Episode 28: Grief and Pain (Part III) - Finding Your Way Back

When Grief Meets Pain, Episode 3: A Five-Step Healing Sequence

Dr. Zev Nevo presents episode three of “When Grief Meets Pain,” describing how major loss can rapidly worsen chronic pain by shifting the nervous system (including increased IL-6 inflammation, HPA-axis dysregulation, disrupted sleep, nucleus accumbens craving, and identity loss). He argues grief-informed pain care is essential and offers a five-step sequence: (1) stabilize the nervous system (coherence breathing, Safe and Sound Protocol, gentle somatic movement, grief-adapted sleep support) until feelings can be observed without total overwhelm; (2) name and witness all layers of loss with a safe other to support regulation; (3) process grief with body-based tools such as Pennebaker expressive writing, grief-specific therapies for complicated/prolonged grief, and a “stenographer” observing practice; (4) reprocess pain with grief-informed PRT and somatic tracking while rebuilding a future self; and (5) reconnect through community, meaning, service, and ritual. He notes when to seek professional help (prolonged grief disorder, suicidal ideation, escalating pain, severe isolation), shares his own losses, and ends with a one-breath, one-loss practice.

00:00 Welcome and Series Recap

00:49 When Loss Amplifies Pain

02:29 Grief Biology Explained

04:43 Why Grief Informed Care

05:10 Five Step Sequence Overview

05:31 Step One Stabilize

08:15 Step Two Name Losses

10:26 Step Three Process Grief

13:28 Step Four Reprocess Pain

16:07 Step Five Reconnect Meaning

17:58 Ritual and Relearning

20:34 When to Get Help

23:13 Personal Closing Story

27:01 Final Practice and Goodbye

This essential pre-roll message serves as a clear disclaimer, stating that the podcast provides pain and trauma-informed psychoeducation for informational and entertainment purposes only, and does not constitute medical advice. Listeners are reminded to always consult a qualified healthcare professional for specific medical conditions or symptoms.

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LINKS:

• Body and Mind Pain Center
• Mind Body Rehabilitation
• Substack

Transcript

Episode 28 | Grief and Pain (Part III) - Finding Your Way Back

[00:00:00] Welcome back to Mind Your Body. I'm Dr. Zev Nevo. This is episode three of our series, When Grief Meets Pain. And if you've been with me across the last two conversations, I wanna say something before we begin. Thank you. Thank you for staying in this with me, because the terrain we've been walking is not easy terrain.

[00:00:23] In episode one, we named the science, what grief does to the nervous system, why loss lights up the same pathways as physical pain. In episode two, we named the losses, all of them, the identities, the roles, the futures, the small daily things nobody sees, the invisible layers that pain strips away.

[00:00:46] And now in episode three, we build the path.

[00:00:49] Here's a pattern I see regularly in integrative pain medicine. Someone's been living with chronic pain for years. They've built a life around it, a careful, managed life. They [00:01:00] have good weeks and hard weeks, and they know the difference. And then a loss arrives, a spouse, a parent, a child. Within weeks, the pain doubles.

[00:01:12] The tools that used to work stop working. Sleep collapses. The person who walked into every appointment with determination now comes in and says something quieter.

[00:01:24] Something like, "I feel like I'm disappearing." That pattern is what this episode is about. Not a miracle recovery, not 10 steps to a pain-free life, a framework, a living adaptive practice, a sequence that respects what grief actually does to a body in pain, and what a body in pain actually needs to receive grief.

[00:01:50] Let's begin. Here's what I see in clinic almost every week. A patient comes in with chronic pain. They've done the physical therapy. They've tried the [00:02:00] medications. Maybe they've done mindfulness or CBT, and it worked, at least somewhat, until something happened. Someone died, a parent, a child, a spouse, a friend.

[00:02:12] And suddenly, the tools stop working. The pain gets louder. The interventions that used to bring it down stop bringing it down. The patient starts to feel like they're doing something wrong, like they're failing. But they're not failing. Their nervous system has changed. Here's what happens when grief enters a body that's already carrying chronic pain.

[00:02:33] IL-6 rises, interleukin-6, an inflammatory messenger. In the weeks after a major loss, IL-6 rises sharply in the bloodstream. This is not a metaphor, it's measurable. And IL-6 sensitizes the pain pathways in the spinal cord and the brain. What that means is that the same pain signal that used to register as a five is now registering as an eight.

[00:02:59] Nothing about the [00:03:00] tissue has changed. The nervous system's volume knob has been turned up. So the standard interventions, the ones that used to work, are still working. They're just working against a much louder signal.

[00:03:12] The HPA axis dysregulates the stress response system. Grief throws it off. Cortisol rhythms go haywire. The body wakes up at 3:00 in the morning, not because of insomnia, because the nervous system is scanning, looking, searching for the person who's gone. And sleep is where the nervous system does its consolidation work.

[00:03:33] Sleep is when pain reprocessing actually locks in. If the grieving patient is getting broken, fragmented sleep, they're losing the neural real estate that healing requires. The nucleus accumbens stays activated, the reward center of the brain. In grief, it activates the same way it does in addiction.

[00:03:53] There's a craving, a neurobiological craving for the person who's gone. And that craving [00:04:00] keeps the nervous system in a state of hypervigilance, searching, scanning, which means safety signals, the ones that pain reprocessing depends on, have a harder time landing. The nervous system can't receive you're safe when it's looking for someone who will never walk back through the door.

[00:04:17] Identity loss. Chronic pain strips away layers of self. Grief takes even more. What's left is often a person who no longer knows who they're becoming. And pain recovery, real pain recovery, requires a future self. 

[00:04:34] A version of you that the nervous system can move toward. If that future self is missing, the recovery has no destination. So here's the clinical reality. Grief-informed pain care is not a nice-to-have. It's not a luxury add-on. For this population, it is the treatment. Anything less is treating the surface while the storm underneath keeps raging.

[00:04:59] The [00:05:00] good news is, once we understand this, we can build something better, a sequence, an integrated protocol, and that's what the rest of this episode is about.

[00:05:10] So let's talk about the five-step healing sequence. I wanna walk you through this in five steps. because these five things build on each other. You can't skip a step. You can't do step four before step one. The sequence matters as much as the tools. Ready? Let's go.

[00:05:31] Step one: stabilize the nervous system first. You cannot process grief in a body that's on fire. You can't do pain reprocessing when the nervous system is in overwhelm. The first job always is stabilization. 

[00:05:48] Think of it this way. If a house is burning, you don't start rearranging the furniture. You put the fire down first, just enough, not to zero, but enough that the walls stop [00:06:00] shaking. For the grieving patient in chronic pain, stabilization looks like a few specific things. Coherence breathing. I use the Heart Math approach with many of my patients.

[00:06:11] Slow rhythmic breathing, focused on the area of the heart. About five seconds in and five seconds out. What this does is bring the heart rate variability up. It signals to the brain gently that the body is not in danger right now, in this moment. We're not asking the nervous system to feel safe about the loss.

[00:06:33] That's too big. We're asking it to feel safe in this one breath. And then the next one. The Safe and Sound Protocol, developed by Stephen Porges. It uses specifically filtered music to gently exercise the middle ear and the social engagement branch of the vagus nerve. For patients whose social nervous system has gone into shutdown, and grief often does exactly this, it can be a gentle way back in.

[00:06:59] Somatic [00:07:00] movement. Not exercise in the traditional sense. Gentle. Slow. Ten minutes of walking. Stretching in bed before you get up. The point is not to burn calories. The point is to remind the body that it's safe to move. That movement doesn't always mean pain. Sleep. Grief-adapted sleep hygiene. Which means understanding that if you're waking up at three in the morning, that isn't insomnia.

[00:07:29] That's your nervous system searching for the person who's gone. And fighting it makes it worse. Getting angry at yourself makes it worse.

[00:07:38] What helps is a gentle re-entry. Warm water, a cool room, a weighted blanket, sometimes a body pillow because the body remembers who used to sleep next to it. That's not weakness, that's neurobiology How do you know when you're stable enough to move on to step two? Here's the marker I use with patients. [00:08:00] You can observe your feelings without being completely consumed by them.

[00:08:04] The wave still comes, but you can watch it come and watch it go without disappearing into it. That's not the absence of grief. That's the beginning of being able to hold it. Step two is to name and witness the losses. Once the nervous system is stable enough, we move to naming. The loss inventory from episode two.

[00:08:26] If you missed it, go back. But the essence is this: you sit down in a safe place with a safe person, and you name every layer of what's been lost. The person, yes, but also the roles, the routines, the identities, the futures that won't happen. The small daily things, the Sunday morning coffee, the voice that used to call your name.

[00:08:47] Naming is not indulgence. Naming is nervous system work. And here's why. When a loss stays unnamed, the nervous system keeps encoding it as ambient threat, a background [00:09:00] hum of something is wrong. When you name it clearly, you give the nervous system a chance to metabolize what actually happened. It's still terrible, but it's no longer diffuse. And here's where witnessing comes in, because the naming needs to happen in the presence of a safe other, a therapist, a trusted friend, a grief group, someone whose only job in that moment is to receive what you're saying.

[00:09:28] This isn't just emotional support. This is physiological regulation. There's a whole framework here called Polyvagal Theory. The short version is this. The human nervous system has a specific circuit called the social engagement system. It runs through the vagus nerve. When we're witnessed by a safe other, when we make eye contact, when we hear a warm voice, that circuit activates.

[00:09:53] Heart rate variability improves, inflammation goes down, pain signaling settles. [00:10:00] We're wired to regulate in the presence of another regulated nervous system. That's not weakness, that's design. So please don't do this alone. If you have a therapist, bring your loss inventory there. If you have a friend who can hold space without trying to fix, bring it there.

[00:10:18] If you have neither, please reach out. A grief support group, a hospice bereavement program. There are people who will witness you. Being alone with grief and pain is not a virtue, it's a risk factor Step three, process the grief specifically. Here's something I say to patients often. Grief is not processed by thinking about it.

[00:10:40] You can't think your way through grief. You can only move through it in the body, with the body, sometimes despite the body. There are specific tools for this. Expressive writing. James Pennebaker, a psychologist at the University of Texas, did the foundational research on this decades [00:11:00] ago. His protocol is simple.

[00:11:02] You write about a traumatic or difficult experience, fifteen minutes a day, three consecutive days. You don't edit. You don't stop. You write the deepest, most honest version of what you're carrying. The results in study after study are striking. Improved immune function, reduced doctor visits, lower pain scores, and better sleep, all from fifteen minutes a day for three days.

[00:11:28] Why does it work? Because writing forces the nervous system to translate a somatic, chaotic experience into a coherent narrative, and coherent narrative is metabolizable. Chaos is not. If you try this, and I hope you will, don't expect to feel better on day one. Sometimes day one and day two feel worse. Day three is usually where the shift begins.

[00:11:53] Grief-informed talk therapy. If your grief is complicated, if it's been more than six or twelve months and you're [00:12:00] still in acute pain around the loss, if you can't function, there are specific protocols. Complicated grief treatment developed by Katherine Shear, prolonged grief disorder therapy. These are targeted evidence-based approaches.

[00:12:14] They're not general talk therapy. They're specifically built for grief that hasn't moved. If your therapist isn't familiar with these, that's okay. But ask. Ask what training they have in grief specifically, because generic support, however warm, may not be enough.

[00:12:31] The stenographer practice applied to grief. When a grief wave comes, and it will, your job is not to fight it, not to run from it, not to fix it. Your job is to observe it like a stenographer taking notes. Where is it in your body? The chest? The throat? The gut? The shoulders? What's its texture? Sharp? Heavy?

[00:12:55] Hot? A pressure? A hollowness? [00:13:00] Does it move? Does it stay? You're the witness, not the flood. This does something remarkable in the nervous system. The prefrontal cortex, the observing part of the brain, comes online, and the amygdala, the alarm center, quiets. You're still feeling the grief, but you're not being consumed by it.

[00:13:22] Practice this in small waves first. Then over time, you can hold bigger ones. Step four: reprocess the pain with grief-informed PRT. Now we come to pain reprocessing therapy, PRT. PRT is one of the most important developments in chronic pain treatment in the last decade. The research is strong. The results in the right population are transformative.

[00:13:47] But standard PRT often falls flat with grieving patients because the reframe at the heart of PRT, that some pain is generated by the nervous system rather than tissue damage, can feel dismissive to someone who's also [00:14:00] carrying enormous emotional pain. It can sound like your pain isn't real. So let me say this clearly.

[00:14:07] Your pain is real, all of it. The physical pain, the grief pain, the pain of losing yourself, every layer is real. What PRT actually says is more subtle. Some of the pain signal is the nervous system's grief, not structural damage, and that doesn't make the pain less real. It makes it modifiable. Here's what somatic tracking looks like in a grieving patient.

[00:14:35] You're having a pain surge. Instead of tensing against it, you get curious. You breathe into it. You ask gently, "What else is here right now?" And often, if you listen carefully, you notice something. The pain surge is happening at the same time as a grief surge, a memory, a song on the radio, the [00:15:00] smell of your loved one's soap, the date on the calendar.

[00:15:04] You name it, out loud if you can. The pain came up because I miss him. This is my body missing him. Not to dismiss the pain, to understand it fully. The pain is carrying the grief, and when you meet it that way, something in the nervous system exhales. The identity piece, the future self. The nervous system needs somewhere to go, a direction, a version of you that's moving forward.

[00:15:35] I don't ask my grieving patients who they were before. That person is gone. I ask them, "Who are you becoming? Not in ten years, just this month. What's one small thing you want to be true about your life a month from now?" Cooking one meal a week, walking around the block, sending one text to a friend. Small, concrete, [00:16:00] yours.

[00:16:01] The nervous system moves toward what it can see, so give it something to see. Step five, reconnect with community and meaning. The final step, and this is not really final because you circle back through all of them, is reconnection. Grief isolates, pain isolates, and when you have both, the isolation compounds, and the isolation itself becomes a driver of both.

[00:16:26] The way out is small, not big. Viktor Frankl, the psychiatrist who survived the concentration camps, wrote about this. He called it logotherapy. The core idea is that even in suffering, meaning is available. Not the meaning of the suffering itself, the meaning you build in response to it. For the chronically ill, for the grieving, this is not abstract philosophy, it's practical medicine.

[00:16:52] Here's what I ask my patients to try. One community commitment per week, however small, a phone call to [00:17:00] a friend, attending a service, a grief group, a meal shared with someone. One act of connection, and one act of service, however small, bringing a neighbor their mail, sending a card to someone who's also grieving, holding a door.

[00:17:20] This is not toxic positivity. This is neuroscience. Pro-social behavior, being of use to another person, measurably reduces inflammatory markers. It raises oxytocin, and it regulates the vagus nerve. We're wired to heal in the direction of each other. If you've lost a person who is your primary connection, this is especially hard and especially important.

[00:17:45] The path back is slow. It's not about replacing anyone. It's about staying in the human community because that community is part of what your nervous system needs to knit itself back together. Ceremony and [00:18:00] ritual. The nervous system needs ritual. It's wired for it. Every culture in human history has invented rituals for loss because our biology requires them.

[00:18:10] You don't need a funeral. You need something small, deliberate, and repeatable. Light a candle. Say the loss out loud. "Tonight, I'm honoring the runner I used to be." Blow out the candle. Write a letter to the self you were. Say what you loved about her. Say what you miss. Fold the letter. Put it somewhere meaningful.

[00:18:34] Have a conversation with one safe person. One. Not a group, not a therapist necessarily, though a therapist counts, but just one human being who can sit with you while you name what was lost. That's a ceremony too. Ritual signals to the nervous system that a transition is happening, that something is being acknowledged, that the story is being witnessed, [00:19:00] and witness at the level of biology is medicine.

[00:19:03] Relearning the world. There's a phrase from the grief literature that I love, and it comes from the researcher Thomas Attig, "relearning the world." The idea is that grief is not something you get over. It's something you integrate, and integration means relearning how to live in a world that's been changed by loss.

[00:19:22] You're not going back to who you were. Say that out loud, gently, with kindness. You're not going back. You're becoming someone who has carried this, someone shaped by it, someone who knows things that the earlier version of you couldn't have known. That's not defeat, that's becoming. Every day, in small ways, you're learning how to be a new self and a new life.

[00:19:49] Which foods work, which social settings are worth the cost, which relationships hold up, which parts of your old identity you want to keep, and which [00:20:00] parts you're ready to release. The work is real work. It counts, even when it looks like you're just sitting on the couch. Five steps. Stabilize the nervous system, name and witness the losses, process the grief specifically, reprocess the pain with grief-informed PRT, and reconnect with community and meaning.

[00:20:25] You don't need to do all five this week. Pick one, the one that landed while I was describing it. That's the one your body is asking for. I wanna be very clear about something. Everything I've talked about today is a framework. It's not a substitute for professional care, and there are specific situations where self-guided tools are not enough.

[00:20:46] I wanna name them without shame, because if you're in one of these places, reaching out is not failure, it's wisdom. Prolonged Grief Disorder. This became an official diagnosis in the DSM-V in [00:21:00] twenty twenty-two. It's real, and it's treatable. Signs include persistent, intense yearning for the person who's gone, an inability to accept the loss more than six to twelve months out, emotional numbness that doesn't lift, a sense that life has no meaning, functional impairment that keeps you from working, connecting, and caring for yourself.

[00:21:21] If this is you, please see a clinician. Complicated grief treatment and prolonged grief disorder therapy exists for exactly this reason. They work. Suicidal ideation. If you're having thoughts of wanting to die, if you feel like the world would be better without you, if you're making plans, please right now tell someone.

[00:21:42] Call a crisis line, nine eight eight in the United States. Go to an emergency room. Text a friend. This is not the moment for pride. This is the moment for help. Pain that's escalating despite everything. If your pain is rising and rising and none of the tools you've tried are moving it, [00:22:00] that's a signal, not that you're failing, that the constellation of what's happening in your body needs more skilled eyes on it.

[00:22:08] Find a grief-informed pain specialist. Ask directly. When you call the office, ask, "Does the doctor have experience with chronic pain in the setting of loss?" If the answer is no, keep looking. Isolation that feels impossible to break. If you haven't spoken to another human in weeks, if your world has collapsed to one room, if the phone feels like a mountain you can't climb, that's a medical situation.

[00:22:34] Please tell a doctor. Please tell one person. That first call is the hardest one you'll make, and it's the one that changes things. Here's what a grief-informed pain specialist looks like: someone who asks about your losses in the first visit, not the fifth, someone who doesn't separate mind and body, someone who knows what the HPA axis is, someone who's heard of polyvagal theory, someone who doesn't roll their [00:23:00] eyes when you talk about emotional pain.

[00:23:02] If you have to educate your doctor about grief, that's okay. Some of us are still learning. But find someone who's at least willing to learn with you. You deserve care that sees all of you. I want to close this series with something more personal than a protocol.

[00:23:17] For those of you who followed all three episodes, you know that I've been navigating my own losses, my father, my daughter, passing just nine days apart I want to name what it's been like to do this work while carrying that.

[00:23:32] There's a paradox in it that I didn't expect. A few weeks after I lost my father and then my daughter, I was sitting across from patients in pain, people whose bodies were carrying their own losses.

[00:23:45] I was trying to hold space for their suffering while my own was still fresh and still raw. I thought at first that I need to step away, that I couldn't possibly show up for them while I was myself unraveling. But something else happened. [00:24:00] Being of use, sitting with someone in their pain, listening to someone describe chronic pain that started the month after a significant loss, watching a person's face soften when I told them that their grief and their pain might be more connected than their other doctors had said.

[00:24:18] That wasn't draining me. It was in some strange way holding me. To know that what I'd learned, what I was in middle of surviving wasn't wasted, that it had somewhere to go, that another human being was being helped by the fact that I understood in my own body what they were describing. I don't recommend this as a healing strategy.

[00:24:39] I'm not saying you should push yourself back to work in the middle of your worst grief. Please don't, and rest when you need to rest. But I want to say this. If you're carrying loss and you have any capacity, however small, to be of use to another human being who's also suffering, do it. 

[00:24:56] That's one of the medicines for treating your own [00:25:00] grief. I want to say one more thing directly to you, whoever you are, wherever you're listening from. You didn't choose this, not the pain, not the loss, and not the intersection of both. But you're here, still listening, still looking for a way through.

[00:25:21] That's not weakness. That's one of the most courageous things a human being can do. And whatever way back looks like for you, I want you to know there is one. It doesn't look like before, but it's real, and it's yours, and it's waiting. I've been doing my own work. I've been naming what I've lost, and there's a lot.

[00:25:44] I've been sitting with people who can witness me without trying to fix me. I've been practicing the same tools I teach because I need them. And some days they work, and some days they don't, and that's the process. I'm not speaking to you [00:26:00] from the other side of this. I'm in it with you. And if I can find my way through while carrying what I'm carrying, you can find yours.

[00:26:08] Not because you're strong, because you're human, and humans are built for this, even when it doesn't feel like it. Thank you for walking through this series with me. Three episodes, grief and pain held together the way they actually live in the body. Episode one, we named the signs. Episode two, we named the losses.

[00:26:31] Episode three, we built the path. If any of this has met you where you are, I'm glad. If you know someone else who's carrying grief and chronic pain, share this series with them. Not because we have all the answers, because sometimes being seen inside the pain is the beginning of finding your way out of it.

[00:26:50] If you want to work with us at Body and Mind Pain Center, our door is open. We see patients in Los Angeles. We work with people from all over, and we bring this integrated [00:27:00] approach when we need to. Before you go, I want to leave you with one practice. 

[00:27:04] Right now, wherever you are, take one breath with me.

[00:27:10] Now name one loss, just one. Out loud if you can, in your head if you can't. One loss that's been sitting in your body unnamed for too long. Say it. Hear it. Let it be real. That's the beginning. I'm Dr. Zev Nevo, and this has been Mind Your Body. Take care of yours.