Exploring the Depths of Chronic Pain
My wife, Tina, has been dealing with chronic pain for almost as long as we have known each other. There was a trigger that resulted in a painful experience at the beginning of our relationship, and ever since then, the pain has become a part of her daily existence. She has attempted to address it on her own and with the help of various practitioners.
We spend a lot of time together, and a significant portion of that time is devoted to discussions about her pain. Tina experiences various types of pain, ranging from aching, gripping, radiating, and tingling to muscle tension and trigger point pain. Her pain moves around from her neck and shoulders, lower back, and rib cage to her hips and legs. She adjusts her lifestyle to alleviate or prevent the pain. She limits sitting too long or traveling long distances. She sleeps with many pillows surrounding her body as a protection from pain. She carries a special pillow or cushion in her car for the same reason. Her pain seems all-encompassing and, by association, affects me as well. I strive to be helpful and supportive, but chronic pain is a formidable force that persists and exhausts.
More recently, Tina has been accessing memories of her experiences with pain stemming from early childhood. She thinks that she always lived with the pain and considered it to be a normal thing. When she got her first job, she recalls that during the lunch break, she would come to her parents' house and lie on the floor to relieve pain in her back and shoulders. She states that chronic pain has become her identity, her personality, and the way she is.
She has been a gadget collector, all in an effort to alleviate her uncomfortable or painful bodily sensations. She owns electrotherapy devices, massagers, supporters for different parts of the body, small and large balls, patches, and many other items that are difficult to name or recall. She has attended various programs, both in person and online, to learn more about misalignment, fascia release, bone health, somatic experiencing, and many others. She has consulted with medical doctors, acupuncturists, chiropractors, physical therapists, craniosacral specialists, and other mind-body practitioners. She has undergone prolotherapy, dry needling, injections, low-dose naltrexone, stretching, yoga, qigong, and other forms of therapy for her chronic pain.
This situation has taken a tremendous toll on both her and indirectly on me because I have become a part of this field of pain with ongoing efforts for its relief. I frequently massage her neck, hips, back, and other parts of the body that are hurting her. It has become a daily ritual between us. Unfortunately, the improvements she experienced were short-lived, leading to crushed hope when the pain resurfaced.
She now realizes that her sensitivity together with stressful and traumatic situations created high-alert states that predisposed her to experience pain, which became so ingrained that it is chronic.
Mindfulness-Based Stress Reduction
My awareness of psychological treatments for chronic pain has been present for a long time, dating back to when I first learned about Jon Kabat-Zinn's Mindfulness-Based Stress Reduction (MBSR) program after it was featured in Bill Moyers's PBS special "Healing and the Mind" in 1993. During the special, Kabat-Zinn demonstrated how mindfulness practices could help individuals suffering from chronic pain by teaching them to become more aware of their bodies and sensations without judgment. Participants in the MBSR program learned techniques to observe their pain with a sense of acceptance and detachment, thereby reducing their emotional suffering. By developing a non-reactive awareness of their pain, participants were able to change their relationship to it and reduce suffering. That was the key, or was it?
Tina had the opportunity to participate in this program when it was offered by a North Dakota State University psychology professor. Although the program Tina attended was not specifically geared toward chronic pain, Tina eagerly took part in it. She became more aware of her body sensations, and over time, mindfulness and other types of meditation became a daily practice, but her pain persisted.
An earlier meta-analysis of mindfulness and pain management found “insufficient evidence” that mindfulness reduced pain intensity (1). However, the latest systematic review reached the opposite conclusion, even though the authors cautioned that the results should be interpreted only provisionally due to limited data and considerable variability in study methodologies (2). Regardless, this treatment strategy didn't work for Tina despite the effort and time she devoted to it. The reason why will become clear later.
Internal Family Systems
Many years later, in 2021, Tina signed up for an online Psychotherapy Networker conference to earn credits for maintaining her license. One of the featured programs was a relatively new psychotherapy called Internal Family Systems (IFS) in the treatment of chronic pain. IFS therapy was conceptualized by psychotherapist Richard C. Schwartz in the 1980s. He introduced this model in 1987 through a scientific paper published in The Family Therapy Networker (3).
Tina allowed me to have access to this part of the program. Here is what I learned about the IFS Model: When we experience emotionally painful states, usually due to traumatic events, stressful circumstances, or being highly sensitive individuals, we compartmentalize these events from our consciousness by creating what are known as “exiles.” We lock them away to prevent them from overwhelming us with their raw emotions, making us vulnerable. If we could, we would like to throw away the key and permanently banish “exiles” from our consciousness. But we can’t. We try our best to avoid re-experiencing these painful states because they greatly disturb us, hence their name. To achieve this goal, we develop parts known as “protectors,” which manage day-to-day situations to shield “exiles” from being triggered. To do this, these protector parts take on roles such as the harsh internal critic, the overachieving perfectionist, or the frightened avoider. However, in extremely critical situations, these protectors may not be sufficient. In such instances, the exiles break through into our consciousness, compelling us to deploy emergency responder parts known as “firefighters.” They use extreme measures such as acute depression, suicidal thoughts, cutting, bingeing, alcohol or drug use, and panic attacks. Both protectors/managers and firefighters may resort to physical pain to protect our exiles.
How does physical pain do that? Here is what the main proponents of IFS wrote: “It’s difficult for us to ignore severe pain, which can overwhelm our senses and render all other priorities moot. This makes it an excellent tool for any part that wants to be heard or to control a person. Pain can keep us from getting close to emotional situations that evoke childhood events deemed too upsetting to face; or it can help us avoid emotions deemed dangerous, such as anger, fear, and sadness. It can arise when boundaries are challenged by unwanted sexual interests or by getting lovingly close to others. It can distract us from feelings that we fear might make us crumble or act in dangerous ways” (4).
In addition to these protective and wounded parts, everyone has a core Self, containing crucial qualities such as confidence, compassion, and acceptance that can be utilized in healing. The goal of IFS therapy is to guide the patient towards accessing their Self part as much as possible, so they can begin to communicate in new compassionate ways to their protective parts and heal their wounded parts.
Even though IFS is an evidence-based therapy, Tina and I never took a hard look at using it for her benefit, as if it didn't apply to her. I am not sure of the exact reason. Perhaps, on the surface, it seemed complicated and required specially trained therapists who were not easily accessible in our community, or perhaps Tina and I were not ready at that time to dive into this new way of looking at chronic pain.
Pain Reprocessing Therapy
Everything changed this year when Tina, after several more years of living with chronic pain and trying to find a cure for it, discovered the book “The Way Out” (5) and enthusiastically came up to me, asking that we read it together and apply its teachings. I initially rejected the idea, probably due to caretaking fatigue, but quickly regrouped, and we started reading the book together. I soon realized its value and the therapeutic approach advocated in it.
Alan Gordon, the author of the book, is a psychotherapist and the founder of the Pain Psychology Center in Los Angeles. He has developed a therapy known as Pain Reprocessing Therapy (PRT), which focuses on transforming an individual's relationship with chronic pain from one of distress and avoidance to acceptance and curiosity. This approach also addresses the heightened fear response and fixation often associated with chronic pain.
The book confidently introduces a paradigm shift, arrived at by the combined effort of neuroscience and psychology. It concludes, based on scientific evidence, that most chronic pain experiencers do not have structural disease or tissue injuries causing the pain. Their pain is related to stress, trauma, and unresolved emotions that activate the same brain areas as physical pain. It is well known that injuries or diseases heal, but pain can persist for years. Basically, in situations of chronic pain, the brain has learned to produce pain without the presence of tissue damage. Alan Gordon calls this pain “neuroplastic” to emphasize that it refers to neuroplasticity, which is the brain's ability to reorganize itself by forming new neural connections. Pain is thus a subjective experience created by the unconscious workings of the brain, heavily influenced by beliefs, fears, and other psychological processes.
The way an individual responds to pain significantly influences whether it becomes chronic. Common and understandable reactions to pain include fear, obsessive focus, frustration, the urge to fight it, dissociation, and attempts to alleviate it. All these responses signal to brains that the pain is dangerous, ultimately reinforcing its persistence (4).
Our brain craves certainty and seeks predictability. Due to this, there exists a mechanism in the brain that encodes all perceived sensory stimuli and assigns them specific values of safety or danger. If the original pain causing the injury is perceived as dangerous and triggers a fight-or-flight psychophysiological response, any future sensation, situation, or activity that the brain associates with the original pain will likely be experienced as pain, even in the absence of any new injury.
This underscores the power of brain suggestibility and forms the underlying mechanism for placebo (helpful) or nocebo (harmful) effects. While numerous examples exist related to this notion, describing them here is beyond the scope of this text. I just want to mention that many nocebo (harmful) effects are induced by medical practitioners who, influenced by their training and indoctrination, inadvertently reinforce the structural (somatic) basis for chronic pain in their patients.
For example, the eager health care professionals assign all kinds of worrisome diagnoses, such as tension or migraine headaches, trigeminal neuralgia, fibromyalgia, small fiber neuropathy, irritable bowel syndrome, interstitial cystitis, pelvic floor dysfunction, pudendal or occipital neuralgia, bulging or herniated disks, or functional dyspepsia as the explanation for chronic pain. More holistic practitioners will talk about adrenal fatigue syndrome, chronic Lyme disease, leaky gut syndrome, toxic heavy metal accumulation, or candida overgrowth (4).
It is not easy for most people to hear these diagnoses and stay calm. Simply reading through this list can trigger feelings of anxiety and worry. However, as the saying goes, “the proof of the pudding is in the eating,” meaning that the effectiveness of treatments provided for these alleged or confirmed diagnoses is often not sufficient to alleviate the associated pain.
To convince chronic pain sufferers that their minds possess the power to generate pain often requires psychoeducation. For instance, it is beneficial to explain that what are commonly referred to as "spinal abnormalities" are not necessarily abnormal. Approximately 50 percent of 30-year-olds and 80 percent of 50-year-olds who experience no back pain exhibit signs of "degenerative disc disease" on an MRI. Spinal stenosis is prevalent among older individuals who are pain-free, while conditions such as scoliosis, leg-length discrepancies, mild osteoarthritis, and imbalances in muscle group activations can be present in people of all ages without chronic pain. This means that when they are found in the presence of chronic pain, they are more often than not incidental rather than causative of chronic pain (4).
Treating chronic pain effectively entails understanding the role psychological factors play and devising strategies to address them. It is common that even when the body’s systems are operating normally, the brain can generate or intensify pain and other distressing sensations due to fear or to fulfill certain psychological needs. Convincing patients that they are not dealing with something dangerous, incurable, or inherently disabling is crucial in the initial phase of treatment. This alleviates their brain's heightened state of alertness and fosters trust in the process. The subsequent step involves searching for evidence that their pain might be influenced by their minds, such as pain that fluctuates, changes location, or is triggered by innocuous activities.
PRT aims to rewire the brain and break the pain-fear cycle by utilizing corrective experiences. This involves exposing oneself to body sensations or avoided activities without fear or expectation that they will result in pain. This approach implies that chronic pain is not caused by the injury itself but rather by the brain’s processing of sensations from the body, reinforcing them in areas that interpret such sensations as indicators of danger. It encourages individuals to approach body sensations with curiosity, courage, and compassion, utilizing a method of somatic tracking.
Somatic Tracking – The Way Out
The saying "what you resist or avoid persists and endures" can be applied here. The phrase suggests that acceptance and acknowledgment of issues or challenges can often lead to resolution or relief, while resistance or avoidance can perpetuate them. This is the main principle upon which exposure therapy rests. In PRT, somatic tracking serves as a type of exposure therapy, as it instructs individuals not to flee from the discomfort of pain, but rather to welcome it with an open and non-judgmental mindset, encouraging curiosity about the sensations experienced.
Somatic tracking combines mindfulness, safety reappraisal, and positive affect to help patients perceive painful sensations through a lens of safety, thereby deactivating the pain signal. By closely observing pain sensations with the understanding that the body is safe, and the pain is not a sign of damage, individuals can become more curious about the sensations, ultimately transforming their fear of pain. The ultimate goal of somatic tracking is to cultivate these corrective experiences through repetition whenever there is an opportunity.
This is how Alan Gordon summarizes the process: “Neuroplastic pain feels great and powerful. It certainly hurts like it’s great and powerful. It seems scary, like it’s caused by something dangerous in your body. But it’s not actually dangerous. Once we expose it as a mistake, made by our brains, it loses its power” (5).
To make somatic tracking easier to understand, he breaks it down into three components:
1. Mindfulness – observing pain without fear (non-judgmentally)
2. Safety reappraisal – sending messages of safety to the brain (reminding oneself that pain is not dangerous, just the misunderstanding between the brain and the body).
3. Positive affect induction – looking at physical sensations with lightness and curiosity.
Again, in his words: “Every component of somatic tracking is designed to reduce feelings of danger and foster a sense of safety. Mindfulness is a way to view your pain without judgment or fear. Safety reappraisal reminds your brain the sensations aren’t dangerous. And a playful mood allows you to explore the sensations in a safe, curious way” (5).
Boulder Back Pain Study
The Boulder Back Pain Study is the definitive study of treating chronic back pain with PRT (6). This is how Alan Gordon describes its outcome: “As we reached the end of the study, I was on pins and needles. Finally, Yoni gave me the results. They exceeded even our highest expectations: 98% of our patients improved, and 66% were pain-free or nearly pain-free. Two-thirds of our patients were in the cured category which Yoni didn’t even think would be possible, compared with 20% randomized to placebo injections and 10% to usual care. The Boulder back pain study was everything we hoped for. It validated PRT, not just as an effective treatment, but as the most effective current treatment for chronic pain” (5).
This remarkable outcome was attained following only four weeks of PRT and remained largely sustained even after one year. What is especially “mind-blowing” is that functional MRI scans of the brains showed changes in pain-generating brain regions. Essentially, they confirmed that the brains had undergone a rewiring process. This was never done before, which makes this study groundbreaking.
Tina’s Experience with PRT
Tina decided to implement somatic tracking right away. Even though she still maintains fear and believes that there is a structural reason for her chronic pain, she is willing to give it her best "leap of faith" attempt. Whenever she experiences pain, especially during the night, she has used somatic tracking with mixed results. The main reason, I think, is that she has doubts and is having difficulties approaching this process with lightness and curiosity. Additionally, she secretly expects a rapid positive outcome.
Alan Gordon warned about the expectations of the outcome as being a tricky thing. It is crucial, in his opinion, to develop a stance of outcome independence, the ability to feel successful regardless of the outcome. He gave a personal example when he first inadvertently tried somatic tracking in the treatment of his back pain. He approached it with outcome independence and his back pain went away. The next time he tried it, nothing happened. His back continued to hurt because he had a clear goal; he wanted the pain to go away. He was no longer exploring the sensation with authentic curiosity. He was frustrated and impatient, and the pain persisted.
He suggests that the practice of somatic tracking, being outcome-independent, reinforces to the brain that the pain is safe. Eventually, the brain will internalize this lesson, leading to the fading of pain. Outcome independence serves as short-term assistance in reaching the long-term goal of pain elimination. It is a hard lesson to learn, and Tina is gradually grasping it.
MindBodyBack
In her ongoing efforts to help herself, Tina sent me an email asking me to review a program she found online called MindBodyBack, which offers detailed instruction through videos and homework assignments, implementing the principles of PRT. Upon watching the introductory video featuring an entrepreneurially minded young Thomas McCarthy, I realized that this approach could benefit Tina greatly due to its multisensory learning process and engaging nature (7).
This program is five weeks long. Every week emphasizes different facets. In the first week, it explores why traditional diagnoses and treatments often exacerbate pain rather than alleviate it, accompanied by an explanation of the true nature of pain. The second week, known as self-discovery, aims to identify high-alert habits that overwhelm the brain and nervous system, resulting in pain. During this phase, participants engage in reflection on their conditioned responses and the associations that perpetuate the experience of pain. Following this, participants move on to learning and actively applying the tools that are introduced in the third week of the program, with a particular focus on somatic tracking as the primary tool. In the fourth week, somatic tracking is implemented, and corrective experiences are reinforced to rewire the brain and nervous system. Finally, the fifth week is designed to sustain a pain-free life.
Tina and I are in the process of following this program and implementing all the teachings for her long-term goal of living a pain-free life. We have both noticed subtle changes and realized that this path is right for us. I hope that this text will aid other chronic pain sufferers in comprehending the healing potential of this emerging paradigm, which remains largely unrecognized or unaccepted by healthcare practitioners.
1. Mindfulness intervention in the management of chronic pain and psychological comorbidity: A meta-analysis, by Yan Song et al., International Journal of Nursing Sciences, Vol.1:215-223, 2014
2. Mindfulness-based Interventions for Chronic Low Back Pain, A Systematic Review and Meta-analysis, by Myrella Paschali et al., Clin J Pain, 40:105–113, 2024
3. Our Multiple Selves, by Richard C. Schwartz, The Family Therapy Networker, 11: 24–31 & 80–831987
4. IFS and Chronic Pain, by Ronald Siegel, Howard Schubiner, and Richard Schwartz, Psychotherapy Networker, pp. 50-58. January February 2021
5. The Way Out: A Revolutionary, Scientifically Proven Approach to Healing Chronic Pain, by Alan Gordon with Alon Ziv, Avery, 2022
6. Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain, A Randomized Clinical Trial, by Yoni K. Ashar et al., JAMA Psychiatry,79: 13-23, 2022
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