A comprehensive road map TO RECOVERY:
5 steps TO UNLEARN CHRONIC PAIN EXPLORED IN THE FILM THIS MIGHT HURT
By Kent Bassett and Marion Cunningham
1. Get an accurate diagnosis
Every day doctors make errors in diagnosing chronic pain. They often identify MRI findings like degenerative disks—which are normal signs of aging like grey hair or wrinkly skin—as the cause of pain. Or they make diagnoses like CRPS or IBS or fibromyalgia that describe a collection of symptoms but not the cause. The film This Might Hurt demonstrates what careful investigation looks like.
Some diagnoses are equivalent to the doctor saying, “We can’t find anything structurally wrong that could explain your pain.” These include fibromyalgia, migraines, headaches, many people with post-infectious syndromes like chronic Lyme and Long Covid, and over 30 others—you can find a full list on this page. The first step in diagnosis is ruling out clearly structural problems like cancer, fractures, infections, muscle diseases, lupus, rheumatoid arthritis, and others.
It is possible that mistakes were made, or that your syndrome is not characteristic of the millions who have learned neural pathways causing their suffering. So the next part of proper diagnosis is “ruling in” a mind-body, or brain-generated diagnosis. Diagnosis is best done by a mind-body-informed physician or therapist; a directory is kept here. You can also try to do the detective work yourself by investigating your symptoms with the questions from this quiz, and reading up more on this pervasive syndrome. Studies suggest about one in every four doctor’s visits are for symptoms with no clear structural damage or disease process. Not all of these patients have brain-generated symptoms, but research suggests that a majority do.
Medical professionals who want to assess patients can ask questions like, "What was going on in your life when the pain first started?" They can interview patients for stress and trauma, noting if life events preceded the onset of a new symptom. They can help patients create a “symptom timeline” for when symptoms first started and what life events may have triggered them. If symptoms move around, switch on and off, and arise in the absence of injury or disease, these are common signs of neuroplasticity. You can get a sense of what the diagnostic assessment process is like by viewing videos on our Pain Reprocessing Therapy page. For some patients, though, the pain is maintained by fear of pain and fear of damage or other factors in the brain—stress and trauma play little to no role.
When combined with the right treatment, this diagnosis of brain-generated, or primary pain is great news: a majority can return to the lives they had before getting sick.
ThIS explainer video showS how to distinguish structural pain from PRIMARY pain:
If you want help with the diagnostic process, we suggest the following options:
Becca Kennedy, MD is Portland, Oregon-based physician who treats a broad range of mind-body conditions and specializes in helping Long Covid patients.
Lilia Graue, MD is physician, coach, and psychotherapist based in Mexico City, who is fluent in English and Spanish.
John Stracks, MD and Howard Schubiner, MD work together at Cormendi Health, where you can reach out about making appointments.
The PPDA has a directory of mind-body informed clinicians based throughout the world who can help with assessments.
2. Understand MOST chronic pain is reversible THROUGH brain RETRAINING
Many chronic pain patients feel their body is broken and that recovery is impossible. They’ve seen countless doctors, tried hundreds of treatments. They’ve been warned by doctors their bodies will never be “normal” again. These are powerful messages that can activate the “nocebo effect”—creating self-fulfilling negative expectations that come true and create a snowball effect. This partly explains why so many people with chronic pain get worse over time.
In this situation, many health professionals have come to believe their patients’ best hope is for better pain management and coping—some doctors even say chronic pain is permanent and nothing can be done to fundamentally change it. Dr. Schubiner, the Psychophysiologic Disorders Association, and diagnostic paradigms like Emotional Awareness and Expression Therapy (EAET) adamantly reject this message. Why manage pain when it can be reduced, unlearned, and often, fully resolved?
The latest neuroscience is clear that chronic pain can be a learned condition, created in the brain through a process of “interoceptive predictions” that lead to a vicious cycle of pain and fear. This is how people can have phantom limb pain, which is pain projected into mid-air: the brain is creating it. Pain being switched on by the brain is a common occurrence—it’s estimated that one in seven people have chronic brain-generated symptoms like pain, fatigue, or GI issues. About 80% of us will experience it at some point in our lives—it’s part of being human, and it is usually reversible through retraining the brain.
Many thousands of people have gone from having debilitating pain to being pain-free. Recovery is possible. And paradoxically, believing recovery is possible—despite all the negative predictions in our brains and incorrect messages from doctors—is one of the keys to getting better.
3. DEACTIVATE the Pain -> Fear -> PAIN Cycle and gently return to avoided activities
Excruciating, unending pain leads to fear, which in turn makes the pain worse. This amplification of pain by worrying becomes a vicious cycle. Learn techniques to deactivate fear and teach your nervous system to understand pain better. When brain-generated pain is recognized as a false alarm—and not as a sign of tissue damage—it causes less fear, and the cycle can be reversed, leading to less and less pain.
A key fear reduction technique is “somatic tracking,” which is a type of mindfulness that helps people attend to sensations of pain with a curious attitude of mind while sending new messages of safety. Sensations of neuroplastic pain can be noticed and regarded as non-dangerous. For these patients, the pain is like a false alarm—it’s not always a sign of damage—the warning system is being over-protective and needs an update, it needs a reset. Pain Reprocessing Therapy (PRT), uses fear reduction as its primary method, and it was shown to eliminate back pain for 66% of people randomly assigned to it in a newly published NIH-funded study. That is an astonishing recovery rate compared to other therapies that have been tested.
For fear reduction to be effective, you cannot skip step 1—getting a proper diagnosis. Learning that the body is not damaged or diseased is a critical step because it reduces fear. As an example of how critical a proper diagnosis is, check out this additional back pain study conducted at Harvard which showed that in the absence of an examination and re-diagnosis, Mindfulness-Based Stress Reduction (MBSR) only moderately helps with chronic pain (25% become pain-free). When combined with education about pain neuroscience and challenging incorrect beliefs about body damage, mindfulness leads to 60% of people becoming pain-free.
In other words, mindfulness is more powerful when combined with an understanding that chronic pain can be 100% reversible.
Motion is lotion: A large number of people with chronic pain begin to avoid certain activities associated with pain, which can create a fear-avoidance feedback loop. They stop doing activities like bending over, standing, sitting, walking, playing sports, playing music, or typing at a computer. They may stop eating foods or drinking beverages that become associated with symptoms as a conditioned response, or because of food elimination diets.
As working with fear starts reducing symptoms, it’s recommended to gently return to activities. People can engage in graded exposure while noting that even when symptoms crop up, the conditioned response is slowly being challenged and unlearned; and the neuroplastic symptoms are safe. While being more active, people can challenge fearful thoughts with phrases like “I am safe.”
4. Do EMOTIONAL PROCESSING
Persistent pain can often be caused by underlying patterns of emotional conflicts that are the result of normal childhood stress, and in some cases, trauma or abuse. In addition, physical trauma can lead to symptoms that last long after the body parts have healed, which brings its own emotional stress. Dr. Schubiner often tells his patients, “Injuries always heal, and scars don’t cause pain.” If your pain persists one year after an injury, there is an extremely low likelihood that the injury did not heal—the brain has usually taken over and is now responsible for the lingering symptoms.
We all need help to see our emotional blind spots. Making links between emotions and pain is often a critical ingredient to recovery, and can be a source of lasting change. In a way pain is an emotion, and the brain can substitute pain for difficult emotions like guilt, anger, grief, and shame, when we are unequipped to allow those emotions arise. Unlike structural pain, with brain-generated pain, processing emotions along with reducing fear can lead to 100% reduction in pain. But it helps to find a therapist who specializes in emotional processing.
Clinicians who practice Experiential Dynamic Therapy (like AEDP, ISTDP, and EAET) and Internal Family Systems (IFS) specialize in helping people resolve early childhood stress by reconnecting with the embodied experience of anger, grief, guilt, and even joy. Processing early memories can dramatically change how emotions, fear, and anxiety show up in the body. Expressive journaling can also be helpful — writing about stressful life events and making connections with what is happening emotionally when symptoms switch on and off, spread, or get triggered by conditioned responses.
For some people, emotional work is a key step, whereas for others, overcoming fear and letting go of inaccurate beliefs about their body being damaged (step 3) is the most important—it varies according to each individual.
To find a therapist trained in brain retraining for chronic pain conditions, we suggest investigating the following directories:
PPDAssociation.org’s Directory
Pain Reprocessing Therapy Directory
5. make life changes if necessary
People with chronic pain often feel trapped in their bodies. They may also be trapped in abusive relationships or exploitive workplaces. As part of recovery they may realize they need to make changes to their lives in order to calm their nervous system and unlearn pain. All of these steps are explored in the feature-length film, This Might Hurt.