I have been a GP in Australia for 30 years and I’m very used to working in the biomedical model. My journey as an IFS therapist and mindfulness teacher began some years ago out of my frustration with the medical system’s approach to mental health and chronic pain. Medical professionals are good at giving facts and figures to patients, but not good at getting patients to adopt new paradigms.
Australia has been leading a worldwide revolution in pain management (1) that is highly relevant to IFS therapists. This pain revolution is as different from the generally accepted linear view of pain, as is IFS to earlier psychological models. To the extent that IFS therapists become part of this revolution, their role will be key in changing attitudes to pain, as well as helping reduce chronic pain experienced by clients. Many clients (and many IFS therapists) experience what is commonly called chronic pain. This is persistent pain, which may be continual or intermittent, and varying in severity, and is out of proportion to tissue healing times.
Modern neuroscience now recognises pain as a protective buffer, rather than as a marker of tissue damage (Lorimer Moseley & Butler, 2017). Old dualistic notions of mind or body are being discarded and replaced with mind and body… embodiment. IFS therapists in Australia are taking on this revolution in pain management to complement their Parts-work, to which the metaphor of pain as a protector, manager or firefighter,is central. Client Parts holding shame can be immensely validated when their pain is accepted as normal, personal, real, not imaginary and not a failure. Understanding that pain is an output of our brain and nervous systems, not an input from our body tissues, helps clients embrace IFS Parts-work.
The absolute key message of this pain revolution is the poor relationship between tissue damage and pain. At one end of the spectrum, we can have no pain, even when we have danger messages sent from damaged tissue…but pain can occur when there is no tissue damage.
This message is exemplified by the two true tales of the two nails. The first nail tail (Fisher, Hassan, O’Connor, 1995) is a famous case study of a 29 year old construction worker who had a scary fall at work. He was brought to emergency services with a seven inch nail right through his boot. He was in severe pain and immediately given morphine. The boot was then carefully removed and…there wasn’t a mark on his skin! The nail had gone right between his toes! The brain doesn’t always get things right when deciding how much pain is needed for protection. Having sized things up, normal signals were misinterpreted: the visual of a nail sticking out of his boot, knowing it was a dangerous work environment, seeing his co-workers’ horrified faces, and his body’s fear and panic, would have set off a cascade of biological and neuro-chemical processes. His brain, instantly synthesising this information, decided that he was in danger, so it made pain to protect him. The second nail tale is on the flip side. Another construction worker was using a nail gun when it unexpectedly discharged, clocking him in the face. Other than a mild toothache and a bruise under his jaw, he thought he was fine. Six days later—six days of eating, sleeping, and working—he went to the dentist, where an X-ray revealed a 4-inch nail embedded in his head. The nail had pierced the worker’s brain. So here, the brain had anticipated the nail going forward and there was no fear, the brain wasn’t on alert, so almost no pain was produced despite actual bodily harm, urgent need for medical intervention, and definite tissue damage! (Dimsdale & Dantzer, 2007).
Believing that pain and tissue damage are synonymous adds more danger signals to our system, encouraging fearful and avoidant protective Parts in both therapists and clients. Therapist Parts can be activated when a client has distressing, ongoing physical pain, particularly if the intensity is high. It may help anxious therapist-parts to understand when the normal healing process of tissues is complete. Tissues may still be unhealthy, sensitive, unfit, or crying out for movement, but by 12 months at the very most they have had all the time they need to heal (Moseley & Butler, 2013). After this period common medical investigations and treatments such as opioids are unlikely to be helpful. They are more likely, in fact to be unhelpful. In fact, the threatening language (e.g., spondylolisthesis, degenerative discs) used in imaging reports and frightening medical diagnoses given by doctors (e.g., interstitial cystitis) can actually activate fearful Parts in the client’s system, hence feeding into a pain-fear cycle (Caneiro, Bunzli & O’Sullivan, 2021). Long term opioids can worsen chronic pain (Garland et al, 2019). Well-educated IFS therapists can avoid referring clients for unnecessary medical intervention, confident that their embodiment and Parts-work will help protector Parts feel safe enough to gradually return to normal activities such as movement.
Like the mind, pain is an astonishingly complex system (Brown, 2006). We have mostly been brought up with a very linear approach and it takes a while to integrate the emergent, complex nature of pain. Blaming pain on any one factor, like “my bulging disc,” is a bit like blaming a complex, emergent traffic jam on a random car amid it all. IFS therapists are in a perfect position to both provide psychoeducation based on modern pain neuroscience to clients with chronic pain and explore this complexity with Parts-work.
Both protector-managers and firefighters may use physical pain to protect our exiles. Parts may be desperately protecting us from what they believe to be dangerous emotional situations with chronic outputs such as fatigue, urinary symptoms, tinnitus, shortness of breath, vertigo, pins and needles in the hands and feet, nausea, heartburn and, of course, pain. Young Parts may have linked trauma with random external factors such as certain sights, sounds, smells, locations, even weather conditions leading to dysfunction and avoidance. We may have suppressed needs like self-care and connection, with manager Parts that prioritise success or caregiving. These suppressed needs may generate pain to get our attention (Schubiner, Schwartz, Siegel, 2021).
Once the pain has become chronic other Parts may arise. The degree of protection offered by pain changes moment to moment and the longer we have pain, the more protective it gradually becomes – the processes that underpin pain become more sensitive. Eventually the system becomes completely overprotective and ironically starts to prevent recovery (Lorimer Moseley & Butler 2017). In IFS language there may be frightened avoidant Parts, driven obsessive Parts, loud inner critics, frustrated, denying, dissociating and “fix it” Parts. Firefighter Parts with suicidal thoughts, or use of alcohol or drugs, may arise. All these protective Parts increase the message to the brain that the pain is dangerous – thus the cycle persists. When pain is severe it can overwhelm us. This is useful for Parts feeling the need to take control of us, or giving us loud messages about emotions or situations that could be dangerous, like anger, fear, grief or sadness. Even when the pain arose from an original injury or disease process, Parts can continue to use pain for “secondary gain”; to keep us being looked after, safely cocooned, away from threatening relationships or possible failure (Schubiner, Schwartz, Siegel, 2021).
IFS therapists know that gentle, curious, compassionate exploration and befriending is most likely to help all Parts, including the ones that underlie pain. We need to appreciate the Parts that hold pain, for their well-intentioned role, listen to messages they may be communicating and, when the time is right, access the exiles they are protecting us from. When Parts feel truly accepted and befriended, they may no longer need pain to communicate or control any more (Schubiner, Schwartz & Siegel, 2021).
“Barbie” is a 50-year-old client of mine who has generously given permission for me to use snippets of her case. Barbie has very high-level complex trauma including neglect, physical, emotional, and sexual abuse from multiple perpetrators from a very young age. The birth of her first child, while still in her teens, was emotionally and physically traumatic. Barbie started therapy to “feel something.” She had been numb for so long. Barbie embraced IFS and attended therapy for nearly three years on an almost weekly basis. It was so inspiring to see the numb shell of a women who was barely living become alive, connecting with her body and emotions. Bringing self-compassion to multiple young Parts – terrified, hopeless, invisible, forgotten, frozen young Parts became her mission. Two years into the therapy she disclosed that she had had pain and difficulty with intercourse since her first child was born. She had been told at the time that her vagina was much too small which reinforced her perception of her vagina as a small, tight, fixed tube that should be dilated using vaginal dilators. I explained to her that the (unhelpfully labelled) dilators are no more than a desensitisation tool; that her vagina was surrounded by a hammock of pelvic muscles and that we could use some pelvic floor relaxations to help those muscles relax. Instantly a belief shifted, and she now perceived her vagina as a space surrounded by muscles, and she knew that muscles could relax. She went home and used breathing, meditative techniques and pelvic floor relaxation exercises in combination with visualisation of intercourse to stay calm and relaxed. Soon after this, intercourse was pain-free and pleasurable for the first time since the birth of her first child. A 5-year-old exile Part emerged soon after, who was burdened by a deep, heavy hopelessness in the lower belly and a belief that she was sexually abused because she was “bad and dirty.” This Part initially did not want to be retrieved to the present but was willing for Barbie and I to be with her and hold her with kindness, compassion, and hope. Barbie realised that the exile needed to know that the adult intimacy was not something she had to worry about, that this was grown up stuff that adult Barbie could look after. Sometime later, another young Part emerged that had been contained for years and really needed to speak up. This second young Part was deeply disturbed by adult Barbie enjoying pain-free sex. “It hurt so much; it’s not ok, don’t tell me its ok” she yelled. Barbie listened patiently and validated all this. In the next session she reported that this young Part was content to stay in another room doing some colouring-in during adult intimacy. She let Barbie know that she didn’t want to dissociate anymore; she liked being away while intimacy was happening and wanted Barbie to check in with her later and see her drawings. Barbie continues to have pain-free, pleasurable sex.
The confluence of modern pain neuroscience and IFS is an exciting development in Australia. Although chronic pain is not a path anyone is likely to choose, if we can be educated in this pain revolution, and be curious, compassionate, courageous, creative and the other C’s, there can be amazing physical, psychological and sometimes spiritual transformation (Schwartz & Sweezy, 2019). It is not uncommon for a client to experience gratitude for the role that chronic pain has played in their personal growth.
- Neuro Orthopaedic Institute Australasia (Noigroup) is a privately owned organisation working predominantly from an office in Adelaide, Australia. Originally founded by David Butler in the 1990’s, NOI’s vision is to seed ‘healthy notions of self through neuroscience knowledge’ worldwide.
Brown. C. (2006). Reconceptualizing chronic pain as a complex adaptive system. Emergence: Complexity and Organization. Link to article
Caneiro, J.P., Bunzli, S. & O’Sullivan, P. (2021). Brazilian Journal of Physical Therapy, 25(1), pp. 17-29. Link to article
Dimsdale, J. E. & Dantzer, R. (2007). A biological substrate for somatoform disorders: Importance of pathophysiology. Psychosomatic Medicine, November. Link to article
Fisher JP, Hassan DT, O’Connor N. Minerva. BMJ. 1995 Jan 7;310(70).
Garland EL, Trøstheim M, Eikemo M, Ernst G, & Leknes S. (2020). Anhedonia in chronic pain and prescription opioid misuse. Psychological Medicine, 50(12):1977-1988. Link to article
Lorimer Moseley, G. & Butler, D. (2013). Explain pain. Noi Group. Link to publication
Lorimer Moseley, G. & Butler, D. S. (2017). Explain pain supercharged. Noi Group. Link to publication
Schubiner, H, Schwartz, R. C. & Siegel, R. (2021). IFS and chronic pain: Listening to inner parts that hold the hurt. Link to article
Schwartz, R. C. & Sweezy, M. (2019). Internal family systems therapy. The Guildford Press.