Pain Reprocessing Therapy (PRT): A New Approach to Chronic Pain

A New Way to Think About Chronic Pain

For most of medical history, chronic pain has been treated as a tissue problem. The body hurts because something in the body is damaged. Find the damage, fix the damage, and the pain should go away. That model works well for acute injury. It works poorly for the millions of people whose pain has lingered for years after the original tissue has healed — or never had a clear injury to begin with.

Pain Reprocessing Therapy (PRT) is one of the most talked-about new entries in this space. It is built on a different assumption: that in many cases of chronic pain, the problem is not in the tissue but in the brain's prediction of danger. PRT aims to retrain that prediction. And in 2022, a randomized controlled trial published in JAMA Psychiatry — the Boulder Back Pain Study — produced results striking enough that clinicians and patients have been arguing about them ever since.

This guide explains what PRT is, what the evidence actually shows, who it is best suited for, and how it compares to the more established CBT for chronic pain (CBT-CP) hub.

What Is Pain Reprocessing Therapy?

PRT is a brief psychological treatment for chronic pain developed by Alan Gordon, LCSW, a psychotherapist and the founder of the Pain Psychology Center in Los Angeles. Gordon laid out the protocol in his 2021 book The Way Out, and it was tested formally in the Boulder Back Pain Study led by Yoni Ashar at the University of Colorado.

The core premise of PRT is what researchers call the neuroplastic-pain model. In this view, chronic primary pain — pain without a clear ongoing structural cause — is generated and maintained by the brain itself. The nervous system has learned to interpret normal signals as dangerous and to produce the sensation of pain as a protective response. The tissue is fine. The alarm is broken.

PRT borrows the language of predictive coding from cognitive neuroscience. Modern pain science holds that the brain does not passively receive pain signals from the body. It actively predicts what is happening, weighs incoming sensory data against those predictions, and constructs the experience of pain accordingly. When the brain's prior expectations are dominated by fear and threat, even neutral sensations can be felt as pain. PRT is designed to shift those expectations.

In plain language: PRT teaches people that the pain signal, in their specific case, is not evidence of damage. And it does that not through reassurance but through structured, repeated experiences that recalibrate the brain's threat assessment.

The Boulder Back Pain Study

The reason PRT is in the conversation at all is the 2022 trial published in JAMA Psychiatry (Ashar Y, Gordon A, Schubiner H, et al., "Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain"). The study enrolled 151 adults with chronic back pain of at least six months' duration and moderate severity, randomized to one of three arms: PRT, an open-label placebo injection, or usual care.

The PRT arm received one telehealth assessment session with a physician and eight sessions of PRT with a trained therapist over four weeks. The results, reported at the end of the four-week treatment period, were dramatic.

66%

Specifically, 66 percent of patients in the PRT arm reported being pain-free or near-pain-free at post-treatment, compared with 20 percent in the placebo arm and 10 percent in usual care. The mean reduction in pain intensity was substantially larger in the PRT group. Functional MRI scans suggested changes in brain regions involved in pain processing and self-referential thought. And the gains were largely sustained at the one-year follow-up.

For chronic-pain research, those numbers are extraordinary. Most psychological treatments for chronic pain, including CBT-CP, produce modest reductions in pain intensity — typically one to two points on a ten-point scale — while delivering larger improvements in function and quality of life. PRT in the Boulder trial appeared to do something different in kind, not just degree.

The honest caveat: this is one trial in one population. We will return to the evidence limits below.

Who Developed PRT, and Where

PRT emerged from Alan Gordon's clinical work at the Pain Psychology Center in Los Angeles, building on earlier mind-body traditions associated with John Sarno and the broader tension-myositis-syndrome lineage. Gordon distilled those clinical observations into a structured protocol that could be taught, manualized, and tested in a trial.

Yoni Ashar, then a postdoctoral researcher at the University of Colorado Boulder and now faculty at the University of Colorado School of Medicine, led the clinical trial. Howard Schubiner, an internist and longtime advocate for the neuroplastic-pain model, served as the medical lead. Tor Wager, a leading pain neuroscientist, contributed the neuroimaging arm.

Gordon's book The Way Out (2021) remains the most accessible lay introduction to the protocol. Practitioner training is available through the Pain Reprocessing Therapy Center, an offshoot of the Pain Psychology Center.

How PRT Actually Works in Session

PRT is brief. The Boulder trial protocol was eight sessions over four weeks, in addition to the initial physician assessment. The clinical work has a few distinct components.

Pain Education and Reattribution

The first task is to help the patient reattribute their pain from "ongoing tissue damage" to "a brain-generated signal that no longer reflects danger." This is not done by lecture alone. The therapist reviews the patient's history, imaging, and prior workup to make a careful case that the pain pattern is consistent with neuroplastic pain rather than structural pathology. The medical assessment in the Boulder trial existed precisely to support this reattribution.

The goal is a genuine, felt shift in belief — not "my therapist told me my pain is in my head" but "I have looked at the evidence and I believe my brain has learned this signal."

Somatic Tracking

The core experiential technique in PRT is somatic tracking. The patient is guided to attend to their pain sensation with a particular stance: curiosity, lightness, and a posture of safety. The therapist coaches a kind of mindful observation — noticing the texture, location, and qualities of the sensation — while simultaneously reframing it as safe.

Phrases that often come up in somatic tracking include "This is just a sensation," "My brain is generating this signal, but my body is fine," and "I am safe right now." The point is not to make the pain go away through force of will. It is to repeatedly pair the pain sensation with a felt sense of safety, so the brain's predictive model updates over time.

In practice, somatic tracking is closer to a guided mindfulness exercise than to traditional cognitive restructuring. The patient is not arguing with thoughts about pain. They are practicing a new relationship to the sensation itself.

Affective and Avoidance Work

PRT also addresses the emotional life that surrounds chronic pain. Fear of the pain, anger at the pain, and avoidance of movements or situations associated with flares are all treated as upstream contributors to the brain's threat signal. The therapist helps the patient reduce avoidance, reengage with feared movements, and process the emotional layer — frustration, grief, fear — that often sits underneath chronic pain.

This part of PRT will sound familiar to anyone who has done CBT-CP or ACT for chronic pain. The graded re-engagement with avoided activities is similar. What differs is the framing: in PRT, the message is not "activity is safe even though pain is real" but "activity is safe because the pain is not signaling damage."

PRT vs CBT-CP vs Standard CBT

PRT is sometimes described as a competitor to CBT for chronic pain. It is more accurate to describe it as a related but distinct approach with overlapping techniques and a different theory of change.

Two things are worth pulling out of that table. First, PRT and CBT-CP share more techniques than the marketing language suggests — both reduce avoidance, both engage with the meaning the patient assigns to pain, both work to dampen the threat response. Second, they differ meaningfully in their target: PRT is more explicitly aimed at eliminating the pain signal itself, while CBT-CP is aimed at reducing the impact of pain on a life. For a head-to-head on the existing alternatives, see our CBT-CP vs ACT for chronic pain comparison.

Who PRT Is Best Suited For

The Boulder trial enrolled a specific population, and the strongest claims for PRT apply to people who match that profile. Based on the trial inclusion criteria and the clinical model, PRT is most appropriate when:

• The pain is centralized rather than structural. Centralized pain — pain maintained by changes in the central nervous system rather than ongoing tissue damage — is the target population. Chronic primary back pain, fibromyalgia-spectrum presentations, and many functional pain syndromes fit this picture.
• There is no clear ongoing tissue pathology. A medical workup that has reasonably ruled out red-flag structural causes is a prerequisite. PRT is not a substitute for medical evaluation.
• Catastrophizing and fear of the pain are prominent. The patients who responded best in the Boulder trial had high baseline catastrophizing scores. PRT seems to work, at least in part, by interrupting the catastrophizing-fear-avoidance loop at the level of belief about the pain signal itself.
• The patient is open to the neuroplastic-pain framing. PRT requires a genuine shift in how the patient understands their pain. Patients who are skeptical of the model, or whose lived experience strongly contradicts it, may struggle to engage with somatic tracking.

PRT is not appropriate, or at minimum should not be a first-line choice, when:

• There is active injury or unresolved structural pathology that has not been medically evaluated.
• There is an untreated mental-health crisis — active suicidality, severe untreated depression, or acute trauma reactions — that needs to be stabilized first.
• The pain is clearly nociceptive and inflammatory in origin (active rheumatoid flare, malignancy-related pain, post-surgical pain in the acute recovery window).
• The patient has been told their pain is psychological in dismissive or stigmatizing ways and is, understandably, primed to reject any model that sounds similar.

For a broader map of which therapy might fit which pain presentation, see our best therapy for chronic pain guide. For the underlying condition itself, the chronic pain condition hub covers pain types and the biopsychosocial model in depth.

What the Evidence Actually Says — and Does Not Say

The Boulder Back Pain Study is a serious piece of clinical research, and its findings are striking. The neuroimaging adds biological plausibility. The one-year follow-up suggests the gains are durable. The treatment is brief and relatively low-cost.

That said, honest appraisal of the evidence requires several caveats.

It is one trial. Replication in independent labs, with different patient populations and different therapist pools, is what turns a striking single result into an established treatment. That replication work is ongoing but not yet complete.

The population was narrow. The Boulder trial enrolled adults with chronic back pain of moderate severity who passed a medical screen and were willing to consider a psychological treatment. Whether the same results hold for fibromyalgia, complex regional pain syndrome, neuropathic pain, post-surgical chronic pain, or pain in older adults remains an open question.

The comparators matter. PRT outperformed an open-label placebo injection and usual care. It has not yet been compared head-to-head against CBT-CP or ACT in a published trial. We do not yet know whether PRT's advantage over usual care reflects something specific to the neuroplastic-pain framing or whether a strong dose of any focused, well-delivered pain-psychology treatment would produce similar results.

Therapist effects are likely large. The Boulder trial used therapists trained directly by Alan Gordon. Whether PRT delivered by less experienced practitioners produces the same effects is unknown.

The framing carries risk. A treatment built around the message "your pain is generated by your brain, not by tissue damage" can land as invalidating if delivered poorly, or to the wrong patient. Patients who have been told for years that their pain is not real have good reason to be wary of any model that sounds adjacent. Skilled PRT clinicians work hard to avoid this trap; less skilled ones will not always succeed.

None of these caveats are arguments against PRT. They are arguments for treating it as a promising, evidence-supported option for the right patient — not as a confirmed first-line treatment that should displace the existing CBT-CP and ACT evidence base.

How to Find PRT, or PRT-Informed Care

PRT is still a relatively small field. The most direct route to a fully trained PRT clinician is through the Pain Reprocessing Therapy Center directory. Many CBT-CP and pain-psychology clinicians have integrated PRT-informed concepts — neuroplastic-pain education, somatic tracking, safety reappraisal — into their existing practice without delivering the full eight-session protocol. That hybrid approach is increasingly common in pain-focused therapy practices.

If you are evaluating a therapist who advertises PRT, reasonable questions include:

• "Where did you train, and how many full PRT courses have you delivered?"
• "How do you decide whether PRT is appropriate for a given patient?"
• "How do you coordinate with my physician on the medical assessment piece?"
• "What is your plan if PRT does not produce the kind of changes seen in the Boulder trial for me?"

A thoughtful clinician will be comfortable answering all four, and especially the last one.

Frequently Asked Questions

The Bottom Line

Pain Reprocessing Therapy represents the most serious attempt yet to translate the neuroplastic-pain model into a manualized, testable treatment. The Boulder Back Pain Study produced effect sizes that, if they replicate broadly, would change the standard of care for centralized chronic pain. The somatic-tracking technique gives clinicians a clear, teachable experiential tool. And the brief format — eight sessions over four weeks — is dramatically more accessible than many existing pain programs.

At the same time, PRT is a young treatment with one major trial in a narrow population. It is not a substitute for medical evaluation. It is not appropriate for every chronic-pain presentation. And it shares a great deal with the better-established CBT-CP evidence base, which remains the most broadly supported psychological treatment for chronic pain.

For the right patient — centralized pain, high catastrophizing, no ongoing structural drivers, willingness to engage with the neuroplastic-pain framing — PRT is one of the most exciting options to enter chronic-pain care in years. For the rest, it is a useful set of ideas and techniques that increasingly informs how all good pain-psychology clinicians work, whether or not they call what they do PRT.