Feel It to Heal It: Chronic Pain and Emotions

by Sarah Awareness Pain Relief Recovery Understanding Pain

If you prefer to listen, here’s an audio version of me reading the post:

 

This piece explores how emotions can influence chronic pain. Historically, pain conditions have often been treated as a part of our physical health, while emotions have been treated as separate experiences related to mental health. Increasingly, however, we recognize that this distinction is not so clear-cut.

For decades, pain has been understood through a biopsychosocial lens, which recognizes that our experience of pain is shaped not only by biological factors, but also by psychological and social ones. Likewise, emotions are not simply “mental” experiences. They involve coordinated changes in our brain, nervous system, hormones, muscles, and behaviour. This close relationship is reflected in the International Association for the Study of Pain (IASP) definition of pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”

Although pain is distinct from emotion, they share many biological purposes. Both draw our attention to what matters, motivate protective action, and help communicate our needs to others. Pain alerts us to potential bodily harm, motivates us to take action to keep our bodies safe, and can communicate distress in a way that signals a need for help.

A popular take on pain and repressed emotions

If you have spent time exploring mind-body approaches to pain recovery, you have likely come across the work of Dr. John Sarno. Sarno proposed that, for many people, chronic pain could arise primarily from repressed emotions—particularly anger—rather than ongoing tissue damage. He believed that the brain generated pain as a way of protecting people from emotions that felt too threatening to consciously experience. When he believed that someone’s pain was the result of repressed emotions, he would diagnose them with Tension Myositis Syndrome (TMS). Most TMS-related books, podcasts, and online communities trace their roots back to Sarno’s work.

Although research supports a much more nuanced understanding of chronic pain than Sarno originally proposed, his work has had a profound influence. Many people credit his ideas with helping them recover, and his work helped spark broader interest in the relationship between emotions and chronic pain. For example, many people report substantial improvements—or even complete recovery—after reading his book Healing Back Pain: The Mind-Body Connection. Public figures, such as Jimmy Kimmel, Howard Stern, and Larry David, publicly credit Sarno’s work for helping them recover from chronic pain.

Notable people in the pain world helped by Sarno’s work

One notable person helped by Sarno’s work is Nicole Sachs. After Sarno’s work changed her pain and her life, she trained under him, and in her work as a psychotherapist, she has become a popular and influential figure in her own right. Her podcast and YouTube channel branded as The Cure for Chronic Pain, as well as her recent book Mind Your Body: A Revolutionary Program to Release Chronic Pain and Anxiety, share her evolution of Sarno’s work, which continues to place emotional awareness and emotional avoidance at the heart of chronic pain recovery. Again, while the science is more nuanced than the idea that repressed and avoided emotions are often a primary driver of chronic pain, her work has also helped a lot of people. For example, NBA forward Michael Porter Jr. has publicly credited Sachs’ work as playing an important role in his recovery from chronic back pain.

Another notable person helped by Sarno’s work is Alan Gordon. Reading one of Sarno’s books was the beginning of things getting better for him. After recovering from pain, Gordon went on to develop Pain Reprocessing Therapy (PRT). While inspired by Sarno’s work, PRT places greater emphasis on how the brain can learn to interpret safe sensations as threatening. Fear plays a central role in maintaining this cycle, alongside processes such as attention, expectation, and avoidance. Even though Pain Reprocessing Therapy is relatively new, it is also meaningfully helping people.

I was inspired to train in PRT by one of my own research participants, who fully recovered from 37 years of relatively debilitating pain. Her recovery was supported by PRT and another approach called Emotional Awareness and Expression Therapy (EAET). You can read what I wrote about her story here or listen to an interview with her on YouTube here.

Another evolution of Sarno’s work

In addition to Pain Reprocessing Therapy (PRT), another psychological approach to pain that was influenced by John Sarno’s work is Emotional Awareness and Expression Therapy (EAET). Dr. Howard Schubiner, a physician who used to work with Dr. Sarno, developed this approach with Dr. Mark Lumley, a psychologist and researcher, with the goal of developing an evidence-informed approach that incorporated aspects of Sarno’s model alongside advances in pain science. While EAET draws from Sarno, it is also informed by decades of research in emotion science, trauma, attachment, stress physiology, expressive writing, and psychotherapy. EAET helps people identify, experience, and express emotions that may have become difficult to access, tolerate, or communicate, particularly when those emotions are connected to trauma, chronic stress, grief, interpersonal conflict, or other challenging life experiences. Rather than viewing emotions as the sole cause of chronic pain, EAET recognizes that unresolved emotional experiences can be one of many factors that influence how pain develops and persists. Research has demonstrated benefits of EAET for some people with pain conditions such as fibromyalgia, irritable bowel syndrome (IBS), musculoskeletal pain, and chronic pelvic pain.

What does the research say? And how much does it matter?

Before I look at the research, I want to share something a physician I used to work with once said during a group medical visit. When someone asked about a less common intervention, she responded, “I have seen so many people helped by things that I learned in medical school were hogwash, so I say, as long as it isn’t going to cause you harm, including financial harm, try everything.” Her point was not that evidence does not matter—research most definitely helps us to understand what is most likely to help, for whom, and under what conditions—but that people’s lived experience of healing sometimes extends beyond what research has captured.

For some interventions, there are side effects or risks of serious complications. Simply, there is a cost to the possible gain. With emotion-focused work, there can be risks, including emotional overwhelm or re-traumatization if the work moves too quickly or is not appropriately supported. There are also practical costs, such as time, money, and emotional energy. However, when this work is paced carefully and approached safely, many people find that it improves not only their relationship with pain, but also their overall well-being—even if pain itself does not change.

So, what does the research say?

Research increasingly supports the idea that, for a meaningful subset of people with chronic pain, emotional experiences can influence how the nervous system processes and responds to threat. This may be particularly relevant for people with trauma histories, ongoing interpersonal stress, relational wounds, experiences that have not been fully processed, or patterns of emotional avoidance. Chronic pain is associated with greater emotional avoidance, and efforts to suppress or avoid difficult emotional experiences can, in some circumstances, increase physiological stress responses. Over time, these patterns may contribute to a nervous system that remains more sensitive to threat. It is also important to recognize that the relationship goes both ways. Chronic pain itself can generate difficult emotions, and those emotional responses can then influence how the nervous system processes pain.

Pain and emotions are deeply interconnected. Understanding and working with emotions may positively influence pain for some people and may also improve life even when pain remains. When evaluating approaches to chronic pain, we need to consider more than whether an intervention reduces pain intensity. Pain is only one part of a person’s experience. Improvements in pain-related fear, functioning, relationships, emotional well-being, and quality of life are also meaningful outcomes.

What does emotional work look like?

As the relationship between trauma and chronic pain becomes more widely recognized, one misinterpretation of this work is believing that we need to find the one buried trauma or emotion that is causing our pain. Emotional work is not about digging endlessly into the past to find the hidden reason you are in pain. It is also not about forcing yourself to feel emotions or trying not to feel certain harder-to-feel emotions. Emotions like anger, grief, and despair can be difficult to feel, and feeling these things is a part of being human. Emotional work is about developing a different relationship with your internal experiences—learning to notice, understand, tolerate, and respond to emotions with greater awareness and compassion. It is not about forcing yourself to feel more. It is about creating enough safety that what has been difficult to feel can become more feelable. Effective emotional processing happens within a window where you are connected to the emotion but still able to stay present and grounded.

How can we do this work?

Two potentially helpful ways of working with emotions are expressive writing and therapy. While these approaches look different, both can help us develop a greater awareness of our internal experiences and create space for emotions that may have been difficult to process. For some people, expressive writing is enough to begin this process. For others, emotions connected to pain may feel too complex, overwhelming, or difficult to access alone. This is where therapy can be helpful.

Expressive writing

Expressive writing was developed by social psychologist James Pennebaker as a research-based writing intervention exploring how putting difficult experiences into words affects health and well-being. It is a writing practice that focuses on approaching difficult experiences, putting emotions into words, creating a coherent narrative about our experience, and allowing ourselves to acknowledge what happened. Creating a coherent narrative does not mean creating a positive story or minimizing what happened. It means helping the brain organize an experience that may have felt confusing, overwhelming, or unfinished.

Common forms of journaling that are different from expressive writing include recording the events of your day, repeatedly venting without reflection, analyzing why you feel bad, and trying to write well.

Expressive writing can be done in many different ways, but here is a basic framework that might be helpful to start:

  • Set aside 15-20 minutes
  • Write continuously without worrying about grammar or structure
  • Focus on a difficult experience, emotion, or ongoing struggle
  • Include your thoughts, feelings, body sensations, and meaning
  • If you become overwhelmed, pause and use a grounding practice before deciding whether to continue.

Again, this process is not about forcing yourself to feel more. As emphasized above, it is about learning to notice, understand, tolerate, and respond to emotions with greater awareness and compassion. The goal is not to get rid of difficult emotions, but to develop a different relationship with them. Research on expressive writing has found a range of physical and psychological benefits, although the effects vary depending on the population, the type of writing intervention, and the outcomes being measured.

Nicole Sachs has a specific approach to expressive writing that some people really like. It is different from the expressive writing protocols that have been studied in research settings, but as discussed above, anecdotally, it has helped many people. It is called Journal Speak, and she teaches about it in YouTube videos and podcast episodes, as well as in the book I mentioned above.

A note for consideration: For people with significant trauma histories, intense emotional writing can sometimes bring up more than they are prepared to process alone. In those cases, working with a trained therapist may provide the support needed to approach these experiences safely.

Therapy

Therapy is one place where we can develop skills such as emotional awareness, emotional acceptance, and emotional expression. Foundationally, emotional awareness can be about emotional literacy—recognizing and naming what we are feeling. People with alexithymia generally have a hard time experiencing, identifying, and expressing emotions. Although not everyone with chronic pain experiences difficulties with emotional awareness, alexithymia is associated with greater pain intensity among adults with chronic pain.

As we begin to grow our capacity to recognize emotions, we can also expand our understanding of our emotional experience. One question I often ask people is, “How do you know that you are feeling ______?” As touched on above, emotions are not just mental experiences. They involve changes in our brain, nervous system, hormones, muscles, and behaviour. Part of emotional awareness is noticing these shifts. A deeper layer of emotional awareness is when we begin to learn from what we are feeling. Emotions are information—not necessarily facts—about what we want, what we don’t want, what we value, and when something needs to change.

Emotional acceptance, another skill that can be developed in therapy, is about moving away from fighting, judging, and fearing our feelings. Rather than being critical of ourselves for feeling certain things, we move towards what we are feeling with curiosity and compassion. This involves recognizing, as noted above, that our feelings are experiences we can learn from. Acceptance does not mean liking an experience, giving up on change, or deciding that things will always be this way. It means making room for what is present so that we can respond more effectively. Self-compassion practices weave in wonderfully here because they emphasize how human it is to feel the full range of human emotions. We don’t live a human life and escape the ones that are hard or uncomfortable to feel.

The final skill I will touch on here is emotional expression. Here we move beyond our own relationship with our emotions and bring our emotions into our relationship with others. When we can share what we are feeling with others, it opens the possibility for deeper connection and for the experience of truly feeling seen and understood.

A final note

Please remember the comment I made above about pacing this work. At the heart of this emotional work is safety learning—learning that we can safely experience emotions that have felt overwhelming, threatening, or difficult to tolerate. As I emphasize in this post on danger and safety learning, “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.”

Step gently into this work. Take care of yourself. Ask for help. In many ways, our own emotions can be one of the scariest things we encounter. It’s okay to feel afraid.

Working with emotions is not about finding a single hidden cause of pain or forcing ourselves to relive difficult experiences. It is about building a safer, more compassionate relationship with our internal world. For some people, this may change their experience of pain. For others, it may bring greater freedom, connection, and quality of life alongside pain. Either way, learning to listen to ourselves can be a meaningful part of healing.

 

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.

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.