The Patient Needs an Experience, Not an Explanation

The patient needs an EXPERIENCE, not an explanation

This quote by Frieda Fromm-Reichmann (1889–1957), a German-American Jewish psychoanalyst whose work dealt, among other things, with the importance of the therapeutic relationship in treating psychosis, is very relevant to one of the central challenges in treating chronic pain — and may explain why a popular, well-known approach in the field, one that sounds perfectly logical, yields disappointing results.

On Pain Neuroscience Education (PNE)

PNE is an educational-therapeutic approach centered on imparting knowledge: patients are taught how pain is created in the brain, that pain doesn't always indicate tissue damage, that MRI findings aren't necessarily the cause of pain, and so on. In short, "brain education" about the pain mechanism as the brain's danger sensor.

The logic behind the treatment is that if the patient understands their pain isn't dangerous, the sense of threat will drop, the brain's "danger mechanism" will calm down, and the pain will decrease.

And indeed, sometimes — that's exactly what happens. There are patients for whom the knowledge alone is enough to create a real change — for example, people who recovered from long-standing pain after reading the books of Dr. John Sarno, an NYU physician who first wrote about the link between brain, emotions, and chronic pain (a phenomenon that got the name "Book Cure," with many accounts of it described on the sites tmswiki.org and thankyoudrsarno.org). I've seen a number of such patients in the clinic, who after a thorough explanation about pain experienced a significant reduction in the long-standing symptoms they suffered from. In those people, the knowledge translated directly into an experience of safety — and it worked.

But these people aren't many, and it's very important to check — what's the research evidence on PNE? A systematic review and meta-analysis published in 2025 in the journal Annals of Physical and Rehabilitation Medicine included 19 systematic reviews with 5,200 participants, covering a decade of research on PNE in chronic back pain [1].

• PNE alone — yielded inconsistent results. Some studies showed short-term improvement, others found nothing. In the long term — a small, unclear effect.
• PNE combined with physiotherapy / physical exercise — the meta-analysis, which included 6 RCTs, showed an average reduction of about 1.1 points out of 10 in pain intensity — a positive result, but small and of almost no clinical significance in the real world…

The review's conclusion: PNE can contribute (a little…), but mainly as part of a combined approach.

So Why Doesn't It Work Well Enough?

Here I'll return to Fromm-Reichmann's sentence from the title. The reason may lie in the gap between two things that look similar but are fundamentally different:

• Understanding that the pain isn't dangerous (a cognitive explanation)
• versus experiencing the pain as safe (a bodily and emotional experience)

A short story: a few years ago I was at a rather makeshift amusement park in an Eastern European capital. One of the rides was a small armchair fixed to the floor — when you get in, you put on virtual-reality goggles showing a roller-coaster ride on a very steep drop (in horribly dated cartoon graphics), while the chair makes slight movements. When I got on the ride I knew perfectly well that I wasn't moving, that I was fixed to the floor, and that the graphics weren't convincing. And still — when the virtual ride went down the first drop, my stomach "dropped."

Our brain operates on two separate channels — the "knower" and the "experiencer." Cognitive knowledge doesn't always "reach" the brain regions responsible for the automatic danger response. This may be exactly the problem with PNE on its own: the information passes to the cortex — but the "danger mechanism" (which includes additional regions deep in the brain) keeps running as usual, because it never experienced that the pain is safe. It only heard that it's safe.

What Can Be Done Differently?

In Pain Reprocessing Therapy (PRT) — a neuroplastic treatment approach developed over the past decade (for more, see the article) — the explanations about the pain mechanism are present and important, but they're only the "opening." The heart of the treatment is providing an experience of safety about the pain, gradually and in a way tailored to each patient, through various experiential and behavioral mental techniques.

The goal: instead of explaining to the brain that the pain isn't dangerous — to let it experience this, again and again, until the neural circuits update from the direct experience.

The explanations about pain are of course an integral part of PRT, but their importance is in the same way that a person with anxiety who thinks they're having heart attacks won't get much out of therapy with a psychologist (however good) if they don't first know what panic attacks are and that there's no danger to their heart.

What Does the Research Say About PRT?

In an RCT published in JAMA Psychiatry (2022) on patients with chronic back pain, about 75% of the participants who received PRT reported the disappearance of the pain — a result that held at a one-year and even a 5-year follow-up!! [2, 3].

A second RCT with a similar approach, conducted by a different research group, showed similar results [4]. Recently, results from a third RCT that hasn't yet been published were presented at a conference, and it appears to have replicated the previous findings. In addition, preliminary, uncontrolled studies have shown impressive results in Long Covid and fibromyalgia too [5, 6].

By comparison: PRT brings about a large and consistent reduction in pain levels and in the disability it causes — an effect not seen at all in studies on PNE.

It's important to say: the direct comparison between these approaches hasn't been done in a head-to-head study, and the research on PRT is also relatively limited, so caution is needed. In addition, PRT too has various significant limitations, and it also needs to fit into a broader treatment model.

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Disclaimer: The information in this article is for general knowledge only. It is not personal medical advice and is not a substitute for it. If you have any health problem, please consult a qualified health professional to evaluate it.