It’s always both: why pain is never just in your head

If you live with chronic pain, there’s a good chance you’ve been told at some point that it’s just in your head. Maybe someone well meaning has suggested that ignoring it or telling the pain it’s not real will make it go away. It’s possible that there’s some part of you that believes these things to be true: there is a scientific basis for this case, after all. But there’s also probably some part of you that suspects it’s not the whole story.

It isn’t.

Pain science has changed rapidly in the past decade, and medicine is catching up. Here’s what we know: pain is an experience that is interpreted through your brain. Neuroscience shows us that the brain integrates signals from the body with past experience, emotional context, and perceived threat, and produces pain as a protective response–not as a direct measure of tissue damage.

None of this suggests that your body is not also involved in the chronic pain cycle. Unfortunately, there’s a trend among those who work with pain right now to frame pain as being exclusively an output of the brain, without acknowledging that it’s also an input from the body.

I have a PhD from UCSF in medical sociology studying neuroscientific interventions in chronic pain. I spent twelve years as a clinical bodyworker, guiding people towards regaining trust in their bodies. I’ve also lived with—and found resolution for—my own chronic pain. I’ve worked with people in pain in one capacity or another for over 20 years, and have watched as medical explanations for pain have changed, and then changed again.

Many people I work with can take a look at their bodies–their physical structure–and see some evidence of their pain. Postural imbalances, inflammation, weakened musculature, or perpetually hyper-toned (ie, tight) areas of the body.

And even those who can’t see physical traces of their pain in their bodies have often been given a biological explanation for why their pain persists. They were told that they lost the genetic lottery and have some condition that keeps flaring up and making them hurt, or that they were born with structural imbalances that will persist throughout their lives. Maybe they’ve seen imaging to account for this (more on imaging at a later date).

Imagine, then, how confusing it can be when a clinician who’s usually very expert and often quite kind later tells them that their pain is occurring entirely in their brains. It can get pretty existential, and a lot of the work I do with clients is unraveling the shock and disorientation of this new explanation of their pain.

Here’s the thing: it’s always both. Your pain is a conversation between your brain and your body (we could get really philosophical here and talk about how the two are actually one and the same). Your brain is involved, and your body is involved, and there are multiple other factors that are also involved in how you experience pain (cultural scripts, your emotional landscape, your social roles and interpersonal relationships—the list goes on).

Your doctor or physical therapist or surgeon or specialist is not lying to you when they say your pain is in your head–to some extent, everything we experience is a product of our brain’s interpretation. They’re just oversimplifying the explanation, which is also not their fault. Oversimplification is just what medicine does. Like it or not, we’re all constrained within a system that flattens complexity in favor of clinical efficiency.

For my PhD, I studied how explanations of pain change over time and why–and how these changes trickle out into our culture. The party line about pain and its treatment has changed dramatically for decades now–many (including myself!) have written extensively about the pendulum swing of pain policy within medicine. Doctors get stuck with the bag when the conversation around pain changes, and patients are often left reeling with conflicting diagnoses and confusing ways of making sense of what’s happening with their pain.

We saw what happened with rapid shifts in pain policy in the early 2000s when opioids were being prescribed at high rates, and then we again observed what happened in the mid 2010s when the tide turned and patients were pulled off of opioids with no comparable replacement. Everyone suffered under those pendulum swings–doctors and patients alike.

Today, pain is typically being managed through psychosocial interventions rooted in neuroscience and pain psychology. These tools can be tremendously effective: I draw on a lot of them in my own practice. Changing how we relate to painful sensations has a tremendous effect on how we experience those sensations. I’m personally thrilled that pain is starting to be treated in this way–I think it’s holistic, it’s evidence driven, and it’s incredibly effective.

However, some of these approaches guide patients to adopt an attitude towards their pain that I find can lead to detrimental effects.