Revising the Story: Pain, Psychedelics, and the Art of Getting Unstuck
Revising the Story
What if chronic pain is well-practiced story the nervous system keeps telling? A loop so familiar that it feels like fact. What if, instead of trying to fight the story, we created the conditions for a new one to emerge?
Persistent pain often comes with reduced psychological flexibility, limited movement variability, and a host of other issues—the system narrows its options, trying to stay safe. Over time, emotional tolerance shrinks, and attentional focus becomes increasingly dominated by pain-related cues. This is where the concept of canalization might offer a nice reframe.
What is Canalization?
Canalization is a term from developmental biology and neuroscience that describes how systems—like the brain—stabilize into well-worn patterns over time. These pathways are shaped by stress, experience, injury, and belief. At first, they’re adaptive. Efficient. Protective. But with repetition, they become rigid, often limiting flexibility and learning.
Think of it like water carving a path through soil. The more it flows that way, the deeper the groove becomes. Eventually, it’s hard to imagine the water going anywhere else.
Image Credit: Carhart-Harris et al. 2023 What is the probability the ball can fall into new grooves and form new patterns?
Video above:
To cut to the chase, skip to the 4-minute mark of this video with Dr. Carhart-Harris explaining canalization—how the brain gets stuck in rigid, overlearned patterns. He uses a beautiful metaphor: psychedelics increase entropy in the brain, like adding heat to a solid to help it loosen and reshape.It’s not hard to see how this might relate to chronic pain—where protective patterns, beliefs, and predictions become so entrenched they start to hurt more than they help.
Canalization and Chronic Pain
In persistent pain, perhaps these grooves become the brain’s default. A movement that once caused harm gets coded as dangerous. A belief like "I’m broken" or "my body can’t handle this" takes root and starts to shape behaviour. Now imagine this pattern being reinforced hundreds of times in multiple contexts ... the groove gets deeper making it challenging to see and do things in any other way.
The result? Avoidance, fear, sensitization, deconditioning, loss of identity—and often, more pain. Here’s the shift: rather than viewing these patterns as dysfunction, what if we saw them as over-learned stability? Not brokenness, but a system doing exactly what it’s been trained to do.
This reframe could help both clinicians and patients meet pain with more compassion, less urgency and open the door to curiosity and change.
How Do We Interrupt 'Canalized' Patterns?
This is where things get exciting. In MSK rehab, the goal isn’t to bulldoze the canal—it’s to create little rifts, gentle interruptions that allow for new possibilities. For the ball to be displaced into a new groove.
In clinical practice, that might look like:
A surprising moment of relief
A novel movement that feels safe
A metaphor or explanation that lands
An act of care that disconfirms fear
These are all ways to introduce expectation violation—a key ingredient in neuroplasticity. When the brain’s prediction doesn’t match the outcome, it pays attention. It updates. That’s learning.
My personal bias: I think this is a lot what rehab is about. Eliciting predictions, running experiments, getting surprised, and learning.
Cory Blickenstaff's Novel Movement and Edgework approach is very pragmatic and puts these concepts we are discussing today in some concrete actions and understandings for clinical practice. Watch the video above for a much more depth and a clinical example.
What Psychedelics Are Teaching Us About Pain?
This is also where psychedelics come in. Substances like MDMA, LSD, and psilocybin primarily act on 5-HT2A serotonin receptors and for some folks, help significantly relax the default mode network (DMN)—the system involved in self-referential thinking, internal narrative, and prediction. The DMN is most active when the mind is at rest and not focused on a specific task. While psychedelics are one way to quiet DMN activity, there are many other approaches—like meditation, movement, and breath work—that can also dial it down, though typically to a lesser extent in the short term.
When the DMN is dominant, the first-person experience often includes rumination, overthinking, and a sense of being trapped in your own story—what’s wrong with you, what might go wrong next, how others perceive you. After psychedelics, many people describe a profound shift: a quieting of that inner narrator, a sense of spaciousness, perspective, and connection to something larger than the self.
This relaxation of the DMN seems to unstick the brain from its usual grooves, creating a window of plasticity—a sea of potential.
Psychedelics are showing promise in treating some of the most challenging mental health conditions with new research starting to emerge in persistent pain populations.
I will outline a few studies in brief:
Treatment Resistant Depression
A phase 2 trial demonstrated large effect sizes and and symptom improvements rapidly after just two psilocybin treatment sessions and remained significant 6 months post-treatment in a treatment-resistant cohort.
Chronic Post Traumatic Stress Disorder
Phase 3 research indicates that MDMA-assisted therapy significantly reduces PTSD symptoms and functional impairment, with particularly strong effects on emotional avoidance, self-experience, and depression—facilitating long-term recovery and even remission in many.
Addiction
Clinical trials have shown beneficial effects of psilocybin-assisted therapy on substance use disorder symptoms, indicating its potential in addiction treatment.
Obsessive-Compulsive Disorder
Obsessive-Compulsive Disorder: An open-label study found that psilocybin administration led to acute reductions in OCD symptoms, suggesting potential therapeutic effects. Moreno et al.
Fibromyalgia
An open-label pilot clinical trial assessed the preliminary safety and effectiveness of psilocybin-assisted therapy in adults with fibromyalgia, providing initial insights into its potential safety and benefits. Also, a study protocol has been developed to investigate the effects of psychedelic-assisted therapy in patients with fibromyalgia, aiming to understand its impact on this chronic pain condition.
Chronic Low Back Pain
A clinical trial is evaluating whether psilocybin therapy can help patients cope more effectively with chronic low back pain.
One participant in a psilocybin-assisted therapy fibromyalgia trial shared:
“The stars pointed to the origin of my original injury… That insight helped me understand how to repair my body—I started moving again.”
Another reflected:
“Gratitude keeps surfacing—grateful for this often challenging body, since it means I’m still alive.”
These are more than just chemical effects—they're narrative shifts. Moments when the old story loses its grip, and something new is allowed to take root. The qualitative findings from these studies are especially compelling, revealing how psychedelics can lead to deeply meaningful realizations. These insights often spark genuine behaviour change and open the door to a better, more connected way of living.
But We Don’t Need Psychedelics to Start!
Psychedelics seem to offer a big window of opportunity, some research suggesting up to1-month, but of course, we don't have any good research showing efficacy and effectiveness in persistent pain just yet. Also, in many countries these drugs are illegal. They are certainly not for everyone, especially those we a family history of schizophrenia, have other real risks associated with them, and should not be positioned as first line care, which no authors are suggesting.
With all that being said, I think its good to see new treatments being developed for these very challenging pain conditions like fibromyalgia.
For first-line care in MSK rehab, I think we should aim to create micro-windows in everyday care.
We can:
Invite new interpretations of pain
Elicit predictions and gently challenge a belief, a fear, a worry or avoidance
Use test re-test with manual therapy
Confront folks with their own strengths
Provide reflective experiences after an exposure
Build safe, trusting relationships
Build a context and narrative for recovery
That’s what good rehabilitation is all about. Creating space for the people and their nervous system to learn something new. To feel safe enough to revise the story.
Final thoughts ...
I don't for a second think canalization is the new biomechanical boogeyman. It’s one of many ways to think about survival strategy. But when the old strategies start holding people back, we have a chance—not to fix them, but to offer something different. Something surprising. Something that might just change the path. Because healing isn’t always about joint mobilizations, 3 sets of 10, and pain science education. Sometimes it’s about finding the right moment to disrupt the pattern—and offering the nervous system a new place to go.
