Frequently Asked Questions (FAQ)

What practical tools can I learn from the film for dealing with all this pain?

The five steps for overcoming chronic pain depicted in the film can be found here.

Is this film about a woo-woo treatment?

No, it is about evidence-based medicine. The treatment explored in the film, EAET, has been listed as a “best practice” by the US Department of Health and Human Services in its interagency task force report to combat the opioid epidemic, and has been shown to be effective in a large randomized controlled trial for people with fibromyalgia. Go here for more info about the evidence base.

It is a counterintuitive treatment, though—we acknowledge that. It is also so new that very few doctors or therapists practice it and most have not even heard of it. By our count, there are only about 12 physicians and 100 therapists in the U.S. who practice using this framework. But more are learning it each month. Providers who are curious can learn about upcoming trainings here.

Are you saying that all chronic pain is “in the head”?

The latest neuroscience suggests that all pain is created in the brain. But what causes it to be switched on by the brain? Some pain is caused by structural or tissue damage in the body. This film explores the hypothesis that other forms of pain have a different cause: pain can be caused by stress, trauma, or by an old injury that has healed but still causes fear, or even the fear of pain itself, and this can occur even when there’s nothing wrong with the body. In essence, pain can be brain-generated. Sometimes, both types of pain are present at once.

What do you mean by “Chronic Pain”?

The term is used differently in different contexts. People who have cancer often have chronic pain, but they are not the subject of the film.

We are using the term chronic pain to refer to the conditions detailed below—pain that does not have a clear structural injury to explain its cause. It’s estimated this category of chronic pain includes over 50 million Americans and about 1 in 7 people around the world.

In 2021, the National Institute for Health and Care Excellence (NICE) recognized the prevalence of neuroplastic, or brain-induced pain and gave it a simple name, “primary chronic pain.” They define primary pain as “out of proportion to any observable injury or disease,” specifically naming fibromyalgia, CRPS, chronic musculoskeletal pain, abdominal pain, and head pain as the major ones.

In contrast, “secondary pain” refers to symptoms deriving secondarily from clear pathophysiological or structural issues like cancer, fractures, diabetes, infections, muscle diseases, lupus, and others. Primary chronic pain like all pain is real, and while you feel it in your back or your head, it does not originate in those body parts. It is projected there by the brain. You can view a short video defining this key diagnostic category, which accounts for 25-40% of all primary care visits, here.

All pain is created in the brain and projected into the body, but with primary pain, the symptoms are driven by profound, unconscious changes to the nervous system related to fear, stress, social conditions, and for some, trauma. The brain can learn pain and maintain or amplify it long after an injury has healed, much like how the brain can create phantom limb pain in a body part that doesn’t even exist. It’s common, and it’s good news, because these brain-induced changes can be unlearned and reversed, and the body part that was assumed to be damaged may be, in fact, healthy.

It should be noted, as we do in our film, that primary and secondary pain can co-exist. Each type of pain requires different treatment. It is very common that people are told they have secondary pain (say from a back injury from 10 years ago) that has been learned by the brain and transformed into primary pain. Most doctors do not know about the existence of primary pain, nor do they have effective remedies. We are hoping our film This Might Hurt can publicize this conversation around chronic pain.

Chronic pain has many shapes and sizes. What about my specific diagnosis? Is the film relevant for someone with my condition?

The EAET approach for treating chronic pain is recommended for 20+ conditions which are often—but not always—brought on by a brain-induced process that is reversible. The following list of symptoms was compiled by physicians at the Psychophysiologic Disorders Association and in Dr. Howard Schubiner’s book, Unlearn Your Pain:

anxiety, chronic abdominal pain and spasms, chronic arm or leg pain*, chronic back pain and spasms*, chronic neck pain*, chronic tendonitis, complex regional pain syndrome (CRPS), depression, dizziness, face pain*, fibromyalgia, insomnia, brain fog, irritable bowel syndrome (IBS), painful bladder syndrome (interstitial cystitis), pelvic floor dysfunction, POTS (postural orthostatic tachycardia syndrome), repetitive strain injury (RSI), temporo-mandibular joint dysfunction (TMJ), tension and migraine headaches, tinnitus, Long Covid, vulvodynia.* You can find a more complete list here.

* “As long as the X-rays and MRIs do not show a tumor, infection, inflammatory condition, or fracture, and if the neurological examination is normal to rule out nerve damage, then: the presence of degenerative discs, spurs, facet problems, and bulging discs should not be interpreted to be causing pain.” (citation: Howard Schubiner, MD)

In This Might Hurt, you see people struggling with and overcoming many of these conditions listed above.

WHY GROUP ALL THESE CONDITIONS AND LABEL THEM “BRAIN-GENERATED”?

Each person must be examined and assessed as an individual. And each patient must guide their own journey through the medical industry. Dr. Schubiner, in his book, Unlearn Your Pain, carefully selected this list of symptoms (above) as typically resulting from neural circuits, rather than structural damage in the body.

In his clinical experience and in the NIH-funded research Dr. Schubiner’s been conducting with fibromyalgia patients and back pain patients, he and his colleagues have found that a majority of people with those conditions have “primary pain,” or pain that is caused by the brain, and not by structural damage. These are not a self-selected group of patients, but rather people randomly assigned in the context of controlled studies.

This is an astonishing finding. NICE, which recogizes primary pain as a common problem, estimates that that a much smaller fraction, perhaps 2-6% of people, have primary pain. At most, that is about one in four chronic pain patients.

As filmmakers, we investigated this and other questions over seven years, including interviews with skeptics, and the result is the feature film, This Might Hurt. Whether chronic primary pain accounts for 5% or more than 50% of pain patients, it’s a lot of people with primary pain. And it is hard to access effective care for primary pain.

Isn’t all pain a combination of the mental and the physical? What’s the point of saying that some pain is “all-mental”?

Physicians like Dr. Schubiner have found that it’s clinically useful to distinguish certain painful symptoms as being brain-induced in contrast to tissue-damage pain.

The reason for this distinction is to deactivate the vicious pain -> fear -> pain cycle that many chronic pain patients get caught in. And to deactivate the conviction, which many chronic pain patients have, that their brains or bodies are broken. This conviction can lead to the nocebo effect, where the expectation of ill health is one of the causes of ill health. When patients with brain-induced pain are obsessively worried about the physical decline of their bodies, they are less likely to recover.

With a neural pathway diagnosis, they’re able to turn their attention towards reducing fear and stress and to resolving trauma in order to find pain relief. Of course, the argument that all pain is about neurons firing in one way or another, and that there is no separation between mind & body—is a fair point. But on a clinical level, distinguishing two types of pain has been profoundly helpful in helping to reduce and unlearn chronic pain.

I’ve been in psychotherapy before, how is this different?

Many therapies for overcoming chronic pain—meditation, reducing fear, talking with a therapist to change (or be more aware of) emotions, thoughts, and beliefs—can become much more powerful when they are framed differently. The EAET and PRT treatments have some key insights that can be incorporated into other therapy models.

In a nutshell, these approaches emphasize differentiating structural causes of pain (like cancer or fractures) from pain that results from neuroplastic changes in the nervous system due to fear, stress, and psychosocial factors.

Non-structural pain, also known as primary pain, is reversible—it can be reduced or completely eliminated when people learn to associate pain not with tissue damage but with neural pathways in the brain, and stop fearing it. Once pain is recognized as neuroplastic, the fear of pain is reduced dramatically, and the pain -> fear -> pain cycle is broken. Pain is seen as a false alarm or as a message that a powerful emotion like anger or fear needs to be acknowledged.

With some exceptions, most common forms of psychotherapy for pain, ACT and CBT, rarely involve assessing chronic pain conditions to differentiate structural pain from primary pain. Additionally, most people in therapy for pain are not taught about the latest neuroscience of pain and the reversibility of pain through brain retraining.

Are you stigmatizing people with chronic pain?

Chronic pain often comes with a huge stigma attached to it. People feel like they’ve tried everything and nothing helped, so they must be permanently damaged. Their doctors are sometimes suspicious of them or they can be accused of seeking drugs for recreation. While making the film we worked to tell the stories of three people with pain from their perspective, and with compassion.

Kent: And as someone who has suffered from primary chronic pain, I found it liberating to learn that my pain was not caused by damage to my arms, but rather, was brain-induced. That meant that there is a potential way out. It didn’t feel stigmatizing to be told my emotions are powerful, my brain is powerful, and my symptoms are reversible. It felt exciting and hopeful—at least, after being very skeptical and rejecting it outright.

How is your film relevant DURING the opioid crisis?

Since 1997, nearly 400,000 Americans have died from opioid-related overdoses, making the epidemic one of the largest public health crises in US history. The Covid-19 lockdowns have led to a resurging opioid epidemic that continues to ravage the nation. One study showed that 60% of those who died from an opioid overdose had a chronic pain diagnosis, suggesting that untreated pain is keeping the epidemic from being controlled.

As we know from two stories in our film, people get hooked on opioids because they're desperate to get rid of pain. One of them was hospitalized for an opioid overdose and nearly died. Because of the twin epidemics—Coronavirus and opioid addiction—non-opioid alternatives for chronic pain are urgently needed now. People who recover from chronic pain are often able to wean themselves off opioids because they no longer need them to mask their pain.

Do you support the effort to make it harder for people with chronic pain to get the opioids they need?

In the wake of the government’s response to the opioid crisis, there has been a major problem with chronic pain patients being abruptly taken off their opioid painkillers. Some have committed suicide out of desperation. Great care needs to be taken when anyone is trying to wean themselves off opioids. We don’t support taking opioids away from people who depend on them to manage their pain.

At the same time, for good reason, the CDC has recommended that physicians not put chronic pain patients on opioids in the first place. There’s good evidence that they don’t work any better than Tylenol, and they have dangerous side effects.

How does this treatment (EaET) compare to holistic and alternative approaches?

You could say the essence of the EAET treatment is looking at the role of fear, the brain, and stress itself in creating or maintaining chronic pain states. Many practitioners and patients, frustrated by allopathic medicine, have embraced alternative medical frameworks. While these can sometimes be helpful, unfortunately, they can also lead to the same obsessive focus on the body along with the conviction that the body is damaged. This can lead to the same vicious cycle of pain -> fear -> pain.

As Marcia Angell, MD discusses it, “alternative medicine” can be a misleading term: “There are not two kinds of medicine. There's medicine that has been tested, and there's medicine that hasn't been tested.” The EAET treatment explored in This Might Hurt has been tested with promising preliminary results.

Along with co-authors Richard Schwartz and Ronald Siegel, Dr. Schubiner recently published an article concluding that “…holistic practitioners might’ve offered alternate diagnoses such as adrenal fatigue, chronic Lyme disease, leaky gut syndrome, toxic heavy metal accumulation, or candida overgrowth. […] Helping clients understand that they don’t have something dangerous, incurable, or necessarily disabling is an important first step in treatment. This relaxes their protector parts and helps them trust that returning to normal activities is safe and even wise.”

Isn’t chronic pain DRIVEN by inflammation OR POOR DIET?

Of course, wholesome diets can bring positive changes. And for celiac disease, lactose intolerance, and some allergies it’s essential to eliminate certain foods to protect one’s health. But food elimination diets in order to reverse pain syndromes can often have a harmful effect if they reinforce fear. Elimination diets can unwittingly teach people’s nervous systems to have a conditioned response where foods trigger fear and symptoms, and hyper-vigilance around diet can take the joy out of eating.

Another problem with elimination diets is they can result in symptom substitution, where irritable bowel symptoms, for example, might subside, but new symptoms (head pain, back pain) emerge in their place. And if IBS symptoms come back, even more foods are eliminated, creating a cycle of symptoms, diet restrictions, more symptoms, and so on.

You can hear a summary of more precise way to think about inflammation and chronic pain here.

What treatments is this film about?

Emotional Awareness and Expression Therapy (EAET) — This therapy is listed as “best practice” by the US Department of Health and Human Services for people with chronic pain in order to combat the opioid epidemic. In a trial with fibromyalgia patients published in the journal PAIN, people randomly assigned to EAET had a 50% reduction of pain at more than twice the rate as people randomly assigned to CBT (cognitive behavior therapy, the standard treatment). It is rare for one psychotherapy to be shown to be significantly more effective than another therapy, so this is a notable study. This study, presented in the film, can be read in full here. A description of how the treatment works can be found here. (but maybe watch the movie too!)

Pain Reprocessing Therapy (PRT) - Some people do not need to, or do not want to do “emotional processing.” Pain Reprocessing Therapy offers a way to work directly with the fear of pain, which is frequently the primary driver of pain symptoms. By learning how to do “somatic tracking” and other mindfulness and cognitive tools, PRT therapists guide patients until they transform their fear of pain.

After a successful PRT treatment, patients know intuitively their chronic pain is not a sign of tissue damage. The pain comes and goes without triggering as much fear, tends to lessen over time, and is no longer mistaken for a structural injury. Alan Gordon, LCSW, Dr. Howard Schubiner and their colleagues used PRT in a clinical study of people with back pain at the University of Colorado-Boulder. The primary author of the study, Yoni K. Ashar, PhD, and Alan Gordon, go into more depth in this article.

Intensive Short-Term Dynamic Psychotherapy (ISTDP) — This treatment has been around since the 1970s and there’s been a number of research studies investigating its effectiveness. Dr. Sarno recommended it especially for people with severe symptoms that are treatment-resistant. His collaborator, Arlene Feinblatt, built a protocol for helping chronic-pain patients process pain, anxiety, and emotions differently so that symptoms lessen over time.

The innovators of EAET (Mark Lumley & Howard Shubiner), have referred to their therapy as a “simplified version of ISTDP,” which is easier for clinicians to learn and offer to patients. ISTDP can be a powerful, robust option, especially for people with treatment-resistant forms of chronic pain and high levels of trauma and adverse childhood events (ACEs).

*Note: ISTDP falls under the umbrella term “experiential dynamic therapy (EDT)” which includes other therapy models like Accelerated Experiential Dynamic Psychotherapy (AEDP). In EDT, the goal is to feel sensations of emotions directly in the body and to overcome internal blocks against feeling anger, guilt, sadness, and compassion. After a successful therapy, all feelings, including compassion and joy, are experienced more fully.

TMS treatment or coaching — Sarno’s preferred term for brain-induced pain was Tension Myoneural Syndrome (TMS). While most who research his treatment have dropped this term, it is still a favorite by many clinicians and people who recovered from reading his books, and who now offer coaching based on the “Sarno model.” You can find these peer coaches on the TMS wiki, and two health tech companies have based their treatment model on coaching: Lin.health and Karuna Labs (Karuna also offers Virtual Reality Brain Retraining).

Other therapies — Of course, there are many therapies that are helpful for people with chronic pain. We limited our list to these therapies because they were all touched on in the film. During our research, these four therapies came up the most frequently by healthcare professionals who emphasize that a huge portion of chronic pain patients have nothing structural going on that explains their pain. If you apply this insight to doing yoga, journaling, meditation—these and many other mind-body modalities can be more effective and lead to 100% reduction of pain and fatigue.