In Your Pants with Dr. Susie G - Your Pain Can Change: The science behind the brain body connection

Episode Date: August 15, 2022

Pain is just neuroscience. Your brain is calculating information 24/7 to keep you safe and alive; when it calculates the threat of danger, pain becomes a protective measure. This information is biological (like recognizing a broken bone, torn ligament, or a cut), but there are other factors the brain is calculating to make a decision on whether or not you're in danger and need pain to rescue you. Knowing the information that both produces and reduces pain levels allows your brain to start to process pain differently. Dr. Rachel shared many of these factors and their impacts, including: Cognition (the way you think) Mood and emotions (the way you feel) Behaviors (what you do) Context and environment (where you are and who you're with) Beliefs around how you feel What other stressors you may already have (like income, available resources, and social support you have access to) Fears (uncertainty and unknowing) Attention (what you're focusing on) History of experiences (what has happened previously when you've had pain Dr. Rachel Zoffness is a leading global pain expert, international speaker, author, and thought-leader in medicine revolutionizing the way we understand and treat pain. She is a pain psychologist, Assistant Clinical Professor at UCSF, and lectures at Stanford. Dr. Zoffness is the author of The Pain Management Workbook and consults on the development of integrative pain programs around the world. She is a regular guest on popular podcasts like Ologies, Jordan Harbinger and ZDoggMD, and her episodes have over 5 million downloads. We cover topics like: Breaking the stress, anxiety, fear, increased pain cycle Science behind how pain is emotional and physical Tips and exercises on recovering from chronic pain RESOURCES: Free sex and pelvic pain resources https://drsusieg.com/resources-for-pelvic-pain-in-men Online Pelvic Pain Relief Program for Men https://drsusieg.com/pelvic-pain-in-men-online-program CONNECT WITH DR. RACHEL ZOFFNESS: Website: https://www.zoffness.com/ Twitter: @drzoffness Instagram: @TheRealDocZoff The Pain Management Workbook: https://www.amazon.com/Pain-Management-Workbook-Powerful-Mindfulness/dp/1684036445 CONNECT WITH ME (DR. SUSIE): Website: https://drsusieg.com/ Instagram: https://www.instagram.com/dr.susieg/ 15-minute call: https://drsusieg.com/pelvic-pain-specialist-15-minute-call Disclaimer: This information is not intended to substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of a healthcare professional with any questions you may have regarding treatment, medications/supplements, or any medical diagnoses. This information is intended for educational purposes only and is in no way to substitute the advice of a licensed healthcare professional.

Hi everyone, this is Dr. Susie G here and welcome to another In Your Pants podcast. I'm so glad that you could be here with me today. on today's show we are going to be diving into the deep oceans of pain using a biological psychological and social cultural framework and to help me do this we have very special guest dr rachel zoffness dr rachel zoffness is a leading global pain expert and pain psychologist she is an assistant clinical professor at ucsf school of medicine and pain education faculty at Dartmouth and Stanford University. Dr. Zofnes is the co-president of the American Association of Pain Psychology and serves on the board of the Society of Pediatric Pain Medicine.

She is the author of the Pain Management Workbook, a treatment protocol for adults living with chronic pain. She also writes the Psychology Today column called Pain Explained, and Dr. Zofnes consults on the development of integrative pain programs around the world. Dr. Zoffness and I dive into some really bold questions in our episode today, starting off with why conventional medicine is treating pain all wrong. Dr. Zoffness then explains to us how pain is both emotional and physical, backing it up by what science tells us. we dive into the myths and misconceptions about pain psychology what it is and what it isn't and why having a mental health professional and psychologist who is trained in contemporary pain

science why that is so important for pain recovery dr zoffness also shares with us what you should look out for as far as questions to ask when searching for a specialist like herself or someone who is well-versed in pain education and neuroscience. We also touched base on some of the special considerations around pelvic pain and why it's even more tricky and a bit more complex. As my mentor Sandy Hilton would say, it's chronic pain in the pelvis is pain plus plus plus plus plus. And so Dr. Zofnes and I unpack why that might be for some folks. And then we talk about expectations around recovery with chronic pain. And both Dr. Zoffness and I are huge advocates of bringing hope back on the table

and also providing this message of that pain can change, that this situation can be different and you can feel different in your body. So you won't want to miss this episode. We do share some really wonderful nuggets and gems with you. And Dr. Zoffness also shares brilliant nuggets and exercises, practical exercises that you can use right away. And those are taken directly from her pain management workbook. All the links to what we, the resources in the show will be in the podcast show notes and also linked in the description on YouTube in the comment section below as well. So I hope you enjoyed the show. Dr. Rachel, thank you so much for being on the show today. Thank you for inviting me. Well, we are going to actually dive in and be bold

because we're going to start this conversation off with talking about why conventional medicine is treating pain all wrong. Yeah. Conventional medicine is treating pain all wrong. And I think most people living with pain know that like people who come to me who have been in pain for a long time will say, I've tried this thing and this thing and this medication and this procedure and this surgery and this thing, and my, I still have pain. So, um, I would say that the primary reason that pain is being mistreated in America and really around the world is that the way we have framed pain historically for many years is incorrect. We have framed pain as a biomedical problem exclusively to be treated exclusively with biomedical solutions. By that I mean when

people have pain, we often focus on the body part and the part that hurts exclusively rather than the whole person. And as everybody knows, pain is complex and multifactorial. And what science actually tells us is that pain is never, not ever purely biomedical. It's actually this like bigger monster of a word. It's biopsychosocial. And what that actually means is that there are, of course, biological components to pain. Nobody denies that that's true. And also there's psychological components. So that means cognitions affect pain, the things you think, believe it or not. Emotions, how you're feeling emotionally affects how you feel physically, which I think we all know. And how you behave or how you act in response to chronic pain also impacts how your body feels. So

a lot of people with pain are stuck at home. They're not moving. They're not going outside. They're not engaging in activities, understandably. But it turns out that not moving, not engaging in activity, withdrawing, not seeing people, turns out makes pain feel worse. And then there's the social or sociological domain of pain, which is socioeconomic status and your social support network and your access to care and friends and family and your environment and your context and all of those things together. This is a long answer to your short question. So all of those things together combined produce and reduce pain a hundred percent of the time. So pain is both produced by biopsychosocial factors, and it's also reduced by biopsychosocial factors. There's

so much to say about all of that, but. Well, I have a follow-up question for you on that, because in our worlds, working with folks who have persisting pain, it's often that they are told it's all in their head. And I'm sure you've heard this before. How do you address that? Yeah. So, you know, I'm, I'm a pain psychologist and like literally no one has ever heard of a pain psychologist before. So the question I get asked most is, oh, well, do you treat physical pain or emotional pain? And the answer to that question is yes. The answer to that question is yes, because this thing we call pain is produced by the way, not by the body, but by the brain, by the brain. So people, yes, are told or given this message. Like it's all in your head and like,

it's not all in your head, but, but it is actually in your brain. So, so, and the reason we know that by the way, there's this condition called phantom limb pain, where people will lose a body part, like an arm or a leg, and they'll continue to have pain in the body part that isn't there. So if you can have terrible leg pain in the leg that isn't there anymore, that tells us that pain can't possibly be produced exclusively by the body. It has to be constructed somewhere else. So neuroscience has, has shown us that that places the brain. So what we do in pain psychology is we target the brain in addition to the body, because you know, what a lot of doctors do is they treat the body, which is great, but also the brain needs to be treated too. So there is a lot

of stigma around pain psychology for sure. And there is this messaging that like, oh, it's all in your head. If you see a pain psychologist, but that's not quite true. It's brain and body working together all the time. And if we don't target the brain, we're not actually treating persistent pain. Right. Okay. So I love that reframe about, well, a brain is an organ. It is the boss, the CEO that's looking out for you, always predicting the next move, the next potential threat, whether that's direct or indirect to protect you for survival, which totally makes sense. Now let's segue a little bit into how does specifically pelvic pain, like pain in our private parts and areas, how is that pain plus, plus, plus, plus, plus

in your opinion? Because I have a theory, well, I have an idea about why, you know, when our genitals hurt or their sexual pain or pain having to do with our reproductive organs. That weighs a lot more heavily on the meaning of that pain and the, you know, the way we interpret, you know, the way we act in the world and how the world acts back to us, especially with that part of our body. So can we unpack that a little bit as far as like, why, why does it hurt a lot more when it has to do with a body part like our genitals. Okay. I, so full disclosure, I am not a pelvic health specialist. So I do chronic pain, all sorts of persistent pain, including pelvic

pain, but that's not my expertise. So I'm actually dying to hear what you have to say. And I'm going to ask you, but, but so what I, what I would say is the way you framed it is perfect and dead on, which is like your brain is your body's danger detector and it exists to protect you from harm. so when something happens to the body the brain is just always on high alert in general right and it wants to know whether or not to make pain and how much so your brain is sort of always performing this wonderful calculation and it's taking into account all available information so like context and environment and your emotions like what's happening in that moment and your thoughts what are you thinking and your perceptions and your beliefs about your body and your pain and i think

Pelvic pain in particular is very loaded for, for many reasons, but, you know, as we all know, sexual health and sexual functioning has a lot to do with our relationships and our identity also. So when something happens, you know, I feel like it's actually, like you said, it's plus, plus, plus, so it's really loaded. And there's a lot of stigma also. And there's also a lot of shame. Like if you can't perform sexually or there's pain or you have pelvic pain, you know, somehow

that compromises how manly you are or how feminine you are, or it somehow compromises your identity or your sexual ability. So, um, I do think it's really loaded. Um, and I am curious to know what you see as, cause you are a pelvic health guru. No, not a guru, just a human that particular interest in pelvic health. But I agree wholeheartedly with you. Honestly, That's really my thoughts on your brain is weighing this part of your body a lot more than it would like stubbing your toe, for example, because this part of your body is used to receiving pleasure and pooping, peeing, and sex are basic everyday functional necessities, activities that from an evolutionary point of view means a lot because that's part of

survival. yeah that's a really really wonderful point like you can lose a toe and you're okay i mean and also i mean technically you could lose a reproductive part and be okay too but you're right evolutionarily it matters more so you're right it makes sense to me that your brain might weigh that a little more heavily and might give like sort of amplify this danger message or this alarm signal to make to force you to pay attention absolutely and you and just to echo what you said about the meaning of this part of our body and the contacts around this part of our body with relationships, sexual identity, sexual voice. And the other thing to that is when we stub our toe

or hurt our hand or finger, we can show people. We could be like, hey, look, this hurts. Have you ever had this before and we can socially engage and reach out for support with pain in our private areas it's definitely like you said there's shame around it it's a bit taboo who do i go and talk to how do i bring this up it's a very challenging layer in addition to not just dealing with pain but on top of that is just having so many barriers to be able to express oneself to you know to express the pain, pain expression is difficult to begin with anyway, but to express pain in a part of the body that has so much, you know, in air quotes here, like embarrassments and shame and shyness and so forth. And then layer on that gender roles and dynamics and, you know, socially

how that all plays out too. So. Yes. You also are making me think of a really important factor that we should talk about, which is the role of fear and anxiety and stress and pain. Because I think what happens with pelvic pain is there becomes a lot of fear. Like I'm not going to be able to perform sexually anymore. Like I'm not going to be a good partner to my partner. Or if you're single, it's like now I'm single forever. Or like my wife or my partner is going to leave me or, and also there's this general fear that we see with chronic pain in general, which is this is never going to end. Like, am I ever going to get better? Is this pain ever going to end? And so I just want to say for a moment, there's this great irony with chronic pain.

So if we think about stressors on human beings, it's like death of a loved one and moving across the country. And like, you know, there's a lot of well-known stressors. One of the biggest stressors on the human body is pain. Like the body is not built to be in pain for weeks and months and years. Like that's not how we're built. So having pain enduringly persistingly over a long period of time is a massive stressor. And the irony is that what we know is that stress and anxiety and fear activate the sympathetic nervous system. And what that does is it turns up pain volume. It actually amplifies in your brain, the response of your brain to the pain you're having. So whatever pain you had, if you're stressed or anxious or feel fearful, your pain is actually

physically going to feel worse. And it's this great and terrible irony because you're, you're stressed and anxious and fearful because you're in pain. And then you're in more pain because you're stressed and anxious and fearful. So part of my job is always trying to break this stress, fear, anxiety, pain cycle, which I know you do a lot of also. And what I find to be so helpful for that is exactly what you're doing, which is spreading pain education and teaching people how pain works and relocating pain from the part of the body, you know, that's hurting to the brain because we have to target the brain if we're going to ultimately target pain. Well said Dr. Rachel, beautifully said. So that brings me to my question to circle back to,

well, how is pain both physical and emotional? Can we talk, can we unpack that a little bit more so that folks understand? Yeah. Um, so the thing that I find that helps the most is using metaphors. I love metaphors when it comes to really complicated, sciencey, nerdy pain stuff, because pain is super, super complicated. Um, so the metaphor I like to use is this metaphor of a pain dial. So it like operates like the volume knob on your car stereo. and there's a lot of things that turn pain volume up. And there's a lot of things that turn pain volume down. So, so just to say stress and anxiety is a thing that always changes pain volume for some of the reasons we were just talking about and mood and emotions are always changing pain

volume. And the reason for that is like we said before your brain's limbic system, which is your brain's emotion center is always processing pain and then attention or what you're thinking about or focusing on. So, so the metaphor goes like this, when stress and anxiety are high and your body and your muscles are tense and tight, and your thoughts are worried, your brain sends a message to this pain dial, amplifying pain volume. So whatever pain you had before stress and anxiety are always going to amplify pain, same with mood and emotions. So what science tells us is that when emotions are negative, which ironically, again, is a thing that commonly happens with pain. So when you're sad and depressed and angry and frustrated, which is normal, your limbic system in your brain will amplify pain. It turns up the pain dial and same with attention. So when we're stuck in bed at home, missing life, missing work, missing social activities, missing sports, our prefrontal cortex in our brain, again, amplifies this pain dial, amplifies pain volume.

but the opposite is also true. And I find that to be so important to communicate to patients because when we have pain, we feel so out of control. Like our bodies and our lives are just so out of control, but there is this pain dial thing that lives in your central nervous system. So we know that when stress and anxiety are lower. So when your thoughts are calm and your body and your muscles are relaxed, your brain will lower this pain dial. And that's why there's abundant research on things like mindfulness, which is annoying for most people. And I understand, but mindfulness and meditation and like relaxation strategies and things like biofeedback can all turn down this pain volume, this pain dial and same with mood and emotion. So when emotions are

positive, you're joyful, you're happy, you're engaged in pleasurable activities. We know neuroscience tells us those things, positive emotions can turn down pain volume and same with attention. So like when we're distracted and we're so absorbed in some activity, we briefly forget about our pain. That isn't magic. That's actually this, this pain dial that lives in your central nervous system. So, so there are, I mean, so again, physical and emotional are always connected. That's just how the brain works because the brain is connected to the body 100% of the time. There's no way around it. And there are all of these cognitive and emotional factors that adjust pain volume a hundred percent of the time. And I'm so glad that you said that it's normal to

have, you know, that anxiety and stress, because I feel that, you know, if we can't find it like from a conventional standpoint, biomedically, then it's gotta be some, we don't know woo thing or some something that's like, Oh, it must be your stress. You're just stressed out and you're anxious. Well, you would be too, if you had a very threatening situation in your life. And I think, and I like that you normalize that. But I'm also hearing you say that although that's a protective mechanism in itself, the feelings, the emotions, the anxiety, the stress, that it can backfire if we're not coping or helping the situation or kind of calming that down or using different strategies to help move forward with this struggle and adversity rather than staying

stuck in a cycle. Agree. And I love the way you said that. Yeah, that's exactly right. So essentially my main message is how you're feeling emotionally is always, and I mean, always because of how the brain works going to affect how you're feeling physically. So if we're not taking care of our emotional health, we're not actually taking care of our pain. And in Western medicine, we have this false and totally erroneous divide. So either you have physical pain and you see a physician or you have emotional pain and you see a psychologist, but as we all now know, pain is always both physical and emotional. So this divide is just, it's sort of BS. That's just not actually how pain works. That's not how humans work.

So we really have to integrate the two. Um, and, and I'm sure we're going to touch on this, but the thing with pelvic pain is it's often associated, not always, but there's often an association with history of trauma or physical abuse or whatever. So not always, and I don't want to stigmatize, but also to your, to your point before, um, one way of thinking about like the depression and anxiety that often comes with chronic pain and incidents is really high is that again, the body's not built to be in pain for like months and years. So, so when people become scared and anxious, like, is this going to last forever? Am I ever going to get my life back? Am Am I, am I going to be happy to be able to have sex with my partner or when people become

depressed about it, that's what we call a normal response to an abnormal situation. Like again, it's the human body isn't built to be in pain for that amount of time. And of course we're going to have a response to that. So I try really hard to make sure that physicians aren't calling this mental illness. Like it's a normal response to an abnormal situation. well and mental illness mental illness mental health in general at least in in our you know in in my bubble this culture it does have a stigma attached to it or historically has and for for those who identify you know as men or male or masculine

in the research in the qualitative research there is a there's a lot of evidence to support that embarrassment is a number one barrier to seeking mental health care, which is such an important part. I mean, it is one of the, part of the four pillars of health, right? Mental health, physical health, spiritual, sexual. Those are, those are four pillars of health by the World Health Organization. So it's not separate from, like you're saying, where did we go wrong? Not us, but particularly where did, where did society go wrong? Where did conventional medicine girl. Where did this, where did this, who dropped the ball? I know. I think about this all the time. I think, I mean, I think Western medicine overly compartmentalizes just for the sake of like,

for ease. Like I have patients who come to me who have various types of body pain and I am not exaggerating. I have patients who have 12 or more physicians to target various parts of their body because medicine isn't integrated. So it's like, as if your foot pain isn't related to your abdominal pain isn't related to the, like everything's connected in the human body. That's just how we're built. But one patient will have 12 specialists giving them different advice and different medications, and nobody's actually targeting the brain. It's just wild. So, wow. And they're not talking to each other oftentimes either specialists, right? No one's talking to each other. And absolutely no one is talking about the role of emotions

or cognitions, even though neuroscience tells us that cognitions and emotions are always fueling any sort of pain fire. Right. So, so it's like, we're not really talking about pain and we're not actually treating pain in Western medicine in any sort of way that makes sense as far as science goes. And it drives me bonkers, but, but I think the answer and the solution is things exactly like this. Like if we educate people who have pain and tell them no, yo, like it's not that you're mentally ill. It's just, we have to take care of your emotions for your brain to process pain differently, that's just how the brain is built. Then hopefully that takes some of the stigma and shame out of it. It's just neuroscience, right? It's just, I love neuroscience.

I'm such a nerd, but yeah. But my hope is that like, oh, well maybe that takes some of the sting out of it. And when we say things like, yeah, it's normal and natural to be depressed and anxious when you've had pain, especially in your penis or like whatever, any part of your body that's extra sensitive or stigmatized or shameful in our culture. Like, yeah, but if we, if we treat that and we talk about it, it's going to actually help your body feel better. You know, exactly, exactly. Yeah. Yes. A hundred percent. So I want to talk about myths, myths and misconceptions of pain psychology, because I know not all psychologists are created equal, just like any other profession. right and I've had and my just from my own experiences and and folks that I work with

and their experiences that they've shared with other psychologists um is that you know some of them are like it just it just didn't help it didn't work for me so can we talk can we talk about that like what should folks be expecting how do they know they're connecting with someone that is going to understands pain from the perspective that we're talking about and can really help you move someone forward. Not saying that all these other individuals are not well-intentioned. That is definitely, I'm not trying to poo poo on someone, um, or the, or their approach, but there is a, there is a difference here that we, a little nuance that I'd like to unpack. It's such a great and important question. It's almost like a pain point for me because,

um, so a couple of statistics, um, most psychology programs, like 99% of them don't train therapists in pain at all. And that goes back to that thing where in Western medicine, physical pain air quotes, there is treated by physicians exclusively. And psychologists like me are intended to treat emotional pain again, in air quotes exclusively. So there's this divide and therapists are often not trained in pain, how pain works and physicians often are not trained in how emotions affect the body. So we have this really unhelpful setup. Um, and so yet the answer is yes. A lot of psychologists are not trained in pain. Um, it makes me crazy. And part of my work in life is to help put resources into the hands of every therapist because it's not rocket

science. It's actually what galvanized me to write the pain management workbook, which is a really dorky pain management workbook that I wrote. And it's a whole cognitive behavioral therapy protocol for pain management. And my goal, what like people were, I have a wait list at any given moment of like, I'm sure you do too, of like 50 patients. And I hate saying no, and I want to help everybody. So I'm like, okay, well, here's a resource. So you can go find any therapist and say, will you go through this book with me? Because, because I can't, at least not right now, I can't change psychology training programs. They make me really mad and it's not fair to people living with pain, but we can provide low cost affordable resources. So in my mind,

I'm like, okay, how do I put resources into the hands of therapists? So the question is a good one. Um, there's also a website called psychology today, and you can type in there like something like chronic pain, and you can find people near you who may have some expertise, but your question is how do you know someone's a good therapist? So number one, you feel comfortable talking to them. That's like the most important piece. If you don't feel comfortable talking to the person across from you, doesn't matter what they're trained in. That's not the right fit for you. So that's thing one. Um, sometimes comfort comes with time. So I would say like, go for a couple of sessions and feel it out and see if you feel like it's a fit. So,

So that's thing one thing too, is, um, I think it's totally okay for you to ask like, Hey, are you trained in pain? And most are going to say no. So I'm not saying that that's a deal breaker because most people are not trained in pain, but that's a fair question to ask. Um, and thing three is cognitive behavioral therapy or CBT as it's known is an evidence based treatment for pain. So there are therapists who are trained in cognitive behavioral therapy who might not

be trained in pain, but I would say seeing a therapist who's been trained in cognitive behavioral therapy is a pretty good place to start because they can use a CBT for pain protocol. If they're already trained in CBT, that doesn't mean they're going to be the right fit for you, but that's, those are some criteria, some like general frame, a framework. That sounds like a nice alternative to folks don't have anyone to connect with that are, but you don't have a specialty or an understanding of pain neuroscience in the way that we're talking about that cognitive behavioral therapy might be another outlet or avenue. What are your thoughts on acceptance, commitment therapy and pain? So for folks who don't know about it, ACT or

acceptance and commitment therapy is a branch off of cognitive behavioral therapy. It was developed from this fund of knowledge that thoughts and emotions and physical sensations and behaviors are all intimately connected. I like ACT. I do not think it's this like panacea that folks are making it out to be. What I like about it is that it incorporates cognitive behavioral strategies into, into any pain management protocol, which as you know, I'm biased. I think we should be doing that already. I will say one thing I don't like about ACT, like I was trained in ACT as part of my training program a long time ago. And I only like later on when I went down the pain rabbit hole learned about it's, you know, people talking about it in the context of pain management.

The one thing that gives me pause is there's this quote that's used in act all the time that pain is inevitable, but suffering is a choice. And that makes me crazy. And I don't think that's true. Um, as someone who has lived with chronic pain, my whole life, that quote actually makes me mad. I think it's suggesting that suffering is a thing that's like the onus is on the patient. And like, if you're suffering, that's your problem, you're choosing it. And I just think that's such a, like flipping a bird in the, like, it's just like flipping the bird to people who are suffering and living with pain. So there are things about act that I love, and there are things about act that I don't

actually love, but I think it's very helpful. And some people find it to be exquisitely helpful for their pain. So, so for me, it's like the recipe is like, whatever works is great. Like, let's try all the things act is like phenomenal for some people with pain and not for other people with pain. So it's like, let's have that in our tool belt. And as providers, we can have those tools available for our patients. And as patients, they should have those tools to use for their bodies and their, and their brains. Um, but yeah, but no, it's not like one size fits all, you know? Right. And I'm also hearing that if, if it didn't work out with

one person not to give up on perhaps the, uh, the approach or the, um, speaking of someone that is a good fit. I mean, that's very common for pelvic therapists too. There are a lot of things that make me cringe when I hear folks say what their experiences or share what their experiences have been with other therapists. And again, well-intentioned individuals, at least that's what I, you know, in my, in my heart, in my mind, well-intentioned individuals who are also human working with other humans who they themselves struggle in it. And again, it's context, you know, it's, it's the time and the place with who we are, with what we have. And it, it, it might not be what you particular need, or as you say in your workbook, it's not the ingredient, the ingredients

for your particular recipe. You use that as an activity. And I want to get back to that actually, because I think it's a really great activity or something to share as a nugget from the book. but yeah so it's it's it's it's not giving up having hope and you know also i think compassion during that process right and and patience um which are very hard and challenging i you know from one human to another very challenging but having that space to to navigate this very very you know treacherous journey um to to get to the other side because i do believe, I do believe that people get better. People can feel, feel well and recover, not just manage, but recover. And, and, and again, that's time dependent as well, you know, depending on

where someone's at and all the other core morbidities and things that might be in that person's world and body. But, you know, I'm a, I'm a firm believer of that, that people can get better and people can have a quality of life that is meaningful and purposeful. Um, anyway, I didn't know where I was going with that, but I agree with you. I emphatically agree with you. And I just want to reiterate that people absolutely can heal from chronic pain. A hundred percent. Yes. Um, pain can change and the way, I mean, everyone knows if pain changes, that means pain can change. I just like go around saying that all the time. If pain changes and everyone's pain experiences changes over the course of the day, over the course of the week, over the course of the month,

if pain can change, that means pain can change period. So yes, people can heal from chronic pain. That's like, absolutely agree. Well, and I'm glad we're talking about that and recovery because, and I'm sure you have a lot of folks ask you like, how long, like, you know, am I going to be like this forever? And how long is it going to take for me to feel, to feel better to recover? And what do you, I want to know, I would love to know what you tell your, um, your patients or clients? Like, how do you address that as far as expectations around the process? Expectations are important and also hard to manage sometimes. So the answer is as healthcare providers, we cannot make any promises about how long it will take. And I always say that to people

who call me that there actually is no answer because every person who walks into my office is completely different. Their history is different. What they've been through is different. The treatments they've tried are different. Their body is different. Their brain is different. The factors that are amplifying their pain and contributing to this pain recipe are different. So, so there is no way to predict, but I do like what I do actually tell people is, um, in my practice, there's like this range of response time. So, um, I was working with a teenager who had chronic pain and working with her parents also. And it took like six sessions and her pain completely broke. And she like went back to life and soccer and was like, totally fine. And I never

heard from them again, which is great. And then I have patients in my practice who have like extensive histories of family trauma and abuse and a lot of other things going on and their pain is lasting longer. And they're with me for, you know, a longer period of time. So it really just depends. Um, really the answer is it just, it just depends. It's a really annoying answer, but there's no, in fairness to our patients, there's really just no way to make a promise like that. Right. And I'm glad that you're, you're, you're saying that and being bold and saying that because as a, as a clinician and practitioner, it does bring up just from my, you know, it's my experience of it is it's, it's, it's disheartening because, you know,

the answer is, well, I'm, I just don't know. And we don't know, but what we do know is that there are many things that we can do to help reduce your pain. We just don't know how long that's going to take. Exactly. Right. And, you know, there is for, for, for, for folks who are and again myself included like hearing that those words are like well i'll be damned you know like i want to know that there's light at the end of the tunnel right because we can endure i mean i can endure i'll speak for myself a lot of um uncomfortable things knowing that it's short-lived right like i know you know this this crappy movie that i'm watching because somebody dragged me to is going to end in the next 45 minutes. Right. Or what have you. Right. And so, so, you know,

it's going to end with pain, persisting pain. That's the thing. And we've talked about that earlier in our conversation of like, sometimes it's random. It's like this threat lurking in the shadow. There's always this like anticipatory, like, is it, it's going to come, it's going to get me right now and so it's like how do we we and I mean collectively like how do we help to establish some mental capacity around that especially when we're giving you know clinicians are saying like well we really just don't know because this is what we do know and there's a lot that we don't know and what we can do is be a support system and a guide during this very difficult time but know that you can get better I mean I feel like you know one hand we're telling

folks yes you can get better there's hope and at the and and at the other end of it we're saying well we just really don't know though right so I feel like sometimes there's that message that comes across to folks of like well you're telling me I can get better I don't believe that I can get better and like that reassurance piece that I think folks really need to hear and believe that they can get better if that belief isn't there or the buy-in isn't there or they're just not you know, I guess open to the process of, of embracing their experience in this way or an approach, then that can, that can be like a rock and a hard place or between a rock and a hard place. If I can say that cliche of a statement, but yeah, I love, yeah. I'd love to hear your

thoughts. So I think there's a couple of things you said in there. I mean, that were just absolute gems, which is, I do think we should be saying to our patients upfront, yes, your pain can change. And yes, I can help you because that's the truth. Like you're a pain expert and I'm a pain expert. And there are things that we can offer that absolutely will help people. So I don't think that's a lie. Like, and I think the other thing that we can do is say, I can't make you any promises because I'm not clairvoyant. And like, that's also fair. You're just being honest. Like I'm like, I am a New Yorker. So I'm like very direct and very blunt and it works for some people and not for other people. But I think it's totally fair to say like, yes, pain changes all

the time. Yes. I can help you. Yes. Chronic pain is treatable and people get better. And I can't tell you when, because I just don't have that superpower. Like that is, I think a great and honest way of framing, you know, what we do for patients. Like we help them heal. We support them on the road to recovery. We give them tips and tools for pain management, and we don't make false promises because no one would trust us if we did, you know? Absolutely. And that's huge. Being honest, open, transparent with the process and, and admitting when, when you don't know something, you know, like, Hey, I just, we're going to try some things, you know, where there's many tools in the toolbox. There isn't a one size fits all. And I'm sure that's in your practice

too, right? Like you said, there's mindfulness, there's, um, you know, cognitive behavioral therapies there's relaxation techniques there's all sorts of tips and tricks and tools to help retrain the brain to help them connect with their body in a more pleasant positive way and provide these positive messages of of this can change and whether or not it does change you know i would say in a positive or negative direction like you're saying if it changes then that's proof right there that it can change whether it is in a positive or negative direction it is information but it's also proof that you, there is possibility and potential for things to really go in a very positive direction. Exactly right. So Dr. Rachel, let's circle back to your book, the pain management

workbook and to some of the activities, uh, the concepts in that book that folks should expect to kind of, you know, when, if they get it, what should they expect, you know, working through that workbook. And then if we can also share a little gem from that workbook about the, I really love the low pain day, high pain day recipe and finding one's ingredients. So yes, let's do it. Okay. Right. So, so I'm a patient advocate and what that means is I'm always advocating for people to have access to high quality and effective care. And it makes me really mad that non-pharmacological treatments for pain are often not covered by insurance companies so so patients who come to see me for cognitive behavioral therapy or other therapists will

often be told by their insurance company that sessions are not reimbursed and like nothing makes me angrier and like what planet like on what in what universe are we living where like only rich people can afford effective treatment it's like makes me nuts so cognitive behavioral therapy for pain, again, is this evidence-based treatment and ACT grew out of it. There's all this evidence of treatment effectiveness for chronic pain. So I just like stuck it all in a workbook. And there's lots of different pieces to it. So one of the pieces is this pain education thing that you and I are such like, we love to get nerdy about it. And there's two gentlemen who are physios who are doing a lot of this pain education work. Laura Mermosley is one and Adrian

Lowe is the other, and I know you know them. And I reached out to them when I was writing this book and I was like, would you guys consult with me? And they did, they read and edited my pain education chapters and they gave me feedback and I tried to pay them and they wouldn't even take feedback, but I wanted to make sure that I would, it was so nice, but I wanted to make sure that I was putting high quality vetted information out into the universe. That's affordable. So part one of the book is just this pain education piece, like how pain works in the brain. Um, you know, ways of adjusting this pain volume, this pain dial thing we were talking about, how emotions impact the pain you feel. I just, I really wanted to make that connection for people and just

de-stigmatize the crap out of it. So that's like part one. Part two is behavioral strategies for pain. And what I mean by that is behaviors are things that we do, and they're also things that we stop doing. So as everyone with chronic pain knows, there's lots of things we stop doing when we have pain and it depends on the condition, but a lot of people with chronic pain stop going to work or, you know, stop engaging in sports and stop having sex and stop, you know, going their weekend activities or their hobbies or their pleasurable activities. So, and again, that's part of the chronic pain cycle that can perpetuate pain when we're stuck inside and we're not engaged in life. So, so behavioral strategies target the things we're not doing and they target avoidance

behaviors. And they also provide strategies that we can use in the positive direction to change pain too. So, um, there's a strategy called pacing for pain, which a lot of PTs, um, talk to me about and help me navigate with my patients and pacing for pain is like pacing for a marathon, right? Like you don't go outside and run 26 miles tomorrow. We would all, some of us would die like me. I would just like be faced down on the pavement, like little bits of activity and motion every day. And there's a recipe in there for figuring out a pacing plan. Um, there's mindfulness strategies and relaxation techniques, again, to shut down the sympathetic nervous system and lower the brain's pain volume or pain dial.

Um, so there's all sorts of behavioral techniques for changing pain. And then there's cognitive strategies, which are so fascinating to me. And cognitive strategies are really going after the crap in your head. Like we all fall into this trap of believing the shit that happens between our ears, right? Like 100%. Yeah. And people with pain, like have what we call, we call them cognitive distortions. And literally all that means is a thought that isn't true, but it sounds like the truth. And our brains feed us distortions all day long. Like when you look in the mirror and you think something really mean and nasty about yourself, or you have a thought in your head and it's like actually your critical dad. And it's just like, you can hear it in your head and he's just like saying mean things to you. there are distorted thoughts we hear all day long and I'm broken. I'll never get better is one of the most common distortions I hear when people have pain, but here's the thing. None of us have

the ability to predict the future. Like if anyone here did, they would be a bazillionaire and they would like buy Fiji. Um, but, but we make these predictions. So what we do with cognitive strategies is we help adjust the pain volume by going after distorted thoughts and beliefs that are amplifying pain volume. Um, and then there's a section on lifestyle medicine and lifestyle medicine is, um, the everyday daily decisions that we make, like the food we put into our bodies and nutrition and sleep because chronic pain often inevitably impacts sleep. So what are some strategies we can use to improve sleep? Um, and then social medicine. So what are things we can do socially with our support network to help lower our pain dial also? So there's just like,

there's a ton of stuff in there. Oh. And I think you have a copy somewhere there for those who are watching. Yeah. I was saying this to you earlier, like my lovely publisher sent me like boxes of books, but they didn't tell me what to do with them. So I do, I have like boxes of books. Now you get to use it. There you go. The pain management workbook is a lovely blue cover with what looks like clouds. I think underneath. Yes. I had nothing to do with it, but I think they did a nice job with the cover. Um, yeah. So your question about the pain recipe. So what I wanted to do was, um, make sure that everybody knew that, you know, just like there's a recipe for brownies and like to get really good brownies, you need, you know, the right

ingredients and the right amount of the right ingredients, and you need to stick it in the oven for the right amount of time. And if you don't, you're going to have like disgusting burned brownies. Right. And it's just the same with pain. Like just as, as a recipe for brownies, there's a recipe for a high pain day and there's a recipe for a low pain day. And I think the issue is we don't really think about it that way. Right. But I love to encourage people to think about, okay, what is my high pain recipe? And most people can tell me their high pain recipe. So it looks something I'm going to ask you, like, do you have a sense of a high pain recipe for one of your patients or just for you? Oh, me? Yes. Yes. Okay. So mine is,

I can tell you mine. Yeah, no, I'll tell you mine. So, so definitely, um, sleeping less than seven hours, totally me too. Eating high, high sugar, like sugary foods, uh, like lots of sugar pastries, that sort of thing, lots of caffeine and not moving. Like if I have to, if I'm sitting and I have not moved my body like in that day or been active or gone for a walk or something like that, that is usually a very, very good recipe to have a really shitty day. Those are all on my list too. Um, and I will add, and I know that this is because I'm a psychologist. So I think about this stuff, but I know that if I have really high stress, like if I have a really long list of things to do, and I'm stressed out about not getting them done. And I'm staying up till

midnight working and I'm not carving out time for relaxation and fun. That absolutely is going to dial up my pain without a doubt. And if I'm having conflict in relationships, like familial or friend or romantic, like any sort of conflict with like people in my social support network also will dial up my pain dial. So, so together, like all of those things for me, I would call my high pain recipe, like crappy sleep, crappy diet, not moving my body, not exercising, not getting sunlight, not going outside, not seeing friends, you know, arguments or conflict and like lots of stress at work. So that for me is like a perfect, a perfectly imperfect high pain recipe. So the trick is, and usually I write this out on a piece of paper, like my high pain recipe over here. And then also

I want my low pain recipe. So when I think about a low pain recipe, it's quite literally just the opposite. Like if I ask people, what's your low pain recipe? People are like, I don't know. I'd like, I have no, if I knew. And the answer is it's the opposite of your high pain recipe. So once it's mapped out in front of you, it's sort of easy to see. And again, it's all these biopsychosocial factors, right? There's like these biological components like sleep and diet. And there's like these psychological components, which is like, you know, my, my emotional state, my stress levels. Um, and then there's the social component, which is like conflict and support. And so, so together, it's like, when you see it mapped out, you're like, Oh, I know what my low pain

recipe is. It's eight plus hours of sleep. It's not loading up on sugar all day. It's making sure I carve out time to go outside and go for a walk. Even if it's just a 10 minute walk and get outside. Um, it's like making sure I have people around me who are supportive and loving and nice to me and you know, saying no and setting boundaries with people who are toxic, you know? So, so a pain recipe is all of those things. And, and it's, it's really easy for people to do that. So I encourage everyone to map out your high pain recipe because it will inform your low pain recipe. And then the next question is, how do I make today and every day more of a low pain recipe? What do I need to change in my life to stack the odds in my favor that I'm going

to have a low pain day. I love it. And it's so practical. It's very practical, realistic, and based on that person's individual circumstances and life. It's not somebody being saying like, you have to do this, this way, this many times, you know, and if you're not, then it's all your fault that you're in this situation. Right. Which is what uncommonly to happens too many times um so yeah that's just a beautiful little activity so i hope folks really really take it on you know have the courage to to try it out and sit down with a piece of paper and their thoughts which can be sometimes scary right um to to have it really reflect in that way like a mirror but again without recognition or awareness where what options do we have then right

when we don't have that awareness so awareness i think is a really big thing is what i'm hearing too just being aware yep um great well dr rachel i've had such a great time on this um with this conversation with you and honestly such wonderful nuggets and wisdom and passion we really do need to have more conversations like this across the board across professions and you know just getting on, on the same page, you know and really helping folks have really good, healthy, not, not painful lives. And it is possible. Just, we're just not doing it. We're doing it all wrong. Like we started this whole conversation, right. Doing it all wrong. Right. But again, if pain changes, then pain can change. So this is a really good place to start. That's right. That's right. Oh,

Well, Dr. Rachel, how can our listeners and viewers connect with you if they wanted to? Right. So I have a really nerdy website. It's just my last name. It's Zafnas.com. And I should say on that website, if people are interested in this pain science stuff, there's a resources page with like a crap load of free resources. And I've been putting it together for like a decade.

So there's a ton of articles on how pain works. There's lists of books. There's free guided audio. I made sure to list free ones. there's podcasts. There's, I mean, there's just like a ton of stuff. So that's an option. I also joined Twitter during the pandemic, which has been absolutely delightful. I've met so many colleagues. So on Twitter, I'm at Dr. Softness. I also joined Instagram, which I'm like not as good at, but I'm working on it and I'm at the real docs off on Instagram. I like got nervous and I

couldn't think of a handle. So that was the one I picked. Yeah. So that I've been trying to do a little more social media stuff. Great. Oh, that's wonderful. And again, thank you so much for being on the show today and for sharing your wisdom. Many people are, I do believe firmly in my heart that they will certainly benefit from this conversation. So I sure hope so. Yes. Thank you. Thank you. And to all of our listeners and viewers, this is Dr. Susie Chi. Until next time and loving wellness for your pelvis. See you later. Thanks for listening to today's episode.

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