Medical Gaslighting in Chronic Pain Care: Recognizing, Preventing, and Rebuilding Trust
Janani Krishnaswami, MD, MPH
Internal and Preventative Medicine Physician at Baylor Scott and White Medical Center and Lin Health Medical Director
Gaslighting Emerges as the #1 Patient Safety Threat
ECRI, a global healthcare safety non-profit, identified “dismissing patient and caregiver concerns” as the top patient safety risk of 2025. This form of medical gaslighting, which is defined in the American Journal of Medicine as “invalidating a patient’s genuine clinical concern without proper medical evaluation,” is not typically malicious or intentional. Rather, it often occurs when busy clinicians unconsciously downplay symptoms that lack clear imaging or laboratory abnormalities.
The Impact of Gaslighting on Chronic Pain Patients
Chronic pain is frequently considered an “invisible illness.” Without clear biomarkers or easily identifiable structural causes, the patient’s lived experience often becomes the primary diagnostic tool. “If the idea that their symptoms are made-up or not fitting a clear 'box' is promoted, that sets the stage for those symptoms to feel 'scarier' or 'dangerous' and even become more amplified over time,” noted Dr. Krishnaswami. She added:
“When patients feel unheard, it creates mistrust while fostering an unconscious pressure to solve their own symptoms because no one is taking them seriously. Patients take on the role of detective to find answers and 'get to the bottom' of what is hurting their health, an incredible responsibility that no one should have to shoulder alone. Combined with fight-or-flight physiology, this creates the perfect storm of suffering and isolation.”
Systemic and Cognitive Barriers for Providers
Even the most compassionate clinicians face headwinds:
- Time constraints that limit careful listening and patient education.
- Performance pressures, including patient satisfaction scores, the need to generate "quick fixes," and prescribing restrictions.
- Cognitive biases such as premature closure, diagnostic overshadowing, or confirmation bias.
“From the provider’s angle, there is a great deal of pressure due to limited time with patients, not to mention the inherent lack of self-efficacy of seeing someone repeatedly in distress where there's no tool or clear 'fix' that can be offered," said Dr. Krishnaswami. "Historically, we haven’t given providers adequate tools or space to handle these complex encounters. That lack of support contributes to frustration, feelings of inefficacy, and ultimately burnout.
"Chronic pain is extremely common, but we’re basically telling providers ‘don’t prescribe opioids’ or controlled substances – which are definitely suboptimal chronic treatments – but still successfully manage someone’s pain.”
Practical Strategies to Avoid Gaslighting
As someone who has overcome chronic pain herself, Dr. Krishnaswami offers advice below with a caveat: “It’s going to look slightly different for each patient because chronic pain care is not cookie cutter algorithm. It’s not simply telling patients that "chronic symptoms can be difficult to experience' or 'I know how hard this can be.' It’s the way you’re saying it; the eye contact, the sincerity behind it. I ask providers not to look at their patient as the 2:30 p.m. chronic low back pain patient, but as the human being behind the symptoms.”
1. Acknowledge and Validate, While Sharing Uncertainty
Dr. Krishnaswami’s #1 advice? Everybody needs acknowledgement, to feel seen. Without this, conflict and inner tension can build while reinforcing low self-esteem. When someone is suffering, they may not be at their best, but are often at their most vulnerable. Picking the right words can be difficult and people can display difficult emotions including anger, sadness, or anxiety. Even in a 15-minute encounter, maintaining space for the patient to express their emotions and the impact symptoms have had for them– and emphatically acknowleding and listening throughout – can go a long way in setting rapport and trust.
Dr. Krishnaswami also walks patients through the exam and thought process: “Here’s what I’m checking and why.” Making the “black box” transparent reduces feelings of dismissal. Statements like “let’s support you in finding answers” and “let’s work together” can make the patient feel cared for while feeling like a part of the team, without taking too much extra time.
It can also be helpful to say: “I don’t know yet, but I’m committed to figuring this out with you.” This builds trust without minimizing symptoms. “In many cases, nothing on imaging or no clear abnormality on labs is a good thing,” noted Dr. Krishnaswami. “We aren’t seeing something life threatening. But it’s really in how the situation is explained – not just what the results are, but how they’re communicated. I hear it all the time from patients: they can easily feel like they’re being dismissed or not taken seriously in these moments. Just because there is 'nothing' on imaging, doesn't mean the symptoms aren't real, and this is what patients need to hear as well as the actual negative findings.”
2. Balance Listening with Focus
Give time for patients to tell their story (within reason), while guiding with focused prompts like, “What matters most about this pain for you?” or “What is the primary thing that you wish you could solve about your pain?”
While listening to an hour-long monologue about the patient's devastating symptoms is not often practical, focused questions can ensure that the patient is able to express the highest priorities regarding their symptoms. Patients who feel interrupted or pigeonholed before they get a chance to explain the most important aspect of their journey or what matters to them most will not feel as trusting. Chronic pain patients may have an extensive medical history, so mixing open- and close-ended questions can give the patient time to speak without the need to interrupt – “it’s a little bit of an art,” concluded Dr. Krishnaswami.
3. Reframe Interactions with Scientific Evidence
“We have a dichotomy in modern medicine where we separate the mind and body, so anything mind-related that doesn't fall into a clear psychiatric disorder can be seen as not real,” noted Dr. Krishnaswami. “And then, if it's physical, something you can see, touch, etc., then we have all of these treatments. We have a tendency in medicine to separate the mind and the body, which is just doing people a disservice because that’s just not the way the body works." She added:
“Explaining how emotions can actually influence biological processes in a measurable way – for example, anxiety that increases heart rate and blood pressure – can help legitimize the connection between mind-body symptoms. This prevents patients from feeling symptoms are being ‘written off’ as ‘just stress.’”
You can also share relatable phenomena to explain causes of physical vasomotor reactions tied to mental and emotional states, such as:
- White coat hypertension: higher blood pressure at the doctor or dentist's office than at home, often due to nervousness at these offices
- Blushing, butterflies in the stomach, or sweaty palms ahead of a big speech
- Functional MRI studies showing areas of the brain that light up with intense emotional pain (like heartbreak) are the same areas that light up in chronic pain
“The brain often doesn’t distinguish subconsciously between emotional and physical causes of pain,” noted Dr. Krishnaswami. “Every physical pain has an emotional component and every emotional pain has a physical component – that statement doesn’t have to be outside of mainstream medicine.”
4. Use Analogies to Give Patients Personal Agency
Dr. Krishnaswami often describes the brain’s “volume dial” for pain, an analogy that helps patients understand how thoughts and emotions influence intensity without implying blame.
“When we’re in a situation where we’re in a high danger, high vigilance state, it’s often because a lot is going on – maybe a number of stressors, then maybe there is an illness the body is dealing with. Hypervigilance sets that pain volume dial high to err on the side of letting you know something is wrong. I like to tell patients there is a way that you can use your conscious thoughts and feelings about the symptoms to turn down that volume dial." She continued:
“When someone is constantly preoccupied about their symptoms, every twinge can feel like a disaster and they’re constantly trying to extrapolate what it means, what surgery they need, what if it never goes away, how am I ever going to live, etc. All of those thoughts, which are very natural, are actually amplifying the danger signal and turning that volume dial up very high.
"So what do we do? We become aware of how we’re thinking about our symptoms and notice the thought spirals; even just that starts to calm the person. It can seem to many people like this is too good to be true – just the process of sincerely working to be aware of how you are thinking. Yet, it's amazing how that can really start to reset things. That’s where you start talking about the evidence in programs such as Lin Health, and how it can help."
5. Reinforce Practice to Retrain the Body’s Response
“When it comes to chronic pain or symptom recovery, many patients are used to relying on a treatment, provider, or therapy to be their answer," said Dr. Krishnaswami. "Without it, they may feel they cannot function. Lin Health is actually turning that on its head because patients who go through this program are learning to rely on themselves, changing the way they’re thinking and being aware of their own thoughts. Lin is very centered on patient empowerment.”
To get people on the same page is not always easy. “Sometimes it takes repeated visits,” noted Dr. Krishnaswami. “Sometimes the person is very attached to the identity, the diagnosis and what it means. And that is no fault to the person – they’re just trying to find a foothold in the scary world of chronic symptoms.
“Talking to other providers, I've also seen how Lin can really take the pressure off of providers of having to explain everything in a 15-minute visit. And the ongoing coaching helps patients become aware of the various impacts on pain and how to address it for each individual. That’s often a process that takes practice – it’s not just reading a line in a book or a one-time doctor visit and hearing how the mind and body are connected. It's easy to say (and most people acknowledge it), but, in order for it to actually make a difference, it has to be integrated into daily life – a process best understood on an ongoing basis with a coach.”
6. Extend Multidisciplinary Care as Not a “Handoff”
“Gaslighting can cause trauma during the healing journey,” noted Dr. Krishnaswami. “When, really, this journey is all about finding solutions and a care team to compassionately and empathetically help you get out of this symptom.”
For these reasons, Dr. Krishnaswami sees value in referring to Lin Health, as she noted:
“Lin Health offers interventions based on behavioral awareness and cognitive retraining that can actually reduce symptoms by as much as 75-80% in some cases and significantly improve a person’s quality of life. We have evidence that this approach can work to actually improve people who’ve been in debilitating pain.”
“Like in smoking cessation, you have to meet the patient where they are, compassionately in a scientific way because there is evidence,” noted Dr. Krishnaswami. “A treatment cannot be presented in a wishy-washy way like ‘we’ve tried everything so maybe try this.’ Based on many studies, the way a provider presents a treatment is very important for setting that patient's expectations as well as the trust and belief in the effectiveness of the intervention.
“By presenting a treatment approach like Lin’s as evidence-based, sharing how it works in a nutshell as well as data on how patients (‘just like you’) have actually done in the program, that sets the stage for a lot more improvement for that patient." She added:
“I have seen a number of patients at Lin who have done very, very well. The number one thing that differentiates Lin are the quality of the coaches, including their level of knowledge, expertise, and experience they have with these conditions. They’ve often surprised me with the many, many conditions that they’ve been able to help patients overcome. But again, most importantly, a good coach always helps a patient understand that the answers are within them.”
Final Word
Gaslighting is rarely intentional, but its impact is profound. By validating symptoms, communicating transparently, and partnering with patients, clinicians can avoid the trap of dismissal – protecting diagnostic safety while rebuilding trust in medicine.
As Dr. Krishnaswami reminds us:
“At the end of the day, it’s about remembering the human being behind the symptom. Even on my worst days, just remembering that enables me to know what to say. It’s very helpful to look at the patient not as a problem to be solved, but more as a human. That small shift transforms not just outcomes, but the entire care relationship.”