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 role of fear and threat perception in maintaining pain
- The three components of somatic tracking in working through pain
- How to create a sense of safety around pain sensations
Yoni Ashar is 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 post-doctoral associate at Weil-Cornell Medicine and completed his doctorate at the University of Colorado.
Connect with Yoni Ashar: Website | X
If you enjoyed this conversation with Yoni Ashar, check out these other episodes:
Living with Chronic Pain with Sarah Shockley
Living with Chronic Illness with Toni Bernhard
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Episode Transcript:
Eric Zimmer 03:10
Hi Yoni, welcome to the show.
Yoni Ashar 03:12
It’s great to be here. Thanks for having me.
Eric Zimmer 03:14
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 wunderkind with the mind of Aristotle and the effortless cool of James Dean,
Yoni Ashar 03:56
don’t believe him mature.
Eric Zimmer 04:00
Alright, 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 in 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 and thinks about it second, and looks up at their grandparents as well which one wins, and the grandparents says the one you feed. So I’d like to start off by asking you what that parable means to you in your life and in the work that you do.
Yoni Ashar 04:36
Now, 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 worlds that can feed chronic pain. There’s a fear Wolf and the more that wolf is active and hungry and feeding, then the bigger and the bigger the pain will get any of the wolf of Something like safety or ease that eventually, you know, 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 that conversation, I’ll make a case for that. Yeah,
Eric Zimmer 05:16
you guys actually use the parable in the book. And there’s a funny line at the end, which says, you know, we might call it The Tale of Two neural pathways, but it doesn’t quite have the same ring to it. You know, I used to say, when I was talking about this early on, I would say, you know, in Buddhism, we talk less about good and bad, and we might say, skillful and unskillful. But I was like, you know, a skillful and unskillful. Wolf is in a very good story, right? It just doesn’t, doesn’t capture the imagination. Right? So let’s talk about the core of your work. It’s really around recognizing that I guess, correct anything I say it’s incorrect. It’s certain types, or even maybe a lot of chronic pain is what you guys would call neuro plastic pain. Can you describe what neuro plastic pain is?
Yoni Ashar 06:03
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, you know, factor processes in the brain that are causing the pain to persist. And this is called neuro plastic. Pain actually goes by many names. It’s also called primary pain, and no sit plastic pain. But that the main idea here is that the pain is not due to physical, structural biomechanical factors. It’s not due to like tissue damage. And we think that, you know, this might be a really large portion of chronic pain, actually,
Eric Zimmer 07:19
now, what you’re seeing 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.
Yoni Ashar 07:45
That’s exactly right. And it’s so important to emphasize the pain is real pain is always real. And this view of You’re making it up or you’re exaggerating, really upsets me, I find that really offensive, you know, to all of us who have had any kind of chronic pain. It’s especially been used to marginalize people like groups like women or other groups that have been written off as hysterical or exaggerating. And it’s not true at that level now, from the total flip perspective, while the brain is in the head, and we 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.
Eric Zimmer 08:30
Yep. 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 neuropathic 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,
Yoni Ashar 08:53
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, like, Whoa, this is really a big deal. So this is a study from the aperion lab at Northwestern that came out five or 10 years ago, and they recruited people who have recently injured their back. And these people had back pain because they have recently injured their back, and they scan their brains. And what they saw was that the pain lived exactly where you would expect it to be. That pain processing parts of the brain. This includes somatosensory cortex, cingulate insula, these are brain regions that any neuroscientists would say yep, that’s where the pain belongs. That’s the part of the brain that does pain processing. Then they follow these people for a year out and then half of them the pain resolved, right the injury healed they went back live as normal, it’s kind of like typical course yeah, you pulled your back now everything’s better. And the other half, the pain persisted. And now this is a year after injury and the back still hurts. And when they scan their brains, they found that the pain was now associated with a totally different set of brain regions, it was associated with medial prefrontal cortex, and with the amygdala. And those are brain regions that have a lot to do with learning, and memory, and emotion and meaning. And what they basically did in the study was they caught on camera, they 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, like live on loop in a way relatively independent of any injuries in the body.
Eric Zimmer 10:55
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.
Yoni Ashar 11:06
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 me 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 paint system has to be predictive, it has to be always thinking ahead about how damaging some action or activity might be, that way you can keep us safe, the paint system are always just reactive, but I’ll be dead if the One Step Ahead of the lion. And once you know, we understand that pain is predictive, that opens up a whole host of thorny problems, because prediction is really challenging. Like, it’s really hard to, you know, to tell the future. And there can be mispredictions. So for example, a person injures their back, they’re bending over, that’s not good, that’s for the injury. So So pain is created. But now the brain, you know, 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 is 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
Eric Zimmer 12:47
you guys also reference another study, which I think is also Northwestern about researchers ability to predict pain, you know, like who’s going to have pain, and apparently, they were accurate 85% of the time. So what was going on there?
Yoni Ashar 13:01
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. Now, let’s look at the brain scan from right after the injury and see if we can predict who’s going to get better and who’s going to develop chronic back pain. And what they found was that patterns of brain activity in the 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 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. The nucleus accumbens is actually really involved in you know, so like addiction. I was just listening to your last episode. Yep. Yeah. The second reason that’s really important is because when you look at like a scans and MRIs of the back, you know, if someone injures their back, those are completely non predictive of who’s going to recover and who is 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.
Eric Zimmer 14:24
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 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 yeah, I mean, I guess one of the big questions would be how does somebody know? Is my pain neuro plastic? Or is it still real signals from the body? Yeah,
Yoni Ashar 15:18
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 Shubin, er who in my mind has really helped develop these methods, as well as you know, many others in the field. But I must have learned from him. So 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 no a clear cause to the pain, I note of caution there is not to go overboard. If you see enough specialists, one of them will find something wrong, I guarantee it. So but you know, do basic due diligence to rule out any obvious medical problems. The second component is the rule. And 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 on my shoulder, and now it’s spread down my arm injuries don’t travel. But right, but sensations spread. And we actually now know, thanks to the work of Bob Coghill, and others, some of the neurobiological mechanisms of this, they’re these neurons called dynamic wide range of neurons in the dorsal horn of the spinal cord that sensitize each other and cause spatial spread of pain. Just something that that, you know, happens in our nervous system, if one area hurts, it’ll sensitize neighboring neurons and cause other signals coming will sensitize neighboring areas and cause spread of pain. Okay, second indicator, spatial variability. So like sometimes the person the left leg, the hurts on the right, again, that really suggests the brains involved here, because the brains are really good at kind of moving things around in the body. Three temporal variability, no, some days, the pain is 10 out of 10, you know, the next day zero out of 10, that, again, does not sound characteristic of like an injury, if you have a broken foot, it’s not gonna, it’ll hurt every time you step on it, you’re not gonna 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 not eight to a three, and that’s still quite large swings for presence of multiple chronic pain or no somatosensory syndromes, you know, in the 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, inflammation. 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 they mean is they have pain in some context, but not in others. And it doesn’t make any like 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 think I’ll stop at the end of the run, and my back would start hurting. And it just like, what’s going on this? That’s kind of something’s 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 started, that was started to create pain, just like Pavlov’s dog has learned to link a bell to food, you know, we can link a certain position to pain, even though that position isn’t objectively more dangerous, or putting our body at risk than like running or some other position is,
Eric Zimmer 19:25
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?
Yoni Ashar 19:41
Yes, so it’s a spectrum. And it could be anywhere along the spectrum. For more, say peripheral tissue causes there’s something in the body that’s really driving it to centralized central nervous system brain causes. So people can be you know, what we call mixed pain, or there’s both of those That being said, I think some of us suspect more and more that a fairly large portion is centralized or primary pain, neuroplastic pain, for example, Eric, like arthritis is not necessarily painful, no severe arthritis is painful, but mild to moderate arthritis is often not painful. So if you have arthritis, you can 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 next have a bulging disc in them. So tons of people who have no pain at all have all kinds of anatomical finding, 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, is you know, great. Now, is that the cause of pain? Yeah. 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 this one site, or if the pains are variable, I mean, is the injury moving? You know, from day to day? Is the disc bulging one day and not the next? Right, there’s probably something else going on.
Eric Zimmer 21:50
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. Yeah, you know, mine is if my back hurts like this at 50, what will I be like it at? 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.
Yoni Ashar 22:40
Yeah, this is really important, Eric. And it also gets to a way that our work is potentially different than some, you know, 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 still there but not as bad. You can actually eliminate the pain by changing some of these mind brain pathways, put it slightly differently. 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.
Eric Zimmer 23:45
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, bingo. 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 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. 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.
Yoni Ashar 24:46
So I think of two broad categories of fear, pain related fear and a 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 of the cost, like you were saying, element two and three, the pain so bad, and you know, it’s going to get worse. And then there’s these other general patterns of putting our brains on high alert mode of thread, this worry and pressure on ourselves and self criticism that could be completely unrelated to the pain, it can be about how we’re performing work, or it could be about you know, beliefs we have that we have to keep everyone else around us happy. And if someone’s unhappy with us, then that’s the problem. Or that, you know, uncertainty about the future is dangerous and have to eliminate all uncertainty. So there could be all these habits and these driver rain into high alert mode. And that will take the whole pain system and just turn up the volume, you know, any sense of threat. So, pain is the appraisal of threat or danger. Pain is our brains way of saying this, something dangerous here. And if there’s a more global sense of threat, or danger, like no, like, some kind of pressure on themselves, like I’m not good enough, whatever the flavor is, then that’s gonna, you know, add that sense of danger, and amplify the pain.
Eric Zimmer 26:16
Yeah, you describe a 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, put an extra pressure on yourself. That’s miserable mentally and emotionally. And now on top of it, I’m driving a physical pain engine potentially, that doesn’t
Yoni Ashar 26:45
matter. Boy, I’ve a lot of compassion that comes up. Yeah, yeah. It seems to me like it’s kind of like a culturally like, contagious thing going around right now. Like, you know, I just saw this, there was a survey that went out, you know, were you in a lot of stress yesterday, a Gallup poll, and over half of Americans said yesterday that they’re in a lot of stress yesterday, and like, that’s, that’s very Son.
Eric Zimmer 27:10
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.
Yoni Ashar 27:23
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 I 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 it’s the easiest to study. And what people said, 90 to 95% of people were saying, old age, an injury, 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 happened. 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 that the person in pain on board with that assessment. And for that, it really helps to have evidence, actually, this is not any leap of faith or 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 neuropathic 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 nothing wrong in the back. Yep. That’s just, that’s what the sensations are felt in the moment. But how do you know that 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? No, it’s neuro plastic pain. And in the book, the appendix has a more detailed elaboration of all these factors I was mentioning earlier. So we call it building the case. So building the case that this is really what’s going on. For me, there’s a really major first step.
Eric Zimmer 29:21
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 could 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. Yeah, like to come up with something, right? I know, in those experiences, it’s been like, you know, you start to go when one doctor is like, it’s this and the next doctor is like, it’s this which is a different thing. And then they both disagree on the way you treatment. You should do physical therapy. No, you shouldn’t do it at all. I mean, You start to go wait a second. Yes. Nobody really knows why I hurt this bad. Yes.
Yoni Ashar 30:05
And that is another great positive indicator for neuroplastic pain, getting different or contradictory stories from multiple different providers. I mean, they don’t know. Yet even if they sound confidence, is it possible
Eric Zimmer 30:17
to have neuroplastic pain in one part of your body and go through a normal healing process with pain and 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 body was hurt, body healed, pain went away. There, I’ve still got neuro plastic elsewhere, is that possible?
Yoni Ashar 30:55
You can have that. And you can also have what we call secondary pain, or like structural biomedical like this, the pain is secondary to some injury. You could have that in one body site and neuro plastic and 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, alright, well, you know, what’s the evidence for that being the cause of pain?
Eric Zimmer 31:28
Yep. 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?
Yoni Ashar 31:49
So we view neuro plastic pain as the brain’s no misperception of threat to the body, so that we want to start to unwind this misperception of threat and the way that you unwind, misperceptions of threat is with no perceptions of safety, actually, that this kind of antidote, there’s a particular technique that we have developed that seems to be quite, you know, 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 in curious about the sensations are watching them the way you might watch clouds fly 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 head, while I’m watching 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 seemed 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 effect 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, and you know you’re in a good mood, it’s much harder to feel afraid. So that can really pull the rug out from under this feeling of threat,
Eric Zimmer 33:51
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 can be really helpful.
Yoni Ashar 34:20
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’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, 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. Yep. But mindfulness alone is not likely from 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 vain, or if you think you have a mindfulness practice, and that’s like all you need. There’s more to it. Yeah, that’s probably not quite enough. Yep.
Eric Zimmer 35:08
Right, because the other two components that you mentioned are this creation of safety. Right? Yeah. And then you know, the positive effect. Exactly, yep. You talk about a couple of mindsets that can help with doing somatic tracking more effectively.
Yoni Ashar 35:27
Yeah. So this is like a light and useful 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, oh, no, what’s it going to do next? Is it gonna 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 clients where they’ll do somatic tracking, and then the pains gone 10 minutes later, and they’re like, oh, my gosh, it’s the first time in 18 years, I haven’t felt any pain, we just did a little exercise, you know, 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.
Eric Zimmer 37:16
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 described several times in the book, when he’s talking about specific clients, you know, that there’s a natural tendency to be like, alright, this is going to fix me, and I’m going after it, right? Like, you know, there’s a mindset that says, like, Okay, I’m going to do somatic tracking, like, 100%, I’m going to nail it, right. And that is the clenching and tensing around it. And so it strikes me a little bit, as we talked about in Zen, you know, trying not to try exactly, you know, which is a little bit of an art
Yoni Ashar 37:57
total art as really hesitating, whether it’s even mentioned 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. Yep, and actually, so that just gonna, you know, 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.
Eric Zimmer 38:33
Yeah, we talked about this 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 gonna do somatic work. 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 why he said, your wills 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 like we’re saying here, like, okay, yeah, of course, you want the pain to go away, that’s gonna get you to the front door of the symmetric tracking session. At that point, we have to try and let go and become more outcome independent. That’s exactly. It’s kind of knowing which tool to apply when you know which mindset to apply when
Yoni Ashar 39:31
that’s very helpful. Thanks for that. I’m gonna use that with my clients.
Eric Zimmer 39:35
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. Yeah. Is important curves. So say more about the role of that in this process,
Yoni Ashar 39:52
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 set effects, 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 exposure, but you’re white knuckling your way through it, you’re like intensely gripping and holding on. And internally, you’re tight and constant, 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 exposures, where we can learn that our bodies are stronger and healthier than then we believed. And so doing somatic tracking during an exposure is a important piece of this approach. So using the same tools to bring attention to the sensations, while you are doing the thing that’s been feared, remembering a client I worked with who, you know, we must have we stood up, we probably did, like 100 times in a row, just bend over, stand up and over, stand up, just watching the sensations like you’re the watch, no water flowing down the waterfall, because, you know, as we were bending over that was kind of the image and just watching the sensations and like, oh, look what happened. When you bend over, look what happened when 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 the interest for your back in any way. It’s actually really good for your back to bend and, and cracking some jokes. And, you know, she had a lot of pain that the you know, first few times we bend over and buy a number 100, it would didn’t hurt at all.
Eric Zimmer 41:36
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 is not the time to be doing somatic tracking and exposure, it reminds me of my coaching work with people. And we talk about some of these skills that we practice to deal with difficult thoughts or emotions. You don’t want to practice those on the hardest thing in your life, it’s not the time to do it, you know, you want to start practicing at a place that’s manageable. You know, you can’t practice if there’s none. So as you guys say, you can’t really do this if you don’t have any pain. But you want to look for those medium to low level times as the time that this exposure and somatic tracking can be most effective
Yoni Ashar 42:24
100%, 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
Eric Zimmer 42:33
what I really like is you say, you know, 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 like, avoidance behavior, bad somatic tracking, good. Yes, depending on the scenario, avoidance behaviors are perfectly good thing to do. If your pain level is really high, it’s when it’s at a lower level, that’s the time to work on somatic tracking and exposure.
Yoni Ashar 42:58
Exactly, because we want the exposures to be corrective learning. So an exposure from which you you learn that the pain is not dangerous. And when the pain is super high, it’s gonna 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, until it becomes more than 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,
Eric Zimmer 43:31
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,
Yoni Ashar 43:47
a corrective experience is learning that the sensation is not as dangerous and threatening as you thought.
Eric Zimmer 43:55
So this strikes me as similar in ways to exposure therapy in other domains, right? Where the idea is expose yourself to the feared stimulus and a manageable dose, you learn that it’s not so frightening. And you’re able to handle more and more. So there’s a corrective experience here. I want to talk a little bit about some of what this path looks like if you get on it. And you start to have some healing because there’s like any path, there’s some ups and downs that can occur. And I’d like to hit a couple of those. But I definitely want to hit also the study that you guys recently published. So tell me about that.
Yoni Ashar 44:33
So this was the first trial testing PRT, we took 151 people and we randomized them to one of three groups course of PRT, which was nine sessions over the course of a month, or there was a placebo control. They got this placebo injection to 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 higher. After 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 scan their brains before and after. And what we found was very large reductions in in back pain for people in the PRT group as compared to the control. So people in the control groups, seven came in, on average, about four out of 10 pain. And in the controllers, people left with about three out of 10 pain by in the peer teager people have 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 have to put some numbers on it, we found that two thirds of people were paying for your 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 cuz 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 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 it really goes after element one, the pain itself.
Eric Zimmer 46:32
And PRT is pain reprocessing therapy, which is your guy’s method. I just think it’s a case any listener didn’t didn’t catch that
Yoni Ashar 46:38
side for that. Okay, yeah. And we followed people for one year after no treatment ended. And the gains were largely maintained. So one year out, half the people are 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 and fear of pain had the largest pain intensity decreases, and that people had the biggest shift and how they think about the causes of their pain shifts from you know, structural mechanical causes to mind brain causes. They have the biggest reductions in pain as well. And we also saw is really interesting changes and how people’s brains are processing pain when we put them in the brain scanner, as well.
Eric Zimmer 47:31
Tell me about that last piece a little bit what shifted? Yeah, so
Yoni Ashar 47:34
we saw reduced activity for purity 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 is basically this inflatable pillow that went under people’s backs while scanning. And when we inflated it, it causes back pain, it might sound nice to have a pillow under under your back. But this was not the way we positioned it in a way rather than flat and people did not like it, it was hurting. And what we saw was, when we expose people to the same stimulus, post treatment and the PRT group, there was less activity in the anterior insula, the mid cingulate, and the anterior prefrontal cortex. And these are bringing regions that do many things. But one of the things they do is track, threatening stimuli. And the more threatening stimulus is the more activity you’ll see in those brain regions. And so the reduced activity we observed in those regions is consistent with this idea that treatment helped people see the sensations as less threatening.
Eric Zimmer 48:42
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 as back hurts?
Yoni Ashar 48:50
Yeah, we had some criteria for trying to get neuro plastic 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 as bulging onto a nerve pushing onto a nerve that’s causing leg pain. Leg pain is not necessarily neuro plastic or not necessarily structural or mechanical adjust 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, and no problem, history of back surgeries, no problem 10 herniated discs, no problem, that those are all welcome. Got it. Got it, because those are often just not the cause of the pain like scoliosis. Not necessarily painful. It could be painful, but you need to do a thorough assessment to see, you know, you might have painful scoliosis, or you might have pain and scoliosis, but the two aren’t connected.
Eric Zimmer 49:48
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,
Yoni Ashar 50:07
it reminds me so much of, you know, PTSD or a person will go, you know, seems like a classic example of like military PTSD, personal being a very dangerous context or loud noises could mean you’re being attacked. And they’ll come home, and they’ll still respond to the same noise as if there’s a threat. But actually, the threat resolved long ago, once you you know, left your deployment, the threat is not there anymore, but you’re still responding as if the threats 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.
Eric Zimmer 50:43
I’m curious in this maybe extrapolating out multiple steps from where you are, but is there a 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,
Yoni Ashar 51:00
that chronic pain can be a really like, shitty, you know, snowball of depression, anxiety, insomnia, pain, it’s the pressure faced with anxiety, which leads to insomnia is the payment against like 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 over exercising more Well, that’s good for depression. So it’s all interconnected. And conversely, we know that, you know, depression, anxiety and insomnia, they’ll amplify pain as well. Yeah.
Eric Zimmer 51:35
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 a reduction in those areas, you know, the benefit continues and continues. Yeah, what
Yoni Ashar 51:50
you know, people in our study told us was that, you know, beyond bringing down pain, people are saying, like, oh, I learned to listen to my feelings. For the first time I got in touch with myself, I’ve realized that was such a bully to myself. So me, I’m putting so much pressure on myself, and I’ve stopped doing that
Eric Zimmer 52:08
that’s really important and meaningful really is. Well, thank you so much for taking the time to come on. I’ve really enjoyed the conversation, I really enjoyed the book, I think the work you guys are doing is incredibly important. I get a lot of requests for people to be on the show, I get a lot of pain stuff. And a lot of it to me looks really like that seems a little sketchy. But when I saw the work that you guys were doing, I saw the studies that were behind it, I felt like this is a really important thing to try and put out there. So thank you for the work you’re doing.
Yoni Ashar 52:41
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 our mind and brain processes can play a bigger role and just narrowly looking at you know, problems below the neck are unlikely to really work as an approach for most forms of chronic pain.
Eric Zimmer 53:04
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 in my case, it’s not I mean, like they’re, they’re pretty clearly connected in any anatomical diagram I have seen like, like, I’m not sure where we got the idea they were separate.
Yoni Ashar 53:24
But nonetheless, thanks so much for having me on.
Eric Zimmer 53:27
Yeah, thank you so much.
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