The One You Feed - Hope for Healing Chronic Pain with Yoni Ashar

Episode Date: October 25, 2024

In this episode, Yoni Ashar explains the elements of neuroplastic pain and offers hope for healing chronic pain. In his work with”Pain Reprocessing Therapy” he delves into how this unique approach differs from traditional pain management techniques. Yoni’s research challenges our understanding of pain and opens up new possibilities for healing and well-being. Key Takeaways: The role of fear and threat perception in maintaining pain Key indicators that your pain might be neuroplastic The three components of somatic tracking in working through pain How to create a sense of safety around pain sensations For full show notes, click here! Connect with the show: Follow us on YouTube: @TheOneYouFeedPod Subscribe on Apple Podcasts or Spotify Follow us on Instagram See omnystudio.com/listener for privacy information.

Tons of people who have no pain at all have all kinds of anatomical findings. If you go and take a hundred healthy, pain-free 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. often not painful. Welcome to The One You Feed. Throughout time, great thinkers 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. I'm Jason Alexander. And I'm Peter Tilden. And together, our mission on the Really Know Really podcast is to get the true answers to life's baffling questions like

why the bathroom door doesn't go all the way to the floor, what's in the museum of failure, and does your dog truly love you? We have the answer. Go to reallyknowreally.com and register to win $500, a guest spot on our podcast, or a limited edition signed Jason bobblehead. The Really Know Really podcast. Follow us on the iHeartRadio app, Apple podcasts, or wherever you get your podcasts. Thanks for joining us. Our guest on this episode is Yoni Ashar, 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 Weill 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 32 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 is a bad wolf, which represents things like greed and hatred and fear. And the grandchild stops, thinks about it a second, and looks up at their grandparents and 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 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 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. Then you have the wolf of something like safety or ease that eventually 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, a skillful and unskillful wolf isn't a very good story, right? It just doesn't capture the imagination. So let's talk about the core of your work. It's really around recognizing that, I guess, correct anything I say that'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 has been a revolution in our understanding of chronic pain that's been unfolding over the past several decades due to advances in medicine, in neuroscience, and in 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 processes in the brain that are causing the pain to persist. And this is called neuroplastic pain. It actually goes by many names. It's also called primary pain and nociplastic pain.

But 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 100% 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 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 now 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 us. Sure. There's been a lot of research in both animal models of chronic pain, particularly in rodents where they kind of 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 of like, whoa, this is really a big deal. So this is a study from the Apcarian lab at Northwestern that came out five or 10 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 somatosensory cortex, cingulate, insula. These are brain regions that any neuroscientist would say, yep, that's where the pain belongs. That's the part of our 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 healed. They went back. Life was normal. It's kind of like typical course. Yeah, you pulled your back. 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 the medial prefrontal cortex

and with the amygdala. And those are brain regions that have a lot to do with learning and memory and emotion and meaning. And what they basically did in the study was they caught on camera, 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 a 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 research, 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, right? 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 were always just reactive, we'd all be dead if we one step ahead of the lion. And once we understand that pain is predictive, that opens up a whole host of thorny problems because prediction is really challenging. that opens up a whole host of thorny problems because prediction is really challenging. Like it's really hard to tell the future and there can be mispredictions. So for example, a person injures their back, they're bending over. That's not good. That's for the injury. So pain is created. But now the brain will start to predict pain when bending over. And even if 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 that 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 a researcher's ability to predict pain. You know, like who's going to have pain? And apparently they were accurate 85% 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 they'll 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 medial prefrontal cortex and the nucleus accumbens 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 then once the pain becomes learned, it can basically become a habit, 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. Uh,

the nucleus accumbens is actually really involved in, you know, so like addiction, I was just listening to your last episode. Yeah. Yeah. The second reason that's really important is because when you look at like, uh, scans and MRIs of the back, you know, if someone injures their back, those are completely non-predictive of who's going to recover and who's going to get worse. So it's really striking that a brain scan, but not a back scan 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 we're, 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 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, Dr. 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 we have with chronic pain. 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 some indicators that can really be helpful in sussing this out. And I want to give credit here to my friend and colleague, Dr. Howard Schubiner, who in my mind

has really helped develop these methods as well as many you know, many others in the field. Yeah, 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, you know, a clear cause to the pain. A note of caution there is not to go overboard. If you see enough specialists, one of them will find something wrong. I guarantee it. But 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 in 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 neuroplastic

pain. One, spatial spread of pain. Pain started in my shoulder, but now it's spread down my arm. Injuries don't travel, 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 neurons in the dorsal horn of the spinal cord that sensitize each other and cause spatial spread of pain. It's just something that happens in our nervous system. If one area hurts, it'll sensitize neighboring neurons and cause, the signals coming will sensitize neighboring areas and cause spread of pain. Okay, second indicator, spatial variability. So sometimes it hurts on the left, sometimes it hurts on the right.

Again, that really suggests the brain's involved here, because the brain's really good at moving things around in the body. Three, temporal variability. Some days the pain is 10 out of 10, you know, the next day it's zero out of 10. That again does not sound characteristic of like an injury. If you have a broken foot, it's not going to, you know, it'll hurt every time you step on it. You're not going to have 10 out of 10 one day, zero out of 10 the next day. It doesn't have to be quite as dramatic as 10 to zero. It can be, you know, an 8 to a 3, and that's still, you know, quite large swings. Four, presence of multiple chronic pain or, you know, somatosensory 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, this volume amplification, and that can be an explanation for these multiple symptoms. Oh, another one that's really important here is when the pain is really contextually sensitive. And so what I mean is they have pain in some contexts, but not in others. And it doesn't make any sense from a kind of 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 does kind of something's a 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, it started to create pain, just like Pavlov's dogs learn to link a bell to food. We can link a certain position to pain, even though that position isn't objectively more dangerous or putting our body at risk than 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 it could be anywhere along the spectrum from more, say, peripheral tissue causes or something in the body that's really driving it to centralized, central nervous system brain causes. So people can 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. 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 alluding to something like 80% of pain-free necks have a bulging disc in them. So tons of people who are of no pain at all have all kinds of anatomical findings. If you go and take 100 healthy pain-free 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's 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 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 bulging one day and not the next all right there's probably something else going on I'm Jason Alexander. And I'm Peter Tilden. And together on the Really No Really podcast, our mission is to get the true answers

to life's baffling questions like why they refuse to make the bathroom door go all the way to the floor. We got the answer. Will space junk block your cell signal? The astronaut who almost drowned during a spacewalk gives us the answer. We talk with the scientist who figured out if your dog truly loves you and the one

bringing back the woolly mammoth. Plus, does Tom Cruise really do his own stunts? His stuntman reveals the answer. And you never know who's going to drop by. Mr. Brian Cranston is with us today. How are you, too? Hello, my friend. Wayne Knight about Jurassic Park.

Wayne Knight, welcome to Really, No Really, sir. Bless you all. Hello, Newman. And you never know when Howie Mandel might just stop by to talk about judging. Really? That's the opening? Really, no, really. Yeah, really. No, really.

Go to reallynoreally.com. And register to win $500, a guest spot on our podcast, or a limited edition signed Jason bobblehead. It's called Really, No, Really, and you can find it on the iHeartRadio app, on Apple Podcasts, or wherever you get your podcasts. Pain has multiple components to it, right? If I were to think of my back pain right now, right? 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 50, what will I be like at 80? 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 on 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 processes 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's 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. And 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 by 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 want to hit a couple other quick things.

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. 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's something threatening. So there's fear and sense of threat about the pain or the gosh, like you were saying, element two and three, the pain's so bad, it's going to get worse. And then there's these other general patterns of putting our brains in 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 at work, or it could be about beliefs we have that we have to keep everyone around us happy. And if someone's unhappy with us, then that's a big problem. Or that 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 brain's way of saying there's something dangerous here. And if there's a more global sense of threat or danger, like, you know, like someone putting a lot 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 being 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, putting 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 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 Gallup poll. 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, it is. 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 somebody.

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. prevalent pain conditions. So that's the easiest to study. And what people said, 90 to 95% of people were saying old age and injury, a herniated disc. 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 is getting 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 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, it's been like, you know, you start to go, hmm, 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 treat me. You should do physical therapy. No, you shouldn't do it at all. I mean, you start to go, wait a second. Nobody really knows why I hurt this bad. Yes. And that is another great positive indicator for neuroplastic pain.

Getting different or contradictory stories from multiple different providers. That means they don't know. Yeah. Even if they sound confident. 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 heals and the pain goes away. So in that case, they went through a normal pain cycle, right? Right. Body was hurt, body healed, pain went away. I've still got neuroplastic elsewhere. Is that possible? Totally. You can have that and you can also have what we call secondary pain or like structural

biomedical, like 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, like 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 view neuroplastic pain as the brain's misperception of threat to the body. So that's where you want to start to unwind this misperception of threat. And the way that you unwind misperceptions of threat is with perceptions of safety. Actually, that's this kind of is with perceptions of safety. Actually, that's this kind of antidote. There's a particular technique that we have developed that seems to be quite, to our knowledge, one of the most effective techniques for changing this perception. We call it somatic tracking, and it's a particular way of paying attention to the sensations. And it has three components. 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, saying like, oh, there really is nothing wrong because I've done this assessment. And then the third piece of somatic 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'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 somatic 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 all 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 somatic 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 Jon Kabat-Zinn back in the 70s. 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 unlearning pain. So if you think you have a mindfulness practice and that's like all you need, there's more to it. That's probably not quite enough. Yeah. Right. Because the other two components that you mentioned are this creation of, of safety, right? And then, you know, the positive affect. Exactly. Yep. You talk about a couple of mindsets that can help with doing somatic tracking more effectively. Yeah. So this is like a light and easeful state of mind that can be really helpful. There is a strong tendency that makes so much sense to like, when we pay 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 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, the sensations start to shift and often to diminish and sometimes even disappear. We've even had, you know, sessions with the clients where they'll do somatic tracking and then the pain's gone 10 minutes later. And they're like, oh my gosh, this is the first time in 18 years I haven't felt any pain. We just did a little exercise, you know, a 10 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 I'm Jason Alexander. And I'm Peter Tilden. And together on the Really No Really podcast, our mission is to get the true answers to life's baffling questions like why they refuse to make the bathroom door go all the way to the floor. We got the answer. Will space junk block your cell signal? The astronaut who almost drowned during a spacewalk gives us the answer.

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texts a week with insightful little prompts and wisdom from podcast guests. They're a nice little nudge to stop and be present in your life, and they're a helpful way to not get lost in the busyness and forget what is important. You can join at OneYouFeed.net slash SMS, and if you don't like them, you can get off the list really easily. So far, there are over 1,172 others from the One You Feed community on the list, and we'd love to welcome you as well. So head on over to oneyoufeed.net 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, OK, I'm going to do somatic tracking like 100 percent. I'm going to nail it. Right. And that is the clenching and tensing around it. nail it, right? And that is the clenching and tensing 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. It's really hesitating whether to even mention that sometimes the pain goes down during somatic tracking because then people will listen and 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 that pain is a dangerous problem and a threat that needs to

be gotten rid of. 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 in 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. 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 when he said, your will is good for getting you to the meditation cushion. Yeah. 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 somatic tracking session. At that point, we have to try and let go and become more outcome independent. That's exactly right. 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 somatic 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 terrified that's

unlikely to be a helpful exposure. It's unlikely to be something that you learn something helpful from. We want to do 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 and we probably did like a hundred times in a row, just bend over, stand up, bend over, stand up, just watching the sensations. Like you would watch,

you know, water flowing down a 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 you get up. You know that bending over is totally safe. There's nothing dangerous. Bending over is great for your back. It's not dangerous for your back in any way. It's actually really good for your back to bend and cracking some jokes. And, you know, she had a lot of pain at the first few times we bent over. And by number 100, 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. 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 coaching work with people. 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 as the time that this exposure and somatic tracking can be most effective. A 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, if your pain is really high, then don't try somatic tracking, use your avoidance behaviors. And so I love how it's not saying, avoidance behavior bad, somatic tracking good. 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 somatic tracking and exposure. Exactly. Because we want the exposures to be corrective learning. So an exposure from which you learn that the pain is not dangerous. And when the pain is 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 a manageable range and then get back on the horse and do the exposures. The somatic tracking,

which is an internal exposure really to the sensation. And is that the primary and do the exposures, the somatic 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 that I can tie all this together. for us so that I can tie all this together. A 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 in 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 151 people, and we randomized them to one of three groups. A course of PRT, which was nine sessions over the course of a 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 or 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 with about four out of 10 pain. And in the control groups, people left with about three out of 10 pain. But in the PRT group, people had one out of 10 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 20% in the placebo group and 10% in the 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. Just in case any listener didn't catch that. Yeah. Sorry for that. It's okay. Yeah. And we followed people for one year after the 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 mechanisms to try to understand, well, how does PRT work? What we found is that people who had the biggest reductions in fear of pain had the largest pain intensity decreases. And the people had the biggest shifts in how they think about the causes of their pain. Shifts from structural mechanical causes to mind-brain causes, they have 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 PRT versus 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. It's 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 and the way it was inflating, people did not like it. It was hurting. And what we saw is when we exposed people to the same stimulus post-treatment in the PRT group, there was less activity in the anterior insula, the mid-singulate, and the anterior prefrontal cortex. And these are brain 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 whose 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 radiculopathy. There might be a disc that's bulging onto a nerve, pushing onto a nerve that's causing leg pain. Leg pain is not necessarily neuroplastic or not necessarily structural or mechanical. It's just diagnosis

can be a little more involved there. So we screened that out. And there was a couple other criteria. But on the whole, we aim for pretty broad inclusion criteria. Now, if someone has scoliosis, no problem. History of back surgeries, no problem. 10 herniated discs, no problem. 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 stop sending the pain sensations but at this point we've learned you know to use the term used earlier we've learned the pain. Yeah. It reminds me so much of PTSD, where a person will go, to use a classic example of military PTSD, a 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 left your deployment, the threat's 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, 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 shitty snowball of depression, anxiety, insomnia, pain, depression, anxiety, insomnia, pain, it's depression which leads to anxiety, which leads to insomnia, which leads to pain, and it can 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 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. Well, 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 I was such a bully to myself. I was so mean and 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 are 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, 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 for having me on. Yeah. Thank you so much. If what you just heard was helpful to you, please consider making a monthly donation to support the One You Feed podcast. When you join our membership community with this monthly pledge, you get lots of exclusive members-only benefits. It's our way of saying thank you for your support. Now, we are so grateful for the members of our community. We wouldn't be able to do what we do without their support, and we don't take a single dollar for granted. to do what we do without their support, and we don't take a single dollar for granted.

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