A Paradigm Shift
The book “The Way Out” by Alan Gordon left a deep impression on me due to its exploration of the topic of chronic pain in an unexpected way (1). What specifically thrilled me about this book is its introduction of a new paradigm for understanding and treating chronic pain, which challenges conventional methods of pain management. It does so by using personable, non-technical language, illustrated with case studies from clinical practice that offer hope—the way out from the misery chronic pain inflicts on many people's lives.
I have lived with chronic pain, primarily alongside my wife Tina but also within my own body, experiencing the types common to many: back pain and neck pain. According to the book, my wife and I belong to the group of 50 million people in the United States and 1.2 billion people worldwide who suffer from chronic pain, significantly impacting quality of life and mental well-being.
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.
How can one look upon pain without flinching, without the desperate urge to rid oneself of it, without hopping from one treatment strategy to another, all in pursuit of peace and rest that never seem to arrive?
This book provides the answer by confidently introducing the paradigm shift, arrived at by the combined effort of neuroscience and psychology. It claims that based on scientific evidence, most chronic pain experiencers do not have structural disease or tissue injury causing the pain (2).
This statement may be a revelation for many, as it was for me and my wife. When a person is in pain, the obvious conclusion is that there must be a physical cause for it. One might think that it could be inflammation, scar tissue, arthritis, misalignment, and many other conditions that the biomedical model of disease supports, and eager healthcare professionals reinforce.
Fear and Chronic Pain
Regardless of the specifics, at the core level, all chronic pain individuals experience a state of high alert, manifested primarily as the emotion of fear, believing that there is something wrong in the body causing pain.
However, injuries or diseases that initially cause pain as an adaptable warning signal heal, but in some people, pain may persist for years. In these situations of persistent pain, the brain has learned to produce pain without the presence of tissue damage. Why is that? 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 the brain that the pain is dangerous, ultimately reinforcing its persistence (3).
Our brains crave certainty and seek predictability. 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.
In the book, we learn that fear triggers a heightened state of alertness in the brain—a signal of imminent danger. This high-alert state alters how the brain interprets signals from the body, particularly in individuals who frequently experience worry, self-imposed pressure, or are prone to self-criticism. Pressure activates regions of the brain linked to fear and vigilance, while self-criticism engages the brain's threat system. The persistent state of worry perpetuates this cycle.
The way we react reinforces either a sense of danger or safety. Pain serves as a dangerous signal, and our reactions determine whether the signal persists or diminishes. When individuals respond to pain with fear, they strengthen its perceived threat. Fear acts as the catalyst for pain, perpetuating a feedback loop where pain triggers fear, putting the brain on high alert intensifying pain, which then induces more fear. The greater our fear of pain, the more likely it is to persist. This cycle often termed the pain-fear cycle, may also be labeled as frustration, despair, stress, anguish, anxiety, or annoyance, basically anything that heightens our sense of danger.
Insights into Neuroplasticity
Alan Gordon calls chronic pain “neuroplastic” to emphasize that it refers to neuroplasticity, which is the brain's ability to reorganize itself by forming new neural connections.
Neuroplasticity is the mechanism that leads to the formation of habits and established brain patterns. It affects the majority of chronic pain sufferers, along with other conditions governed by similar principles.
During my morning meditation, the group leader once quoted, "Sow a thought, and you reap an action; sow an act, and you reap a habit; sow a habit, and you reap a character; sow a character, and you reap a destiny," attributed to Ralph Waldo Emerson.
I loved the quote, and my association immediately went to the neuroplasticity of the brain. Certain activities become entrenched because of the pathways that are created. If thought and action are repeated over and over, then free will is not free anymore. It becomes a predictable destiny, an automated habit.
There is plenty of evidence that the brain is very adaptable to experience. We call this ability experience-dependent neuroplasticity. The brain is capable of developing new cells (neurogenesis), creating new connections (synaptogenesis), and reinforcing existing connections.
This process was first described by the renowned Canadian neurobiologist Donald Hebb and summarized in this quote, “Neurons that fire together, wire together”(4). He thought that everything in the brain was interconnected and collaborative. His theory was that whatever we experience in our surroundings triggers a set of neurons called a cell assembly to develop new connections. Whatever we stimulate in the brain tends to grow stronger over time.
The brain excels at acquiring useful skills, but it can also develop detrimental habits, such as experiencing chronic pain under the conditions outlined above. When pain persists, neurons become increasingly interconnected, reinforcing the sensation of pain. Essentially, the brain unintentionally learns to perceive pain, misinterpreting signals from the body and mistakenly perceiving normal messages from the body as threats.
Neuroplastic pain occurs when the brain undergoes changes that amplify chronic pain. While pain typically serves as a beneficial warning signal, neuroplastic pain is an error in interpretation. It arises when the brain incorrectly views harmless signals from the body as dangerous.
Overcoming Barriers
The book outlines the three main barriers preventing us from accepting that pain is not the result of physical damage to the body:
Barrier 1: Biology
Many of us struggle to accept that pain could be attributed to the brain. Even if we grasp this concept logically, on an instinctual level, we feel there must be something physically wrong with our bodies.
Barrier 2: Conditioned Responses
Conditioned responses occur when the brain associates a physical symptom with a neutral trigger. In the case of chronic pain, the conditioned response occurs when pain becomes associated with a particular physical position or activity. This association makes it difficult to acknowledge that the pain originates in the brain. For example, if someone experiences back pain every time they sit, it seems reasonable to assume that sitting is causing the pain.
Barrier 3: Medical Diagnosis
Modern medicine operates within the framework of the biomedical model, which aims to treat conditions by identifying a single structural cause and addressing it. However, in the context of chronic pain, the biomedical model often exacerbates rather than alleviates the problem. Physicians frequently search for structural causes, and in doing so, they often find them—even if they aren't the root cause of the issue. Chronic pain sufferers are frequently assigned diagnoses such as degenerative disc disease, repetitive strain injury, fibromyalgia, and many others.
Evidence
There is a singular solution to overcoming these barriers: evidence. The more evidence we gather showing that nothing is wrong with the body, the easier it is to accept that the brain is the culprit. Occasionally, when fully immersed in the present moment, pain doesn't get what it needs to keep going – fear, its driving force. Identifying these exceptions makes it easier to admit that it is coming from the brain, not the body. But even with lots of evidence, holding onto it when in pain is hard. Thus, the goal isn't just to gather evidence but also to make sure it is robust and reliable. The evidence needs to be reinforced.
Reinforcing the Evidence
At this point in the book, we are learning about the tools used in Pain Processing Therapy. The primary tool is based on the principle that "what you resist or avoid persists and endures." This tool is called somatic tracking and it 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 eliminating 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” (1).
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” (1).
If we feel safe while exposed to the source of our fear, it constitutes a corrective experience. This pathway leads to overcoming chronic pain. Through sufficient corrective experiences, the brain learns that the signals emanating from the body are, indeed, safe. During somatic tracking, the act itself holds greater significance than the outcome. It's crucial to maintain a so-called outcome-independent mindset in the short term to assist the brain in reinforcing the notion that pain is safe. Eventually, the brain will learn this lesson, and pain will fade away.
The Opposite of Exposure
When we face the source of our fear, that is exposure; when we try to escape our fear, that is avoidance behavior. When we use it strategically, avoidance behaviors are an effective tool for overcoming fear. They are common in chronic pain situations. Anything we do to reduce our pain or to keep from triggering it in the first place is an avoidance behavior. When we suffer from chronic pain, avoidance behaviors become a part of life. Through trial and error, we learn how to prevent and manage our pain as much as possible.
In the book, we learn that “When you have a high level of pain, your brain senses a lot of danger. That means it is pretty much impossible to have a corrective experience. So we are not even going to attempt somatic tracking. When the pain is high, we want to engage in avoidance behavior. The one thing you don’t want to do is push through the pain. In addition to engaging in avoidance behavior, you want to send yourself messages of safety. These messages may be anything that makes you feel safe. The goal is to help calm the brain's high-alert state. Here are some examples that worked for my patients: "This is temporary. I am going to be OK. I am safe and my body is fine. My brain thinks I’m in danger, but this is just a false alarm. And of course, trust the process." The words themselves don’t matter as much as the spirit behind the words. Your brain is feeling danger and you’re calming it down with messages of safety. This is a big part of breaking the pain-fear cycle” (1).
On the other hand “When the pain is low or moderate, and you have low or medium levels of pain, you can still engage in avoidance behavior. It is always OK to feel more comfortable if you can. But now that your pain is more tolerable, you have the opportunity to get some corrective experiences with somatic tracking. If your pain changes or moves or decreases while you’re tracking it, that’s fine. But a successful corrective experience doesn’t mean the pain goes away. That’s your long-term goal, but right now, we are just reinforcing that the pain isn’t dangerous. And we do that by tracking without trying to change anything and without intensity. The goal is to feel good. You gradually make sessions longer. If you find yourself straining or it gets too painful, then you stop. Listen to your body. If you are exploring your pain with curiosity and lightness, feel free to keep going. If it feels like a chore or it becomes intense, this is the time to stop. You know you’re doing somatic tracking right when it feels relaxing, safe, and good. Quality is more important than quantity. The goal is to enjoy your life as much as possible by snatching the corrective experiences here and there” (1).
Catching Your Fears
Pain Reprocessing Therapy (PRT) aims to weaken associations leading to pain, such as fear, danger, and anxiety while reinforcing connections associated with safety, calmness, and freedom. Hence it is important to pay attention to our inner state so that we inadvertently don’t strengthen associations in the brain that can lead to pain.
The book emphasizes the importance of noticing fearful thoughts while resisting their hold over us. Each instance of recognizing a negative thought is an opportunity to refrain from dwelling on it and instead send ourselves a reassuring message, thereby lessening the perceived threat in the brain.
It is normal if we initially struggle to believe these messages of safety. Sometimes, it is through consistent action, like repeating affirmations, that belief gradually follows. In this context, embracing the idea of “fake it until you make it” can be beneficial.
Constantly obsessing over every minor bodily sensation can lead to a heightened sense of threat, as we question whether each sensation signals something wrong or potentially painful. This hyper-vigilance toward negative sensations often disconnects us from experiencing positive ones. Therefore, the book advises redirecting our attention to pleasant sensations, which helps the brain feel secure and fosters a healthier connection with our bodies.
Empowerment
Alen Gordon's encouraging words resonated with me as I was finishing this review. They are full of hope and meant for everyone dealing with chronic neuroplastic pain. I strongly recommend “The Way Out” book to be read and re-read, as I did. It can give you comfort and empower you with wise advice and practical tools to overcome pain, fear, and even other brain habits that don’t serve you anymore.
Here is Alen Gordon one last time: “When we look outside ourselves for salvation, we are searching in the wrong place, because we have the power to create the life, we wanted all along. When I was in chronic pain, I was desperately looking for someone who could cure me. Each new practitioner brought a fresh sense of hope, and each failed treatment brought crashing disappointment. When I learned about neuroplastic pain, it changed my perspective. I realized it was my brain that was making a mistake, so only my brain had the power to fix it. This notion was a little scary. After all, I had been looking to others to cure my pain for so long. But it was empowering. I had the capacity to heal myself. The fundamentals of PRT are universal: Fear is the fuel for pain. Safety is the cure for breaking the pain-fear cycle. But the specifics vary. I trust you to figure out what resonates with you and heal yourself. I’ve been giving you a toolbox, but you are the one who is going to take these tools and get yourself out of pain. It takes time to form new habits. It takes practice to develop new pathways” (1).
Rewiring the Brain
Why do I like the book “The Way Out” so much? The answer is simple and straightforward. It brings enthusiasm and hope to people who suffer from chronic pain, empowering them to take control rather than constantly seeking help from various sources that may not provide the necessary relief. Through the use of modern medicine and clinical research, it's possible to observe how the brain's activity changes with PRT. The brain moves the energy from multiple pain centers to areas indicating new learning and rewiring, allowing sensations previously interpreted as painful and dangerous to be experienced as benign and innocuous.
Nowadays, this therapy is considered the most effective treatment based on the Boulder Back Pain Study (2), providing long-lasting, if not lifelong, relief for chronic pain. What is also amazing about this book is that the tools used in PRT can be applied to other chronic conditions, particularly those related to mental health such as anxiety disorders, mood disorders, and addiction disorders, among others. The primary tool involves teaching individuals suffering from these conditions not to feel threatened by their symptoms but to approach them with curiosity and lightness, exposing themselves to body sensations or emotional states without withdrawing. It is a wonderful approach that encourages individuals to confront what they usually shy away from and engage parts of the brain that foster compassion, courage, curiosity, creativity, observation, and witnessing, rather than ruminating on victimization and stress. I wish you a happy reading and success in applying the tools for whatever habit you want to rewire.
1. The Way Out: A Revolutionary, Scientifically Proven Approach to Healing Chronic Pain, by Alan Gordon with Alon Ziv, Avery, 2022
2. 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
3. IFS and Chronic Pain, by Ronald Siegel, Howard Schubiner, and Richard Schwartz, Psychotherapy Networker, pp. 50-58. January February 2021
4. The Organization of Behavior: A Neuropsychological Theory, by D.O. Hebb, John Wiley & Sons, 1949
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