Podcasts about zoffness

You can also check out this episode on Spotify!Pain is an inevitable part of life. But did you know that pain is not just about body parts?Dr. Rachel Zoffness is an Assistant Clinical Professor at UCSF and leading global pain expert who is revolutionizing the way we conceptualize pain. She explains that hurt (pain) and harm (damage) are not the same—and that pain is never purely biological. Similarly, treating pain is never just about pills. It's about addressing the social-emotional context around it. On this episode, Dr. Zoffness sits down with Dr. McBride to discuss how thoughts and feelings inform the experience of pain. And how treating pain must include treating the brain. Join Dr. McBride every Monday for a new episode of Beyond the Prescription.You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.Please be sure to like, rate, review — and enjoy — the show!Transcript of the podcast is here![00:00:00] Dr. McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor for over 20 years, I've realized that patients are much more than their cholesterol and their weight, that we are the integrated sum of complex parts.[00:00:33] Our stories live in our bodies. I'm here to help people tell their story to find out are they okay, and for you to imagine and potentially get healthier from the inside out. You can subscribe to my weekly newsletter at and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So let's get into it and go Beyond the Prescription.[00:01:02] I'm delighted to welcome to the podcast my friend Rachel Zoffness. Dr. Zoffness is a PhD, pain psychologist, assistant clinical professor at UCSF, and an author of a new book called The Pain Management Workbook. She believes like I do, that our bodies and minds are inseparable and that we need to think about pain in a much more nuanced way.[00:01:25] In other words, when I was trained in medical school, we thought pain was about the body part and that pills were the solution. When actually, as doctors, we describe pain as a biopsychosocial phenomenon. Rachel, I am so happy you're here today. Thank you for joining me.[00:01:42] Dr. Zoffness: Thank you for inviting me on, Dr. McBride.[00:01:45] Dr. McBride: What I love about you is that we agree that mental and physical health are inseparable. When I was training in medical school in the 1990s and early 2000s, we were taught that pain was about the body part itself, and that we used medicines to treat pain. We used Tylenol, Advil, opiates, and we were taught to get ahead of the pain and to get people more opiates than we thought they might need because it was cruel to deprive people of pain meds, which of course it is in many ways.[00:02:16] But we now know just how addicting these medications are, and we also know that pain is about more than the limb that is hurting. So could you describe for me how you talk about pain, this bio psychosocial model? Because it's a big word and I'd love to break it down.[00:02:34] Dr. Zoffness: Yeah, it's sort of frustrating for people who have been living with pain and also for healthcare providers who treat pain because medicine, as you know, has been rooted in this antiquated, dinosaur era biomedical model, which teaches people that everything to do with pain is just anatomy and physiology.[00:02:54] But neuroscience has known for many decades that that's not actually true when it comes to pain. And one of the reasons we know this is because of this syndrome called phantom limb pain. And phantom limb pain is when someone loses a limb and arm or a leg, and they continue to have terrible pain in the missing body part.[00:03:14] Now, if you can have terrible leg pain in a leg that is no longer attached to your body, that tells us pretty definitively that pain does not just live in your leg, and it does not just live in your back. And what science says is that, of course the body is involved in pain production, but ultimately pain is constructed by the brain. [00:03:38] And the reason that's so profound, at least for me as someone who treats pain and has lived with pain as many of us have, and all of us will because everybody, everybody is gonna have pain at some point, is that there's lots of parts of the central nervous system that process pain. It's not just there's one pain center, and that's how that goes.[00:03:56] There's lots of parts of the brain that contribute to the pain experience including the brain's emotion centers contribute to the pain experience, and what that means is how you're feeling emotionally in any given moment, whether you're stressed or anxious or depressed affects intimately the pain that you feel.[00:04:15] So we know from neuroscience that pain messages are amplified during periods of anxiety or during a global pandemic. That's not gonna surprise anybody, and we all know this. We all know that our bodies feel worse during times of duress. So it's really not that shocking. And we also know that, say if you stub your toe at work on the day you get fired, that exact injury feels completely different than if you stub your toe on a day at the beach when you're hanging out with your friends in the sun. So context matters, emotions matter, thoughts matter. Everything matters to the brain when it's deciding whether or not to make pain and how much, and that's always true.[00:04:54] Dr. McBride That's a great example and the phantom limb pain is, is, I'd love to talk more about the phantom limb pain because I mean there couldn't be a better example of the construct that pain is—not to say it's not real— it's to say that it's more than just about the limb. So take that example for a second. How do you treat someone who has phantom limb pain? If it's not about the limb?[00:05:18] Dr. Zoffness: So there is this frustrating thing that happens in medicine where people with chronic pain are often told it's all in their head. Especially if there's no known etiology for the pain. If you've had a lot of scans and tests and you know, people just aren't sure, the doctors are like, we don't know.[00:05:31] We can't find a thing. So people get told often that pain is all in their head, and that is not what I'm saying. So I want to be very clear. Pain is never all in your head. If you have pain, your pain is real. The important thing to know about pain is that it's the brain in conjunction with the body always working together.[00:05:47] The interesting thing about phantom limb pain, again, we've said you can have pain in a leg that's no longer attached to your body. And we've said that's because your brain is implicated in the processing of pain in your brain. You have what's called homunculus, and a homunculus is literally a map of your entire body that lives in your brain.[00:06:06] So if I said to you, Lucy, without doing anything or moving, sense into your foot, can you feel your foot on the ground? Notice if your foot is warm or cold. Can you feel if your foot is moving or… you can do that. And the reason you can do that is because you have a map of your whole body that lives in your brain, your homunculus. [00:06:23] So sometimes if you lose a limb, you've lost the limb, but you haven't lost the leg part in your brain map. So with mirror therapy, what we do is. We hold a mirror up to people who have phantom limb pain and they go through a series of activities and structured exercises to help the brain become unconfused and realize that pain, which is your body's danger detection system, doesn't need to send you any more danger or warning systems because the damage has already occurred and there's no warning signals that need to continue. So that's one of the treatments for phantom pain.[00:06:58] Dr. McBride: It's such a great example and I love the way you described it because I think for a lot of people, doctors included, we have a hard time wrapping our arms around this concept of suffering you can't measure or you can't see it, but everybody who's listening right now can think about their toe or their foot and know that you're directing your attention to it, and there's a reason for it's in our brain. So that is great. That's a beautiful way of opening this conversation about pain being more than just physiological.[00:07:31] Dr. Zoffness: Exactly right.[00:07:32] Dr. McBride: Talk to me about—breakdown biopsychosocial, because when someone hears pain is biopsychosocial they may think, oh wow, it's more complicated than I thought, but they don't necessarily know what that means. So what is it?[00:07:45] Dr. Zoffness: Right. So I happen to really love big words, and this big word in particular has helped me make sense of a lot of different things, not just pain, because it turns out anxiety is biopsychosocial, and depression is biopsychosocial and diabetes. So I'm going say what this word means. So biopsychosocial, what we know now about pain, is that it is never a purely biological thing. It's never just to do with your bad knee or your aching back. Never. It is more complicated than that. Of course it is. And so with this word, biopsychosocial means, and we know that that's what pain is. It means that there, of course, are biological components or triggers for pain contributors [00:08:25] So the bio components of pain are genetics and tissue damage and system dysfunction and inflammation, and things like diet and sleep and exercise. Those all are biological contributors to pain. They're very, very, very important. However, what we know about pain is that there's other things that contribute to your experience too, and they're just as important.[00:08:48] It's not that they're less important. So in the psych, we have bio, we have psych, and we have social or sociological. And the psych domain of pain has so much stigma around that. And I am a pain psychologist, and let me just tell you all day long, all I do is try and explode the stigma around these quote unquote psychological contributors to pain.[00:09:08] So I want to very clearly say, When you say that pain has psychological components, that's not, again, that it's all in your head. What it means is neuroscience shows that emotions intimately affect the pain we feel, and that negative emotions are going to amplify pain volume and positive emotions and feelings of calm and relaxation are going lower pain volume, turn pain volume down so that lives in that psych bubble.[00:09:35] Also, in that psych bubble, we know that thoughts and beliefs intimately change the pain we feel. This is supported by many decades of science, for example. We've all heard of the placebo effect. The placebo effect means, Lucy, I'm gonna give you a sugar pill. I'm going to tell you as a pain doctor that this is gonna lower your pain volume, and low and behold, you actually feel better.[00:09:59] That happens a lot of the time, and the reason that happens is not that the placebo pill is nothing, rather the placebo means you change your beliefs and your brain understands that these danger messages are not needed anymore. So your pain volume is lowered. Beliefs and thoughts change the pain you feel.[00:10:19] That doesn't mean you can think your way out of pain. It's more complicated than that. But thoughts and beliefs matter. We also have in this bubble coping behaviors. What do I mean by that? People with pain often, understandably believe that they need to stay home, stay inside, not move, not go outside, stop going to work, stop their activities, stop moving.[00:10:40] Reasonable. However, what science shows is that that ultimately is also going to amplify pain volume and that to treat chronic pain, we have to get out of bed and back to life very slowly and in a structured way, and I'm not telling people to go outside and do things, but behaviors, how we act, how we handle our pain also changes the pain experience.[00:11:01] Then I said, we have this third domain of pain. It's the social or the sociological domain of pain and what science says is that social factors matter all the time. When it comes to pain and health, humans are social animals. We know that the worst punishment you can give a human being is not Thanksgiving traffic, and it's not your in-laws, it's actually solitary confinement. And what happens when we are lonely and isolated and alone, which happened during the pandemic to a lot of people, our brain amplifies pain volume because a lot of brain chemicals change. So in the presence of others, our brains produce all these chemicals that literally make us feel good.[00:11:42] Dopamine, serotonin, oxytocin, and endorphins. Endorphins are our brains' natural painkillers. They are our endogenous opioids. So in the presence of other people, brains produce painkillers. There's other sociological factors that matter also. It's community, it's context, it's environment, it's even race and race and ethnicity, and even racism.[00:12:07] It's poverty and it's access to care, it's trauma. There's so many, so many things that live in this sociological domain, so, All of it together contributes to the thing, this experience that we call pain. And what's happened in medicine is that we've distilled it down to just the biological, the bio bubble. And what that means is that what we've been doing in medicine is missing two thirds of the pain problem. And part of the reason I do things like this and come on podcasts, is to try and change the way we're thinking about pain so that we can change the way we treat pain.[00:12:41] Dr. McBride: It is so important, Rachel, because as you just said, we have reduced the patient to a set of lab tests, a set of complaints, and because doctors don't have time and they aren't trained—we are not trained in pain management like we should be—People who are in chronic pain are often thought to be nuisances, thought to be malingering or thought to be making it up, because we don't have sophisticated ways of treating pain and because it takes time to access the 360 degree version of the person we prescribe pills. Now, I love Advil for a headache. I love Tylenol when I have a fever. But I think what you're saying is that we need to look at the whole person. We need to look at their emotional health, their mental health, their physical health, their story, and address the various complex parts of this person because they're integrated and they show up in pain.[00:13:40] Dr. Zoffness: That's exactly right.[00:13:41] Dr. McBride: Can you give me an example, Rachel, of a patient who had intractable pain, who was treated inappropriately by the medical establishment and then got better with this model.[00:13:52] Dr. Zoffness: It's really interesting. I'm in private practice and I see people with chronic pain and I happen to love working with teenagers in particular. They're sort of forgotten in medicine, especially in the world of pain. We have pediatric pain and we have a lot of adult pain and older adult pain work. It's not being done right in my humble opinion. But we do have a lot of attention and money being thrown at it. And then we have teenagers who are sort of in this messy middle, like they're not quite children, they're not quite adults, but meanwhile, all they want is an adult who will talk to them as if they're an adult.[00:14:21] They want that sort of respect. They don't wanna be talked down to like a child anymore. And teenage pain is very confusing for a lot of doctors, in part because they fall into this messy middle category and people aren't sure, do we involve parents, do we not? So one of the patients I was thinking of who came through my program was a 16 year old who had been diagnosed with chronic daily migraine that was so debilitating that he couldn't get out of bed. He also had been diagnosed with abdominal migraine, so chronic stomach aches, stomach pain, and he also had diffuse, amplified body pain of no known etiology. So no one really knew where it was coming from or what was going on. [00:15:00] And when I met him, He had been in bed for about four years and had missed four years of school. And when he showed up in my office, I want to describe him to you because I will never forget this as long as I live. He came into my office, he had long unwashed hair and he was pasty and pale, and he was heavy because he hadn't been moving his body and hadn't been exercising, had truly been bedridden.[00:15:25] And he started rocking himself back and forth on my couch with the pain. And I remember thinking like, he's been through Stanford, he's been through UCSF. Who am I to do that? I almost called his neurologist to say I can't do it. Thank God I didn't. But it's just funny. I think as healthcare providers, we all have a little bit of this imposter syndrome—can I do it? And so when I take a history, I don't just ask about the pain and when it started, I want to know everything. Because as we all know now, there's always a pain recipe. There's always bio ingredients and there's always emotional ingredients. There's always contextual and environmental ingredients.[00:16:03] There's family ingredients, there's trauma. There's coping behaviors—all of that is baked into a pain recipe. So I asked him about his emotional health. He had been paralyzed with social anxiety for most of his life, untreated. He was depressed. He was suicidal, which is not that surprising actually, when you're 16, you have no life, You've been in bed for four years. He had been on 40 medications. He had seen 14 specialists and experts. It's understandable to me that a 16 year old might feel hopeless and helpless and in fact, that's true of a lot of patients who come to me. I am the last stop on the train. Nobody wants to see a psychologist for pain.[00:16:42] Nobody, and I understand why I also would not want to. So, I realized pretty quickly that there were a lot of parts of his pain recipe that were not being treated. So when we started the program, we did get his parents involved for a number of different reasons, and one of those reasons was that he needed support doing some things to help his social anxiety go down, help his mood improve and help us pain improve, because all of those things are intimately connected all of the time.[00:17:10] My mantra is that the brain and body are connected 100% of the time. They're never not. Ever. So of course your emotional health affects your physical health. So one of the things we needed him to do in order to help his pain and his mood was start moving his body. And you can't ask someone who's been in intractable pain for four years to go outside and hang out with friends.[00:17:30] That's not how that goes. So week one, he went out onto his porch and stood in the sun for 10 minutes a day, every day for a week. Week two, he walked the corner mailbox and his mom would give him mail to put in the mailbox. Week three he would walk around the block and he would stop at the corner store and order tea or coffee or whatever, just to have human interaction. And by the way, this was paralyzingly difficult for him and part of our pacing plan, because that's what this was and I'm happy to explain what that is. You go slowly to increase activity, whether it's social activity or physical activity. It was really hard for him. And he would have pain flares. Absolutely.[00:18:11] And we built that into the treatment strategy. So he would take breaks, as many as he needed. He could take the whole day to get the walk around the block and the stopping for coffee done. Week four, he walked his dog to the dog park and had a conversation with someone. Week five, he mixed in a little bit of jogging and texted a few friends. So as you can see, there was a gradual increase in activity, both social and physical. It was targeting his anxiety, it was targeting his depression. We know that behavioral activation is very critical for depression. We know that social exposure is very critical for treating social anxiety and slowly, slowly, slowly, his mood improved.[00:18:49] Anxiety started receding, pain volumes started going down. At some point, his neurologist called me and said, “What magic purple pill are you giving this kid?” And I sort of had to say—suppressing my frustration—yeah, that's the whole point. It's not a magic purple pill. And he gradually got back to school and he rejoined his soccer team and he started playing soccer again and his pain went away and he went off to college and became captain of his swim team or whatever. And listen, just to say, this is a kid who's still, he's an adult now who still has migraine, but his migraines do not debilitate him and they will never again dominate his life. And he will never again be in bed for four years because now he knows he has to look at his whole pain recipe. He can't just take medications forever. And I am not. Saying that medications are not helpful, thank God for medications. What I am saying is that it's a bigger picture and humans are more than just a body part.[00:19:50] Dr. McBride: Amen. Hallelujah. I mean, this applies to really any suffering I think that you cannot measure in a blood test whether it's depression, anxiety, PTSD, chronic fatigue. Patients who don't fit in the mold or, or who don't have a diagnosis that we can see on paper get so easily dismissed by the medical establishment and also get, there's self-stigma, right? When people don't have a, when there's nothing you can hang your hat on from a lab abnormality, it can eat away at your sense of self. And then what's worse is when doctors are not counting your story and you don't then have access to your whole interior world, which is of course essential to how we function in the world every single day.[00:20:44] And you're right—there's no partition between head and body. It's not like there's a neck down kind of version of humankind. What is your advice to people who are listening who have chronic pain, say from hip injury, a herniated disc, migraines who are thinking to themselves, Huh? I have some imitrex for my migraines. I have some Advil for my back pain. I know how to stretch and move. My life is stressful, but I'm managing it. What else should I be doing?[00:21:17] Dr. Zoffness: So I'm one of these people who believes that appropriate pain care should be affordable and accessible to everybody. So I published a book during the pandemic called the Pain Management Workbook, and in there is everything to do with pain science. Very digestible. It's like neuroscience that anyone can read, and it also has a ton of strategies in there.[00:21:39] And I think the most important thing, if you're living with pain or if you treat pain and you're not sure what to do next, is to figure out how to put together a pain recipe. And that's in the book, the Pain Management Workbook. And I'm gonna say what that is and what it means. Every single person has a pain recipe, everyone. So for me, my pain recipe, for example, is sitting for too many hours without getting up and moving, not exercising, eating poorly, not taking care of my body, poor sleep, fights with my family or my partner or whatever. A lot of stress at work. I know that if it's a high stress day, I probably will not have a good pain day.[00:22:22] And also my level, managing my level of stress and anxiety, so whether I'm actually actively incorporating self-care, like am I going for walks? Am I going outside in the sun? Am I making sure that I'm scheduling time to be in nature or go to pleasurable activities? So that's my pain recipe.[00:22:42] And as you can see in that pain recipe, there are bio components, there are cognitive and emotional and behavioral components, and there's social components always. And so when you put together a pain recipe, the cool thing about it is, there's always a high pain recipe. Like I like to ask people like, you know, do you like to cook or bake?[00:23:00] Because I do not. But as you know, if you like to cook or bake, there's always a recipe that will get you to the end point that you're seeking. And the same is true for pain. Like just as there's a recipe for brownies, there's a recipe for pain. And so I just gave you my high pain recipe. The cool thing about a high pain recipe is that a low pain recipe is the exact opposite. A little bit more nuanced than that, but there's always this high pain recipe, low pain recipe sort of thing. So for me, sitting for too many hours without taking a break is part of my high pain recipe, and the reason that's great valuable information is because I know that to manage my pain, I need to set my alarm every hour and go for a walk outside, even if it's literally two minutes, five minutes, or my next phone call, I take it on a walk around the block, whatever.[00:23:49] Whatever I have to do to structure in these things that I need to get to a low paying recipe. That's what I do like scheduling pleasurable activities and walks in nature on the weekend and making sure to see friends and making sure to put boundaries around toxic relationships and not spend time with certain people, because guess what? You're allowed to do that. So whatever ingredients are in your high pain recipe, figuring out that recipe is the way to lower pain volume. So that's one of the strategies in the pain management book. [00:24:16] Dr. McBride: I love it. I think at the root there, Rachel is, is a self-awareness. Giving ourselves permission to look inside and to think about, as I say, our stories and how they live in our bodies. To take time to look at the narratives inside, some of which are rooted in fact, and some of which are not rooted in reality.[00:24:34] For example, the patient who says, I've been in bed for four years. I am a broken person. I'm an identified patient in the family, I'm a problem. You know, if you, if you organize your thoughts, feelings, and behaviors around a narrative isn't fully fact-based, then that's only gonna exacerbate the very problems you have.[00:24:56] So, making sure, obviously someone who is suffering is entitled to feel like they are a patient or a challenge. But if we can look inside and access our stories and then ideally rewrite some of those narratives like I can and I will and I'm able, I mean the agency there. I think a little bit of what you're talking about is sort of making your own recipe, making your own kit so you don't feel so helpless and a victim of yourself.[00:25:28] Dr. Zoffness: And I think that goes back to this thing where there's cognitive components to pain and beliefs matter a lot. This particular patient I was talking about believed that there was no hope for him and understandably so. And the first thing I told him when he came to my office was that I was going to help him. And of course, I didn't know that for sure, but I knew for sure that he needed to believe that. So I said, I can help you and, and I knew that he needed to believe in me for any of this to even work.[00:25:53] Dr. McBride: The other thing is the trust you're describing. I mean, for me to help someone—I'm sure it's the same for you as a clinician—to help someone who has an intractable problem, whether it's obesity or PTSD, heart disease, to feel like they have hope and possibility. They have to really, really trust the messenger and the guide because if you feel hopeless, if you feel like there's nothing out there for me and you've been treated like a bag of organs and not a person, that alone is a barrier to care. And so just aligning with the patient and leading with empathy and curiosity in my mind opens the door to that partnership, which sounds almost corny and hokey, but there's an incredible therapeutic benefit to the patient when you can align… And it's like, believe the patient, they are not making this up.[00:26:49] No one wants to make up a story of, I'm in so much pain, or I have experienced something that is unique to me, no one's ever experienced and I'm alone. No one wants to feel that way. And so just giving people permission to be human and then by a doctor or PhD, Rachel's Zoffness, that's a meaningful intervention.[00:27:10] Dr. Zoffness: Yeah. I was also thinking about what you were saying before about how, and it's so true, how chronic pain patients are such a challenging population for doctors to treat, and there's a bunch of papers actually that have come out on this that show that one of the reasons for this is that there's a lack of pain education in medical school, and there's this crazy statistic that sort of blows my mind, which is that 96% of medical schools in the United States and Canada have zero dedicated compulsory pain education. And all these subsequent papers that came out where physicians were interviewed, like, how comfortable do you feel treating pain? And it's what you were saying before, there's this lack of comfort, understandably.[00:27:47] How are physicians supposed to feel, or any of us as clinicians supposed to feel comfortable treating a thing that we haven't truly been taught about in part because it's not really well understood. It happens to be well understood, but it's not really, the education is so poor. Like as a patient. Do you ever get taught about pain if it's not really being taught in medical school, it's not being taught to, to the lay public. So how do we treat a thing unless we really understand it?[00:28:14] Dr. McBride: Exactly, and then doctors don't have time. It's not the doctor's fault, it's the system's fault. We don't have time to elicit the whole story and the whole landscape of that person's interior world, and then we have to know what to do with it. And that takes time. And that's just not what modern medicine is designed to do right now.[00:28:32] Dr. Zoffness: No it's not. It's a profit driven healthcare system.[00:28:34] Dr. McBride: It's awful. What do you see as the relationship between chronic pain and addiction?[00:28:41] Dr. Zoffness: So it's interesting. I started teaching at Stanford a couple of years ago and I'm teaching the Addiction Medicine Fellows, and I remember when I first went down this rabbit hole in pain science, realizing that addiction, medicine and chronic pain have started to become synonymous, and I am a nerd, and the way I make sense of the world is by reading everything.[00:29:05] So I started reading every single paper I could find. Here's a heartbreaking statistic. 80% of people in America who have become addicted to heroin started out as pain patients. There's this disconnect, I think until recently that we, and there's also a lot of blame, like people with addiction are blamed for their addiction. But 80% started out as pain patients. That means they went to their doctor, this person they trusted and they were like, help me. I have pain. And the doctor, totally, understandably because doctors were lied to for forever [and told that this] medicine is the thing you need to give. It's the treatment for pain. They gave this medication that hijacks the brain and hijacks your central nervous system.[00:29:46] Dr. McBride: You're talking about narcotics and opiates.[00:29:49] Dr. Zoffness: Correct, oh, did I not say that? Sorry. Yeah.[00:29:51] Dr. McBride: No, but that's, I just wanted to tell you because I mean, that's what we were taught in medical school.[00:29:54] Dr. Zoffness:Yeah. Oh, no, no, absolutely.[00:29:56] Dr. McBride: That's what we were taught. Get ahead of the pain opiates, Oxy five, 10 milligrams Q4 to six hours, more than you think they need.[00:30:04] Dr. Zoffness: Right, of course. And, and that's because there was great marketing. Everyone who has seen dope sick knows this now. Yeah. And there's a book called Drug Dealer MD by Anna Lemke that all of this has just been really blown open over the last couple of years. And of course now pharma is paying a 26 billion payout in reparations, but in my mind, that is absolutely not enough.[00:30:28] The number of lives lost and the way that pain medicine has been completely hijacked is pretty gnarly. And I also want to be clear to say I am not anti-opioid. Thank God for opioids post dental surgery. If that's something that your body can tolerate, you don't have a history of addiction, like I am not anti-opioid, But the issue for me is the way we've framed pain as a biomedical problem that requires a purely biomedical solution. And we know that that's not true, and we know that that's actually wrong. And we also have known for a very long time that opioids can be very dangerous for people. So the fact that that's sort of become the de facto treatment, especially for chronic pain, is so heartbreaking.[00:31:08] Rachel: I treat so many patients who have been in pain for a really long time and now they have two issues. You asked, like with a relationship, there are all these dual diagnosis clinics now around America where the dual diagnoses are chronic pain and opioid addiction. Like what are we doing to people with pain? It's so unacceptable.[00:31:28] Dr. McBride: It's completely unacceptable. And then when you think about the mental health world and the false dichotomies there—I know you talk about your frustration and anger about the way. People are treated in the current medical industrial complex. My particular cross to bear is the way we talk about mental health, which is as if mental health calmness, serenity, and the ability to be happy when mental health is really the ability to have an appropriate emotional response to the setting and to have agency and tools to manage the inevitable potholes on the road of life. [00:32:15] And then we talk about the mentally ill, which as if there's some kind of distinctive line in the sand where you go from mentally healthy to one click over, oh, mentally ill broken person, totally healthy person over here. So just like you do with your own patients, when I'm talking to my patients about their emotional health because it's relevant to their physical health, surprise, surprise, I don't say, are you anxious or, are you depressed? I say, okay, given that everyone has anxiety, where are you on the continuum of anxiety and what are you using to manage the anxiety? Where are you on the continuum of mood given that you're located somewhere on the mood continuum? What's your depression recipe? What, I don't say that but what is the thing that, what brings your mood down? And then what brings it up? And if it's recreational drugs, then maybe we should think about an alternative plan. If it's nature and being with your loved ones, maybe we need to lean into that avenue. And if your mood is pulled down by a toxic relationship, maybe we need to put a fence around it. I believe in Prozac. I believe in Zoloft. I believe in psycho-pharmacology. I also believe in treating the person and not just the pathology.[00:33:34] Dr. Zoffness: So you said it exactly the way I would say it. And I do teach about a depression recipe. And of course there is one. During the pandemic, calls to suicide hotlines went up 8000% in some parts of our country. Now, was everyone mentally ill during the pandemic or was there an external situational trigger that made us all anxious and fearful about our loved ones or whatever?[00:33:59] However you responded to that thing or made you feel depressed because you couldn't do all the things you wanted to do. You couldn't go to work, you couldn't go to the movies, you couldn't go to restaurants. You couldn't see your grandparents in the hospital. Of course there's a depression recipe. And depression again is biopsychosocial also always, all the time for everyone. It's not just a chemical imbalance. And by the way, a paper came out recently by Joanna Moncrieff showing that, we've all known this for a long time also, but there's no such thing as a chemical imbalance. That is an effing lie. That is a lie. If you look at all the brains of people who are depressed and not depressed, there actually is no evidence to support that people who are depressed have less serotonin than people who are not depressed.[00:34:40] Actually, that has no evidence and no traction in medicine. So the one issue with that is, if you believe the lie you've been sold by big pharma, that depression is a biological problem that requires a biological solution, All you'll ever do is take a pill, and it's the same as true with pain, but depression is just as bio psychosocial as pain is.[00:35:02] Dr. McBride: That is exactly right. It is not true that depression or anxiety or PTSD is a result of a chemical imbalance. That is a narrative that has been pushed out for whatever reason. And, and as a result, we end up treating patients with pills and pills alone, not uniformly. I wanna make it clear though, that's not to say that Zoloft Prozac, all these SSRIs cannot and do not help people with depression, anxiety, PTSD, and that they are appropriate for some people in the context of the biopsy psychosocial model. In other words, when that paper came out, which illustrated what we've known for a long time, it just needed to be said again, that chemical imbalance is not accurate. Patients of mine were calling and saying, well, does that mean that I shouldn't be on my Zoloft? Does that mean I shouldn't be on my Prozac? [00:35:52] Meanwhile, as I say to my patients, Zoloft is one piece of the larger puzzle of your health and wellbeing. If it is helping you tolerate the anxious thoughts and feelings and the cognitive distortions that then allow you to get more out of therapy, that allow you to activate on the recipe for feeling better, then that is an entirely appropriate medication. It doesn't mean you're mentally ill if you take medicines and you're mentally well if you don't take medicines. It's just a piece of the puzzle, just like being in nature and exercising. So I think it's important to be clear that just because it's not true that these phenomena are chemical imbalances, it can still be true that medications can help. This is where the nuance gets lost. Because if you're someone who believes in the middle ground, where biopsychosocial elements intersect, you run the risk of people misunderstanding and thinking that you are anti-medication and that everything in our world is fixable with willpower, thoughts, and behavioral modification when that's not true.[00:37:04] Dr. Zoffness: Yeah, I think that's why it's so important to say like there's always a bio component to everything. Of course genetics matter and you know, of course neurotransmitters matter. But I think the message, the take home message here is that whether it's depression or anxiety or diabetes or migraine, there's always a recipe of factors that are contributing every single day. And we know that because what I like to say to my patients is like, if you tell me certain times over the course of the day that pain goes up and pain goes down, or if you monitor your pain over the course of the week, you know that there are certain times that pain goes up and pain goes down.[00:37:37] Rachel: And what that means is that if pain is always changing, Pain can change. If pain can change, then pain can change. And what that means in any given moment or hour of your day or your week, there's different bio psychosocial factors that are contributing to your pain recipe. So times when your pain is low might be you're distracted, you're with friends, you are watching a funny movie and shoving ice cream in your face and during that period of time, those two hours, your pain volume is a little bit lower. Your pain volume might be higher when you're driving to the doctor's office for a procedure that's upcoming and you're feeling really worried and you feel your heart is racing and your body is tight, and of course we know that those are gonna contribute to a higher pain volume. So it's always all the things working together. It's never just one thing.[00:38:24] Dr. McBride: This morning I was talking to Lisa Damour about anxiety, and I think there's some parallels here with pain. Insofar as some anxiety is helpful and productive. In other words, if we didn't have anxiety, we would walk into traffic. We would not turn in our term paper. We would not veer away from the bus that's coming at us. Anxiety is a problem potentially when it's out of proportion to the actual threat and takes on the life of its own. Pain too has a function. I mean, it's a warning signal. It's telling us that, you know what, you've stepped on a thorn. You have arthritis in your knee, that maybe means it's time for an evaluation of your surrounding muscle structures and maybe you need a new knee. So how do you describe to patients, when pain is okay or enough and when we should tolerate it and when it's not enough? Because a pain-free existence is impossible.[00:39:20] Dr. Zoffness: Yeah, so I like to always talk about pain as the body's danger detection system. It's our warning system, right? So as you said, you put your hand on a hot stove. If you don't get those danger messages, you'll leave your hand on the. Dove and your skin will melt off. Or you go for a run and you break your ankle and you don't stop running and seek help and rest so your bones can repair, you're screwed. You're going to further damage your body in bones and tissues. So pain is a very important danger message. And I remember when I was an undergrad at Brown, I had this wonderful professor, Mark Bear, who I talk about all the time now because his neuroscience textbook changed my life. And he would talk about how some people are born without the ability to feel pain like this congenital insensitivity, this high threshold.[00:40:04] And I remember thinking, gosh, that sounds so. Lovely. And then he went on to say, and they don't live very long because again, if you imagine you, you damage your body, but your brain doesn't give you any of these warning messages or these danger messages. You're not gonna live very long. So pain is important and we have to pay attention to pain.[00:40:23] So acute pain is pain that's three months or less. And acute pain is like the pain of childbirth or like you get a virus and you have muscle pain and then it goes away. Or the pain of a broken bone or torn ligament—that's acute pain. Chronic pain is pain that lasts three months or longer or beyond expected healing time, which is very nebulous and the definitions are just not that great, but pain that lasts beyond expected healing time.[00:40:52] And we know that there's a difference between these two things. And one of the ways I like to talk about this, when people come to my office, they say, well, I've been in pain for seven years, 10 years, why is my pain chronic? How did this happen? And there's a number of ways by which pain can become chronic.[00:41:13] But one of the processes that underlies chronic pain is called central sensitization. And what that means is we talked about the location of pain construction and how that happens in our brain and we know that our brains are like the muscles in our body. The more we use certain pathways in our brain, the bigger and stronger those pathways get.[00:41:34] So for example, for me, I played the piano growing up. I didn't really like to and I didn't really want to, but my mom would say, Rachel, sit down and practice. It's the only way you're gonna get better at it. And over time, of course, she was right. The more I practiced, the bigger and stronger the piano pathway, which isn't a real thing, but the piano pathway in my brain got bigger and stronger with time until I could sit down at the piano and my fingers would just know what to do. Right? Not magic. That's just your brain changing with time and experience and exposure. And there's a word for that, and it's called neuroplasticity.[00:42:13] Neuroplasticity literally means your brain over the course of your life is always changing, always, even into adulthood. It's morphing every time you have an experience. It's the reason you can learn a new language, even when you're 62. So just as practicing the piano made the piano pathway in my brain big and strong, the same happens when we have pain all day long, over and over for many months and weeks and years. What happens is the more we accidentally practice pain, the bigger and stronger the pain pathway in your brain gets. And I wanna say that carefully because there's no actual pain pathway. There's a lot of different ways that pain is processed by different parts of the brain, but we know that of course circuits in the brain and neural networks get stronger with use in time.[00:43:03] So pain pathway for the sake of this metaphor, gets bigger and stronger with use. The more and more we use it. And when that happens, we say that your brain has become sensitive to pain. And I think about that word all the time. What does sensitive mean? So if you have a dog, and it's the 4th of July, we know that of course dogs are much more sensitive to sound than we are. So when all the fireworks are going off on July 4th, all the dogs in America are hiding under our beds. We give them thunder shirts or whatever, thunder jackets so that they'll calm down and it's because their brains are very sensitive to sound. And the same is true with our brains when we become sensitive to pain over time.[00:43:48] Small bits of sensory input from the body to a sensitive brain sound and feel very big. So for example, an example I'd like to use is for my fibromyalgia patients. You go for a picnic with a bunch of friends and you're sitting under a tree in the sun, and we can all agree that that is not dangerous. But your brain might give you very amplified danger messages anyway. So things that are not dangerous can result in a very loud danger alarm. And when, when, when that happens, we know that the brain has become sensitive. And that's a chronic pain process. That's not true of acute pain.[00:44:26] Acute pain and chronic pain are different processes, and they're both biopsychosocial. There's bio, cognitive, emotional, behavioral, sociological factors that play into both, but it's really important to think about how to desensitize a sensitive brain once pain has become chronic.[00:44:44] Dr. McBride: Rachel, I think we need you on every corner of America because as you opened with pain is an inevitable part of life. And when we medicalize it and put it in a box and prescribe a pill, we're really depriving people the opportunity to have access to their internal world and then have agency. And I just wonder, how are you're gonna get this message out there even more than you already are. You were on the Ezra Klein show. You've written this phenomenal book. You're talking to me today. You are making a difference every day with your patients, but like I want you to have a megaphone because this is so important. It's so relevant.[00:45:31] Dr. Zoffness: It's so relevant. I also think about this distinction between like, like you were saying before, it's like pain patients to the left and like providers and everybody else to the right and like. That's not how pain works. Pain is coming for everybody. There's no one that escapes the human experience of pain, whether you had it in childhood or you have an injury now, or you know, pain later in life. So it seems so critically important to me that we all are the holders of the truth. Like I'm just tired. Like you were talking before about, gosh, why were we all sold this big lie that depression is due to a chemical imbalance. The answer is that was a pharma marketing device. That's why that we all, we all got that message cuz it was literally plastered.[00:46:15] I remember I lived in New York City growing up—I mean I'm a New Yorker born and bred—and there was this huge 20 foot ad on the side of a building and it said depression is not a flaw in character, it's just a flaw in chemistry. And I remember thinking, God, that's so brilliant. It's making you feel like, oh, it's not my fault, it's just my chemistry. So like if your chemistry is broken, of course the only fix is a pill. It's brilliant marketing, and we all have been sold this lie for very many decades about pain, about depression, about anxiety. It is a lie. That's not the solution. The solution is never just a pill ever, ever, never.[00:46:53] Dr. McBride: Which is ironically not anti-pill.[00:46:56] Dr. Zoffness: No, I'm not at all anti-pill.[00:47:01] Dr. McBride: We could talk about big pharma all day long… [00:47:04] Dr. Zoffness: It's just not the only solution. It's much more complicated. As humans we're just more complicated than that. Right. We're not just chemistry, we're more than that.[00:47:11] Dr. McBride: To close. I want to ask you about you. You told me a little bit about your pain recipe and what you do to manage discomfort, psychological, biological. What are the sort of biggest insights you've learned from your own patients, who I find my best teachers. What have you learned from your patients about how to care for yourself?[00:47:34] Dr. Zoffness: Two different answers to that question. The first thing that comes into mind, just what have I learned from my patients has been this, I don't believe necessarily in magic or miracles, but when I see teenagers get out of bed and go back to life, like I told you about this patient that I had who had chronic pain all over his body and chronic migraine and went back to soccer and went back to school. And what I didn't tell you, he got asked to prom when he went back to school, not by one girl, but by two. And watching this kid, he invited me to his graduation and at his high school graduation, he got on stage and said, if you told me four years ago I'd be graduating high school, I never would've believed you.[00:48:17] And this magic miracle is just science. I don't have a magic wand, it's just disseminating this information about what pain really is and how pain really works. And I see it every day as my patients get out of bed and back to life. And it's it's what galvanizes me to do things like this. I actually am a library mouse and I do not like public speaking, but I can do it here with you because it's just you and me, so it's fine. It galvanizes me to go out into the world and just spread the message. You have to bridge the gap between physical pain and emotional pain if you want to treat pain because it's this lie in Western medicine that either your pain is physical and you see a physician or your pain is emotional and you see a therapist, and that's never how pain works ever. Emotional pain is physical. Anyone with anxiety can tell you how physical. That pain is, you have chest pain and you know there are times your body hurts and your sweat. There's so many physical parts of emotional pain and physical pain is emotional. People with chronic pain have 50% higher rates of depression and suicidality. Physical and emotional pain are connected always. So the biggest message I get from my patients is that this is real and we all need to be practicing it.[00:49:35] We can't just be talking about it theoretically. We all need to go back into our offices or to our doctors or to our patients and reframe this thing that has been broken and put it back together, and it is doable. It's absolutely positively doable. And the most important message I want to convey is that chronic pain is always treatable. Anyone who tells you that it's not doesn't understand pain. Chronic pain is always treatable. There is always hope for treating pain. Always.[00:50:04] Dr. McBride: So tell me, Rachel, where can people follow you?[00:50:06] Dr. Zoffness: I am on Twitter. What is I think actually how we initially connected, I think I commented on one of your posts. I'm @DrZoffness on Twitter. I also do a lot of pain education on Instagram. I'm @therealdoczoff which is very funny cause I picked that initially as a joke. I joined, I think, maybe at the end of 2019 and didn't actually do anything there and just planned on following some of my friends. But now I really am using it to disseminate information about pain. And I also have, uh, websites, just my last name, zoffness.com and there's a ton of free resources. It's super important to me that pain information and treatment is affordable and accessible to everybody. I'm so tired of this lack of insurance reimbursement and it's really, it's unacceptable. There's an entire resources page with books and videos and websites and just a to a ton of free stuff. [00:50:59] Dr. McBride: And then there's your, there's your workbook, which is just such a great resource.[00:51:02] Dr. Zoffness: yeah, the Pain Management workbook is on Amazon and it's on my publisher's website, their new Harbinger. It's just called the Pain management Workbook. I figured go simple![00:51:11] Dr. McBride: It's great. It's great. Rachel, I want to say thank you so much for joining me today. You're an inspiration and I wish it wasn't true that you're a rare bird in this medical system, in this country, but I think it's pretty rare. And I think that's why I reached out to you. It's why I connected with you. It's why I've been so excited to have you on the show because it's really a crying shame that this is unusual information when it's basic human 101.[00:51:40] Dr. Zoffness: I Totally agree.[00:51:41] Dr. McBride: and you do such a good job of explaining it. So, Rachel, thank you so much for joining me. It's been a pleasure.[00:51:49] Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you like this episode to rate and review it. And if you have a comment or question, please drop us a line at info@lucymcbride.com. [00:52:11] The views expressed on this show are entirely my own and do not constitute medical advice for individuals that should be obtained from your personal physician. Get full access to Are You Okay? at lucymcbride.substack.com/subscribe

For the final episode of Season Five, Courtney Harler speaks with two Courtneys, Courtney Zoffness and Courtney Maum. Maum is, of course, a returning guest, and Zoffness is new to the podcast.Courtney Zoffness is the author of the debut memoir in essays called Spilt Milk, out in 2021 from McSweeney's. As a fiction writer, Zoffness was the second-ever woman to win the Sunday Times Short Story Award in 2018, the world's richest prize for a single short story. She's taught for many institutions and currently directs the creative writing program at Drew University.Courtney Maum is the author of several novels, and most recently the memoir called The Year of the Horses, out in 2022 from Tin House. She's also helped countless writers navigate the publication process with her craft guide, Before and After the Book Deal. Courtney Maum is a writing coach and executive director of the nonprofit learning collaborative called The Cabins.Today we talk about the humble beginnings and early invisible work of writers, vulnerability, publication and promotion in the digital age, distractibility, reading recommendations, and more.PWN's Debut Review is hosted by Project Write Now, a nonprofit writing studio. Learn more at projectwritenow.org.

Today, Courtney Zoffness discusses Spilt Milk (memoirs), why pregnancy and early parenthood is a fertile time for creatives (haha see what I did there), moving between fiction and nonfiction, “going long,” working with McSweeney's, and more!  Courtney Zoffness is the author of the memoir-in-essays SPILT MILK, out now in paperback. Spilt Milk was named a best debut of the year by BookPage and Refinery29, and a “must-read” by Publishers Weekly and Good Morning America. Also a fiction writer, Zoffness was the second-ever woman to win the Sunday Times Short Story Award, the most valuable international prize for short fiction, amid entries from 38 countries. She joined a list of winners that includes Anthony Doerr and Junot Díaz. Other honors include an Emerging Writers Fellowship from The Center for Fiction and two residency fellowships from MacDowell. Her writing has appeared in the New York Times, The Paris Review Daily, Guernica, No Tokens, and elsewhere. Zoffness holds graduate degrees from the Writing Seminars at Johns Hopkins University and the University of Arizona, and a B.A. from the University of Pennsylvania. She's taught at a dozen different institutions and delivered readings and talks at venues across the US and abroad. Currently she directs the creative writing program at Drew University. She lives with her family in Brooklyn, NY. Learn more about your ad choices. Visit megaphone.fm/adchoices

Rachel Zoffness, PhD, author of The Pain Management Workbook, joins us to discuss the science of pain. She is a leading global pain psychologist and expert, international speaker, author, and thought leader in medicine revolutionizing the way we understand and treat pain. She is assistant clinical professor at the University of California, San Francisco; and lectures at Stanford University. Zoffness is also author of The Chronic Pain and Illness Workbook for Teens, and consults on the development of integrative pain programs around the world. She is a regular guest on popular podcasts such as Ologies, Jordan Harbinger, and ZDoggMD; and her own podcast episodes have more than five million downloads. Visit our website at www.newharbinger.com and use coupon code 'Podcast25' to receive 25% off your entire order. Buy the Book: New Harbinger - https://bit.ly/3ZfXDf4 Amazon - https://a.co/d/1fZxKDS Barnes & Noble - https://www.barnesandnoble.com/w/1136014101 IndieBound - https://www.indiebound.org/book/9781684036448

Physical pain is a universal human experience. And for many of us, it's a constant one. Roughly 20 percent of American adults — some 50 million people — suffer from a form of chronic pain. For some, that means having terrible days from time to time. For others, it means a life of constant suffering. Either way, the depth and scale of pain in our society is a massive problem.But what if much of how we understand pain — and how to treat it — is wrong?Rachel Zoffness is a pain psychologist at the University of California, San Francisco, School of Medicine and the author of “The Pain Management Workbook.” We tend to think of pain as a purely biomechanical phenomenon, a physical sensation rooted solely in the body. But her core argument is that pain is also produced by the mind and deeply influenced by social context. It's a simple-sounding argument with vast implications not only for how we experience pain but also for how we treat it. She points to numerous underused tools — aside from pills and surgeries — that can help lessen our pain.We discuss Zoffness's surprising definition of how pain serves as “the body's warning signal”; how our mood, stress levels and social environment can amplify or dial down our pain levels; what phantom limb syndrome says about how the brain “makes pain”; how our emotions and trauma influence our pain levels; the crucial difference between “hurt” and “harm”; why studies on back pain have yielded such bewildering results about the sources of perceived pain; how to figure out and improve your personal “pain recipe”; the roots of our chronic pain crisis and how our health care system could be better set up to treat it; why she says, “If the brain can change, pain can change”; and more.Mentioned:“Neuroimaging of Pain” by Katherine T. Martucci and Sean C. Mackey“Targeting Cortical Representations in the Treatment of Chronic Pain” by G. Lorimer Moseley and Herta Flor“Psychological Pain Interventions and Neurophysiology” by Herta Flor“Sham Surgery in Orthopedics” by Adriaan Louw, Ina Diener, César Fernández-de-las-Peñas and Emilio J. Puentedura“Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations” by W. Brinjikji, P.H. Luetmer, B. Comstock et al.“A Biological Substrate for Somatoform Disorders: Importance of Pathophysiology” by Joel E. Dimsdale and Robert Dantzer“Undergraduate Medical Education on Pain Management across the Globe” by Nalini Vadivelu, Sukanya Mitra and Roberta L. Hines“Lifestyle medicine for depression” by Jerome Sarris, Adrienne O'Neil, Carolyn E Coulson, Isaac Schweitzer and Michael BerkBook Recommendations:Why Zebras Don't Get Ulcers by Robert M. SapolskyThe Body Keeps the Score by Bessel van der KolkPain by Patrick WallThoughts? Guest suggestions? Email us at ezrakleinshow@nytimes.com.You can find transcripts (posted midday) and more episodes of “The Ezra Klein Show” at nytimes.com/ezra-klein-podcast, and you can find Ezra on Twitter @ezraklein. Book recommendations from all our guests are listed at https://www.nytimes.com/article/ezra-klein-show-book-recs.“The Ezra Klein Show” is produced by Emefa Agawu, Annie Galvin, Jeff Geld, Roge Karma and Kristin Lin. Fact-checking by Michelle Harris and Kate Sinclair. Mixing by Sonia Herrero and Isaac Jones. Original music by Isaac Jones. Audience strategy by Shannon Busta. The executive producer of New York Times Opinion Audio is Annie-Rose Strasser. Special thanks to Carole Sabouraud and Kristina Samulewski.

This week, host Jason Jefferies is joined by award-winning author Courtney Zoffness, who discusses her new book Spilt Milk, which is published by our friends at McSweeney's.  Topics of conversation include memoirs, parental advice, anxiety, "Hot for Teacher", ownership of one's body, organized religion, Roe v Wade, raising a boy in the current political climate, truth vs. fantasy, and much more.  Copies of Spilt Milk can be purchased here with FREE SHIPPING for members of Explore More+.  

Pain isn't just a sensation we feel in our body, it is a complex experience fueled by our minds. In this episode, Nicole and Shieva sit down with Dr. Zoffness, a leading expert in pain psychology, to uncover the root cause of chronic pain. Dr. Zoffness reveals the biopsychosocial factors that increase pain, uncovers some of the common misconceptions regarding pain management and discusses how we can turn down the dials of chronic pain. To learn more about Dr. Zoffness: https://www.zoffness.com/about twitter (@drzoffness), and Insta (@therealdoczoff) Resources discussed in this episode: Pain workbook: https://www.newharbinger.com/9781684036448/the-pain-management-workbook/ Resource to find a pain psychologist: https://aapainpsychology.org/ Music by - Glasses on the Table by Crowander

I'm so excited to welcome Dr. Rachel Zoffness to the podcast. Dr. Zoffness is a leading global pain expert who is working to revolutionize the way we understand and treat pain—she's a pain and health psychologist, lecturer at Stanford University, and assistant clinical professor at the UCSF School of Medicine. She's the author of The Pain Management Workbook and Chronic Pain and Illness Workbook for Teens, which are treatment guides for people living with pain. On this episode, we talk about:  why a pain recipe revolutionizes how you deal with pain (+ how to figure out yours) the three hidden causes behind all types of pain why, from a neuroscience perspective, literally all pain can be lessened  a guide to developing your own pain plan the three things that universally help reduce pain, regardless of what caused it the best diet to manage pain  what causes chronic pain, and why it impacts some people more than other  what to do today to avoid pain in the future if you aren't experiencing it right now the relationship between trauma and pain  the surprising way our genes impact how we feel pain the scientific reason why some people like pain in sexual situations how to activate your brain's natural opioid system  exactly when it makes sense to take pain killers  a genius way to communicate your pain to other people in a way that they understand it  if taking CBD for pain is actually doing anything  and so much more! We would LOVE to hear from you any thoughts, reactions, or takeaways you have as you're listening, so definitely screenshot and tag me @lizmoody and Rachel @therealdoczoff on Instagram.  To enter the giveaway to be one of the 15 winners of Rachel's Pain Management Workbook, comment on my most recent post mentioning something you loved or learned from the episode, and follow me @lizmoody and Rachel @therealdoczoff on Instagram.  To join the Healthier Together Podcast Club Facebook group, go to https://www.facebook.com/groups/healthiertogetherpodcast. This episode is sponsored by AG1 by Athletic Greens. Visit athleticgreens.com/healthiertogether and get your FREE year supply of Vitamin D and 5 free travel packs today.  This episode is sponsored by MUD/WTR. Go to mudwtr.com/lizm and use code LIZM for 15% off your order. This episode is sponsored by Cymbiotika. Get 15% off using code LIZ at cymbiotika.com.  This episode is sponsored by Pique. Get 5% off plus a free blooming teas pouch complete with premium Pique samples when you purchase 2 or more cartons from piquetea.com/LIZMOODY and use code LIZMOODY.  Healthier Together cover art by Zack. Healthier Together music by Alex Ruimy.

The murky middle during memoir writing is one that deserves it's own episode because you're quite literally writing about your own life, so it can feel a bit more personal. I'm excited to have Courtney Zoffness, Sunday Times Short Story Award winner and author of Spilt Milk on the Secret Library today. She shares her decades long journey of authorship and how to stay encouraged, navigating the risk of sharing your work, knowing what material to include in your book, and more. If you're feeling unsure of your own story as an author or you're ready to tell your story, this episode is for you. Visit this episode's show notes page here.Connect with Caroline on Instagram: @carodonahue Hosted on Acast. See acast.com/privacy for more information.

Courtney Zoffness is the author of Spilt Milk, out now with McSweeney's, and forthcoming in paperback in September 2022. Spilt Milk was named a best debut of 2021 by BookPage and Refinery29, and a “must-read” by Good Morning America. Also a fiction writer, Zoffness won the 2018 Sunday Times Short Story Award, the most valuable international prize for short fiction, amid entries from 38 countries. She joined a list of winners that includes Anthony Doerr and Junot Díaz. Other honors include an Emerging Writers Fellowship from The Center for Fiction and two residency fellowships from MacDowell. Her writing has appeared in the New York Times, The Paris Review, The Southern Review, Guernica, No Tokens, and other venues, and she had essays listed as “notable” in Best American Essays in2018 and 2019. Zoffness holds graduate degrees from the Writing Seminars at Johns Hopkins University and the University of Arizona, and a B.A. from the University of Pennsylvania. She has taught English at a dozen different institutions, including Yale University and the University of Freiburg (Germany), and delivered readings and talks at venues across the US and abroad. Currently she directs the creative writing program at Drew University. She lives with her family in Brooklyn, New York. Books Recommended: Emerson Whitney, Heaven Carmen Marie Machado, In the Dream House Emily Fridlund, History of Wolves Chris Holmes is Chair of Literatures in English and Associate Professor at Ithaca College. He writes criticism on contemporary global literatures. His book, Kazuo Ishiguro as World Literature, is under contract with Bloomsbury Publishing. He is the co-director of The New Voices Festival, a celebration of work in poetry, prose, and playwriting by up-and-coming young writers. Learn more about your ad choices. Visit megaphone.fm/adchoices Support our show by becoming a premium member! https://newbooksnetwork.supportingcast.fm/literature

Courtney Zoffness is the author of Spilt Milk, out now with McSweeney's, and forthcoming in paperback in September 2022. Spilt Milk was named a best debut of 2021 by BookPage and Refinery29, and a “must-read” by Good Morning America. Also a fiction writer, Zoffness won the 2018 Sunday Times Short Story Award, the most valuable international prize for short fiction, amid entries from 38 countries. She joined a list of winners that includes Anthony Doerr and Junot Díaz. Other honors include an Emerging Writers Fellowship from The Center for Fiction and two residency fellowships from MacDowell. Her writing has appeared in the New York Times, The Paris Review, The Southern Review, Guernica, No Tokens, and other venues, and she had essays listed as “notable” in Best American Essays in2018 and 2019. Zoffness holds graduate degrees from the Writing Seminars at Johns Hopkins University and the University of Arizona, and a B.A. from the University of Pennsylvania. She has taught English at a dozen different institutions, including Yale University and the University of Freiburg (Germany), and delivered readings and talks at venues across the US and abroad. Currently she directs the creative writing program at Drew University. She lives with her family in Brooklyn, New York. Books Recommended: Emerson Whitney, Heaven Carmen Marie Machado, In the Dream House Emily Fridlund, History of Wolves Chris Holmes is Chair of Literatures in English and Associate Professor at Ithaca College. He writes criticism on contemporary global literatures. His book, Kazuo Ishiguro as World Literature, is under contract with Bloomsbury Publishing. He is the co-director of The New Voices Festival, a celebration of work in poetry, prose, and playwriting by up-and-coming young writers. Learn more about your ad choices. Visit megaphone.fm/adchoices

Courtney Zoffness is the author of Spilt Milk, out now with McSweeney's, and forthcoming in paperback in September 2022. Spilt Milk was named a best debut of 2021 by BookPage and Refinery29, and a “must-read” by Good Morning America. Also a fiction writer, Zoffness won the 2018 Sunday Times Short Story Award, the most valuable international prize for short fiction, amid entries from 38 countries. She joined a list of winners that includes Anthony Doerr and Junot Díaz. Other honors include an Emerging Writers Fellowship from The Center for Fiction and two residency fellowships from MacDowell. Her writing has appeared in the New York Times, The Paris Review, The Southern Review, Guernica, No Tokens, and other venues, and she had essays listed as “notable” in Best American Essays in2018 and 2019. Zoffness holds graduate degrees from the Writing Seminars at Johns Hopkins University and the University of Arizona, and a B.A. from the University of Pennsylvania. She has taught English at a dozen different institutions, including Yale University and the University of Freiburg (Germany), and delivered readings and talks at venues across the US and abroad. Currently she directs the creative writing program at Drew University. She lives with her family in Brooklyn, New York. Books Recommended: Emerson Whitney, Heaven Carmen Marie Machado, In the Dream House Emily Fridlund, History of Wolves Chris Holmes is Chair of Literatures in English and Associate Professor at Ithaca College. He writes criticism on contemporary global literatures. His book, Kazuo Ishiguro as World Literature, is under contract with Bloomsbury Publishing. He is the co-director of The New Voices Festival, a celebration of work in poetry, prose, and playwriting by up-and-coming young writers. Learn more about your ad choices. Visit megaphone.fm/adchoices Support our show by becoming a premium member! https://newbooksnetwork.supportingcast.fm/new-books-network

Courtney Zoffness is the author of Spilt Milk, out now with McSweeney's, and forthcoming in paperback in September 2022. Spilt Milk was named a best debut of 2021 by BookPage and Refinery29, and a “must-read” by Good Morning America. Also a fiction writer, Zoffness won the 2018 Sunday Times Short Story Award, the most valuable international prize for short fiction, amid entries from 38 countries. She joined a list of winners that includes Anthony Doerr and Junot Díaz. Other honors include an Emerging Writers Fellowship from The Center for Fiction and two residency fellowships from MacDowell. Her writing has appeared in the New York Times, The Paris Review, The Southern Review, Guernica, No Tokens, and other venues, and she had essays listed as “notable” in Best American Essays in2018 and 2019. Zoffness holds graduate degrees from the Writing Seminars at Johns Hopkins University and the University of Arizona, and a B.A. from the University of Pennsylvania. She has taught English at a dozen different institutions, including Yale University and the University of Freiburg (Germany), and delivered readings and talks at venues across the US and abroad. Currently she directs the creative writing program at Drew University. She lives with her family in Brooklyn, New York. Books Recommended: Emerson Whitney, Heaven Carmen Marie Machado, In the Dream House Emily Fridlund, History of Wolves Chris Holmes is Chair of Literatures in English and Associate Professor at Ithaca College. He writes criticism on contemporary global literatures. His book, Kazuo Ishiguro as World Literature, is under contract with Bloomsbury Publishing. He is the co-director of The New Voices Festival, a celebration of work in poetry, prose, and playwriting by up-and-coming young writers. Learn more about your ad choices. Visit megaphone.fm/adchoices Support our show by becoming a premium member! https://newbooksnetwork.supportingcast.fm/literary-studies

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

THIS IS PART 2 OF A 2-PART CONVERSATION! IF YOU HAVE NOT WATCHED PART 1, GO BACK TO LAST WEEK'S EPISODE!YOU'RE BACK!! AND SO ARE WE!!! This time, we're getting more specific with Dr. Zoffness about more specific and controversial chronic pain and invisible illness pain. We're talking about the active plans that you can use to LITERALLY CHANGE THE WAY YOUR BRAIN PERCEIVES PAIN! Don't forget to check out Dr.Zoff's workbook, which helped me change my view of living with chronic pain! FOLLOW DR. ZOFFNESS:BUY HER WORKBOOK HERE: https://www.amazon.com/Pain-Management-Workbook-Powerful-Mindfulness/dp/1684036445/ref=sr_1_2?gclid=Cj0KCQiA3-yQBhD3ARIsAHuHT64wsB38EBgM2KsO76yIjPuWgeSF6PrYecF9mayTvl3sBs1zeMDEkrIaAhTeEALw_wcB&hvadid=526277223033&hvdev=c&hvlocphy=9030971&hvnetw=g&hvqmt=b&hvrand=16637284662388268403&hvtargid=kwd-1301329534690&hydadcr=15523_10340803&keywords=dr+rachel+zoffness+book&qid=1646001488&sr=8-2FOLLOW DR. ZOFFNESS:https://www.zoffness.com/https://www.zoffness.com/resourceshttps://www.instagram.com/therealdoczoff/?hl=en@DocZoffness on twitterBUY KELSEY'S BOOK! AND SENSITIVE MERCH! OUT NOW!BOOK:https://shopc.at/dfpMERCH:https://shopcatalog.com/shop/tag/kelsey-darragh-collection/Follow Kelsey & Keep Up with her life!https://linktr.ee/kelseydarraghSign up for Kelsey's new company at swapskis.coSupport this podcast at — https://redcircle.com/confidently-insecure/donationsAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

Calling all chronic pain babies! I'm talking back pain, fybro, POTS, CRPS, ANYONE AND EVERYONE IN CHRONIC PAIN!! Listen up! Dr. Rachel Zoffness, chronic pain specialist, is here for a whopping whole 2 part conversation about CHRONIC PAIN!!!! in this VERY IMPORTANT first episode, we chat about what exactly IS chronic pain and WHY do we have it?! Why and HOW does pain become chronic in the BRAIN (thats right, THE BRAIN, NOT JUST OUR BODIES!!!) And i'm so excited for you to hear this first part of our chronic pain special!!FOLLOW DR. ZOFFNESS:https://www.zoffness.com/https://www.zoffness.com/resourceshttps://www.instagram.com/therealdoczoff/?hl=en@DocZoffness on twitterBUY KELSEY'S BOOK! AND SENSITIVE MERCH! OUT NOW!BOOK:https://shopc.at/dfpMERCH:https://shopcatalog.com/shop/tag/kelsey-darragh-collection/Follow Kelsey & Keep Up with her life!https://linktr.ee/kelseydarraghSign up for Kelsey's new company at swapskis.coSupport this podcast at — https://redcircle.com/confidently-insecure/donationsAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

On episode 107, Leon speaks with Dr. Rachel Zoffness about the medical history of pain management; how the opioid crises is fueled by a purely biological understanding of pain; the emotional, social, and biological components of pain; the neurological anatomy of pain; the unhealthy thoughts and actions associated with pain and how changing them helps us modulate it; why therapists often fear treating chronic pain; the negative correlation of opioid use, wherein opioids cause us to become more sensitized to pain as we become desensitized to them; why thoughts and emotions are physical and should be discussed in relation to our bodies; and the critical components of CBT for chronic pain. Dr. Rachel Zoffness is a Health and Pain Psychologist, international speaker, author, and thought-leader in pain medicine. She is an Assistant Clinical Professor at the UCSF School of Medicine, lecturer at Stanford, pain education faculty at Dartmouth-Hitchcock, and a 2021 Mayday Fellow. Dr. Zoffness was trained at Brown, Columbia, NYU, UCSD, and Mt. Sinai Hospital. Dr. Rachel Zoffness | ► Website | https://www.zoffness.com/ ► Twitter |  https://twitter.com/DrZoffness ► Instagram | https://www.instagram.com/therealdoczoff ► The Pain Management Workbook: https://amzn.to/3my4L5C Where you can find us: | Seize The Moment Podcast | ► Facebook | https://www.facebook.com/SeizeTheMoment ► Twitter | https://twitter.com/seize_podcast  ► Instagram | https://www.instagram.com/seizethemoment ► TikTok | https://www.tiktok.com/@seizethemomentpodcast

We notice it in our lower backs, our hips, our necks and then there's that headache. Pain. It hurts. It aches. It pinches. All of it matters! September is Pain Awareness Month so Jenn dedicates this episode to those suffering from pain and those who know someone who suffers. Covering why typical treatments for pain are challenged and what to do instead, the focus is a multidisciplinary approach that's biopsychosocial, just like the pain itself. To top it off, Jenn discusses the Placebo Effect and how it actually holds incredible promise. Listen now to help us end the stigma of pain and move us all forward in healing.Outline:Welcome back & welcome back, ChristineIntro today's topicSources for today's conversation & resources for youDr. Rachel ZoffnessKaiser PermanenteUS Pain FoundationCurableUnderstanding pain & the challenges in treating itWho experience itThe causesThe consequencesChronic vs acute painOur doctors, stigmaWhat's happening now with pain treatment researchBiopsychosocialPhantom limb pain, butterflies in your stomachCommonalities between pain-related diagnoses…traumaThe biology of why this is the caseACEs (Adverse Childhood Experiences)Trauma, triggersCentral SensitizationThe vicious cycle of painHow opioids workPart of healing is desensitizing the brainUndo the stigma, undo the separation of mind & bodyAddress all 3 pieces of biopsychosocialThe way out is through, with measured, monitored exposuresCBT & biofeedbackStress reduction techniques, nutrition, exercise & activity, sleep, communityParts of the brain involved & which parts leadPain as a volume dialTurn Up: Fight or flight, negative emotions, focusTurn Down: Laughing, positive emotions, distraction/focusThe need for habits & routines, motivationDetangling the back of the brain/middle of the brainActivating the front of the brainMeditation, source code meditationVagus nerve toningIdentifying & expressing emotions vs keeping them insideTea KettlingWho we surround ourselves with & the therapeutic allianceMood & thoughtsSerotonin in the gutStomach aches connected to moodVagus nerveWhy we can't think our way out of this things FIRSTYour ANTS (automatic negative thoughts)The social piece of asking for others' perspectivePlacebo effectPutting it all together: Miriam Jacobson's story as published in Huffington Post on September 10, 2021Final thoughtsCurableUS Pain FoundationDr. Rachel ZoffnessWe want to hear about your  pain – https://bit.ly/step1anodunosLinks:Become a MemberConnect with us! FB Page & Private FB Group & Jenn's InstagramTake the free Weight Loss Profile, Jenn will send you a Menu PlanTell Us About Your PainQuotes:"'Pain is a ubiquitous human phenomenon…we all deserve to understand it.'" – Jenn Trepeck"50 million Americans endure pain every day." – Jenn Trepeck"When doctors can't see anything on a scan or x-ray they say ‘It's all in your head,' and I find it SO dismissive." – Jenn Trepeck"All health, including pain, is biopsychosocial." – Jenn Trepeck"One commonality between pain-related diagnoses is trauma." – Jenn Trepeck"Pain counts! Even if it's not crippling you or sending you to the ER, it counts." – Jenn Trepeck"The way out of pain is through it and addressing all three elements of biopsychosocial." – Jenn Trepeck"Cursing helps us release stress." – Jenn Trepeck“Notice your ANTS, your Automatic Negative Thoughts.”– Jenn Trepeck“We can reclaim control of our health and healing.” – Jenn Trepeck

In this episode, Co-President of the American Association of Pain Psychology, Dr. Rachel Zoffness, talks about treating chronic pain. Today, Rachel talks about the failed biomedical model, pain neuroscience, and effective non-pharmaceutical pain treatments. When is the right time to refer someone to a pain coach? What are some multidisciplinary approaches to pain management? Hear about the biopsychosocial nature of pain, how pain treatment in the US is actually about money, how thoughts and emotions affect pain, and The Pain Management Workbook, all on today's episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways “What science tells us is pain is not purely biomedical. It's actually this different and more complex thing, which is biopsychosocial.” “Pain is complex, and doing one single thing over years and years that has not worked, is probably not the right way to go.” “Pain is never purely physical. It's always also emotional.” “Unless we're taking care of our thoughts and emotions, we're actually not really treating this thing we call pain effectively.” “If it's okay to go to soccer coach to get better at playing soccer, it is surely okay to go to a pain coach to get better at living with chronic pain.” “96% of medical schools in the US and Canada have zero dedicated compulsory pain education.” “Pain, by definition, is a subjective experience.” “Keep doing exactly what you're doing and follow your gut. Trust your intuition, and know that following the path of the thing that you love is the thing that's going to bring you to where you need to be professionally.”   More about Rachel Zoffness Dr. Rachel Zoffness is a pain psychologist and an Assistant Clinical Professor at the UCSF School of Medicine, where she teaches pain education for medical residents. She serves as pain education faculty at Dartmouth and completed a visiting professorship at Stanford University. Dr. Zoffness is the Co-President of the American Association of Pain Psychology, and serves on the board of the Society of Pediatric Pain Medicine. She is the author of The Pain Management Workbook, an integrative, evidence-based treatment protocol for adults living with chronic pain; and The Chronic Pain and Illness Workbook for Teens, the first pain workbook for youth. She also writes the Psychology Today column “Pain, Explained.” Dr. Zoffness is a 2021 Mayday Fellow and consults on the development of integrative pain programs around the world. She was trained at Brown University, Columbia University, UCSD, SDSU, NYU, and St. Luke's-Mt. Sinai Hospital.   Suggested Keywords Pain, Psychosocial, Emotional, Physical, Neuroscience, Treatment, Thoughts, Management, Healthy, Wealthy, Smart, Coach, Physiotherapy, Healing,   Dr. Zoffness Latest Podcast: Healing Our Pain Pandemic Dr. Zoffness's Book: The Pain Management Workbook   To learn more, follow Rachel at: Website:          https://www.zoffness.com Twitter:            Dr. Zoffness Instagram:       @therealdoczoff LinkedIn:         Rachel Zoffness   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:                https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the full transcript here:  00:00 Okay, so whenever so I, you will know when we're recording because like I said, I'll do like I'll do a quick clap. And then I'll just say, hey, doctor's office. Welcome to the podcast and off we go. Okay, ready? Perfect. Okay. Hi, Dr. softness. Welcome to the podcast, I am excited to have you on today to talk about chronic pain and treating patients with chronic pain. So this is a real treat. So thanks for coming on. I think you are very cool. Karen Litzy. And I'm excited to be here. Excellent. So what I what we're going to talk about today, just so the listeners knows, we're going to talk about kind of treating chronic pain from a bio psychosocial standpoint versus a biomedical standpoint. So I know a lot of people have no idea what those terms mean. So doctor's office, would you mind filling in the listeners as to what a biomedical model is and what a bio psychosocial model is? to kind of set the tone for the rest of the podcast?   01:10 I totally Can I talk about this all the time, because it makes me so mad. Okay. So the biomedical model is the one that we all know the best, because it's the way we've been treating pain for many decades. And the biomedical model of treating pain and health in general, is essentially viewing and understanding and treating pain as a problem that is purely the result of bio biological or biomedical processes like tissue damage and system dysfunction, and on anatomical issues, and then throwing pills and procedures at it. That is how we've been treating pain for many decades. And of course, we know it isn't working, we have an opioid epidemic, the opioid epidemic is getting worse during the COVID pandemic. People are really suffering, chronic pain is on the rise. It's not being cured. It's not magically disappearing. incidence isn't even decreasing. So the way we're doing it is broken, and also very expensive for people living with pain. However, what science tells us is that pain is not purely biomedical. It has never been purely biomedical. It's actually this different and more complex thing, which surprises nobody, which is bio psychosocial, which is a big and complicated word, but makes intuitive sense, once we start talking about it, I think to people who have experienced pain, which means that yes, of course there are biological processes at work when we're living with pain, acute and chronic. And I can say what those mean to short term pain versus long term pain, longer term pain.   03:02 Yes, and there are also many other processes that work too. So if you imagine this Venn diagram of three overlapping bubbles, which I draw a lot, but I cannot draw right now, we've got the biological or the biomedical bubble on the top. And then we've got the psychological bubble. And that's the one that I struggle to explain to people the most, because I think there's so much stigma around this idea that cognitive and psychological processes might be involved in this experience we call pain because there's so much shame and embarrassment and stigma around anything to do with psychology, which is so unfortunate. But in this psychology bubble of pain, there's a lot of stuff that I think people know intuitively can amplify or reduce pain. So there's thoughts about your body and about your pain and just thoughts you're having about life in general. There's emotions, like stress and anxiety and depression, even suicidality. And we know that negative emotions amplify pain. And we know that positive emotions can sort of turn pain volume down, there's memories of past pain experiences. And those are stored in a part of your brain called the hippocampus. And we know research shows that memories of past pain experiences can change your current experience of pain. And also in the psychology bubble, we've got coping behaviors. So that's quite literally how you deal with the pain you have. And a lot of us who have lived with pain, and that does include me engage in a lot of coping behaviors that make sense in the moment. But actually, they can make pain feel worse over time. And a great example of that is the resting indefinitely plan or the doing nothing plan, as I like to call it which is totally, you know, normal and natural for those of us who pay into Engage in because when your body is telling you, you know that you're hurting, it's understandable that the thing you think you're supposed to do is stop all activity. But ultimately, what we know about that particular coping behavior is that it makes chronic pain in particular worse over time. So the do nothing plan or the stay home or rest indefinitely plan is a coping behavior that lives in the psychology bubble that can actually make pain feel worse. And of course, there's coping behaviors that can make pain feel less bad, like the counterintuitive things like leaving your house and seeing people and walking and getting out into the sunshine. And, you know, these things that we don't necessarily know can help pain. And then the third, overlapping bubble, and our bio, psychosocial Venn diagram, is the social or the sociological domain of pain. And that's what I like to call the everything else bubble. So it's socio economic status. And family and friends have culture and race and ethnicity and access to care, and socio economic status, and history of trauma and early adverse childhood experiences, and culture, and context. And environment, like quite literally, everything else your environment, believe it not changes the pain you feel. And in the middle of those three things, and I know that's a lot of things, is pain. So when we try and pretend that pain is just this simple biomedical thing, the treatments don't work. And I think all of us who have lived with pain know that our pain is much more complicated and sticky. I know that was a lot of words.   06:44 No, and, and I'm glad that you described everything in the way that you did, because I think that gives the listeners a really good idea of what's in each of those bubbles. Number one, and number two, how complex pain actually is. Exactly, it's not. So if I think if the listeners take away anything from this conversation, if pain is complex, and doing one single thing repeatedly over years, and years and years and years, that has not worked, it's probably not the right way to go.   07:15 That's right. And you know, the other misconception that we all understandably have is that, you know, the way to treat pain is just by going to your physician. And, of course, that makes perfect sense. But we have this misconception in western medicine, that either you have physical pain, and you see a physician, or you have emotional pain, and you go to a therapist, or a psychologist, someone like me, and the really fascinating thing about pain, and the reason I love studying it, and treating it and talking about it so much is that neuroscience tells us that pain is never purely physical, it's always also emotional, because the part of your brain called the limbic system actually processes pain 100% of the time. So pain is always both physical and emotional. But most people don't know that most people have never been told that. But the limbic system plays a huge role in the experience of pain. And we know that, you know, emotions are always changing pain volume all the time. So this idea that pain is either physical or emotional, is not actually a thing, you know, and the way we treat pain by going to a physician exclusively is not actually nine times out of 10, probably more than that going to actually, you know, be the answer for any sort of chronic pain problem.   08:37 And so I'm glad that you brought that up that yes, we know emotions play a role in pain. And as a matter of fact, the International Association for the Study of pain, change their definition of pain in 2019, I believe to include that it is an emotional experience. And I think that really set the stage for greater discussion and research, which I think is amazing. But when you say to someone,   09:05 let's see, can I interrupt the flow to say, they did change the definition, but the the word emotion was always in there? Oh, was it? It was? Okay.   09:16 Let me so when we talk about kind of the emotional part of pain, and I have had patients say this to me, which probably meant I was explaining it incorrectly, and I take full responsibility for that. And I'm sure you've heard this before his patients saying, so you're saying it's all in my head. Totally. And how do you react to that?   09:42 Yeah. I love that. You asked that question. I think probably the worst thing about being a pain psychologist is you know, you're the last stop on the train. You're the last person anyone wants to see nobody wants to go to a psychologist or a mental health professional for a physical experience like pain. And I know you can't see me, but I'm putting air quotes around the word physical. Because again, pain is not a purely physical experience. It's physical and emotional. But of course, no one wants to go to a pain psychologist for pain, right? You think you're supposed to go to a physician, and a referral to a psychologist means you must be crazy or mentally ill or the pain is on your head. And no, that's not what it means at all. And I find that the way that I most effectively target that is by explaining, believe it or not pain neuroscience. And I, I usually do that in the simplest way, I know how just by distilling down that, that, you know, it's easy to believe that pain is something that lives exclusively in the body, right? Like, if you have back pain, it's so easy to believe that that pain lives exclusively in your back. But what we know and what neuroscience has taught us is that actually, it's your brain working in concert with your body that's constructing this experience we call pain. And we know that because of this condition called phantom limb pain, wherein, you know, someone will lose a limb like an arm or a leg and will continue to feel terrible pain in the missing body part. And if pain lived exclusively in the body, no limb should mean no pain. So if you the fact that you can continue to have terrible leg pain, when you have no leg tells us that pain can't possibly live exclusively in the body. And I find that when I explain this to the patients who come see me, first of all, there's more buy in that the role of the brain in pain is really significant. And second of all, it sort of gives me some leverage to then explain that, again, one of the parts of the brain. And one of the most influential, influential parts of the brain that processes pain is your limbic system, which is your brain's emotion center. So unless we're taking care of your thoughts and emotions, we're actually not really treating this thing we call pain effectively, we're just treating one small component of it. So that's, you know, and I also always, by the way, validate that, of course, you have, you know, of course, it feels like someone's saying that the pain is on your head, or that it's a psychological problem. Because of this, again, this like false and ridiculous divide we have in western medicine between physical pain and emotional pain, when neuroscience has known for decades that that's not actually a real distinction, like your head is connected to your body 100% of the time, you know?   12:24 Yeah, absolutely. And as let's say, as a practitioner who's not a pain psychologist, a physical therapist, occupational therapist, maybe your yoga Pilates, and you are working with someone with persistent pain? How, how can we encourage our patients or recommend to our patients, that, hey, you might really benefit from seeing a pain psychologist, without them thinking that we're telling them they're crazy? Yeah.   12:57 I do think that taking 30 seconds, or maybe even 60, to explain, you know, this basic painter science thing. And the phantom limb thing is a really, really effective strategy. So anybody can use that. That piece of information. You don't have to be a pain psychologist. So that's thing one is just like taking a few moments to talk about how pain works in the brain. I think patients are so grateful to learn that no one's ever told them this before you're going to be the first person to ever let them know. And then the other thing that I always do is a trick that I learned from a really nerdy journal article I read years ago by a guy named Scott powers. And he said that one trick that we can use is to call pain psychologists or you know, therapists who are trained in things like cognitive behavioral therapy for pain, pain coaches, and I love that. So I usually tell physicians and other allied health professionals to refer to me as a pain coach. And the way I pitch that to families and tell other health care providers to pitch it to their patients is to say, if it's okay to go to a soccer coach, to get better at playing soccer, it is surely okay to go to a pain coach to get better at living with chronic pain. Because living with pain is so hard. And you deserve support. You know, and usually that removes the stigma and the stigma, especially when you present that in conjunction with some science that supports the role of the brain and the role of cognitions and the read the role of emotions and coping behaviors. In the experience of pain, I find that that really is super effective.   14:41 Yeah, that's really helpful and a great way to frame how to frame that recommendation to someone coming from someone like me coming from a PT because people often come to physical therapists I mean, it's in the name Because they want us to heal or to fix their physical problem, which in this case is persistent pain or chronic pain. And so then that leads me to my next question is, as a physical therapist or as someone who's working with the body, when do we refer this person to a pain coach or pain psychologist?   15:25 I'm curious to know what you're going to think of my answer. Ready? Here's my answer. I once had a friend who said to me, man, like, everyone's always going around talking about how many miles they ran today. And you know, how you like the Strava app, like, you know, how many miles they biked? And how many hours they did yoga this week? And can you imagine what it would be like if everybody, you know, came, came to each other and started bragging about how many hours they spent working on their shit? Like, what I spent three hours working on my anxiety today, or like my family stuff? Or like, my complicated relationship is, like, just why do we prioritize working on the body over working on our minds? You know, it's so strange. So my honest answer is if you're ever treating a patient who's living with chronic pain, and again, that's pain that's lasted three or more months, I think it's worth a referral to a pain psychologist or therapist who's trained in cognitive behavioral therapy. I just, I can't imagine any human being who wouldn't benefit from the opportunity to navigate the complicated experience that is living with pain and having someone in the role of support and coping behavior coach is just, you know, and partner and in processing, the experience of it just just seems to me like such a great gift to be able to give to patients.   16:51 And my answer to how I react to it is I agree. And, and again, this takes into a takes into account really this multi discipline, multi disciplinary approach to pain and approach to pain treatments and management. And so in your opinion, what makes that multidisciplinary approach effective for that patient?   17:20 I mean, what the research shows is that trying to approach and treat pain from just one angle is usually not sufficient, because as we were saying at the beginning, pain is such a complex, bio psychosocial thing. So if we're just looking at the biomedical components, we're not really doing our job, if we're just looking at the psychosocial components, we're not really doing our job. So, you know, a multidisciplinary team as a team made up of, you know, psychologists and pts, and OTS and physicians and nurses and biofeedback providers, and all these different people who are sort of coming at this complicated things from maybe slightly different angles and perspectives. And when we do that, what the research shows is, we have the most robust outcomes, the care is most effective, and the most comprehensive, and people walk away with a whole tool belt of tools to use when treating their pain, you know, across scenarios and across symptoms. So multi disciplinary is really like, how can we all come together as a team with our unique backgrounds and our unique training because, you know, as you know, trainings, especially in the United States, the disciplines are also siloed. You know, like, psychologists are trained in this one way, and pts are doing this thing over here. And OTS are over there. And anesthesiologists are over there as physiatrist. Or, I mean, it's just it's so fractured. So a multidisciplinary team is hopefully working together to target this complex animal that we call chronic pain. And what's really interesting is, you know, I have a private practice, where I see a lot of patients with chronic pain. But I feel like the bulk of my work sometimes is coordinating care with this really complicated treatment team. And I'm seeing a really complicated patient right now who has crps complex regional pain syndrome, which is a really tricky, chronic pain syndrome. And, you know, the way that we his case has been so complicated. It's been many years of treatment. And I think today as a team, we finally decided upon a treatment plan. And it really wasn't until we all were talking that that came together and jelled. So I think that's one of the most important components of treatment actually.   19:38 Yeah, I, I agree. And and when you're in private practice, like you said, sometimes it can be a little bit more difficult, but the more communication you have with people on that team, again, we're doing all of this for the person in the center and that's the patient and so being being able to provide vied so much coordinated care for that patient. Like you said, the research has shown that this is that this works versus a piecemeal, one person's doing this over here. And someone's doing this over here, and they're hearing, and then the patient's hearing contradictory treatment plans. And so it gets really confusing.   20:21 Yeah, it gets super confusing when there's, it's almost like too many cooks in the kitchen, if you're not working together, because they're getting all this different advice from all these different people. And oftentimes, and I'm sure you've seen this, too, they're on, you know, 40, they've tried 40 different medications by the time they've gotten to you. And, you know, I mean, I think what it leads to is like, this treatment, burnout, where like, our patients are just so burned out on all the treatments they've tried, and they have this sense of hopelessness, like, nothing's gonna work. Nothing's working. So far. I've tried all these things. I've seen 40,000 million doctors, and, you know, I've, yeah, I've tried herbs. And yeah,   20:58 I've heard that from people like, they're like, I don't want to go to one like I'm all doctored out, if I have to go see one more doctor, or take one more medication, or do one more procedure, or one more scan, like I'm done. I don't want to do this anymore. Yeah. And I blame them. Yeah, it's exhausting. It's totally exhausting. And you know, we've been talking about things that don't work. Right. So we talked about all that being on medication after medication, opioids, we know these, they don't work for people with chronic pain. So let's talk about non pharmacological treatments. And what does work or what can work for people with chronic pain, so I'll throw it over to you.   21:44 Yeah, so non pharmacological treatments, there's like a whole host of them, there's a wide range of them. And there's a lot of literature on a bunch of different things. So what I use the most in my practice, because I really love it and have found it to be so effective is cognitive behavioral therapy, or CBT, which is different by the way than CB, cb, D, that's something different CBT cognitive behavioral therapy. And an arm off of that is a treatment called Act, which is acceptance and Commitment Therapy, which is become very big in the PT world, which by the way, originated from CBT, and was adapted for pain. There, there's also Mindfulness Based Stress Reduction, or mbsr, which has a huge literature base for the treatment of chronic pain. And there's other things too, like biofeedback, I happen to really love as a treatment for pain. And there's a whole host of other things, too. But, yeah, God,   22:43 I was gonna say, could you explain briefly what biofeedback is so that people understand what that is? Exactly.   22:50 I'm so glad you asked. I've been doing this for so long that I forget. I just forget that. Certain things are not known entities. But I also did not know what biofeedback was when I first started treating chronic pain. And so I'll someone said to me, oh, you're treating patients with pain, you should refer them to biofeedback. And I said, You know, I don't refer my patients to things that I don't understand. So I did a buttload, of reading about biofeedback for pain, and I got a bunch of books. And then I found myself a biofeedback provider. And I went to this gentleman, his name is Dr. Eric pepper. Dr. Pepper is just a great name for any doctor. And He is a professor at the University of San Francisco and I admired him right away, he was obviously very smart. And he sat me down in a chair. And he hooked me up to this machine. And he said, This machine is going to read a bunch of your biological outputs, it's going to read muscle tension, galvanic skin response, your finger temperature, and a bunch of other things, your heart rate. And I was like, what that's really interesting. And he showed me which monitor was, you know, giving me feedback about which thing and hopefully you're picking up on the fact that there's biological processes that you're getting feedback about? And he said, and now I'm going to teach you to raise your finger temperature to 90 degrees, using your mind. And I said, Excuse me, sir. I am a scientist. And I do not believe in Voodoo. And he said, Well, how about you just try it out and see how it goes. So he did a couple of techniques with me had me close my eyes, he did some relaxation strategies, and diaphragmatic breathing, and he used imagery of like hot soup and hot air flowing down my arms from my shoulders into my fingertips, and autogenic training and autogenic phrases and that's when you say things to yourself that are suggestive like my arms are heavy and warm. My hands are heavy and warm. And as I was doing, as I was doing all these things, I noticed, because the machines were giving me feedback about my biology, that my hand temperature was going up. And within two sessions, I was able to warm my hands using my mind. And I am a person with chronically cold hands, because I'm stressed out all the time. And no one had ever told me that cold hands and feet, by the way, are a sign that you are stressed out. So I can now warm my hands on command, which is absolute magic. And when I teach it to my patients, they oftentimes say things like, Oh my god, I can make fireballs with my hands with my mind, what else can I do? And that's exactly what we want. For people living with pain, this idea that the mind and body are connected 100% of the time, and that you have more agency and control over your body than you thought you did. And you can make changes to formerly unconscious biological processes like skin temperature and muscle tension and pain. And biofeedback teaches you some skills to do that. Which is why I really like it so much.   26:13 Yeah, it sounds so like sci fi doctor who kind of stuff. Dr. Pepper. Exactly. Yeah, right. Exactly. Right. But yeah, it just sounds like Wait, what? But yes, I mean, I've never I have not done biofeedback myself, but it is something that I'm just constantly interested in for the exact reasons that you just said, like, Whoa, I can control what my body does. This is pretty cool.   26:41 It's worth it, I highly recommend it. It is so worth it. It's it makes you feel like, you know, it's this sense of like, if you almost feel like the Incredible Hulk like gotta have all this untapped power and potential that I just didn't even know about.   26:55 Yeah, it's, it's wild. Thank you for giving us that kind of definition of biofeedback, because I guarantee a lot of people who are listening did not know that at all. I didn't either, I totally didn't either. Very, very cool. So now, all of this, these non pharmacological treatments, CBT, a CT, biofeedback, we can maybe put physical therapy, occupational therapy into that as well. I mean, obviously, all of these things, cost the system money cost the patient money. But let's talk about the money aspect of treating pain, especially here in the United States. So what, you know, when people think about treat treatment of chronic pain, they often don't think about the money involved. So I will throw it over to you to kind of elaborate on that, and what does what that means for the patient and for the system.   27:52 You're actually making me realize that when you asked me about non farm approaches, I of course, immediately went to like, you know, like psychological treatments for pain. But yeah, of course, you're right, PT, OT, all these things, of course, are all the things and approaches. Yeah, absolutely. So yeah, it was a really sad day for me, when I realized that the treatment of pain historically has actually been about money. That was a really sad wake up call for me. So I used to be a member of this organization called the American pain society, it was very well established, very well known organization. And they went belly up after it came out. And I don't know if this is proven or not. But I should say, after they were accused of taking money from Big Pharma, to promote the use of opioids for the treatment of pain, despite the fact that it was known that opioids a were highly addictive, and habit forming and B sensitize the brain to pain over time and are therefore not actually effective. Because if you go off of them, as most people who have tried this, no, pain feels worse, your brain is actually more sensitive to pain. And so they went belly up, and they were, and then I read this book that was formative for me, by Anna Lemke. Le MBKE, who is now a friend of mine, called drug dealer, MD, drug dealer, MD, a very controversial and very compelling title. It is a thin, little book, I think it came out in 2016. If I'm not mistaken, I read it. Or I should say, I consumed it in a couple of hours. And I am not someone who writes in books. But I must have written on every page of this book. You must be joking. Oh Mfg. Like curse words and exclamation points. Because essentially, it's the story of how pain medicine has been about earning a buck off of people who are suffering and as we all know, with these lawsuits that are now how Like with the Sackler family and a lot of and also big pharma, you know, what we're learning is that despite the fact that these people and these companies have known for many, many years that opioids are highly addictive, highly habit forming not actually effective over time. And, you know, especially in high doses. Yeah, it's sort of this story of like, you know, follow the money. It's sort of horrifying. So, you know, I also have had conversations with physician colleagues who say things to me, it's a true story that, you know, it's clear that pain psychology plays a huge role in pain and pain management, and would be hugely helpful as with all of these psychosocial treatments, but that a lot of the times because insurance doesn't reimburse these treatments, they either don't get recommended, or they don't get integrated into pain management programs, even at hospitals sometimes, because insurance reimbursement is so crappy, which is just like another eye opening moment like we wait. So you're saying that, you know, these things work? You say that, you know, they're effective, but we're not recommending them and we're not hiring pain psychologists, because insurance doesn't reimburse. So again, it's a money thing. What? So the effective treatments are out there, they're known entities. But, you know, big pharma has billions of dollars to, you know, promote this idea that pain is a purely biomedical problem that requires a purely biomedical solution. So as long as you believe that you're going to buy into that model, and you know, as long as insurance companies are not reimbursing non farm approaches to pain, then you know, we're going to say stay stuck in this loop of treating pain, like a biomedical problem when we know it's a bio psychosocial one. So it's really complicated. Just this discovery that pain medicine has historically really been about the dollar. And it's sort of nauseating and horrifying.   31:56 Well, I mean, I think you can take away pain from that and just say medicine.   32:00 Yeah. Insert health condition here.   32:03 Yeah, yeah, I think it doesn't matter what it is, right? Because it's always going to come back to following the money and where, where can you get the biggest bang for your buck? And unfortunately, that, like you said, Those non pharmacological treatments are oftentimes not covered. So you're getting zero bang for your buck. So as a business, which a hospital is, even if it's not for profit, or an outpatient clinic, are you going to do things you're not going to get reimbursed for? Right, you know,   32:35 no, you know, that's true. And like, I don't mean to sound on empathic. Like, of course, yes, hospitals are businesses, and they have to stay open, and they have to earn money. So so the question for me, like, as I roll along, in this world of this totally insane world of pain medicine, and build my own business, by the way, like, how do we change the system? Like, yeah, we really are patient, patient centric, and like our goal, actually, at the end of the day, is to help our patients get well, what needs to change first, like, does public perception and understanding of pain need to change first? Like, do we need to be training our healthcare providers across disciplines better, like in PT, school, and in OT, school, and in psychology programs like mine, where By the way, I was in school for 40 100 years, and I got zero training and pain, like in my undergrad, brown neuroscience class, we learned about pain, and I became obsessed, and then like, wrote papers and stuff, but but that was it, like not, I have two master's degrees never learned about pain. At no point in my PhD program, did we get training and pain? So? So like, do we need to go, you know, backwards and insert pain education programs in medical schools? Yeah, I know, I know, you and I have talked about this, like the statistic that I'm obsessed with, like 96% of medical schools, in the united in the United States and Canada have zero dedicated compulsory pain education. So it's like, where do we start with this problem, isn't it? Do we like go after the insurance companies and reimbursement rates? where like, where the it's the system is so broken, I sometimes get discouraged, like, where do we start? But I think I actually think what you're doing is a really great place to start, like educating healthcare providers, and the general public about pain, and getting enough people riled up and angry about the way pain has been mistreated, and the way we're Miss educating our health care providers are just not even bothering. Maybe that's the place to start. Like maybe if there's enough of a clamor, and enough people are pissed off about it. Something will change.   34:38 Yeah. And and I agree, I think education, education, education, it has to start there. And especially in medicine, in medical school, especially with the physicians who are oftentimes they are the frontline providers, right, your your regular, your local PCP, primary care physician is often your frontline person and But they're also the people who were traditionally prescribing opioids for everyone, when they would come in with back pain instead of saying, Hmm, maybe maybe you need to see a physical therapist or a pain psychologist, let's sit down and talk to you. How can we let's find out what your needs are, what your bio psychosocial needs are. And so I think if, as the practitioner if you're not getting any education in that you don't know what you don't know. So you're not going to do it. And then I agree, I think, and I think insurance companies need to reimburse doctors and therapists across the board to talk to their patients. Talking doesn't get reimbursed procedures get reimbursed. Right. Right. What's the most important part of diagnosis when you're with a patient? talking to them, understanding what's going on with them, like that is paramount, and that needs to be reimbursed. But insurance companies won't do that they won't reimburse you for talking with your patient. Especially if you're like a PT, we get reimbursed by codes. And and none of those codes are, I'm going to really sit down and try and get into the nuts and bolts of what my patient's problem is. So   36:20 yeah, we need to code for pain, education, community, healthcare provider to patient.   36:25 Yeah, yeah. And some people say, Oh, you could use like the neuromuscular, neuromuscular treatment code for that. But there should be a code for let's talk to our patients, there should be a code for the subjective exam. Yep. Yeah. Oh, yeah. Because how were you supposed to learn about their bio psycho social situation, if you can't talk to them? And ask those probing questions, ask those open ended questions, like you said, In the beginning, bio, psychosocial, a lot of things go into that bucket. And we as the practitioners need to learn as much as we can about all those things that go into that bucket, if we're going to treat this patient efficiently.   37:10 There's so many things in the bucket. And I think, when we assess issues that have to do with pain, we really are assessing the biomedical bucket like 99% of the time. And, you know, if we really are thinking about this as this Venn diagram with three bubbles, if you're only assessing or looking at the biological domain of pain, you're literally missing two thirds of the pain problem. It's just wild to think about it that way. Yeah, if not more? Yeah, yeah, exactly more right now. So like, maybe all of us should be assessing for history of trauma. And maybe all of us should be assessing for aces, the adverse childhood experiences, which we know there's like this slew of studies that show that aces impact, you know, the development of chronic pain and illness and adults, maybe we should all be assessing for, you know, abuse and, you know, poor access to care. And just like so many things that we need to assess for if we're actually going to, you know, do a workup of pain, and instead of just this, you know, tell me about your anatomical issues. And let me do some scans.   38:14 Right, right, on a scale of zero to 10. How would your pain? Oh, it's a 10 out of 10? Well, this is like my little soapbox is what I hate. I see this a lot in physical therapy, student Facebook groups, things like that. Yep. And you know where I'm going with this? They'll say, Oh, well, if someone comes to me, and they're 10, out of 10, I'm going to call the ambulance because they must need to be in the emergency room. Poor education, that therapist was not educated on pain. No, I've not. No, that's wild. Yeah, I hear this all the time. Or those similar Sam 10 out of 10. It's a really, because if like I chopped your hand off, that would be 10 out of 10. So what's your pain now?   38:57 Right? Like this? Right? This lack of awareness that pain, by definition is a subjective human experience. And whatever your patient says it is, that is what it is. And you you actually don't get to argue with them about it. You don't negotiate down someone's pain. Right. And I mean, I think what I've learned over time about pain is there's really valuable clinical information when your patient tells you, like I hear a lot of times like 11 out of 10 literally what your patient is communicating to you is I can't handle this anymore. It's beyond my capacity to cope with this level of suffering. That is what they're saying to you. And usually also, at least for me as someone who really, really likes and appreciates the pain catastrophizing scale, the PCs, which is a potentially controversial term, some people don't like the term catastrophizing, I happen to appreciate it. I think it's very valuable, but don't want to go down that rabbit hole. But the pain catastrophizing scale, but they're also telling me is that when people tell me their pains, Out of 10 or an 11 out of 10, there's a high likelihood that their thoughts around their pain are very intense and catastrophic, and that they're having very intense emotions around their pain too. So it's good clinical information. You know, like you said, You can't bargain with someone about their pain number. Yes, we don't pain haggle. Right. Right. It's not like being at the market. No, like a price price that you get on fish. But but there's rich clinical information in there, if you're willing to, like, Listen for it, they're telling me that they're having an emotional experience that's beyond their ability to   40:37 navigate. Right to cope. And, and that's where I think like, I'll ask that question to all of my patients, because for me, that's my window to crawl in, and really get down to maybe the psycho or the social part of their pain experience. So like you said, if someone says to me, oh, my pain is like, it's at 12 out of 10. Today, and I'll say, Okay, well, can you tell me a little bit more about that? You know, what are you? What are you? What are your feelings around that? Or what's going on at home? What are your responsibilities at home? How does, you know? How does that play into why this pain is? 12? out of 10? Today, right? Right, you know, so it is, like, I always ask the question, but it's a nice way to kind of get in and be able to ask more questions. And, and just because someone says their pain is 12 out of 10, it doesn't mean you call the ambulance, they shouldn't be in the emergency room, they probably worked all day have to go home and have two kids to take care of. Yeah. And they're doing all of this at a 12 out of 10. because like you said, they've reached the end of their way to the ladder. And our job as clinicians is to increase their capacity to handle that. And how and to do that, like you said before, through a multidisciplinary approach to pain management is really the way to go. Because now you have more people who can add to that capacity. Yep. So anyway, that's my soapbox. I will come down stepping down from the soapbox. I appreciate your soapbox. I think Kevin, I'm Sherif share box, but it drives me crazy. Okay, so we talked a lot about different treatments. And I want to talk about treatment that you have created the pain management workbook. So let's talk about that. And how this book that you wrote, can help people who are experiencing pain.   42:40 One of the nicest emails I got in the last couple of weeks was from someone named Karen Litzy, who responded to my email and said that she really liked the pain management workbook and was referring to her patients. And I happen to admire Karen Litzy. So I was really flattered by that. So so the pain management workbook isn't on its own, like some new fangled treatment plan. But rather, I got really frustrated by what I felt like was a lack of resources out there for people living with pain, and also for healthcare providers. In particular, you know, I am a nerd, like a real nerd. And I think pain is just so interesting, and complex and fascinating that I have like, amassed all of these books and journal articles and, you know, resources. But I felt like there really wasn't something that synthesized it in language that all of us can understand and easily give to our patients. So I took a lot of stuff that I loved and was reading, like there's a book called pain, the science of suffering, that I happen to really love. And there's all this work by Lorimer, Moseley, and Adrian low in the PT world, I happen to really love the way I love the language they use for explaining pain. And there's all this neuroscience literature out there that I think is so fascinating and so useful, like melzack, and walls, gate control, theory of pain, and all the things that have evolved from there. You know, and there's all these workbooks on cognitive behavioral therapy for pain, but I couldn't find something that, in my mind, put together all of it into one resource that, you know, anybody with pain can pick up and use right away and use have exercises and guided audio and handouts and all that stuff. So So I wanted to create something that was very user friendly, and I felt like especially during COVID, having accessible and affordable resources could not be more important because here we are talking about how pain at the end of the day is often about money and care is so expensive, and you know, cognitive behavioral therapy and these other things that are not easily or readily reimbursed, end up costing families and patients, sometimes many 1000s of dollars and it should Then be that way. So I literally took everything I was doing in my practice, and everything I was reading and stuck it in a workbook. So it's a lot of pain education. And I have to say, you know, a big thanks to Lorimer Moseley, and Adrian Lowe, who both of them were kind enough to agree to read through my pain education content and give me feedback and consultations and edits, which was like, so kind, and they didn't even charge me anything. And I offered to pay them both. And I wish they had taken my money. But yeah, I wanted them to vet the content. So there's this pain education piece, and then it's a series of chapters of tools. So, you know, again, affordable, accessible care isn't just, by the way, here's how pain works. It's now what can I do about it? So I wanted to make sure that I was offering, like a tool belt of options for healthcare providers to offer their patients like here are 17 different pain management strategies that have evidence of effectiveness that come straight out of the literature, you know, pick a few that work for you, whether it's mindfulness or using guided imagery, or, you know, cognitive strategies, or, you know, sleep hygiene and nutritional tips, like, how do we put this all together to create a unique pain management plan for each one of our unique patients who walk through our door with a unique profile of suffering. So that's how that happened. And I should also say that the book almost did not happen, because my deadline was in 2020, which, as everyone knows, was a shit show of the year. My, my bandwidth was zero, I would sit down to edit, you know, my lovely publishers would send me a couple of chapters, and they'd say, here are some edits, go ahead and make some changes. And I like, couldn't even read through the work I had written, I like my brain just was on overdrive. And I was trying to process what it meant that we were in the middle of a global pandemic. And I sent them an email, and I was like, you guys, I don't think I can do it. So the book almost didn't happen. But in December, it was actually shockingly painstakingly born. So I'm more proud of it than anything I've ever done. I don't know if anyone will ever read it. But I, I'm very proud of it. So I hope it's of use to health care providers to people living with pain.   47:21 Yeah, absolutely. And is this only for adults.   47:25 So the pain management workbook I wrote in language that's usable for everybody. I mean, it's not only for adults, it's. So the book I actually wrote first is called the chronic pain and illness workbook for teens. So it has a lot of similar content, but I wrote it for kids, because there just isn't anything out there for kids. And there's even less for health care providers who are working with kids with pain. So this is adapted from that it has like twice as much content, I would say and is expanded content. So the pain management workbook is sort of intended to be for everybody. And the chronic pain and illness workbook for teens is more specifically for kids in the health care providers working with them. But I've been told by people who just have that book that they have used it successfully with adult patients, too. So   48:14 yeah, so excellent. And where can people find all of this and find you if they want to get in touch with you? They have questions. They want the book, they just want to chat, where can they find you.   48:24 So the pain management workbook. And the chronic pain and illness workbook for teens are both on Amazon. And they're like 20 bucks, which is so much less expensive than around of cognitive behavioral therapy. But I do recommend oftentimes to healthcare providers that they offer the book to their patients, and then offer to go through it with them. Because it's just so nice to have a pain coach to be going through a treatment protocol with. But of course, it can be used as a self help book, you know, on your own. I   48:50 just like love that. I   48:51 love the supportive model. So yeah, there are those are on Amazon. And yeah, I have a really dorky website that has a ton of resources on it. It's just my last name. It's softness, calm. And there's a resources page with like, apps and websites and books and podcasts and guided audio and all sorts of stuff for people living with pain and their healthcare providers. And I also joined Twitter during the pandemic, because I don't know, it seemed like social media was where everybody was, and I couldn't see any of my friends and I couldn't go to conferences. I couldn't have conversations with cool people like you. So I joined Twitter and Twitter, my Twitter handle is at doctors office. That's been really interesting and fun. It's been a really interesting platform. That's I think that's actually how I found you. And then I'm also on Instagram where I post some pain education content too. And that's at the real Doc's off, because I couldn't think of a better name and I got really nervous because social media makes me nervous. So   49:49 well, at least now people know where to find you. How to get in touch with you where to get your book. So this is great. This was a great talk. I you know, I could keep going on and on and on too. about this, I could do like a 10 hour podcast, just on on pain alone. Because it's something I'm passionate about. And it's there's just not enough good information out there for people to access. So hopefully people listening to this will then access some of your resources and education, education education right. Now, before we end, I have one last question for you. And that's knowing where you are now in your life. And in your career, what advice would you give to your younger self?   50:33 What advice would I give to my younger self? Oh, wow, you know, the advice I would give to my younger self is keep doing exactly what you're doing and follow your gut. And trust your intuition and know that following the path of the thing that you love is the thing that's going to bring you to the place you need to be professionally. Like, I wanted to live at the intersection of medicine and psychology, and education and science writing. And I couldn't figure out how to do that. So I had all these different jobs. You know, I was like, a science teacher at the Wildlife Conservation Society. And I was a science writer at a Science Magazine, and I worked at the NYU child Study Center, and I got a PhD and I just couldn't, but but I think, you know, organically what happened over time, just from following my passion, my like, actual passion is that I was able to do all these things. So now I have a private practice. And I'm seeing patients, and I'm writing books. And I have a column in Psychology Today called pain explained where I do a lot of science writing about pain, and I'm teaching pain education at Dartmouth, and at UCSF, which I deeply, deeply love because I get to connect with physicians and other health care providers. And, you know, it's just sort of the it is sort of naturally and organically, exactly what I feel like I was called to do you put it out, you put it out into the universe, and it happened. Yeah, I mean, but not without a lot of trial and tribulation. But I think I would just tell my younger self to trust your gut and trust your instinct and you you actually are on the right path. If you're doing something that you love, you are on the right path, even if you don't know   52:09 Excellent advice. Well, Rachel, thank you so much for coming on the podcast and chatting today. I really appreciate it and I appreciate you. So thank you so much. Thank you for having me. Absolutely. And everyone. Thank you so much for listening, have a great couple of days and stay healthy, wealthy and smart.

Cognitive Behavioral Therapy isn’t just a buzzword flying around the chronic pain community, it’s a well-established treatment approach with abundant evidence of effectiveness. That’s why Dr. Rachel Zoffness is on a mission to make it more accessible, cost-effective, and widely used. In this episode, Dr. Zoffness breaks CBT down into simple terms, providing actionable strategies that people in pain can use at home right now. Join us as she advises people in pain AND clinicians on how to harness the power of CBT safely and easily.

Recorded live on Tuesdays at 8pm (UK time) on the Sports Therapy Association Facebook Page and also streamed live to YouTube, host Matt Phillips (creator of Runchatlive) brings guests from the Sports Therapy industry to answer YOUR questions and discuss topics chosen by YOU. In Ep.51 of the Sports Therapy Association Podcast (recorded live the slightly LATER time of 9pm UK), we are absolutely honoured to bring you the inspirational Dr Rachel Zoffness, highly respected pain & health psychologist and author of 'The Pain Management Workbook' - an integrative, evidence-based treatment protocol for adults, and 'The Chronic Pain & Illness Workbook for Teens' - the first pain workbook for youth. Dr. Zoffness, a world-renowned expert on nonpharmacological approaches to pain management, discusses & answers live questions on 'Pain Management', a hugely important topic that drives the need for evolution in the health care we provide. Topics included: Understanding and embracing of the BioPsychoSocial model of pain How to explain pain to patients Metaphors like the 'pain dial' that can be useful in understanding pain Why healthcare still uses such an outdated model of pain The introduction of pain education as part of school curriculum.    It was a fantastic hour that seemed to pass quicker than any other episode! Dr Zoffness' passion and skill at presenting the complex topic of pain left many of the therapists that joined us live in absolute admiration! Be sure to check out Dr. Rachel Zoffness' website including details of up and coming workshops.     Join us next week LIVE for Ep.52 - May 25th 8pm: 'Insurance Special' with guest David Balens of Balens Insurance. Enjoyed the episode? Please take a couple of minutes to leave us a rating & review on Apple Podcasts. It really does make all the difference in helping us reach out to a larger audience. iPhone users you can do this from your phone, Android users you will need to do it from iTunes. All episodes are streamed live to our YouTube channel and remember all soft tissue therapists (non members included) are welcome to join us for the LIVE recording on Tuesdays at 8pm (UK time) on the Sports Therapy Association Facebook Page Questions? Email: matt@thesta.co.uk

Courtney Zoffness's debut, Spilt Milk (McSweeney's, 2021), received starred reviews from Publishers Weekly, Booklist, and BookPage, and was named “most anticipated” or “must-read” book by Good Morning America, LitHub, Refinery29, The Millions, Publishers Weekly, and others. Zoffness won the 2018 Sunday Times Short Story Award, the largest international prize for short fiction, amid entries from 38 countries. Other honors include fellowships from the Center for Fiction and MacDowell, and the Arts & Letters Creative Nonfiction Prize. Her writing has appeared in several outlets, including the New York Times, the Paris Review Daily, and Guernica, and she had essays listed as “notable” in Best American Essays 2018 and 2019. She directs the Creative Writing Program at Drew University, where she's an Assistant Professor of English, and lives with her family in Brooklyn, New York.Without These Books is a thank-you-inspired Video/Podcast. Each episode celebrates authors, books, and characters that changed us as writers, readers, and as people. Listen on Apple, Spotify, or wherever you podcast. Watch on our YouTube channel or at withoutbooks.org.Without Books®, a division of Heritage Future, is an author-centric book initiative. Our resources support authors. We also provide access to millions of books.Courtney Zoffness selected Dept. of Speculation by Jenny Offill for her episode of Without These Books.

Courtney Zoffness is the author of Spilt Milk, a collection of memoirs available now from McSweeney's. It is the official May pick of The Nervous Breakdown Book Club. Zoffness writes fiction and nonfiction. She won the 2018 Sunday Times Short Story Award, the most valuable international prize for short fiction, amid entries from 38 countries. Other honors include an Emerging Writers Fellowship from the Center for Fiction, the Arts & Letters Creative Nonfiction Prize, and two residency fellowships from MacDowell. Her writing has appeared in various outlets, including the Paris Review Daily, the New York Times, The Southern Review, Guernica, and the Los Angeles Review of Books, and she had “notable” essays in Best American Essays 2018 & 2019. Zoffness holds graduate degrees from Johns Hopkins University and the University of Arizona, and a B.A. from the University of Pennsylvania. She directs the Creative Writing Program at Drew University and is a faculty member at Writing Workshops in Greece. She lives with her family in Brooklyn, New York. *** Otherppl with Brad Listi is a weekly literary podcast featuring in-depth interviews with today's leading writers. Launched in 2011. Books. Literature. Writing. Publishing. Authors. Screenwriters. Life. Death. Etc. Support the show on Patreon Merch www.otherppl.com @otherppl Instagram  YouTube Email the show: letters [at] otherppl [dot] com The podcast is a proud affiliate partner of Bookshop, working to support local, independent bookstores. Learn more about your ad choices. Visit megaphone.fm/adchoices

Did you know that: - Pain is not biomedical, it is biopsychosocial. - Tissue damage and pain aren’t correlated. - Critical to pain management is getting in touch with bodies and emotions. - Mental health practitioners are an integral part of a patient’s pain management team. Learn this and so much more on DanceWell Podcast’s 88th Episode: On Pain with pain psychologist, Dr. Rachel Zoffness, PhD. Get in touch with Dr. Zoffness: The Pain Management Workbook: https://www.amazon.com/Pain-Management-Workbook-Powerful-Mindfulness-ebook/dp/B084JJ926N/ref=nodl_ Website: www.Zoffness.com Twitter: @drzoffness Instagram: @therealdoczoff Support DanceWell Podcast by donating - gf.me/u/yxv25p Host: Marissa Schaeffer Co-Hosts: Ellie Kusner and Marissa Schaeffer Website: www.dancewellpodcast.com Email: DanceWellPodcast@gmail.com Introduction Soundscape: Brendan Berry and Dylan Ezzie

Pain and health psychologist Dr. Rachel Zoffness joins to discuss a biopsychosocial approach to treating and managing pain. Book for kids is here Adult book is here Follow Dr. Zoffness on Twitter @drzoffness   Follow Dr. Zoffness on Instagram @TheRealDocZoff Dr. Ahmar Zaidi on Twitter Dr. Michael Callaghan on Twitter BloodStream Media For all inquiries: mailbag@bloodstreammedia.com (subject: Cheat Codes) Subscribe to and rate Cheat Codes Subscribe to and rate The BloodStream Podcast Subscribe to and rate The Ask The Expert Podcast Subscribe to and rate BloodStream Journeys Connect with BloodStream Media: Find all of our bleeding disorders podcasts on BloodStreamMedia.com BloodStream on Facebook BloodStream on Twitter

The podcast is back from hiatus with its timeliest episode yet! This week's episode features Dr. Rachel Zoffness, a pain & health psychologist with 2 published books and a column in Psychology Today. She and Christina talk about the concept of anxiety contagion, the science behind emotions and pain, conspiracy theories, self-care for the end of the world, and more. Stay safe and enjoy!   Find out more about Dr. Zoffness on her website or by following her on Instagram @therealdoczoff. Her article, Anxiety Contagion: Tips for Relief, is referenced in this episode. --- Send in a voice message: https://anchor.fm/picklesandvodka/message Support this podcast: https://anchor.fm/picklesandvodka/support