Recovery Through Relearning: Chronic Symptoms as Protective Responses

by Sarah Pain Relief Recovery Understanding Pain

If you’ve spent time learning about pain, you may have come across Lorimer Moseley, a well-known pain researcher from Australia. His work is widely recommended in pain education programs, and you can explore some of it on the Learn About Pain page of my website.

Moseley is now applying what we’ve learned about pain to a broader group of conditions he calls the “Five Big Protective Disorders”: pain, fatigue, anxiety, depression, and post-traumatic stress. When chronic, he suggests that all of these conditions may be protective responses that have become overprotective and persistent. Here’s a quick overview of how these responses can be protective:

  • Pain – Pain captures our attention so we can protect a potentially injured or threatened body part. It motivates action to increase safety.
  • Fatigue – Fatigue helps conserve energy, promote recovery, and encourage rest when the system perceives depletion or threat.
  • Anxiety – Anxiety increases vigilance and prepares us to detect and avoid potential danger.
  • Low mood/depression – Low mood can reduce activity, risk-taking, and effort during times of loss, significant stress, or overwhelm.
  • Post-traumatic stress – After a threatening or overwhelming experience, the nervous system may stay on high alert. Hypervigilance, avoidance, and strong emotional reactions are all ways the body tries to prevent future harm.

Recovery as relearning

When we think about these conditions as persistent overprotection, recovery begins to look different. Rather than focusing solely on symptom reduction or tissue repair, recovery becomes about learning—helping the brain and nervous system update outdated predictions about danger and safety. In other words, recovery becomes less about “fixing what is broken” and more about retraining a system that has tried so hard to keep us safe that it has learned to protect too much.

Danger learning and safety learning

It can be helpful to frame this retraining as danger learning and safety learning. Danger learning occurs when the brain learns to perceive something as a threat. Danger learning happens quickly, promoting immediate survival by creating strong, fast-acting fear responses.

In contrast, safety learning is slower, requiring repeated experiences to teach the brain that a situation is no longer hazardous, effectively inhibiting fear responses over time. It involves helping the brain and nervous system update their predictions by learning, “This is safe—I don’t need this level of protection here.” The goal is not to eliminate protection, but to help the system respond more accurately, reserving protective responses for genuine danger rather than learned or outdated threats.

Explicit learning and implicit learning

It’s also helpful to distinguish between two different ways of learning: explicit learning and implicit learning.

Explicit learning is conscious, verbal, and logical. It’s the kind of learning where you can say, “I know this,” or “I understand this.”

Implicit learning is unconscious, emotional, sensory, and experiential. It shapes gut reactions, habits, conditioned responses, and automatic feelings of safety or danger—often outside conscious awareness. It’s learning that comes through experience.

Understanding these two ways of learning matters because many chronic protective responses are rooted in implicit danger learning. We might not think we are in danger, and in fact, we might know that we are safe. But, on an unconscious, implicit level, our nervous system is still predicting danger. Lasting change often requires implicit safety learning—new lived experiences that help the nervous system genuinely update how it identifies and predicts threat.

A note on embodiment and learning

Embodiment is the experience of being connected to and aware of your body, emotions, sensations, and internal experience—and allowing that experience to inform how you relate to yourself and the world around you. Many people learn to disconnect from aspects of their bodily and emotional experience as a way of surviving difficult or overwhelming experiences, especially early in life. This disconnection is often adaptive and protective.

Explaining embodiment fully deserves its own post, but it’s important to briefly mention here because embodiment can help bridge explicit and implicit learning. When we are more connected to our internal experience, intellectual understanding is more likely to become felt and integrated—not just something we think, but something the nervous system begins to experience as true. This is part of why practices that support embodiment—such as therapy, mindfulness, somatic work, and other mind-body approaches—can play such an important role in healing.

More about danger learning

While we often think of more obvious dangers as threats (things like physical injury or unsafe situations), the brain can also learn to interpret a remarkably wide range of experiences as threatening. Below, I’ve listed examples of common places (with a few examples of each) to find danger learning.

  • Movement: specific movements (bending, lifting, twisting), general activities (walking), repetitive tasks (sitting to standing)
  • Body sensations: tightness, tingling, fatigue, dizziness, heart rate changes, gut sensations
  • Contexts or environments: driving, workplaces, social situations, medical settings, crowds
  • Emotions: stress, anger, sadness, grief, overwhelm
  • Thoughts: “I can’t do this,” “This is getting worse,” “I won’t be able to cope,” “What’s the point?”
  • Time-based patterns: time of day, duration of activity, anticipated crashes or flare-ups
  • Social and relational experiences: conflict, feeling misunderstood, encountering or being around certain people, asking for help, feeling judged
  • Sensory input: light, sound, smell, temperature
  • Food: specific foods, hydration, meal timing, portion size
  • Sleep: difficulty falling asleep, waking during the night, poor sleep quality
  • Medical: diagnoses, imaging findings, practitioner language, previous medical trauma

The brain can learn to associate almost anything with danger. In Lorimer Moseley’s framework, these learned danger cues are called DIMs, which stands for danger-in-me. Because many DIMs are learned implicitly through past experiences, we can be completely unaware of them. Some are obvious, while others can be surprisingly subtle and tricky to find.

Mapping your own danger learning

Pain is not a direct measure of tissue damage. Rather, pain is a protective alarm that sounds when the brain perceives that the body might be in danger. This means that understanding what your brain has learned to associate with danger can be an essential part of recovery—not just for chronic pain, but for many persistent protective symptoms. 

A helpful starting point is to gently begin identifying your own DIMs. This is not about judging whether your brain’s associations are rational or accurate. It’s simply about understanding the protective patterns your system has learned. Awareness creates the foundation for change.

More about safety learning

We can use safety learning to retrain a system that has become overprotective, and it is important to think about learning safety both explicitly and implicitly.

Explicit safety learning

Explicit safety learning involves conscious, cognitive understanding. This kind of learning can happen through books, courses, podcasts, therapy, or educational conversations. In the context of chronic pain, fatigue, anxiety, or other protective symptoms, learning about the neuroscience behind these conditions and about how these protective systems work can reduce fear, create hope, and begin shifting harmful beliefs. Reading this blog post is an example of explicit safety learning.

Implicit safety learning

You may consciously know you are safe, but deeper parts of your nervous system may still respond as though danger is present. The brain’s protective systems are most powerfully updated through repeated, credible experiences of safety rather than from information alone. In other words, recovery often requires helping the body and nervous system experience safety often enough that protection no longer feels necessary.

This helps explain why insight alone may not fully resolve chronic symptoms. You can understand pain science, believe in mind-body recovery, and yet still experience symptoms if your implicit protective system has not yet updated.

How implicit safety learning happens

Safety learning often involves intentionally creating experiences that provide the brain with new evidence: evidence that movement, sensations, emotions, or situations may be safer than previously predicted. Safety learning is most effective when experiences are tolerable, believable, and repeatable. Too much too fast may reinforce danger. A helpful idea for this work is: go slow to go fast. Safety learning may be supported by:

  • Graded exposure
  • Somatic tracking
  • Emotional exposure
  • Corrective experiences
  • Play
  • Pleasure
  • Self-compassion
  • Nervous system regulation
  • Graded activity
  • Connection

We want to give our nervous systems repeated experiences that contradict danger predictions. In other words, we want to experience safety repeatedly until the nervous system updates. Over time, we will increase our safety cues, or what Lorimer Moseley refers to as SIMs—safety-in-me. And when our brain perceives there to be more credible evidence of safety than of danger, the protective responses will no longer be needed.

How therapy can support safety learning

Therapy can support both explicit and implicit safety learning, and it can also help uncover danger learning that is more difficult to recognize on our own. Put simply, therapy can help make the implicit more explicit—bringing automatic or outside-of-awareness patterns into awareness.

On an explicit level, therapy can help people make sense of their symptoms through a new lens: learning about protective responses, danger learning, and the ways the nervous system adapts through experience.

Fully explaining how therapy supports implicit learning would require another lengthy post. But, in short, experiential approaches to therapy help bring older protective patterns into awareness while creating new experiences that gently challenge and update them. This can be especially important for people with histories of relational trauma. Over time, the therapeutic relationship itself can become a place where vulnerability feels safer and connection becomes possible without as much protection.

As this happens, emotions that once felt overwhelming may become more tolerable, and body sensations may feel less threatening. Rather than simply trying to eliminate symptoms, therapy can support the gradual retraining of a system that has learned to expect danger—helping the brain and body rediscover safety, flexibility, and trust through lived experience.

Somatic Tracking: A Powerful Tool for Pain

by Sarah Pain Relief

What is somatic tracking?

Somatic tracking is a gentle practice that involves curiously paying attention to sensations in the body without trying to change them. It comes from Pain Reprocessing Therapy, a psychological approach to chronic pain, and it also supports broader brain retraining processes used in the treatment of many chronic health conditions. In Pain Reprocessing Therapy, fear is seen as a fuel for pain, and somatic tracking directly works with fear by retraining our brain to interpret more experiences as safe.

Why practice somatic tracking?

Because ongoing challenges with pain tend to impact our lives negatively, pain sensations themselves can become increasingly perceived as a threat. When pain itself is activating our system, it can start a pain-fear cycle that progressively makes things worse. When pain triggers fear or a perception of threat, the nervous system moves into higher alert. This increased vigilance amplifies the protective response of pain, which leads to further increases in fear or perception of threat—and the cycle continues.

The aim of somatic tracking is to break the pain-fear cycle by retraining the brain to have a different relationship with the pain sensations. Over time, somatic tracking helps the brain learn that pain sensations don’t require danger responses, which can reduce pain intensity and frequency.

So, somatic tracking changes pain?

Importantly, with somatic tracking, we are not trying to force pain to change in the moment; we are supporting long-term change by teaching the brain that sensations are safer than it expects. Rather than trying to force pain to go away, we focus on learning to feel safe while feeling painful sensations. Many people experience meaningful pain relief through this approach.

Some people notice changes quickly, while for others, this is a gradual process of building safety and confidence with their body. Somatic tracking is not about pushing through pain or forcing yourself to tolerate sensations. It is done gradually, with choice and safety. In fact, somatic tracking is only recommended when pain levels are mild or moderate—not when they are high.

A note on the word sensations.

In Pain Reprocessing Therapy, we’re encouraged to change our language. Instead of using the word pain, we use the word sensations. Why? Because the word pain, itself, is often linked to danger and threat. The more neutral word sensations helps the brain learn that this sensory experience is safe.

What does somatic tracking involve?

Somatic tracking has three components: mindfulness, safety reappraisal, and positive affect induction. Below, I briefly explain these three components in the way that they are generally described and provide an overview of the way I currently explain them to people in session.

It is worth noting that the principles of somatic tracking can be applied in different ways to all sorts of different experiences – pain, fatigue, anxiety, insomnia, and more.

The three components of somatic tracking

Somatic tracking can be done for longer periods of time, as well as in brief moments throughout the day. It involves weaving together and moving back and forth between the three different components. Outside of not being recommended when pain is high, generally, the more you practice, the better.

Mindfulness

  • Observe the sensations with a curious and non-judgemental attitude.
  • Notice the characteristics and the location of the sensations, as well as how they move or change.
  • Attend to the sensations without trying to fix, change, or escape them.

Safety reappraisal

  • Actively communicate messages of safety to your brain.
  • Remember that pain is a protective alarm warning you of the possible need to protect your body. Remind yourself that there is nothing you need to do right now to protect your body—nothing you need to run from, nothing you need to fight. You are safe enough in this moment.

Positive affect induction

  • Foster a lighthearted and positive emotional state. This makes it easier to attend to sensations through a lens of safety and positivity and signal to your nervous system that there is no emergency.
  • Positive affect doesn’t have to mean happiness or joy—it can be as simple as curiosity, neutrality, or a slight sense of steadiness.
  • Some common ways to induce this state include humour, visualization, recalling pleasant memories, and engaging in comforting activities.

Working with the three components

Mindfulness: Mapping the territory

Imagine you are a curious explorer meeting these sensations for the first time, and you want to understand them well enough to draw a very detailed map. You might first begin by noticing where the sensations are and where they aren’t. You might imagine intensity to be like sea level, noticing if there is variation across the sensations or if it is more of a flat, prairie-like experience. You could imagine different qualities of sensation (e.g., tingling, achy, tight) to be like different terrains (e.g., rainforest, desert). And throughout your practice, you may need to revise your mapping as your experience shifts. Stay open to the possibility that you might notice things about these sensations that you have never noticed before.

Safety reappraisal: Safety in mind

Imagine a spectrum of safety perception. On one extreme, we perceive ourselves as safe, and on the other, we perceive ourselves to be in immediate threat of significant danger. With safety reappraisal, we are trying to shift in the direction of perceiving ourselves as safe through what we do with our mind. The primary tool here is our thoughts. The type of thoughts people use can vary a lot and are influenced by factors such as the nature of their pain and their understanding of pain. It’s about what works for you.

Some examples of thoughts used for this practice include:

  • This is uncomfortable but not dangerous.
  • My body is safe (or my body is safe enough).
  • There is nothing I need to do right now to protect my body—nothing I need to fight, nothing I need to run from.
  • This is just a sensation.

Positive affect induction: Safety in body

With positive affect induction, we are exploring what we can do to increase our perception of safety through our body or nervous system. There are many ways to do this work—and different approaches work better for different people. Some people use imagination or visualization to connect with something that helps settle or soften their system. Imagining yourself in nature, with adorable animals, surrounded by loved ones, in a favourite place, or doing a favourite activity are a few examples. Recalling memories that bring a smile to your face or thinking about things that make you laugh. Anything that cues your awareness to the fact that you are not running from a threat—deep breaths, feeling your feet on the floor or your hips in your chair, placing a hand on your chest—could work well.

With safety in body work, it’s important to consider any history of trauma. For people who have experienced trauma, cues that are meant to increase safety may sometimes feel uncomfortable, inaccessible, or even activating. This is not a sign that something is wrong—it simply means the nervous system learned, for good reasons, to stay alert. In these cases, trauma integration and healing may be an important part of gradually increasing the body’s sense of safety, and this work is always approached with choice, pacing, and care.

Learn more about somatic tracking

Here are a few resources for learning more:

Practice somatic tracking

The free meditation app Insight Timer has many guided somatic tracking practices. I have a therapist profile on this app, and through my profile, you can find a folder of somatic tracking practices that I think might be helpful ones to work with.

I also guide somatic tracking practices in session, and if you work with me in that context, you are more than welcome to record the practices I guide in session.

*If you follow my therapist profile on the app, here is how to access the folders that I’ve put together: Teachers > My Teachers > Teachers

How Therapy Can Help with Chronic Pain

by Sarah Pain Relief Understanding Pain

Earlier this year, I wrote a piece on how therapy can help with chronic pain for Turning Point’s blog. You can read it here, but I have woven much of the original text into this updated version.

I’ve structured this post as a blend of old and new content to intentionally illustrate that my understanding of how to most effectively help people living with persistent pain in a therapy context is always evolving. For many people, an important part of therapy being an effective intervention for pain is understanding why a psychological approach makes sense and why it can make a meaningful difference. So, if you are looking to change pain, I encourage you to read through this piece.

In the first part of the original piece, I summarized the complex nature of pain, our understanding of pain as a protective alarm, and how a whole-person approach to pain requires us to look at how psychosocial factors are impacting that protective alarm.  Except for minor edits, I’ve kept this part of the original post as is.

First Part of the Original Post

It’s not uncommon for people living with chronic pain to be reluctant to seek help from a therapist. For some, it feels like admitting that their pain isn’t real and that it is “all in their head.” Others don’t see how a mental health provider could help with something they see as a physical issue.

What do we get wrong about pain?
We tend to misunderstand pain as a symptom of tissue damage. But we didn’t just make this idea up. It dates back to nineteenth-century medical textbooks, which stated either that pain had an objective visible cause or that it was imaginary and all in one’s head. Despite decades of research demonstrating otherwise, this misconception persists and influences the types of practitioners that people seek when they are navigating ongoing challenges with pain.

If pain isn’t a measure of tissue damage, what is it?
Pain is a protective alarm. It alerts us to the possible need to protect our body. Our brain constantly scans for danger—whether from an injury, inflammation, or even emotional stress—and if it interprets a potential need to take action to keep our body safe from threat, it will sound the alarm.

But it (usually) hurts when I hurt myself.
Absolutely. If I break a bone (an example of a structural problem in the body), that will result in a flood of danger signals being sent up to my brain, and in most situations, I will experience pain. The critical thing to understand is that I don’t experience pain because I have a broken bone. My brain produces pain to pull my attention to this injured part of my body so that I can take action to keep myself safe.

Sometimes, though, severe injuries don’t immediately cause pain. This can happen, for example, when a parent is hurt but focused on their child’s safety over their own, or when someone injured in the wild must keep going to access help. Can you think of a time when your body was harmed but you didn’t feel pain at first (or at all)?

What about persistent pain?
When we understand pain as an alarm, we can begin to appreciate that many different factors can contribute to its persistence. Research shows that the sensitization of the pain system plays a role in persistent pain. We now understand more about how the pain and immune systems interact, with inflammation providing a danger signal. (It makes sense that these systems are working together—both are trying to protect us!) We also understand a lot more about psychosocial factors that can play a role in the development and maintenance of persistent pain, which is a place where therapy can be beneficial.

Reflections & Edits to the Second Part

In the second part of the original post, I broke therapy for pain down into three different aspects of care. Writing this was a helpful process for me as a clinician. It has helped me to communicate more clearly with clients in session about the different types of work that could be involved in therapy for persistent pain.

But, as I have spoken about it with more and more clients, I have refined my framing of these three different aspects of care—and added a fourth. Here is how I am broadly thinking about the different ways that therapy can help with persistent pain:

1) Coping with all the things that pain makes hard.

In the original post, the heading for this section is “3) Processing the emotional impact of pain“, and what I wrote in the paragraph under this heading still captures a lot of what this part of the work can look like. Here is what I wrote originally:

Living with ongoing pain can be incredibly challenging. Many people experience profound grief for the person they once were and the life they once lived before pain. Pain can play into a vicious cycle of fear and anxiety, as fear and anxiety make the pain worse, and the fear of making the pain worse can significantly increase anxiety. Living with pain can also make us feel irritable a lot of the time. And it’s common for folks to be angry about how their life has changed, angry that things haven’t improved, and angry that no one seems to be able to help. Living with chronic pain can also result in heartbreaking levels of isolation and loneliness. And then, of course, there is depression. It’s common for folks to feel depressed—and even suicidal—when they are facing relentless pain. Understandably, these emotional challenges get pushed to the side in favour of pursuing interventions aimed at “fixing” the possible physical causes of the pain. Ironically, many people find greater relief and healing through work that addresses the emotional pain of living with physical pain. 

Something that I didn’t mention in the original post is that, historically, this has largely been considered the role of therapy in pain care. We haven’t historically looked to therapy to change pain; we have looked at therapy as a resource for helping people cope with pain. While I don’t want to downplay the meaningful role that therapy can play in helping people to face the challenge of living with persistent pain, therapy has a lot more to offer than just coping skills.

2) Learning helpful tools and strategies

This aspect of care is a new addition to this piece. I think I originally missed it because I associate these things so strongly with the work that I did as a group program facilitator at Change Pain for well over a decade. But they also come up regularly and consistently in therapy. Examples of this work can include things like working with tools from Cognitive Behavioural Therapy for Insomnia (CBT-i) to improve sleep, coaching around pacing to help avoid pain flare-ups, and guidance around graded activity to support folks in slowly increasing their activity levels. Relaxation and mindfulness practices are another example of this aspect of care, and practicing communication skills is another common piece. People often find it difficult to communicate with others about their challenges with pain, whether it is family and friends, co-workers, or other healthcare providers, and therapy can provide the opportunity to develop helpful skills in this area.

3) Addressing predisposing and maintaining factors

In the original post, I titled this aspect “1) Addressing causes.” There are many psychosocial factors known to make developing persistent pain more likely (predisposing factors), as well as many factors known to keep people in pain (maintaining factors). The original post does a nice job of succinctly summarizing some of these factors. Here is what I wrote about them:

There is a lot to unpack here. Often, people living with pain want to get back to how things were before the pain started, but it is important to remember that there are reasons the pain persisted—and many of them might have nothing to do with the physical structure. 

Trauma is an important piece. People with chronic pain are 8.5 times more likely to have PTSD, and up to 75% of those seeking PTSD treatment also live with pain. Early life trauma increases the risk of developing chronic pain later in life, and in some cases, chronic pain can be considered a legacy feature of trauma. Processing and integrating trauma can be a key part of healing. 

Other factors known to play a role in the development and maintenance of persistent pain include people pleasing, perfectionism, anxiety, catastrophic thinking, emotional suppression, hypervigilance, fear-avoidance behaviours, a hyper-focus on problem-solving, disconnection from one’s internal state, a lack of boundaries, and self-criticism. In different ways, these factors all reinforce the perception of a lack of safety and can play a role in chronic pain. 

What I want to change from the original post is the use of the word causes. Persistent pain is complex. To refer to anything as the cause of pain is an oversimplification. Pain is multifactorial, meaning that it is influenced by many different factors—including predisposing and maintaining factors that can be addressed in therapy.

4) Training your body’s system to experience more safety

This final aspect was referred to as “2) Targeting pain reduction” in the original post. What I wrote in the original piece only scratches the surface of what this work can involve, and it is worth revising.

Understanding this part of the work comes back to understanding pain. Remember, pain is a protective alarm. It is alerting you that a part of your body may need protecting. When your brain decides to sound (or not sound) this protective alarm, it is taking into account every piece of information it has about whether you are safe or under threat.

Read the sentence above again. And then really let it sink in.

Training your system to experience more safety is going to involve building resources to help you access experiences of feeling safe, as well as challenging things that your system has learned to experience as threats. Not everything we have learned we need to protect ourselves from is actually something we need to protect ourselves from—and feeling our feelings is a great example of that for many people.

There is an incredibly wide range of things that could be involved in training an individual’s system to experience more safety, but broadly, it can include things like retraining our relationship to emotions and sensations (like pain itself), learning to express parts of ourselves that were disavowed in our early life experiences, and exploring the deeper motivation behind habitual behaviours.

The Original Ending—A Hopeful Outlook

When we are stuck in the story that pain results from a structural problem in the body, there is only one path forward: we must find a practitioner to identify the problem and fix it. When we embrace a modern understanding of pain, there is much more possibility and many different paths forward. For years, pain treatment focused on management—helping people cope but assuming pain would always remain. In recent years, however, there has been a shift. Leading researchers and clinicians are talking about recovery. While I don’t believe that the human experience is ever a pain-free one (however one defines pain), I have witnessed remarkable healing, and we have more tools than ever to help people move beyond chronic pain. And therapy can offer access to some of those incredibly powerful tools.