Has the pain been assessed by a doctor? This is the first question. The programme does not start without a medical assessment, and it never replaces one. If the person has not seen a doctor about their pain for a long time, or if the pain has changed since, they go back before session 2 (section 3).
Is there a somatic red flag? They are listed in section 3, and you go through them in session 1, even when the pain has lasted for ten years: an old pain does not rule out a new disease.
Is there a suicide risk? It is higher in chronic pain (section 9), and it is asked about explicitly.
Is another disorder in the foreground? Severe depression, opioid or alcohol use disorder, post-traumatic stress disorder, or pervasive health anxiety may come before or alongside the programme (section 8).
Who is the referring doctor? You write down their name and agree with the person what you will write to them, and when. The programme is conducted in liaison with them, or with the pain clinic that follows the person (section 14).
What this programme does not treat
It does not treat the medical cause of the pain. Osteoarthritis, rheumatoid arthritis, endometriosis, nerve damage, migraine all have their medical treatments, which continue. The programme complements them; it does not replace them.
It does not treat acute pain, nor pain linked to active cancer, which fall under other teams and other rules, in particular for analgesics. When, in a person with cancer, it is the distress that becomes excessive, lasts or prevents them from living, the manual Supporting a person with cancer: a therapist's manual offers a programme designed for them, from diagnosis to the end of life; the pain itself remains in the hands of the team that treats it.
It does not treat opioid use disorder on its own. When the person has lost control of their analgesic use, obtains them from several prescribers or without a prescription, or takes them for their effect on mood, the disorder is treated with an addiction medicine specialist, and this programme can accompany it afterwards (section 32).
It does not treat severe depression or acute suicide risk on its own. These fall under Treating depression in adults: a therapist's manual and Suicidal behaviour in adults: a therapist's manual, and call for a psychiatric opinion; the programme resumes when the person's condition allows.
It is not meant for children or adolescents, for whom chronic pain calls for programmes centred on the family and school.
How to use it
Read the whole manual before the first session, in particular sections 3, 6 and 14 — triage, the model and the framework —, then sections 28 to 32 before the sessions that draw on them. Each session is described with the same structure: the objective, the step-by-step procedure, what you say and what you do not say, common mistakes, and the criterion for moving on.
Three warnings are specific to this indication.
The most frequent trap is implying that the pain is psychological. Most people who come to a psychologist for pain have heard, at some point, that "it's all in your head", that "it's stress", or that "the tests are normal, so there's nothing wrong with you". They often come reluctantly, because they were referred, and they are watching for the sentence that will confirm they are not believed. The whole first session must show them the opposite: their pain is real, and the work is about what it does to them, not about whether it exists.
The symmetrical trap is to make promises. A person who has been in pain for years has often heard many promises, and each one ended in disappointment. The manual says honestly what research establishes: real and modest effects, which bear more on life with pain than on its intensity (section 11). Saying this from session 2 onwards protects the relationship.
And the body is in the session. This programme requires getting people moving, measuring, and exposing them to feared movements. If you are not comfortable with this bodily side, work on it in supervision, and in liaison with a physiotherapist when possible: the programme gains a great deal when movement is also worked on by them (section 14).
3. What falls to the doctor first: red flags
Why this section comes before everything else
Chronic pain can coexist with a new disease, and an old pain can change its cause. The psychologist does not have to make a medical diagnosis, but they are often the person who sees the patient most regularly, and they are therefore well placed to spot a change. The signs below do not mean that something serious is happening: they mean that a doctor needs to take a look, sometimes quickly. They are not an exhaustive list; it is a screening list, which you go through in session 1 and each time the person describes a change. It draws on the red flags adopted by the Haute Autorité de santé (the French National Authority for Health) for low back pain (Haute Autorité de santé, 2019) and on those of the SNNOOP10 list for headache (Do et al., 2019); their division between what calls for the emergency department and what calls for prompt advice is a clinical guide, which you adjust with the doctor.
What requires a call to the emergency services, without waiting
New sphincter or perineal problems. These may be difficulty passing urine, loss of control of urine or stools, or loss of sensation in the skin around the genitals or the anus, especially when they come with back pain or pain that runs down the legs.
Weakness that sets in rapidly also calls for this, whether it affects both legs or a single limb, or progresses from one day to the next.
A sudden and very intense headache calls for it too, whether it is the worst the person has ever had or is accompanied by disturbances of vision or speech, weakness on one side of the body, confusion, or fever with neck stiffness.
Pain that appeared after major trauma, such as a fall or an accident, calls for it as well.
What requires prompt medical advice, within the next few days
Pain that clearly changes in nature, location or intensity for no apparent reason calls for this opinion, as does a new pain that does not resemble the usual pain.
Fever, unexplained weight loss or a decline in general health call for it too.
Pain that wakes the person every night and does not ease with rest, or that remains constant whatever the position, calls for it as well.
Numbness, tingling or weakness that is spreading also justifies a prompt opinion.
Some history changes the reading: cancer, even in the past, immunosuppression, prolonged corticosteroid treatment, intravenous drug use.
In a person with chronic headache, a new kind of headache also calls for a prompt opinion, as does use of acute pain medication that has become almost daily, which can itself maintain the headaches and calls for the doctor.
What you do
You ask the questions in session 1, saying why: "I'm going to ask you a few medical questions. It isn't my job to make a diagnosis, but I want to be sure we don't miss something that needs a doctor."
You act according to severity. For signs in the first group, the person calls the emergency services, and you help them do so if needed. For signs in the second group, they make an appointment with their doctor within the next few days, and you write to the doctor about what you have observed, with their consent.
You do not reassure in the doctor's place. "It's probably nothing" is a sentence you are not in a position to say.
And you do not suspend the programme for nothing. A flare-up that resembles the usual pain, only stronger, is not a red flag: it is the subject of the flare-up plan in session 11. The distinction rests on novelty, not on intensity.
The opposite mistake
Medical vigilance can become a trap for the programme itself. A person who asks for a new test at every flare-up, who consults several doctors to finally find the cause, or who interprets every sensation as the sign of a serious disease does not fall under this section, but under the work on reassurance seeking (sections 5 and 8). The rule is simple: a change in nature is reported to the doctor; a variation of the usual pain is worked on in the programme.
4. What chronic pain is
The definition of pain
The International Association for the Study of Pain (IASP) revised its definition of pain in 2020. Reformulated, it describes an unpleasant sensory and emotional experience, associated with actual or potential tissue damage, or resembling that which one would experience in the event of damage (Raja et al., 2020). The notes accompanying the definition specify three points on which this manual is founded: pain is always a personal experience, influenced to varying degrees by biological, psychological and social factors; pain and the nerve signal produced by damage, called nociception, are two distinct phenomena, and pain cannot be inferred from the activity of sensory nerves alone; and what a person describes as pain should be respected (Raja et al., 2020).
The second idea is the most useful in practice: one can be in pain without visible damage, and have visible damage without being in pain. The third sets your position: you never dispute the reality of the pain.
Chronic pain according to ICD-11
The eleventh revision of the World Health Organization's International Classification of Diseases (ICD-11) contains, for the first time, a systematic classification of chronic pain, built by an IASP task force. It defines chronic pain as pain that persists or recurs for more than three months, and divides it into two families (Treede et al., 2019).
Chronic primary pain. This is pain, in one or more regions of the body, that has lasted or kept recurring for more than three months, that is accompanied by significant emotional distress — anxiety, anger, frustration, depressed mood — or by significant functional impact on daily life and social roles, and that is not better accounted for by another diagnosis (Nicholas et al., 2019). It is considered a condition in its own right, and not the mere symptom of something else. It includes chronic widespread pain, including fibromyalgia; complex regional pain syndrome; chronic primary headache and orofacial pain; chronic primary visceral pain, such as irritable bowel syndrome; and chronic primary musculoskeletal pain, which includes a large proportion of so-called non-specific low back and neck pain (Nicholas et al., 2019).
Chronic secondary pain. This is pain that another disease explains, at least initially: cancer-related pain, chronic post-surgical or post-traumatic pain, neuropathic pain, which arises from damage to or disease of the nervous system, secondary headache, and secondary visceral and musculoskeletal pain, such as that of osteoarthritis or inflammatory diseases (Treede et al., 2019).
What this changes for you. It changes two things. The two families can coexist in the same person, and a secondary pain can, over time, take on the characteristics of a primary pain, which goes beyond what the disease explains. And the diagnosis of chronic primary pain is a positive diagnosis, not a diagnosis by default: it does not mean "nothing was found", but "the pain itself is the problem to be treated".
Three mechanisms: nociceptive, neuropathic, nociplastic
To describe what produces pain, the IASP distinguishes three mechanisms.
Nociceptive pain arises from actual or threatened tissue damage, which activates pain receptors: a sprain, osteoarthritis, inflammation.
Neuropathic pain arises from damage to or disease of the nervous system that transmits sensations: sciatica caused by compression of a nerve root, shingles, diabetic neuropathy.
Nociplastic pain, described in 2016 and adopted by the IASP in 2017, refers to pain arising from altered nociception, without clear evidence of tissue damage that would activate receptors, nor of damage to or disease of the nervous system that would explain the pain (Kosek et al., 2016). It accounts for fibromyalgia, some chronic low back pain, irritable bowel syndrome and other frequent presentations. A review in The Lancet describes its characteristics: pain that is often widespread or multifocal, more intense than observable damage would explain, often accompanied by fatigue, sleep disturbance, memory and concentration difficulties, and heightened sensitivity to other stimuli, such as noise or light; it discusses possible contributions of the central nervous system, but also of the immune system and peripheral tissues (Fitzcharles et al., 2021).
What this changes for you. These categories describe mechanisms, and the same person can combine all three. You do not have to decide between them: that is the doctor's job. But the notion of nociplastic pain gives you precise language to explain to the person that their pain is real, that it comes from a modified functioning of the system that produces pain, and that this functioning can change (session 2).
Sensitisation, explained simply
When pain lasts, the nervous system can become more sensitive: signals are amplified, the painful area spreads, movements that did not hurt end up hurting, and touch or pressure become painful. Researchers speak of sensitisation, and of central sensitisation when it concerns the spinal cord and the brain. It is one of the mechanisms discussed in nociplastic pain, but its exact importance in a given person is not measured routinely, and its mechanisms remain debated (Fitzcharles et al., 2021). In session, it is explained with an image, that of an alarm that has become too sensitive, without claiming to know more than is known (session 2).
What the person describes
The pain itself often varies from one day to the next and over the course of the day, with flare-ups whose cause is not always identifiable.
Fatigue is almost constant; it comes from the pain, fragmented sleep, some medications, and deconditioning.
Sleep is hard to get, interrupted by pain and unrefreshing.
Mood is often low, with irritability, discouragement, sometimes anger at the pain, at healthcare professionals, at those who do not understand.
Life shrinks: hobbies are given up, work is reduced or stopped, outings become rarer, roles are lost — the one who used to carry the shopping, the one who used to play with her grandchildren.
And the feeling of not being believed by healthcare professionals, the employer, sometimes those close to them, comes up in almost every account.
Epidemiology, in one useful figure
A survey carried out in fifteen European countries and Israel, among more than forty-six thousand people, found that about one adult in five had had pain of moderate to severe intensity for at least six months; a large proportion of these people said that their pain reduced their ability to work, and few were followed by a pain specialist (Breivik et al., 2006). Chronic pain is therefore common, and most people who suffer from it will never see a specialist service: all the more reason for the psychologist who sees them to know how to work with it.
5. What maintains pain and disability
The mechanisms below do not cause the pain; they maintain disability and distress, and often the intensity experienced. They are the target of the programme.
Interpreting pain as a danger
When pain is read as the sign that the body is being damaged — "something is tearing", "my disc is being crushed", "I'll end up in a wheelchair" —, every sensation becomes an alarm. This reading is often fed by what the person has heard: a word remembered from an imaging report, such as "hernia" or "wear and tear", a piece of advice to be careful given at the first episode and never lifted. It is the starting point of the fear-avoidance cycle (section 6).
Catastrophising
The term is poorly chosen, because it sounds like a reproach; it refers to a way of thinking about pain that many people adopt when it lasts and is frightening. Sullivan and colleagues described three dimensions: rumination, when one can no longer think of anything but the pain; magnification, when a sensation becomes the sign of worsening or of a threat; and helplessness, the feeling that nothing one does will change anything (Sullivan et al., 1995). Catastrophising is one of the psychological factors most consistently associated with more intense pain and greater disability, and it is also associated with suicidal ideation in chronic pain (Racine, 2018).
Fear of movement and avoidance
When a movement is judged dangerous, it is avoided. The relief is immediate, and it is this relief that reinforces avoidance. But avoidance prevents learning that the movement was not dangerous, it deconditions the body, and it narrows life. The term kinesiophobia refers to an excessive fear of movement linked to the fear of injury or re-injury (Vlaeyen et al., 1995).
The swing between overdoing and crashing
Not everyone avoids. Many people, especially in fibromyalgia and widespread pain, catch up on everything on the days when they are in less pain, then pay for these excesses with one or more days of crashing. This swing teaches a false lesson: that activity always hurts. A meta-analysis found that avoidance and persisting with activity despite pain, to the point of worsening, were both associated with poorer functioning (Andrews et al., 2012). Activity pacing, which treats it, is described in section 28.
Body monitoring and protective behaviours
Scanning one's body several times an hour, testing the movement that hurts to see whether it still hurts, wearing a lumbar support belt all the time, walking stiffly: these behaviours bring relief in the moment, but they keep attention on the pain and prevent the body from regaining its flexibility.
The search for a single cause
Hoping for the test that will finally find it, the specialist who will understand, the procedure that will sort everything out: this is human, and a new opinion is sometimes legitimate. But when the search for the cause becomes the only project, life stays on hold, and every normal result is experienced as a failure. This search is fed by the feeling of not being believed, which is often well founded.
Sleep
Sleep disturbances are common in chronic pain, and the relationship works both ways: pain disrupts sleep, and prospective studies suggest that poor sleep predicts pain at least as much as the reverse (Finan et al., 2013). Sleep is therefore a treatment target in its own right (session 9).
Mood
Depression is common in people in pain, and pain is common in depressed people; when the two coexist, each weighs on the other and on the prognosis (Bair et al., 2003). Low mood reduces activity and increases rumination and the attention paid to pain.
The context
A job lost or under threat, a compensation claim or litigation, money difficulties, a conflict with the employer or the insurer, a relative who does everything for the person, or on the contrary who does not believe them: the context often maintains disability, and it cannot be worked on by ignoring the pain. The reactions of those around the person matter particularly: attention that only appears when the person is in pain can, without anyone intending it, reinforce the expression of pain and withdrawal.
The complete cycle
Pain appears or increases. It is read as a danger. Fear rises, attention fixes on the body, and the person avoids movement or, on a good day, overdoes it. The body deconditions, or wears itself out in the swing; sleep deteriorates; mood drops; life shrinks. The pain, amplified by all this, seems to confirm that protecting oneself was indeed necessary. This is the diagram you draw with the person in session 3.