Many people are justifiably cynical about the power of the mind to treat chronic pain. Meanwhile, millions of others carry on optimistically trying to treat pain with psychology in many, many ways, from cognitive behavioural therapy to placebo. This March, I got fascinated just trying to list all of them — about three dozen and counting — and then by trying to classify them in some way.
Today I’m sharing my work-in-progress, the taxonomy of Jedi pain tricks. All of this is preparation for adding more about these topics to PainScience.com, especially meditation/mindfulness (a glaring omission from my library of articles).
So I will give you a big list of mind-over-pain treatment ideas: all the psychological, perceptual, mental approaches to treating pain — good or bad, popular or obscure, practical or exotic. Everything you can do to try to treat pain like it’s a problem that either comes from by whatever’s between your ears, or at least tamed by it.
I will also offer a way to organize and critically assess all those ideas: the four main ways to treat pain, a way to start making sense of this mighty mess of claims.
Because, make no mistake, it is a mess. In fact, every single one of these treatments is experimental. It is a rogues’ gallery of highly speculative methods, supported by scientific evidence that is incomplete and/or unimpressive at best.
Why a list, exactly?
I probably should have titled this post “36 Ways to Treat Pain With the Spooky Power of Your Mind!!!” But that is not my style. I am more of a “guy who likes spreadsheets” than a “guy trying to sell ad views on a blog.” So you just get a simple list.
As I tried to tackle some awkward scientific questions about deep breathing and relaxation — stay tuned for more on that — I kept getting sucked into related sub-topics: psychotherapy, biofeedback, placebo, mirrors, virtual reality, repressed anger, Sarno! There’s a prominent new paper about Pain Reprocessing Therapy that I really need to write about — a mind-over-pain modality that got a huge boost from a maybe-too-good-to-be-true study recently (see Ashar).
It was getting bewildering! I decided it was time for a major reboot of all these related and overlapping topics, but you cannot reboot what you cannot even define. What is this category? What defines it and what’s in it? Where are the edges?
Just listing turned into a project in itself. I asked folks on Facebook for ideas, and the response was overwhelming, dozens of comments ranging from the useful to the bizarre to the angry. Some people objected to the question itself. Many were concerned that I was endorsing these treatments, because they regard them all as quackery — or the opposite!
But I just wanted to list them.
“Mind over pain”?
There are many possible and overlapping meanings of “mind over pain,” and it’s not clear that those words are the best way to label this category — but it’s the best I’ve come up with so far. They all have something do with the role the mind in helping people with pain.
I’ve provided links wherever I have related articles that cover these topics to some degree. (There aren’t many, and that’s partly why I am doing this — so I can decide what to write more about!)
The List: all the approaches to mind-over-pain
This list is very roughly in order of “importance” (popularity, mainstream acceptance, and scientific plausibility).
- Mainstream psychotherapeutic approaches, primarily cognitive behavioural therapy (CBT), behavioural therapy (BT), and acceptance and commitment therapy (ACT). Notably, these are mainly about helping patients cope with pain — but there’s also a hope that they could blunt pain more directly via other mind-over-pain mechanisms.
- Psychotherapy is much bigger than CBT, BT, and ACT, of course. For instance, there are many kinds of care for other mental health problems that can drive pain: anxiety, depression, addiction, insomnia. And so this must also include complex pharmacotherapy with psychological goals (but especially anxiolytics and anti-depressants). The idea that pain is caused by “repressed” emotions is so prevalent that it also belongs here: another popular psychotherapeutic goal.
- Problem solving and goal setting, often the focus of occupational therapy, are also focused on coping and function rather than reducing pain directly — but, again, the hope is that there are many spin-off benefits.
- Lifestyle medicine — the pursuit of overall health and fitness — may be relevant to pain (by reducing biological vulnerability) and may require extensive psychological work, even a major mental makeover. This is mostly an unbranded, improvisational, self-help strategy with a very roundabout mechanism of action: changing your mind to improve your health to reduce your pain. And yet millions of people do exactly and mainly this.
- Meditation/mindfulness, breathing exercises of many kinds (but mostly either “slow” or “fast” approaches), relaxation, and stress reduction. All of these are similar and closely related, and yet distinct. For instance, meditation is not just a breathing exercise.
- Smartphone apps — like Curable, Pathways, and Ouchie — are now a major delivery system for many of these approaches to pain. They are so popular that deserve their own spot on the list.
- Cannabis (THC) is not usually thought of primarily as a “mind” treatment, but that is probably how we should think about it: to the extent that it helps anyone with pain, its psychoactive effects are the most plausible active ingredient. This is more obvious in the case of psilocybin and LSD, more trendy new ways of trying to treat pain (especially when it is suspected of being tangled up with other mental issues, especially trauma).
- The major branded mind-body medicine approaches like Sarno’s “mind over back pain,” and Schubiner’s Pain Reprocessing Therapy. The controversial Rehabilitation for Amplified Pain Syndromes (RAPS) Program (and many others it has inspired) is extremely physical, but arguably it’s almost entirely about the psychology. There are other gurus and brands of this type, of course, but these are the only major ones I can think of that are particularly focused on pain.
- Knowledge is power. If the mind has power over pain, maybe the source of that power is knowledge: simple education, fancier pain neuroscience education (best by exemplified by Explain Pain), and rational confidence building (what I started calling “the confidence cure” about a decade ago, discussed at length in my back pain book).
- Neuropsychological “hacks”: virtual reality, mirror therapy, hypnotherapy, biofeedback, EMDR. I discuss several of these in Mind Over Pain (though not enough). Then there’s placebo, which can be further subdivided: (1) good old fashioned fooling people with sugar pills and saline injections and so on; (2) the trendy idea of “open-label” placebo (“this is a sugar pill but it will cure you because placebo is amazing”); and (3) the important concept of sensation-enhanced placebo (which powers most manual therapy).
- Distraction, pursuit of pleasure and happiness, catharsis or “venting,” philosophy and spirituality, art therapy (music, writing, dance, painting, etc). I don’t know what to call this subcategory, but much of it is under the umbrella of general personal growth: all the many ways that people try to get wiser, casting a very wide psychological net that might catch some pain relief.
- There are some therapies that involve some physicality or sensory input, but the active ingredient is probably mostly emotional/psychological. Gentle massage, touch therapy and spa treatments are the only real contenders here, but there are much more obscure ones that exemplify the idea, like cuddle therapy (yes, actually a thing). RAPS (mentioned above) is another weird example of a treatment that looks physical, but the point is psychological.
- Treating pain as a conditioned behaviour is a specific hypothesis. There are not only some clues that pain might work this way but also that it might be possible to disrupt that conditioning (in a very neuro-hack way). While not a popular idea, or an easy one to apply, it is super interesting.
- Amnesia. There are some clues that pain can literally be forgotten, that amnesia might actually cure some kinds of pain. Inducing amnesia is obviously not a treatment anyone is actually using for chronic pain, nor is even a confirmed phenomenon. (But, if it was confirmed, it would be a fascinating validation of some basic mind-over-pain principles.)
Phew! That’s really a lot of overlapping ideas. In the next section, I will try to impose some order — a meaningful way to categorize these kinds of interventions, into four major types of pain treatment.
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Part II: The four pillars of pain
This is a framework for thinking about pain treatments that I have been musing about for ages. It isn’t specific to mind-over-pain treatments — it can be applied to any kind of pain treatment — but it finally spilled out on my keyboard last week as I tried to wrap my head around that bewildering list.
Every pain treatment is trying to do one or more of these four things:
- remove the cause
- reduce the sensation
- tinker with perception
- mitigate the suffering
It’s impossible to talk about any of those without considering the others. One of the best examples: if the cause of pain is mostly dysfunctional perception, then changing the perception would effectively remove its own cause! 🤯 Which sounds like the holy grail of pain management. And that is why it’s the focus of my Mind Over Pain article. And it’s a good example of 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 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!)
Just a reminder that I am mostly avoiding endorsement (or condemnation) of these ideas for now: I’m just talking about what people hope and believe.
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:
- Sensation is probably modulated by systemic inflammation.
- 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.
- 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.