Member Columnist - Melany Cohen, LMFT

How Can Psychotherapy Help With Back Pain?

Why Does This Matter?

There are approx. 60 million Americans living with chronic pain. About 16-20 million are suffering from chronic back pain. Because over 90% of back pain cases are “non- specific 1 ,” diagnosing the exact root cause is very difficult, leading to treatments that are often trial and error. Usually, the end of the line treatment for people with persistent back pain is surgery. But back surgery is so notoriously ineffective, there is actually a name given for these failed surgeries, Failed Back Surgery Syndrome (FBSS). 2

How I Become Interested in Pain

When I first started experiencing prolonged back pain, I had no idea that psychotherapy would be a crucial part of my healing journey. The pain started after a serious car accident, where my vehicle skidded off the freeway and crashed into a tree. Thankfully, I didn’t have any serious injuries. I had minor back and neck pain. The pain wasn’t very severe in the beginning, but it got progressively worse. The more preoccupied I became with my symptoms, the worse they got. At times, I couldn’t get up off the floor. And my pain persisted for years after the accident. Initially, I sought medical treatments for my pain. Desperate for relief, I tried everything that was suggested; acupuncture, cortisone shots, physical therapy, even something called Rolfing (which caused even more excruciating pain). The pain would subside intermittently but it always came back (especially during times of stress). Ultimately, I saw a spine surgeon who did an MRI and discovered I had a disc herniation. The physician informed me that my next best option was surgery. But the idea of surgery scared me more than the pain itself. So I opted to live with the pain. Sadly, that’s what many people do when they’re forced to weigh the risks of surgery against the unpredictable outcome of such an invasive procedure.

Learning About Mind Body Pain

One day, a friend gave me a book called Mind Over Back Pain, by John Sarno. It was my first foray into the world of neuroplastic pain. Sarno discovered that structural abnormalities- such as herniated discs, spinal stenosis and degenerative arthritis- are rarely the true cause of chronic back pain. He observed that these “abnormalities” are a normal part of aging and are equally prevalent in people with no back pain whatsoever. His findings shifted the focus of pain management to psychological mechanisms that were keeping the pain alive. The idea was that fear, avoidance, and repressed emotions were the actual drivers of chronic back pain. Sarno’s book gave me hope. It opened my eyes to the possibility that the cause of my persistent pain was not the car accident or the herniated disc. I began to address the psychological mechanisms that were perpetuating my pain. I learned to respond differently to pain flares, I practiced exposure to feared pain triggers and I made lifestyle changes that lowered my stress. Over time, the pain pathways (i.e. the habits and patterns that were reinforcing my pain) began to change. I had longer periods of relief. And eventually, my brain “forgot” to produce the pain.

What is Neuroplastic Pain

Pain is like a sophisticated alarm that goes off whenever the brain senses that the body is in danger. Normally when we injure ourselves and there is tissue damage, the alarm will go off and we will experience pain. Neuroplastic pain refers to pain that persists not because of ongoing tissue damage, but because the brain and central nervous system have developed a maladaptive habit of generating pain signals. It’s like a false alarm.

Since this type of pain is generated in the brain, psychological treatments make the most sense. Saying that the pain is ‘generated in the brain’ is not the same as saying the pain is imaginary. In fact, the opposite is true. Brain imaging studies have shown that neuroplastic pain is a real physiological experience, involving genuine changes in neural activity and learned pathways within the nervous system. 3 The good news is that if the pain is learned, it can also be unlearned. That’s where Pain Reprocessing Therapy comes in.

What is Pain Reprocessing Therapy?

Pain Reprocessing Therapy (PRT) is an evidence-based psychological treatment that helps patients eliminate or reduce chronic pain by retraining the brain to reinterpret pain signals as non-threatening. The main components of PRT include:

 Learning about the role of the brain and nervous system in generating pain
 Reducing fear of pain
 Somatic tracking (attending to sensations through a lens of safety)
 Changing beliefs about pain
 Gradual return to activities that have been avoided

PRT gained attention after a 2021 study published in JAMA Psychiatry found significant improvements in many people with chronic back pain who received the treatment. 4 In the group who received PRT, an astounding 98% reported significant improvements and 66% were pain-free or nearly pain-free at the end of treatment. The outcomes were largely maintained long term. More on the study as well as the PRT approach can be found in the book The Way Out, by Alan Gordon.

What Is it Like To Be a Chronic Pain Therapist

When I was far enough along in my own healing journey, I began to wonder whether my pain had served a purpose. Through navigating it myself, I gained insights and perspectives that could help illuminate the path for others facing similar struggles. When I decided to shift the focus of my psychotherapy practice to helping patients with chronic pain, it felt like a natural fit. Practicing as chronic pain therapist has been both challenging and rewarding.

One of the challenges of this work is that, while many people can intellectually understand the concept of neuroplastic pain, it often conflicts with our deeply ingrained beliefs about what pain means. Most of us instinctively view pain as evidence of a physical problem. As a result, the idea that pain can persist even when the body is fundamentally safe can feel counterintuitive, and at times difficult to fully embrace.

Part of the therapeutic process involves helping clients move beyond simply understanding the concept and toward experiencing a new relationship with their symptoms. This shift requires questioning long-held assumptions about pain and developing trust in the body’s resilience. For some, this can be one of the most challenging aspects of treatment.

One of the most rewarding aspects of this work is witnessing what becomes possible as patients’ symptoms begin to ease. As pain becomes less central, people’s lives often become richer, more expansive, and more aligned with what they value most.

I would never have chosen the experience of chronic pain, but I am deeply grateful for the path it led me to and the opportunity it has given me to help others find their way forward.

Melany Cohen, LMFT LMFT is a California-licensed Marriage and Family Therapist and a certified Hypnotherapist. She received her Masters from Antioch University in 2012 and completed an extensive training in Clinical Hypnotherapy, with an emphasis on pain management. In addition to her private practice, Melany is also a Supervisor at the Pain Psychology Center. She facilitates healing workshops for the Pain Reprocessing Therapy Center. She is also trained in Brainspotting, a brain-body therapy for healing unresolved trauma.