The author of Tell Me Where It Hurts advocates for a holistic model that highlights the brain’s role

The author of Tell Me Where It Hurts advocates for a holistic model that highlights the brain’s roleIn 2014, Bessel van der Kolk published The Body Keeps the Score, a groundbreaking book that explored how trauma can rewire the brain and body, leading to chronic pain and emotional dysregulation. It was an instant bestseller and revolutionized how doctors and patients approached trauma, healing and post-traumatic stress disorder.

As much as van der Kolk changed our understanding of trauma, psychologist Rachel Zoffness seeks to reframe the treatment of chronic pain. In her new book, Tell Me Where It Hurts: The New Science of Pain and How to Heal, Zoffness presents pain as a biopsychosocial phenomenon produced by multiple factors: neuroscience, biology, mental health and a person’s physical environment. “Pain is our body’s danger system,” says Zoffness, adding, “When I wrote this book, it was with the intention of elaborating on the science and making the science user-friendly.”

Zoffness writes that chronic pain is constructed by the brain and central to the nervous system, influenced not only by injury, but by emotions, expectations and environment. If our brains can control emotions and thoughts, she says, there is also more potential for it to control chronic pain. Of course, all pain is not equal. A paper cut, for example, produces a stab of pain, but heals quickly. By contrast, an athlete can be covered in bruises after a game, but their physical pain is kept at bay by distraction, pleasure, joy and adrenaline. “We assume that the amount of pain we have is representative of the amount of tissue damage we have,” she says. “But we know that’s not true.”

She supports a multidimensional approach to managing chronic pain, including a recipe to diagnose and alleviate triggers. Zoffness, who has a PhD in clinical psychology and serves as a volunteer assistant clinical professor at UCSF, acknowledges the biopsychosocial model in medicine is not new. Indeed, in 1977, George Engel, the late physician and University of Rochester professor, popularized the idea in the journal Science, writing that it was not enough to understand the biological factors of a person’s medical condition, but that emotions, thoughts, socioeconomic factors, mood and environmental issues should be considered too. 

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While the biopsychosocial model for chronic pain has been adopted by some healthcare systems and medical school curricula, most do not. Zoffness says “there is an egregious lack of pain education across disciplines. We’re talking not just medical doctors, but also physical therapists, nurses, occupational therapists” and others who devote their lives to healing patients.

Zoffness differentiates between chronic pain, which lasts more than three months, and acute pain, like a broken leg. She is not unopposed to medicine when necessary. Her research has taken on new interest given the ongoing opioid epidemic in the U.S. The number of deaths due to opioid overdose grew tenfold between 1999 and 2023, according to the Centers for Disease Control. It reported that 125 million opioid prescriptions were dispensed in 2023,   when nearly 8.6 million Americans 12 years of age or older reported misusing prescription opioids. 

Pharmaceutical companies, Zoffness says, are partly to blame for “selling us all the lie that pain is purely biomedical and you can cure it with a pill.” (In May, New York state announced that Purdue Pharma, whose aggressive marketing of painkillers to doctors was a primary catalyst in the opioid crisis, would be shut down as part of a nationwide settlement.) Zoffness says she recently has seen more openness among doctors to the idea that several factors contribute to chronic pain, but many people, including patients, “are very rooted in this idea that pain lives just in the body part that hurts. It’s the narrative they’ve been sold.”

Zoffness champions a more holistic approach to pain management in Tell Me Where It Hurts, which involves discussion with doctors, physical and occupational therapists and other medical professionals. She likens pain management to a recipe that can be adjusted depending on how a patient feels. “Most of my patients can tell me their high-pain recipe, like, poor sleep, eating a crap diet, sitting in front of their screens for too many hours, not protecting time to move their bodies, not saying no to demands at work,” she says. “Right there you have a bunch of biopsychosocial ingredients, and it gives you a road map for healing.”

If poor sleep is a pain amplifier, Zoffness suggests a sleep hygiene protocol, which can include limiting screen time before bed and sleeping longer hours. Good nutrition is essential to battling chronic pain too, she says, as are relaxation strategies. Even setting boundaries to manage stress and anxiety can lessen chronic pain. And sometimes, pain is simply an indicator that the body is out of balance. “Many of us, including me, have had hunger headaches,” says Zoffness. “That is a sign your body needs food. You will feel physically uncomfortable and maybe even in pain when you’re dehydrated.”

The recipe model, she contends, is intuitive. So much so, she adapted one for herself. In writing her book, Zoffness says she was under loads of stress, working long hours and not taking breaks, and began having eye symptoms, including redness and seeing flashes of light. When she talked to doctors, she says, they did not ask if her work routine changed. So she came up with her own recipe: She found an application that read articles aloud, used an alarm to remind her to stretch, bought a big computer monitor and carved out time for walks. Her eyes, she says, feel better.

“If we could teach that to every doctor and every healthcare provider, we would absolutely change the face of pain medicine,” says Zoffness.