Detailed guides to painful problems, treatments & more

Mind Over Pain

Pain can be profoundly warped by the brain, but does that mean we can think the pain away?

Paul Ingraham • 100m read

Our brains can make pain out of seemingly nothing, or virtually ignore trauma that should be extremely painful. They don’t always do that, but they can, and they do. Pain is not a reflex, not an inevitable result of tissue insult. It is a complex experience that is not just thoroughly tuned by your brain but completely generated by it. The results are often strange and counter-intuitive, like quantum physics, but the science is clear: every painful sensation is 100% Brain Made®.1

So… does that mean can we think pain away? Just how much power does the mind have over pain? Can confidence, optimism, and education cure? Meditation? Hypnosis? Cognitive behavioural therapy? Mostly no — there’s no compelling evidence that anyone can “think away” serious chronic pain, and certainly not just by force of will or an attitude adjustment. But there might be indirect methods. The fundamental challenge is to convince our brains that there’s no need for an alarm, and there are many ways we might be able to do that.

This overlaps with mind-body and lifestyle medicine, which mostly focusses on trying to treat vulnerability to pain, the root causes of pain in our lives and minds: things like the impact of severe stress, sleep-deprivation, and poor nutrition, which can all drive painful pathologies. That’s all important and related, but this this article is focused on tinkering with pain perception itself.

Making pain neuroscience useful

Mind-over-pain and “mind-body” cures have always been big. In more recent history, strong evidence of the brain’s near infinite power to modulate pain has given new life to many old ideas about the psychology of pain, and spawned a new wave of optimism… and maybe false hope. The neuroscience is often used to tease patients with hopeful implications, but practical advice is scarce. Patients are left with the impression that pain can be muted by the mind, but are often given no real idea how.

Just explaining pain itself can increase people’s confidence, reassuring them that the danger implied by pain — especially chronic pain — may be greatly exaggerated, and perhaps actually easing the pain. But explaining pain is hard! And doing it carelessly can all-too-easily sound like hectoring patients to have a better “attitude” about their pain. We have to do better than that.

In this article, I get specific and detailed about what’s realistic about the mind and pain. There’s both good and bad news. The bad news is that your mind is not the boss of your brain, and we cannot directly order it to stand down.

On the other hand, there are things that can be done to influence the brain’s pain hijinks, some Jedi pain tricks.

But you cannot hack a system you don’t understand. It’s critical to have a good sense of just how weird pain science can get. I will explain the basics here, but there’s another article dedicated to explaining the neuroscience as painlessly as possible. If you’re really determined to wrap your head around this topic, please start there:

Pain is Weird — Pain science reveals a volatile, misleading sensation that comes entirely from an overprotective brain, not our tissues. (16,000 words, 66-min read)

All the approaches to mind-over-pain

There are many possible meanings of “mind over pain,” and most of them overlap to some extent with modifying perception. I’ve provided links wherever I have related articles that cover these topics in more detail than I do in this one.

This list is very roughly in order of “importance” (popularity, mainstream acceptance, and scientific plausibility).

What a mess! That’s a lot of overlapping ideas. The next section will try to impose some order — a meaningful way to categorize these kinds of interventions.


The four pillars of pain

Mind-over-pain is a dizzyingly complex theme, with dozens of major sub-topics and ideas, from placebo to biofeedback to cognitive behavioural therapy. Let’s organize those a little. Every pain treatment is trying to do one or more of these four things…


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  1. remove the cause
  2. reduce the sensation
  3. tinker with perception
  4. mitigate the suffering

This article mostly does not deal with curing causes or nuking sensations. The focus here is on reducing perception. If all pain is an output of the brain — and it really is — then perhaps the brain can be convinced to knock it off, to stop perceiving pain so intensely. This page is all about pulling on that thread in as useful a way as possible.

But it’s impossible to talk about any of these categories without considering the others. There’s plenty of overlap and feedback, and one of the best examples is, in fact, directly relevant to perception: if the cause of pain is mostly dysfunctional perception, then changing the perception would effectively remove it’s own cause! 🤯

That sounds like the holy grail of pain management! That’s why it’s the focus of this article, and it’s also why we need to consider all four kinds of intervention.

1. Remove the cause of the pain — curing

“Curing” is the most difficult of all ways to treat pain, of course. But it’s all you need, if you can get it! Identifying and treating the source of pain is what most musculoskeletal and sports medicine aspires to but mostly falls short of achieving. Problems like back pain, fibromyalgia, and irritable bowel syndrome usually have no known specific cause.

Most mind-over-pain methods do not claim to cure — but some do, probably because more definite medical cures are so hard to come by. These methods need a hypothetical psychological cause of pain to cure, and many bridge the gap between psychology and pathology with “stress”; they claim that stress and anxiety drive some basic physiological mechanism that causes pain.

The most notorious example is probably Sarno’s “mind over back pain.” His original simplistic idea was that stress and other toxic emotional baggage painfully chokes off blood supply to muscles, causing back pain. Solve the stress, solve the problem!

Another major mind-cure hope is that a lot of chronic pain is not just complicated by dysfunctional or amplified perception, but substantially caused by it. At its most conventional and traditional, we’re just talking about hypochondria, the idea that some pain may actually be “all in the head,” or (more reasonably) just “mostly” there, a seed of pain truth embiggened by health anxiety. If so, then the cure would be entirely or mostly psychotherapy for anxiety.

(To this day, I have no idea if there is any such thing as a chronic pain problem that is truly “hypochondriac.” That question is as thorny as they come!)

2. Reduce the sensation of pain — analgesia, pain-killing

Analgesia is the muting of alarm signals from the tissues, the attenuation of “nociception” — which is infamously difficult to do thoroughly, persistently, and safely. Like “cheap, good, and fast,” you can’t have all three.

Most approaches to analgesia are neurobiological: pain meds, nerve blocks, anaesthesia. Getting frozen at the dentist is probably the ultimate familiar example — very safe and nearly perfect, but also transient and highly localized.

It might not seem at first like sensation has much to do with the mind. If there is a link, here’s how it might work:

  1. Sensation is probably modulated by systemic inflammation.
  2. Inflammation roughly correlates with our overall health and fitness. If you’re extremely out of shape, you’re also probably more inflamed, and everything hurts more than it should.
  3. And overall health and fitness is obviously tangled up with your mental health.

So things like stress, anxiety, depression, addiction could a major (modifiable) risk factors for being so unhealthy that you’re more inflamed and therefore, perhaps, actually producing more sensation than someone.

Yoga is the perennial mind-body favourite that most obviously leverages this idea. It seems like regular meditative exercise really ticks all the boxes: one-stop shopping for better mental and physical health, so you can really cover a lot of bases by registering for just one class.

But that link between overall health and sensation is tortuous and tenuous … and there are no shortcuts to better health anyway. Very few people take the yoga train from Burnout City all the way to Superfitnessville.

But yoga isn’t the only way! It’s just the popular “fast food” of lifestyle medicine, which is generally a reasonable approach to chronic pain.

3. Reduce the perception of pain

Perception is what happens to pain after it has been pumped through all the complex filters of our brain. It is what we make of pain, how seriously the brain takes it, what it means to us, and how “loud” and scary the sensation seems — based on complex contextual clues and history.

We know from some extreme examples that perception can be surprisingly powerful, and it can be changed by the right circumstances (see Pain is Weird). This enables the great hope that some chronic pain is dominated by dysfunctional perception — pain as a disease in its own right, “sensitization” — and if you can treat that then you are effectively hacking away at the roots of the pain.

The big question is how much chronic pain actually works like that, and whether we actually have any more control over the perception of pain than we have over, say, a fear of heights.

The best known mind-over-pain idea that is mainly about changing perception is probably pain neuroscience education, which aims to reduce pain through boosting confidence that the danger might not be as real as it feels.

But this is a large category, and many treatments target perception in a wide variety of ways. Placebo effects are probably the most conceptually pure and obvious example, because it’s entirely about changing what someone thinks or feels about a treatment.

4. Reduce the suffering that comes with pain — coping

This is usually just thought of as just “coping”: improving our function and mood in spite of the pain. It is the main goal of the conventional psychotherapeutic approaches to pain, chiefly cognitive behavioural therapy (CBT). Occupational therapy is also a major player here, but with a more pragmatic emphasis.

Perception and suffering overlap so much that at times they seem almost impossible to separate, very yin-yang. In almost all cases, anything that targets one is hoping to achieve the other as a feedback effect. For instance, the goal of psychological therapy for chronic pain is usually framed not as an attempt to actually treat pain directly, but to help people “live a full life with confidence in managing that pain” (Managing chronic pain in adults).

Despite that disclaimer, many a psychologist has suggested to their clients that better coping can actually lead to lower pain levels — maybe through reduced perception of pain, or even reduced sensation thanks to reducing stress and anxiety — which in turn makes it easier to cope, of course. Wisely or not, mental health professionals do often aspire to treat pain indirectly via that virtuous cycle. It’s not clear that it works, but that’s definitely the hope.



Mind over pain snake oil: Sarno’s legacy

Mind-body medicine has been rich soil for gurus and quacks. Of all the prominent figures in 20th Century mind-body medicine, only Dr. John Sarno was specifically focused on pain, and more in his early years. He started out with the pet theory that unexplained back pain was caused by “tension myositis syndrome,” a painful restriction of blood flow to muscles. And what was the cause of this restricted blood flow?

The mind, of course. Stress and anxiety leading to painful clenching, basically.

Sarno’s big idea had both seeds of truth and a lot of problems from the start… and then he got a bit carried away, drank deeply of his own Kool-Aid, and started claiming that essentially all health problems can all be chalked up to our emotions and attitudes. With that hyperbole, he became one of the major mind-body quacks, reaching way beyond the evidence and selling false hope to millions.

To this day, years after his death, Sarno is responsible for an immense amount of unjustified belief in the great power of the mind over pain.

And yet his original idea was about a direct effect of the mind on physiology, a circulatory effect. He was hypothesizing a specific biological mechanism for pain which was sensitive to the mind, not a direct effect of the mind on pain itself.

Leveraging the neuroscience to try to treat the perception of pain — the focus of this article — is quite different. It’s agnostic about what’s going on in the tissues — what we care about here is what the brain does with those signals.


“Pain is an opinion”: Ramachandran’s excellent phrase

Ramachandran said that “pain is an opinion” — which sounds like a flaky New Age mind-over-matter theory. But Ramachandran is no mystic or guru: he is a neurologist and scientist. This passage is mainly known for the first few words, a pithy statement of the modern understanding of how pain works:

Pain is an opinion on the organism’s state of health rather than a mere reflexive response to an injury. There is no direct hotline from pain receptors to ‘pain centers’ in the brain. There is so much interaction between different brain centers, like those concerned with vision and touch, that even the mere visual appearance of an opening fist can actually feed all the way back into the patient’s motor and touch pathways, allowing him to feel the fist opening, thereby killing an illusory pain in a nonexistent hand.

Phantoms in the brain, by VS Ramachandran and Sandra Blakeslee

He then tells the story of an extraordinary cure of a man with phantom limb pain, tortured by agony in a clenched fist that was not there. With a clever arrangement of mirrors, Ramachandran created the illusion that the man’s amputated arm was restored — a sort of “virtual” limb. The mere appearance of his phantom hand opening and closing normally cured his agonizing “spasms.” He felt better because of the illusion that he was better — because he thought he was better.

The mirror-cure of phantom limb pain is one of the most curious anecdotes in all of pain science. In all of medicine, in fact.

Since then, “mirror therapy” has been studied and applied in many ways. A good quality 2007 study showed that mirrors aren’t actually necessary to achieve this effect.4 Mirror therapy is probably just a “fun” way to visualize healthy movement — which also works quite well without a mirror!5

Stranger still: painless injuries, and injuryless pains

Stranger still are tales of severe pain without injury, illustrating that pain can be entirely in the mind. (Technically, it always is.) One of the strangest of these was reported in the British Medical Journal in 1995:

A builder aged 29 came to the accident and emergency department having jumped down on to a 15 cm nail. As the smallest movement of the nail was painful he was sedated with fentanyl and midazolam. The nail was then pulled out from below. When his boot was removed a miraculous cure appeared to have taken place. Despite entering proximal to the steel toecap the nail had penetrated between the toes: the foot was entirely uninjured.

JP Fisher, senior house officer, DT Hassan, senior registrar, N O’Connor, registrar, accident and emergency department, Leicester Royal Infirmary6

His pain was a “nocebo” — the opposite of a placebo.7 Extreme examples like this are rare, but probably not as exotic as you might think. More to the point, even if they are rare, for every case like this there must be hundreds more where the injury is real but the patient is convinced that the damage is much worse than it really is — with proportionately exaggerated pain. And indeed there is evidence of this: in a 2012 experiment, for instance, fear of pain made people more sore for longer after a workout.8

Happily, it also works the other way: people may feel much less pain than they “should” when they are confident for any reason, such as not realizing how bad the damage is.

Injury and pain are not in lock step with each other. And yet that is exactly what nearly everyone assumed for a long, long time. And many professionals, even though they may “know” better, often seem to forget how powerfully pain is influenced by perception, context, and meaning.

What is surprising is how malleable pain signals are—how readily the intensity of a pain signal is changed by the sensations, feelings, and thoughts that coincide with the pain. … The brain is not a mindless pain-ometer, simply measuring units of ouchness.

Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, 187, 193


Part 2

Can We Think the Pain Away?

I have good news and bad news…

Lorimer Moseley, Professor of Clinical Neurosciences, from his TED talk on pain:

“100% of the time, pain is a construct of the brain.”

If this is true — and it really is technically true9 — does that mean can we think brain-built pain away? Can our minds un-build pain? Yes and no, because, as Dr. Moseley explains, “Pain really is in the mind, but not in the way you think.”10 This is a good news, bad news kind of thing. I will get to the good news, but let’s get the bad news out of the way first:

It’s not really possible to think pain away in general. Many wise, calm, confident optimists still have chronic pain.

Pain is a motivator. It exists to get us to act. We hurt when our brains reckon we should do something differently, for safety … but safety is not always possible. The nature of the danger isn’t always clear. Or avoidable.

And the brain worries too much: from hangnails to fibromyalgia, it overstates the danger … for rock solid evolutionary reasons. So it can’t be overruled by wishing, force of will, or a carefully cultivated good attitude. The brain powerfully but imperfectly controls how we experience potentially threatening stimuli, but I’m sorry to report that you do not control your brain.

Managing expectations: on pain “hacks” and false hope

This article leans a little on the concept of “hacking” pain: a clever or technical fix, a shortcut to solve a complex problem. But it’s a problematic metaphor. Dr. David Gorski:

I hate, hate, HATE the term “hacking” or “hack” when applied to any thing other than hacking computers or cutting things.

“Biohack” = pseudoscience and quackery.


Pretty much. I have minimized the metaphor in this article for exactly this reason. I loathe how often it has been abused for profit. Every guru of mind-body medicine — every “influencer” who has exaggerated the power of the mind, especially over pain, giving people false hope — deserves a good humbling by kidney stones.

Or gall stones. Or calcific tendinitis. Or gout. Or a tooth abscess. Or complex regional pain syndrome. And so on.

Speaking of exaggeration, I’ve just used some. This is a bit tongue-in-cheek: probably literally no one believes in any kind of mind-powered analgesia for such notoriously savage and/or acute pains. But there are certainly many who do profit from the idea that most chronic pain is something you can cleverly beat with various flavours willpower and mindfulness.

And those people deserve humbling.

There really is such a thing as blunting pain with psychological sorcery and neurological “hacks,” but there are many caveats. It isn’t easy, straightforward, practical, or predictable, and it will fail in many kinds of cases.

(Actual hacking, by the way, is also not very easy.)


Mind versus brain

Consciousness and “mind” are by-products of brain function and physiological state. It’s not your (conscious) opinion of sensory data that counts, it’s what your brain makes of them, entirely independently of consciousness and self-awareness. The independence of brains is obvious with something like blushing:

Blushing occurs when the blood vessels of the head and neck dilate and become infused with blood. It is an instantaneous physical change seen on the surface but reflecting a feeling of embarrassment or happiness that is held inside. When it happens I can’t control it. That point is important. My blushes betray a feeling and, even when they increase my embarrassment, I cannot stop them.

It's All in Your Head, by Suzanne O’Sullivan, 3

But it is also true of pain. As Todd Hargrove put it, “Pain is sometimes immune to logic,” because pain is handled by a part of the brain that is not easily over-ruled by other brain “modules” — like an optical illusion that you can’t “un-see” even when you understand it.11 As he put it elsewhere:

Humans don’t get to decide what they find threatening, stressful or painful any more than a cat does. That decision is left to ancient unconscious systems that can’t really be reasoned with.

Todd Hargrove, Treat Your Client Like a Wild Animal

And that is why many wise, calm, confident optimists still have chronic pain. Your brain modulates pain based on factors that are completely out of your control. Or rather difficult to control. Or even just impractical to control.

But it’s not hopeless. We have some leverage, albeit usually indirect. This is the first sprinkle of good news in this story.


Three cool 😎 examples of the power of brain over pain (but not necessarily “mind”)

Here are some examples of ways that the mind definitely has power over pain, but without much practical value, at least so far: being in love, looking through filters, and not looking at all! These are mostly examples of our lack of conscious control over pain, but they also point to some potential opportunities to workaround that limitation.

Romance as a pain-killer

Thanks to a couple quirky studies in 2010 and 2014 study, science has confirmed that being in love relieves pain — a lovely example of the potential power of the mind over pain.1213 Falling head-over-heels is not exactly a convenient solution. As researcher Dr. Sean Mackey put it, “We can’t give you a prescription for love” — not one that’s easy to fill, anyway.

But we can work to give love more of a chance to grow and thrive. You can’t benefit from the pain-killing effect of love if you aren’t in love, and there are obviously ways to improve your chances of getting there.

Closely related: pain is also muted when romantic partners hold hands. Aw.14 ❤️

Weird illusions! Shrinking pain with de-magnification

Cartoonish illustration of a magnifying glass looking at a swollen, red thumb.

If you view a painful hand through a magnifying glass, it will actually get more swollen and inflamed — that is, if you make it look bigger, it will feel like a bigger problem, and even be bigger and more of a problem!15

And the reverse is true too! Use optics to make a sore, swollen hand look smaller, and the swelling will go down. Incredible, right?

But … do you have a de-magnifying glass handy? Where do you buy even one of those, let alone a big one? (They really are hard to find. How about looking backwards through binoculars? Not a great solution.16) And what happens if the pain isn’t in a place that’s so easy to de-magnify, like your low back? We mostly can’t see our backs at all, at any size!

The de-magnification trick is dang interesting, but it’s obviously not a practical approach to most pain. The effect is real under the right circumstances, but trying to use it as a treatment is like trying to take a magician’s trick home with you.

Maybe someday virtual reality tech will make “visuotactile illusions” like this more accessible and convenient. A nifty proof-of-concept study demonstrated that a couple of other illusions can reduce osteoarthritis pain by up to 40%, at least temporarily.17 So what visual sorcery can kill more pain than any other known treatment for that condition? Two similar illusions, using virtual reality goggles to make it look like the knee was either shrinking or stretching. 😜 Whoaa, duuuuude …

Not looking! What you can’t see can’t hurt you (as much)

Getting an injection actually hurts less when you don’t watch.18 Out of sight, out of mind: if the brain can’t see the threat, it is less sensitive to it.

So that’s interesting, and like the magnification/stretching/shrinking experiments, it clearly demonstrates that the brain modulates pain and, in that circumstance, we can modulate it with an easy and conscious intervention. “With the power of my mind, I shall … look away!”

It’s easy to look away from a needle, but with most chronic pain, what is there to avoid looking at? We usually can’t see the threat in the first place.

Although this demonstrates that is indeed the brain’s prerogative to ignore painful signals from your tissues, that doesn’t mean that there’s any way we can usually convince it to do so — if there is a destructive disease process going on, for instance, the brain will usually not ignore those signals! The pain system evolved to report problems, and you can count on it to do so most of the time.


The power of positive thinking versus the power of toxic positivity

Almost every patient with unexplained chronic illness has a story about a doctor giving up on them, or worse: dismissing them with the patronizing, trite advice to “think positively.” It has happened to me more than once in my life. It’s such a common experience that it’s a cliché.

Talking to chronic pain patients about the power of positive thinking is thin ice for this reason. Optimism isn’t medicine.

But that idea is everywhere. Our culture is saturated with the idea that a positive attitude is potent:

Toxic positivity

The power of positive thinking is so pervasive that it has been extensively satirized (“I’m good enough, I’m smart enough…”). But there has also been plenty of more serious pushback against the excesses of the positivity “industry” over the years.222324 A backlash concept has emerged, the yang to optimism’s yin: toxic positivity.

Toxic positivity is the excessive faith that many serious problems can be solved by the power of positive thinking, and its consequences.

I agree with the contrarians; I think toxic positivity is a real problem. So it is with great trepidation that I dare to suggest that optimism, confidence, and attitude may still be important for chronic pain patients.

But I’m going to suggest it anyway! Cautiously!

So what about pain? Can sensible, non-toxic positivity help that?

At one extreme, we have the blatant bullshit of believing that you can “manifest your desires” or cure cancer with good vibes. But just because the power of optimism has been exaggerated and tainted by gurus and cranks and market forces doesn’t mean it’s useless.

At the other extreme, the evidence is overwhelming that optimists do better in life in many ways (and, unfortunately, that truth continues to serve as an invaluable seed of truth for many overheated and book-selling claims about the power of positive thinking).

Pain occupies an awkward middle-ground between those extremes. It’s a complex question, and no one should be convinced that optimism is good for pain… or that it isn’t. As this video amusingly illustrates, it’s kind of a no-brainer that optimism is almost certainly helpful for pain to some degree:

When it comes to treating pain, I prefer to frame positivity in terms of rational confidence and hope, not “optimism” or “positive thinking.” Even though there’s obviously a lot of overlap, confidence and hope are a bit different… and they aren’t quite so conceptually adjacent to toxic positivity.


The science of confidence: does it reduce pain?

How do we convince people in pain that we understand that they are in pain but it’s not just about the tissues of their body? A key conceptual shift that we think is really important is that you can understand that pain is the end result, pain is an output of the brain, designed to protect you … it’s not something that comes from your tissues.

Lorimer Moseley, from his surprisingly funny TED talk, Why Things Hurt 14:33

It’s time to start focusing on the positive implications of the brain’s role in pain, and I’ll start with the “power of confidence” — subtly different from the power of positive thinking. Confidence can probably reduce pain, directly and/or indirectly, in some people, at times — however one achieves it.

Many specific approaches to mind-over-pain are just variations on this theme, different ways of achieving confidence and optimism. But nothing is simpler than a reasonable, rational basis for hope.

One of the top five questions I am asked, about any condition, is simply Is there hope? The answer is nearly always the same: yes, there’s hope. There’s never a guarantee, but there’s always hope, and recovery from most kinds of severe chronic pain is not only possible but fairly common. There is rarely any reason to fear that it’s impossible to recover from a chronic pain problem. For the same reason that pain can be absurdly persistent and out of proportion to any clear cause — because it is so brain-tuned — it also never rarely loses the potential to finally shift and evaporate.

The evidence so far

There’s been a fair bit of indirect evidence about this for a long time, but one of the first really good, direct scientific tests was finally published in 2013 by Vibe-Fersum et al.25

Classification-based cognitive functional therapy (CB-CFT, or more often now just CFT) for low back pain is a “body/mind approach to understanding and managing this complex problem” that “targets the beliefs, fears and associated behaviours” of patients (what I have called the “confidence cure” for many years). The big idea of CFT is that the cycle of pain and disability can be broken by easing patient fears and anxieties, specifically “reframing the persons’ understanding of their back pain in a person-centred manner, with an emphasis on changing maladaptive movement, cognitive and lifestyle behaviours contributing to their vicious cycle of pain.”

Translation: pretty much any strategy that restores confidence.

In that 2013 trial, CFT was tested on 62 patients with moderate back pain, and compared to 59 who were treated with manual therapy and exercise. Three months and a year later, the CFT group was much better off.26 CFT was “more effective at reducing pain, disability, fear beliefs, mood and sick leave at long-term follow-up than manual therapy and exercise.” As the authors put it for, “Disabling back pain can change for the better with a different narrative and coping strategies.”

There were some blemishes on the study methods, but nothing dire; the results can be safely regarded as actually promising.27

2023 update: that big CFT trial in the Lancet

In the spring of 2023, that old 2013 study was upstaged by a much larger, more rigorous, and even more promising trial of CFT published in The Lancet.28 In a nutshell, CFT showed reduced and lasting pain relief and reduce disability compared to "usual care." It’s easy to look at the results and think, "Eureka, CFT is now good evidence-based medicine!" And I would really love to believe that myself.

But I don’t yet. “Good evidence-based medicine” is a very high bar to clear, and CFT hasn’t done it yet. This trial falls well short of proving that CFT is efficacious, due to a variety of flaws and limitations. It has been strongly criticized by some, probably over-hyped by the researchers and their “fans,” and many professionals are justifiably wary of the strong potential for branding and for-profit promotion of CFT … which strongly resembles what many good clinicians already do as a matter of course.

So we have quite a ways to go yet before celebrating a CFT triumph. Maybe someday.

Meanwhile, I’d choose CFT any day of the week over almost any conventional structuralist approach to pain.


Whilst the problem is superficially a physical one, the real challenges faced by someone with chronic pain are mental. Mental state is the biggest modulator of physical pain. Things hurt more when you’re stressed or sad, and the increased pain makes you both stressed and sad. The way out of this vicious circle is a wholesale change to how you perceive fear, suffering and setbacks.

How chronic pain has made me happier, by Rob Heaton

Part 3

Jedi Pain Tricks!

What are the practical applications of knowing that pain can be brain-tuned?

Chronic pain is not all about the body, and it’s not all about the brain — it’s everything. Target everything. Take back your life.

Dr. Sean Mackey, Pain & the Brain lecture

Pain is “another *%$@!! growth opportunity” — an intense provocation to mature as a person. For many people with severe and chronic pain, learning coping skills is a necessity. But personal growth is a much greater opportunity than merely coping with pain. We may not control our brains, but we do have considerable indirect leverage. We can’t micromanage every sensation, but we can tinker on a large scale. We change the context and direct our experience of life on a large scale. For instance…

Animated GIF of a realistic looking brain wobbling.

Mind ≠ brain. But mind can, maybe, exert some influence on the brain, which is quite “plastic.”

Pain education

Dr. Lorimer Moseley explains that “education is universally recommended as first-line treatment for acute and persistent back pain.”29 And what does modern pain education look like? “It is not reciting pages from a textbook or giving a patient ‘the pain talk’,” meaning the basics of modern pain science. It’s more complex, nuanced, and fine-tuned to an individual’s specific case. Doing it right plenty of knowledge, skill, and even charisma. You have to “sell” it.

Fear and anxiety probably have more power to aggravate pain than any other emotional state, and acquiring knowledge and perspective are superb remedies for fear and anxiety. A confident and happy brain amplifies danger signals less than an anxious, miserable brain. This explains some interesting results in pain research (not to mention clinical observations), such as:

But meaningful education doesn’t come easily. One look at the avalanche of shoddy information online — shallow or misleading or worse — is enough to make that clear. Or consider the fact that it’s nearly impossible to go see a healthcare professional without being told something significant about your case that the next healthcare professional think is bollocks.

But nothing causes more anxiety than uncertainty, and education is a proven cure for uncertainty. One of the most important reasons to be educated is so that you have the power to be skeptical about diagnosis — so that you don’t just buy into the first scary story you hear about what is supposedly wrong with you. More on this coming up below: see “Doubt all diagnosis.”

How pain education can go awry

So many ways.

Pain education is often oversimplified and impractical to the point of being not just useless, but insultingly trite — indistinguishable from toxic positivity, the excessive faith in the power of positive thinking to solve serious problems. It’s not really surprising to see this coming from individual clinicians, but I also see it coming from much more carefully prepared educational resources.

For instance, there’s a very nice Australian video about pain — it does a great job of explaining the neurology of pain. Its main messages are mission critical stuff, and I give an A-grade to their explanation of the general nature of pain. But I have some nitpicking to do…

Their advice to pain patients? The application of the information? Not so good! Much too trite! The video comes dangerously close to just advising patients to “don’t worry, be happy” and it flirts with the dreaded “all in your head” implication — and that’s really not what we want here.

Yes, pain is indeed a brain thing, but this must not be dumbed down to the point that people have no idea what to do with it or, much worse, feel blamed for it. People with chronic pain feel bad enough already!33

The video portrays pain as a problem with a dysfunctional brain that can be “trained” back to good behaviour, like a terrier with behavioural issues. That is way too optimistic. Brains are not terriers. Although it makes sense to try, there is no good evidence that this actually works, and clearly it’s just impossible in some circumstances. There are many possible reasons why.

For instance, mood disorders (depression, anxiety) and stressors can be virtually invincible. Most people with chronic pain aren’t just a little stressed, they are a lot stressed, and often by major life challenges and social injustices that they absolutely cannot solve.34 Even when those problems are theoretically more manageable, most people find it extremely difficult to troubleshoot their own mental health. So while it’s technically correct to tell patients to “learn to reduce stress” and “consider how your thoughts and emotions are affecting your nervous system,” that advice is shallow to the point of being useless. The video sinks all the way down to advising us to “recognize deeper emotions.” 🙄 I think most patients will dismiss that as insultingly flaky. Don’t underestimate how hard that kind of talk can rub people the wrong way. Consider this comment I got by email:

Your ‘nitpicking’ of the cute cartoon video — which had already infuriated me before I found your analysis — was just spot on. You so eloquently expressed my feelings that I almost wept. And I’m English! We don’t do that!

I applaud the emphasis on psychological and social factors, but it’s also really important to keep it real and make it practical.


Doubt all diagnosis! Beware nocebo!

Be extremely skeptical of diagnosis — both your own ideas, and the theories of healthcare professionals. Most ideas about what causes persistent pain are bogus or exaggerated, and mostly serve to convince us that we are more broken or fragile than we actually are — causing anxiety that has real power to make pain worse. There are many classic examples, like the infamous predeliction for diagnosing back pain as a “slipped disc,” a scary-sounding, specific diagnosis that is much less common and serious than most people believe, a major reason why so many experts think of MRI as a false alarm machine.35

Meanwhile, alternative medicine churns out diagnostic speculation that is overconfident and simplistic at best. All freelance healthcare professionals, even relatively mainstream physical therapists,36 have a nasty habit of diagnosing problems that they can sell their solutions to, profitably pathologizing people, a road to hell paved with the best of intentions.37

Everyone is guilty of perpetuating this pattern — even patients themselves, who encourage it with their routine refusal to take “I don’t know” for an answer and willingness to pay for anything that gives them hope. It is vitally important to be extremely slow to believe any specific idea about what is causing your pain.


Huff, puff, and blow your pain down: changing state with vigorous breathing

We can alter our physiology some deep, vigorous breathing, instantly creating new sensations — and your brain will go along for that ride, and maybe it will also re-interpret your experience of pain (among other things). For more about this odd idea, see The Art of Bioenergetic Breathing.

To be clear, yes, I am talking about “hyperventilating,” just without an anxiety component (let alone panic). It’s okay, as that article explains in more detail. It’s quite a safe way to tinker with your biology.

There are many similar ideas. They all have the common denominator of changing your state in some way. I chose vigorous breathing as the primary representative because I think it’s one of the most practical and direct.

You can certainly change your state by swimming in an icy lake, too. Or sky diving. Or going on a 10-day fasting and meditation retreat. But these things are considerably less convenient (and/or come with other baggage, risks, etc).

Another particular popular example of state-changing — vigorous exercise — is a bit too familiar and problematic for many pain patients. Lots of pain patients can’t go for a run, or just don’t want to for very understandable reasons, or can’t do it three times a day.

But almost anyone can do a couple minutes of huffing and puffing five times a day.

And it’s strange and novel, and that is a feature: when you’re trying to affect your brain, “change is as good as a holiday.” Experiencing something odd and new to you is part of the point.


Create new social contexts (using team sports as an example)

There are many ways you can create new social situations for yourself, but playing a team sport is a really powerful one and a good example. It’s obviously, definitely not for everyone, but it is great for some of us — I love playing ultimate for exactly this reason.38 It illustrates an important principle…

Group competition is really good for re-contextualizing pain, good for changing what it means to hurt. Because we are highly social animals, other people counting on you is a potent force. The painful consequences of intense exercise (or the pain we had when we went into it) can be significantly re-framed as tolerable, even desirable, and you can put up with quite a lot more. It’s “for a good cause.” According to your brain.

You can’t think your way to that kind of pain tolerance/coping — but you can place yourself in a situation where it is much more likely to occur regardless of what you think. Infamously, soldiers are powerfully motivated this way, regardless of almost anything else.

Sports aren’t the only situation in which other people might be counting on you. It’s just the most intense and accessible for the average person.

This psychology is also why Haven — a counselling school, which many people go to just to learn more about themselves — uses “experiential” workshops, putting people through a bunch of interesting and intense experiences together. Their whole deal there is systematically, creatively tinkering with your social context… because they know that humans beings are so interested in each other that our social experiences utterly dominate our nervous systems.

Change your social experience, change your brain. If not sports, something else that involves social interdependence.


Early intervention is vital

“As early as possible” is the best time to prevent acute pain from transmogrifying into chronic pain.39 It is clear that chronic pain can cause neurological changes, both in nerves themselves and in how their activity is interpreted by the brain, a state broadly known as sensitization, in which we feel more pain with less provocation.

Pain chronification probably has many mechanisms, like becoming “pathologically emotional,”40 or even classical conditioning — an automatic, learned response to a stimuli.

Regardless, however it happens, it really happens — and once those changes occur, recovery is much harder, at great cost in suffering and medical expense. Persistent pain should not be ignored. Deal with it sooner, not later, as best you can. Don’t wait around just hoping things will get better. Obviously this is the mother of all easier-said-than-done challenges, but here’s a strong practical example of how to make it happen despite the difficult: a strategic temporary prescription of tranquilizers. This needs some serious elaboration…

The transition from acute to chronic pain is often a time of howling anxiety, both because of the pain and often other stresses. Treating anxiety during that transition is a tall order, but also potentially high value and urgent — because this is exactly when “freaking out” may actually drive pain chronification. But how do you treat anxiety “urgently”? Actually, it’s easy: cautious use of benzodiazepines (Valium, Ativan, etc), a modest dose for a couple weeks at most. More is flirting with disaster.41 But for a week or two? Nearly magical anxiety relief — seriously, that stuff really works — right when you most need it. (And probably better sleep too, another high-value benefit).

Naturally, you should also use that opportunity to do everything possible to start taming anxiety in other, safer, more sustainable ways: see Anxiety & Chronic Pain. Many of the other ideas here harmonize with this goal.

The brain cells that produce pain get better and better at producing pain. They become more and more sensitive …

Lorimer Moseley, pain researcher, Why Things Hurt 14:33


Reject the self-hating idea that your pain is “just” psychological or merely psychosomatic

Paradoxically, even though pain is strongly modulated by your central nervous system, it is probably never “all” in your head. Although pure psychosomatic pain might exist, it is disproportionately and disrespectfully suspected and diagnosed. (I explore this question in detail in Can the mind create pain?42) Using that brush to paint every other chronic pain patient is scientifically obsolete and can be thrown out with yesterday’s trash. Any health professional talking like that should just be ignored. We know better these days: pain does not have to be driven by easily diagnosed tissue damage to be “real” and serious, and it can also have major psychological dimensions without being just psychological.

Patients often find themselves trapped in a zone between the worlds of medicine and psychiatry, with neither community taking full responsibility.

It's All in Your Head, by Suzanne O’Sullivan, 9

If you are going to confidently defend yourself from the corrosive idea/diagnosis of psychosomatic pain, you’re going to need a really clear understanding of this…

So what’s the difference between “pain is an opinion” and “it’s all in your head”?

Unfortunately, it’s tricky to tell patients “sometimes pain correlates poorly with tissue damage” without them hearing “it’s all in your head.” This miscommunication hazard is baked right into modern pain science, and I think it’s a serious problem. I have experienced it myself as a patient, and seen lots of other evidence of it.

For example, here’s the beginning of an amazing, uplifting back pain story, told by Dr. Jerome Groopman in his book, The Anatomy of Hope, about his own experience with super severe chronic low back pain:

Dr. Rainville planted the MRI scan of my spine on a lighted box on the wall and systematically inspected the film, vertebra by vertebra. Seemingly satisfied that he had reviewed all the relevant data, he turned and stood before me.

“You are worshiping the volcano god of pain,” he declared. “The volcano god of pain is your master.”

I had been warned that Rainville was a brash, in-your-face clinician who held contrary views. But what on earth was he talking about?

The “volcano god worship” lecture Groopman gets from Rainville is really great: an intense, dramatic version of a major tenet of modern pain science, that pain can get disconnected from reality. Despite the artfulness of the explanation, Groopman struggles with the implications like any patient:

And what was he really saying, in cold biological terms, not flamboyant metaphors of volcano gods? That changing my beliefs could dampen flaming circuits of pain? Was I some mystic or yogi who could walk barefoot over hot coals or lie down on a bed of nails?

Rainville was saying that the pain was not “all in your head” but his brain’s “opinion” of the situation. Hypchondria versus sensory dysfunction. Here is that difference “in cold biological terms.”

Awkwardly, there is overlap between hypochondria and exaggerated pain. They are at two ends of a spectrum, and most people are living somewhere between them. Of course everyone wants to believe that the weirdness of their pain is more like the seed-of-truth variety, a distorted and exaggerated but legitimate signal. It cannot always be that way, but it routinely is. And that is what you should believe — ideally after some serious soul-searching.

Meanwhile, many healthcare professionals will insinuate that you’re much more of a hypochondriac than you probably are. And that is pure poison.

“All in your head” isn’t in my vocabulary

Especially the all part.

Of course I acknowledge the power of the mind to warp and magnify pain and illness — that’s well-established, in many ways. But I reject the idea that honest people ever “fake” or “perform” their suffering, consciously or unconsciously.

Objection! Aren’t there “drama queens” who seem to pour emotional gasoline on their chronic pain and illness fires?

Sure. I have met them. And there are probably some extreme cases out there.

But drama that’s actually the main driver of serious disability? The cause? I think that’s rare to the point of barely existing — especially in the absence of other conspicuous signs of mental illness.


Be kind to your nervous system

Create pleasant, safe sensory experiences — positive inputs. Seek comfort. Be a hedonist. The grown-up version of building a blanket fort. Or maybe just actually build a blanket fort…

If your brain thinks you’re safe, many kinds of pain will ease — and pleasure and comfort almost always feels safe. Achieving comfort and pleasure is a good way to be sure that you are feeling particularly safe, at least temporarily.

So be “nice” to your CNS in every way that you can think of. Make your life — a small patch of it, anyway — feel safer, gentler, more pleasant. Do it in general ways (soak the whole system in a hot tub), but also more specifically: pleasantly stroke a sore knee, give a screaming shoulder the “comfort” of a sling for a while, or cautiously but thoroughly move a troubled joint to demonstrate to your brain that it’s okay. See, brain? We can do this! No big deal! Here’s that Moseley guy yet again

To reduce pain, we need to reduce credible evidence of danger & increase credible evidence of safety.

Lorimer Moseley. Explainer: what is pain and what is happening when we feel it?

Autonomous sensory meridian response as a clear, specific, sensory experience that represents safety

A particularly strong and specific indicator that your brain is convinced that it’s comfortable and safe is the weird sensory thrill of autonomous sensory meridian response (ASMR): a wave of euphoria with a shower of tingles over the head and upper torso.

“[The ‘ASMR effect’ is] clearly strongly related to the perception of non-threat and altruistic attention [and has a] strong similarity to physical grooming in primates [who] derive enormous pleasure (bordering on euphoria) when being groomed by a grooming partner…not to get clean, but rather to bond with each other.”43

“Bordering on”? I’m going to go ahead and say that primates definitely do euphoria during grooming.

Not everyone knows the ASMR effect, alas, and it’s not necessarily easy to bring it on either (a microcosm of the whole mind-versus-brain thing). But it’s not exotic either. It is known. Its triggers are ordinary, and it often crops up when while receiving quiet, focused attention from a healthcare professional, and I strongly suspect it correlates strongly with good bedside manner (not that anyone has studied that). It’s probably more prevalent in certain kinds of healthcare, like massage therapy. But ASMR has a variety of other oddly specific triggers, and the internet is full of videos intended to cause ASMR — which means that it’s something you can seek it out, like a form of meditation, but perhaps more interesting and more fun.

At the least, ASMR is the apotheosis of pleasant, luxurious sensation, a clear indication that you are in a great “mode,” doing something to your nervous system that’s helpful for pain, substantively helping your nervous system to feel safer and less vulnerable to false alarm.

At best, ASMR might be more directly analgesic, a particularly good example of a mind-over-pain hack — you just have to get your brain into that state. Your mind must make “arrangements” that increase the odds of your brain doing that thing. You have to cultivate ASMR, which is not necessarily easy, but it is a clear and specific goal, and definitely more possible for more people than the rarefied goal of a meditative trance.

Personally, I far prefer the idea of chasing ASMR than meditation and mindfulness — even though there might be a lot of overlap.


Analgesic catharsis or “emotional release”

Does swearing reduce pain? @^#@%, yeah! And so does saying “ow!” according to a 2009 study of swearing as a response to pain:44

In our study, saying “ow” increased pain tolerance by about 20%. One may speculate that benefits in real life may, perhaps, even be larger. There, vocalisations are typically less measured. That is, people are likely to say “ow” and other things more forcefully and can do so continuously without the somewhat unnatural breaks that were introduced for standardisation in our study.

“Less measured” and “more forceful” indeed.

From cursing to catharsis: a large but reasonable leap of logic

The analgesia of cursing isn’t at all surprising. It fits amusingly well with what we know about pain. It may not have much direct relevance to chronic pain… but it’s interesting, and fun, and it hints at a more complex, general possibility that has not been studied (and probably never will be): catharsis could be pain-killing.

Catharsis is psychological revival achieved through profound emotional experiences, especially self-expression. (See also the obscure psychological concept of “sublimation”: the transformation of socially unacceptable behaviour into something more copacetic.)

In plain English? Catharsis is venting. Just expressing “negative” emotions, finding “healthy” outlets for frustration, aggression, and anxiety. “Emotional release.” Some clichéd examples:

Art, history, and philosophy-based medicine

Other than a small study of the analgesic effect of swearing on pain, do we have any good reason to think that merely expressing emotion is useful? LOL, no! There’s not even much in the psychology literature about this as a path to improved mental health, let alone as an analgesic.

But catharsis is something people crave so deeply we almost can’t avoid it; sooner or later, we vent. As my wife says, “The energy has to go somewhere.” This craving has tangled roots in art and philosophy reaching all the way back into human prehistory.

And the idea of venting-as-analgesic is at least consistent with pain being a threat-sensitive system. It seems plausible to me that bottled up anger, frustration, anxiety, sadness can all ramp up the brain’s conviction that we’re in trouble. The profound relief that we can feel when we “let go” of those emotions, even temporarily, definitely might make a difference.


Change something — almost anything! — about how a painful area feels

Make a chronically painful area, and adjacent regions, feel as different as you can (and as cheaply as you can). Sensations are some of the major ingredients the brain uses to bake the pain pie (along with context and meaning). If you can make a body part feel significantly different in any way, it may help — but especially if you can make it feel safe, protected, stabilized. In fact, this probably explains why many treatments for pain problems are popular and seem to help sometimes, despite being unreliable and generally minor.

Often we see inexplicable and “weird” changes in painful conditions, good and bad, and often in response to an attempt at treatment — and yet at the same time it’s incredibly rare to find good evidence that any particular treatment works better than placebo.

Classic examples include: taping, bracing, strapping, splinting, salving, vibrating, heating, icing. Regardless of how they supposedly work — there are many overly complex explanations — most of these methods probably mostly just change how a body part feels.46

The science of novel sensory input

Why would changing feelings result in any analgesia at all? Broadly speaking, because input changes output. Nearly anything that happens to the body has the potential to affect how the body feels and works. Pain is an “output” — a perception the brain produces in response to sensory and contextual inputs — and so is a lot of wet, messy biology. Tissue state is just chemistry, and the chemistry of everything is constantly micromanaged and hyper-regulated. Dysregulation and uncomfortable trade-offs and compromises in these processes are routine, but it’s still full speed ahead until we die, all the time, damn the torpedoes, always a chemical balancing act. Any input has the potential to change that complex equation, even though it tends to resist change47 — the problem is that it’s incredibly difficult and maybe even impossible in principle to predict what inputs will help, or make any difference at all.

But the simplest example is well-described and highly reliable. Counterstimulation is a well-known method of achieving minor temporary pain relief with a sensory “distraction” from pain. It is based on the well-known neurological principle of gate control, first reported by Melzack and Wall in 1965,48 which is why noxious sensory input can be curiously pre-empted by other sensations. This is why we instinctively rub on/near acute minor injuries. It’s the most basic example of input changing output, of blunting pain by introducing other sensations.

Counterstimulation is not typically a potent effect, but it’s also definitely not the only example of pain modulation. Gate control was just the tip of the iceberg of the neuromatrix: the sum of all parts of the system that produces pain as an output. Gate control is just one small outpost of the neuromatrix, “only the beginning of a continuing selection and filtering of the input.” In Melzack’s words, expanding on that point many years later:49

“The gate control theory’s most important contribution to understanding pain was its emphasis on central neural mechanisms. The theory forced the medical and biological sciences to accept the brain as an active system that filters, selects and modulates inputs. … The great challenge ahead of us is to understand brain function.”

So the question is: are there fancier and more robust kinds of counterstimulation, based on the great power of the brain to modulate pain? Probably. Melzack thought so. As early as 1981, he was publishing about how even relatively simple pain gating could have a more lasting effect.50 But such benefits would be predictably unpredictable, much messier and more complex.

In principle, it seems clear that interesting sensory input would be the way to chase that whole class of potential effects. If the neutromatrix is going to change its output, it needs new data to integrate, new facts to consider. And sensory data is probably the most relevant. In a sense, you could consider all of the suggestions in this article to just be variations on this theme, but the hypothesis here is that sensation has the greatest potential to change the output of the neuromatrix.

That all sounds impressive, but the reality is messy and uncertain. No reason not to add “novel sensory input” to the toolkit, though, with reasonable expectations.

How to do it

Use any cheap, convenient, creative method you can imagine. Here are some ideas and examples … all assuming that you like these sensations. Most of these are self-treatments, but many can be improved by help from a partner.

So massage, basically? Spa massage, yes. Therapeutic massage, not so much. Most of these ideas are massage-like or massage-adjacent, but most massage therapy for pain patients is all about pressing on muscles, about “working the kinks out,” and mostly focused on the tissue that hurts, or close to it. These techniques are much more about sensory pleasure and novelty — principles that are mostly (and sadly) neglected in modern therapeutic massage. Spa massage, on the other hand, tends to be much more about sensory novelty and pleasure. The right massage of this type might actually be more therapeutic for some pain patients than “medical” massage.


Fix the fixable in your life

Our major life problems are the elephants in our rooms, responsible for most of our stress, anxiety, and depression — which means that our problems also have a direct impact on how much we hurt. And many of those problems simply cannot be solved, or only with great difficulty.

But some can. At least partially.

But we humans also tend to be our own worst enemies, most of us aren’t quite as stuck as we think we are, and some of our worst and oldest problems probably can still be solved. There are many examples of hard life problems that can usually be fixed with hard work and/or a leap of faith: toxic marriages and friendships, bad jobs and bad bosses, a house or city or climate you don’t like; addictions, insomnia, and many more.

Finally taking action to fix such problems is a long and winding road to relief, and is hardly guaranteed. It’s just too complex a strategy. But it is directly relevant in principle… and it’s not like such an effort will ever be wasted. Which is lot more than you can say for most other pain treatments. For a deeper dive into this strategy, see Pain Relief from Personal Growth: Treating tough pain problems with the pursuit of emotional intelligence, life balance, and peacefulness.

I would apply the 80/20 rule to stress management: 80 percent of the stress reduction is accomplished with the first 20 percent of effort.

Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, 414


Positive movement (and posture?)

One of the big ideas in evolutionary psychology is that our minds have many specific skills, rather than an all-purpose intelligence. If the part of the brain responsible for pain — the pain “module” — isn’t easily swayed by the part that thinks, are there other modules that might have more influence?

Probably. Todd Hargrove: “The movement modules would be first on my list.”53 (You can reframe several of the ideas in this article in terms of trying a different brain “module.”54)

“Positive movement” may be more potent than “positive thinking.” Another way of phrasing that: positive movement may be a better way of “thinking” positively.

And what is positive movement? Moving as if you are more comfortable than you are: build up your confidence with whatever movement you can reasonably handle. Move in ways that are as pleasant, fun, and/or inspiring as possible. Pain limits movement — so push against those limits gently, creatively, playfully.

The “power pose”

“Power posing” is a notoriously over-hyped idea. It might even be the best-ever example of a half-baked, unconfirmed scientific finding catapulted to fame by a TED Talk.55 However, follow-up research has been solid enough that I feel comfortable concluding that a confident posture can influence our emotional state… at least a little.56 It may not be a huge effect, but it’s probably there.

And, if posture can influence emotions, then of course it can probably modulate pain too — at least a little — and there is even some actual evidence of that.57 Once again, we see potential for some mind-over-pain leverage that is indirect: we can’t tackle pain head on, but we can tackle things that affect it.

Tits up!

So by all means, don’t just move positively, but also stand confidently: assume a bold posture, a “power” posture. Or, as a mentor of mine liked to describe that posture: “Tits up!” It might actually reduce pain — a tiny bit. A temporary reduction in sensitivity is hardly a cure for chronic pain, if it works at all, but trying certainly isn’t going to do any harm.

Posture can also be an expression of self-limiting beliefs and attitudes, and tinkering with it may also be helpful on a longer journey to personal growth. I explore the psychology of posture in more detail in Does Posture Matter?.

To pretend to be calm is to be calm, in a way.

Gillian Flynn, Gone Girl


Don’t be a pain drama queen!

“It feels like a jagged, flaming, poisoned sword ripping through my body over and over again.”

People really talk like that, when they are in pain. My father talks like that. And I too have the impulse — genetic and/or learned — to talk like that. The apple does not fall far from the tree.

We must beware of colourful and extreme descriptions of our pain. They are tempting. There are quite a few reasons to exaggerate pain. For instance, pain is such a private experience — so often minimized or even denied by health professionals — that patients are often tempted to dramatize their pain to make it seem more real. But it’s a trap! Before you know it, you’ll believe your own story! When you exaggerate and dramatize your pain, you directly exacerbate the neurological end of the chronic pain problem. The ability to weather emotional storms — being unflappable in the first place, or recovering relatively quickly — probably affects pain levels.58

The pain scale is the imperfect replacement for flaming, poisoned swords. If you have chronic pain, you’ve probably been asked many times to rate your pain, and probably on a scale of 1 to 10, and maybe with a visual aid like this:

A typical doctor’s office pain scale chart.

On the one hand, the pain scale is an essential pain research and clinical tool, with proven value — it’s the main way that we measure the effect of therapies, to see if they really work. On the other hand, the opportunities for abusing the pain scale are legion, it is a source of perpetual confusion in health care offices throughout the land. It sounds so easy: just rate your dang pain! But people are often stumped by the question, or they overthink it, or they wildly exaggerate.

Many times I have seen pain-scale discussions nose dive into philosophy. Is #10 reserved for the worst pain we have ever experienced, or the worst pain we can imagine? “I don’t know, I can imagine quite a bit.” Can we ever really know what someone else’s pain feels like? (No.) If pain fluctuates, do we take the average? For really horrible pain do we go off the scale? Or recalibrate?

The thing is, people like to go off the scale. Drama is fun. Hyperbole is fun.

“Definitely a 15. Having a baby, yikes, that was like a 19 with spikes to 38.”

The irony is that the pain scale is supposed to help you think more objectively and rationally about your pain, but it often just creates another opportunity for melodrama. So use the pain scale, but use it wisely. Use it as a tool for getting a little more real about your pain.

Speaking of hyperbole…

This pain scale business has often been satirized and mocked. My personal favourite is from Allie Brosh of the brilliant, scribbly blog Hyperbole and a Half. Look back at #8 on the pain scale chart above. Does that look like a #8? According to Brosh, #8 seems to be thinking: “The ice cream I bought barely has any cookie dough chunks in it. This is not what I expected and I am disappointed.” So she did her own. Here’s her take on #8:

“I am experiencing a disturbing amount of pain. I might actually be dying. Please help.”

Now that’s more like it! No ambiguity there! Brosh’s pain scale is so funny that you will spray milk out your nose. (Assuming you drink some milk first.) Read the whole thing. But get the joke!


Limit pain talk (and the “How are you?” problem)

Never mind being a pain “drama queen,” just talking about our pain is problematic. Any kind of “pain talk” at all, even just politely answering the question “How are you?” could exacerbate pain.

Avoiding pain talk might also just be a quality of life improvement. Adira Bennet for, on answering “How Are You?”:

Every chronic illness fighter has experienced the piercing awkwardness of sharing too much with the wrong person or at the wrong time where your pal is like, ‘Oh… uh… feel better soon. I gotta go.’”

Anyone who has been in significant chronic pain for long enough knows how tiresome it gets trying to explain to people how you are doing. So you may benefit from learning not to. Tom Bowen of writes (and citing White et al):59

I recommend limiting pain talk. We can socialize without talking about pain, or worse complain about it. We are more than our pain. While pain talk can help us validate our pain, it has been shown to worsen pain. Conversely, well talk has been shown to reduce pain intensity.

I completely agree, but limiting pain talk can also be a tricky skill to learn. Finding graceful ways to answer as minimally as possible isn’t always easy. Important note: you can lie (“I’m fine, how are you?”) but you don’t have to. You can deftly, quickly navigate quickly to other topics, emphasizing the positive for the sake of avoiding the negative, even if it feels forced and absurd to you. Remember that your pain is only the “elephant in the room” from your perspective.

There’s also a big ol’ grey zone between those times when candid conversation with good friends is truly cathartic, therapeutic, and useful… and, at the other extreme, pointless, reckless oversharing with acquaintances.

But learning to minimize pain talk as best you can is probably a wise course to set — and not just to reduce those awkward conversations trying to answer the dread “how are you?” question, but because it may actually help the pain. This is another great example of the indirect mind-over-pain power.


“Unlearn” pain

Can chronic pain be a “learned response” to things that shouldn’t hurt, like Pavlov’s dogs salivating to the ring of a bell? Classical conditioning is not widely believed to be a factor in chronic pain, but it’s broadly plausible, with several lines of reasoning and evidence that point straight to it (without taking us all the way there).

I review the topic in much greater in a separate article: Chronic Pain as a Conditioned Behaviour. For our purposes here, imagine that pain can indeed be conditioned — now what? The optimistic implication: what is learned might also be un-learned.

That optimism could be badly misplaced. I can’t! The persistence of traumatic memory isn’t just analogous — it’s probably a neurological sibling. Maybe we do learn pain, and maybe we don’t… but it’s a dead end if getting out of deep neurological ruts is basically impossible anyway.

Or maybe it’s just tricky and subtle. Like a hyperbolic video game difficulty setting, maybe the challenge is “epic” or "insane"… but some people can do it.

Disrupting the pain habit

I have a couple new vocabulary words for you: “reconsolidation” and “disruption.”

Memories and habitual responses to stimuli aren’t just “stored” like data on a hard-drive — they are re-saved over and over again, like a computer auto-saving a document. That’s reconsolidation, a well-established neurological phenomenon in the context of memory and classical condition.

That’s what we want to disrupt. But how?

Sensory Disruption of Reconsolidation (SDR) is an experimental chronic pain therapy method pioneered by Christine Sutherland, an Australian behavioural therapist and researcher. To absurdly oversimplify it, SDR triggers reconsolidation so that it can be disrupted, weakening and hopefully breaking the link between the stimulus and response of feeling pain.

If anything in this article qualifies as a mind-over-pain “hack,” this is it: an exploitation of an advanced mechanistic understanding of how conditioning works. Easy in principle, it is something you can do with your mind that has the potential to actually affect your pain-controlling brain. In principle, anyway.

In practice, there’s nothing remotely easy about it. It’s just like computer hacking that way. It’s not a do-it-yourself thing any more than knowing how to hack into someone else’s iPhone.

That said, there’s nothing wrong with trying. You learn what conditions trigger your pain, you pull on those triggers, and then you disrupt your brain’s processing of them (reconsolidation) with competing actions, thoughts, and sensations. And you practice… because this is a difficult thing to do well on your own.

Again, there’s more detailed information in the conditioned pain article:


Cognitive behavioural therapy for chronic pain

If it’s possible to treat pain with your mind, why wouldn’t you get professional help from someone who is expert in the ways of the mind? If the mind can control pain, even a little bit, then surely the field of psychotherapy knows a little something about that? One would hope!

But people don’t often ask mental healthcare professionals to treat pain. Maybe it’s because psychotherapy as we know it simply has no reputation for effective pain management. Or maybe it’s the all-in-your-head stink and the more general stigma of going to a “shrink.” Or maybe it’s because the fantasy of mind-over-pain is all about doing it yourself, while talking to a psychologist seems more like therapy-over-pain. What good is “mind over pain” if you need someone else’s mind to give your mind a boost?

Speaking for myself, however, I would absolutely take such a boost if I thought it would help. Unfortunately, it’s not clear that many mental health professionals are actually equipped with the skills to give this particular boost.

Here are a some key points about psychotherapy for pain:

All of these points and more are explored in greater detail in an article dedicated to psychotherapy.


Resilience as victim-blaming bullshit

The idea of “resilience” has been overused and abused in the world of pain medicine, and someone should pound the table about it a little bit. This rant was inspired by this tweet from @DrCopps:

“I feel like ‘resilience’ has just become medicine’s way of victim-blaming people who burn out instead of actually enacting structural change.”

I think Dr. Copps was speaking more generally, and not about my own world of pain medicine, but it got me thinking about how this applies to things like unexplained chronic pain, back troubles, or injuries that won’t heal.

Talking about resilience is just fine for many patients in the worried-well category: people who are mostly healthy, but struggling with a new painful problem, can really benefit from some strong reassurance.

But not everyone. For many others, resilience talk is tone-deaf, preachy, ableist bullshit that completely ignores elephants in the room.

When resilience is worth talking about

The concept of resilience is often genuinely needed as the antidote to widespread fears of musculoskeletal fragility, and especially spinal fragility. This fear is routinely flamed by healthcare professionals who don’t know any better, who like to blame painful problems on glitchy anatomy and biomechanics (“structuralism”) way too much, rather than the much messier reality.

In that context, resilience can definitely be a handy concept. It might be applied by telling a patient something like this:

“Back pain does not mean your back is fragile and degenerated. In fact, spines are extremely strong and resilient… even with substantial signs of arthritis.”

In other words: you are strong and resilient, pain doesn’t mean you’re wrecked, you got this. That kind of reassurance can probably help a lot of people.

This theme has emerged as one of the main ways to talk to people about their pain in a way that acknowledges the neurological reality: pain is thoroughly modulated by the brain, and often aggravated by excessive pessimism and anxiety based on bogus beliefs. If the anxiety and pessimism can be relieved, if the bogus beliefs driving them can be corrected, great, by all means: embrace “resilience.”

When resilience talk is clueless garbage

Some healthcare professionals are so eager to dispel myths about fragility that they forget that there are other reasons why people get pessimistic and anxious. They may well be struggling with chronic pain and injuries for much more profound reasons than “I’m afraid poor posture will destroy me.”

Many people actually are not resilient … and trying to convince them that they are sounds like empty propaganda to them.

The whole reason that many people are in trouble in the first place is that they have high vulnerability for reasons that are hard or impossible control: metabolic syndrome, maybe a genetic gift of chronic pathology, or a sleep disorder, an addiction or two, and let’s not forget overwhelming stresses from poverty and social injustice. And so on and on.

For people like this, it often seems like they just have to glance at a tendon wrong and it bursts into flame. Maybe in some fantasy world where 80% of their problems are solved, they could be easily reassured. But the idea of resilience usually sounds hollow to these patients.

It also sounds privileged. It’s a luxury to be in a position where being told that you are tougher than you think is all you really need to feel better. Many people are just nowhere close to that.

And then there’s the really tough cases

That’s just normal unhealthiness. Don’t forget everyone with unexplained chronic illness/pain — and there are millions of us.

Most days my own body feels about as resilient as a burning house of cards. If a healthcare professional tried to convince me that I am more resilient than I think, my impulse would be to laugh. Or punch them.

Okay, truthfully, I would just roll my eyes. Inwardly. I am not actually very confrontational.


About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:

Part 4


Related Reading

What’s new in this article?

This document has a complex editorial history, and the update log is a bit spotty and confused in places. Originally there was only one article, Pain is Weird, which covered both the “pain is an opinion” paradigm and tackle the thorny mind-over-pain implications. In mid 2021, I moved the mind-over-pain subject to its own page.

May 26, 2023 — New section: Added a section about the overuse and abuse of the idea of “resilience,” from a 2021 members-only post now made public. [Updated section: Resilience as victim-blaming bullshit.]

May 26, 2023 — Science update: Cited and critically analyzed that big new study of cognitive functional therapy (Kent) — more on this to come, but the process of citing it widely on PainSci has begun. [Updated section: The science of confidence: does it reduce pain?]

May 26, 2023 — Many minor adjustments: I remember crafting this summary extremely carefully back in 2021. But it’s amazing how steadily my ideas evolve — especially on this topic in the last two years — and I saw a need for a whole bunch of edits. The idea that you could create something like this and leave it alone is kind of laughable. [Updated section: All the approaches to mind-over-pain.]

2021 — Added examples: The big idea of this section here was too abstract, so I added several concrete examples of how you “change something about how a painful area feels.” [Updated section: Change something — almost anything! — about how a painful area feels.]

2021 — Major edit: Completed a comprehensive edit, making dozens of minor and major improvements. Although not really new, the article is now so much like new that I’m giving it a fresh publication date.

2021 — New section: No notes. Just a new chapter. [Updated section: Cognitive behavioural therapy for chronic pain.]

2021 — More information: [Updated section: Positive movement (and posture?).]

2021 — New section: No notes. Just a new chapter. [Updated section: The power of positive thinking versus the power of toxic positivity.]

2021 — New section: No notes. Just a new chapter. [Updated section: “Unlearn” pain.]

Archived updates — All updates, including 17 older updates, are listed on another page.




  1. Melzack R, Katz J. Pain. Wiley Interdisciplinary Reviews: Cognitive Science. 2013;4(1):1–15. PainSci Bibliography 54582 ❐

    This is just one of many possible citations for this, but it might be the best of them. The authors, my fellow Canadians Drs. Ronald Melzack and Joel Katz, have a long history of interesting research and clear writing on this topic. This is their short, technical version of the major premise for this article:

    Pain is a personal, subjective experience influenced by cultural learning, the meaning of the situation, attention, and other psychological variables. Pain processes do not begin with the stimulation of receptors. Rather, injury or disease produces neural signals that enter an active nervous system that (in the adult organism) is the substrate of past experience, culture, and a host of other environmental and personal factors. These brain processes actively participate in the selection, abstraction, and synthesis of information from the total sensory input. Pain is not simply the end product of a linear sensory transmission system; it is a dynamic process that involves continuous interactions among complex ascending and descending systems.

  2. Kent P, Haines T, O'Sullivan P, et al. Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial. Lancet. 2023 May. PubMed 37146623 ❐ PainSci Bibliography 51276 ❐
  3. Ben Cormack, Peter Stilwell, Sabrina Coninx, Jo Gibson. The biopsychosocial model is lost in translation: from misrepresentation to an enactive modernization. Physiotherapy Theory and Practice. 2022:1–16. PubMed 35645164 ❐ PainSci Bibliography 52047 ❐

    This thoughtful paper argues that Engel’s biopsychosocial model (“an important framework for musculoskeletal research and practice”) has been misapplied in 3 ways:

    1. biomedicalization — just paying lip service to humanism & holism, but still being really rather biomedical
    2. fragmentation — tendency to perceive patients' complaints as this or that (e.g. bio or psycho or social), instead of this AND that (it’s always all of the above)
    3. neuromania — it’s ALL about the 🧠!

    Result? “Suboptimal musculoskeletal care,” in the opinion of the authors.

    I explore this paper and topic in much more detail in BPS-ing badly! How the biopsychosocial model fails pain patients.

  4. Brodie EE, Whyte A, Niven CA. Analgesia through the looking-glass? A randomized controlled trial investigating the effect of viewing a 'virtual' limb upon phantom limb pain, sensation and movement. Eur J Pain. 2007 May;11(4):428–36. PubMed 16857400 ❐
  5. Moseley L, Gallace A, Spence C. Is mirror therapy all it is cracked up to be? Current evidence and future directions. Pain. 2008 Aug;138(1):7–10. PubMed 18621484 ❐


    Despite widespread support of mirror therapy for pain relief in the peer-reviewed, clinical and popular literature, the overwhelming majority of positive data comes from anecdotal reports, which constitute weak evidence at best. Only two well described and robust trials of mirror therapy in isolation exist, on the basis of which we conclude that mirror therapy per se, is probably no better than motor imagery for immediate pain relief, although it is arguably more interesting and might be helpful if used regularly over an extended period. Three high quality trials indicate positive results for a motor imagery program that incorporates mirror therapy, but the role of mirror therapy in the overall effects is not known. Obviously, more robust clinical trials and experimental investigations are still required. In the meantime, the relative dominance of visual input over somatosensory input suggests that mirrors might have utility in pain management and rehabilitation via multisensory interactions. Indeed, mirrors may still have their place in pain practice, but we should be open-minded as to exactly how.

  6. Fisher JP, Hassan DT, O’Connor N. Minerva. BMJ. 1995 Jan 7;310(70). PainSci Bibliography 55248 ❐

    This small item in the “Minerva” column of the British Medical Journal from 1995 is the source of a widely cited medical anecdote. The gist of it is that a man came to the hospital in terrible pain from a nail through his foot… except that the nail had actually gone between his toes. The anecdote is popular because it seems to support a very popular idea: that pain can occur without injury or nociception (danger signalling from injured tissues). If true, it means that people can "hallucinate" pain based on perception alone. By extension, that would also strongly suggest that pure psychosomatic pain is also possible. So a lot hinges on this little story.

    But is the boot-nail-guy story for real? There is at least a somewhat credible source. If you are determined, you can verify the citation with a free trial membership for But there is not much to verify: barely more than a photo with a caption, in the full text of the “Minerva” column. It is not a formal case study.

    There is not much reason to doubt the overall veracity of the story, but there certainly are reasons to doubt that it is exactly what it seems to be, or that it actually constitutes compelling evidence of pain-without-nociception. Most notably, even though Boot Nail Guy probably did have an unpleasant trip to the hospital, it’s also possible (even likely) that the incident did not play out just exactly as described, and it seems very plausible to me that the whole thing was not so much perfectly uninjured person experiences terrible pain and more like slightly injured person is really freaked out until proven safe.

    This slightly formal anecdote is not compelling “evidence” of pain without nociception at all, but it can be a credible example of a pain experience that may have been exaggerated by the mind. For a more detailed discussion of this odd source and its significance, see The legend of Boot Nail Guy reconsidered, or Pain is Weird (where it is put into a broader context).

  7. “Nocebo” is roughly the opposite of placebo: instead of relief from belief, it’s grief from belief. The word is Latin for “I shall harm” (great supervillain slogan). It refers to the harmful effect of … nothing but the belief in or fear of a harmful effect. Give someone a sugar pill and then convince them you actually just fed them a deadly poison, and you will probably witness a robust nocebo effect. Nocebo is one of the chief hazards of excessive X-raying and MRI scanning: showing people hard evidence of problems that often aren’t actually a problem is a great way to make them suffer.

    And that is one of the main reasons it can be valuable to learn about all this.
  8. Parr JJ, Borsa PA, Fillingim RB, et al. Pain-related fear and catastrophizing predict pain intensity and disability independently using an induced muscle injury model. J Pain. 2012 Apr;13(4):370–8. PubMed 22424914 ❐ PainSci Bibliography 54315 ❐

    The fear of pain was assessed in 126 brave volunteers with a questionnaire before — yikes — “inducing muscle injury to the shoulder.” (Don’t worry, nothing too awful for the subjects: they just did a workout with a lot of eccentric contraction that made them super sore.) The results were not what the researchers expected. This study is interesting because it found evidence that fear of pain before injury can predict recovery time. In other words: how well you respond to injury and recover is affected enough by fear that it can actually be predicted by measuring fear beforehand. That’s profound!

  9. It’s not academic hair-splitting. It doesn’t mean that pain isn’t real, or that tissues can’t genuinely be in trouble. What it means is that all pain — always, no matter what — is an unreliable interpretation of information coming to your brain from your body. Just like your brain “constructs” the reality that you see and hear and touch, it also constructs the experience of pain.
  10. [Internet]. Moseley L. Pain really is in the mind, but not in the way you think; 2013 Jul 20 [cited 14 Jan 6]. PainSci Bibliography 54649 ❐
  11. [Internet]. Hargrove T. Why Your Body is a Hypocrite; 2017 September 7 [cited 17 Sep 7]. PainSci Bibliography 52951 ❐

    As usual, Todd goes deep to find insight into pain science, this time mining evolutionary psychology and the modular theory of mind. (I am glad he did this reading and thinking so that I didn’t have to. Dense source material! But neat.) The article is about how different parts of your brain don’t necessarily cooperate much.

  12. Younger J, Aron A, Parke S, Chatterjee N, Mackey S. Viewing pictures of a romantic partner reduces experimental pain: involvement of neural reward systems. PLoS One. 2010 Oct;5(10):e13309. PubMed 20967200 ❐ PainSci Bibliography 51708 ❐
  13. Nilakantan A, Younger J, Aron A, Mackey S. Preoccupation in an early-romantic relationship predicts experimental pain relief. Pain Med. 2014 Jun;15(6):947–53. PubMed 24716721 ❐ PainSci Bibliography 52835 ❐
  14. Goldstein P, Weissman-Fogel I, Shamay-Tsoory SG. The role of touch in regulating inter-partner physiological coupling during empathy for pain. Sci Rep. 2017 Jun;7(1):3252. PubMed 28607375 ❐ PainSci Bibliography 53159 ❐
  15. Moseley GL, Parsons TJ, Spence C. Visual distortion of a limb modulates the pain and swelling evoked by movement. Curr Biol. 2008 Nov;18(22):R1047–8. PubMed 19036329 ❐


    The feeling that our body is ours, and is constantly there, is a fundamental aspect of self-awareness. Although it is often taken for granted, our physical self-awareness, or body image, is disrupted in many clinical conditions. One common disturbance of body image, in which one limb feels bigger than it really is, can also be induced in healthy volunteers by using local anaesthesia or cutaneous stimulation. Here we report that, in patients with chronic hand pain, magnifying their view of their own limb during movement significantly increases the pain and swelling evoked by movement. By contrast, minifying their view of the limb significantly decreases the pain and swelling evoked by movement. These results show a top-down effect of body image on body tissues, thus demonstrating that the link between body image and the tissues is bi-directional.

  16. That’s creative problem solving, but I think it only makes the impracticality point stronger: the very narrow field of view of binocs probably undermines the illusion significantly. Seeing an exaggeratedly remote looking arm through a peephole may not have the same effect. Not that it isn’t worth trying, but for this to work the brain must actually be fooled.
  17. Stanton TR, Gilpin HR, Edwards L, Moseley GL, Newport R. Illusory resizing of the painful knee is analgesic in symptomatic knee osteoarthritis. PeerJ. 2018;6:e5206. PubMed 30038863 ❐ PainSci Bibliography 53038 ❐
  18. Höfle M, Hauck M, Engel AK, Senkowski D. Viewing a needle pricking a hand that you perceive as yours enhances unpleasantness of pain. Pain. 2012 May;153(5):1074–81. PubMed 22520059 ❐
  19. Which includes plenty of reasonable ideas, and mostly focusses on nutrition and fitness. But there’s also a strong focus on stress management and “love and support,” which is strongly synergistic with the positivity zeitgeist, and has often been overinterpreted and exaggerated by its advocates patients. It’s certainly not a surprise to see titles like “Why Positive Thinking is Good For Your Heart” on

  20. Ehrenreich B. Smile or Die: How positive thinking fooled America and the world. London: Granta; 2009.

    A surprisingly dysfunctional cult of optimism sprung up around breast cancer in the 1990s. Barbara Erenreich wrote about it brilliantly for Harper’s way back 2001, eventually leading to her amazing book, Smile or Die (“Bright-sided” in the US: “How How Positive Thinking is Undermining America”).

  21. Placebo is fascinating, but its “power” isn’t all it’s cracked up to be: the power of belief is strictly limited and accounts for only a modest portion of what we think of as “the” placebo effect. There are no mentally-mediated healing miracles. But there is an awful lot of ideologically motivated hype about placebo! For more information, see Placebo Power Hype: The placebo effect is fascinating, but its “power” isn’t all it’s cracked up to be.
  22. [Internet]. Razzetti G. The Antidote to Toxic Positivity: The dark side of positive vibes; 2021 Jul 13 [cited 21 Sep 17]. PainSci Bibliography 52106 ❐

    Psychology Today is notorious contributing to the phenomenon of “toxic positivity,” with countless covers and headlines over the years devoted to the power of positive thinking. But credit where due: they also published this good quality perspective (and many others over the years as well).

  23. [Internet]. Greenberg G. The war on unhappiness: Goodbye Freud, hello positive thinking; 2010 Sep [cited 23 Apr 13]. PainSci Bibliography 52107 ❐
  24. [Internet]. Coyne J. Questioning Whether Psychotherapy and Support Groups Extend the Lives of Cancer Patients; 2013 Jul 23 [cited 23 Apr 13]. PainSci Bibliography 54624 ❐
  25. Vibe-Fersum K, O’Sullivan P, Skouen JS, Smith A, Kvåle A. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. Eur J Pain. 2013 Jul;17(6):916–28. PubMed 23208945 ❐
  26. CFT patients got a 13-point boost on a 100-point disability scale, and 3 points on a 10-point pain scale. Those are not amazing results, but enough to be considered clinically significant, and they beat manual therapy and exercise handily (those patients improved by only 5.5 and 1.5 points on the same scales).
  27. “Promising” is a badly abused word in modern science. I have gotten extremely fed up with “promising” research, because it’s almost always exactly the opposite: just a pathetically weak signal p-hacked out of a bunch of noise and spun into something worthy of a press release.

    Meme of Inogo Montoya with caption: “Promising. You keep using that word. I do not think it means what you think it means.”

    And so I use the word myself with great caution. In this case, however, the effect size is actually clinically significant — not just statistically significant, an important difference. It still needs replication, but unlike the vast majority of “promising” results, it actually has a fair to middlin’ chance of being replicated.

  28. Kent P, Haines T, O'Sullivan P, et al. Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial. Lancet. 2023 May. PubMed 37146623 ❐ PainSci Bibliography 51276 ❐
  29. Moseley GL. Whole of community pain education for back pain. Why does first-line care get almost no attention and what exactly are we waiting for? Br J Sports Med. 2018 Jul. PubMed 29982226 ❐

    Dr. Moseley makes the case for back pain education, and it’s quite inspiring:

    Contemporary pain education is potentially more powerful for persistent pain than drugs and as powerful as anything else we can offer. Education is a missing link that would actually make advice to be active, to exercise and to consider psychological therapy a sensible strategy for back pain. Research shows that when someone with persisting pain begins to understand their pain, they actually engage in active, psychologically informed strategies and can have drastic reductions in pain and disability over the next 12 months; for these people, recovery is back on the table.

    Truly excellent outcomes are possible for those persistent pain sufferers who take on the journey of retraining their overprotective pain system to be less protective. Contemporary pain science offers compelling reasons to suggest that recovery is within the realms of possible for many persistent pain sufferers. There is genuine hope—not for a quick fix but for a pathway to gradual recovery. It is not for the faint hearted, but people with persistent pain seldom have faint hearts.

  30. Schultz IZ, Crook J, Meloche GR, Berkowitz J, et al. Psychosocial factors predictive of occupational low back disability: towards development of a return-to-work model. Pain. 2004 Jan:77–85. PubMed 14715392 ❐

    This study identified factors affecting return-to-work time after an episode of low-back pain. From the abstract: “The key psychosocial predictors identified were expectations of recovery and perception of health change.”

  31. Brison RJ, Hartling L, Dostaler S. A randomized controlled trial of an educational intervention to prevent the chronic pain of whiplash associated disorders following rear-end motor vehicle collisions. Spine. 2005 Aug 15;30(16):1799–807. PubMed 16103847 ❐

    This is one of a few studies showing a benefit to education for neck pain specifically. Researchers showed a reassuring educational video to more than 200 patients with “whiplash associated disorders” (i.e. whiplash injuries that become chronic neck cricks), and found that they had less severe symptoms than patients who received no educational intervention. The effectiveness of education probably depends a lot on the type of neck pain and the type of education, making it very hard to study. A recent review of the scientific literature found that most such studies are negative (see Haines or Ainpradub), but I believe that there are still reasons to be optimistic about education for pain problems. Above all, it depends on the type and quality of the education! The right education may be effective, and the wrong could even be harmful. The fact that some education has been shown to be beneficial is promising.

  32. [Internet]. Moseley L. The therapy might work, but does it work in the manner you think it does?; 2012 Jun 18 [cited 15 Jul 15]. PainSci Bibliography 54304 ❐

    We know that “explaining pain” seems to reduce it, but how? Do we really know what’s going on? “The theory behind explaining pain is that it decreases pain by changing the underlying schema about what pain actually is.” Dr. Moseley methodically applies a validity test to that theory, which it passes with flying colours, meaning that it is a reasonable, working theory about how pain education works (not proof that is does work — a technical but important difference).

    For contrast, note that in a follow-up article, he concludes that graded motor imagery does not satisfy the burns test — a nice demonstration of the integrity of his reasoning.

  33. Toye F, Seers K, Allcock N, et al. Patients' experiences of chronic non-malignant musculoskeletal pain: a qualitative systematic review. The British Journal of General Practice. 2013 Dec;63(617):829–41. PubMed 24351499 ❐

    This paper reviewed qualitative research on musculoskeletal pain to shed light on what it’s like to have chronic pain. Several worrisome themes were clear. Chronic musculoskeletal pain often forces patients into the awkward position of having to prove the legitimacy of their condition: “if I appear ‘too sick’ or ‘not sick enough’ then no one will believe me.” Many end up doubting themselves and questioning their own identity and wondering who is “the real me.” Many lose hope and feel lost (or lost by) the health care system.

  34. For instance, it is next to impossible for impoverished single mothers of children with serious health problems and inadequate social services to support them to meaningfully “reduce stress,” and advising them to do so borders on insultingly naive paternalism.

    The realm of stress management is mostly about techniques to help deal with challenges that are less than disastrous. It is pretty effective in that sphere. But it just won’t work to generate a cult of subjectivity in which these techniques are blithely offered as a solution to the hell of a homeless street person, a refugee, someone prejudged to be one of society’s Untouchables, or a terminal cancer patient.

    Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, 405

  35. Overuse of MRI and X-ray for back pain is an over-medicalization disaster, criticized for decades for generating way too many false alarms. Low back pain is extremely multifactorial, and the spinal glitches that imaging reveals are just one ingredient in a rich stew of risk factors, and often a minor one. Spinal degeneration is shown by MRI in many asymptomatic people. Diagnosis based mainly on imaging is almost always misleading and unnecessarily spooks patients, doing real harm through the power of nocebo (placebo’s evil twin). There are also huge quality control problems with MRI. It should be use minimally, only when strongly indicated by persistent major symptoms. Patients should refuse early MRI and take radiology reports with a huge grain of salt. See MRI and X-Ray Often Worse than Useless for Back Pain: Medical guidelines “strongly” discourage the use of MRI and X-ray in diagnosing low back pain, because they produce so many false alarms.
  36. Pseudo-quackery is quackery that passes for good medicine despite strong evidence that it doesn’t work. Unfortunately, not all quackery is obvious — not even to skeptics. “Pseudo-quackery” appears to be mainstream, advanced, technological, “science-y,” or otherwise legit — quackery without any sign of being way out in left field. It has enough superficial plausibility to persist in the absence of evidence against it. This subtler type of snake oil is a more serious problem in musculoskeletal health care, because it hides right in the mainstream. For instance, it’s nearly synonymous with the early history of physical therapy, and remains alarmingly prevalent in that profession. So pseudo-quackery is extremely common, and generates more false hopes and wasted time, energy, money, and harm than more overt quackery, which is relatively marginalized. See Pseudo-Quackery in Physical Therapy: The large, dangerous grey zone between evidence-based care and overt quackery in treatment for sprain and injury.
  37. It’s not an accident that chiropractors diagnose spinal subluxations, and massage therapists diagnose tight muscles, and naturopaths diagnose “imbalances” to be corrected with elaborate regimens of supplements, and so on.

    I was a “freelance therapist” for a decade — a massage therapist in private practice — so I have good direct experience with the economic pressures. I am an enterpreneur, and I don’t think it’s inherently wrong to charge fees to help and educate people (some people actually do believe that) but obviously a financial motive can be highly corrosive to professional integrity. It is every health care professional’s highest ethical responsibility not to confuse profitable recommendations with good health care. They are rarely the same thing.

  38. Ultimate is a Frisbee team sport, co-ed and self-refereed, with soccer-like intensity and usually the mood of a good party. Players tend to be jock-nerd hybrids: lots of engineers and scientists. Hippies invented the sport, but have mostly been displaced. I’ve been playing since 1997.
  39. Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis and treatment. 1st hardcover ed. Lippincott Williams & Wilkins; 2000.
  40. Apkarian AV, Baliki MN, Farmer MA. Predicting transition to chronic pain. Curr Opin Neurol. 2013 Aug;26(4):360–7. PubMed 23823463 ❐ PainSci Bibliography 53165 ❐

    The gist of this complex paper is that the brain’s anatomic and functional properties predict development of chronic pain, and correlate with emotional state. It’s not necessarily correct, but it’s certainly interesting! It’s important to note that Apkarian is associated with some other particularly bad research (see Vachon-Presseau 2018).

    As always, Todd Hargrove does an admirable job explaining research like this: see "To Predict Chronic Pain, Look to the Brain."

  41. These are truly effective drugs, but that also makes them dangerous: the risk of addiction is real, and withdrawal can be a devastating experience (think “anxiety on steroids”). The only truly safe way to use benzos is temporarily. For much more information, see A Story of Benzodiazepine Withdrawal Gone Horribly Wrong.
  42. As of 2023, my impression is the mind probably cannot "create" pain. But it’s complicated, I do not know, and I am not done exploring the topic (and may never be). The mind can certainly harm us in ways that lead to pain in time, and it might be able to amplify pain, but so far I have be unable to find any clear evidence that the mind can generate pain from nothing, with no injury or pathology at all. And there seem to be many reasons to suspect that it either isn’t possible, or it’s rather rare and only associated with relatively glaring mental illness.
  43. Collins, Sean T. "[Why music gives you the chills](". BuzzFeed. September 10, 2012. Retrieved Jul 2, 2021.
  44. Stephens R, Atkins J, Kingston A. Swearing as a response to pain. Neuroreport. 2009 Aug;20(12):1056–60. PubMed 19590391 ❐
  45. Intense exercise can be cathartic, of course, but the idea here is to explore more direct expressions of emotion, not just generally being intense. Also, vigorous exercise simply isn’t a good option for many chronic pain patients, or would feel much more like a direct confrontation with painful limits.
  46. Obviously bracing a knee with a ruptured ligament is a different case, and straighforward. Similarly, you can certainly tape up a sprained ankle for pure stability — not a sensory effect. But bracing is often prescribed for much less clear reasons, and taping gets even weirder, like the absurd colourful tape that was so faddish in the 2011 Summer Olympics. These approaches to rehab often have wildly speculative rationales, when most likely they are all just creative ways of changing sensation.
  47. An analogy: perception resists change like a gyroscope resists changes to its axis. Biology and perception are intensely regulated homeostatic systems with extensive “normalization” mechanisms, checks and balances that kick in like reflexes. Our state has “momentum” — a fairly strong tendency to carry on in the same direction. It is possible to change that momentum, but complex systems are generally resistant to minor inputs. We can’t have biology and perception spinning out of control every time they get nudged!
  48. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965 Nov;150(3699):971–9. PubMed 5320816 ❐

    This is Melzack and Wall’s seminal paper arguing that (emphasis mine) “pain perception and response is triggered after the cutaneous sensory input has been modulated by both sensory feedback mechanisms and the influences of the central nervous system. We propose that the abstraction of information at the first synapse may mark only the beginning of a continuing selection and filtering of the input.” Among other things, this is the paper that described the mechanism of gate control and ultimately gave rise to the highly influential concept of the neuromatrix (Melzack).

  49. Melzack R. From the gate to the neuromatrix. Pain. 1999 Aug;Suppl 6:S121–6. PubMed 10491980 ❐
  50. Melzack R. Myofascial trigger points: relation to acupuncture and mechanisms of pain. Arch Phys Med Rehabil. 1981 Mar;62(3):114–7. PubMed 6972204 ❐
  51. The fear of talcum power causing cancer has been greatly overstated. However, there are several alternatives, all from the grocery store: cornstarch, baking soda, tapioca starch, arrowroot starch, rich starch, and oat flour.
  52. This is due to contextual effects, which probably explain we can’t tickle ourselves: tickle is a kind of threat, and you can’t threaten yourself. Your brain knows what you are up to before you do, so you can’t surprise or deceive it. When a sensation is produced by someone else, however, no matter how much you trust them, your brain pays much closer attention. Just in case. But with a trusted partner, there’s a happy middle zone where the sensations are “interesting” and vivid, even deliciously so… but not “threatening.”
  53. Hargrove 2017, op. cit. I’m paraphrasing and riffing off of Todd’s thinking here — almost just a synposis of his idea, really.
  54. For instance, the “be kind to your nervous system” advice could also be described as using the “pleasure module” to tame the pain module. And the advice to “create new social contexts”? That’s leveraging the “social module” — the particularly huge subdivision of our neurology dedicated to social interactions.
  55. Carney DR, Cuddy AJC, Yap AJ. Power posing: brief nonverbal displays affect neuroendocrine levels and risk tolerance. Psychol Sci. 2010 Oct;21(10):1363–8. PubMed 20855902 ❐

    This famous paper presents the original evidence that “power posing” will not only make people feel more powerful but also cause some hormonal changes: more testosterone, less cortistol (stress hormone). This was the inspiration for one of the most popular TED talks of all time, and subsequent studies conspicuously failed to replicate their results. There probably is a power-pose effect, just not a dramatic one (see Gronau 2017).

    (See more detailed commentary on this paper.)

  56. Quentin F. Gronau, Sara Van Erp, Daniel W. Heck, et al. A Bayesian model-averaged meta-analysis of the power pose effect with informed and default priors: the case of felt power. Comprehensive Results in Social Psychology. 2017;2(1):123–138. PainSci Bibliography 53062 ❐

    Carney et al infamously reported that “power poses” not only made people feel more powerful and daring, but that they had a biological fingerprint: more testosterone and less cortisol (stress hormone). And then the trouble started: “these power pose effects have recently come under considerable scrutiny,” which is a bit of an understatement: there have always been strong concerns about both the science itself and the way it was presented (premature hype).

    This meta-analysis took a crack at producing the “last word” on this topic. It was part of a special edition of Comprehensive Results in Social Psychology, in which Carney herself was deeply involved (see CRSP special issue on power poses: what was the point and what did we learn?). It concluded that follow-up evidence for the original finding was “very strong,” and yet with a spectacular hold-your-horses caveat: “when the analysis is restricted to participants unfamiliar with the effect, the meta-analysis yields evidence that is only moderate.”

    Translation: belief in the power of power posing will make you feel more powerful than power posing itself! Expectations seem to be the more potent active ingredient.

    “Expansive postures” probably do make people feel more powerful … but only a little. Unless you believe in them, in which case you’re really off to the races. Which is fine. (“Why not both?”)

  57. Bohns V, Wiltermuth S. It hurts when I do this (or you do that): Posture and pain tolerance. Journal of Experimental Social Psychology. 2012 Jan;48(1):341–345. PainSci Bibliography 54508 ❐
  58. Ruiz-Aranda D, Salguero JM, Fernández-Berrocal P. Emotional Regulation and Acute Pain Perception in Women. J Pain. 2010 Jun;11(6):564–569. PubMed 20015703 ❐ Two groups of women were tested for pain tolerance with the traditional, unpleasant method (immersion of the hands in ice water). One group was rated with better emotional coping skills, and (predictably) they were more tolerant of pain than women with poorer coping skills.
  59. White B, Sanders SH. The influence on patients' pain intensity ratings of antecedent reinforcement of pain talk or well talk. J Behav Ther Exp Psychiatry. 1986 Sep;17(3):155–9. PubMed 3760222 ❐


    This study sought to determine whether positive verbal reinforcement for pain talk or well talk could effectively influence chronic pain patients' subsequent ratings of pain intensity. Four female chronic pain inpatients were each exposed over seven consecutive days to two conditions within an alternating treatments design. Inter-rater reliability analysis from the audiotapes on occurrences of pain and well talk, verbal reinforcement and appropriate reinforcement of verbal behavior across conditions resulted in agreement values from 91 to 100%. Findings revealed that subjects' pain intensity ratings were consistently and significantly lower after verbally reinforcing well talk compared with verbally reinforcing pain talk.

  60. SDR is indeed superficially similar to Eye Movement Desensitization and Reprocessing, Emotional Freedom Technique, and Neuro-Linguistic Programming — all notoriously dubious psychotherapeutic modalities that skeptics have been warning people about for a long time. But it really not the same thing.
  61. Williams ACd, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2020 Aug;8:CD007407. PubMed 32794606 ❐
  62. [Internet]. Williams A. Managing chronic pain in adults: the latest evidence on psychological therapies; 2020 October 8 [cited 20 Oct 8]. PainSci Bibliography 51870 ❐


linking guide

22,000 words

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