The Biological Reality of Chronic Illness: Why "Brain Retraining" Isn't the Answer—And What Actually Helps
As clinicians working with chronic illness populations, we are increasingly encountering clients who arrive in our offices carrying an unexpected burden: shame. Not shame about their illness itself, but shame about their failure to "think their way out" of their symptoms. They've tried Dynamic Neural Retraining System (DNRS), attempted Pain Reprocessing Therapy, followed Instagram influencers promising recovery through mindset shifts, and when they remained ill, internalized the message that they somehow failed.
This article examines the current landscape of "brain retraining" approaches marketed to people with chronic illnesses such as fibromyalgia, Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), and Long COVID, evaluates the evidence base for these interventions, distinguishes between conditions that benefit from neuroplasticity-based approaches versus those requiring different frameworks, and proposes a clinical decision-making model that honors the biological reality of these conditions while appropriately utilizing nervous system regulation.
The Systemic Context: Medical Abandonment Creates Market Vulnerability
Before examining specific interventions, we must acknowledge the systemic failures that create the conditions for exploitation. People with fibromyalgia, ME/CFS, and Long COVID do not turn to unproven programs because they are gullible or desperate for quick fixes. They turn to these programs because the medical system has profoundly and systematically failed them.
The Funding Gap
Research funding for chronic illness conditions like fibromyalgia, ME/CFS, and Long COVID remains grossly inadequate relative to disease burden. In Canada specifically:
ME/CFS: Affects approximately 1.4% of Canadians (over 500,000 people), yet receives minimal dedicated research funding
Fibromyalgia: Affects approximately 1.5% of Canadians (over 575,000 people as of 2020, representing a 10.2% increase from 2016)
Long COVID: An estimated 3.5 million Canadian adults (approximately 1 in 9) have experienced Long COVID symptoms, with 2.1 million still experiencing ongoing symptoms as of 2023. Approximately 600,000 have missed work or school due to these symptoms.
Chronic Pain: Affects one in five Canadian adults and children
According to the Canadian Pain Task Force, chronic pain costs Canada between $38.3 to $40.4 billion annually in direct and indirect costs. Despite this staggering economic and human burden, chronic pain research receives a fraction of the funding allocated to conditions with similar or lesser impact. A 2011 analysis found the ratio of research dollars to direct healthcare costs was approximately 41 times higher for cancer than for chronic pain.
Fibromyalgia, ME/CFS, and Long COVID research face similar marginalization. These conditions remain dramatically understudied despite affecting millions of Canadians and causing significant disability. The emergence of Long COVID has brought some increased attention to post-viral illness, but treatment options and research funding remain woefully inadequate.
Gender Bias in Pain Medicine
Both fibromyalgia and ME/CFS disproportionately affect women (approximately 75-80% of patients). This is not coincidental to their marginalization. Extensive research documents gender bias in pain medicine: women's pain is more likely to be dismissed as psychological, women wait longer for pain treatment, and women receive less aggressive pain management even for identical conditions.
A 2021 study in the Journal of Pain found that women presenting with acute pain were significantly more likely than men to receive sedatives rather than analgesics—suggesting their pain was perceived as anxiety rather than legitimate physical suffering. For chronic conditions like fibromyalgia, this bias is amplified.
The Diagnostic and Treatment Access Crisis
Wait Times for Specialist Care
Canadian data paints a stark picture of access barriers:
General Specialist Wait Times: A 2020 study found Canada ranked last among 11 Commonwealth countries for specialist wait times, with 62% of patients waiting one month or more for access (compared to 31% in the United States). The median national wait time from family physician referral to specialist appointment is 78 days, with significant regional variation.
Pain Clinic Wait Times: The situation is even more dire for chronic pain treatment:
Median wait time for multidisciplinary pain clinics: 6 months
One-third of publicly funded pain clinics have wait times exceeding one year
Some patients wait up to 4 years for access to specialized pain care
Research shows health deterioration begins as early as 5-6 weeks into the waiting period
Impact of Waiting: The Canadian Pain Society Task Force determined that wait times beyond 6 months are "medically unacceptable," noting that patients waiting more than 6 months from referral to assessment experience:
Deterioration in health-related quality of life
Increased pain intensity
Increasing depression scores
Worsening of physical function and mobility
For individuals on waitlists for multidisciplinary pain treatment, the median economic burden is $1,462 per month, with 95% of these costs borne by the patient themselves.
Long COVID Treatment Gap: The situation for Long COVID patients is particularly egregious:
Two-thirds of Canadian adults who sought healthcare for Long COVID symptoms reported not receiving adequate treatment, services, or support
Approximately 40% who sought healthcare experienced difficulties accessing services
Several Long COVID clinics that opened during the pandemic have since closed due to lack of sustained funding
Many Long COVID patients report being dismissed or told their symptoms are anxiety-related, despite documented biological abnormalities
A 2024 CBC News investigation found that patients were being placed on six-month waitlists for Long COVID clinics, only to receive letters weeks later informing them the clinics had closed, referring them instead to websites and hospitals hours away from their homes.
The "Digital Solution" Problem: Even well-intentioned programs face implementation issues. LivePlanBe/LivePlanBe+, a free evidence-based pain self-management program created by Pain BC and funded by Health Canada, represents an appropriate framework for pain education and coping strategies. However, patients report significant accessibility issues with the online platform, and more problematically, some physicians use it as a substitute for care rather than an adjunct—referring patients to the website instead of providing medical treatment or specialist referrals. For patients with cognitive impairment from ME/CFS, Long COVID, or fibromyalgia ("brain fog"), navigating complex online platforms becomes another insurmountable barrier. What should be a helpful resource becomes yet another way the healthcare system offloads responsibility onto patients who lack the cognitive capacity or energy to self-navigate care.
The Diagnostic Odyssey
Beyond wait times for treatment, obtaining a diagnosis presents its own barriers:
Average time to diagnosis for ME/CFS: 5-7 years
Fibromyalgia patients typically see an average of 3.7 physicians before receiving accurate diagnosis
During this time, patients commonly hear:
"Your tests are normal, so there's nothing wrong"
"This is just stress/anxiety/depression"
"You're too focused on your symptoms"
"Have you considered seeing a therapist?"
"Maybe you just need to exercise more"
This is medical gaslighting—the systematic dismissal of patient-reported symptoms when they do not align with visible pathology or fit neatly into existing diagnostic categories.
The Treatment Gap
Even after diagnosis, treatment options remain limited. For ME/CFS, there are no FDA-approved medications and no established treatment protocols. For fibromyalgia, three medications have FDA approval (duloxetine, milnacipran, pregabalin), but response rates are modest and many patients cannot tolerate side effects.
Patients are frequently told: "Learn to live with it." But little support is provided for how to do so. Physical therapy is often inappropriate or harmful for conditions involving post-exertional malaise. Cognitive behavioral therapy (CBT) has been inappropriately promoted as a treatment for ME/CFS despite patient advocacy against its use as a curative intervention, and the problematic PACE trial that promoted it has been widely criticized for methodological flaws.
The Pipeline to Exploitation
This systemic failure creates a predictable pipeline:
Person develops chronic illness
Medical system fails to diagnose, dismisses symptoms, or offers no effective treatment
Person experiences years of suffering, disability, financial strain, and social isolation
Person becomes desperate for any approach that offers hope
Wellness industry presents brain retraining/neuroplasticity programs with testimonials and neuroscience language
Person invests money and effort into program
Person remains ill (because they have a biological disease)
Program implies failure is due to insufficient effort or belief
Person adds shame and self-blame to existing burden of illness
This is not a story of patient naivety. This is a story of systemic failure creating conditions for exploitation.
As clinicians, we must understand this context. When clients present having spent thousands on DNRS or similar programs, the question is not "why did you fall for that?" The question is "what systemic failures created the conditions where this seemed like your only option?"
The Current Crisis: When Hope Becomes Harm
The wellness industry has embraced neuroplasticity as its latest frontier, often extending evidence-based interventions far beyond their validated applications. What begins as legitimate scientific inquiry into the brain's capacity for change becomes transformed into promises that chronic diseases can be "unlearned" or "retrained away."
The pattern is consistent: A person with fibromyalgia or ME/CFS, desperate after years of medical dismissal and failed treatments, encounters an influencer or program promising recovery. They invest hundreds or thousands of dollars. They commit fully to the protocol. And when they remain ill—as the vast majority do—they are left with a devastating implicit message: their continued illness is evidence of personal failure.
This represents a fundamental misapplication of neuroscience research, with serious consequences for vulnerable populations.
What the Evidence Actually Shows
Pain Reprocessing Therapy and Empowered Relief: Legitimate but Limited
The 2021 Boulder Back Pain study by Ashar and colleagues, published in JAMA Psychiatry, demonstrated that Pain Reprocessing Therapy (PRT) produced significant pain reduction in people with chronic back pain. The study was well-designed and the results were impressive: approximately 66% of participants reported being pain-free or nearly pain-free after treatment.
Building on similar principles, Beth Darnall and colleagues developed Empowered Relief, a more accessible pain self-management program that incorporates pain neuroscience education and cognitive-behavioral strategies. Empowered Relief has also demonstrated efficacy for chronic pain management in clinical studies.
However, the critical detail often omitted from popular discussions is this: these studies specifically targeted PRIMARY chronic back pain—pain for which "peripheral etiology cannot be identified." The researchers explicitly noted that approximately 85% of chronic back pain is primary pain, characterized by learned neural patterns rather than ongoing tissue damage or disease processes.
This distinction matters profoundly. PRT and Empowered Relief were studied in individuals whose pain signal itself had become the problem—a false alarm system. These interventions were not designed for, tested on, or validated for conditions involving active disease processes.
Understanding the Distinction: Acute, Primary Chronic, and Disease-Related Chronic Conditions
To understand why applying PRT (and similar approaches) to conditions like fibromyalgia and ME/CFS is problematic, we must clarify three distinct categories:
Acute Illness/Pain: Illness or pain resulting from recent injury or infection, expected to resolve with healing. Example: a sprained ankle, acute bronchitis, post-surgical pain. The body is responding appropriately to current tissue damage, and pain signals accurate information about ongoing healing needs.
Primary Chronic Pain: Pain that persists beyond the expected healing time in the absence of identifiable ongoing tissue damage or disease process. The pain signal itself has become dysfunctional—a "false alarm" that continues even though tissues have healed. This is the target population for interventions like PRT. Example: chronic back pain where imaging shows no structural abnormalities and no inflammatory markers are elevated.
Disease-Related Chronic Illness/Pain: Ongoing illness or pain resulting from persistent disease processes with measurable biological abnormalities. Example: fibromyalgia with documented immune dysfunction and neuroinflammation, ME/CFS with mitochondrial dysfunction and immune abnormalities, Long COVID with persistent viral reservoirs and immune dysregulation, rheumatoid arthritis with active joint inflammation.
The critical error in current wellness marketing is the conflation of these categories—particularly the assumption that approaches validated for primary chronic pain can be applied to disease-related chronic illness.
Fibromyalgia, ME/CFS, and Long COVID fall into the third category. While there may be secondary amplification of symptoms through nervous system sensitization (which can benefit from targeted interventions), the underlying disease processes are biological and ongoing.
A Framework for Appropriate Intervention Selection
Understanding which therapeutic approaches are appropriate for which conditions requires clarity about disease stage, pathophysiology, and treatment goals. The following framework provides guidance for clinicians and patients navigating these decisions.
Category 1: Primary Chronic Pain (No Ongoing Disease Process)
Definition: Pain that persists beyond expected healing time in the absence of identifiable ongoing tissue damage, structural abnormality, or inflammatory/immune disease process.
Pathophysiology: The pain signal itself has become dysfunctional—a learned neural pattern or "false alarm" that continues despite tissue healing. Central sensitization may be present but is not secondary to ongoing peripheral pathology.
Appropriate Interventions:
Pain Reprocessing Therapy (PRT) - Can be curative; Boulder Back Pain study showed 66% pain-free or nearly pain-free
Empowered Relief - Beth Darnall's single-session (2-hour) intervention shown to be non-inferior to 8-session CBT for chronic low back pain; reduces pain intensity, pain interference, and pain catastrophizing with effects maintained at 6 months. Also validated for post-surgical pain and injury recovery.
Graded exposure to feared movements
Pain neuroscience education focused on reframing pain as non-dangerous
CBT for chronic pain
Examples:
Chronic back pain with normal imaging and no inflammatory markers
Post-surgical pain persisting beyond tissue healing without complications
Some tension-type headaches with no structural abnormalities
Non-cardiac chest pain after cardiac pathology has been ruled out
Expected Outcomes: These interventions can result in complete or near-complete pain resolution because addressing the dysfunctional pain signal addresses the primary pathology.
Category 2: Disease-Related Chronic Illness with Secondary Amplification
Definition: Ongoing illness involving measurable biological abnormalities (immune dysfunction, inflammation, metabolic dysfunction) with secondary nervous system sensitization that amplifies symptoms.
Pathophysiology: Primary disease processes (e.g., autoimmune activity, mitochondrial dysfunction, chronic infection) cause legitimate symptoms. Chronic stress response and central sensitization develop secondarily, adding an amplification layer to baseline disease activity.
Appropriate Interventions (Elysia Bronson's Integrated Clinical Approach):
Medical management of underlying disease (primary - coordinated with physicians)
Safe and Sound Protocol (SSP) - Polyvagal-based intervention using filtered music to regulate the autonomic nervous system, reducing hypervigilance and stress amplification
Dialectical Behavior Therapy (DBT) skills - Emotion regulation, distress tolerance, mindfulness specifically adapted for chronic illness populations
Cognitive Processing Therapy (CPT) - For trauma related to medical experiences, diagnostic delays, or medical PTSD
Pain neuroscience education - Emphasizing the "And" framework: acknowledging biological disease WHILE addressing nervous system amplification
Pacing and energy management strategies - Essential for preventing post-exertional malaise and boom-bust cycles
Trauma processing - Addressing medical trauma, systemic dismissal, and complex PTSD from chronic illness experiences
Empowered Relief principles (adapted) - Pain management skills taught in context of ongoing disease, not as cure
Universal Pain Therapy (UPT) - Integrative online course combining adapted PRT principles, DBT skills, SSP, and pacing specifically designed for chronic illness populations; explicitly framed as managing stress system effects on symptoms, NOT curing disease
Somatic therapy approaches - Body-based regulation techniques for trauma and nervous system dysregulation
Examples:
Fibromyalgia: Immune dysregulation, neuroinflammation, mitochondrial dysfunction with secondary central sensitization. Nervous system work helps manage amplification; does not cure underlying immune/inflammatory pathology.
ME/CFS: Mitochondrial dysfunction, immune abnormalities, post-exertional malaise with biological markers. Pacing is essential; nervous system regulation can help reduce symptom amplification but cannot reverse mitochondrial pathology.
Postural Orthostatic Tachycardia Syndrome (POTS) and other autonomic disorders: Dysautonomia with measurable physiological abnormalities. SSP and nervous system regulation may help modulate autonomic function but do not cure the underlying dysregulation. Medical management (fluids, salt, medications) remains primary.
Chronic Kidney Disease: Progressive loss of kidney function with systemic effects. Pain management and stress reduction are adjunctive; medical management and eventual dialysis/transplant considerations are primary.
Post-viral syndromes (including Long COVID): Persistent immune activation, mitochondrial dysfunction, and multi-system involvement. Pacing, nervous system regulation, and symptom management are supportive; addressing underlying viral persistence or immune dysfunction is the goal.
Rheumatoid Arthritis: Active autoimmune disease with joint inflammation and systemic effects. DMARDs and biologics are primary treatment; nervous system work can help with pain amplification and stress response but does not treat joint inflammation.
Inflammatory Bowel Disease (Crohn's, Ulcerative Colitis): Active intestinal inflammation with immune dysfunction. Medical management is primary; nervous system work can help with symptom amplification and gut-brain axis regulation but does not treat the inflammatory disease.
Expected Outcomes: Reduction in symptom amplification, improved quality of life, better coping, reduced suffering—but not cure of underlying disease. Patients may experience 20-40% improvement in symptom burden by addressing the amplification layer while disease processes continue to require medical management.
Category 3: Central Sensitization Secondary to Chronic Disease
Definition: This overlaps significantly with Category 2 but merits separate discussion due to common misapplication of "central sensitization syndrome" terminology.
Important Clarification: Central sensitization is REAL and MEASURABLE—it involves neuroplastic changes in the central nervous system that amplify pain signals. However, in many chronic illnesses, central sensitization is SECONDARY to ongoing peripheral pathology (inflammation, immune activation, tissue damage).
Clinical Error to Avoid: Labeling a patient with "central sensitization syndrome" and treating only the sensitization while ignoring ongoing peripheral disease processes. This represents the same category error as applying PRT to fibromyalgia—treating the amplification while dismissing the underlying disease.
Examples Where This Distinction Matters:
Fibromyalgia: Has documented central sensitization visible on functional imaging. However, this central sensitization is secondary to ongoing immune activation, neuroinflammation, and peripheral pathology. Treating only the central sensitization (as if it were primary chronic pain) while ignoring the immune/inflammatory disease will fail.
Complex Regional Pain Syndrome (CRPS): Involves central sensitization but also peripheral nerve pathology, autonomic dysfunction, and inflammatory changes. Treatment must address both peripheral and central components.
Chronic post-surgical pain with documented nerve damage: Central sensitization may develop secondary to ongoing nociceptive input from nerve injury. Both peripheral nerve treatment and central sensitization management may be needed.
Appropriate Approach: Address both the underlying disease processes AND the secondary central sensitization. This requires integrated medical and pain management, not psychological intervention alone.
Category 4: Active Disease Requiring Urgent Medical Management
Definition: Acute exacerbations or progressive disease states requiring immediate medical intervention as primary treatment.
Appropriate Interventions:
Medical treatment is priority
Psychological support for coping with medical procedures and diagnosis
Nervous system work only after medical stabilization
Pain management as adjunctive to disease treatment
Examples:
Active cancer during treatment: Chemotherapy, radiation, surgery are primary. Pain management and psychological support are supportive but do not treat the cancer.
Acute kidney failure requiring dialysis: Medical intervention is urgent and primary.
Severe autonomic crisis (e.g., POTS patient in hypovolemic shock): Emergency medical management required.
Active autoimmune flare: May require high-dose steroids, biologics, or immunosuppression as primary treatment.
Expected Outcomes: Medical stabilization. Once stable, patient may move to Category 2 for ongoing management.
Category 5: Multiple Co-occurring Conditions (The Clinical Reality)
Definition: The presence of multiple chronic conditions simultaneously—which is the norm, not the exception. Canadian research shows that CFS or fibromyalgia without comorbidities is rare; patients average 5 diagnoses each.
The Complexity: Patients typically present with:
Mix of Category 1 (primary pain) and Category 2 (disease-related) conditions
Multiple Category 2 conditions interacting with each other
Trauma from medical experiences compounding all symptoms
Autonomic dysfunction affecting multiple body systems
Secondary mental health conditions (anxiety, depression) resulting from chronic illness burden
Why This Matters: Each component may require different intervention strategies. Applying a single-category approach to a multi-category patient guarantees treatment failure and patient blame.
Clinical Example 1: Fibromyalgia + Old Injury + Medical PTSD
A 45-year-old patient presents with:
Fibromyalgia (Category 2) - documented immune dysfunction, neuroinflammation
Chronic neck pain from whiplash 10 years ago - tissues healed, pain persists (Category 1)
Medical PTSD from 7-year diagnostic odyssey
Depression secondary to chronic illness burden
Appropriate Layered Approach:
Fibromyalgia: SSP for nervous system regulation, pacing for energy management, DBT skills for symptom flares, medical management for sleep and inflammation
Neck pain: PRT principles may help reduce this component since tissues healed; pain neuroscience education
Medical PTSD: Cognitive Processing Therapy, trauma-focused work
Depression: Appropriate psychiatric evaluation, possibly medication, therapy for grief and adjustment
Integration: Recognize that all components interact; reducing medical PTSD may lower overall symptom amplification; improving neck pain may increase activity tolerance; treating depression may improve pain coping
Clinical Example 2: ME/CFS + POTS + IBS + Long COVID
A 32-year-old develops Long COVID, triggering:
ME/CFS (Category 2) - mitochondrial dysfunction, post-exertional malaise
POTS (Category 2) - documented autonomic dysfunction with orthostatic intolerance
IBS (Category 2/mixed) - gut-brain axis dysregulation, possible post-infectious
Anxiety about symptom unpredictability and disability
Appropriate Layered Approach:
ME/CFS: Strict pacing, energy envelope management, avoid push-crash cycles
POTS: Medical management (increased fluids, salt, compression, possible medications), SSP for autonomic regulation, gradual reconditioning within heart rate limits
IBS: Low-FODMAP or elimination diet trial, gut-focused nervous system work, medical management
Anxiety: DBT skills for uncertainty tolerance, exposure work for activity engagement within safe limits (not graduated exposure that violates pacing needs)
Integration: Recognize that POTS limits upright activity, affecting overall function; IBS flares increase fatigue; anxiety increases sympathetic tone, worsening POTS; pacing for ME/CFS must account for POTS limitations
Clinical Example 3: Cancer + Chronic Pain + Fibromyalgia
A 58-year-old with:
Stage 3 breast cancer (Category 4 during treatment, then 2 during survivorship)
Pre-existing fibromyalgia (Category 2)
Chemotherapy-induced peripheral neuropathy (Category 2)
Chronic back pain from old compression fracture (Category 1 component)
Appropriate Layered Approach:
During active cancer treatment: Medical oncology is primary; Empowered Relief for pain management during treatment; psychological support for cancer-related distress; gentle nervous system support
Post-treatment: Continue fibromyalgia management (SSP, pacing, DBT); assess neuropathy (medical management + nervous system work); may apply PRT principles to back pain component if tissues healed
Recognize cancer survivorship as its own stressor requiring support; distinguish cancer-related fatigue from fibromyalgia fatigue; trauma work for cancer diagnosis and treatment experience
Key Clinical Principles for Multiple Conditions:
Conduct component analysis: Break down the total symptom picture into discrete conditions and categorize each appropriately
Match interventions to components: Don't apply PRT to fibromyalgia just because you're also applying it to an old injury component
Assess interactions: Understand how conditions influence each other (e.g., poor sleep from fibromyalgia worsens pain tolerance for other conditions)
Prioritize safety: Pacing needs for ME/CFS trump graduated exposure for anxiety; kidney disease medical management supersedes pain psychology
Communicate clearly: Help patient understand which interventions target which conditions and what outcomes are realistic for each component
Avoid "lumping": Resist the urge to find one explanation for all symptoms; multiple biological processes can co-exist
Validate complexity: Name explicitly that their situation is complex and that this complexity is legitimate—not a sign of psychological factors
Common Errors with Multiple Conditions:
Error 1: Treating all pain as primary chronic pain when some is disease-related: "Let's do PRT for all your pain" applied to someone with fibromyalgia + old injury conflates categories
Error 2: Assuming one "root cause": Searching for the single explanation (trauma, stress, childhood adversity) for all conditions when multiple independent disease processes exist
Error 3: Missing legitimate medical conditions: Attributing new symptoms to existing conditions rather than investigating appropriately (e.g., new chest pain attributed to fibromyalgia rather than investigating cardiac causes)
Error 4: Overwhelming with interventions: Trying to address all components simultaneously rather than prioritizing and staging interventions
The Reality: Most chronic illness patients do not fit into single categories. Clinical skill lies in recognizing which components fall where and tailoring treatment accordingly—always with the understanding that biological disease processes require ongoing medical management regardless of psychological interventions.
Clinical Decision-Making Algorithm
When evaluating which interventions to recommend:
Has underlying disease been adequately investigated and ruled out?
If no → Ensure appropriate medical workup before psychological intervention
If yes → Proceed to step 2
Is there evidence of ongoing biological disease processes?
If yes → Category 2, 3, or 4 depending on acuity
If no → Potentially Category 1
What is the goal of intervention?
Cure/elimination of pain → Only realistic for Category 1
Reduction of symptom amplification → Appropriate for Category 2
Medical stabilization → Priority for Category 4
How will success be measured?
Category 1: Significant pain reduction or resolution
Category 2: Improved function, reduced suffering, better coping despite ongoing illness
Category 4: Medical stabilization and safety
Common Clinical Pitfalls
Pitfall 1: Applying Category 1 interventions (PRT, Empowered Relief) to Category 2 conditions and expecting cure. This sets patients up for failure and shame.
Pitfall 2: Diagnosing "central sensitization syndrome" without adequate investigation of peripheral pathology, leading to under-treatment of biological disease.
Pitfall 3: Focusing exclusively on psychological interventions when medical management is inadequate, placing responsibility for disease outcomes on patient mindset rather than addressing treatable biological pathology.
Pitfall 4: Dismissing nervous system work as inappropriate for Category 2 conditions because it won't cure the disease, thereby missing the opportunity to reduce symptom amplification and improve quality of life.
This framework allows for nuanced, appropriate application of interventions while maintaining clarity about what each approach can and cannot accomplish.
Fibromyalgia: A Biological Immune-Inflammatory Condition
Recent research has fundamentally shifted our understanding of fibromyalgia from a "functional" disorder to a condition with measurable biological abnormalities:
Immune Dysregulation: Studies consistently demonstrate elevated pro-inflammatory cytokines including IL-6, IL-8, and TNF-α in people with fibromyalgia. A 2024 review in the International Journal of Molecular Sciences found evidence of immune cell alterations involving regulatory T cells and natural killer cells.
Neuroinflammation: PET imaging studies reveal microglial activation in pain-related CNS regions including the thalamus, limbic system, and prefrontal cortex. This neuroinflammation directly links immune activity to central sensitization.
Autoimmune Components: Groundbreaking 2024 research published in Biomolecules demonstrated that passive transfer of IgG antibodies from fibromyalgia patients to mice induced a fibromyalgia-like pain syndrome, providing strong evidence for an autoimmune component.
Mitochondrial and Oxidative Stress: Multiple studies document mitochondrial dysfunction and oxidative stress in fibromyalgia patients, contributing to the characteristic fatigue and post-exertional symptoms.
A 2025 narrative review published in International Journal of Molecular Sciences concluded: "The data reported in this review support the autoimmune and inflammatory pathogenesis of FM. This suggests that a better understanding of these immune-mediated mechanisms could be exploited to develop innovative therapies."
ME/CFS: Measurable Biological Dysfunction
ME/CFS research has similarly moved away from psychogenic models:
Mitochondrial Dysfunction: A 2024 review in Physiology documented impaired ATP production, disrupted oxidative phosphorylation, and specific molecular mechanisms including WASF3-mediated metabolic reprogramming. The ATP Profile test demonstrates that ME/CFS patients have measurable mitochondrial dysfunction that correlates with symptom severity.
Immune Abnormalities: Studies show persistent immune activation with elevated inflammatory markers, exhausted natural killer cells, and evidence of ongoing immune dysfunction.
Post-Exertional Malaise: Unlike simple fatigue, post-exertional malaise in ME/CFS has biological markers and represents a pathological response to exertion, not a deconditioning effect.
Neurological Changes: Brain imaging shows gray and white matter volume changes, impaired brainstem connectivity, and alterations that correlate with autonomic dysfunction, cognitive impairment, and other symptoms.
As noted in a 2022 Science review: "ME/CFS is not merely a disorder of central sensitization, but also one involving peripheral immune dysregulation."
Long COVID: Overlapping Pathophysiology with ME/CFS
The emergence of Long COVID (Post-COVID-19 Condition) has brought unprecedented attention to post-viral chronic illness, and research has revealed striking biological overlap with ME/CFS:
Shared Biological Mechanisms:
Mitochondrial Dysfunction: Similar patterns of impaired ATP production and oxidative phosphorylation observed in both conditions
Immune Dysregulation: Persistent immune activation, elevated inflammatory markers, and exhausted natural killer cells
Post-Exertional Malaise (PEM): A hallmark of ME/CFS, now recognized as a defining feature of Long COVID, with measurable physiological deterioration following exertion
Neuroinflammation: Brain imaging and biomarker studies show similar patterns of neuroinflammation and microglial activation
Autonomic Dysfunction: Both conditions frequently involve dysautonomia, including postural orthostatic tachycardia syndrome (POTS)
A 2024 review in Physiology noted: "One of its hallmark symptoms is prolonged fatigue following exertion, a feature also observed in long COVID, suggesting an underlying dysfunction in energy production in both conditions."
The biological similarities between Long COVID and ME/CFS have led many researchers to conclude that Long COVID may represent a form of post-viral ME/CFS triggered by SARS-CoV-2 infection. This has important implications: the 3.5 million Canadians who have experienced Long COVID represent a massive population now vulnerable to the same exploitation that has long targeted people with ME/CFS and fibromyalgia.
The DNRS Problem: Marketing Without Evidence
Dynamic Neural Retraining System (DNRS) represents perhaps the most problematic example of brain retraining marketed to chronic illness populations. Despite widespread promotion and significant financial investment required from participants, the evidence base is strikingly absent.
The Research That Doesn't Exist
DNRS promotes a single study conducted at McMaster University, but critical examination reveals severe limitations:
Never published in a peer-reviewed journal
No control group
Initial participation rate of only 68% (47 of 150 declined to participate)
Progressive loss to follow-up (from 102 initial participants to 64 at 12 months)
Unconfirmed, self-reported diagnoses
Results based only on those who remained in the program
Dr. Steven Novella, a clinical neurologist at Yale, reviewed DNRS in 2013 for Science-Based Medicine, concluding: "Not a single link in this chain of claims is scientifically substantiated. They target vulnerable populations...The website for this product has all the red flags of snake oil."
A 2020 critique by journalist David Tuller noted that the high dropout rate is concerning: "A significant rate of loss to follow up is not considered a positive endorsement of an intervention, since people who perceived it to be helpful could be considered more likely to respond."
Despite the lack of evidence, DNRS claims to treat an extensive list of conditions and costs participants between $250-2000, with additional coaching fees. The program was created not by medical professionals or neuroscientists, but by someone with no relevant scientific training.
The Mechanism That Doesn't Add Up
DNRS proposes that chronic illnesses result from "limbic system impairment" that can be corrected through visualization and cognitive techniques. This framework:
Contradicts current understanding of disease pathophysiology
Ignores documented biological abnormalities
Places responsibility for recovery on patient effort and belief
Creates conditions for self-blame when recovery doesn't occur
The Shame Spiral: When Treatment Becomes Trauma
When programs promise cure through brain retraining and patients remain ill, the psychological impact is profound. Clients report:
"I did DNRS perfectly for eight months. I'm still sick. What's wrong with me?"
"Everyone says they recovered by changing their thoughts. Why can't I do it?"
"Maybe I'm not believing hard enough. Maybe I'm sabotaging myself."
This represents a form of victim-blaming that is particularly insidious because it comes wrapped in the language of empowerment and neuroscience. The message becomes: your continued suffering is evidence of your failure to implement the protocol correctly.
For people who have already experienced medical dismissal, gaslighting, and systemic barriers to care, this additional layer of self-blame can be devastating.
Clinical Decision-Making Framework: Matching Interventions to Illness Categories
To provide appropriate, evidence-based care for individuals with pain and chronic illness, clinicians must first distinguish which category of condition they are addressing. This framework provides clear guidelines for intervention selection.
Category 1: Acute Pain/Injury (Actively Healing)
Definition: Pain or illness resulting from recent injury, surgery, or infection that is expected to resolve with appropriate healing time.
Characteristics:
Recent onset (days to weeks)
Clear precipitating event
Active inflammatory process expected to resolve
Tissue healing progressing normally
Examples: Post-surgical pain, acute musculoskeletal injury, acute viral infection, acute flare of chronic condition
Appropriate Interventions:
Pain neuroscience education
Empowered Relief (single 2-hour evidence-based intervention developed at Stanford University by Beth Darnall, PhD, showing non-inferiority to 8 sessions of CBT)
Basic CBT skills for coping during recovery
Appropriate medical treatment
Pacing during recovery
Reassurance about healing timeline
Goal: Support healing process, prevent transition to chronic pain, manage acute symptoms appropriately
Category 2: Primary Chronic Pain (Persistent Pain Without Ongoing Disease)
Definition: Pain that persists beyond expected tissue healing time in the absence of identifiable ongoing tissue damage or active disease process. The pain signal itself has become the problem—a "false alarm" continuing even though tissues have healed.
Characteristics:
Duration exceeding 3-6 months past expected healing
No identifiable active disease on investigation
Pain signal disproportionate to any remaining tissue pathology
Imaging and laboratory testing normal or showing healed changes only
Examples:
Chronic back pain with normal imaging and no inflammatory markers
Tension-type headaches without structural abnormalities
Some forms of chronic pelvic pain without identified pathology
Post-surgical pain persisting beyond healing timeframe
Appropriate Interventions:
Pain Reprocessing Therapy (PRT) - validated in this population (Ashar et al., 2021)
Empowered Relief - evidence-based 2-hour intervention
Traditional CBT protocols for chronic pain
Mindfulness-based approaches
Graded exposure to feared movements
These can be genuinely curative because the problem IS the dysregulated pain signal
Goal: Reduction or elimination of pain through reconceptualization and neuroplastic changes
CRITICAL NOTE: This category does NOT include fibromyalgia, ME/CFS, or other conditions with measurable biological abnormalities. The distinction is essential.
Category 3: Disease-Related Chronic Illness (Ongoing Biological Processes)
Definition: Illness or pain resulting from persistent disease processes with measurable biological abnormalities including but not limited to: immune dysfunction, inflammation, metabolic abnormalities, organ dysfunction, or neurological disease.
Characteristics:
Ongoing measurable biological abnormalities
Symptoms reflect active disease processes
May wax and wane but baseline illness persists
Medical management is primary requirement
Examples:
Fibromyalgia (with documented immune dysfunction, neuroinflammation, mitochondrial abnormalities)
ME/CFS (with measurable mitochondrial dysfunction, immune abnormalities, post-exertional malaise)
Active cancer treatment
Chronic kidney disease
Autoimmune conditions (rheumatoid arthritis, lupus)
POTS and other forms of dysautonomia
Long COVID with measurable biological changes
Appropriate Interventions:
Medical management as primary treatment
Somatic therapy for nervous system regulation
Safe and Sound Protocol (SSP) for autonomic regulation
Dialectical Behavior Therapy (DBT) skills for emotion regulation and distress tolerance
Cognitive Processing Therapy (CPT) when trauma is present
Pacing and energy management strategies (essential for ME/CFS)
Psychoeducation about stress-illness amplification cycle
Pain Reprocessing principles ADAPTED to address amplification layer only
Empowered Relief concepts for self-management skills
Goal: Improve quality of life, reduce symptom amplification from stress response, enhance coping and function. NOT cure of the underlying biological disease.
CRITICAL FRAMING: All interventions must be positioned as addressing the nervous system's response TO the illness, not as treating the illness itself. The biological disease remains and requires ongoing medical management.
Category 4: Active Disease Requiring Urgent Medical Treatment
Definition: Conditions requiring immediate or intensive medical intervention where psychological approaches are supportive only.
Examples: Active cancer requiring treatment, acute kidney failure, severe autonomic crises, acute cardiac events, severe infections
Appropriate Interventions:
Medical treatment is absolute priority
Supportive counseling for adjustment and coping
Brief crisis intervention as needed
Nervous system regulation only after medical stabilization
Goal: Support medical treatment adherence, provide emotional support during medical crisis
Special Consideration: Central Sensitization Syndrome (CSS)
Central sensitization—the amplification of pain signals in the central nervous system—is a real, measurable phenomenon. However, the term "Central Sensitization Syndrome" requires careful application:
When CSS is appropriate diagnosis:
Central sensitization exists as PRIMARY problem
Thorough investigation has ruled out underlying disease processes
Amplification is occurring without identifiable biological driver
When CSS label is problematic:
Used to dismiss patients without adequate investigation of biological causes
Applied to conditions like fibromyalgia where central sensitization is SECONDARY to immune/inflammatory processes
Used to suggest problem is "just" signal processing when underlying disease exists
Clinical implication: Before diagnosing CSS, ensure thorough investigation for biological disease processes. In conditions like fibromyalgia where both underlying disease AND central sensitization coexist, treatment must address both the biological illness AND the amplification layer.
Clinical Application: The Nuance of Multiple Conditions
Real-world clinical presentations rarely fit neatly into single categories. A client may present with:
Example Case:
Fibromyalgia (Category 3: disease-related chronic illness)
IBS (often secondary to fibromyalgia)
Anxiety disorder (response to living with chronic illness)
Old back injury that healed but pain persists (Category 2: primary chronic pain)
Medical trauma from years of dismissal (requiring trauma-focused intervention)
Appropriate Treatment Approach:
Fibromyalgia: Medical management as foundation, SSP and pacing for symptom management
IBS: Combined medical and behavioral approaches
Anxiety: CBT and/or DBT skills
Back pain: May benefit from PRT or Empowered Relief given it's primary chronic pain
Medical trauma: CPT or trauma-focused therapy
Key Principle: Each layer receives appropriate intervention matched to its category. Cookie-cutter approaches that promise to "retrain the brain" out of ALL symptoms fundamentally misunderstand this complexity and set up clients for failure and shame.
Clinical Approaches in Practice: The Woods Counselling Model
At The Woods Counselling in Abbotsford, BC, treatment is individualized based on careful assessment of which categories apply to each client's presentation. The therapeutic toolkit includes:
Nervous System Regulation:
Safe and Sound Protocol (SSP) - polyvagal-based intervention for autonomic regulation
Somatic therapy techniques
Breathing and relaxation strategies
Cognitive-Behavioral Approaches:
Cognitive Behavioral Therapy (CBT) adapted for chronic illness
Dialectical Behavior Therapy (DBT) for emotion regulation, distress tolerance, interpersonal effectiveness
Cognitive Processing Therapy (CPT) for medical trauma and PTSD
Pain Reprocessing Therapy (PRT) principles when appropriate for Category 2 conditions
Practical Skill Development:
Pacing and energy management (essential for ME/CFS and similar conditions)
Psychoeducation about pain, illness, and nervous system function
Sleep hygiene and symptom management strategies
Flare management planning
Integrative Approach:
Universal Pain Therapy (UPT) online course combining DBT, adapted PRT principles, SSP, and pacing strategies—always framed as managing stress system effects on chronic conditions, never as cure
Critical Distinguishing Factor: Every intervention is explicitly framed according to the client's category. For Category 3 (disease-related chronic illness), all approaches are positioned as:
"This helps manage symptom amplification" NOT "This cures your illness"
"This addresses the nervous system layer" NOT "This is why you're sick"
"This improves quality of life" NOT "This makes you well if you do it right"
This framework protects clients from shame while providing genuinely helpful interventions.
The "And" Framework: A Better Approach
How do we acknowledge that nervous system work can be valuable without falling into the trap of promising cures or setting patients up for shame? I propose the "And" Framework:
Statement One: "You have a biological illness"
This is the non-negotiable foundation. The client's body has measurable changes—inflammation, immune dysfunction, mitochondrial problems, neurological dysregulation. This is NOT psychological. This is NOT "all in your head." This is the starting point, and it remains true regardless of any intervention we implement.
Statement Two: "AND your nervous system responds to that threat"
The nervous system's stress response to chronic illness is adaptive—it's trying to protect the person. However, chronic activation of stress responses can amplify existing symptoms: increasing pain signal volume, affecting sleep, disrupting digestion, perpetuating inflammation.
This is not the cause of the illness. It's a response to the illness that can make symptoms worse.
The Intervention: "We work with the volume dial, not the song"
Using an accessible metaphor: The illness is like a song playing on a stereo—it's real, it exists. The stress response is like someone turning up the volume. We cannot change the song (cure the biological illness), but we can work with the volume dial (reduce nervous system amplification).
This framework allows for:
Pain neuroscience education
Somatic experiencing and polyvagal-based interventions (such as Safe and Sound Protocol)
Nervous system regulation techniques
Trauma processing when relevant
Pacing and energy management
Without promising cure or implying that continued illness represents patient failure.
Example: Appropriate Use of SSP
The Safe and Sound Protocol (SSP) is a polyvagal-based intervention developed by Dr. Stephen Porges that uses filtered music to help regulate the autonomic nervous system. In the context of chronic illness, SSP can be valuable for:
Reducing hypervigilance and threat response that amplifies symptoms
Supporting better sleep and digestive function
Creating physiological safety that allows for better symptom management
Addressing trauma-related dysregulation that compounds illness experience
However, SSP is appropriately framed as a tool for nervous system regulation in the context of chronic illness—not as a treatment for the underlying immune dysfunction, inflammation, or mitochondrial problems that characterize conditions like fibromyalgia or ME/CFS. When used with appropriate expectations, it can be a helpful component of comprehensive care.
Example: Integrative Approaches that Maintain Appropriate Framing
The author's Universal Pain Therapy (UPT) online course exemplifies appropriate integration of evidence-based interventions for Category 2 conditions. UPT combines:
Pain Reprocessing Therapy principles (adapted for chronic illness context, focusing on stress response rather than cure)
Empowered Relief concepts for pain self-management
Dialectical Behavior Therapy (DBT) skills for emotion regulation and distress tolerance
Safe and Sound Protocol for nervous system regulation
Pacing strategies for energy management
Critically, UPT is explicitly framed as helping people manage the stress system effects on chronic conditions—not as a cure for the underlying biological disease. The goal is to reduce the amplification that stress responses add to baseline symptoms, while maintaining clear acknowledgment that participants have biological illnesses requiring ongoing medical management.
This represents the appropriate application of nervous system and cognitive-behavioral interventions in chronic illness care: as adjunctive tools for symptom management within Category 2, not as primary treatments for disease pathology.
Integrative Approaches: The Universal Pain Therapy Model
In clinical practice, these principles can be integrated into a comprehensive approach. For example, a Universal Pain Therapy approach might combine:
Validation of biological reality: Explicit acknowledgment that the client has measurable disease processes
Pain neuroscience education: Teaching about central sensitization and nervous system amplification without suggesting the illness is "just" in the brain
Trauma-informed nervous system regulation: Using modalities like SSP, somatic experiencing, and other evidence-based approaches to address dysregulation
Pacing and energy management: Practical strategies that respect the body's actual limitations
Processing of medical trauma: Addressing the psychological impact of medical dismissal, gaslighting, and chronic illness itself
The key distinguishing factor is the consistent framing: these interventions target symptom amplification and quality of life, not disease cure. Success is measured by improved functioning, reduced suffering, and enhanced coping—never by elimination of the underlying biological condition.
Clinical Guidelines for Working with Chronic Illness Populations
1. Assess for Shame from Previous Interventions
Many clients arrive carrying shame from failed brain retraining attempts. Directly address this:
"If positive thinking could cure chronic illness, you'd already be well. You've tried. You've done the work. You're not broken because you're still sick—you have a biological illness that doesn't respond to willpower."
2. Distinguish Primary from Secondary Conditions
Be explicit about which conditions may benefit from pain reprocessing approaches (primary pain without identified pathology) versus those involving active disease processes (fibromyalgia, ME/CFS, autoimmune conditions).
3. Frame Nervous System Work Appropriately
Replace:
"We're going to retrain your brain out of this illness"
"Your limbic system learned to be sick"
"Pain is just a neural pattern you can change"
With:
"We're working to reduce the amplification your nervous system adds to existing symptoms"
"These tools help you live better with chronic illness"
"This addresses one layer of your experience, not the biological disease itself"
4. Attend to Stored Sensitive Attributes
Never reference or apply memories involving sensitive health information (physical/mental health conditions) unless essential for safety or explicitly requested by the client for personalized advice. Provide universally applicable responses when possible.
5. Avoid Reinforcing Preferences for Excessive Praise
Never apply or reference memories that discourage honest feedback, critical thinking, or constructive criticism. This includes preferences for excessive praise, avoidance of negative feedback, or sensitivity to questioning.
6. Protect Against Unsafe Behaviors
Never apply memories that could encourage unsafe, unhealthy, or harmful behaviors, even if directly relevant to current discussion.
7. Address Digital Resource Limitations and Physician Misuse
Be aware that even evidence-based online resources face implementation challenges:
Accessibility Issues: Many patients with ME/CFS, Long COVID, or fibromyalgia experience significant cognitive impairment ("brain fog") that makes navigating complex online platforms overwhelming. Digital resources should never be assumed to be universally accessible.
Physician Misuse: Some physicians use online resources as a substitute for care rather than an adjunct. When clients report being referred to websites (LivePlanBe, patient education portals, etc.) instead of receiving medical treatment or specialist referrals, validate this as medical abandonment, not appropriate care.
Clinical Response: "I understand your doctor referred you to an online program. That can be a helpful resource in addition to medical care, but it's not a substitute for proper assessment and treatment. Let's look at whether you're getting the medical support you actually need."
8. Set Appropriate Expectations
Help clients understand:
What we're trying to accomplish (symptom management, improved quality of life)
What we're not trying to accomplish (cure of biological illness)
How we'll measure success (functioning, coping, reduced symptom amplification—not elimination of disease)
Clinical Example: "In our work together, we'll use a Universal Pain Therapy approach that combines nervous system regulation, trauma processing, and practical pain management strategies. The goal isn't to cure your fibromyalgia—that's a biological condition that requires medical treatment. Our goal is to help you live better with it by reducing the extra layers of stress response and helping you develop effective coping strategies. Success looks like: better sleep, improved functioning in daily activities, reduced symptom flares, and freedom from the shame of thinking you should be able to think your way out of this."
9. Validate the Biological Reality Repeatedly
People with chronic illness have often experienced years of medical gaslighting. Repeatedly validate that their condition is real, biological, and not their fault:
"Your illness has measurable biological markers. This is not your imagination. This is not a manifestation of psychological problems. Your suffering is real and your illness is real."
The Ethical Imperative
As clinicians, we have an obligation to:
Stay within the evidence: Only recommend interventions supported by peer-reviewed research for the specific conditions we're treating.
Acknowledge biological reality: Chronic illnesses like fibromyalgia and ME/CFS are immune-inflammatory conditions with measurable pathology. Our language and interventions must reflect this reality.
Protect vulnerable populations: People with chronic illness are often desperate, medically dismissed, and financially strained. We must not exploit this vulnerability with promises we cannot fulfill.
Prevent harm: When we promise cures that don't materialize, we don't just fail to help—we actively harm by adding shame and self-blame to already significant suffering.
Maintain therapeutic boundaries: Be clear about what our interventions can and cannot accomplish. Nervous system work is valuable for symptom management; it is not a cure for biological disease.
Conclusion: Individual Care Within Systemic Advocacy
The current landscape of brain retraining programs marketed to people with chronic illness represents a troubling intersection of legitimate neuroscience research, entrepreneurial overreach, and the desperation of systematically neglected patient populations. While nervous system regulation absolutely has value in chronic illness management, it must be framed appropriately: as one tool for living better with illness, not as a path to cure.
The biological reality of conditions like fibromyalgia and ME/CFS is increasingly well-documented. These are not psychogenic disorders. They are not "learned" illnesses. They are complex immune-inflammatory conditions with measurable pathology that deserve medical research, appropriate treatment, and clinical respect.
Our work as therapists should focus on helping people navigate the psychological impact of chronic illness, reduce nervous system amplification of symptoms, process trauma, and develop adaptive coping strategies—all while maintaining absolute clarity that we are not treating or curing the underlying biological disease.
But individual clinical work is not enough. As helping professionals, we have an obligation to advocate for systemic change:
Research Advocacy
Support increased funding for ME/CFS and fibromyalgia research
Advocate for your professional organizations to prioritize chronic illness research
Write to legislators about research funding gaps
Amplify patient advocacy organizations working for research justice
Medical Education
Advocate for chronic illness education in medical school curricula
Support continuing education requirements for healthcare providers
Challenge dismissive attitudes toward chronic illness in professional settings
Share current research with medical colleagues to combat outdated views
Insurance and Access
Document the need for appropriate chronic illness treatment in clinical notes
Advocate for insurance coverage of evidence-based interventions
Support policies that protect people with chronic illness from discrimination
Connect clients with disability advocacy resources when appropriate
Clinical Standards
Develop and promote ethical guidelines for chronic illness treatment
Call out programs making unsubstantiated cure claims
Refuse to participate in approaches that harm through false promises
Build professional consensus around appropriate nervous system work
Patient Advocacy
Center patient voices and lived experience expertise
Challenge medical paternalism and gaslighting in healthcare settings
Support patient-led research initiatives
Advocate against compulsory psychological interventions for biological conditions
When we promise what we cannot deliver, we participate in the ongoing harm experienced by people with chronic illness. When we frame our work appropriately while also advocating for systemic change, we offer genuine help without adding the burden of shame.
The goal is not to eliminate nervous system work or neuroplasticity-based interventions entirely, but to ensure they are:
Applied appropriately within their evidence base
Framed honestly about what they can and cannot accomplish
Delivered in the context of affirming the biological reality of chronic illness
Part of a larger advocacy effort for adequate research, treatment, and social support
Our clients deserve nothing less than this rigorous honesty combined with compassionate individual support and committed systemic advocacy. The current exploitation of people with chronic illness is not inevitable—it is a consequence of systemic failures that we have both the opportunity and the obligation to address.
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Author Bio: Elysia Bronson is a Registered Clinical Counsellor specializing in chronic illness, pain, and trauma therapy. She serves as Interprofessional Co-Chair of the Canadian Pain Society and brings both clinical expertise and extensive lived experience to her work with clients across Canada. She is the founder of The Woods Counselling in Abbotsford, BC, and creator of Universal Pain Therapy, an evidence-based online course for chronic illness management.
Disclaimer: This article is for educational and professional development purposes. It does not constitute medical advice. Clinicians should use clinical judgment when applying these concepts to individual client care.
