Dr. Kennedy’s personal and professional stories are interwoven. She is a Family Medicine Physician, a board member of the Association for the Treatment of Neuroplastic Symptoms, and a member of the Oslo Chronic Fatigue Consortium.

Ten years into her career she was really baffled by the many patient medical problems that she couldn’t help. In medical school she learned that the majority of diagnoses are based on the patient’s history, not on testing or examination. The normal practice was diagnosis by exclusion—do testing to rule causes out and make a diagnosis based on patterns. She frequently saw people with a history of trauma, mental health disorders, and pain, who had seen specialists but were still seeking help for their pain or other symptoms.

That situation is not unusual. Many studies show that 40% of primary care appointments are for symptoms with no medically discernable cause.

For several years she read and took courses, to try to figure out these missing pieces of the challenge to an effective remedy for which there was no apparent cause. A Google search led her to the Mind Body Institute at Harvard which had studied effects of meditation on the nervous system. She incorporated the recommended healthy practices (stress reduction, mindfulness, diet, cognitive behavioral therapy, etc.) into her patient care, but her patients still had undiagnosable symptoms.

Then a physician friend suggested she send patients with chronic pain to Howard Schubiner and “…they come back to me with no pain.” That led her to seek training for treatment of neuroplastic symptoms from Dr. Clarke in Portland. Her employer, Kaiser’s Integrative Clinic, gave her a half-day weekly to get started treating neuroplastic symptoms. She was learning how to talk to patients about the way pain is a danger signal meant to protect people from structural bodily injury. Patients reported that understanding those concepts was helpful for them and their positive responses led to a flood of other patients into her clinic, desperate for treatment of their pain.

Being a shy person who didn’t like to make waves, she tried to inform other doctors and clinic leaders about the brain’s protective mechanisms and pain treatment. Their response was not supportive, and she wondered if patients and colleagues thought she was crazy, but she couldn’t go backwards because she knew that treatment of pain diagnosed as neuroplastic was credible.

Subsequently, she developed knee pain similar to an earlier injury but realized it as an old neuroplastic pain pathway. That pain episode only lasted one day. But several months later when she was entertaining the family of an old friend, the emotional stress led to pain in that same knee, which worsened and spread to her ankles and hips. A steroid injection reduced the pain, but the pain came back after several weeks.

Eventually, following the neuroplastic symptom treatment she had learned, she began to do the deep emotional work, learning to stand up for myself and express her anger and emotions in productive ways rather than suppressing them. Although she was initially dubious about somatic tracking and expressive writing, she learned they were very helpful tools in resolving her pain symptoms.
She began to use these tools with her patients—teaching them to feel and express their emotions, to “re-write” childhood memories from the perspective of an adult rational brain. Eventually she started her own clinic, focused on patients with neuroplastic symptoms.

Dr. Clarke is a gastroenterologist (GI) who spent his career at Oregon Health Science University, then in 2010 was one of the founders and President of The PsychoPhysiologic Disorders Association (PPDA), a nonprofit corporation for treating Stress related disorders.  The name was changed to The  a description of the resources provided by the PPDA to healthcare workers and patients related to stress illness.  The ATNS provides a continuously expanding list of resources, but the remainder of the original interview does not accurately describe the current association offerings, so is not included in this 2025 curation of the original interview video.  

Dr. Clarke answers the 12 questions (shown in the Key Ideas and Transcription) about his career and what he calls the Blind Spot of diagnosis and treatment between the medical and mental health communities.  One reason his interview was chosen for the PSLS archive, is that it addresses that aspect but also because it provides a broader perspective on how recognition and treatment of neuroplastic symptoms has evolved in recent decades based on new neuroscience findings.

His awareness of stress illness began related to his gastroenterology graduate training in southern California which involved diagnosis of a chronic intestinal ailment that hospitalized a woman multiple times a year.  They anticipated their unique diagnostic test would reveal the cause and lead to successful treatment.  They didn’t find anything wrong, so could offer no treatment!  He was assigned the discharge interview with the woman and following a best practice before providing their conclusion, he asked her what was happening in her life.  Her answer was a surprise, so he referred her to a psychiatrist he understood was interested in similar cases. 

About a month later he inquired with that doctor about the woman’s progress and was shocked to learn she was cured of her stress illness.  Realizing he might encounter a few similar situations in his practice, he learned from the psychiatrist the essence of asking a patient questions about the experiences in their life.   It took him many years to fully develop his ability to diagnose and treat stress illness.  By the end of his multidecade career in gastroenterology he had diagnosed and treated about 7000 patients with stress illness, nominally one-third of all patients initially referred for gastrointestinal aliments. 

In 2007 he published a book titled: ‘They Can’t Find Anything Wrong’, which includes many excerpts from cases he has treated, and offers ‘7Keys to Understanding , Treating, and Healing Stress IIlness’. 

A major motivation for his continued effort is to move the healthcare world toward a system that serves those with stress illness in the Blind Spot between the mental and medical healthcare worlds.   “A human being , who is suffering , should be able to get appropriate diagnosis and relief for their symptoms, if it’s possible from the healthcare system, not matter what is causing their illness.”

Almost everyone has experienced a stress related symptom, like blushing or a knot in their abdomen in a tense situation, and undesired stress-symptoms afflict one in six adults.  Chronic pain is common symptom.  One patient had 27 symptoms that were ultimately relieved.  Many patients had been ill for 10 or more years. 

There is a wide range of speed with which people recover, which depends on the particular stress experienced by the individual and their ability to be in touch with their emotions.  Sometimes that road is long but sometimes a one-hour conversation finds the problem.

The patient’s ability to fully embrace the understanding that their illness is caused by stress, (meaning, the belief that the issue is in the Mind-Body/Neuroplastic realm) and not by disease or structure abnormality, can have an influence on their progress toward recovery.    The more stubborn cases may require a therapist with experience in Mind-Body realm.  https://www.symptomatic.me/ is a first source for locating a capable therapist.

Insight to the cause of symptoms in the Blind Spot are not generally within the training of most healthcare professionals.   So, your doctor may not be prepared understand the Blind Spot or treat the cause of stress illness. 

Scientific studies have demonstrated that ‘Pain Reprocessing Therapy’ and ‘Emotional Awareness and Expression Therapy’ have the capability to change the physiologic underpinning of the brain wiring and treat illnesses in the Blind Spot.  

Therapies for neuroplastic symptoms search for the underlying cause of the symptom rather than temporarily reducing the symptom.  Many times, the cause will be stressful events in the recent past or frequently from childhood.  There isn’t any magic in the treatment.  Rather the task is to find the stress or stresses your brain has repressed and get them relieved. 

Terminology in every technical discipline changes as the discipline develops and ‘neuroplastic’ is currently the most useful label for the underlying concepts in stress illnesses.

An interest in body building led Jeff Blanchard to love anatomy and kinesiology. That, in turn, led him to a career in Physical Therapy. His biomedical model PT training taught him to understand pain as “injury A, signal B, pain C.” Given his focus on diagnosis for choosing the appropriate treatment, he pursued a lot of continuing education over the course of his 25+ year career. Yet he noticed that--particularly with chronic pain patients--it seemed like his exercise skills and manual therapy tools were not enough to provide long-term benefits.

When his son required treatment for cancer, the emotional pain Mr. Blanchard experienced led him to practice meditation and to a counseling/coaching approach called “Healthspan” (pillars: nutrition, movement, sleep, mindfulness).

He went on to focus his study on chronic pain and realized that people are programmed from a young age to seek pleasure, avoid pain, and conserve energy despite getting inconsistent benefits.

He integrated ideas from Maslow’s hierarchy of needs and from the ACES research study of the impact of adverse childhood events into his PT practice. Dr. Kevin Cuccaro’s PAIN TRIANGLE and Alan Gordon and Alon Ziv’s book “The Way Out” gave him greater insight about the complexity of pain  He uses the analogy of a Venn Diagram for understanding the blend of biological, social, and psychological factors that produce pain.

His experiences al;omg with listening to his physical therapy patients has led Mr. Blanchard to boil the interaction down to “increasing safety and increasing love.”  He listens. Then he teaches his patients that inflammation is linked to their minds, not just their bodies.  When he sees that a patient’s needs are beyond his Physical Therapy scope of practice, he refers them to an appropriate practitioner.

He also uses patient education resources such as “What We Say Matters” from “Oregon Pain Guidance” and its website. When his patients describe their pain experience using nocebic language, he tries to gently have them consider how their thoughts and beliefs about pain increase their fear of pain.

Additional educational/treatment methods he used include teaching (1) parasympathetic breathwork (drawing out the exhalation), (2) loving kindness meditation, and (3) self-compassion (reference given to a book by Kristen Neff). He may suggest that patients keep a journal to help them identify how their thoughts and beliefs are holding them back.

Over the last year and a half, he developed a series of classes to provide patients with more in-depth education. Topics include: Understanding pain; The pain neuroscience; What is neuroplastic pain?; Understanding how stress and lack of safety negatively affect the mind and the body; How important it is to calm the brain in order to calm pain; The importance of understanding mindset and being able to hear your thoughts in order to recognize what you're thinking and start making a shift in the way you think about your body; Quality of habits; The power of self-compassion; The power of appropriate nutrition; The power of movement; and The power of sleep.

In Summary: (1) pain is not just a bodily sensation and (2) the level of depression, stress, and anxiety people are experiencing in today’s world makes chronic pain more prevalent and a bigger issue for practitioners with chronic pain patients.

‘Pain and Occupation: How Pain Science Shaped My Career ‘

Throughout her growing up years, Alyssa Phillips spent time with relatives on both sides of her family who experienced pain and limited mobility. She came to equate pain as “Unable” to fully participate in life’s daily activities.

With an undergraduate degree in Psychology, her desire to understand what motivated people to engage in particular activities led to her interest in health professions, particularly Occupational Therapy. Her early Occupational Therapy training regarding pain relied on the Biomedical Model and its focus on tissue damage. The Gate Control Theory was the science then and “No pain, no gain” was the approach to treatment.

As the newer Bio-Psycho-Social Model was applied to Occupational Therapy practice, a new idea emerged—that the way we feel about/view pain affects our experiences with pain. However, her overall understanding of pain continued to see pain as a body-based experience which sends pain signals to the brain.

Dr. Phillips’ first Occupational Therapy job was at a rehabilitation facility focused on treatment of the upper extremities. Its “Work Hardening” approach taught patients to lift/carry/push/pull heavier and heavier loads using safe movement patterns, preparing them to go back to work. She struggled to understand why her patients still reported pain long after their injuries had healed.

Using her undergraduate Psychology learning, she enjoyed the multidisciplinary approach to pain treatment of another Occupational Therapy job. She was learning to go beyond its “no pain, no gain” focus and look more deeply into her patients’ perceptions and expectations regarding pain and healing and how that affects their daily activities. She started to see pain as both a “brain and body thing.”

Then she went on to work in a clinic serving underinsured patients, many of whom were experiencing chronic pain. Mulling over chronic pain and how her patients’ actual body physiology, emotions, and sense of safety shaped their pain experience, she felt a sense of scientific enlightenment.  She began to see her Occupational Therapy job as “looking at what pain is communicating” to her patients.

In this process, questions she asked herself included: (1) Is it nociceptive pain due to a cut, broken bone, or the like? (2) Do really traumatic experiences lead to central sensitization/amplification of pain signals in her patients’ brains? (3) Is the pain simply a sign that her patient isn’t feeling safe?

She was beginning to see that there are many reasons for pain and the amplification of pain: that pain is a communicator; that pain is shaped by a person’s perceptions; and that pain is not always linked to tissue damage. She also saw that a “no pain, no gain” focus pushed people into a “boom and bust” cycle that was not an effective method to comfortably and safely help her patients carry out their Activities of Daily Living.

When she experienced an on-the-job low back injury—first off work and using workers’ compensation benefits, and then, working with job accommodations—she struggled.   Despite her knowledge about pain, she would catch herself falling into a “boom or bust” activity cycle, stress, poor sleep, and fear of the loss of her Occupational Therapy profession. She knew she had to consciously “go back to the basics.” She reminded herself that her low back had healed and that she needed to “practice what I preach.” Treatment techniques she applied to herself included self-pacing activities, deep breathing, mindfulness, icing, and taking breaks.

In 2022, she and colleagues presented “Occupational Therapy’s Role in Chronic Pain Management” at the American Occupational Therapy Association Annual Conference.  In short, she believes that pain science has shaped her career in many ways. As a university professor, she is teaching Pain Science concepts to her patients and students— including the effects of psychosocial factors on peoples’ pain experiences--adapting meaningful activities; exploration of one’s roles; and identifying meaningful roles and tasks.

(This 20 page Summary, the curator’s take-aways prepared in January 2025, offers a non-professional perspective rather than a condensation of the text.  The reason for including this review among pain science informed stories is that van der Kolk offers neuroscience insights about brain functions that are related to neuroplastic pain and symptoms.  Professionals may find useful clinical insights in the omitted portions of the book.  The book captures a glimpse of both his perspectives and initiatives, along with historical timelines to help understand changes in: trauma effects, causes, and treatments; the diversity of perspectives and innovation in mental health; and the response of the health community to new approaches.)

Learn more here

This is the story written by Bessel van der Kolk, an MD Psychiatrist, describing his life’s work on trauma disorders and evolution of the understanding of the related causes, effects and remedies for trauma.  The story spans from the 1960s to about 2014, the copyright date, and he continues his work in 2025.  He is considered to be a major influence in the US on treatment of trauma disorders that don’t fit well into either the current professional medical or mental health communities.  He promotes the ‘Consensus Proposed Criteria for Developmental Trauma Disorder’, which he fostered.  The book seems to be aimed at mental health professionals, but using a dictionary for unfamiliar terminology will be helpful for others.

The Prologue:  Facing trauma

Humans are resilient but traumatic experiences leave traces: dark secrets on our minds and emotions.   By definition trauma is unbearable and intolerable, creating unpleasant emotions.    We may push trauma memory out of our conscious mind as if nothing happened but may still feel damaged beyond redemption.  Would it be possible someday to understand how our brains, minds, and love work, as well as we understand, how other bodily systems work?

Three new branches of science birthed a vast increase in our knowledge about the effects of trauma, abuse and neglect:  1) neuroscience;  2) developmental psychopathology; and 3) interpersonal neurobiology.  The new understanding demonstrates that trauma causes actual changes in our brains, which helps explain why we may repeat the same problems, but the result is not necessarily a moral failing.

New possibilities to reverse that damage take three avenues:  1) top-down, by talking to others while processing memories;  2) medications and technologies that change the way the brain organizes information and;  3)  bottom-up, by allowing the body to have experiences that contradict the helpless resulting from trauma.

His life work is anchored at the Trauma Center he founded in 1984 to collaborate with others to discover the effects of traumatic stress and demonstrate the efficacy of various treatments.  Their goal was to understand how people can gain control over the residues of past trauma and return to being masters of their own ship.   Well-designed studies to obtain definitive insight of concepts and treatments are a common thread through his work.

Outline of Contents:

The first four parts of the book (12 chapters) describe:  1) the current revolution in understanding, informed by recent neuroscience insights of how the brain functions during a traumatic event;  2) the relationship between the brain and body during a trauma experience;  3) the unique influence of trauma on the brain construction of children in their developing years and;  4) how memories of trauma are rooted in the brain and produce unwanted emotional reactions afterward.

The last part of the book (8 chapters) briefly describes eight treatment methods that have been demonstrated to be effective in some cases, including:  owning yourself; finding language to communicate with your subconscious; Eye Movement Desensitization and Reprocessing; inhabiting your body via yoga; self-leadership; creating structures; brain/computer interface technology; and communal rhythms.

Prologue, chapters, and Epilogue = 359 pgs, plus 87 pgs Acknowledgements, Appendix, Resources, Further Reading, Notes, and Index.

Epilogue

We now understand: the effects of trauma on the brain; how it disrupts social engagement throughout life; that abuse and neglect in childhood causes are the single most preventable cause of mental illness, substance abuse, and shortened lifespan; that trauma, abuse and neglect are endemic with poverty; that trauma damage is treatable; and that the greatest hope for effected children is education in a safe school were they learn how their bodies and brains work and how to understand and instill the resilience to deal with emotions and trauma in life.

Feeling safe with other people defines mental health.  Trauma is our most urgent public health issue.  Our choice is to act on what we know to be effective.

Part One – The rediscovery of trauma

Chapter 1 – Lessons from Vietnam veterans.

His professional introduction to trauma was in 1978 at the Boston Veterans Administration Clinic.  Initially it involved listening to veterans telling their trauma stories from the war, their subsequent problems, and his search for medical references on the problems they described. He found only one, ‘The Traumatic  Neurosis of War’ (Kardiner), published in 1941, based on World War I veterans and released in anticipation of shell-shocked soldiers in WWII.

Kardiner described the same phenomena van der Kolk heard in his patient’s stories.  What Kardiner called traumatic neuroses, we now call PTSD.    He saw lives shattered by overwhelming experiences and his quest became to understand how to enable them to feel fully alive again.

The first study he did at the VA was to systematically learn what had happened to veterans in Vietnam.   A close associate of his was Sarah Haley, one of the first to write about the phenomenon, in ‘When the Patient Reports Atrocities’ (1974).  They report that they despise themselves for how terrified, dependent, excited, and enraged they felt.  Years later, van der Kolk encountered similar phenomenon in victims of child abuse.   The consequences of trauma include losing one’s sense of self, a part of you seems forever destroyed – the part that was good, honorable and trustworthy.   There may be confusion about whether you are a victim or a willing participant.

Numbing to emotions is another symptom, not able to really feel anything.  Never feeling fully alive and keeping busy or indulging addictions are ways to avoid confronting your demons.

Another study he conducted explored how trauma changed a person’s perceptions and imagination.   Humans are meaning-making creatures, and our brains try to assign meaning to things we see, hear and sense.  Traumatized people look at the world differently than other people.   Imagination is absolutely critical for quality of life, the essential launchpad for making hopes come true.  When people are stuck in the past without imagination there is no hope.  Traumatic events have a beginning, middle and end, so they are in the past but unwanted memories lack real time bounds and can replay past emotions when triggered.

Progress in diagnosing posttraumatic stress was slow, the turning point was 1980.  A group of Vietnam veterans and two New York doctors lobbied the American Psychiatric Association to create a new diagnosis for PTSD (posttraumatic stress disorder).  This led to an explosion of research and attempts at finding effective treatments.  He proposed a study on the biology of traumatic memories, did memories differ between those with PTSD and others?  That proposal was rejected by the VA because it had never been shown that PTSD was a relevant mission of the VA.  He left the unwilling VA organization to teach psychopharmacology at the Harvard Teaching hospital.  There he noted the similarity of the symptoms from molestation and family violence to symptoms his earlier veterans.  For many people war begins in the home, 3 million children a year in the US.  It is difficult for growing-children when their source of terror is their own caretakers.

The new understanding of trauma began in the early 1990s with brain imaging tools.   We have learned that overwhelming experiences affect our innermost sensations and our relationship to physical reality – the core of who we are.   Trauma is not just an event in the past but leaves an imprint on mind, brain, and body, resulting in reorganization of the way the mind and brain manage perceptions.  Finding words to describe their trauma is helpful, but not enough.   The body beyond our conscious brain needs to learn the damage is past for real change to take place.  Their search to understand trauma changed their thinking about the structure of the mind as well as the processes that help it heal.  (He seems to equate the mind with our conscious brain.)

Chapter 2 – Revolutions in Understanding Mind and Brain

In the late 1960s, his initial years in medical school, he was an attendant at a research ward and became an accidental witness to the profound transition in the medical approach to mental suffering.   His job was to keep the patients, college-age students from Boston universities with unpredictable behaviors, engaged in normal activities like eating pizza, sailing, camping, and Red Sox games.  On sleepless nights they told him their stories of trauma at the hands of parents, relatives classmates and neighbors.   He was permitted to observe morning rounds where the doctors rarely heard the stories he had heard patients tell.   The study from that research effort was published in 1968 showed that drug treatment for schizophrenic patients had a better outcome than talk therapy, a milestone on the road to changing from talk therapy to a brain-based model of discrete disorders.  The primary treatment for mental illness shifted in the 1950s and 60s from talk therapy to medical intervention.

A few years later as a doctor doing physical exams prior to electroshock treatment for depression, he observed the medical model in action where the stories he heard patients tell him would later be erased from their memories.  He wondered if the earlier stories he heard students tell in the nighttime were fragments of memories rather than hallucinations.

Later in his psychiatry training his mentor taught that the greatest source of our suffering is the lies we tell ourselves, and people can never get better without knowing what they know and feeling what they feel.  You can be fully in charge of your life only if you can acknowledge the reality of your body, in all its visceral dimensions.

The available technology has always determined the medical approach to treatment.  The new paradigm fixed ‘disorders due to chemical imbalances’.  He embraced the pharmacological revolution in 1973 when he became chief resident at a Boston health center.   Antipsychotic drugs were a major factor in reducing the number of people living in mental hospitals from 1955 to 1996.   The ability to measure hormones and neurotransmitters in patients led eventually to publication of the Diagnostic and Statistical Manual of Mental Disorders in 1980.

He attended a 1984 neuropsychopharmacology meeting looking for ideas about traumatic stress.   A presentation on learned helplessness in dogs and their stress hormone levels captured his attention about the underpinnings of traumatic stress.   Later research revealed that traumatized people continue to have high levels of stress hormones long after the actual danger is passed, and that cortisol ends stress response but is low in PTSD patients.

A presentation in the 1985 neuropsychopharmacology meeting showed that sensitivity of the amygdala to threat depended on its level of serotonin.  Prozac, which increases serotonin in the brain, was marketed first in 1988.  He prescribed it, and observed beneficial effects on his patients, but it had no effect for veterans with PTSD.

The pharmacology revolution gave doctors a tool beyond talk therapy, and did much good, but in the end may have done as much harm as good, because drugs deflect attention from the underlying issues.   The brain-disease model takes control over people’s fate out of their hands, transferring it to doctors and insurance companies.  After three decades of psychiatric medications more money is spent on them, and more people are taking them.  They make children more manageable, but they interfere with motivation, play, and curiosity, which are indispensable for maturing into a well-functioning and contributing member of society.  Because drugs are so profitable studies of nondrug treatments are rarely funded.  The fact that we can change our own physiology and inner equilibrium by means other than drugs is rarely considered.

The brain-disease model overlooks four fundamental truths: 1) restoring relationships is central to restoring well-being; 2)  we have the power of language to change our situation; 3) we have the ability to regulate our own physiology; and 4) we can change social conditions to create safe environments  for children and adults to feel safe and thrive.  Considering the limitations of drugs, he wonders if we could find natural ways to help people deal with post-traumatic responses.

Beginning in the 60s, drugs were a major factor in releasing thousands of people from mental hospitals into mainstream society.

Chapter 3 – Looking into the Brain: The Neuroscience Revolution

In the early 1990s PET (positron emission tomography) and fMRI (functional magnetic resonance imaging) technology provided the ability to observe which parts of the brain were activated in certain tasks or remembering events of the past.   He was asked about a study to understand what happens in people’s brains who have flashbacks and proposed a study of 8 people’s brain activity using two scripted audio tapes as the test circumstance.  The first script re-enacted the images, sounds, and feelings of a past trauma and the second reenacted a scene where they felt safe and in control.   He identifies bright areas of one set of three scan images: the right limbic area (the emotional brain including the amygdala), the visual cortex (where images first enter the brain), and the speech center.    The amygdala warns of danger and activates stress response.

The most surprising finding was that the speech center was deactivated whenever a flashback was triggered so feelings are almost impossible to articulate.  They were also surprised to see the visual cortex activated (apparently with images from the trauma event), so long after the event.

The right side of the brain processes intuition, emotion, spatial, and tactual aspects while the left side processes rational, sequential and analytical aspects.   Images of past trauma activate the right side and deactivate the left side.  Usually, the two sides work together but in different ways.  During a trauma the left side may not work very well.  Without sequencing we can’t identify the cause and effect to grasp the long-term effects.  When something reminds traumatized people of the past, it’s as if it were happening now, but they may not be aware it is a past event.

Another possible response to threat is denial, (not a discernable response in scans), where the mind goes on as if nothing happened.  But the alarm signal from the emotional brain continues producing stress hormones, because the body continues to keep the score.  For hundreds of years textbooks have recommended talking about distressed feelings to resolve them, but trauma gets in the way of that effort.  The rational brain is impotent to talk to the emotional brain out of its own reality.  The scanned volunteers had not integrated their experience into the ongoing thread of their life, so were not able to be fully here in the present.

Three years later one of the eight volunteers was successfully treated with EDMR (Chapter 15).   Her body kept the score for 16 years.

Part Two – This is your brain on trauma

Chapter 4 – Running for your life: Anatomy of Survival

Two adaptive responses to threat are becoming an agent in your own rescue and creating alternatives to help others.  Traumatized people become stuck in their growth.  A group of his veterans gave him a WWII era watch, because their lives had stopped in one sense in 1944.  After trauma the world is experienced with a different nervous system, focused on suppressing the inner chaos.

The whole body is organized to respond to the threat, including all organs and muscles and trauma survivors are prone to continue to protect themselves.  Knowing how the system works is essential to understand how trauma affects each part and can serve as a guide to resolving traumatic stress.

The most important brain job is survival, managing 5 aspects: 1) internal signals to control organs; 2) create a map of where to go to satisfy needs;  3) generate the energy and actions to get there;  4) warn of dangers and opportunities and;  5) adjust actions to cope with current conditions.   Psychological problems occur when any aspect is inadequate.

He uses a three-part brain model here.   The cognitive, rational brain occupies the top part of the skull, about 30% of the volume.   Below are two subconscious brains that manage everything else.  The lowest brain develops first in newborn babies and controls organ functions that sustain life.   The next brain to develop above that is the limbic brain which manages living in complex social networks.  It develops in response to life experiences and has neuroplastic characteristics that permit the default patterns to change.    He calls the two lower brains the emotional brain.

The rational brain provides: planning, anticipation, sense of time, context, empathy and understanding.   The limbic brain provides: organization/surrounding map, emotional relevance, categorization, and perception.   The lowest brain provides: arousal, sleep/wake, hunger/satiation, breathing, and chemical balance.

The emotional brain response is rapid and automatic, based on incoming information similarities to past experiences.   The rational brain begins to develop in the second year of life enabling language, abstract thought, creativity, and empathy.   In 1994 a group of Italian scientists discovered mirror neurons that lead to understanding empathy, imitation, synchrony, and language.   Realizing other people think and feel differently from us is a developmental step for two- and three-year-olds.   Trauma involves not being mirrored to easily respond to others emotional state.

Information initially enters the limbic brain, which routes it rapidly to the lowest brain for an evaluation of threat to survival, then more slowly to the rational brain for a nuanced evaluation.  The lower brain functions like a preprogrammed fire detector and the rational brain like a watch tower.   Problematic rational decisions are fewer than problematic emotional decisions.

When the lower brain makes a high threat conclusion, whether warranted or not by the situation, it initiates release of stress hormones to the whole body to prepare for action.   But the rational brain has some ability to moderate the stress response.   Dealing with stress is a balance between the detector and the watchtower influence, which are described as ‘top-down and bottom-up influences.  Top-down efforts strengthen the capacity of the watchtower to monitor body sensations.  (Mindfulness meditation and yoga have been demonstrated to help this mode.)  Bottom-up attempts to recalibrate the autonomic nervous system in the emotional brain to increase the accuracy of the detector response.   (Breathing practice, physical movement, and touch have been demonstrated to help this mode.)

Emotions assign value to experiences as a foundational aspect of reason.  Our self-experience is a balance between our emotional and rational brains, perhaps like a more or less competent rider and his unruly horse.  But when the limbic system (emotional brain) decides something is a matter of life and death, communication between the rational and emotional brains becomes extremely tenuous so in a conflict moment the rational brain has less influence so emotions tend to prevail.

An example of Stan and Ute’s brains on Trauma ends Chapter 4.  In September 1999 Stan and Ute encountered dense fog traveling to a business meeting, which resulted in a multi-vehicle pile-up.  They were trapped in vehicle 13 of the 87-vehicle pileup and heard a girl pounding on their roof and screaming for rescue from flames.  They were unable to assist, and she died.  He eventually broke their windshield and climbed out while Ute was sitting, frozen in her seat.  They were taken to a hospital and their injuries were minor.

That night neither could sleep, feeling if they let go, they would die.  They were irritable jumpy and on edge, could not stop the images and the what-if questions from haunting them, drank wine to numb their fears, and after 3 months sought help from a Dr. Lanius a psychiatrist who had been van der Kolk’s student.  She used a fMRI to capture their brain images in response to a script of their trapped experiences.  The MRI showed the activation visual images, smells, and other sensations they had experienced trapped in their car 3 months earlier, were still trapped in their brains.

Stan immediately experienced a flashback from the trapped experience with sweating, heart racing and high blood pressure.  He relived what had happened 3 months earlier rather than remembering it an event of the past.   The detector in his brain was on overdrive and the timekeeper link between his rational and emotional brains had collapsed so he was unable to separate the actual and fMRI events as past and present events.  Talk therapy won’t work as long as people keep being pulled back into the past but they need to be physically grounded or anchored in the present during the therapy.

Ute had nearly the same trapped experience in the pileup, but her mind went blank and the fMRI showed no activity, a condition called dissociation or depersonalization.    After seeing her fMRI van der Kolk concluded talk conventional therapy also would be useless for her.  He later realized she responded differently because in surviving difficult events in her childhood she had learned to blank out her mind during horrible events.  She eventually recovered with a bottom-up therapy approach.  Numbing is the other side of the coin in PTSD.

The challenge of trauma treatment is enhancing the day-to-day experience while dealing with the past.

Chapter 5 – Body-Brain Connections

A person plans, plays, learns, and attends to the needs of others in the conscious part of their brain, while the subconscious brain communicates with the person only by sensations and feelings in their body.   Hunger pangs, sensations to urinate and move bowels, and sensations that prompt babies to cry for attention exist early.

Various emotions produce subconscious bodily effects like: smiling, blushing, lump-in-the-throat, and knot-in-the-stomach associated with different levels of pleasure or threat.   These emotions are also communicated to that person, and to others in the vicinity, by subconscious changes in: breathe and heart rate; facial muscles; posture; movement; voice tone and speech speed, etc.

Subconscious emotions and bodily changes are transmitted through the autonomic nervous system (ANS), which has two branches: the sympathetic nervous system (SNS) that acts as an accelerator, or through the parasympathetic nervous system (PNS) that acts as a brake.  The sympathetic label associates it with ‘emotional’ arousal like fight or flight, while the parasympathetic label is ‘against emotions’ like digestion and healing.

Inhaling a deep breath activates the sympathetic system, so short deep breaths result in a burst of adrenaline and an increased heart rate.  Exhaling slows down the heart rate through the parasympathetic system.   Heart rate variability (HRV) is a measure of the flexibility of the system and more fluctuation is better.   Instruments to measure HRV can be used to help treat PTSD.

In 1994 Polyvagal Theory (related to the significance of the vagal nerve which connects the brain to numerous organs) was introduced and put social relationships in the forefront of research rather than the effects of fight or flight.    It clarified why knowing we are seen and heard by the important people in our lives can make us feel calm and safe, while being ignored and dismissed can precipitate rage reactions or mental collapse.

Our mirror neurons register their inner experience, and our bodies make adjustments to whatever we notice.   Most of our energy is devoted to connecting with others.   The standard medical practice of discovering the right drug for a particular ‘disorder’ can distract from grappling with how the problems interfere with our functioning with other humans.  The critical issue is reciprocity, we need to feel safe, seen and heard by the people around us.   Social support is the most powerful protection against being overwhelmed by stress and trauma.  Discovering initial relationships with animals like dogs and horses is an entry path for some trauma patients.

Trauma changes the nervous system’s perception of risk and safety.  Losing consciousness but otherwise uninjured in an event can lead to mental collapse.  Some people panic during the trauma and stay frantic until effective treatment.   Some remain calm and resourceful in helping others during the trauma experience.  An explanation for these three levels of response by the autonomic system defines ‘social engagement’ as the first level, i.e. help from those around us.  If no help comes the second response is ‘fight or flight’, followed by ‘freeze or collapse’ to expend the least energy possible.   Stan responded in the social engagement mode but Ute in the collapse mode, perhaps because she felt more trapped.

The natural state of mammals is to be somewhat on guard.  On order to play, mate, or nurture young the brain needs to turn off its natural vigilance.  Past trauma can lead to either heightened vigilance because danger is everywhere or a loss of vigilance because defending seems futile.   Treatment programs centered on play and rhythmic body movements, like yoga, can create a small safe social engagement that has been helpful.

The body keeps the score.  So, if trauma is encoded in our organs by emotions, then understanding emotional regulation will be to remedy route rather than changing a person’s rational thinking.

Chapter 6 – Losing your body, losing yourself

He describes Sherry’s experiences, because she taught him that many people with trauma lose their sensory perception of whole areas of their body.  Living a normal life means integrating ordinary sensory experiences.   He referred her to a massage therapist.

A study by his colleague in 2004 on the difference in the ‘default state network’ (DSN) comparing normal adults to PTSD patients with early life trauma, revealed the person’s sense of ‘self’ by their thought activity when they have nothing in particular in mind.   There was almost no activation of any self-sensing brain area in the PTSD patients.  He now understands why they frequently asked him for advice about ordinary things.   How could they make decisions if the relationship with their own inner reality was impaired?   You can’t do what you want until you know what you are doing.

The core of our self-awareness rests on the physical sensations that convey the inner states of the body.    The consequences of having emotion and attention are entirely related to the fundamental business of managing life within the organism.  Recalling an emotional past event causes reexperience of the visceral sensation felt during the original event.

Agency, owning your life, means feeling in charge of it.  Trauma shuts down that inner compass, the watchtower mentioned earlier, robbing a person of the imagination to create something better.  Our gut feelings signal what is safe, life sustaining or threatening, even if we can’t explain why.  Traumatized people feel unsafe inside their bodies, the past is alive in the form of gnawing interior discomfort, unable to detect what is dangerous or harmful but also what is safe and nourishing.  Neuroplastic symptoms are ubiquitous for traumatized people.

People with emotional blindness, having no words for feelings, tend to describe action or problems as emotion rather than a feeling needing their attention.    They can be professionally successful but have bleak intimate relationships.   They can’t tell what is upsetting them.  Recognizing the relationship between their physical sensations and their emotions is the key to their improvement.

Trauma victims need to befriend the sensations of their body.  Being frightened is a body on guard, angry.   Physical self-awareness is the first step to releasing the tyranny of the past.   Clinging to another person is the most natural way to toward calmness.

Many traumatized people are unable to make eye contact with others.  Their mirror neurons were not activated which means their ability to make friends and get along is impaired.   They need to experience others as separate individuals in order to have genuine relationships.

Part Three - The Minds of Children

Chapter 7 – Attachment and attunement

Babies ‘attach’ their sense of being and what is real to whoever functions as their caregiver, by means of their physical and emotional interactions.   Attachment encodes a sense of safety in the baby’s brain.    They learn about the give and take of actions and feelings that are similar and different than their actions and feelings.    The need for attachment never lessens and most humans cannot tolerate being disengaged from others for any length of time.

Secure attachment develops when caregiving includes emotional attunement, the ability for a child to synchronize their emotions with those of another being.  Associating intense sensations of changing situations with safety, comfort, and mastery is the foundation of self-regulation.

Babies have a sense of agency when they understand their actions can change how they feel and how others respond to them.   When their body and mind become the place where they live, their sense of identity is real.    These concepts become the foundation of how babies become whatever the mother’s idea of what a baby is.

Abused children can be very sensitive and tend to interpret changes in the emotional situation as threats rather than as clues for how to stay in synch.   Children learn to live with the parents they have, by developing a coping style to get at least some of their needs met, either by being chronically upset or more passive and withdrawn.

With most ‘good enough’ caregivers children learn that broken connections can be repaired.   One study of middle-class children showed about 62 % secure, 15% avoidant, 9 % anxious, and 15% disorganized.  Traumatized parents need help to be attuned to their child’s needs.   A child’s reaction to painful events is related to how calm or stressed their parents are.

Disorganized attachment is characteristic of either pre-occupied mothers or helpless, fearful mothers, usually related to the mother’s childhood.

Infants in secure parent relationships can communicate both frustrations and distress, and also their interests, preferences, and goals.   Dissociation means simultaneously knowing and not knowing, feeling lost from the world.  What cannot be communicated to the mother cannot become part of the baby’s self.    When you cannot tolerate what you know or feel, the only option is denial and dissociation.

Early attachment patterns create inner relationship maps in the emotional brain that are not reversible by understanding how they were created.    Being in synch means resonating with people around you through the sounds and rhythms of daily activities.

Chapter 8 – Trapped in relationships: the cost of abuse and neglect

A child’s viewpoint of the world is unique, with them at the center.   They trust the viewpoint of those around them.    Whether they were told they were cute and worthy, or abused and worthless, they would believe it.    Later in life the ‘worthy’ person would protest inconsistent treatment, but the ‘unworthy’ person would fail to protest mistreatment and conclude they deserve it.

It’s possible to help an ‘unworthy’ person to reconstruct their inner map of the world. Reconstructing inner maps changes may spontaneously occur during adolescence or when becoming new parents.    The change occurs when a person learns to use their rational brain to override their emotional brain.    Learning to trust is a major challenge.

In order to have an identity we must know we are real.   That means being able to observe our surroundings, label them correctly, and trust our memories.   Losing awareness and cultivating denial might be essential for survival at times, but the price you pay is knowing who you are, what you are feeling, and of what and whom you can trust,

Trauma is not stored as a narrative with a beginning, middle, and end but jumbled in disconnected fragments of various types.   The will to live one’s own life counteracts trauma at the time and many consider survivors to be heroes, particularly their determination to recover.

Chapter 9 – What’s love got to do with it?

Psychiatry as a subspecialty of medicine that aspires to understand mental illness with the precision like understanding a specific cancer.    But the complexity of the mind, brain, and human attachment systems is beyond the current understanding.   A definitive diagnosis is a key characteristic of effective treatment in the medical community but mostly not achievable in the mental health community.

The first serious attempt in the mental community was in 1980 with the third edition of  the Diagnostic and Statistical Manual of Mental Disorders, (DSM-III).    Sale of that document earned the American Psychiatric Association $100 million since then.

Many psychiatric diagnoses can have serious consequences and are often mere tallies of symptoms, which don’t seem to be helpful.   Collaborating with others, van der Kolk has tried to change the way diagnoses are made.   The first attempt was the Trauma Antecedents Questionnaire (TAQ), which starts with who does what in your home, then explores childhood relationships.

In one study 81% of hospital patients who were diagnosed with Borderline Personality Disorder (BPD) reported severe histories of child abuse, the vast majority beginning before age 7.  Those children did not have a sense of safety but were making their way in the world unprotected and unseen.   When does a hypothesis become a scientifically established fact?  That study changed the Trauma Center’s direction from focus on singular events (PTSD), to looking at long term relationships.   He concluded that the brains of children who lack a deep memory of feeling loved and safe, fail to develop the capacity to respond to human kindness.

That prompted their study to determine if the symptoms of patients with different trauma type histories (childhood physical or sexual abuse; recent domestic violence; and natural disasters) were the same or different, and it showed a dramatic difference, particularly between abused children and those in natural disasters.   He presented the results to the DSM-IV work group, which voted overwhelmingly to establish a new diagnosis for victims of interpersonal trauma, which they labeled ‘Complex PTSD’.  But DSM-IV in May 1994 did not include it, nor did revisions -V and -VI.    (a ‘Consensus Proposed Criteria for Developmental Trauma Disorder’ is included in the book Appendix.)

A study, now referred to as the ACE study (Adverse Childhood Experiences), by the Kaiser Permanente Department of Preventive Medicine in San Diego, involved over 17,000 patients responding to 10 new questions about early childhood experiences in their existing comprehensive evaluation was published in 1998.    It revealed that a significant portion of the healthcare challenges for the whole population are related to mental challenges in childhood.   This book is a significant influence in focusing increased attention on preventing that gap in attention to continue by diagnosing and treating childhood trauma so that abuse and neglect do not burden the next generation of children.

The 1964 publication of the Surgeon General’s report on smoking unleashed a campaign that changed the lives and health prospects for millions.  Child abuse is America’s most costly health care issue, exceeding the cost of cancer or heart disease.   In the first twenty years after the ACE’s publication a similar effect has not occurred and the daily life of children in treatment centers remained virtually the same.
Chapter 10 – Developmental Trauma: The hidden epidemic

Child abuse isn’t something you get over but an evil of unchecked violence perpetuated within our culture.

No genes have been found that change DNA but experiments with mice and monkeys (called epigenetics) revealed that chemical modifications attached to DNA affect how they are turned on and off.

Congress established the National Child Traumatic Stress Network (NCTSN) in 2001 in response to a broad effort van der Kolk and others began in 1998.   By the book publication of ‘The Body Keeps the Score’ date in 2014 it had expanded to 150 centers.   An early survey of about 2000 children in the network showed they mirrored  the middle-aged, middle-class adults with high scores in the ACES study.

The adoption of the DSM-III PTSD diagnosis in 1980 led to greatly increased focus and funding toward PTSD so that it can now be effectively treated.    However, 82% of traumatized children do not meet the PTSD criteria, but are diagnosed with 3 to 8 different DSM disorders which together are not a useful diagnoses for treatment.

Over a 4 year period a group of clinician researchers specializing in childhood trauma analyzed 130 studies covering 100k children and drafted a proposal for an appropriate diagnosis which they called a ‘Developmental Trauma Disorder’ (DTD).    They discovered a consistent profile of: 1) a pervasive pattern of dysregulation;  2) problems with attention and concentration; and  3) difficulty  getting along with themselves and others.

DTD located the origin of abused children’s problems in a combination of trauma and compromised attachment.   They submitted the proposed diagnosis to the American Psychological Association (APA) for inclusion in revision DSM-5, but it was declined because of a committee consensus there was no new diagnosis needed to fill: ‘a missing diagnostic niche’.

A study of Risk and Adaption began in 1975 to address the issue of nature versus nurture as a cause of disorders.  One hundred-thirty children and their families were followed from 6 months before birth to the child’s age 30.    The fundamental questions were:  1) how do children learn to pay attention while regulating their arousal and,   2) what kinds of support do they need and when?   Two clear patterns developed:  children who received consistent care giving became well-regulated kids while erratic caregiving produced unpredictable children.

A study begun in 1986 with 84 girls with confirmed family incest, on the impact of sexual abuse on female development.    After 20 years the negative effects were unambiguous compared to other with other girls of the same age, race, and social circumstances; sexually abused girls suffer from a large range of negative effects.

DSM-5 published in May 2013 included 5 new disorders associated with early life trauma.  Even before it was published the APA released the results of validity tests on various new diagnoses indicating they lacked reliability in a scientific sense.  In April the National Institute of Mental Health (NIMH) rejected the symptom basis of the DSM in favor of Research Domain Criteria, which like the DSM conceptualized mental illness as a brain disorder and focused on exploring brain circuits.

After DSM -5 was published without the DTD, thousands of clinicians sent small donations to the Trauma Center for a large field trial of the DTD, which was published in 2013.  Van d

er Kolk sees the difference in DTD to be that it: follows the science of neuroplasticity; assumes parents do the best they can; and has the potential to make a difference in reducing the violence in our society while reducing its cost.

Part Four – The imprint of trauma

Chapter 11 – Uncovering secrets: The problem of traumatic memory

A study of 200 Harvard sophomores to understand Adult Development began in 1939 with later detailed interviews in 1945/6, and 1989/90, which included involvement in WWII.  Comparing war experience descriptions, the majority described different accounts in the two interviews, but for those who developed PTSD their descriptions were the same, their memories remained the same.

Day-to-day memories pass into oblivion, but insults and emotional injury remain, if only dislike for the person involved.    Studies have shown that the more adrenaline secreted during the incident, the more precise the memory will be.

Two examples cited are:  of the cigarette girl who escaped from the Coconut Grove fire in 1942 then annually reenacted her escape during the 1970s and1980s, and a Vietnam veteran who annually staged an armed robbery implying he had a gun in an unconscious attempt at ‘suicide by cop’.

When a traumatic event is reactivated in an fMRI study there is no integration of the rational brain story with the emotional brain feelings.   The rational brain shuts down and only the fragmented sensory and emotional memories are active.

The difference between narrative memory and traumatic memory was demonstrated in the 1880s.   Traumatized people have little memory of the story of the events but later tend to act the events out emotionally.     The problem with PTSD is dissociation of the rational story from the emotional events, but when the two versions are reassociated (reintegrated), the undesired emotional effects end.    How can doctors, police, and social workers recognize someone is suffering from traumatic stress if he reenacts rather than remembers it?

Chapter 12 – The unbearable heaviness of remembering

Soldiers were traumatized in both world wars, but the effects and treatment were different, and You Tube has videos of soldier’s symptoms from both wars.

It was called shell shock in the first war variously labelled neurasthenia, ‘not yet diagnosed, Nervous (NYDN), officially denied and explained as men undisciplined, unwilling , and unfit to be soldiers.

In 1924 Congress awarded each US soldier $1.25/day overseas but it was never paid.   A Veteran demonstration of 15,000 on the Washington Mall for Immediate payment was forcefully dispersed.   The 1929 book ‘All Quiet on the Western Front’ and the movie in 1930 became the primary public description of the situation.  Van der Kolk links denial of the consequences of trauma with debasement of human rights and the rise of Hitler.

At the outbreak of WWII two psychiatrists published accounts of their work related to trauma in WWI in 1941.

After the first war affected men would flail, display facial tics, and collapse with paralyzed bodies but after the second war affected soldiers talked, cringed, had stomachs upset, hearts race, and overwhelming panic.   Culture shapes the expression of traumatic stress.
Van der Kolk observed in his work at the VA the young were admitted for psychiatric treatment but the old for medical treatment.    ‘The Body Keeps the Score’.    The physical ailments of veterans were treated at the VA but the psychological scars were not.  The latest writing on combat trauma he could find was in 1947.   The Vietnam war prompted numerous studies and the inclusion of the PTSD diagnosis.

Memory loss, repressed memory, is reported in people related to natural disasters, accidents, war, kidnapping, torture, concentration camps, physical and sexual abuse and PTSD.    A study of 136 girls, ages 10-12 admitted to the hospital for sexual abuse were interviewed in the 1970s and again 17 years later.    Thirty-eight percent did not recall the abuse (younger girls), 12% stated they had never been abused, and 68% reported other sexual abuse.

Recent neuroscience research has revealed that memories are modified in the recall process, the act of telling changes the tale.   Watching horror movies does not cause PTSD.  The terror and helplessness associated with PTSD can only be studied in the brains of traumatized people.

A 1994 study van der Kolk collaborated in asked 76 volunteers to describe a non-traumatic event in their lives and a traumatic event.    Two main differences were how the stories were organized and the teller’s physical reactions.   Non-traumatic events had a beginning, middle and end, but traumatic events were disorganized.    Eventually during the interview 85% could tell a coherent trauma story.  The five who had been abused as children had the most fragmented stories.    Their study confirmed an earlier report that traumatic memories are different than ordinary stories.

Research has shown that Cognitive Behavior Therapy (CBT) to find words to describe what happened to you can be transformative but does not always abolish PTSB symptoms.

He concludes the chapter with a long description of the director of nursing at a hospital who consulted with him several times related to anesthesia awareness after a routine outpatient laparoscopic surgery, which was traumatic.     After surgery her disturbing dreams were related to memories of conversations in the operating room.   She functioned well at work after returning but otherwise her life was greatly impacted by the memories, she lived a dual existence.  She finally found some help in psychodynamic therapy and Pilates.

Part Five – Paths to recovery:

Chapter 13 – Healing trauma: Owning yourself

A review of the new focus on integrating the emotional brain with the rational brain, including limbic system therapy, befriending the emotional brain with hyperarousal, mindfulness, relationships, and communal rhythms and synchrony, integrating traumatic memories, CBT, desensitization.    Available drugs treat some symptoms but do not treat the cause.

Chapter 14 – Language: Miracle and tyranny

Expressing your feelings, self-discovery, telling your story, our dual awareness, the body is the bridge, writing to yourself, art, music, and dance, and becoming ‘Some Body’.

Chapter 15 – Letting go of the past: EMDR

Eye Movement Desensitization and Reprocessing is able to eliminate painful recreations of trauma.    It was discovered by happenchance in 1987 when a psychiatrist noticed painful memories were dramatically removed by rapid eye movements.    Van der Kolk studied EDMR and collaborated in a study EDMR was more effective than drugs and cured rather than masking the symptoms.

The procedure can be done by a patient watching a clinician’s finger oscillate and doesn’t involve the relationship between the two of them.    There seems to be a relationship between EDMR and rapid eye movements during sleep.   How it works is not understood.

Chapter 16 – Learning to inhabit your body: Yoga

Focuses on the need to become safe in your body before being able to go back to explore your experiences.   The connection between breathing and heart rate variations, (a bottom-up regulation approach), and PTSD was first published by van der Kolk and collaborators in 2014.

Chapter 17 – Putting the pieces together: Self-leadership

Addresses the reality that the person with DTD primarily needs to do the work to heal, rather than getting fixed by a professional.

Chapter 18 – Filling in the holes: Creating structures

The focus is on PBSP (Pesso Boyden System Psychomotor) therapy, a partially scripted small group theater where one person is the protagonist, who is the focus of the process, which is claimed to access the protagonist’s amygdala.   The ‘witness’ asks the protagonist to describe some portion of their past experience, which the witness reflects back to their description in a supportive manner.    The witness then asks specific members of the group to represent various people in the protagonist’s story and exploration of the story continues.

Van der Kolk became a Pesso student and later when he was the protagonist and furniture rather than people were the only participants other than Pesso.  It is a method of rescripting your life by revisiting your past.

Chapter 19 – Applied neuroscience: Rewiring the fear-driven mind with brain/computer interface

Brain waves research demonstrates that all parts of the brain normally synchronize to extract the meaning of new information received but the brain waves of people with PTSD are less coordinated.  Van der Kolk describes the use of a neurofeedback to help the brain focus and calm the fear center which decreases trauma-based problems and improves executive function.

Chapter 20 – Finding your voice: Communal rhythms and Theater

Our sense of agency, how much we feel in control, is defined as our relationship with our body and its rhythms.   Collective movement and music create a larger context for our lives, a meaning beyond our individual fate.    Traumatized people are terrified to feel deeply and afraid of conflict.

Theater programs for angry frightened people have demonstrated great possibilities to help them embody their experiences and become competent.    Van der Kolk describes several variations that have been effective.

Epilogue: Choices to be made

Poverty, unemployment, social isolation, inferior schools, availability of guns, and substandard housing are all breeding ground for trauma.   Child abuse and neglect is the single most preventable cause of mental illness and a significant contributor to major lifestyle diseases and death.   The greatest hope for traumatized, abused, and neglected children is to receive a good education in schools where they are seen and known, where they can learn to regulate themselves and develop a sense of agency.   Feeling safe with other people defines mental health.  Trauma is now our most urgent public health issue.

Dr. Ranes specializes in applied neuroscience, i.e. taking new insights about how the brain operates from the laboratory, then doing the research and development work to make sure new clinical treatments and therapies are actually beneficial for patients with chronic pain.

The world of ‘Chronic pain’ found her while she was working for United Health Care.  Her task was to find insights to reduce the cost of chronic pain treatments.  She found about 21% of the population will deal with chronic pain sometime in their life.  The annual costs in the US related to chronic pain are over 500 billion dollars, and the pain can be debilitating for an individual.

She found that chronic pain was not significantly correlated with bodily damage, 80 to 90% of chronic pain has no clear structural cause.   However, laboratory MRI image studies of human brains showed chronic pain is correlated with life experiences that prompt a person’s brain to predict a threat of injury when no actual threat is present.

So, she started what she called ‘The Brain First Pain Clinic Experiment’ (in Las Vegas in 2020) where patients were referred by their medical doctor when no structural damage could be found.   Some clinicians had resistance to the possibility that a brain-centered therapy could provide realistic benefit and would not refer patients, so their patients were the control group.

The Clinic used therapies to help the patient reprogram their brain pathways away from unwarranted threats and therefore away from the pain (and other symptoms the brain uses to get the owner’s attention to change the situation that presents a perceived threat).  It worked, but the clinic was too small to meet the demand.

Her mission at Interoceptlabs.com is to scale the effective concepts from that Experimental Clinic into a format that will be embraced by future clinicians and patients.  To be effective, brain-based clinical elements need to have high engagement with both patient and the clinician, but the results are not instantaneous.  So, the therapy needs to continue long enough to change the neural pathways in the patient’s brain.

That means to do well in the mainstream setting, the therapy has to feel good to do, all by itself.  It is a really big journey to reprogram neural pathways and that has to be important to you, the patient.  The focus needs to be on the specific value for that person doing the reprogramming.

She recommends two books:  ‘Atomic Habits’ by James Clear and ‘Tiny Habits’ by BJ Fogg on concepts for making things really convenient and ‘sticky’.

Finally, she offers Bonus Tips around the concept of neuroplasticity (changing neural pathways).  Think of your most used neural pathways as regularly used freeways, but some take a high-threat route.  Building a low-threat route is like finding an alternate path through the adjacent woods to avoid the high-threat route.  Each attempt at a new neuron pathway builds a more serviceable alternate route.

Reducing the stress in your life, perhaps using meditation and mindfulness (e.g. Sitting with your mind to understand and accept its patterns.) helps you find new ways of thinking about the new route and a new belief system about the cause of your pain.  Getting enough sleep is super critical.

She writes a neuroscience blog ‘Firing and Wiring’ on Medium.com and invites questions.

In his final phase of gastroenterology training at UCLA Harbor Medical Center, a 37-year-old woman was referred to him for specialized testing after other universities had found no cause for her ailment of a single bowel movement per month.  Their test also found no cause and he was designated to do her exit interview.  He had never encountered anything like her situation.

He asked about stress in her life, expecting all prior doctors had also inquired, and she revealed her father molested her hundreds of times up to age 12, but she was otherwise happily married with two children.  It seemed improbable that stress 25 years prior could be a factor in her ailment, but he referred her to Dr. Kaplan, a psychiatrist he heard might be interested in this unusual mind and body problem.

Two and a half months later he inquired about the patient and Dr. Kaplan said she had met with the patient one hour a week for 8 or 10 weeks and she was cured with her bowels back to normal.  Thinking he might encounter a few such cases in his career he asked her to train him on her framework for evaluating and treating patients, i.e. the questions to ask patients to uncover the stress in their lives.  With that background he planned to send any similar unsolvable cases to a local mental health provider where he was practicing.

He actually encountered 5 – 6 such cases per week (7000 in his career) but only Cognitive Behavioral Therapy was available in Portland, Oregon. So, to serve his patients, he eventually learned how to uncover the stresses that caused ailments in patients referred to him with various illnesses that had no structural or disease cause.  He published a book in 2007 titled "They Can’t Find Anything Wrong” describing his approach and the key factors in about four dozen widely varying cases.

In 2011 he co-founded the PsychoPhysiologic Disorders Association and has served as President of the Association since then.  He refers to the illness as a PPD and shows statistics that 20% of the population suffers from the disorder, or about 20% of the adult population. The PPD population is 80% larger than the diabetic population and absolutely can be diagnosed.  PPD symptoms range from dizziness, to coughing, rashes, irritable bowel, migraine and a long list of both pains and non-pain symptoms.

He shows results of a randomized controlled trial, the Boulder chronic back pain study (published in 2021) where 150 patients with an average of 10 years of chronic pain, responded to 8 hours of Pain Relief Psychology with a 75% reduction in pain scores which was far better than standard treatment or placebos, and was sustained for the 1-year duration of the study.

He then describes how a disorder is diagnosed, citing blushing, physical discomfort prior to public speaking, and phantom limb pain as common examples of physical changes produced by emotions.   Adding an example of a nail in a worker’s boot that produced agonizing pain, but no tissue damage because the nail passed between his toes.

His 6-step evaluation process attempts to: discover the chronological relationship between stress experiences and ailments in a patient’s life story; then explore current stresses in their life; possible stress from adverse childhood experiences; and finally, three mental health factors; depression, post-traumatic stress, and anxiety.

Having patients make a list of all stresses in their lives, past and present, is a very useful technique.  Then start working to reduce some of the stresses on the list to discover those that relate to their symptoms.  When symptoms change that is encouragement to continue the process.  Reduction of current stress may yield to changes in personal boundaries or improving self-care like adequate sleep, nutrition, and personal time.

For previous stress experiences, revealing past emotions in secret, through writing or verbally   recording, elevates the emotion that causes a symptom into consciousness which relieves the brain from producing the symptom as a protective notice.

He recommends reading the resources available in the PPDA website, including a self-assessment questionnaire and his 2007 book ‘They Can’t Find Anything Wrong!’

He cites studies from Harvard, the Boulder Back Pain study and a West Los Angeles VA study, that all showed so much more long-term improvement in pain compared to normal treatment or Mindfulness practice that there is ‘nothing comparable in pain relief literature’.

Three doctors in a medium-sized city in New York were so enthusiastic they said the insights put the joy back into their practice and it then spread to 72 doctors in the community.

Pain is produced by the brain and can be chronic or acute. Chronic pain, which affects one in five Australians, is less about physical damage and more about nervous system sensitivity. To address chronic pain, it's important to retrain the brain through medication, stress reduction, lifestyle changes, emotional exploration, and gradual physical activity. Surgery may not be helpful, so a second opinion is advised. Taking a holistic approach can provide opportunities for managing and improving chronic pain.

Cindy Orr, a young woman who started a horse rescue program, tells her story of multiple adverse events in her earlier life and the relationship between her recovery and how her horses help people recover from adverse events.

Repeated traumatic experiences from the age of 3 and on into her adulthood shaped Ms. Orr’s life. She was frequently ill and in pain. Eventually her diagnoses included Lupus, PTSD, high blood pressure, irregular heartbeat, pain, anxiety, and depression. She was taking 16 medications and seeking advice and education related to pain management.

About five years ago she was at OHSU for medical tests related to sky-rocketing blood pressure and an irregular heartbeat. She experienced “the biggest turning point in my life” as she worried about who would take care of her 40 horses and 17 dogs if she died, then decided to recover to be able to care for them.

When she got home, she carefully read her medication labels and was shocked to realize how all their side effects affected her PTSD, anxiety, and depression. Ms. Orr focused on learning more about the links between trauma and pain as she got off all but her blood pressure medication. Given the understanding that pain was how her brain was protecting her from PAST threats, her sense of safety reassured her that she could increase her on-going activity level. She even began to jog for exercise.

Ms. Orr began Linn County Animal Rescue in 2008 and now runs a monthly “Healing Hearts with Horses” program. With her new sense of being “grounded,” she was able to shift her focus from sickness and pain to set goals to be around people and to help other people benefit from being with her horses.  Every month people with PTSD, physical disabilities, autism, and other mental/social/physical issues are welcomed to her stables.

Tyler recalls his early understanding of pain, that it was part of the human condition and pain was something that lived in our tissues.  He had traditional biomedical training in physical therapy including nociceptive fibers and the gate theory which focused on treatments to essentially shut the pain gate by overwhelming the skin with robust sensory stimulus   The presence of pain meant there was damage in the tissue.   Pain was a one-way signal in the nervous system.

In his first internship after therapy school he was introduced to ‘Explain Pain’ by Butler and Moseley but wrote it off because he was focused on manual therapy.  He thought he had magic hands and could fix anyone with just the right manipulation.  He used very medical language to explain things to his client.

After a number of years in practice he wasn’t seeing his persistent pain patients getting better, and realized they were stigmatized within the healthcare profession for not embracing the treatment they were offered.  So, he began to focus on listening to his patients tell their story, which led him to conclude there was a lot related to their situation that was not happening at the tissue level.

He became curious about the psychology of pain and the idea of trauma as a factor.  He found a lot of insight in multiple books he read, citing ‘The Body Keeps Score’ and six others, including ‘Explain Pain Supercharged’.   All together, they were the capstone that changed his practice.

He tried to become fluent in the multiple languages used by niches in healthcare and observed most treatments are passive, something the provider does for the patient.    He shifted the patient to the center of the healthcare team, changed his language toward less biomedical treatment to hopefully prevent it from inducing chronic pain in his patient.

The process of integrating a pretty dramatic paradigm shift to move from the underlying biomedical model to the biopsychosocial model is a challenge.   They now ask patients a lot of questions, but probably don’t afford the same grace to their colleagues because it is easier to teach patients who don’t rely on the biomedical model.

He offers four tips, related to reasons behind a belief system: 1) the need to listen and understand a patient or colleague’s beliefs ; 2) colleagues sometimes feel forced to abandon all their prior understanding and  change their practice overnight; 3) the mental discomfort in changing a belief system to include conflicting values; 4) the task of restructuring their belief system.  Evidence and logic are important, but beliefs are heavily tied with our values and our emotions.

He identifies two problems in his experience with other healthcare workers: 1) challenging a colleague’s belief system and; 2) that pain science informed treatments are physical ‘hands-off’ which is quite different from traditional physical therapy.  But it doesn’t have to be either this way or that way, it can be ‘both and’.

He recommends reshaping the language used so that it fosters a sense of safety and active neuroscience interventions.   He mentions a review of 8 studies comparing exercise with manual intervention and with neuroscience education for chronic low back pain.

Changing the beliefs and practices of providers is intertwined with emotions and values.  Use story and rely on the shared values among healthcare workers.

For 20 years Australian Trevor Barker took pills, minimized his movement, tried out various therapies, and was tested by numerous clinicians and specialists to help him deal with pain that started in his lower back and eventually spread all over his body. Instead of “failed low back surgery syndrome,” he self-diagnosed “TRMS” (Therapy Resistant Muscle Syndrome) and “PMS” (Poor Me Syndrome).

Participation in a three-week inpatient pain clinic enabled him to gradually taper off pain medication completely. And several months later he heard David Butler talk about DIM/SIM Therapy at a “Pain Revolution” event. His life changed as he applied these ideas and experiences. Instead of ending up living in a nursing home--as he had been expecting--Mr. Barker re-married, resumed work full time, and has built an “indoor rainforest” to enjoy.

DIM/SIM Therapy stands for "Danger in Me" and "Safety in Me." When people are stressed and worried, pain increases in response to a sense of danger. Calming an oversensitive pain system dials down pain levels that we experience as we feel safer and safer.

So, what do we do with the DIMs in our life? The dangers in me? It is possible to reflect on what they are and just think about what they are. He was able to change his DIM--"move, and you'll be in a whole lot of pain--"into a SIM by understanding that “moving is safe and helpful to me.” Now he has identified a very long list of what is safety in me.

When we identify our DIMs, the danger in me is often related to other people's stress. As he set out to identify his SIMs, he realized they are anything that gives him a calm, safe, fun, joyful time. His SIMs include sitting in his beautiful rainforest, having a cup of coffee or tea with his wife, unwinding and relaxing, warm water exercise, walking, going to work, being with family, and volunteering. There are many things that we can do that are SIMs.

The application of DIMs and SIMs really works on calming down our oversensitive pain system in a very practical way. Stress blocks the production of our happy hormones and calm releases them.

After asking “What are our ideas that generate SIMs?”, he provided some real-life examples that occurred shortly before his wedding: (1) Being unable to drive his car because his right leg “just decided to stop working” and he was in incredible pain. He called a friend who said, "Trevor, do you think you might be a bit stressed?" His leg got better quite quickly. (2) He needed two fillings, one on each side of his mouth. By using anesthesia, the dentist could do the fillings one at a time over a six week period or get them both done right away without anesthesia. He told himself, "Well, let's give this DIM/SIM theory ‘a real red hot go’--No needle." He sat back in the dentist chair and told himself, "This bloke knows what he is doing. He's alright. This is safe. I'm okay. And this is good for me." As the dentist started drilling, he had a gentle rubbing sensation.  Then halfway through getting drilled, he felt a “lightning bolt of pain” that seemed like “a joke on himself--my brain telling me that, ‘Yeah, we know something's going on here’." Getting the fillings finished all at once really worked out well for him.

Per Mr. Barker’s report, he learned that applying some self-management to his situation, taking responsibility, getting support, and calming down that oversensitive pain system really makes a big difference. His encouragement to people living with pain and to clinicians is to take a really good look at DIM/SIM Therapy and enjoy life. “Just great to talk with you.”

A minor incident fractured the ankle of a woman aged 26 but she didn’t have it examined.  Forty-one years later after many years of chronic ankle pain, an X-ray revealed multiple fractures, but surgical correction was not possible because lymphedema probably would hinder healing.

As the pain got worse, she sought physical therapy for some relief.  A program featuring Movement, Mindfulness, and Pain Science brought her the tools to manage her pain.  She realized she was anticipating pain each time she put pressure on her ankle and the Pain Triangle concepts helped her feel safe by learning to manage the anticipation and the pain.

Russell Wimmer is a Certified Physician Assistant and a member of the Oregon Pain Management Commission with two main parts to his comments: a) pain is a more complex concept than pain is physical suffering, or it results from a bodily disorder, and b) hearing his patient’s story is the most important and productive interaction he has with them.

He describes the well-documented case where a construction worker observes a spike sticking up through his boot and experiences tremendous pain.  Eventually with enough narcotics to calm him, they cut the boot off and find the spike between his toes, so no physical injury.  His pain was real but tissue damage wasn’t present, but his pain was real.

A 90 year old patient of his said her hip was bothering her for 2 weeks, walked up o his second floor office and said: ‘they made me come here’.  An x-ray revealed her femur broken but she wasn’t in a lot of pain.

The old approach assumed that if you had tissue damage, then you have pain, so when the damage is fixed the pain will go away.   But the truth is you can have pain without damage and damage without pain, a more complex situation.

He tells a third story of a patient who developed chronic pain after several abdominal surgeries.  Over the years a series of various clinicians had eventually prescribed methadone, which controlled the pain better than other medications.  Her next clinician refused to renew the prescription because they assumed she was addicted, and she eventually came to him.   He was able to change her pain experience because he listened to her story and was able to help her have more influence over her pain.  She still has some persistent pain but her life is very different.

He asks: ‘why is pain so difficult to communicate?’.  They just stop trying’.   His approach is: ‘I just want to know your story.’   It takes vulnerability for the patient saying: ‘I just want you to understand’.   How pain affects the patient is what he wants to hear.   He takes his eyes off the screen and asks: ‘What do you mean?’  That is the bridge that opens the opportunity or others to help change the story.   No one was really hearing what she was saying.

He learned this perspective by shadowing Sharna Prasad (PT at Lebanon hospital).  Not all pain can go away, but it can change and the process starts by the patient sharing what pain is to them so a whole team can help make the change.   Going forward is the only thing to do.

I am Mo Forrest. I am 78 years old and the Treasurer of the Oregon Pain Science Alliance. My trauma started in my early childhood because my father was an abusive alcoholic. I’ll just say I was very scared of him; I would tell my mom that my bones shake.

When I was seven, my Mother’s Brother (a Catholic priest), came to see us and asked my mom why she didn’t leave. She said because divorce is a sin. He said “God does not want you to live this way” that he needed a house keeper and she could bring us kids. That was the security she needed. She gave us each a paper bag and said to pack what we wanted. I didn’t want to pack for fear he would come home. Life was better living in the rectory. I felt more
secure although I had dreams that he would find us and kill us. My dad died when I was 12 and the dreams stopped. We were in the rectory for three years.

I always tried to hide the pain from my mother. I was protective of her, having seen her abuse. I never wanted to worry her. When I was 14, I had bad pain in my abdominal area. and she found out. The first doctor I saw said he didn’t know what it was, but was definitely not the appendix. I couldn’t relax for an examination, so an exploratory surgery was done. Finding nothing wrong with my female organs he looked at the appendix. It was estimated that it had been ruptured for two months. Gangrene and peritonitis had set in. I lay in the hospital bed, and I could hear people outside my door saying, “she should be dead.” I got so I wouldn’t talk to anyone. It was a trauma for me.

Eventually my mom had a boarding house. I had my three brothers and mom and felt safe. My mom was always sick, and I had a lot of responsibilities. I got married at 19 and my husband worked nights. I started to have real bad pain at night. It was my joints would cramp so bad I couldn’t move. My doctor sent me to a physiatrist. After working with her for a while, she thought the pain was because my dad came home at night. WOW, that was it. I wasn’t given any help on how to get over the pain at night I just figured that pain was to be my life.

About five years ago my son took a class called Acceptance, Commitment and Therapy, taught by Lianne Dyche. He said it was a good class and I should take it, so I did, and it was a good class. About that time the Samaritan Lebanon Hospital Physical Therapy Department was teaching a class called Movement, Mindfulness and Pain Science. Lianne thought I should take the class next, so I did. What I learned in that class changed my life.

I was on 18 different meds including an opioid then, but now just 6 and no opioids. I have had 16 surgeries. I have Crohn’s disease, which causes cramping in my abdomen and inflammation in the joints. I have neuropathy. My legs and my feet are numb with shooting pains and I have
kidney disease. I had a stroke and have a pacemaker. But now I am doing great.

So what did I learn that helped me so much? I learned that chronic pain is where there is no tissue damage and is often caused by trauma. I learned I can manage the pain and that all pain is real. The Pain Triangle (analogy) was very helpful where the three sides are sensations, thoughts, and emotions. And like the Fire Triangle, if you remove any side, you can control (the fire or) your pain. I learned that we have a powerful brain that controls pain. And better
yet, we can (re)program the brain so it doesn’t send out pain messages when there is no tissue damage. I also learned how important movement is. If you feel like you can’t move the best thing to do is to move even it is only a few feet to start. I also learned not to visualize that something is going to hurt; if you do, then it will hurt. I learned to pace myself. Now that I understand the pain science what I use most is deep breathing and mindfulness.

So how did I apply what I learned to manage my chronic pain? I always thought that I would be like my Mom. That her fate would be my fate. After the doctor said I couldn’t take care of her at home anymore, she was in a nursing home for years. When she died she had strong seizures and only her face moved. How different her life would have been if the new pain science was known then. I got over fear by deep breathing and mindfulness. I would feel my breath come in threw my nose and down to abdomen and back out slowly keeping my mind on the breathing.

I would say over and over again that I was not my mother, that I am a separate person. That I am an individual who is healthy and strong, which helped my back pain. It takes a while (to learn) but it works. I still get pain but I know what to do so I can keep functioning. What I did for the chronic pain caused by my fear of my dad was the same method, deep breathing and mindfulness. I would say over and over again that nighttime was a peaceful
time. That everything slows down and it is a quiet time. There is nothing outside that isn’t out there during the day. I completely got over the night pain and the fear of the night.

What works for me may not work for you. We are all different. Find out what works for you. Join our Self Care Meetings; we (the Oregon Pain Science Alliance) have 8 meetings per year. Check our Resource List. Have your doctor give you a referral to the MAPS classes (Samaritan Hospital Lebanon, Oregon). You can also search YouTube for “pain science” and Lorimer Moseley. Give us your email and we will keep you informed.

My mom always said to love our dad, that he was sick. I couldn’t understand how she could say that. I realize due to the stress and anxiety that runs in the family that she was right; he was self-medicating. I forgave him and learned to love him.

Dr. Katie Smith, occupational therapist, discusses how she integrates the concepts of pain science into her clinical practice and her own life.

The old paradigm initiated by Descartes considered the Mind/energy and Body/matter to be separate and different, a duality of two separate entities.    That perspective interpreted an internal result to be due to an external stimulus, so pain had a mechanistic cause from something external to the body.   When an external entity has the power, a person has no internal power, or agency to change the situation.  Prior to modern science research the understanding of the Mind/energy influence was not measurable.

The new paradigm is an understanding based on the tools of science.   Specialized areas like psychoneuroimmunology, epigenetics, neuroplasticity, and quantum physics can return power and authority to our lives.

The notion of Emergent processes combines multiple internal and external factors to become something other than the sum of the factors.  Pain, fire and baking a cake are examples of emergent processes.

Her clinical process as an OT includes both psychoemotional and cognitive factors.  Using a concept from REBT (Rational Emotive  Behavioral Therapy) and CBT (Cognitive Behavioral Therapy) helps find where and how change can happen for a person.   The new paradigm considers the Activating event and Beliefs that act to produce the Consequence, A + B > C, while the old paradigm was simply A > C.   For example, if you step on my foot (A), and if I believe you did it because you are a jerk (B), then I get angry (C).   So Beliefs are the seat of power.   We cannot control the Action and there will be a Consequence, but our individual power in the sequence is focused by our Beliefs.

Her process is to initially focus on supporting the person’s sense of internal power and decreasing their sense of external threat.   Internal resources are sleep, stress management, energy and pacing, nutrition and exercise, etc., while decreasing threat involves: Environmental modifications, sensory modifications, task adaptations, etc.  That sequence supports therapeutic alliance, increases self-efficacy, to shift from survival to creativity and cognitive flexibility where change is possible.

Then she addresses the individual’s beliefs

Her personal story included learning helplessness and a sense of enfeeblement as a child, pain in young adulthood, and her search for a diagnosis and external support.   Three encounters with different healthcare providers were pivotal in shifting her beliefs from being vulnerable and weak to strong and resilient.

Despite all of my training and everything I did in the clinic; my pain patients weren’t consistently improving; I was noticing dichotomies that didn’t make sense; and it felt like I was playing a game of “whack-a-mole.” That humbling experience started me on this transformative journey.

I started reading--including old research--focusing on neurobiology to learn more about pain. There were neurosurgical experiments which taught us about the different fibers sending signals throughout your body up to your brain, and how the brain uses them differently. Melzack and Wall originated the Gate Control Theory of Pain in 1965. In 1968, Melzack & Casey proposed a new model which identified sensory, motivational, and central control determinants of chronic pain. It was easy for me to make sense of their sensory aspect of pain—but I wasn’t well-trained regarding the emotions, depression, and understanding trauma. That led me to the 1970’s work of John Sarno, a physiatrist at Columbia University who published a very popular book called Healing Back Pain. After getting mixed treatment results, Dr. Sarno concluded that long-lasting pain without an identifiable cause is due to repressed emotions constricting the back muscles and causing pain to shoot to the brain.

I was struggling to put what I was learning all together--asking myself questions, trying to take in and make sense of this information. IF acute pain and chronic pain are different, how can we still make sense of chronic pain? IF -as Melzack posited in his 1999 “Neuromatrix Theory”- pain has a sensory-discriminative aspect, affective-motivational aspect, and cognitive-evaluative aspect, how does this make sense for chronic pain?

My very, very first pain model featured pain, sensation, and experience. It was a real struggle to put together what I had learned about how emotions, trauma, and early life experiences impact pain. The model included a microphone, sound mixing board, and a speaker system. It was very sequential, with inputs leading to pain as the output.

Currently people talk about “mind body integration” and how “bio-psycho-social factors” influence pain, but they are still equating pain with sensation, with bodily damage.   Pain is actually a protector. A lot of people, including Lorimer Moseley, identify learned pathways or learned patterns. And how can we explain experiences like Sarno’s patients, who went to a presentation or read a book and their pain went away? Unfortunately, none of these amazing practices consistently make sense and acute pain is generally not included—because it’s nociceptive and seems so easy to understand. Something was missing, so I went back to reading, reading, and reading.

The first fundamental to understanding pain is shifting away from the idea that pain indicates bodily damage. The second fundamental is understanding pain as a constructed process of Melzack’s three critical components coming together all at the same time—not sequentially. I thought I understood it, but my thoughts kept going round and round until I was listening to a business podcast introduced me to a concept called “emergence.” Our brains actually work in an emergent fashion as they deal with complex information in milliseconds in order to create a multi-faceted perception.

The Fire Triangle (commonly used in outdoor and institutional safety training settings) shows us how to put out a fire by taking away its fuel, its oxygen, and/or its heat. An experience of pain requires all three of its elements--sensation (fuel), emotion (oxygen), and cognition (heat), hence “The Pain Triangle.” Extending the analogy to pain means that reducing or removing one or more of the pain components decreases the pain experience.

The Pain Triangle dimensions diagram.

Given that pain is a constructed experience, we have to be thinking in a minimum of three dimensions when working with our patients. Three examples are given: acute pain with obvious tissue damage, acute pain with no obvious tissue damage, and chronic pain. This thinking process is a lot simpler in acute care settings.

This lack of an emergent category of thinking is by far the biggest problem that I think that we have when it comes to pain and pain education. And the Pain Triangle has been the fastest way I’ve found to teach an emergent process. Patients can sense increased control in their lives and their experiences as they understand why and how they feel, and they're empowered to make changes. And that's the power of the Pain Triangle.

(This is a follow-on presentation from PSLS 1007 where he describes The Pain Triangle and how he uses it in practice.)

Dr. Jonathan Betlinski is a professor at Oregon Health Science University and Director of Public Psychiatry.  His story (Linking Trauma and Pain) opens with three personal experiences that piqued his interest relating to trauma and pain—concluding with: ‘Why is it some things hurt, and others don’t?’

• At 16, he encountered loose gravel while mountain biking.  He lost control, was thrown from his bicycle, and experienced multiple abrasions.   He felt little pain and continued with his ride.
• At 20, while mountain biking on a dirt track, he flipped end-over-end. Before his hitting the ground, he experienced pain.
• That same year, a water-skiing incident caused his ski to hit him in the mouth, breaking two teeth and damaging the rest.  This only caused pain on impact, but no pain afterward.

During his medical training, the Veterans Health Administration added ‘pain’ as the 5^th vital sign which added a dramatic shift in healthcare practice to minimize chronic pain.  This practice helped to create the opioid crisis with the use of addictive opioid medication.  His internship in the ER treating overdose and withdrawals led to a psychiatry residency and furthered his interest in how trauma relates to pain.

His talk identifies the similarity and overlap between symptoms of PTSD and Chronic Non-Cancer Pain using statistical data, then discusses how ‘traumatization occurs when both internal and external resources are inadequate to cope with the external threat’ and how similar threats may not produce similar responses in everyone, or on every instance.

Dr. Betlinski then addresses the Adverse Childhood Experiences (ACEs) study.  This revolutionary research asked yes/no questions regarding 10 possible life experiences (including abuse, neglect, domestic violence, substance abuse, divorce).  More than 2/3 of the 17,000 subjects had at least one adverse childhood experience, and often more than one.  Those 10 questions account for more than half of one’s risk of developing chronic diseases or having a shorter lifespan.  The study clearly displays the trauma/pain relationship and how trauma changes us.

His discussion further looks at how early trauma impacts the life of an individual through brain development and functionality, and that the kind of environment your brain is in when you’re growing has a profound effect.  The number of cells in the brain and their interconnections change through life, sometimes rapidly; the number of cells depends on a person’s experiences; and changes in the number of cells continue to occur throughout life, not only from the impact of trauma, but also of healing.

He goes on to cover the differentiating roles of the decision centers in the brain:

1. The Amygdala, which develops first in children for spontaneous and quick responses to protect one in a fight or flight situation (e.g. a newborn or young baby crying for help)
2. The Hippocampus, which starts to develop around 4 months of age, helps with short- and long-term memory.  By 2 years of age, a child can take stock of immediate surrounding to either agree or disagree with the Amygdala’s threat assessment.
3. And last, the Prefrontal Cortex, the last to develop (around puberty), where thought-based decisions are made, which take much longer times for decisions that are dependent on the person’s attention to various situations.

Growing up in a traumatic environment leads people to rely on their amygdala’s assessment in order to survive.  These people may be able to use other pathways for thinking and reasoning when they feel really safe, but their default becomes relying on the amygdala.  And, in fact, functional MRI testing in these cases shows a thinner, less robust cortex, and sometimes even a poorly developed hippocampus.  The brain is wired to the body and all organs through the vagus nerve thus affecting function and development.

Trauma overwhelms us.  It overwhelms our ability to self-regulate.  And when we can’t do that, we stop being able to recognize our own emotions.

Dr. Betlinski credits Dr. Bruce Perry’s suggestion to change the basic question when addressing someone who has been affected by trauma from “What’s wrong with you?” to “What’s happened to you?”  This allows us to reinterpret what’s happened through the lens of trauma exposure.  By listening to understand what’s going on for other people instead of listening for our turn to talk, communication is open and healing can begin to happen.

In summary, trauma and pain are common.  They require our brains and bodies.  Recovery can be our expectation.  Change starts with us.

Dr. Cuccaro weaves his journey throughout his discussion of concepts around modern pain science. He was trained in: anesthesiology at the University of Chicago, pain medicine fellowship at University of Michigan, and as the Associate director of a Navy medicine pain fellowship program.

He was engaged in the group practice model in the military where patients were diagnosed, treated, and followed-up by different doctors. That could be called discordant care, but his colleague’s practices were not hidden from him. Some were conservative, some aggressive, so the actual practice varied greatly. He observed patients with the same pathology and procedure got vastly different results, which he thought it was
due to the military practice model.

Afterward, he became the sole pain specialist, using standard conservative practices in a Corvallis clinic, so could follow all the evidence. He quickly realized his results were as inconsistent as the military model, which was discouraging because he wanted his patients to be back out in the community living life. He began looking with critical eye at interventional pain procedures and found very little evidence to support
them. Treatments for persistent pain had minimal if any evidential support. The procedures didn’t work, which led him to ask himself if he understood the pain problem.

He started looking at the published literature on pain and found vast amounts of good research. Lorimer Moseley of Adelaide Australia became his mentor. There was more to pain than he had been taught in school. Understanding the neuroscience of pain fundamentally changed his practice.

He stopped doing needle interventions, got involved in clinical education and changed his personal relationship with pain. Pain was no longer threatening and his new insight changed how he lived his life. He then discussed four transformative topics:

1. Pain is protection
2. Pain construction and deconstruction
3. Pain and time
4. Pain and power

What is pain? Do we actually understand what it is and is not, and how and why we experience it? He displays a picture of a large nail penetrating a worker’s boot and asks, if the wearer experienced pain? Yes, he was in a lot of pain, but in fact the nail went between his toes, so there was no tissue injury.

A second picture shows a nail through a worker’s thumb, from a video showing the crew joking while they cut the nail and pulled it out. The worker had pain, but not extreme. The current healthcare system can’t explain the different reactions in the two situations, this is not a matter of real pain vs faked pain. All pain is about protection. It’s a complex biological experience associated with each person’s past experiences. Increased threat leads to increased pain.

The common understanding is that pain comes from somewhere, but the two earlier examples demonstrate the failure of that explanation. When there is pain in the foot but no injury, the only explanation that makes sense is that the experience of pain was in the brain itself. He shows a 15 th century medical diagram suggesting that a pain-pus particle from a pain sensor in the foot stimulates the brain. Medical treatments try to block or minimize that ‘flow of pain’, so if that nerve was cut the pain should end, but it does not.

He displays a slide of statistics on treating persistent pain, showing the pain change after surgery, injections, or drugs the pain situation is not better, which is the case anywhere in the world. The correlation between tissue damage and pain experienced is not a cause-and-effect phenomenon. A linear process relationship between injury and pain doesn’t explain all pain.

He then displays a different way to think about pain, the Melzack and Wall neuromatrix theory, that he calls the construction of pain. A pain experience has: multiple inputs, including sensory inputs; long-term memory; and evaluative input.

Thinking about mastering pain is like firefighter thinking for controlling a fire. Three elements are needed for fire: fuel, oxygen and hea; so a fire is controlled by removing or reducing one or more of the elements. Similarly, pain is constructed in a dynamic process from three aspects: sensory, emotional, and cognitive. The sensory input is like fuel; pain meaning from memories is like oxygen; and finally actually paying attention, i.e. current thoughts are like heat.

Sensory inputs are not the same thing as pain. Pain is a constructed process. What else is happening that threaten the person? The Key transformation concepts are: thinking pain doesn’t equal damage; increasing a sense of safety and protection; and alignment with past experiences. Two final concepts are: the three different time perspectives in the brain: past, present, and future; and the sense of whether the person sees protection or threat in the present situation.

(The continuation of Dr. Cucarro’s Key Transformation Concepts is in PSLS 100.)

Her husband said her explanation in this presentation makes sense, pain is in the brain and real.

1. Her story
   • 2008 med grad, learned: pain markers; opiate dosage; her goal was for patients to have no pain
   • 2012 started residency, knew everything, thought she could solve anything
   • 2014 felt like she was failing, pain must mean be tissue damage, but her patients got sicker
2. 2021 went to Oregon Pain Summit 2019, 2 day intensive learning about the science of pain, began listening to patients, I’m still learning, but am now closer to where I want to be.
3. My Presentation goals’
   • How to explain pain so it makes sense, i.e. what happens when I stub my toe?
   • How does pain become chronic?
   • How does knowing about pain science help?
   • In the 1600s doctors thought pain was a single, off or on signal, sent from the injured tissue location to the brain. (Jrk, That explanation probably represents the belief of most people based on their pain experiences.)
4. ‘How can we know if that pain model is true?’
   • Consider the insight from these 4 neuroscience experiments, which reveal that the danger signal sent by nociceptive sensors in the skin, is not an off/on signal. In the first three experiments a heated probe contacts the skin of a volunteer and the signal from nociceptor sensors is recorded, along with the subjective response of the volunteer.
   • The sensors begin to send ‘Danger’ signals at 105.8F, but the pain threshold (when the volunteer says ‘ouch’) occurs at 111F: so the nociceptor signal is not an off/on pain signal, but functions as a danger signal.
   • Sharp pins were applied onto but not into the volunteer’s skin, at room temperature the pin produced a sensor signal pulse rate 2/sec, hot pins caused a sensor signal rate of 10/sec, the nociceptor signal rate increased between start and ouch temps: so again, the sensor signal is not an off/on signal, and the volunteers were not able to differentiate signal rate change as the pin temperature increased.
   • Skin Probe diameters of 1, 4, and 20 mm were applied to volunteer’s skin, all at 113F, which was above the ouch threshold, the volunteers described the probe feeling as: pricking pain for a 1mm size probe , stinging pain for a 4mm probe, and a pleasant strong warmth for a 20mm probe: so the perceived sensation varied with the contact area of the probe, but the temperature was the same for all sizes of probe.
   • A fourth experiment applied a painful hot or pinching stimulus to a volunteer’s skin for 15 seconds: the recorded nociceptor danger signal was initially very active, then decayed to nothing, but the pain feeling continued to increase as the signal level decayed: so the perceived pain level did not correspond to the presence of a nociceptor signal.
5. ‘What is really happening?’
   • The nociceptor sensor was not actually in contact with the test probes, but only nearby. Other experiments revealed the activation of a nociceptor sensor initiated the release of chemicals in the sensor area that are necessary for the tissue to heal itself, (serotonin, etc.), whether the pain is perceived as acute or chronic.
   • And the response was influenced by endorphins.
   • The nociceptor signal was transmitted to the spinal cord, where the signal changed the chord sensors and they become more sensitive, based on past injuries to the same nociceptor sensor site.
   • Signals were then sent on to the thalamus in the brain, which influences other parts of the limbic system, but all parts of the brains seem to be involved, including memories and cognitive aspects: the more frequently an experience occurred, the easier it was to prompt a painful response.
6. How does pain stick?’
   • Salience is an important neuroscience concept - if a pain experience is salient to well-being, it will stick, otherwise recovery is rapid.
   • An injury will prompt either a catastrophizing loop or a recovery loop in a person’s brain.
   • The tendency for an injury to activate either loop varies for individuals.
   • This tendency is ‘hardwired’ and not the fault of the individual.
7. Institute of Medicine report in 2011 by Turk and Theodore, (pain scientists at the University of Washington) - contains a quote she loves:
   • ‘In fact, beliefs, anticipation, and expectation are better predictors of pain and disability than any physical pathology’.
   • That ties it all together for me!
   • Beliefs seem to be ‘hardwired’, rather than simply individual choices.
8. As an example, Adverse Childhood Experiences, (ACES) have been shown to be directly related to general health and longevity.
   • A 1995 study revealed that youth chronic pain was significantly associated with toxic (destructive) stress, for example fibromyalgia in youths:
   • was greater for children with a history of physical abuse, neglect, household dysfunction, and
   • The life cycle of chronic pain risk factors depended on belief about pain (see slide)
9. ‘Maslow’s hierarchy of needs’ (a theory from the 1940s)
   • (slide shows 5 levels of need: Physiological, safety, love. belonging, esteem, self-actualization.)
10. Considering pain an absence of safety, i.e. perhaps it reflects a threat to the first physiological level elements of breathing, food, water, sec, sleep, homeostasis, excretion.
11.  ‘Why does this matter?’
    • a person can change the way they think about pain. (Jrk - that’s the reason pain science understanding is important for mastering pain.)
    • (Slide contrasting two differing perspectives that consider pain either as tissue injury or protection, for these four responses to a pain experience: the person’s goal (expected outcome) of the experience, their reaction to worsening pain, their willingness to move, and their thoughts about the future.)
    • ‘Because of neural plasticity, the brain can restore connections and the experience of pain can be changed.’
12. ‘Summary - what I have learned’
    • All pain is pain
    • All pain is real
    • All pain can change

The basic concepts of Occupational Therapy center on four occupations of our daily lives: work, play, rest, and sleep. “Work” includes unpaid activities that have monetary value, for example cooking a meal is “work.” “Play” is what we do for fun. “Sleep” is sleep. “Rest” is activities that promote a sense of peace and calm. Occupational Therapy patient care goals relate to these four occupations. Since her 1978 graduation from USC, most of Candace’s career focused on the occupations “Work” and “Rest.”

Around 1983 she took a job in Sacred Heart Medical Center’s new regional rehabilitation program for people who had been injured on the job. The Injured Workers Program (IWP) was an all-day 4 week out-patient multi-disciplinary program. The care team included a Psychologist, Rehab. Medicine doctors, Vocational Counselors and three kinds of therapists—Occupational, Physical, and Recreational.

IWP’s approach to treating chronic pain was based on Melzack and Wall’s 1965 Gate Control Theory. The team was expected to help their patients “close the gate” between their brain and spinal cord to reduce their pain by the combination of biofeedback/relaxation training, gradually increasing activity and exercise levels, psychological treatment, and focusing on the hope of return to work. When oxycontin was being promoted as “safe” for people with chronic pain, it was occasionally prescribed for patients.

IWP’s overall goal was for patients to have the self-management skills, strength, and endurance to return to their regular jobs. Truck driving and millwork were the most common jobs.

As an Occupational Therapist, her primary role was to collaborate with the patient to identify their really challenging job tasks. Then think of a way to simulate those job tasks. They’d start at an easy level and gradually increase their physical capacities. She probably visited every type of mill there is to be able to more accurately simulate her patients’ job tasks.

When the Injured Workers Program was eliminated in 2001, she went to a brand-new Occupational Therapy job in the Employee Health & Safety Department, where she was an in-house consultant. Her task was to apply ergonomic principles to manual materials handling jobs, patient care jobs, and office jobs. She did Job Analyses and assisted with the return-to-work process for injured staff. Typically, pain and fear were the barriers to injured hospital staff’s return to regular work.
In the late 2000-teens she stumbled onto the You Tube video ‘Understanding pain in less than 5 minutes and what to do about it’, https://www.youtube.com/watch?v=C_3phB93rvI&t=17s. The video presented multiple factors contributing to pain which were already familiar to her, so it was easy to discuss with injured workers. She now realizes the frame of reference behind the Understanding Pain video was not the old familiar Gate Control Theory, but a pain-science-based understanding of how pain is constructed. At the time she still thought acute pain was very different from chronic pain. She didn’t really grasp the news that pain scientists had found that pain originates in the brain and not in the injured body part.

Thinking over her patient care experiences, it’s clear that both her IWP patients and her injured co-workers were afraid of overdoing it. They worried about increasing their pain level. They worried about causing bodily harm.

Although Candace hadn’t learned to see pain as a “Protector,” one focus of her Occupational Therapy practice was increasing injured workers’ sense of “Safety” and “Security.” During her Injured Workers Program days, the security and safety came from simulating key job tasks in the clinic and gradually increasing their level of physical demand to match the workers’ real-life jobs. During her Employee Health & Safety days, the doctor’s Return-to-Work Release served as a guide to safety and security.

The work release usually specified the amount of weight and force the injured worker could lift, carry, push, or pull. It might also set specific restrictions for walking, reaching, standing, and sitting. For example, if a Certified Nursing Assistant was released to 10 lb, intermittent reach above shoulder height, and no bending or twisting, Candace could the assure the C.N.A. that they were safe doing the following job tasks: greet and direct visitors, stock small supplies, collect meal trays and small patient care machines, assist patients with grooming & feeding, answer call lights, and prepare rooms for new admits (including moving the overbed table).

Another thing she did to build up an injured worker’s sense of safety and security as they performed physically active jobs was teaching them what she calls “Positions of Strength.” These are movement patterns based on biomechanical and ergonomic research. She would meet Sacred Heart injured workers at their job sites and they would practice these movement patterns.

Candace finds it ironic that she started to learn about the newer understanding of pain right when her job was being eliminated. In March 2019 at the Governor’s Occupational Safety and Health Conference she had the opportunity to hear a presentation by an OHSU Psychologist, Catriona Buist. In October 2019 at the Annual Conference of the Occupational Therapy Association of Oregon she heard a talk by Dr. Kevin Cuccaro about the new understanding of pain and met Physical Therapist Sharna Prasad who told her about the January 2020 Second Oregon Pain Summit. Since then she has taken classes from Dr. Cuccaro and read books by Lorimer Moseley.

Doing this presentation led Candace to remember her own worst experience with pain. It was a frozen right shoulder. Her car had a stick-shift so she had to take the bus to work. She was very angry about the hassle, the pain, and the inconvenience. Her Physical Therapist treated her with modalities and range-of-motion exercises. The pain went away and she was glad to drive a car again.

Why didn’t it all drag out? Candace asked herself: Was it because I trusted that my PT and my doctor knew what they were doing? Was it because they were sure of how long it would take me to get better and I believed them? Was it because my PT had a very soothing manner? With my new understanding of how pain works, I’d say it was everything put together—cognition, emotion, and sensation.

What’s next for her Occupational Therapy career and Pain Science? She hopes to teach POSITIONS OF STRENGTH in community settings--possibly Parks & Recreation Departments, Senior housing, community groups—and even 1:1 as the opportunity arises. POSITIONS OF STRENGTH aren’t directly related to Pain Science, but concepts such as safety, protection, and brain-body connections can be woven into the benefits of moving through POSITIONS OF STRENGTH.

Mr. Murphy has been a Physical Therapist for 11 years and has a pain coaching business.  Recently he was certified in Pain Reprocessing Therapy. Personal experience with repeated bouts of back pain and unsuccessful treatments as he worked in a geriatrics/home health setting derailed his career and family plans.

One of his therapists tried to tell him about mind and body approaches and the science of pain and he just didn't get it. Now he has learned that pain is a lot more complicated than just a message signal that travels up through your body from an injury and rings a little pain bell in your brain.

The most common cause of long-term pain is different from acute pain. Researchers have found that only about 10% of long-term pain is caused by existing physical or structural problems. Most long-term pain results from neuroplastic causes or origins, meaning there's been some change within the nervous system that produces the pain.

Neuroplastic pain is a brain mistake, safe sensations within the body are interpreted as dangerous. In Mr. Murphy’s case, “My back had healed but the sensations in my body around my back were no longer being interpreted as safe by my brain and my nervous system.” Analogies of neuroplastic pain are an extremely loud hearing aid setting or a mis-calibrated alarm system.  Neuroplastic pain mistakes can be changed.

Regardless of its cause, all pain is real.  It is all experienced in the body. In fact, researchers have found that neuroplastic pain mimics real physical pain in any part of the body and the same areas of the brain are involved with that experience of pain.

Researchers use a “functional MRI” to look at real time brain activity. When human subjects are poked with a hot probe to provoke pain, certain parts of their brain light up with activity. If subjects were told under hypnosis that they were being poked with a hot probe, the same areas of the brain lit up with pain and they reported experiencing pain. It doesn’t matter whether they have acute pain or neuroplastic pain, the same areas of the brain are involved with that same pain experience.

This whole idea was a real turning point for Mr. Murphy—he felt hopeful enough to try mind-body treatment approaches instead of thinking that repeated injuries to his back were causing his pain.

The whole goal of mind and body treatment approaches is to help the brain begin to reinterpret those sensations as “safe” or “neutral” and reduce or turn down the neuroplastic pain level. Going back to his hearing aid analogy—it’s possible to reduce the amplification of these sensations in the body so they no longer experienced as long-term pain.

Researchers using functional MRI scans of brain areas have found the following effects associated with mind body practices to reduce neuroplastic pain:

1. When neuroplastic pain is present, pain areas in the brain are active all the time and the pain interferes with sleep, digestion, the endocrine and immune systems--all kinds of normal body functions.
2. After the subjects have engaged in mind-body practices, they report reduced neuroplastic pain. Repeat brain scans show that the previously active pain areas have quieted down and are engaged in their normal brain functions. And when subjects experience an acute injury (prodding with a hot probe), the brain scans light up, then go back to their normal resting state, and wait to warn of danger rather than just being on constantly.

What are mind and body approaches? Common ones are yoga and tai chi, meditation, mindfulness, somatic tracking, guided imagery. There are tons of resources—You Tube, books, websites, videos. Two resources that effectively blend mind-body approaches with pain science education are the Curable app and Pain Reprocessing Therapy.

How can it be determined if long-term pain is due to neuroplastic causes/changes in the brain and the nervous system?  Symptom patterns in people who have neuroplastic pain are very different from symptom patterns associated with structural or physical-caused pain. He provides a list of eleven characteristics of neuroplastic pain.

Mr. Murphy has put together an online neuroplastic pain questionnaire and can give you a personalized response to help you determine if your pain is neuroplastic. Pain Reprocessing Therapy Pain Quiz (murphypaincoaching.com)

In summary, yes, your pain is real. If you've had it a long time or a short time, from an injury or not--no matter where it's coming from, pain is real. The reason that healthcare treatments for your pain have failed may be because they've been focused on the wrong target. If treatments have been focused on physical structural problems, but long-term pain is usually neuroplastic, that is, a change in the nervous system rather than in body tissues. But there's hope. Neuroplastic pain is reversible. Mind body approaches are very effective at helping to retrain the brain, calm down the nervous system, and help reduce pain.

I am 78 years old.  My name is Mo Forrest.  I have been in pain since I was 14 years old due to Crohn’s disease.  Tonight I am going to talk about my Father.

He was an abusive alcoholic.  I watched him beat my Mother, my brother and myself.  He would hold me up by one hand and beat me with his belt.  I was so scared of him that I would tell my Mother that my bones would shake.  I remember waiting in the car outside a tavern for my Dad to come out.  I saw the lady next door go into the tavern.   A few days later she helped my Mom make sandwiches for lunch.  I would not eat mine because she had touched it.   She had been in a tavern and taverns are bad.  I was 6 years old.  I remember him passed out on the kitchen floor and Mom saying she had to give him his insulin shot or he would die.  I went around the corner and prayed she wouldn’t give it to him.  I felt guilty about my prayer.

My Uncle, a Catholic Priest, asked why she didn't leave.  She said it was a sin to get a divorce.  He said God didn’t want her to live that way.  He would help her and she became his housekeeper.  I lived in a rectory for a few years.  I was 7 when we left.  Life was better but I had a dream that he would come and kill us all.  I was 12 when he died.  The dreams stopped but I still had fears of the night.  In my 20’s I was in constant pain at night.  I think it got worse because as an adult I had to go out at night and my husband worked nights.  My pain would get so bad I couldn’t move.  My Doctor gave me no instructions on anything that would help me.  I was sent to a psychiatrist.  She said it was because I was afraid my Dad would come home at night.  BINGO that was it.  But I had no instructions on how to handle that fear.  I felt that pain was to be my life.

About 8 years ago I took a class called Acceptance and Commitment Therapy taught by Lianne Dyche.  Lianne suggested that I take the ‘Movement, Mindfulness and Pain Science’ class at the Lebanon hospital.  That class changed my life. My son tells me I am a different person.  I always thought chronic pain meant severe pain.  It means there is no tissue damage.  So how the heck was a doctor going to cure me with pills?  I must cure myself and the pain-science doctors taught me how.  I had to work on it.  I learned that I have a powerful brain, we all do, you do too.  My brain controls my pain.  I was understanding what I was doing.  I knew I had so much anxiety, stress, negative thoughts, fears that my emotions were sky high.  I learned that this can comes from trauma, especially childhood trauma.  I learned if I perceive pain, I will have pain, no doubt about it, I will have pain.

So what did I do with this new knowledge?  First I practice deep breathing, called belly breathing, while I practice mindfulness.  I learned how helpful it is to live in the present.  Once I was shopping and felt I couldn’t finish. I was going to call my son, but remembered to be in the present.  I decided to notice every color in the store and started to name them off.  I finished my shopping and checked out.

Fear, that is a big one.  Pain is a protector and when it would start to get dark my brain notes this is a dangerous time and sends out pain.  I am simplifying this but that is basically what happens.  I deep breathe while repeating to myself that night time is a good time, it is a safe time and a peaceful time.  That there is nothing out there that isn’t there during the day.  I found that visualization very helpful.  I would visualize I was outside and it was very peaceful.  I have completely lost my fear of the dark at night.  I was able to make peacefulness my main thought, not fear.  My Crohn’s pain is better, I have slips but I know what to do in order to get back on track.

I am happy now, I feel I have overcome my childhood.

I have had 16 different surgeries.  I feel some could have been avoided if I knew about pain science years ago.  I once took 18 different meds.  Just 6 now and mostly prescribed supplements.

One of the most important things I did was to forgive my Dad.  There are a lot of alcoholics in my family and we are also dyslexic and have an attention deficit disorder.  We are smart people and it is hard with this disability.  I can now see that my Dad was self-medicating.  There wasn't the knowledge back then.   My Mother always said to love our Dad because he was sick.  I didn't understand how she could say that, but she was right.  I wish I could have known the other side of my Dad.  I am learning new findings all the time.  The Alliance offers a resource book list.  I encourage you to look up Dr Moseley, and Pain Science on the web and come to our Community Meetings.  What helps me may not help you, we are all different.   I am grateful for the people that helped me.  You don’t have to suffer, there is help.

Sharla is a teacher, writer with a family, and shares her story about what she learned from Alan Gordon’s 2021 book, ‘The Way Out’ – (of chronic pain).  Her father kept giving her books about pain science and she resonated with neuroplasticity , a key concept in the book, so tells her personal pain story from a self-care viewpoint.

She raised her 4 children in Corvallis Oregon and Bangalore India.  While teaching them, her brain also learned pain.

Neuroplasticity is important for the college success skills she teaches, i.e. students need to appreciate they’re not limited to what they know now, but their brains can change, build new neural pathways.  The most used pathways get stronger, while the less-used become weaker.

Gordon’s book is extremely readable and practical for the average person.

She read the book in a time of stress and anxiety and wondered if the concepts might also reduce her anxiety rather than her back pain.  She tried some of the strategies in the book and found they reduced her anxiety, and her back pain!

Gordon describes The Boulder Back Pain Study, published in September 2021, where 98% of the 151 participants improved and 66% were pain-free after Gordon’s Pain Reprocessing Therapy.  Cool results she thought.  She also cracked up over the title of another study Gordon described, which had the words ‘chronification’ and ‘pain shifting’ in the title.  Functional MRI imaging showed that when injury pain became chronic, the location of pain activity ‘shifted’ to a different part of the brain.

Gordon defines neuroplastic pain as a brain mistake, which constructs a protective pain experience based on a misinterpretation of normal sensations.   It’s real pain, but the cause is not linked to new injury.

She moved to India just after her closest Grandmother passed away, and she’d had a recent miscarriage.  She thought her back pain was lifting boxes during the move.  It continued off and on, and sometimes she had neck pain which she associated with bumpy roads, bad posture, or playing candy crush too long.  Her brain definitely learned pain but there was no specific injury.

She wore a neck brace in the car and found she couldn’t play violin with her daughter without neck pain.  It was really hard to believe her pain was not caused by bad posture, chairs, roads, because its hard to believe a pain isn’t caused by something wrong in the body.

The book authors recommend looking for evidence that her pains might be neuroplastic, so she went through the evidence list in the book.  She checked: originated at time of stress, common personality traits, delayed pain, triggered by stress, increased in times of high anxiety, pains moved around, and lack of physical diagnosis.  Her physical therapist assured her there was no injury.

The book is very rich and deep, but she finished her story focusing on the 90 techniques it recommends for helping your brain feel safe.

She made the evidence sheets; practiced somatic tracking (meaning observing what’s going on in your body at a particular time without being judgmental); sent safety messages to her brain; treated the process lightly, without an agenda; avoided behaviors associated with the higher pain levels; and the big one for her, reduced overstimulation.    Her cell phone; social media; looking at work messages except at work; planning to manage uncertainty; catching her fears; and embracing positive sensations; all were her new focus!!

If you want to retrain your brain, she found Gordon’s book really helpful to understand what pain science had revealed about how her body works.

As a rheumatologist Dr. Jones specializes in autoimmune diseases where the body’s immune system starts to attack your own body.   He describes how his understanding of pain associated with the inflammation produced by the immune system in the healing process changed from a biomedical model to a biopsychosocial model.   Previously it was based on the biomedical model that a painful stimulus from an injured location sends a pain signal to the brain, which produces the pain experience.  He has previously done research on osteoarthritis bone samples looking for a protein signature in the sample that might correlate with arthritic pain.

Five years ago he encountered the ‘Pain Triangle based’ explanation of an incident where a worker was in extreme pain with a spike through his boot, but the spike passed between his toes so he had no injury.   The biopsychosocial explanation of the unexpected incident prompted him to rethink how he cared for patients, and he now understands inflammation symptoms are for protection, but inflammation is harmful when overexpressed.

In an injured area, immune cells (cytokines) leak from capillaries, and nerves release them, to cause the inflammation.  He shows research results demonstrating that individuals exposed to psychogenic stress had more inflammation than unstressed individuals when capsaicin was applied to their skin.  Cytokines in synovium fluid cause joint swelling in rheumatoid arthritis.   He briefly discusses anti-CCP antibodies, neuroimmune factors, interleukin-6, and TNF associated with rheumatoid arthritis.

He reports the 16-fold increase of inflammatory arthritis in teenagers with more than 4 adverse childhood events, which suggests a relationship between the disease and the brain being in a higher state of threat.   PTSD is also related to a higher incidence of rheumatoid arthritis.

He shows the hands of a man with rheumatoid arthritis, (which almost always occurs symmetrically in both hands or feet), and then shows his normal left hand two year later as the result of a stroke.  Half of his brain was not functional after the stroke, which produced the unusual non-symmetrical arthritis.

Patients with very active rheumatoid arthritis, that did not respond to multiple medications, experienced a decrease of about one third in the disease activity after a six-minute daily treatment for 42 days with a vagal nerve stimulator.   That result from a nonmedication intervention was an amazing demonstration of the relationship between the disease and the nervous system.

He poses a variation to the model of inflammation; it remains a protective response to threat to tissue, but neural activity may also simulate and direct inflammatory response.  So together with medication to control inflammation, he anticipates that decreasing the sense of threat can help change the neural stimulation and enable decreased medication.

A heightened sense of threat can lead to increased pain and increased inflammation.   So treatment of rheumatoid arthritis is focused on both the immune cells and the state to the brain.

Before I developed pain, life was good for me. I enjoyed working as a Physical Therapist in home health care.  I enjoyed my family. I was healthy and active.

Then, in March 2017, I was working with a gentleman who was very weak after a long hospitalization. His legs gave out when I was assisting him back to his wheelchair. Suddenly I experienced pain in my back.  Back pain is common and I expected the pain to resolve.  But it became worse. It traveled down my right leg.  I was no longer able to do my job. I was diagnosed with a massive L-5 herniated disc and the doctor suggested conservative treatment of anti-inflammatory medications, rest, and physical therapy. I was totally confident that I would get well with physical therapy.

After about four and half months, I felt good and went back to work full time. I had a little stiffness and fatigue at the end of the day.  I took my son skiing again, went hunting, and started a home renovation project.

Then, about eight months after I went back to work and a year since the initial injury, I felt pain in my back that continued to get worse. I was worried.  I stopped all activities; was using ice, heat, and topicals; and resumed physical therapy treatment. Over the next six months the pain kept getting worse and I had to quit work entirely. I was worried about the effect it would have on my family.

I had an MRI and was told that my back had healed so I should go back to work.  I couldn’t believe it!  Then I remembered that eight months earlier my physical therapist, who had advanced training in pain science, recommended that I review courses in pain science.

Now with no help left, I finally did it. I cannot describe the hope and excitement that filled me when I learned that there is a scientific explanation for my pain and that I was not alone.

I learned the effective and simple practices used to master pain. They helped me to think differently about my pain. As I implemented these practices in my life, I had less pain and more mobility. I began to envision my life free of pain.

The practices were rooted in the basic understanding of how pain works. I learned that my brain was just in an overprotective mode and my pain was not an indicator of harm. I learned to think differently about my pain and how to care for myself.

Before the doctor would clear me to return to work, I had to lift 75 pounds.  I felt strong but knew that I needed to start out lighter and slower.  I used good mechanics.  I went to the gym, began by lifting 40 pounds, and went on to lift 75 pounds.

Using pain science, I have been working full time for the last two and half years. I have been able to resume my life.  I take my son to the ski slopes, I had success with buck hunting, and I finished adding a second bathroom to our home.

I can’t put into words the awful reality of what my life would have been like if I hadn’t found pain science.  I am eternally grateful.   It saved my life.

In my practice I teach pain science, the practices and how to think differently about pain.

I am grateful to share my story with you.

My emerging understanding of pain is that it’s something our body creates to protect us from potential damage rather than a symptom of disease to be diagnosed. Pain has a memory in our bodies and when our environment feels unsafe, we can start experiencing pain in various parts of our bodies. Pain is fluid, fixable, and changeable.

Everything I’ve seen and read and observed in my patients’ responses and statements teach me. It’s understandable that people develop really negative relationships with their pain because it is an unpleasant experience. As a clinician I do my due diligence to make sure there is not a disease that is causing pain as a symptom. Understanding pain changes my understanding of obesity, mental health disorders and the effects of adverse childhood events throughout the lifespan and how important it is to help patients understand that.

He describes two examples of positive patient encounters:

“John”- a man in his late 30’s, was experiencing such severe back pain that in the past, I would have thought he needed surgery by a specialist and his life would be dramatically different. Instead, I asked to understand his story of early life trauma and pain.  My pain science explanation made immediate sense to John, so he planned to talk about it with his therapist. The next time I saw him, he was back at work as a mechanic, spending time with his kids, doing things he enjoys.

“Bonnie”- a long-time patient who I would try to help understand how her pain might relate to some of her prior abuses and trauma. She hurt her ankle and was given standard care including x-ray, cat scan, and MRI. Her pain persisted and her ankle was turning colors and changing temperature. She was scared and made an appointment with me. I asked her if she thought her fear and uncertainty might be making the symptoms worse. She said, “absolutely.” We created a rehab plan designed to gradually increase her activity level over several weeks. Bonnie actually resumed her normal activities within a week or so!

He cites three of his mentors in pain science and offers.

As a teenager, I was physically fit due to Tae Kwan Do, soccer, and skateboarding. It was a big surprise when I threw my back out! Chiropractic and pain meds helped. I was told to use better lifting techniques. But over the years I’d throw my back out doing something stupid, get some pain meds, and push through, working as a carpenter.

Then in 2016 my left foot was injured and had to be amputated. My gait pattern as I learned to walk again hurt my back. My Physical Therapist started using the PAIN TRIANGLE to teach me about how pain works. Learning that pain is a protector, not a punisher, and that it has physical, cognitive, emotional components had a huge impact on my life. Previously, I thought pain was a punisher that I got rid of by popping pills and moving on with my day.

These recent years of COVID were hard and things have really gone kind of sideways. Previously I dealt more with the physical aspects of pain but then I started to dissect my pain and reevaluate emotions.

I've actually had more back episodes than usual and there’s nothing that has changed physically or cognitively. It's just stress, stress, stress. Now I can totally see my emotions are affecting my back pain, not tissue damage.

I love the analogy that pain is like a smoke detector and when you hear it, you want to be looking for what the real problem is and taking care of that. In addition to the PAIN TRIANGLE, there are some other helpful things I learned from the “MMAPS” class that are my “toolbox” and I want to share them with you:

1. THE HANDFUL OF HEALTH = Breath & Laughter, Water & Urination, Food & Pooping, Movement & Sleep, Attitude of Gratitude & Relationship. Just getting more oxygen into my body changes my pain experience. I try to eat well, get enough sleep and activity.
2. MOTION IS LOTION: Heavy exercise isn’t as important as movement, even if it’s just done in a chair.
3. THANKFULNESS: Despite stresses, I’ve got a lot to be thankful for—family, job, friends. I still do take hydrocodone if nothing else in my “toolbox” has helped. If it’s three o’clock in the afternoon and I won’t make it through the rest of my workday, I do mindfully decide to take some pain medication. That's my story. I hope it encourages somebody, and thanks for listening.