Is the Pain All in My Head?

A new treatment called pain-reprocessing therapy promises to cure chronic pain. But maybe not for everyone.

Photo-Illustration: The Cut
Photo-Illustration: The Cut

For as long as I can remember, I’ve been in pain. It started with my jaw, which ached even in elementary school. My dentist thought braces might fix the problem, but all I got was a $10,000 smile and green bruises below my cheekbones. In adolescence, my right knee had a nasty habit of dislocating — at home, at school, and once in the middle of downward dog. As I got older, the pain pushed up like a storm front, where it still thunders between my shoulder blades. Today, my doctor suspects I have hypermobility, likely because of an underlying connective-tissue disorder. I’ve tried everything to alleviate the pain — physical therapy, psychotherapy, massage therapy — and found at most intermittent relief.

So when I heard Alan Gordon’s controversial claim that he has found a cure for chronic pain, I was intrigued. The 40-something psychotherapist’s signature technique, pain-reprocessing therapy, is deceptively simple: Help a person reframe the source of their suffering, and it will go away. “Pain is an opinion,” Gordon, whose recent book promises The Way Out, recently told me. “It’s your brain’s opinion of what’s going on in your body.” All you have to do is get rid of the old idea that your pain stems from nerve or tissue damage and replace it with a new one — in this case, that the pain is in your brain.

The Way Out, which was released in August, has received celebrity endorsements from Jared Leto, B.J. Novak, and Mayim Bialik. It has already been translated into nine languages. Based on hundreds of glowing Amazon and Goodreads reviews, Gordon says researchers at the University of Southern California, where he is an adjunct professor, plan to study whether reading the book is itself a treatment for pain. It’s all just a part of spreading the good news: “There’s 50 million people in this country in chronic pain,” Gordon says, “and probably 40 million don’t have to be.” Is he right?

Receiving a physical diagnosis helped me, like many pain patients, put my pain into perspective. When a doctor first suggested that a single disorder could account for all my many symptoms, I felt the rush of expert reassurance. That’s what makes Gordon’s confidence that chronic-pain patients could throw out their hard-won self-knowledge and start over with pain-reprocessing therapy so unsettling even if a fix awaits us on the other side.

Still, the possibility is tantalizing. Pain patients have a long and complicated history with psychotherapy stretching back more than a century. Today, many end up in cognitive behavioral therapy, or CBT, which often feels like nothing more than a Band-Aid on the bigger issue. Pain-reprocessing therapy, by contrast, is one of the only psychological treatments known to cure pain — at least in some patients with nociplastic pain, or pain that occurs in the absence of obvious physical damage. “That’s one of the unique things about the people that respond to this therapy,” says Daniel Clauw, a professor of anesthesiology, rheumatology, and psychiatry at the University of Michigan, “which is why I think it should be offered to anyone for whom this might work.”

In pain-reprocessing therapy, therapists start with reeducating patients about the source of pain, usually with personalized evidence from their medical history. Gordon believes that most physical findings, from CT scans of degenerated disks to symptoms of hypermobility, are incidental. If they really caused pain, he asks, why do most people show some signs of wear and tear but only some of us suffer from it? If the patient accepts this premise, the therapist works to help their client reframe pain sensations as harmless and refocus their attention on more positive feelings. In a recent trial, 66 percent of research participants with chronic low-back pain were almost or completely pain free after eight sessions with Gordon, an almost unheard-of success rate in a field still mired in mystery. Clauw thinks it’s an overestimate.

In most studies of emotional-awareness and expression therapy, another psychological treatment for pain that researchers began testing in the early aughts, a much smaller fraction of patients — around 20 percent in one trial of people with fibromyalgia — reported a significant reduction in their pain. That’s on par with just about every pain-management tool including opioids, antidepressant and anti-seizure medications, meditation and mindfulness therapies, massage and physical therapy, and more. A fraction of people find significant relief with any given treatment, while others soldier on. Gordon’s pain-reprocessing therapy may really be an outlier, helping more patients than any other method, but only further research will prove it.

The allure of a psychotherapeutic solution for pain remains strong, especially in an anti-opioid culture and a post-Sackler world. While Gordon’s results make a strong case for his methods, pain-reprocessing therapy won’t cure every patient — and his suggestion that it could might hurt those it leaves behind. “You don’t conflate the fact that a subset of people will respond really well to this type of therapy” with the idea that “it works for everyone,” Clauw says.

Acute pain is a universal human experience, but chronic pain — obliquely defined as pain that lasts longer than should be expected from the initial injury — defies the supposed boundaries between sickness and health, the mind and the body, often with startling results. Where Aristotle thought pain was an emotion (like happiness or sadness) and René Descartes saw it as a sensation (like hot or cold), chronic pain today looks a lot like an identity, a defining way of moving through the world. But those who share the label often have little else in common as chronic pain is associated with everything from low-back pain, arthritis, headaches, and migraine to multiple sclerosis, fibromyalgia, post-viral syndrome, nerve damage, and genetic disorders.

For centuries, faulty assumptions about the nature of pain have bred contempt between chronic-pain patients and the psychotherapists who are supposed to support them. Western cultures have long been obsessed with the idea of other people malingering, says Daniel Goldberg, a public-health ethicist at the University of Colorado. This fixation on separating “real” suffering from “fake” has led doctors, psychotherapists, policymakers, and even friends and family to dismiss the reality of others’ chronic pain, especially when it has afflicted women, children, the elderly, the poor, and people of color. In the early 20th century, Sigmund Freud argued chronic pain was real — but only because women “converted” their psychological trauma, namely sexual abuse, into bodily symptoms (an idea that is regaining ground today in best sellers such as The Body Keeps the Score). Later, psychoanalysts proposed that chronic-pain patients were unconsciously motivated by supposed “secondary gains” — the “personal advantages” of sickness that contributed to a “patient’s choice to remain in the sick role.”

The result is patients get tossed around by specialists, denied pain-relieving medications, and feel routinely invalidated in their suffering. “The majority of patients who have made it to my office have been discarded by the medical system,” says Johnathan Goree, director of the chronic-pain division at the University of Arkansas for Medical Sciences. “They have been told that whatever is wrong with them can’t be fixed.” Patients often see their conditions worsen in the absence of effective treatment. In the case of Goree’s speciality, complex regional pain syndrome, patients can be effectively treated if the condition is identified early. But without intervention in the form of physical therapy, medication, or spinal-cord stimulation, the syndrome can become permanently disabling.

Many people with chronic pain end up in CBT either for the pain or for its cascading consequences on their lives. There, they learn skills for regulating the emotional experience of pain, including mindfulness and distraction. Many patients are glad to have such tools, broadly referred to as “distress tolerance,” and some report a reduction in their day-to-day pain as a result. But others have called CBT’s emphasis on changing the way they think about their pain — instead of treating the pain itself — as beside the point or as full-blown “medical gaslighting.” Aaron Beck, the so-called father of CBT, acknowledged its shortcomings in this arena: “At long last,” he wrote in his endorsement of The Way Out, “a successful treatment for chronic, disabling pain.”

Chronic-pain patients have a growing body of evidence to support their lived experience. In 2017, the International Association for the Study of Pain carved out a third category of pain: nociplastic. In addition to pain caused by tissue damage and nerve damage, doctors now recognize that some pain comes from changes to the central nervous system. It often begins with physical damage, but even as the injury heals, the pain can linger, becoming chronic, widespread, and unusually intense.

The trouble comes when the latest advances in pain science are plugged into a skeptical culture steeped in outdated theories of the mind. If the current conception of nociplastic pain is correct that it results from a hyperattunement of the nerves, spinal cord, and brain to pain signals, that can sound a lot like pain being “all in your head” — doubly so if it can be cured by psychotherapy. There is a kernel of truth here: Our emotions can amplify our pain, and pain can in turn lead to depression, anxiety, and other mental-health issues. But these attitudes often end up serving as further ammunition for the noxious idea that people dealing with difficult diseases are in fact just difficult patients.

Dana Wynne Lindquist has navigated the stigma of chronic pain for almost 30 years. It started in 1994 with the birth of her daughter. “I had a horrific delivery,” Lindquist told me from her home in North Carolina. The pain began in her pelvis and spread from there. In the years since, “I have had many really serious things missed by doctors,” Lindquist says. Today, she has two diagnoses: ME/CFS, better known as chronic-fatigue syndrome, which has no known cure, and mixed connective-tissue disease, an autoimmune disorder that can be treated with immunosuppressants. In 2020, Lindquist started hydroxychloroquine, which has eliminated the swelling in her fingers and the joint pain in her hands. While previous stints in cognitive behavioral therapy helped her learn how to manage the anxiety of navigating an impersonal health-care system, Lindquist says a physical diagnosis was just as important.

Lindquist and I have markedly different conditions, but I know the pain of invalidation well. By the time I was in my late teens, doctors had dismissed me for so long I stopped sharing. I’d been in and out of therapy for the better part of a decade, but it never occurred to me to talk to people paid to deal with my anxiety about the physical symptoms compounding it. And then in my early 20s, I found not a way out but a way forward.

For Deborah Barrett, the pain started one day in June 1994, as she was weeks away from finishing her Ph.D. in sociology at Stanford University. A burning sensation started in her arms and swept across her body. Instead of continuing with a planned postdoctoral fellowship, she withdrew to her parents’ home in Pennsylvania. Eventually, she pursued a diagnosis — fibromyalgia — and found a new calling in psychotherapy.

While Barrett, 56, didn’t intend to focus her career on chronic-pain patients, she found a glaringly unmet need. Instead of CBT, Barrett had begun to practice dialectical behavioral therapy, or DBT, which psychologist Marsha Linehan developed in the 1980s for people with suicidal or other self-destructive thoughts or behaviors. Linehan found that her patients didn’t respond well to behavioral therapy (saying they should simply change their thoughts implied something was wrong with them) or to acceptance (agreeing that their lives were totally miserable suggested they could never improve). That led Linehan to the idea of a dialectic, or holding two contradictory truths in hand at the same time and working to find a synthesis. Clients plow through workbooks on mindfulness and attend group skills-training sessions to retool coping mechanisms, but the desired outcome can be summed up with a mantra from improv: “Yes and.” If pain-reprocessing therapy contends there’s just one answer for nociplastic pain (it’s in your brain), DBT suggests suffering exists in the mind and the body.

DBT may sound like common sense, but Linehan’s model offered a major revolution in psychotherapy. In 2013, Barrett, a clinical associate professor in social work and psychiatry at the University of North Carolina, Chapel Hill, started a skills group for people with chronic pain and shared the dialectical perspective with them. They were people with pain and they had what Barrett calls “capacity,” or the ability to act in some way in the world. Today, Barrett calls this method dialectical pain management. It remains niche; though Barrett has published one paper on the topic, she is mostly focused on running her small-group meetings. But Barrett believes everyone could benefit from asking themselves “What’s a life worth living?” and pursuing their values even in the face of obstacles.

Unlike pain-reprocessing therapy, dialectical pain management doesn’t promise to cure anybody’s pain, but it can ease suffering, says Rita Svetlova, one of Barrett’s group members. “What makes pain really painful is our perception of it,” Svetlova, who has a heart condition and chronic low-back pain, told me. When pain is purposeful (like in childbirth) or has a clear expiration date (like a broken arm), it’s easier to endure. In the case of chronic pain, which feels both endless and purposeless, people must make meaning for themselves.

I learned about DBT and its applications for pain in 2018, when I had the bright idea to contact a psychotherapist in New York City with a hypermobility disorder like mine. For the first time, I had someone who would listen and empathize with my constant physical discomfort but also push me to reduce pain wherever possible. Some of her suggestions were obvious (get a better desk chair) but others (you don’t have to go back to a doctor who doesn’t listen to you) pushed a 180-degree rotation in my perspective. In every session, she modeled this kind of audacious self-care, pausing our conversation to make an adjustment to her own seating arrangement or Zooming in from bed as she recovered from surgery. I began to cultivate that kind of confidence in myself.

Which brings me back to Gordon. When I called him for the first time last fall, while reporting this story, he told me his chronic-pain story, and I told him mine. Gordon was in graduate school when a pain in his upper back spread throughout his body and stuck around for years. He got every diagnosis in the world, but no medical treatments seemed to help until a book by the pain guru Dr. John Sarno inspired him to shift his mentality. The reason nothing seemed to work, Gordon decided, was because his pain wasn’t in his back or his leg — it was in his brain. He wanted to share his techniques with others and free them from their suffering.

And then, in the last moments of our interview, Gordon caught me off guard: My pain is almost certainly nociplastic, he told me, not actual ongoing damage from any physical disorder. He had once been wrongly diagnosed with hypermobility, he said. If I was open to it, pain-reprocessing therapy would almost certainly cure me too.

I thanked Gordon and hung up, but I felt fear and rage coursing through my body — and a pounding headache forming just below my prickling scalp. Was this really all in my head? No, I told myself, desperately trying to slow my pulse. But, I thought in the spirit of the dialectic, also maybe yes. For in truth, I do think my pain is nociplastic, and I am open to trying pain-reprocessing therapy to fix it. In the past few weeks, just sitting with Gordon’s ideas has allowed me, at times, to notice stressors in my work and life that would normally erupt into pain and to stop them before they start. But I would never have even gotten this far if I hadn’t learned to take my own suffering seriously — and to ask the same of others.

Is the Pain All in My Head?