Episode 27: Grief and Pain (Part II) -The Invisible Losses

Chronic Pain as Unnamed Grief: Invisible Loss, Ambiguous Loss, and the Selves It Changes

Dr. Zev Nevo argues that chronic pain is an often-unrecognized grief experience, especially when losses are unnamed, unmourned, and unsupported by cultural rituals. Citing a 2026 paper, he outlines four “epistemic barriers” that cause chronic-pain grief to be missed: grief is assumed to be only about death, the loss is invisible, it lacks a clear start date, and it is often misread as depression (distinguishing depression’s hopelessness from grief’s missing what was real). He describes five layered losses chronic pain can create: the physical, relational, professional, future, and spontaneous selves. Drawing on Pauline Boss’s concept of ambiguous loss, he explains how chronic pain’s lack of closure can keep the stress response activated, and notes a 2023 review linking unresolved grief to chronic illness, somatic distress, and insomnia. He shares his own recent losses and previews episode three’s step-by-step approach to treating grief-amplified pain.

00:00 Welcome Back Setup

00:23 Unnamed Grief In Pain

01:54 Four Barriers Overview

02:28 Grief Beyond Death

04:02 Invisible Losses

05:29 No Start Date

07:00 Grief Or Depression

08:46 Five Layers Of Loss

09:02 Physical Self Loss

10:16 Relational Self Shifts

11:30 Work Identity Grief

12:38 Future Self Taken

13:38 Spontaneity And Calculation

15:27 Ambiguous Loss Framework

16:40 Nervous System Impact

17:53 When Bereavement Meets Pain

19:24 Personal Closing And Next

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.

About Dr. Nevo
Read what patients are saying...

LINKS:

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

Transcript

Episode 27 | Grief and Pain (Part II) - The Invisible Losses

[00:00:00] Hi, I'm Dr. Zev Nevo. Welcome back to Mind Your Body. If you were with me for episode one, thank you for coming back. We talked about what happens when grief and chronic pain arrive at the same time, the neurobiology of it, the reason grief makes pain louder, three practices to help you find your footing.

[00:00:23] Today, I wanna sit with something different. What if the grief you're carrying has no name? No one sent flowers. No one gave you permission to grieve. No one even called it grief, and yet something was lost, something real, something that mattered.

[00:00:43] This is the episode for anyone who's been living with pain for a while, maybe years, maybe decades. And under the pain, there's this other thing, a quiet sadness, a fog you can't quite locate, a sense [00:01:00] that some part of you is missing, but you can't point to what. It's also the episode for people who are carrying both: a recent loss, someone you loved, and a body that's been in pain for a long time.

[00:01:15] Because when those two meet, the losses start to layer, and the layering itself becomes its own kind of weight. I wanna make a case today that chronic pain is a grief experience. 

[00:01:28] That it's been sitting in your life unrecognized, unmourned. And when a loss goes unmourned, the nervous system cannot put it down. So let's give it a name. Let's give it a shape. Let's give it the ceremony it deserves. Take a breath with me before we begin. Okay, let's go. There's a paper from 2026 in the journal Medicine, Healthcare, and Philosophy [00:02:00] that named something I felt in my exam room for years but never had the language for.

[00:02:06] The authors describe four epistemic barriers, four reasons the grief inside chronic pain gets missed; by doctors, by family, by friends, and by the person carrying it. I wanna walk you through all four because once you can see them, they lose some of their power over you. Barrier one: grief is assumed to be only about death.

[00:02:34] When someone dies, our culture knows what to do. There's a funeral, there's a card in the mail. People take time off work. They text, they show up. But when a person loses their body slowly over years, no one knows what to do. 

[00:02:52] There's no funeral for the version of you who can run five miles on a Sunday morning. There's no ceremony for the hands that [00:03:00] used to play the piano before the arthritis set in. There's no obituary for the woman who used to say yes to every dinner invitation. And so the losses pile up silently without acknowledgement, without ritual.

[00:03:17] I had a patient a few years ago who'd been living with chronic hip pain for three years following a surgery. She told me she felt guilty for how sad she was because her mother had also died around the same time, and she felt like she was allowed to be sad about her mother, but not about the hip. That's barrier one right there.

[00:03:36] The cultural rule absorbed without even realizing it. Grief is for the dead. Everything else is supposed to be handled with willpower. But the body knows better.

[00:03:49] The body is grieving the walks that used to happen with the person who's gone. The two losses have grown into each other, and without a framework for either [00:04:00] of them, both go unprocessed. Barrier two: the loss is invisible. When someone breaks a leg, you can see the cast. When someone has cancer, you can see the treatment.

[00:04:14] There's a visible marker. Other people know how to respond. Chronic pain, however, has no visible marker. You look the same. You walk in the door of a family event and everyone says, "You look great," and you smile, and you find a chair to sit in as soon as you can.

[00:04:35] And no one knows that getting dressed took you 40 minutes, that you took two medications to be able to be there for an hour, that you'll be in bed tomorrow paying for tonight. The loss is real, but there's no ritual, no ceremony, no recognition from others. 

[00:04:53] Which means the person carrying it starts to question whether the loss even counts. Think about someone in the [00:05:00] trades: a contractor, a carpenter, someone whose livelihood and identity are built with their hands. When chronic pain starts to limit what those hands can do, there's nothing to show. The hands look the same.

[00:05:14] And when the people around you stop believing the pain is as real as it is, sometimes you start to wonder yourself. You can't mourn what you can't name, and you can't name what the world refuses to see. Barrier three: the temporal structure is different. This one's important. Bereavement grief, the grief of losing a person, has a start date.

[00:05:40] There's a phone call, a moment. 

[00:05:41] A before and an after. You can point to the day. Chronic pain grief has no start date. It comes in slowly. First, you stop hiking, then you stop running, then you switch to walking, then you shorten the [00:06:00] walks. Then one day you realize you haven't been on a real walk in two years. When did that happen? You can't say.

[00:06:08] It happened by inches. Because there's no start date, there's no anniversary, no moment where friends check in, no calendar marker that says, "Hey, this year has been hard. I see you." The loss keeps unfolding. New pieces of your life keep going, and each small loss is small enough on its own that it feels silly to grieve.

[00:06:34] So you don't. And the ungrieved losses pile up silent in the corners of your life. I want you to think for a moment. When was the last time you did something you used to love? Not a modified version, the real thing, the version of it that felt easy. If you can't remember, that's a loss and it deserves to be [00:07:00] named.

[00:07:00] Barrier four: chronic pain grief gets misread as depression. This one matters clinically, and it matters personally. When someone with chronic pain shows up in a doctor's office sad, tired, disengaged, the assessment often lands on depression, and sometimes it is depression. Sometimes depression is present alongside everything else, and it needs to be treated on its own terms.

[00:07:28] But often, what looks like depression is actually grief. Grief for the self who used to be here, and the treatments for those two are not identical. Because grief is not a disorder. Grief is a response to loss, a healthy, human necessary response. Here's the difference: Depression tells you the future is hopeless.

[00:07:54] Grief tells you the past was real, and you miss it. One closes the [00:08:00] door, the other keeps the door open because what was behind it mattered. If a doctor tells you that you're depressed and something in you says, "No, that's not quite it," listen to that voice. It might be pointing you toward grief, toward a set of losses that have never been given their proper name, and naming them changes what happens next.

[00:08:24] Four barriers: grief assumed to be only about death, the loss is invisible, there's no start date, and the grief keeps getting misread as depression. If any of those landed for you, stay with me because the next part is about the specific shapes these losses take. 

[00:08:46] Chronic pain doesn't take one thing from you. It takes in layers. I wanna walk you through the layers slowly, and I want you to notice which ones land for you. There's no right answer. There's only what's [00:09:00] true for your life. Layer one is the physical self. This is the one people talk about when they talk about it at all.

[00:09:10] What your body used to be able to do. Maybe you used to be the one who moved the couch when your friends were moving apartments. Maybe you used to carry your daughter on your shoulders. Maybe you used to sleep through the night without doing math in your head about how you were going to move in the morning. The physical self is not just about athletic performance.

[00:09:33] It's about the small, easy movements you used to do without thinking. Bending down to tie your shoes, reaching up to a high shelf, sitting on the floor to play with a child, and then getting up again. When those small things start requiring calculation, something is being lost. I had a patient, a grandmother, who told me the hardest part wasn't the pain itself.

[00:09:58] It was that she [00:10:00] couldn't get down on the floor with her grandson anymore. She used to build block towers with him. Now she sits in a chair and watches. She said, "I'm not the grandma I wanted to be." That's a loss, and it deserves to be named. Layer two is the relational self. This is who you were to the people around you.

[00:10:22] Maybe you were the provider, the one who made things happen, the one everyone leaned on. Maybe you were the caretaker, the one who showed up when someone was sick, the one who cooked, the one who drove people to the airport at five AM. Maybe you were the active one, the friend everyone called for a hike, the parent who never missed a soccer game.

[00:10:45] Maybe you were the strong one, the one who didn't complain, the one who held it together for everyone else

[00:10:52] Chronic pain rewrites those roles without your consent. You start saying no more often. You start asking [00:11:00] for help. You start being the one who needs the ride instead of the one giving it. The relational self doesn't disappear all at once. It shifts, and every shift is a small loss, and the small losses add up to something big.

[00:11:15] If you've ever thought, "I'm becoming a burden," I want you to hear me clearly. That thought is grief. It's grief for the self you were to the people you love, and it deserves to be named, not fought off with willpower. Layer three is the professional self. For many people, work is not just what they do, it's who they are, it's how they contribute, it's where their sense of purpose lives.

[00:11:41] Chronic pain changes the relationship with work. Sometimes it ends careers outright. Sometimes it forces a change of role. Sometimes it just changes the pace, the hours, the ambition. Think about a nurse, twenty years in trauma bays [00:12:00] who has to leave because of a back injury that never fully heals.

[00:12:04] What gets lost is not just the paycheck or the schedule. It's the knowing that you were useful in a way that mattered, that when things were at their most dire, you were the one the room needed. 

[00:12:16] That's professional grief, and it's real, and it deserves to be named. Even if you're still working, even if you're working at the same job, if pain has changed what you can bring to it, some version of your professional self has been altered. That deserves a place in the inventory.

[00:12:38] Layer four is the future self. This is the one that hurts the most in my experience. The plans you made, the version of yourself you were becoming. You had a picture in your head of who you'd be at fifty, at sixty, at seventy, of the trip you'd take with your spouse when the kids were [00:13:00] grown, of the garden you'd build, of the second act.

[00:13:05] Chronic pain doesn't just take from the present. It reaches into the future and takes from there too. It rewrites the picture without asking. And the grief for the future self is quiet. It shows up in offhand moments. Someone at a dinner party talks about their plans for retirement, and something in you closes off because you can't picture yours anymore, not the way you used to.

[00:13:32] That's a real loss, but no one will bring you a casserole for it. But it's worth naming. Layer five is the spontaneous self. This is the one people rarely talk about, the ability to just say yes. There was a version of you who could get a text at four PM and be at dinner at six PM and not think about it, who could accept a last-minute weekend invitation, who could be present in a moment [00:14:00] without calculating what it would cost your body tomorrow.

[00:14:03] Chronic pain replaces spontaneity with calculation. Every yes runs through a filter. Is this worth a flare? Do I have the reserves? What will I have to cancel later? The calculation is exhausting, and it's invisible, and it's one of the loneliest losses I know of because you can't explain to a friend that saying yes to their birthday dinner requires you to rest for two days beforehand.

[00:14:30] The spontaneous self is a loss, so name it. Five layers: the physical self, the relational self, the professional self, the future self, and the spontaneous self. I want you to hear me say this. You're not depressed, you're grieving, and those are not the same thing. Depression says the future is hopeless.

[00:14:59] Grief [00:15:00] says the past was real, and I miss it. One closes the door, the other is a door left open because what was behind it really mattered. Grieving the self you were before pain is a healthy, human, necessary response to real loss. It's not weakness. It's not failure. It's not something you have to fix.

[00:15:22] It's something to move through slowly with witness and with time.

[00:15:27] I wanna introduce you to a concept that changed how I think about all of this. It comes from a family therapist named Pauline Boss, who spent her career studying a particular kind of grief. She called it ambiguous loss.

[00:15:43] Ambiguous loss is loss without closure, without ritual, without social acknowledgment. She originally developed the framework for families of soldiers missing in action, for families of people with dementia, for situations [00:16:00] where someone was physically present but psychologically absent, or physically absent but not confirmed dead.

[00:16:08] There's no funeral. There's no clear ending. The loss keeps unfolding. Chronic pain is a form of ambiguous loss. There are moments where you catch a glimpse of them. Good days. Windows where the pain settles, and you remember what easy felt like, and then it comes back.

[00:16:30] There's no funeral for who you were. There's no anniversary. There's no closure. The loss keeps unfolding indefinitely. Here's why that matters at the level of your nervous system. When a loss is clear, the nervous system can begin the process of resolving it.

[00:16:50] Grief has stages in a loose sense, not a rigid ladder, but a movement, and the nervous system knows how to move through it given time and support. [00:17:00] But when a loss is ambiguous, the nervous system cannot resolve it. There's no signal that says, "This is over now. You can begin to reintegrate."

[00:17:09] There's no signal that says, "This is over now. You can begin to integrate." The stress response stays activated. The vigilance stays on. The body remains in a state of ongoing threat, even when there's no immediate danger. A 2023 systematic review of prolonged grief disorder studies found that 72% of them linked unresolved grief to chronic physical illness, somatic distress, and insomnia.

[00:17:42] 72%. That's not a small effect. That's the body telling us over and over that unmourned losses have physical consequences. Now layer that on top of what happens when someone has both: a recent bereavement, someone they loved, [00:18:00] and chronic pain, which is its own ambiguous loss. The two amplify each other in specific ways.

[00:18:07] The bereavement pulls the nervous system into acute grief, HPA axis activation, inflammatory markers rise, sleep breaks down, appetite shifts. The chronic pain already living inside an unresolved loss state gets amplified by the acute grief. The pain flares. The body can't buffer the new stress on top of the old.

[00:18:32] And here's the part that catches people off guard. The acute grief also reawakens the ambiguous grief. Losing a parent can bring back all at once every small loss the pain has taken over the years. The plans you had for retirement together, the walks you'll never take, the version of yourself you thought you'd be by the time this moment arrived.

[00:18:57] The two griefs are not separate. They [00:19:00] braid together, and unless you can see both threads, you can't untangle them. This is why in my practice, I ask patients not just about their pain. I ask them what they've lost, and I ask them who they were before. Not to make them sad, but to help them see what has never been named.

[00:19:20] Because you can't heal what you can't see. I want to end with a personal word. In the last episode, I told you that I lost my father and my daughter in the past few months. I told you I was speaking to you from inside the storm, not from the other side of it. I'm still there. I'm doing the work I'm asking you to do.

[00:19:42] I'm naming losses I didn't know I was carrying. I'm finding rituals that fit my life. I'm learning that some of what I thought was fatigue was grief. Some of what I thought was distraction was grief. Some of what I thought was fine was not fine. It [00:20:00] was quiet. It was carrying. 

[00:20:03] So I want you to know that when I ask you to name your invisible losses, I'm naming mine too, in my own quiet way, in my own time. I'm relearning the world. I'm becoming someone who has carried this, and so are you. Whoever you are, whatever you're carrying, whatever you've lost that no one ever noticed, whatever version of yourself is behind you now, still worth honoring.

[00:20:33] Give your losses their names Even the ones that came without a funeral. Even the ones that arrived slowly. Even the ones you're still in the middle of. They deserve to be seen, and so do you. Next time in episode three, we build the path. We're going to talk about how to actually treat grief-amplified pain, [00:21:00] a practical integrated sequence step by step.

[00:21:04] And we're going to talk about why standard chronic pain approaches often fall short for grieving patients and what to do instead. If today's episode landed for you, I wanna ask you a small favor. Share it with one person, someone who might be carrying a loss they've never named. That single share could be the ceremony that starts something moving.

[00:21:26] Thank you for being here, for being brave enough to look at what's been quiet in your life for too long. Be gentle with your body this week. Be gentle with your losses. Be gentle with yourself. I'll see you next time.