Tons of people who have no pain at all have all kinds of anatomical findings. If you go in take a one hundred healthy pain for people off the street and scan their bodies, you will see a wonderful symphony of bulging disks and herniations and protruding this and tears on this tendon and this ligament. And they're typically not painful, or they're often not painful.
Welcome to the one you feed. Throughout time, great tinkers have recognized the importance of the thoughts we have. Quotes like garbage in, garbage out, or you are what you think, ring true. And yet for many of us, our thoughts don't strengthen or empower us. We tend toward negativity, self pity, jealousy, or fear. We see what we don't have instead of what we do. We think things that hold us back and dampen our spirit. But it's not just about thinking.
Our actions matter. It takes conscious, consistent and creative effort to make a life worth living. This podcast is about how other people keep themselves moving in the right direction, how they feed their good wolf. Thanks for joining us. Our guest on this episode is Yoni A shar A
clinical psychologist and neuroscientist. Yoni's research uses brain imaging and other tools to understand how beliefs and emotions influence health, especially pain, and to develop novel neuroscience based treatments for chronic pain. Yoni is a postdoctoral associate at wild Cornell Medicine and completed his doctorate at the University of Colorado.
Hi, Yoni, Welcome to the show.
It's great to be here. Thanks for having me Eric.
I'm really excited to have you on. We're talking about some really important work that you have been a researcher on and involved in. It's detailed in a book called The Way Out, a revolutionary, scientifically proven approach to healing chronic pain. And I'm particularly interested in this one because obviously I know a lot of people who have chronic pain, but one in particular is my mother, and so I'm really excited to share this episode with her when we
get done. The book is written by Alan Gordon. However, I think I got the better end of the deal here because he describes you in the book as the man who ran the show, a thirty two year old wonder kind with the mind of Aristotle and the effortless cool of James Dean.
Don't believe him? Not true?
All right, we will get into pain reprocessing therapy here in a moment, but let's start like we always do with the parable. There is a grandparent who's talking with their grandchild and they say, in life, there are two wolves inside of us that are always at battle. One is a good wolf, which represents things like kindness and bravery and love, and the other's a bad wolf, which represents things like greed and hatred and fear. And the grandchild stops, thinks about a second and looks up at
their grandparents says, well, which one wins? And the grandparent says, the one you feed. So I'd like to start off by asking you what that parable means to you in your life and in the work that you do. Yeah.
I love that parable, and I think it's very relevant to the work we're doing with the chronic pain here. There really are two wolves that can feed chronic pain.
There's the fear wolf, and the more that wolf is active and hungry and feeding, then the bigger and the bigger the pain will get any of the wolf of something like safety or ease that eventually you can lead to the large reductions or even elimination of chronic pain, which you may not believe me quite yet, but hopefully at the end of the conversation I'll make a case for that.
Yeah, you guys actually use the parable in the book, and there's a funny line at the end which says, you know, we might call it the tale of two neural pathways, but it doesn't quite have the same ring to it. You know. I used to say when I was talking about this early on, I would say, you know, in Buddhism we talk less about good and bad, and we might say skillful and unskillful. But I was like, you know, a skillful and unskillful wolf isn't a very
good story, right, It just doesn't. It doesn't capture the imagination. Right, So let's talk about the core of your work. It's really around recognizing that I guess correct anything I say, it's incorrect that certain types or even maybe a lot of chronic pain is what you guys would call neuroplastic pain. Can you describe what neuroplastic pain is?
Yeah, you got it right. So there's been a revolution in our understanding of chronic pain that's been unfolding over the past several decades due to advances in medicine and
neuroscience and psychology and other fields. And what we now know is that a person could get injured, of course they'll have pain, you know, surrounding the injury, but then the injury can heal and the pain can persist for years or decades beyond that, and at that point the pain is no longer caused by the injury because the injury is long since healed, and there are other factors, particularly you know, factor processes in the brain that are
causing the pain to persist. And this is called neuroplastic pain. Actually goes by many names. It's also called primary pain and no syplastic pain. But that the main idea here is that the pain is not due to physical, structural, biomechanical factors. It's not due to tissue damage. And we think that, you know, this might be a really large portion of chronic pain.
Actually, now what you're saying here, I think there's nuance to this. It's important because you know, we've all heard the it's all in your head thing, right, which is a way of sort of dismissing something. It's all in your head. And what you guys are saying, is the pain is absolutely one hundred percent real. It is there. It's just that what's causing it is loops in the brain, not signals from the body.
That's exactly right. And it's so important to emphasize the pain is real. The pain is always real, and this view of you're making it up or you're exaggerating really upsets me. I find that really offensive, you know, to all of us who have had any kind of chronic pain. It's especially been used to marginalize people like groups like women or other groups that have been written off as hysterical or exaggerating. And it's not true at that level.
Now from the total flip perspective, while the brain is in the head and we I know that all kinds of brain processes that can amplify or inhibit pain, that those are very important and they're no less real in any way.
Yeah, what are some of the things that have happened neuroscience wise that have caused us to start to uncover this and for us to be able to start to tell the difference between say, what is neuroplastic pain versus other types of pain. You talk in the book about short term versus chronic pain and how that's in different parts of the brain. Share some of that science with this.
Sure, there's been a lot of research in both animal models of chronic pain, particularly in rodents where they create chronic pain conditions, and in people who have chronic pain. There's one study that comes to mind in particular that was, at least for me, a kind of lightning bolt moment, like, WHOA, this is really a big deal. So this is a study from the A. Carrion Lab at Northwestern. It came out five or ten years ago, and they recruited people
who had recently injured their back. And these people had back pain because they had recently injured their back, and they scanned their brains and what they saw was that the pain lived exactly where you would expect it to be the pain processing parts of the brain. This includes smatisensory cortex, singulate insula. These are brain regions that any neuroscientists would say, yep, that's where the pain belongs. That's
the part of the brain that does pain processing. Then they followed these people for a year out and in half of them the pain resolved right the injury heel they went back, life was normal, it's kind of like typical course, Yeah, you pulled your back and now everything's better. In the other half, the pain persisted, and now this is a year after injury and the back still hurts. And when they scanned their brains, they found that the pain was now associated with a totally different set of
brain regions. It was associated with medial prefrontal cortex and with the amygdala, and those are brain regions that have a lot to do when learning and memory and emotion and meaning. And what they basically did in the study was they caught on camera, not using the brain scanner. They caught on camera this transition of pain to moving to these different brain circuits where it can now, as you said, live on loop in their way, relatively independent of any injuries in the body.
That is absolutely fascinating. That really is amazing to be able to show that transition and what those different parts of the brain tend to be more involved in.
And there's been eric this other kind of surge of research that's also been looking at not clinical researcher, I would say, but it's trying to understand what is pain fundamentally, because the old view of pain was that pain was a direct readout of problems in the body. So this is like, you know, you stub your toe and your toe hurts, because that's letting you know that something happened in your toe. That's true. Pain can be that, and we now know that pain is much much more complex.
And one of my favorite ways of thinking about pain is as a learning signal for guiding behavior. So the job of pain is to keep us safe and healthy, keep our bodies intact. Now, in order to do that job well, the pain system has to be predictive. It has to be always thinking ahead about how damaging some action or activity might be. That way, it can keep us safe. If the pain system are always just reactive with all we did, if they one step ahead of
the lion. And once you know, we understand that pain is predictive, that opens up a whole host of thorny problems because prediction is really challenging, like it's really hard to you know, to tell the future. And there can be mispredictions for example, personal injuries. Their back they're bending over. Ah,
that's not good, that's for the injuries. So so pain is you know, created, But now the brain, you know, will start to predict pain when bending over, and even after the injury is healed, there's a prediction that's present in the nervous system, not consciously in any way, just kind of in the brain. This prediction is there, and the pain will be generated because it's been associated with that motion in the past, and it can be a misprediction.
You guys also reference another study which I think is also Northwestern, about researchers' ability to predict pain, you know, like who's going to have pain? And apparently they were accurate eighty five percent of the time. So what was going on.
There that was actually the same group of subjects and what they did They said, like, okay, so these are the changes that happened with people as the pain went from you know, post injury pain to chronic pain. And now let's look at the brain scan from right after the injury and see if we can predict who's going to get better and who's going to develop chronic back pain.
And what they found was that patterns of brain activity in the media prefrontal cortex and the nucleus occumbents was able to predict who would develop chronic pain and who would resolve. And that's really important for at least two reasons. First, those two brain regions are very involved in learning processes, so it suggests that there's a learning about the pain that's happening in the brain, and once the pain becomes learned, it can basically become a habit. It can become a
pain habit. Again, not an intentional habit. No one's choosing to be in pain. No one's like, you know, wanting that, but it can recruit the same circuitry the nucleus accumbans is actually really involved in, you know, so like addiction.
I was just listening to your last episode. Yeah. The second reason that's really important is because when you look at like a scans and MRIs of the back, you know, if someone injuries their back, those are completely non predictive of who's going to recover and who's gonna get worse. So it's really striking that a brain scan but not a backscan, can tell who will get better and who will not.
Yeah, that is just amazing that the brain is more predictive than the back, even though where the pain is in the back, the injury is in the back. What I love about what you guys have done here and the way you've brought this together is I mean, this is not a brand new idea, right. There's a guy, doctor John Sarno, who's been around a long time who's advocated similar ideas, but there's way more actual science here, and there are differences. I'm not trying to tie your
work to his. I'm just saying that there are similarities, which is saying that there is a clear mental element to this. And I would even say, based on your work and others, there's a clear mental and emotional element to what what we have with chronic pains. So, I mean, I guess one of the big questions would be how does somebody know is my pain neuroplastic or is it still real signals from the body.
Yeah, so there are there are some indicators that can really be helpful in sussing this out. And I want to give credit here to my friend and colleague, doctor Howard Schuberner, who in my mind has really helped develop these methods as well as you know, many others in the field. But I must have learned it from him, so that's why he's my guru when it comes to assessment. So two components of figuring this out. First, is the rule out you can see a doctor, see a relevant specialist,
try to, you know, get clarity. Is there anything clear and physical in the body that's a clear cause to the pain. I note of caution there is not to go overboard. If you see enough specialists, one of them will find something wrong. I guarantee it. So, but you know, do basic due diligence to rule out any obvious medical problems. The second component is the rule in And here's where I think there's actually a lot of value and juice for a lot of people to try to figure out
what kind of pain is this? So if any of the following are present, these are indicators of their plastic pain. One spatial spread of pain. Pain started on my shoulder, but now it's spread down my arm. Injuries don't travel but right, but sensations spread. And we actually now know, thanks to the work of Bob Coghill and others, some
of the neurobiological mechanisms of this. There are these neurons called dynamic wide range of neurons in this dorsal horn of the spinal cord that sensitize each other and cause spatial spread of pain. And just something that that you know happens in our nervous system. If one area hurts, it'll sensitize neighboring neurons and cause you know, the signals coming will sensitize neighboring areas and cause spread of pain. Okay. Second indicator spatial variability. So like sometimes the hurts in
the left line, it hurts on the right. Again, that really suggests the brains involved here, because the brain's are really good at kind of moving things around in the body. Three temporal variability. You know, some days the pain is ten out of ten, you know the next zero out of ten. That again does not sound characteristic of like an injury. If you have a broken foot, it's not gonna you know, it will hurt every time you step on it. You're not gonna have ten out of ten
one days, zero out of ten the next day. It doesn't have to be quite as dramatic as ten to zero. It can be eight too. A three, and that's still quite large swings. Four Presence of multiple chronic pain or you know, somemat of sensory syndromes. You know, in a person's history, if you have a history of headaches and stomach aches and sound and light sensitivity, and you know, now your hip is hurting. So it's possible that you have a stomach problem and the hip problem and the
head problem. But it's also, you know, even more likely that there might be something in how the brain is processing input from the body that is causing this gain of signal, its volume amplification. That can be an explanation for these multiple sometimes. Oh, another one that's really important here is when the pain is really contextually sensitive. And so what I mean is they'd have pain in some context but not in others, and it doesn't make any
sense from a biomechanical perspective. So for example, when I had, you know, years of chronic back pain, my back would always hurt when I stood, but it never hurt when I ran. And I could run for you know, miles and my back felt great. And then I would you know, stop at the end of the run and my back would start hurting, and it just like, what's going on this? That's kind of something's little fishy here, like why would
that be? And I later understood when I got into all this research that I had developed a conditioned response that my brain you know, had paired standing still with pain, and so whenever I stood still and started to create pain, just like now Pavlov's dogs learned to link a bell to food. You know, we can link a certain position to pain, even though that position isn't objectively more dangerous or putting our body at risk than like running or some other position.
Is is it possible that you would have both that you might have, say you're an older person and you have some arthritis, which you know is probably actually causing some pain, So you might also have neuroplastic pain. Is there a place where it's not one or the other.
Yes, So it's a spectrum, and you could be anywhere along the spectrum for more, say peripheral tissue causes there's something in the body that's really driving it to centralized central nervous system brain causes. So people can be you know, what we call mixed pain where there's both of those. That being said, I think some of us suspect more and more that a fairly large portion is centralized or primary pain. Neuroplastic pain, for example, eric like arthritis is
not necessarily painful. No severe arthritis is painful, but mild to moderate arthritis is often not painful. So if you have arthritis. You could have arthritis and you could have pain, but the arthritis might not be the cause of the pain. For example, exact numbers eluding to something like eighty percent of pain free necks have a bulging disc in them. So tons of people who have no pain at all
have all kinds of anatomical findings. If you go in take one hundred healthy pain for people off the street and scan their bodies, you will see a wonderful symphony of bulging discs and herniations and protruding this and tears on this tendon and this ligament. And they're typically not painful, or they're often not painful. And so knowing that you might have one of these findings in your body, is you know great?
Now?
Is that the cause of pain? Does that explain? You know, if there is spatial variability, if the pain is moving around, well, gosh, that's not so consistent with like, you know, this one injury in this one site. Or if the pain is very variable, I mean, is the injury moving you know from day to day? Is the disc one day and not the next, Right, there's probably something else going on.
Pain has multiple components to it, Right, If I were to think of my back pain right now, Okay, I've got a physical sensation that I would ascribe to it, right. And then there are a couple other elements right that are very obvious if you sort of watch your mind. Element one is just my overall resistance to it. No, no, no, I don't want it. My resistance, my amplification, my all that. And then the third is all the stories I start
saying about what this pain might mean. You know, mine is if my back hurts like this at fifty, what will I be like at eighty? Will I be able to do this? So there's all this stuff that goes on, and so I've talked about that with various people in the show, and when I was reading your work, you lead into the primary thing that drives the neuroplastic pain engine is fear.
Yeah, this is really important, Eric, And it also gets to a way that our work is potentially different than some current framework. So everyone agrees that there is this whole layer of resistance and storytelling and unhelpful narratives that can be on top of the pain that can make us miserable and make things worse. And everyone would agree
that limiting that or reducing that will be helpful. What I think is really provocative about our work is suggesting that mind brain processes could really be at the root of the pain, and by changing some of these process you can eliminate the pain. It's not an added layer on top that you can remove and now you're left with no pain still there, but it's not as bad. You can actually eliminate the pain by changing some of
these mind brain pathways. Put it slightly differently, Now, if the pain is due to mind brain processes, then the solution might lay there as well, and we could eliminate the pain by changing those pathways.
Yeah, I think that's an important point. In using my analogy, you're saying, not only can you take away element two and three in what I just described, you actually might take away element one the sensations themselves that are there.
And what's interesting though, is that, and I want to get into your method, it seems to me that these approaches, even if you start to by targeting two and three, you may very well just buy that very nature of doing it be working on one also, because targeting two and three is the same mechanism you're talking about, which is basically becoming a little bit more present to the pain and a little bit less afraid around it. So let's move into your method. Well, actually, before I do that,
I'm going to hit a couple other quick things. One is in the book it says this shows up over and over again that there are sort of three habits that are seen again and again in patients that trigger fear and aggravate neuroplastic pain. They're worrying, putting pressure on yourself, and criticism or self criticism.
So I think of two broad categories of fear pain related fear and say general kind of fear or threat. And when I say fear, I'm thinking, you know, threat or a sense of there something threatening. So there's fear and sense of threat about the pain the cost like you were saying ele in two and three, the pain
so bad and you know it's gonna get worse. And then there are these other general patterns of putting our brains on high alert mode of threat, this worry and pressure on the selves and self criticism that could be
completely unrelated to the pain. It could be about how we're performing work, or it could be about you know, beliefs we have that we have to keep everyone else around us happy, and if someone's unhappy with us, then then that's a big problem or that you know, uncertainty about the future is dangerous and I have to eliminate all uncertainty. So there could be all these habits and these drive our brain into high alert mode and that will take the whole pain system and just turn up
the volume, you know, any sense of threat. So pain is the appraisal of threat or danger. Pain is our brains way of saying, that's something dangerous here. And if there's a more global sense of threat or danger, like you know, like someone putting out of pressure on themselves, like I'm not good enough, whatever the flavor is, then that's gonna you know, add to that sense of danger and amplify the pain.
Yeah, you describe at one point neuroplastic pain in a false alarm in essence, right, yeah, which I think speaks to that. As I'm hearing you say all this, you know, in my brain, I'm thinking, man, that sucks, right, Like it sucks that if you've got excessive amounts of self criticism, worry, and you know, put an extra pressure on yourself, that's miserable mentally and emotionally. And now on top of it I'm driving a physical pain engine potentially.
That is miserable. I have a lot of compassion that comes up. Yeah, yeah, it seems to me like it's kind of like a culturally like contagious thing going around right now. Like you know, I just saw this. There was a survey that went out, you know, were you in a lot of stress yesterday? Like a gallop Paul, and over half of Americans said yes to that. They're in a lot of stress yesterday, And like, that's that's very sad.
Yeah, ideas, I want to get to the method. There's a couple other places I could go, but let's let's go into you know, the broad strokes of how you work with some we think it's neuroplastic, right, we think that's what's going on here.
So that's step one. And that's actually I don't want to glide over that because it's really important because this is a huge mental shift for many people. I need to like emphasize, like, yeah, and our research. I just did a study where I asked people, tell me, in your own words, what do you think is the cause of your pain? This was back pain, because that's the most prevalent pain condition. So that's the easiest to study. And what people said, ninety to ninety five percent of
people were saying old age and injury herniated disk. So by and large, many many people are thinking that the cause of their pain is something on the structural biomechanical level, and so shifting from that to saying, oh, the cause of my pain is neural pathways and fear is a major shift that happens. So step one is kind of assessing that, you know, you know, as a clinician, you would assess that, and then step two was getting that the person in pain on board with that assessment. And
for that it really helps to have evidence. Actually, this is not any leap of faith we're asking anyone to take. This is a scientifically grounded, evidence based process where you can look through your life and if you know, when I was earlier listing the indicators of neuroplastic pain, if you're sitting there going check, check, check, that's a list of evidence right there, you know, And on the flip side, what's the evidence that there's actually something wrong in your body?
And don't say, well, my back hurts, because we know that's not evidence that there's something wrong in the back. Yeah, that's just that's where the sensations are felt in the moment. But how do you know there's something actually wrong there? You know, what's the evidence for that. Maybe there's strong evidence, maybe there isn't, And what's the evidence that you know it's neuroplastic pain. And in the book, the appendix has a more detailed elaboration of all these factors I was
mentioning earlier. So we call it building the case. So building the case that this is really what's going on for me is a really major first step.
Yeah, And you talk about different barriers in the book to overcoming that, and one of them, you know, is indeed medical diagnoses right. And you know, I know from being involved with people who had chronic pain taking them to doctors. You can see a doctor and you're like, I'm in an incredible amount of pain. There's a lot of pressure on that doctor to go, well this, you know,
like to come up with something right. I know in those experiences that it's been like, you know, you start to go hmmm when one doctor's like it's this and the next doctor's like it's this, which is a different thing, and then they both disagree on the way you treatment you should do physical therapy. No, you shouldn't do it at all. I mean you start to go, wait a second, Yes, nobody really knows why I hurt this bad.
Yes, And that is another great positive indicative of neuroplastic pain getting different or contradictory stories from multiple different providers. I mean they don't know. Yeah, even if they sound confidence.
Is it possible to have neuropl plastic pain in one part of your body and go through a normal healing process with pain in another part of your body. So for example, you have let's make the assumption, we've gone through the process, we've done assessment, we go, you know, your lower back pain neuroplastic. That same person breaks their arm, They're in pain, but then the arm heels and the pain goes away. So in that case, they went through a normal pain cycle, right right, the body was hurt,
body healed, pain went away. I've still got neuroplastic elsewhere? Is that possible? Protaly?
You can have that, and you can also have what you call secondary pain or like structural biomedical like this, the pain is secondary to some injury. You could have that in one body site and neuroplastic in another body site. Got it. You know, it's really based on evidence and really hold any explanation you might get from a provider, including from what I'm saying. I hold it up to
the evidence. Does this hold water? This doctor says, Oh, I'm having this pain because this is pushing on that nerve, and like, all right, well, you know what's the evidence for that being the cause of pain? Yeah?
Okay. We've gone through the work of really sort of gathering the evidence, trying to determine is this what I have. If I arrive at the conclusion by myself or by working with a clinician, I arrive at the conclusion that at least some portion of what's going on here is neuroplastic pain, where do I start in unwinding this?
So we viewed neuroplastic pain as the brain's misperception of threat to the body. So that's what we want to start to unwind, this misperception of threat. And the way that you unwind misperceptions of threat is with you know, perceptions of safety. Actually, that's this kind of antidote. There's a particular technique that we have developed that seems to be quite you know, to our knowledge, and one of
the most effective techniques for changing this perception. We call it sematic tracking, and it's a particular way of paying attention to the sensations. And it has three components. So the first is this element of mindfulness, so becoming a bit you know, like interested and curious about the sensations, watching them the way you might watch clouds float through the sky. Oh, the sensations, you know, kind of tingly and moving a bit, you know, towards the center of
my body. Second component is safety reappraisal, and this is as you're paying attention, telling yourself there is nothing wrong in my hip while I'm watching these sensations. My hip is healthy, my hip is safe, my hip is intact. These sensations are being caused by my brain. Basically literally saying those things to yourself while you're watching the sensations, you know, being genuine about it, like, oh, there really
is nothing wrong because I've done this assessment. And then the third piece of semitic tracking is bringing some fun and some playfulness. We call it positive affect induction in the science world because this sense of fun and playfulness and humor will cut the threat appraisal right when you're having fun, when you're being playful. When you know you're in a good mood, it's much harder to feel afraid, So that can really pull the rug out from under this feeling of threat.
And is semitic tracking. It's got these three components. It sounds a little bit like the sort of thing that might be helpful to be guided through. Is that some of the work that a clinician will do is guide someone through that. Are there guided quote unquote meditations for it. It strikes me as the sort of thing, like a lot of types of mindfulness that you can get really lost in and having somebody to sort of guide you through and bring you back and do that could be
really helpful exactly having a guide. You could google it and you'll find some examples, and there's clinicians and apps that can also, you know, guide people through it.
It's very important for me to emphasize that somaut of tracking is not mindfulness. Mindfulness is one piece of it. Yep, mindfulness can help with pain. Actually, you know, one of the first, if not the first study like scientific study of mindfulness was in chronic pain with John Kevin's in back in the seventies. But mindfulness alone is not likely from the data we see, mindfulness alone is pretty unlikely to get someone out of pain. It's just one piece
of the puzzle for un learning pain. So if you think you have a mindfulness practice and that's like all you need there, there's more to it. Yeah, that's probably not quite.
Enough, ye, right, because the other two components that you mentioned are this creation of safety right, yes, and then you know the positive affect exactly. Yeah, you talk about couple of mindsets that can help with doing somatic tracking more effectively.
Yeah. So this is like a light and easefull state of mind that can be really helpful. There is a strong tendency that makes so much sense to like when we pay your attention to the pain, to tighten around it, to clench around it, like you said earlier, to resist it, to fight it, or to be like laser focused on it, like oh no, what's it going to do next? Is it going to get worse? So the mindset of like you know, ease and safety and mindfulness and relaxation and
doing it because it feels good. What's really amazing to me and what I'm super interested in as a scientist is that you know, sometimes I would even say many times during somatic tracking. As people start doing this practice and paying attention without fear, year the sensations start to shift,
often to diminish, and sometimes they even disappear. We've even had you know, sessions with the clients or they'll do somatic tracking and then the pain's gone ten minutes later and they're like, oh my gosh, this is the first time in eighteen years, I haven't felt any pain. We just did a little exercise, you know, ten minute exercise. So that's a really good sign that you have neuroplastic pain. You know, if you change how you're paying attention to
the pain and the pain goes down. Guess what, Your brain is playing a big role. We just proved that.
So listener, consider this. You're halfway through the episode Integration re Mind. Remember knowledge is power, but only if combined with action and integration. It can be transformative to take a minute to synthesize information rather than just ingesting it in a detached way. So let's collectively take a moment to pause and reflect. What's your one big insight so far and how can you put it into practice in your life. Seriously, just take a second, pause the audio
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slash sms and let's feed our good Wolves together. You guys talk about when you're doing this, you know, turning down the intensity and trying to be outcome independent, which is really hard to do right when what you're trying to do is get rid of pain. But Alan describes several times in the book when he's talking about specific clients. You know that there's a natural tendency to be like, all right, this is going to fix me, and I'm
going after it right. Like, you know, there's a mindset that says like, Okay, I'm going to do somatic tracking like one hundred percent. I'm going to nail it right. And that is the clenching, intensing around it. And so it strikes me a little bit as we talk about in Zen, you know, trying not to try exactly, you know, which is a little bit of an art.
Total art that's really hesitating. Whether it's to even mention that sometimes the pain goes down during somatic tracking, because then people will be like, oh, I'm gonna go do this thing to get rid of my pain, and that, unfortunately, is going to backfire because as soon as you're trying to get rid of your pain, you're reinforcing the idea of the pain is a dangerous problem and a threat that needs to be gotten rid of. Yeah, And actually,
so that's just going to add fuel to the fire. Really, what we're trying to build is this attitude of pain is something we can be curious about and be unafraid of, and so we can somatic track to kind of get to know it a bit better and to welcome it in because it's not dangerous.
Yeah, we talk about this and mindfulness communities, meditation communities, but Zen talks a lot about this, and I'm a Zen practitioner, and you know, one of the ideas that I found really helpful in that regard is that outcome oriented focus is sort of necessary for you to do the practice at all, Like, otherwise, why are you going to do it right? Nobody's going to do somatic right. So you want to get rid of the pain, So
you're going to do somatic tracking. But then and a spiritual teacher said this to me while he said your will is good for getting you to the meditation cushion, at that point you have to shift and you have to let go of that. And that's kind of what we're saying here, like, Okay, yeah, of course you want the pain to go away. That's going to get you to the front door of the sematic tracking session. At that point we have to try and let go and become more outcome independence.
That's exactly.
It's kind of knowing which tool to apply when you know which mindset to apply when.
That's very helpful. Thanks for that. I'm going to use that with my clients.
So we're doing sematic tracking. It's got these benefits. You say at another point, if you want to overcome any fear, and we're saying that the fear is kind of the engine of this thing. Exposure to the thing you're afraid of is important, so say more about the role of that in this process.
Super important. So this is starting to engage in the things we've been afraid to do because of the pain. If it's sitting down, starting to sit, if it's biking, starting to bike, So starting to do these activities, but definitely not overdoing it. And what's really important is the quality which we bring to the exposures. So something we call white knuckling. This is when you're doing an exposure
but you're white knuckling your way through it. You're like intensely gripping and holding on and internally you're tight and clenched and terrifying. That's unlikely to be a helpful exposure. It's unlikely to be something that you learn something helpful from. We want to do with the exposures where we can learn that our bodies are stronger and healthier than we believed. And so doing somatic tracking during an exposure is an
important piece of this approach. So using these same tools to bring attention to the sensations while you are doing the thing that's been feared. Remembering a client I worked with who you know, we must have we stood up.
We probably did like a hundred times in a row, just bend over, end up, bend over, stand up, just watching the sensations like you would watch no water flowing down the waterfall, because you know, as we were bending over, that was kind of the image, and just watching the sensations and like, oh, look what happened when you bend over? Look what happened when that you get up? You know that bending over is totally safe. There's nothing dangerous. I
think over is great for your back. It's not dangerous for your back in anyway. It's actually really good for your back to bend and cracking some jokes. And you know, she had a lot of pain that the you know, first few times we bend over, and by a number one hundred, it didn't hurt at all.
Yeah, and you guys talk in the book very well about not doing this. As you're saying like, when you have a high level of pain, that's right, And if you're in a high level of pain, it's not the time to be doing somatic tracking and exposure. It reminds me of my coaching work with people, and we talk about some of these skills that we practiced to deal with difficult thoughts or emotions. You don't want to practice those on the hardest thing in your life. It's not
the time to do it. You know, you want to start practicing at a place that's manageable. You know, you can't practice if there's none So as you guys say, you can't really do this if you don't have any pain, But you want to look for those medium to low level times is the time that this exposure and sematic tracking can be most effective.
One hundred percent. That's so important to emphasize to you know, start using these sorts of skills when the pain is in the low to medium range.
Yeah. And what I really like is you say, you know, if your pain is really high, then don't try sematic tracking, use your avoidance behaviors. And so I love how it's not saying like avoidance behavior bad, sematic tracking good. Yes, depending on the scenario avoidance behaviors are a perfectly good thing to do if your pain level is really high. When it's at a lower level, that's the time to work on sematic tracking and an exposure.
Exactly because we want the exposures to be corrective learning. So an exposure from which you learn the pain is not dangerous. And when the pain's super high, it's going to be very hard to get that takeaway. If you encounter it when the pain is raging, you know it'll be very tough, and so at that moment, just anything that's kind of can help bring it down, you know, ice packs, cold packs, laying down for a bit, you know, until it becomes more in an manageable range, and then
get back on the horse and do the exposures. The sematic tracking, which is an internal exposure really to the sensation.
And is that the primary tool in the method. By doing somatic tracking, by having exposure to the pain, which causes what you guys are calling a corrective experience, describe corrective experience for us so I can tie all this together.
The corrective experience is learning that the sensation is not as dangerous and threatening as you thought.
So this strikes me as similar in ways to exposure therapy in other domains, right where the idea is expose yourself to the feared stimulus and a manageable dose you learn that it's not so frightening and you're able to handle more and more. So there's a corrective experience here.
I want to talk a little bit about some of what this path looks like if you get on it and you start to have some healing, because there's, like any path, there's some ups and downs that can occur, and I'd like to hit a couple of those, but I definitely want to hit Also the study that you guys recently published, so tell me about that.
So this was the first trial testing PRT. We took one hundred and fifty one people and we randomized them to one of three groups a course of PRT, which was nine sessions over the course of the month. There was a placebo control they got this placebo injection into their back, and then the usual care control group of people who kept doing whatever they usually did to care for their back, whether it was acupuncture, chiropractor, or medication.
And we asked people to tell us how much pain they were in before and after and how much fear of pain they had, and what they thought was the
cause of their pain. And we also scanned their brains before and after, and what we found was very large reductions in back pain for people in the PRT group as compared to the control So people in the control groups, so everyone came in on average about four out of ten pain and in the control groups people left with about three out of ten pain, but in the PERT group people had one out of ten pain on average,
and it was a really large reduction. And what was especially striking was that a number of people were pain free at the end of the study. They had zero pain, you know, to put some numbers on it, we found that two thirds of people were pain free or nearly so at the end of PRT as compared to twenty percent in the PLACEBA group and ten percent un usual care group. And this is really striking because you just
don't really see psychological treatments making people pain free. So this is part of what this kind of conceptual framework that PRT is coming from that is different than some of the existing psychological approaches to pain, where like we said earlier, they target mostly elements two and three, but PRT really goes after element one.
The pain itself, and PRT is pain reprocessing therapy, which is your guy's method. I just think in the case any listener didn't catch that.
Yeah, sorry for that.
Yeah.
And we followed people for one year after no treatment ended, and the gains were largely maintained. So one year out, half the people were pain free or nearly so, even though they had received no treatment in that intervening time. And when we looked at the mechanism to try to understand, well, how does PRT work, What we found is that people who have the biggest reductions and fear of pain had
the largest pain intensity decreases. And the people with the biggest shifts and how they think about the causes of their pain shifts from you know, structural mechanical causes to mind brain causes, they had the biggest reductions in pain as well. And we also saw these really interesting changes in how people's brains were processing pain when we put them in the brain scanner as well.
Tell me about that last piece a little bit. What shifted.
Yeah, So we saw reduced activity for purity verus control in these three brain regions as people were processing or experiencing back pain. So we put people in the brain scanner with this back pain evocation device as basically this inflatable pillow that went under people's backs while scanning, and when we inflated it, it caused back pain. It might sound nice to have a pillow under your back, but
this was not. It didn't feel good the way we positioned it, in the way it was inflating, people did not like it. It was hurting. We saw as when we exposed people to the same stimulus post treatment in the PERT group, there was less activity in the interior insula, the mid singulate, and the anterior prefrontal cortex. And these are bringing regions that do many things, but one of the things they do is track threatening stimuli. And the more threatening stimulus is the more activity you'll see in
those brain regions. And so the reduced activity we observed in those regions is consistent with this idea that treatment helped people see the sensations as less threatening.
Did you screen people before the study to see if you thought they had neuroplastic pain or did you just take a bunch of people's back hurts.
Yeah, we had some criteria for trying to get neuroplastic pain We excluded people with leg pain worse than back pain, because that's a sign that there might be ridiculopathy. There might be a that's bulging onto a nerve, pushing onto a nerve that's causing black pain. Leg pain is not necessarily neuroplastic, are not necessarily structural or mechanical. It just diagnosis can be a little more involved there. So we
screened that out. And there's a couple other criteria, but on the whole we end for pretty broad inclusion criteria. You know, if someone had scoliosis, no problem, history of back surgeries, no problem, ten hernia, the discs, no problem. That those are all welcome, got it, Got it, because those are often just not the cause of the pain,
like scoliosis, not necessarily painful. It could be painful, but you need to do a thorough assessment to see you know, you might have painful scoliosis, or you might have pain and scoliosis, but the two aren't connected.
And is it possible that with a lot of these conditions, there was an initial burst of pain from that condition and then the body adjusts to it and heals and stops sending the pain sensations. But at this point we've learned, you know, to use the term you used earlier, we've learned the pain.
It reminds me so much of you know, PTSD, where a person will go, you know, to use like a classic example of like military PTSD. Person will be in a very dangerous context where loud noises could mean you're being attacked, and they'll come home and they'll still respond to the same noise as if there's a threat, but actually the threat resolved long ago once you you know, left your deployment. The threat is not there anymore, but you're
still responding as if the threat's present. Complete parallel to this injury healing model where the threat was there but there's no longer a threat, but your brain responding as if it's still there.
I'm curious, and this may be extrapolating out multiple steps from where you are, but is there thought of trying to measure psychological well being as well as pain reduction. Do you think that you perhaps kill two birds with one stone, so to speak.
Yeah, chronic pain can be a really like shitty you know snow of depression anxiety. Insomnia. Pain leads the depression feats to the anxiety, which leads insomnia needs the pain against cycle, and if you can take out one component of that cycle and everything else can also start to come down as well. You start sleeping better, you start feeling better, you start getting more active, oh, exercising more. Well,
that's good for depression. So it's all interconnected. And conversely, we know that you know, depression, anxiety, and insomnia, they all amplify pain as well.
Yeah, and if the method brings down these three types of thoughts that you guys say really trigger fear, worry, pressure, and criticism, if your method is actually helping with the reduction in those areas, you know, the benefit continues and continues.
Yeah. What you know people in our study told us was that, you know, beyond bringing down pain, people were saying, like, oh, I learned to listen to my feelings for the first time, I got in touch with myself. I've realized that I was such a bully to myself, so me, you know, putting so much pressure on myself and I've stopped doing that.
That's really important and meaningful.
Yeah, it really is.
Well, thank you so much for taking the time to come on. I've really enjoyed the conversation. I really enjoyed the book. I think the work you guys are doing is incredibly important. I get a lot of requests for people to be on the show. I get a lot of pain stuff, and a lot of it to me looks really like that seems a little sketchy. But when I saw the work that you guys were doing, I saw the studies that were behind it, I felt like, this is a really important thing to try and put
out there. So thank you for the work you're doing.
Thanks Eric. There is a big shift happening in the field. And yeah, the way a lot of us are thinking about chronic pain is shifting to really appreciate everything we've been talking about, how mind and brain processes can play a bigger role, and just narrowly looking at problems below the neck are unlikely to really work as an approach for most forms of chronic pain.
Yeah, I mean, I think anything that sort of tries to divide the mind from the body. You know, we talk about the mind body division as if it's a thing, and I'm like, it's not. I mean, like they're pretty clearly connected in any anatomical diagram I have seen, like you know, like I'm not sure where we got the idea they were separate, but nonetheless.
Thanks so much for having me on.
Yeah, thank you so much.
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