Body/Mind Approaches for Treating the Complex Chronic Pain Patient

In 2011, the Institute of Medicine (1) reported that 100 million Americans, or almost one-third of the population, are affected by chronic pain.  Half that number, or 50 million people, experience severe or daily pain, with increased debility and costs to the health care system (2).  Chronic pain is persistent pain, continuing after an injury heals, or emerging in the absence of an apparent injury (3).  And so, a significant minority of our patients experience chronic pain, as well as the impairment in daily functioning, sleep and psychological and social well-being that accompanies it.

The disparaging comment that patients (rightly) dread is, “It’s all in your head,” is no less inaccurate than the more acceptable idea that pain is a strictly body-based phenomenon.  Chronic pain is a body-mind phenomenon, and current research on the theory of Central Sensitization elucidates the mechanisms by which chronic pain emerges (4).  Data supporting Central Sensitization suggests that chronic pain results from three types of changes in the central nervous system:  Sensitization of pain circuits, generalization of pain to non-pain circuits, and failure of inhibitory pathways to dampen pain.  Central Sensitization can occur after a single injury, repeated injury, or even no apparent injury to the body.  Sensitization of central nervous system pain circuits mean that mild or even benign stimuli (e.g., a gust of wind across the cheek of a Trigeminal neuralgia patient) produce pain.  Further, non-pain-related central nervous system circuits (e.g., those that carry temperature signals between brain and body) get “hijacked” into the pain system, generalizing, and thus enhancing, the pain experience.  Finally, central nervous system pathways from brain to body that inhibit pain fail to work effectively, creating another avenue by which pain is intensified. Interestingly, Central Sensitization is being explored as the common underpinning for seemingly diverse conditions such as chronic pain, irritable bowel syndrome, and PTSD. 

Complicating matters further, a past history of psychological trauma or adverse experiences, particularly in childhood, is correlated with an increased likelihood of developing a variety of chronic medical conditions, including chronic pain (5).  Autonomic system sensitization and dysregulation often accompanies trauma (6), manifesting as a hypervigilant, or sympathetically activated, state; a disconnected, or parasympathetically activated, state; or most often, a distressing swing back and forth between the two.  The body is tense, numb, or even both at the same time, contributing to pain through muscle tension, poor sleep, and a limited ability to discern the effects of pace or type of behavior on the body’s well-being. 

In the past, psychologists have focused on helping chronic pain patients learn to cope with pain.  Mind-body approaches grounded in the research regarding the psychophysiology of pain and trauma allow us to contribute meaningfully to multi-disciplinary efforts to decrease patients’ pain.  Since patients with trauma histories and chronic pain have difficulty with foundational mind-body regulation, they are often too over- or under-stimulated to effectively use cognitive and behavioral strategies, despite their sincere desire to do so. In order to help them, we need a “bottom up” approach emphasizing experience before analysis, sensing before cognition.  Given the power of adaptive attachment to facilitate autonomic re-regulation, it is also very important for clinicians to cultivate the “right-brain to right-brain” aspects of the therapeutic relationship (7).  These are primarily non-verbal expressions of interest and care toward the patient, for instance, the ability to convey sincere understanding and compassion for the patient’s feelings or impressions before attempting to modulate patient experiences.  With a foundation of an attachment-informed approach to treatment, the primary goal of a psychophysiological approach to treatment of chronic pain is to facilitate experiences that enable awareness, tolerance, and modulation of the dysregulated mind-body to help decrease pain, decrease distress, and improve functioning.

Strategies to facilitate healing take advantage of moment-to-moment dysregulation in the patient to be curious about where it is and what it feels like.  Easy though the idea of noticing is for patients to understand, it is often a fairly foreign experience, so repeated practice is essential.  Tools that enable patients to stay with or tolerate noticing are essential to enabling a more nuanced and realistic appraisal of what they are experiencing.  These tools emphasizing toggling between a painful area and a neutral place in the body or environment.  Unlike distraction techniques, which, if relied upon, actually contribute to pain chronicity, toggling is a way of modulating distress which concludes only after the patient notices even a small decrease in discomfort in the painful area.  Not only is this more comfortable in the moment, but with repetition, toggling diminishes the anticipatory anxiety/autonomic system dysregulation that body awareness tends to induce in the complex chronic pain patient. 

Awareness of the body/mind is the patient’s self-assessment tool, the jumping off point for exploring “what’s needed for my comfort?”  (Assuming that patients’ medical providers have addressed their diagnostic questions, we want to encourage a focus away from “why?”, where many of our patients can get stuck, and onto “what’s needed?”).  This is where modulation strategies come into play.  We explore possibilities for comfort, including observing patient’s automatically massaging a stiff neck as they become aware of it, exploring a soothing exercise they are learning in physical therapy, or practicing relaxed breathing again.  We invite patients to therapeutically daydream about what their body needs in the moment, regardless of whether it is available or doable; and then we “drill down” until some aspect of that desire feels possible.  For instance, a daydream of comfort involving a tropical beach may lead to a plan to use a heating pad and inviting the body to release instead of immediately getting to work on dinner upon their return home from work each day.  

Facilitating healing in complex chronic pain patients requires us to understand the psychophysiology of pain, of trauma, and of the power of adaptive attachment relationships to enable a re-regulation of the mind-body.  We identify strategies that enable awareness, tolerance and modulation of the system to decrease painful swings between hypervigilance and disconnection, and to enable more “comfortable enough” experiences in their lives.  Perhaps most importantly, facilitating healing in complex chronic pain patients challenges us to recognize that small, and not-so-small, experiences of comfort in and out of the therapy room are the foundation of healing and adaptive change.  

Suzanne Candell, Ph.D., LP, is a Clinical Psychologist whose approach to treatment is grounded in the science of psychophysiology, the neurobiology of attachment, and psychoneuroimmunology.  She has a particular expertise in addressing the complicating effects of psychological trauma on physical health.  This article is based on her presentation of the same name at the 2016 MPA Annual Convention.


  1. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press (US); 2011. 1, Introduction. Available from:

  2. Richard L. Nahin. Estimates of Pain Prevalence and Severity in Adults: United States, 2012. The Journal of Pain, 2015; 16 (8): 769 DOI: 10.1016/j.jpain.2015.05.002

  3. National Institute of Neurological Disorders and Stroke.  NINDS Chronic Pain Information Page.

  4. Woolf, C.J. (2011).  Central sensitization: Implications for the diagnosis and treatment of pain.  Pain, 152 (3 Suppl); S2–15. (Also, see Paul Ingraham’s “jargon to English” translation of key aspects of this theory at

  5. Davis, D.A., Luecken, L.J., Zautra, A.J. (2005).  Are reports of childhood abuse related to the experience of chronic pain in adulthood? A meta-analytic review of the literature.  Clinical Journal of Pain, 21(5):398-405.

  6. van der Kolk (2003), The neurobiology of trauma and abuse.  Child and Adolescent Psychiatric Clinics,12; 293 - 317.

  7. Schore, A.N. (2003).  Affect Regulation and the Repair of the Self. New York, Norton. 


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