Beyond the Scan: Understanding and Working with Persistent Pain
Presented by Sophie O'Dwyer. Written by Yvette Tan. Reviewed by Bernie and Sophie, registered psychologists.
On the Couch is a series that brings expert knowledge into the room, translating the insights of health psychology professionals into accessible, thoughtful reads for anyone curious about the intersection of mind and body.
In this instalment, Sophie O'Dwyer, a psychologist with a focused practice in persistent pain, draws from a presentation she delivered to a group of health psychology professionals. What follows is an exploration of persistent pain from a psychological perspective, what it is, how it is approached, and what the work of supporting someone through it actually involves.
About Sophie
Sophie O'Dwyer is a psychologist working in pain psychology. She works within a multidisciplinary pain clinic alongside pain physicians, physiotherapists and a dietitian, seeing individual clients and facilitating group programs. She has also co-founded Paced Health, a telehealth multidisciplinary clinic, having recognised a need for more psychologists with a specific focus in pain psychology and wanting to connect more people with psychological care for persistent pain.
Why Pain Persists
What distinguishes working with persistent pain from other psychological conditions is the understanding that the pain a person experiences can be disproportionate to the amount of damage or harm actually occurring in the body. In persistent pain, the pain system itself can become overprotective.
An individual may have had scans that come back completely clear, or investigations that have ruled everything out, and yet they are still living with very real, very debilitating pain.
Pain, as Sophie frames it, serves a purpose, just as anxiety or anger do, it exists to protect us. But in persistent pain, that protective system can become overprotective. Helping clients understand this, and think of their pain as something trying to keep them safe rather than something happening to them, can make it feel less threatening.
Sophie uses two metaphors to make this tangible for clients. The first is the smoke alarm. If the toast burns, the smoke alarm goes off as if there is a fire, but it is really just a piece of toast. The alarm is doing its job, but responding disproportionately. The second is the sunburn. When you take a warm shower with a sunburn, water that would normally feel pleasant becomes painful. The water is not harmful, but the pain system is responding as if it is.
This is where hurt does not always equal harm becomes an important distinction. Clients may need to expect some discomfort as they gradually become more active in their treatment journey, and that discomfort does not mean damage is occurring. It is also why chronic pain requires a fundamentally different approach from acute pain.
Sophie looks for existing evidence of safety in each client's experience. This might be a scan that came back clear, or simply the observation that their pain varies with stress or sleep, anything that demonstrates the pain is not signalling new or ongoing damage. This evidence becomes the foundation for helping clients form more helpful and accurate beliefs about what is happening in their body.
Delivering these ideas is its own clinical skill. Sophie's approach is to meet the client where they are in their understanding rather than immediately correcting their beliefs or overwhelming them with information. Where possible, she also aims to reinforce consistent messages across the team, and when a client hears the same framework from their psychologist and their physiotherapist, it carries more weight and provides a greater sense of coherence in what can otherwise feel like a confusing and contradictory system.
The Psychological Toolkit
Building an individual's confidence and capacity to manage their pain independently is at the heart of what Sophie does in her sessions. She draws on a range of approaches including Cognitive Behavioural Therapy (CBT), Acceptance and Commitment Therapy (ACT) and active self-management skills, tailoring her work to each individual's needs and circumstances.
Among the active self-management skills Sophie draws on, pacing is one of the most central. It addresses two unhelpful patterns that commonly develop in persistent pain. The first is the avoidance cycle: under the assumption that movement causes damage, the client does less and less, becomes more deconditioned, more sensitive to movement, and more depressed, which in turn increases their experience of pain. The second is boom and bust: on a good day, the client pushes through and overdoes it, which leads to a flare and a crash, and the cycle repeats.
Pacing offers an alternative to both. It means doing little and often, taking planned breaks before fatigue and pain kick in, and building activity gradually from a comfortable baseline, and done consistently, it can reduce the frequency of flare-ups over time. To help individuals understand what is driving their pain and fatigue on any given day, Sophie uses a stress bucket exercise, identifying what is filling it up and what is emptying it. This often surfaces deeper work around core beliefs about productivity and self-worth, where self-compassion becomes an important part of the process.
When flare-ups do occur, having a plan already in place makes a meaningful difference. A pain flare often takes a significant toll on an individual's mental health and emotional wellbeing, which is why Sophie works with each individual to develop a personalised flare-up plan in advance, covering helpful thoughts, helpful actions, warning signs and things to avoid. The aim during a flare is not to stop everything but to find a middle ground, doing things a little differently rather than not doing them at all.
Managing pain in the moment is another area Sophie addresses. When pain is present and attention is drawn toward it, the aim is to shift focus toward areas of the body where there is neutral or positive sensation rather than keeping attention fixed on pain. Breathing and progressive muscle relaxation are among the tools she uses, alongside grounding techniques and distraction, all of which help bring attention away from the pain itself.
Across these tools and approaches, what Sophie is working toward is a meaningful shift in how an individual experiences their pain day to day. The goal, as she describes it, is not necessarily to eliminate pain but to improve function and quality of life, and to help individuals feel more in control.
When Things Get Complex
Working with persistent pain is rarely straightforward. Some situations come up regularly that require particular care and consideration.
Clients feeling invalidated is one situation Sophie addresses directly. Many individuals living with persistent pain have had the experience of being told there is nothing wrong, or that the pain is in their head, particularly when scans come back clear. Sophie's starting point is validation: the pain is real, it is not being made up, and psychology is not there to suggest otherwise. From there, she meets the client at their level of understanding before gradually introducing more helpful frameworks about what is happening.
Diagnostic uncertainty is another situation that comes up. When a client is presenting with significant confusion about the origins of their pain, or has received a lot of mixed messages, Sophie finds it helpful to refer to a pain physician or pain-informed physiotherapist for a comprehensive assessment. This helps clarify what is and isn't known, giving the psychological work a more solid foundation.
Trauma history is something Sophie describes as common in this population. A thorough initial assessment helps identify whether trauma is present, and a trauma-informed approach is important throughout the work. Ongoing exposure to triggers can perpetuate dysregulation and make it harder for the client to engage with treatment. Sophie also highlights medical trauma specifically, where invalidating experiences within the healthcare system itself can make engaging with a new clinician feel unsafe. When trauma is significant, Sophie's starting point is the window of tolerance. Safe place exercises and helping the client identify where safety exists in their life come first, before moving into pain-focused work.
Underlying all of this is something Sophie returns to consistently: meeting the client where they are and not moving faster than they are ready for.
A Closing Thought
Across everything Sophie shares, the understanding of why pain persists, the tools for managing it, and the challenges that come with the work, the goal remains consistent: helping individuals move from a place where pain dominates their lives to one where they have the knowledge, skills and confidence to live well alongside it.
That does not always mean eliminating pain entirely. For some individuals it means significantly reducing it; for others it means reaching a point where pain is no longer the thing that defines their days or limits what they can do. Progress is rarely linear, and the work requires patience, both from the individual and from the team supporting them. But as this article makes clear, meaningful change is possible, and understanding persistent pain differently is where that possibility begins.
