What Else Do You Say? Expanding the Framework for Communicating About Chronic Pain

The Hidden Impact of Words

Language around chronic pain carries huge weight. Telling a patient “It’s in your head,” or implying it (however gently) can increase hopelessness and even suicide risk. Clinicians juggle modern pain neuroscience concepts—“pain is a brain output,” “it’s a misinterpretation of a signal,” “alarm systems”—often hoping to empower. Yet, if not communicated with clarity and compassion, these phrases feel shaming, or worse, like a dismissal of genuine suffering and like there is nothing else a patient can do.

Pain Neuroscience: The Promises and the Traps

What’s Good:

●      Pain is a real and multifaceted experience, not just tissue damage.

●      The nervous system’s filters and amplifiers mean signals can be turned up or down by many factors—injury, trauma, stress, and more.

●      Empowering patients to use “danger in me/safety in me” strategies helps many people exert some control over their experience of pain.

What Goes Wrong:

●      Technical words (“misinterpretation,” “brain chooses,” “false alarm”) can land like a punch if not explained with nuance.

●      Patients with real findings on scans, or who have lost jobs and relationships, feel gaslit when told “There’s nothing wrong,” despite evidence to the contrary.

●      Pain programs are often oversold—patients need realistic expectations: these help with coping i.e. suffering and function, not necessarily eliminating pain.

A Four-Part Framework for Better Conversations

Find and Fix What You Can

Exhaust reasonable diagnostics and treatable drivers (structural, inflammatory, metabolic, psychiatric). Admit when limitations exist.

Filter, Downregulate, and Distract

Teach concrete self-management skills: breathing, movement, sleep hygiene, environment control.

Turn Down the Amplifiers

Collaborate to address amplifiers: metabolic problems, mood and anxiety, sleep issues, and hypermobility.

Rewire and Renew

Support neuroplastic rewiring: movement, gradual exposure, changing narratives around pain and capacity.

This approach recognizes both the structural and amplifier sides of pain—and sets up a shared language and plan.

Conversation Tips for Real Healing

●      Explicitly acknowledge pain as real and valid.

●      Discuss diagnostic findings honestly—never minimize or deny.

●      Set modest, realistic goals (“improved coping,” not “cure”).

●      Use empathy: “Let’s figure this out together.” Ask: “If our roles were reversed, would I feel heard?”

●      It’s OK to say “I don’t know”

●      Avoid phrases that sound like blame.

●      Stay open to revisiting and revising the plan—collaboration is a process, not a one-time fix

Our Takeaway for You

Improving how you express and relate to patients in a way that both explains pain and validates their experience without creating additional harm, is crucial to building a positive therapeutic relationship that actually helps the patient get better.

For more insight and practical advice, tune in to episode 12 of It’s Not in Your Head Podcast.