[NS1] Nocebo Effect-Too Complex?

When Sofia walked into our pain clinic for the first time, she looked like she’d been carrying a mountain on her back. Years of back aches, pelvic discomfort, and migraines had robbed her of sleep and joy. Worse, the health-care system had labeled her as “too complex.” Every doctor she saw treated a single symptom, wrote another prescription, and sent her to someone else. No wonder she wondered whether there was any point in trying again.

This is the reality for many people with chronic pain. Pain that sticks around for months or years doesn’t just hurt - it wears down mood and hope. Studies show that long-term pain and mental health are deeply intertwined. It’s common for people with anxiety or depression to also experience pain, and constant pain can make anyone feel isolated and afraid. The brain responds to the way pain is talked about: supportive words can calm it down, while dismissive ones make symptoms feel worse.

Listening First

Instead of rifling through Sofia’s mountain of medical records, we started by asking her to tell her story. She talked about missing her daughter’s dance recital because she couldn’t get out of bed and about feeling like a burden. When she was done, I took a breath and said: “I believe you. We might not have all the answers yet, but we’ll figure this out together.” Her shoulders loosened, and tears welled up. Sometimes, the act of truly listening is the first piece of the healing puzzle.

Building Layers, Not Silos

In the past, Sofia’s pain was divided into parts - a scan here, a pill there. We decided to build a layered framework instead of siloed solutions. That meant putting together a team that included a doctor who understands the body, a counselor who understands emotions, a dietitian who understands food, and a physical therapist who helps people move without fear. Each of them saw Sofia as a whole person, not a sum of symptoms.

As we worked together, patterns emerged. Stress at work and hormone swings seemed to trigger her flare-ups. Childhood experiences of not being believed made her expect the worst. There was no single magic treatment, but there was a map that connected mind and body.

Words as Medicine

A turning point came when Sofia said, “Every time a doctor rolled their eyes at my chart, my pain got worse.” Neuroscience backs up what Sofia felt. The context in which treatment happens - the tone of a voice, a doctor’s confidence, the space to tell your story - sends powerful signals to the brain. In fact, a recent study showed that patients with chronic back pain who were cared for by very empathic physicians felt less pain and disability over a year than those whose doctors were less empathic.

Empathy isn’t fluff; it’s part of how bodies heal.

Finding Agency

Our plan for Sofia included gentle movement, breathing practices to calm her nervous system, and talking therapy to rewrite unhelpful stories her mind told her. She adjusted her diet to steady her energy and learned to pace herself rather than push and crash. As she reclaimed small pieces of her life - a walk with a friend, sitting through an entire movie without pain - her confidence grew. Her symptoms didn’t disappear completely, but she stopped feeling like a victim of her own body.

Frameworks for Providers and Patients can use

The lessons from Sofia’s story form a framework that anyone dealing with complex pain - patient or provider - can put into practice:

• Start with the story. Ask open questions and listen without judgment. Validation can be as powerful as medication.

• See the whole person. Pain, mood, sleep, stress, and relationships all influence one another. Integrated teams and family support matter.

• Mind your language. Words like “degenerative” or “failed” can feel like curses. Choose a language that conveys possibilities, not doom.

• Encourage agency. Small, achievable steps help people regain control. Celebrate progress rather than focusing only on what remains.

• Foster connection. Empathy from clinicians and loved ones activates the brain’s own pain-relief systems. Isolation does the opposite.

The Bigger Vision

When we started our clinic in 2013, it was just my assistant and me. Today, our team has grown to more than seventy people, and we’ve helped over 65,000 patients. We’ve learned that healing isn’t about finding a single cure — it’s about creating frameworks that align science with the human experience. Chronic pain often coexists with mood issues, and the relationship between patient and provider can change outcomes.

Women’s health and pain are not side issues; they’re central to healthy families and communities. By acknowledging the complexity, challenging dismissive attitudes, and weaving care around people’s stories, we can build a health system that empowers instead of labels. Let’s commit to frameworks that honor the whole person and make space for hope.

Brenda’s path forward reflections:

Often, we see patients who are labeled by the system as being complex because symptoms involve multiple systems with varying degrees of intensity and have often failed numerous other standard therapies. So it's easy to see why more than 70% of patients with pain lasting more than one year start developing a significant decrease in mental well-being, sadness, feeling frail, and alone. The stigma begins.

We as doctors have rarely been taught, if at all, that the words in our mind mean everything when it comes to healing.

I'm not saying that just words alone will solve the problems, but I am saying that the words we choose change the interaction with your patient from how the symptoms present to what we find on exam. These words change what options we offer and change the level of activation and motivation a patient feels to follow through on them.

In particular, the first interaction is a precious moment for setting the healing journey.

Typically, when we see a new patient, doctors will review the chart notes and any history provided, including imaging results and prior consultations. Patients with multiple issues are often deemed “complex." They often get handed off from one specialist to another, and there starts a cycle of fragmented, unaligned care.

However, at the first consultation, if the words in our mind are “person is too complex, and I don’t think we can help or “ not another one,” the patient will feel that, and healing doesn't begin. The medical trauma deepens.

I have seen patients turn the corner on years of pain not because we found a new pill or a better injection, but because, for the first time in years, someone looked them in the eye and said, ‘I believe you. I see you. I may not be able to solve all the issues, but I will walk this with you.’

That moment isn’t fluff - it’s neuroscience. It changes their brain’s prediction about the future, quiets threat responses, and awakens a sense of agency.

And agency is the first step toward recovery.

As providers, the words we hold in our minds before we meet a patient, the tone we use, the space we make for their whole story - these moments have measurable impact.

They shape whether a patient leaves with a next step… or with the courage to take it.