Hope for Healing: Dr. John Stracks with Dr. David Clarke

Video: Watch the full session here → https://www.youtube.com/watch?v=537pQrKyJLc

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Dr. John Stracks: Welcome, everybody. I am Dr. John Stracks, and I'm here with my friend and colleague Dr. David Clarke. For those of you who don't know us, I'll introduce us. I am a family and integrative medicine physician in Chicago who runs the only mind-body medicine program in this area. I trained in general medicine and integrative medicine and moved back to Chicago in 2009, partly to open a mind-body medicine program at Northwestern Hospital in downtown Chicago. I stayed there for seven years and then opened my own practice in 2017 as a way to get this type of medicine out to as many people as I possibly could.

Currently, during coronavirus, I'm running a virtual clinic. I see people for consultations for mind-body medicine. I have some groups, classes, and discussion groups that I run. I run the Hope for Healing series for Curable, inviting guests like Dr. Clarke on to talk about mind-body medicine, and I do ongoing consultations with my patients who are looking for this type of care.

Tonight's discussion is part of an ongoing series that we've been doing both for my own practice and for the Curable app that many of you know about. Dr. Clarke and I will be talking for a little bit about mind-body medicine, what we've learned about it, and how we've practiced it over time. Then we'll spend the second half of the time taking questions from you who are viewing us at the moment.

This is a new format, the Zoom webinar format, that we're trying out for the first time tonight. It's fairly user friendly. At the bottom of your screen you should see a Q&A button. If you have a question for us at any time this evening, go ahead and click on that button, type in your question, and hit send. It will show up here in my studio in Chicago, and we'll be able to answer it during the Q&A period at the end of the webinar. If you're on the phone, unfortunately you don't have access to that Q&A button, but if you want, you can send a message to my office in Chicago at [confirm email address]. It will get to Lisa, she will get it to me, and our goal is to answer as many questions as we can before the end of the evening, which will be roughly around 6:45 Chicago time.

So with that, let me introduce Dr. David Clarke, who is the president of the Psychophysiological Disorders Association and an assistant professor of gastroenterology emeritus at Oregon Health & Science University in Portland, Oregon. He's board certified in gastroenterology and internal medicine and practiced gastroenterology in Portland for 25 years before retiring in 2009. During that time he interviewed over 7,000 people about symptoms that were not explained by conventional medicine and diagnostic testing. He's received numerous awards over the years for patient care, including from Kaiser Permanente, Pacific University, and Portland Monthly magazine. He's a member of the American Academy of Psychosomatic Medicine, the Psychosomatic Society, and the Collaborative Family Healthcare Association, where he co-chairs the special interest group on medically unexplained symptoms.

He's lectured extensively about psychophysiological disorders to internal medicine groups, family medicine groups, gynecology physicians, mental health professionals, physician assistants, nurse practitioners, and other groups of practitioners, including chaplains, pharmacists, and chronic pain specialists. He's done over 20 television interviews and 100 radio broadcasts, including those by Rosie O'Donnell, Montel Williams, and Michael Rosen. He also wrote the book that many of you have read, called They Can't Find Anything Wrong!, about medically unexplained symptoms in gastroenterology, and he currently donates all the royalties from his book sales to the Psychophysiological Disorders Association. He's been a close friend, colleague, and mentor for over a decade now, and I'm thrilled to have him here talking about this topic of mind-body medicine with me this evening. So Dave, thanks for being here. Did I leave anything out?

Dr. David Clarke: You left out the book that we both contributed to, the new textbook called Psychophysiologic Disorders. I was very honored to have you as one of our chapter authors. As you know, it's written mostly for professionals, but we worked very hard to keep the jargon out of it so that the mental health professionals could read the medical chapters and vice versa. One of the happy results of that is that most people who are not professionals in health care can also get a lot out of it.

Dr. Stracks: The title is simply Psychophysiologic Disorders. That came out last year and has done well. It's been well regarded and has been bought by, as you said, both medical professionals and people not in the medical field.

Dr. Clarke: Yes, it's done really well and it's gotten great reviews on Amazon, so we're very pleased to have that out there. It's got 16 contributors from 16 different specialties from five or six different countries around the world. It's been wonderful to have such diversity and perspectives all come together in one volume.

Dr. Stracks: It was fun to work on. Anyway, I want to talk with you about mind-body medicine before we get to people's questions, and I know that people will have many for both of us. One very important question that I promised my son I would ask before we get started: he is a misplaced Portland Trail Blazers fan in Chicago, Illinois, and was dying to know if you've actually been in the Moda Center, and if so, what is it like to watch a game there?

Dr. Clarke: The main thing you need in the Moda Center is earplugs, because it is unbelievable. Along with our soccer team, they're the only professional sport we have in Portland, so they've got a tremendous fan base. They set the record for the most consecutive sellouts, and whether the team is doing well or not doing well, the city supports them tremendously. I'm sure it was just like Chicago when the Bulls were winning all those championships 20 years ago. It's a tremendous environment for basketball, with very great fan support.

Dr. Stracks: All right, well, good. It is a post-quarantine goal of his to get out to Portland, Oregon, and say hello and come to a game. So you've been involved in the mind-body medicine world for a long time. Can you talk a little bit about how you came into that form of practice earlier in your career?

Dr. Clarke: It's almost embarrassing as a physician to admit that I went through seven and a half years of education and training without having a clue that mind-body issues could cause physical symptoms. But inevitably I ran into a patient who had those problems, very severely, and was referred to where I was in training at UCLA from another university where they had utterly failed to help her or even to figure out what was wrong. We failed as well. But just sort of by accident, I asked her about stress in her life and alluded to the possibility that maybe stress from the past could be a factor, because I was completely out of ideas. There was no biomedical explanation for her very severe condition.

She shocked me by beginning to tell me that she'd been abused as a child, fairly severely. She was telling me about this in a very calm voice, the same tone that you might use to read a grocery list. There was no emotion about this from her. I was initially concerned I might stir things up or make her worse somehow, but she seemed to have everything under control and not to be bothered anymore by these events that had taken place 25 and more years in the past. It was a very shocking story to hear, and I didn't think it could possibly be relevant to her illness, but I thought, what have we got to lose? So I called a psychiatrist that I knew was interested in mind-body issues and got them together for an appointment, and forgot all about it.

A couple of months later I ran into the psychiatrist in an elevator and, just to make conversation, asked what had happened to the patient. I was shocked again to learn that the patient was now completely cured with less than three months of weekly counseling sessions. There was nothing in my education, and for most medical students to this day there is nothing in their medical education, that even hints that such an outcome would be possible. I was just kind of amazed. I got myself hooked up with this psychiatrist, whose name was Harriet Kaplan, and prevailed upon her to sit in with us in the outpatient gastroenterology clinic. We always came up with at least two or three patients that she was able to provide useful perspective and advice about, and that was how I got started learning that you actually could get good outcomes if you knew what to look for.

The result of that, 35 years later, is the textbook. It's crystallized a lot of the wisdom from other people around the world who've followed a journey similar to my own. At the time I was learning this, there wasn't any textbook, there wasn't any fellowship you could take, and there was no place you could go for training. When I came to Portland, Oregon, to begin practice, there was no Harriet Kaplan here, and a lot of the patients who went to mental health professionals got no benefit from that, because few mental health professionals gain experience with people who are physically ill as opposed to having a mental or emotional problem. So I learned by doing. I learned through trial and error. I learned by listening. I sometimes tell people I had 7,000 teachers. Gradually, over probably three, four, five years, things began to come together and make some sense, and I was getting good outcomes, so I just kept on going with it. It was very rewarding work, as I know you found yourself.

Dr. Stracks: Absolutely. My pathway is a little bit different than yours because I went to medical school with this knowledge of the mind-body connection. I had had my own pain issues before. In the process of applying to school, when I was 28 years old, I read a book by our colleague Dr. John Sarno, who had done a lot of this work in the 1980s and 1990s, and it sorted out what was going on with me. After about a year my symptoms went away, and so I got to school with this knowledge. I thought, oh, I'll just tell everybody what they need to know, and you were way ahead of everybody else, including me. But I had that little short white coat on, so nobody would listen to me for a long time. Gradually, as I went through my journey in training, I learned to talk in a way that made sense to people, and so I was able to help more people make this connection between stress and non-physical factors that related to their physical symptoms, and people started to get better.

In the gastroenterology world, right at this point in 2020, it makes perfect sense to us that stress and other non-physical factors would come out in people's stomachs. Did you learn that early on in your training? Was there a discussion about the fact that GI specifically was going to see a lot of people who had non-physical causes of symptoms, or is that also something that you learned as you went on, this incredible gut-brain connection?

Dr. Clarke: There was certainly discussion that one-third of the patients you were going to see had one or more variations of irritable bowel syndrome, or IBS. But the teaching was that there wasn't any known explanation for irritable bowel syndrome, and there wasn't really much you could do about it. You might tell people to see if they could reduce their stress levels some, and there were various medications, but those only treated the symptoms. It was generally thought of as a therapeutic dead end.

What I learned from Dr. Kaplan was that there was a whole world of psychosocial stresses lying underneath most patients with irritable bowel syndrome, and if you could uncover what was going on with those, bring them to the surface, bring them to conscious recognition, then you could almost always do something therapeutically beneficial for the patient that would in turn lead to relief of the symptoms. I struggled for a number of years early on trying to find out what those psychosocial issues were, because the patients themselves often were not consciously aware of what was going on, so they couldn't put it into words. You had to know the right questions to ask. You had to know how to take little jigsaw puzzle pieces that people would sometimes give you and put them together into a complete picture that you could then show the patient in a way that they weren't seeing for themselves.

When you did that, very often the patient was on a pathway to healing. Sometimes the pathway would take years, and sometimes they needed psychotherapy for a prolonged period of time, but in other cases patients improved dramatically, sometimes for the first time in a very long time. One of my patients had 55 years of unexplained stomach pains. I saw him back in the days of paper charts, and volume three was eight centimeters thick. He got complete relief in less than three months. It was extraordinary.

Dr. Stracks: It's amazing. We see so many people who have all kinds of symptoms: migraine headaches, back pain, neck pain, foot pain, fibromyalgia. Having practiced gastroenterology for 25 years, what is your own sense of why so many of these symptoms come out in the GI system, with stomach issues, IBS, and any other GI disorder that we frequently see?

Dr. Clarke: The GI tract has lots and lots of nerves in it that are connected to the brain. In fact, it has been called a second brain, it's got so many nerves in it. The origin of that is very likely in the fact that when you are threatened by something, let's go back in evolution to the time when we were all living in the jungle or the forest and something threatened us, you don't want to have your circulation going to your GI tract. You don't want to have to stop and have a bowel movement when you're being chased by a tiger. So you need to have a way for your brain-body system to shut the gut down so that the circulation and all the energy can go to your muscles, where they're needed. That system is in all of us and it serves a good purpose. But when we are threatened by something emotional or traumatic or stressful, the same system is called into play, and when it gets too active, it can actually produce symptoms.

Dr. Stracks: There's a lot more going on than that. A lot of it has to do with the fact that if your emotions are suppressed because you're growing up in a challenging environment as a child, then when those emotions are triggered as an adult, you don't have a sense for what an emotion is. So you get a sensation in your GI tract, for example, and you don't know that it's an emotion that you're feeling down there. You start to think, oh, there's something wrong, and you start to get afraid. That triggers a cycle where you get even more worried that something's wrong, which can trigger even more sensations in your GI tract that you can't interpret as an emotion because you didn't learn that as a kid. The cycle just continues until you've got a pretty significant symptom going on. The main issue is that the brain and the gut talk to each other all the time.

Then you jump into the medical system, which also oftentimes doesn't recognize what's going on. So not only are you not aware that that's an emotion, but nobody else is either. You start getting all these messages that, oh, it could be something serious, and we need to get these blood tests, and we need to do a scope and look in your stomach, and then we're not sure what's wrong. Then people hear physicians say, well, maybe it's your head, as if that's a bad thing, and we're going to dismiss you because of it. My experience with people is that the medical system kind of recreates some of this trauma for them, not only by not providing correct answers but also oftentimes by ramping up the fear and the worry that then makes it worse.

Dr. Clarke: That's right. So many people have their symptoms exacerbated simply by the fact that no one can tell them what's causing their physical symptoms. You can imagine how that would make anybody worry about what's going on, that even expert doctors from a variety of specialties, with every sophisticated diagnostic test that we have in the 21st century, can't tell them what's wrong. I don't know if the word criminal applies here, but it's a terrible thing that so many health care professionals have no idea that mind-body issues are even possible, let alone that they can be diagnosed and successfully treated.

Dr. Stracks: And then you retired, actually shortly after I met you. I think you and I met in 2008 or 2009, and you retired from your GI position at OHSU shortly after that. Can you tell everybody what you've been working on since then as a way to expand both practitioner and patient access to mind-body medicine?

Dr. Clarke: You bet. I don't actually think of it as retirement. I think of it more as I closed my practice because I felt like I had done as much as I could with one-on-one medicine, and I really wanted to spend my time teaching as much as possible. I was very grateful to you and Howard Schubiner, who put on a conference in Ann Arbor, Michigan, that was a starting point for many of us in this field. We met each other for the first time. So many of us had been working in isolation with really no colleagues to share ideas with prior to that point. I hadn't even heard of Dr. Sarno until about a year before that conference took place, so that tells you how isolated I was.

Once I found this group and we had this conference, we started talking about creating a non-profit corporation that would work to share these ideas among health care professionals and the public. We did that over the next couple of years. We founded it in March of 2011 and we've been going ever since. We have an executive director based in New York City, we've got a Facebook page, and ppdassociation.org is our website. We've created a webinar-based training course for health care professionals that, again, we've kept the jargon out of so the public can also use it. We created the textbook, with your support and that of many others, and we are teaching health care professionals at conferences and individually all over the country and, to a limited extent, in Europe as well.

Dr. Stracks: It's amazing to think where we were in 2009. I think there were maybe 30 of us that showed up in Ann Arbor, which was a lot at the time. But to think of how it's grown: we've got an email list between the physicians who do this work and the psychotherapists that I think is well over several hundred at this point, and the momentum continues to grow. Obviously Curable is an amazing addition to this work and a way to get this information out to, I think it's over half a million people who've downloaded the app at this point. Where do you see the continued work going? What are some of your goals for what we're doing over the next several years?

Dr. Clarke: Ideally, the kind of care that you and I provide would be as routine as anything else, so that when people have a symptom, whether they use Dr. Google to find out about it or they use their own personal physician, there's a general awareness that mind-body issues should be considered and can be evaluated in parallel with everything else. If you have an abdominal pain, for example, yes, we want to make sure you don't have a gallstone or an ulcer, but right along at the same time that we're doing that, we should find out about the stresses in your life. Those can be done in parallel with each other. They're not mutually exclusive, and it should be just a routine part of care.

When physicians learn how to do this, they love it. Imagine practicing in an environment where 30 or 40 percent of the people who come through your door have no explanation for their symptoms and you don't know what to do. That's tremendously frustrating and, in fact, burnout-inducing for a lot of doctors. Then you can completely flip that 180 degrees. One doctor who received some training from us in this area took me aside and said, "This work has put the joy back into my practice." Now, instead of these patients being frustrating dead ends, she knows what to do. She knows what to look for, what to diagnose, and how to refer them to get the exact help they need for the particular stress or stresses that they're coping with. Their symptoms get better. They're not necessarily cured on the spot, but they're at last on a pathway toward healing. It's night and day for the doctors that learn how to do this.

Dr. Stracks: When you teach physicians how to do this work, do you have them become aware of the issue, aware that we can express non-physical issues in physical ways, and then address that with people and generally refer out to, say, a psychotherapist or another colleague who has either more time or more expertise in dealing with the stress aspect? I always feel like physicians are busy and have limited time, so I like that model, but there's always the risk of having to see a psychotherapist or switching fields. I'm just wondering what models you've seen in that regard.

Dr. Clarke: What we teach is to begin with an initial stress evaluation, we call it, looking for the major types of stresses that people are prone to have when they've got a mind-body disorder: stress in your life right now; limited ability to do self-care skills, to spend time doing enjoyable things rather than taking care of everybody else in the world; and stress from the past, from adverse childhood experiences, which is huge and is present in a majority of people with mind-body disorders. Then we look for mental health conditions that are common in this population, as you know: anxiety, depression, and post-traumatic stress. A physician can screen for those things, not necessarily all in one visit, but depending on the length of time they have with each patient, they can gather that information over time.

Once they uncover what's happening, depending on the complexity, they have a variety of responses. They can take care of it themselves in many cases, because again you're talking about 30 or 40 percent of their practice, so they're not going to be able to refer out everybody who's got a mind-body disorder. They can handle a lot of it themselves after the training that we provide. When they can't, there are now, as opposed to when I first started practice, a lot of resources out there in terms of books that people can read, videos, webinars, lots of things that people can do to self-educate. Curable is the shining example of that, and it's hard for me to imagine somebody I wouldn't refer to Curable.

Finally, if it's a really complex issue and they've got some very serious stuff going on, they're suicidal, they're having incapacitating anxiety, they've got overwhelming stress from childhood abuse, those kinds of very complex, deep-rooted issues that are going to need a psychotherapist, then that's within the psychotherapist's sphere of expertise. Once those are uncovered, you refer to the psychotherapist and you say, "You don't have to worry about the physical symptoms. We've uncovered the issues that we want you to focus on." Most psychotherapists are going to feel comfortable with the psychological aspects of this because that's what they've been trained to do, and the physical symptoms will get better as a side benefit of that. So there's a wide range of people with mind-body disorders calling for a wide range of different responses, but it's well within the reach of normal front-line primary care docs around the world.

Dr. Stracks: For those who are listening who aren't familiar with Curable, and there may be some people who are, it's an app that was developed five or six years ago. Three of my friends were interested in potentially getting more information about mind-body medicine out, and so we would meet for breakfast periodically at the hospital in Chicago and they would tell me their ideas. We were talking one day and they said, "So Dr. Stracks, somebody sees you for mind-body medicine, they get better, they have a relapse. What do you do?" I said, well, oftentimes some people email me in the middle of the day like, "I'm getting a really bad migraine, I don't know what it's about," and I'll email back and say, "Well, what happened yesterday? What's happening today? What's happening tomorrow?" Then I'll get an email back in about an hour saying, "Oh, thanks, I figured it out, I really appreciate it." One of them, John or Eric or Laura, said, "Dr. Stracks, we don't need you to do that. We can get an app to do that just fine." That was one of the ways that we recognized how effective this can be for people.

I joke with them, and I've probably said this to people before, that Clara, the bot who runs Curable, the app, is substantially more empathic than a lot of physicians I've met over the course of my career.

Dr. Clarke: It's terrible to say that, but you're right. They've done a really good job at making her empathic.

Dr. Stracks: Have you worked with them closely on any pieces? You and I are both medical advisors to them, but I don't know what specifically you've worked on in terms of helping to continue to make it a more and more effective tool.

Dr. Clarke: Two major areas, I would say. I met John probably back in 2017, and it might have been because you referred him to me. He moved to Denver, and I spend a lot of time in Denver with my grandchildren, and we started meeting for coffee at a mutually convenient coffee shop and just talking over these issues, the same way you did. One of the ideas that I recommended was that they generalize Curable from just focusing on migraines to working on the full range of mind-body issues, because the principles are the same. This is something that you find out fairly quickly in doing this work, as you know: people with one mind-body disorder often have another one at the same time, or many of them. My personal record patient had 27 different symptoms that he was suffering from. It's really the underlying causes that are important and not the particular symptom that the person manifests with. So I thought it would be a pretty easy segue to go from a focus on migraines to a focus on all symptoms that don't have a biomedical explanation or an explanation in structural abnormalities or organ diseases. That was one area that I recommended to him.

The other was about the links between what are called ACEs, adverse childhood experiences, and physical symptoms in the present day. One of the mediating pathways between the two is various personality factors that many workers in this field have identified: trying to be good all the time, trying to be helpful to others, paying attention to details, not being very assertive about your own needs, and low self-esteem in many cases. All of these things that Dr. Sarno pointed out in his patients in his books, and that Dr. Schechter in his books calls the Type T personality, derive from ways of coping with an adverse childhood environment. If you can trace the roots of the patient's symptoms back through those personality features all the way to what they experienced as children, it facilitates the recovery, let's put it that way. I wanted to see if Curable could incorporate some of those ideas. I went into a lot more depth, obviously, than we can do here, but I felt that incorporating them would make Curable even more effective by helping people to see those issues in their own lives, because, as you know, they're so huge in people with mind-body symptoms.

Dr. Stracks: I think they've done a tremendous job in incorporating all of that. It was a big step for them to move from migraines, which is what it was initially, to all symptoms, and then they've done a fantastic job as well in talking with many of us around the country and getting the best of so many of us who do this work and being able to put it in there. For those of you who haven't tried it, curablehealth.com is the website for it, and Dr. Clarke and I both highly recommend that as part of the tools that people are using for their healing.

Dr. Stracks: I'm going to switch gears just a little bit for a second. In this time of COVID and quarantine, I've been asking everybody who I come in contact with what their experience has been like with quarantine, and specifically whether there are any things that you have done that have helped you get through this time. I don't know precisely what it's been like in Portland, but I assume it's like most of us in the rest of the country, where you've been told to stay inside and shelter and not have a lot of contact with people around you.

Dr. Clarke: We're very lucky in Portland that we have a very low rate of infection in our community. I think it brings the fear level down a lot when you know that it's one out of every several hundred people out there rather than one out of every 50 that might be carrying the virus. That has helped us in Portland, but we still have the lockdown. My wife and I have limited ourselves to occasional visits with our son and his family, who live three miles from us here in Portland, and other than that we've not seen anybody for two months now.

There are a lot of ways to cope with this that are of greater or lesser feasibility for different people. We try to get outside to walk. We wear masks, we distance from other people out there, and we walk in areas that are not popular so that we don't run into too many people. We try to walk three or four miles a day, just to get outside, get what sunshine there is, and get some exercise. That's important. Having a routine is helpful: try to get dressed in regular clothes, make the bed, and have meals at certain times and not just kind of eat all day long. We limit how much news we take in. We'll read newspapers either online or in physical form in the morning, we'll listen to the evening news on the radio, and then the rest of the day we try not to pay too much attention, so we're not getting overwhelmed by all the badness that's going on out there. We use technological tools to stay connected with our friends and family. As I mentioned, we have family in Denver, and we've got all of our friends here in Portland and some others around the country that we can connect with, and share a meal or a beverage over the screen. That helps a lot too.

Dr. Stracks: Any hidden benefits of quarantine for you? It's another question I've been asking a lot of people lately. For me, I started doing yoga almost every morning with recorded classes from Thousand Petals Yoga studio in Chapel Hill, North Carolina, who put together this great online resource for yogis, and my yoga and flexibility has gotten much better in quarantine. We've had a lot of family walks down to the lake that we probably wouldn't have taken. We have taken to coming down to my office. My office is being used for a remote studio for me and a remote classroom for my kids, because the Wi-Fi here is much better than at home, and we have a 75-inch screen that we've actually never used in our resource room here. We come down every weekend and we're slowly working our way through the Marvel Avengers movie series. I think we're eight movies into the 23-movie series. There are things that we wouldn't necessarily have done, and clearly nobody wants quarantine, but there have been these small hidden benefits that I've seen people find in the midst of a difficult situation.

Dr. Clarke: There are some. Every year I teach in two different grad schools, and it's always been by webinar because the students are all over the country, so that came along at the perfect time. It started two months ago and I just finished my first one, and I'm starting the second one at the beginning of July. I love my students, and they're forever sending me written work that I have to comment on and grade, so it kept me pretty busy for the last two months. The work of the PPD Association has for me always been online, as I mentioned. My executive director is in New York City, so we interact technologically on a regular basis. More fun things: I always have more books than I have time to read. My office is just loaded with things where I think, oh, that looks interesting, and that looks interesting, and my ambition to read them is greater than the time that I have to actually do that. But I'm getting to look at stuff that I wouldn't have otherwise. I'm reading a history of the city of Portland. There's a friend of mine who walked across Antarctica and wrote a book about the experience, so I'm looking at that, and lots of random topics that I might never have had access to otherwise.

Dr. Stracks: Speaking of books, you wrote the book They Can't Find Anything Wrong!, which came out about 10 or so years ago. We're going to move into the question and answer in just a minute, and there are already about 15 questions waiting for us. For those of you who are listening and want to put more questions in, we have the time, so if you want to, click the Q&A button at the bottom of your screen, type in whatever you want, and send it to us here in our studio. But before we get to the Q&A, there are obviously a number of patients who have done well who showed up in your book. Any nice stories that you want to share with people about patients who have done well with their symptoms after recognizing what the cause of them was?

Dr. Clarke: The book has four dozen different stories in it, and I love to tell their stories because their improvements were so dramatic and oftentimes very rapid. The first story in the book is a woman who had been hospitalized at a major university 60 times in 15 years, and they still didn't know what was wrong with her, and she was cured with a one-hour conversation. But I have a soft spot in my heart for the 74-year-old lumberjack who had been ill for 55 years, that I mentioned before. He was a man of very few words. You need communication skills to get over psychophysiologic disorders, and he just didn't have them. I would ask him a question and he would give me a two- or three-word answer, and I'm going, oh my gosh, how am I going to help this man? Fortunately his wife was there and she would fill in the details.

To make a long story short, he'd been physically abused by his dad on an extremely regular basis, and he finally couldn't take it anymore and just walked away from his home when he was 15 and began working in the woods. We've got lots of timber here in the state of Oregon, and that was his job until he retired at 65. But he started having his physical symptoms when he was 19, and he rarely went for more than a week or so without having those. He'd been with the same health insurance firm for decades and nothing ever turned up. I sent him to a class that we had at that time for adult children of dysfunctional families. It was two hours a week for eight weeks. He came back after the class and he hadn't had any symptoms, so I asked him to tell me what happened in the class.

What happened was he sat through the first two hours, with a lot of mutual sharing going on among this small group of people about the abuse that they had suffered, and he just wasn't willing to open up. Next week he comes back, two more hours go by, and he doesn't say a word. Third class, finally a couple of sentences about himself. It was a pretty savvy class at that point, and everybody just kind of sat back and waited, and there was this long, awkward pause. Finally he yielded to the group pressure and started talking about himself again, and he couldn't stop. He went on for 35 or 40 minutes telling his story to this very supportive, very open group of people. For him, that was the moral equivalent of a Russian novel, to speak for that long, that many words. And that was it. It's a principle I've seen over and over again, as I know you have: if you can convert your emotions into words, then they don't have to express themselves as symptoms. That was the case for him. After that third class he finished the other five classes and didn't have any symptoms that whole five weeks. He came back to see me a few weeks after that, still no symptoms, and as far as I know he's been fine to this day.

Dr. Stracks: It's amazing. Do you have thoughts for people who don't get better right away, who tap into the emotions, who go to the classes, who use Curable, who struggle with this, but still their symptoms linger?

Dr. Clarke: Yes. The process that I've seen very often is that a person can be making steady progress mentally without any physical benefit for a long time. In a sense, the benefit that's happening for them is going on beneath the surface, and it can take a long time and a lot of work before that surface manifestation, the benefit to the symptoms, begins to kick in. It has to do with the severity of the stresses that a person went through. It has to do with the resilience factors that they bring to the table, which often is just something people were born with, or has a lot to do with whether they experienced any forms of support when they were growing up. Maybe, did you have a kind grandmother who believed in you, or did you not? There's a big difference between those two phenomena.

But the key concept is: keep working at it, keep going in the same direction, keep thinking, keep writing, keep contemplating what emotions might be in there. Use the symptoms as a signal that there's a stress issue going on that you need to get in touch with and figure out. Find a good therapist, and eventually all of those pieces of the puzzle come together. It may be that you've done 90 percent of the work that you need to do before you see any benefit to your symptoms, but you're not wasting your time. There was a woman in the Facebook Curable group just recently who was 70 years old, found Curable, and got better right away. The reason, I'm convinced, was that she'd been having symptoms since she was a teenager and had been working on this for 50 years, and Curable was the last piece of the puzzle. Sometimes it takes lots of putting together of pieces before, at the very end, you finally see the benefit.

Dr. Stracks: I tell people about that model a lot, where you're doing a lot of the work under the surface, which I see, and then at some point it starts to coalesce and the physical symptoms get better as well.

Live Q&A: Mind-Body Medicine Questions Answered

Dr. Stracks: We're going to move into the Q&A. It looks like there are about 20 questions waiting for us, and we'll try to get through as many as we can. We've got almost 60 people on the call at the moment. The first question is about reflux. This was sent to me in my office earlier this week. It's about gastroesophageal reflux disease (GERD), and specifically laryngopharyngeal reflux (LPR). Do you think that those can be manifestations of mind-body disease, and if so, do you think that this type of treatment can help them?

Dr. Clarke: Gastroesophageal reflux and laryngopharyngeal reflux are basically a more severe form, where stomach contents reflux, which means they come up the esophagus and get all the way up to the larynx area and can cause damage to the larynx, which is your voice box, very delicate tissues in there. Stress can affect the muscle contractions of the GI tract in such a way that reflux is more likely to happen. There is not always a psychophysiologic component to that. We can't say that it's a hundred percent of the time a mind-body concern, but very often it is, and it's well worth doing the stress evaluation to find out what psychological issues, stress issues, or trauma issues might be going on in a particular person, and then address those issues and see if you get better.

That's pretty much the same answer to this kind of question no matter what the symptom is. People say, "I have symptom X, Y, Z. Could it be a mind-body issue?" and the answer is almost always yes, it could be. Sometimes it's 95 percent certain that it is a mind-body issue, and other times it's only five percent. But the answer is very often yes, there could be a mind-body component to this, and we don't have a diagnostic test to tell us. So what we need to do is find out what your stress issues are, bring those out to the surface, treat them, and see if you get better. That's the only way to find out how much of your particular version of these symptoms is mind-body related.

Dr. Stracks: With reflux specifically, I've read that there are many people who have physiological reflux into their esophagus who walk around feeling just fine, so there's more to the story than just what's going on in the body, which is true for so many mind-body disorders. I've definitely seen people who have worked on their reflux specifically, and I've also seen people who've worked on their back pain and gotten that better and come back and said, "Oh, by the way, my reflux went away as well." We see it regularly.

The next question is about a 35-year-old with a fair amount of trauma in her life who recently moved to a new place and finds that it's harder and harder to keep the emotions and trauma down. She has been to a lot of physicians, everything is "normal," and she tries to do this work but slips in and out of being able to do it effectively. Do we have ideas for how to continue with this work when it tends to get a little bit overwhelming?

Dr. Clarke: It's a hard question to answer without knowing a lot more detail about the person themselves. I was very blessed that I had 60-minute appointments with each of my patients, where I could talk to them in great detail about exactly what they had gone through. The fact that something feels overwhelming, that you may experience what some people call brain fog, is an indication that your brain is working extremely hard on these things, and that's a really good sign. Even as bad as it feels, even though the traumas may feel overwhelming, at least they are being processed by your brain, and your brain is working as hard on this as it possibly can. You can have a lot of confidence that all of that work is going to pay off eventually. So yes, it's a very difficult experience to go through, but it is going to be a benefit for you in the long run.

One concept that is helpful to many people, not necessarily everybody, who are going through this experience is to write a letter to the person who mistreated them when they were growing up. Not to mail it, just to write it. There are a lot of different varieties of writing exercises that people can do, and this is only one of them, but it's been very helpful to a lot of my patients to sit down and write all the thoughts and feelings they have about this person, especially if that person is still active in their life, which is even more difficult to cope with than if they are completely gone out of your life. The more you put onto a piece of paper or onto a computer screen, the less of that needs to go into your body to express itself.

Dr. Stracks: I think too, if there's a lot of trauma involved, oftentimes it's very hard to work through this on our own, and finding a trusted professional to work with can sometimes make the entire difference between being able to move forward or not. Sometimes that's possible, sometimes it's not. I actually did a podcast on Curable last year talking about my experience of leaving the hospital and setting up my own practice, which was super fun and has been fantastic, and has been quite stressful as well. I had a relapse in symptoms in ways that I hadn't in a couple of decades, and I needed to reach out to some colleagues who do a different kind of work and have people help me through it, because it just wasn't a situation that I could get through completely on my own. Reaching out and asking for help is oftentimes difficult but can make a huge difference. For trauma specifically, I think of colleagues who work in the fields of sensorimotor psychotherapy and somatic experiencing, which are forms of psychotherapy that are very much body-based and were developed to aid in the healing of trauma. If there are options to find people who have expertise in those modalities, it can make a big difference in how people can move forward trying to heal the experiences that they've had.

Dr. Clarke: I absolutely agree with that, and don't hesitate to do a pre-interview with anybody you're considering to be your psychotherapist. Make sure you feel comfortable with them and that you feel that they can help you. If they're helping you, great. If they're not helping you after a couple of visits, don't hesitate to move on. It can take some time to find somebody who's a good connection for you. It's not like fixing a fractured leg, where most orthopedic surgeons are going to be able to do that for you with skill. When it comes to psychotherapy, a lot depends on the connection between the two people.

Dr. Stracks: Next, some questions about food sensitivities. I get this a lot. There's a lot of talk about food sensitivities in our culture these days. How much do you think that's an issue versus how much of it is more likely to be a mind-body issue?

Dr. Clarke: In the case of food sensitivity, it's probably over 90 percent mind-body issues. Probably not quite that high for various forms of reflux, but with food sensitivity it's so common for someone who's got a gastrointestinal symptom to blame whatever it is they just ate for causing that symptom. Then you add on to that the fact that there are numerous tests out there that people can get that purport to identify when you have a food sensitivity or food allergy, and the tests are mostly invalid. Even the gold standard, which is a double-blind test of giving you a food that you feel like you're sensitive to, has issues as well. So it's very hard to give people a clear-cut diagnosis of whether they have a food sensitivity or allergy or not.

I think the best we can do in a short space of time here is this: if you've got a food that gives you symptoms 10 times out of 10, then that's probably something to stay away from for the time being. If there's some concern about sensitivity to gluten and related compounds, you should be tested for sprue, because that is a reliable test that we can do for you. But short of that, if you've only got symptoms some of the time with a particular food, that's probably not a true food allergy. A true food allergy is a biochemical phenomenon that's going to happen almost every single time you put that substance in your GI tract. So if it's only happening some of the time, go for the mind-body issues, and even if it's happening almost all the time, still work on the mind-body issues and then give yourself a shot at trying that food again after you've made some improvement in the mind-body area.

Dr. Stracks: I agree. I'm not opposed to taking people off of various foods, gluten being a common one, sometimes dairy. But I also see people who come to my office having taken dozens or sometimes hundreds of foods out of their diet, oftentimes without a huge resolution in symptoms. The more foods that people are supposedly sensitive to, the more I'm thinking about a mind-body explanation and adding in that form of treatment. The same kind of thing applies to small intestinal bacterial overgrowth, or SIBO. There are people who actually have that, but only a small fraction of the number of people who think they have it.

This next question is about a flare-up. The pain was triggered by a concussion, and the person has done a lot of this work and gotten better, but now there's eye pain and trouble with eye-related activities. No matter what they do, the symptoms continue to flare, and there's panic as well. It's a complicated, quite overwhelming situation. Is there a good way to approach those kinds of complex disorders that don't have an obvious answer right away? I know that's not GI-related, so not necessarily in your purview.

Dr. Clarke: As with you, even though I started out in gastrointestinal medicine, the patients that came to see me over the years had a wider and wider range of symptoms. The answer to the question so many people have here, "Here is my particular symptom X, Y, and Z. Could it be mind-body related, and what can I do?" is very often the same: evaluate for sources of stress. What stresses are you having in your life at the moment? The fact that there's a strong anxiety component in this person's symptoms suggests to me a high likelihood of a mind-body connection. Of course, you want to have a physician, potentially a specialist, look at the eye situation and make sure there's not an organ disease or a structural abnormality going on. If they find nothing of that sort, that significantly increases the chances that mind-body issues are the cause, and you can go forward with even more confidence looking for those.

So, stresses in your life at the moment: are you the kind of person that takes care of everybody else in your world but has difficulty putting yourself on the list of people you take care of? Did you have significant adverse childhood experiences? The best question for that is: when you look back at your own childhood, if you imagine a child that you care about growing up exactly the same way you did, how would that make you feel? Would you be sad or angry to see a kid trying to cope with everything you had to cope with as a child? Think about that for a while, maybe do some journaling about that for a while. That can help you connect with some emotions that perhaps you didn't know were there. And finally, lots of people with depression don't feel that depressed, but they are manifesting their depression in a physical way, and the same can be true of post-traumatic stress and anxiety disorders. In many cases, addressing those, addressing the anxiety that this person mentioned, may alone be sufficient to provide some relief.

Dr. Stracks: Interestingly, I do see a lot of eye symptoms as part of mind-body medicine. Especially when there's a lot of trauma and a history of abuse, it seems to come out in the eyes, so I would be confident that the eyes can be part of this whole package, and at some point we can stop looking for physical explanations and really focus there.

This next question is similar. It's about symptoms that bounce around from place to place, especially if they're in the same part of the body: throat, neck, teeth, jaw, reflux. What's the best way to not get sidetracked into thinking that these are physical disorders that need evaluation, and to be confident that you can work on them in a mind-body way?

Dr. Clarke: The more symptoms bounce around, the more likely they are to have mind-body as a cause. When you think about it, a tumor isn't going to bounce around, and something that's infected isn't going to bounce around, so that's an excellent sign that you're dealing with a mind-body condition when the symptoms migrate around. On the ppdassociation.org website we have a list of 30 questions that I put together with one of your other guests, Howard Schubiner, in the past, and the more of those questions that you answer yes to, the more likely it is that there's a mind-body condition underlying the symptoms. People can go to the website and look at those. There's also a downloadable Hidden Stress screening questionnaire, just nine questions, with a little guide to help you interpret the results, that you can use to screen yourself for sources of stress that might be underlying the symptom. But that's a key indicator that mind-body issues are responsible for the symptoms: when they move from place to place in the body.

Dr. Stracks: And like I was saying, in terms of being confident that these are mind-body medicine issues, it's never wrong to have it evaluated, but after you've been evaluated a couple of times, or for a lot of our patients a couple of dozen times, it really is part of the cure to work on how to reassure yourself that you're in the right place. Clearly, patients who are part of my practice can always reach out and get my feedback on that. If you're not part of my practice, after you've had the message and had the experience a few times of finding out that you're physically cleared and you can get better using mind-body medicine techniques, try to somehow keep that in mind so that you don't have to go back and constantly reevaluate whether it's physical or not in its origin.

Dr. Clarke: Yes. Use those symptoms as your body trying to tell you something. It wants you to look for the source of stress. It's a gift. It's a guide.

Dr. Stracks: Any thoughts about how to find a good TMS therapist?

Dr. Clarke: Finding any therapist is going to be heavily dependent on your relationship with that person. Are they understanding you? Do you feel understood when you talk to this person? Do you feel like you've been heard? Do you feel like you are gaining insight into yourself through your interactions with that person? If you don't feel that after a couple of visits, then you should move on. It's painful to have to conduct a search like that, especially when it takes a couple of visits and a certain amount of money, but this is your life, and finding someone who is well connected with you and who helps you make progress is ideal. It's not unusual to go through more than one individual before you find the right one for yourself. We also have directories available on the ppdassociation.org website, and there's one on the TMS Wiki, of people that have expressed an interest and developed some expertise in mind-body issues, so that's often a good place to start. Many of those therapists are willing to work via technology over the internet, so they don't have to be physically present in your city. I put an answer to a question on the Curable Facebook page with a couple of my colleagues, the psychotherapy colleagues who had specifically volunteered to work with people by Skype or FaceTime as opposed to in person. I put that answer up a couple of weeks ago.

Dr. Stracks: I also think, like I said, that my colleagues in sensorimotor psychotherapy and somatic experiencing have a lot of knowledge of being able to work in the body, and so they are oftentimes good matches. This particular question actually said that one of the issues is trying to figure out ways to get anger out. It turns out that a surprising number of psychotherapists aren't great at working with people's emotions. I think there are complicated reasons for that, but I was talking to Dr. Schubiner one time, who did a study on helping people with emotions in medically unexplained symptoms, I think specifically for fibromyalgia, and he was complaining to me about how difficult it was for people to enter into the world of emotions. I was like, "Howard, it's hard for people. What do you expect?" He's like, "I'm not talking about the patients, I'm talking about the therapists." So checking and getting a sense of whether the therapist is comfortable with emotions is an important thing to do as well.

Dr. Clarke: There's good evidence on that. How you feel about the relationship with the therapist: do you feel heard, understood, and making progress? Those three areas. As long as those three things are happening, then you're in a good place. If they're not happening, then talk to the therapist about it, make sure they know that it's not happening for you, and see if you can find a way to change the situation. Otherwise you may just not be compatible, or the benefit of that person may have reached its limits, and that's okay. Keep looking.

Dr. Stracks: The next question is about pudendal neuralgia after a routine colonoscopy. The symptoms aren't comfortable. The person has been to pelvic physical therapy, had fear going into the colonoscopy, and has some PTSD from other health experiences as well. As a gastroenterologist, what's your thought about that? Do you think there's any possibility that there's a structural issue related to the colonoscopy, or is it possible that it's mind-body related?

Dr. Clarke: The odds are that it's mind-body related. I can't tell you how many thousands of colonoscopies I've done, and I've never had a patient who developed pudendal neuralgia from one. But there's abundant evidence of pudendal neuralgia, pelvic pain, and persistent genital arousal disorder being connected to mind-body concerns, so that's the most likely explanation. One study that I love to quote, from the University of Washington, now 30 years old, was of two groups of women with pelvic pain who were undergoing laparoscopies. About a third of the women with the pain had something wrong in their pelvis when they looked in there with the metal tube, which is the laparoscope. But it turned out that a third of the women without the pain also had those same abnormalities, such as endometriosis, which is the lining of the uterus that's leaked out into the pelvis, or scar tissue adhesions, or ovarian cysts. So in one group, no pain whatsoever, so probably not causing the pain. And in the group with the pain, two-thirds of those women had no abnormalities in their pelvis at all.

The researchers went on to investigate other potential causes for the pelvic pain and asked all the women in both groups if they'd been sexually abused as girls. It was about 20 percent of the women with no pain, which is unfortunately about average for adult American women, but in the group with the pain it was 64 percent. That doesn't prove cause and effect necessarily, but it does show a strong link between a source of huge stress and physical symptoms later on in life, and that kind of association has cropped up in my practice over and over and over again. So the likelihood is that the pudendal neuralgia in this patient is connected to some form of stress rather than to the colonoscopy.

Dr. Stracks: Agreed. The next question is related, speaking to trauma with a small "t" as opposed to trauma with a capital "T." We clearly recognize physical abuse, sexual abuse, and abandonment as traumatic experiences, but what about emotional neglect or attachment trauma, that this person asks about? Has your experience been that those kinds of issues can bring up symptoms? I can speak to this too.

Dr. Clarke: Those are trauma with a capital "T." That was one of the things that I had to learn early in my practice career: emotional neglect, or even just treatment of the child in such a way that nothing they do is ever good enough. No matter how hard they try as a kid, they'll run through walls to get some praise from their parents and it just isn't happening. Or if they do get a little bit of praise, the next time the bar of achievement that they have to reach to get praise from the family or from the parents is raised that much more, and it always seems to be out of reach, so they're always failing. Anything that makes you feel like a second-rate human being is trauma with a capital "T," and it can have the same long-term impacts as more obvious forms of trauma like sexual abuse. I would not have guessed that 30 years ago.

Dr. Stracks: This person also specifically talked about her mother and her mother's anxiety and the connection between her own emotions and her mother's emotions. This concept of setting solid boundaries is something I talk with people about all the time. A lot of people grow up in families where the boundaries aren't clear between what belongs to whom physically, and what belongs to whom emotionally or psychologically. People aren't able to keep their own thoughts and emotions separate from other family members, and my patients who have learned to be able to draw those boundaries, and draw them effectively, get huge physical relief in being able to do that. One story that I tell regularly is about a patient of mine with chronic fatigue syndrome who came into my office one day, and I said, "How are you?" She said, "I'm great." I was like, "Really? You rarely say that you're great. What's going on?" She said, "I stopped talking to my mother." That's not necessarily a prescription for anybody else, but for her, she drew that solid boundary and it freed up all this energy that she was using to manage that relationship that she didn't recognize.

Dr. Clarke: It is a great story to hear, just the long-term power of those experiences. When you've got a mother who's anxious, which is what the questioner you were mentioning described, the child in that family is going to try to solve that anxiety and they are going to fail, and so they are going to get that sense of themselves as a second-rate human being. That will put them on a treadmill where they are always trying to fix problems that they don't have the capability of fixing, and it distracts their attention from their own needs onto the needs of everybody else. That's not sustainable. Your body is going to protest if you don't have the ability to get off of that treadmill and focus on your own needs. That's an essential human skill, the ability to tell everybody else to take a hike and just do something that has no purpose but your own joy. A lot of my patients simply did not have the ability to do that, and until they learned it, they were going to keep on having symptoms.

Dr. Stracks: Another excellent point about that case is that in order to draw those boundaries between yourself and a toxic person in your life, you have to feel worthy. You have to feel like you deserve to have that boundary drawn there.

Dr. Clarke: One of the best ways to feel worthy is, again, to go back to that idea of imagining a child you care about growing up exactly the way you did, and to see the heroism and the perseverance of that child to endure in that environment, and begin to think about that child that was you in heroic terms. The more you recognize that they were born on the far side of a dangerous mountain and had to climb up and over to get to be an adult, the more respect you're going to have for what that little kid accomplished, which translates into more respect for yourself, which translates into the strength to put those boundaries down and feel worthy of having those boundaries be there.

Dr. Stracks: Absolutely. These are awesome questions, and we're making zero headway, because every time we answer one, two more pop up. It's 6:45. Do you have 15 more minutes to stay and answer a couple more questions?

Dr. Clarke: Yeah, absolutely.

Dr. Stracks: I will add on a bonus 15 minutes and end right about seven o'clock Chicago time. This next question is from a sister of one of my patients about a chronic cough for nine years. It's been evaluated, it's not a lung problem, and it doesn't look like it's infected. It started a year after her husband died. She has tried all sorts of acupuncture and diets and has been to an alternative medicine center in Minneapolis. Any suggestions about how to move forward, and can she consult with you when she's in Portland?

Dr. Clarke: I don't really see patients so much anymore, but every once in a while, if somebody is referred by somebody I know, like yourself, John, that would be fine. I limit it to a handful of people that I know well who send me cases, and I see one or two people a month that way, so that would be fine. I typically meet with people in a coffee shop, but sometimes I'll use technology to interview people as well, and I'm happy to do that when the person is referred by somebody that I know.

But for that particular situation, my approach would be to do what I call a stress evaluation, and we've talked about the various components of that: What are the stresses today? How are the person's self-care skills? What ACEs, adverse childhood experiences, did they have? Do they have symptoms of depression, PTSD, or anxiety? Usually we come up with one or more of those issues that haven't been uncovered or addressed successfully, and the symptoms will make progress when we do. This particular situation started after her husband died, and whenever I hear that kind of timing, that's where I focus most of my attention. We would want to be considering the grief aspect.

Dr. Stracks: There's an interesting study from a while ago in Pediatrics about lingering coughs and hypnosis as a modality for getting the coughs to go away: sort of explaining to the children that the cough had its place and did its job and now it's lingering past its welcome, so it's okay to thank the cough for what it did and allow it to go away. The children in the study had significant improvement in that particular symptom. So I would be wondering about both of those. Are there ways that we can get a sense of what the cough was doing there and allow it to go away? And is there something about the grieving process that is incomplete or unfinished or still needs to happen? Those would be the things that I was thinking about.

Dr. Clarke: Absolutely. You're reminding me of a patient whom I had write a letter to her husband who was deceased, and things came out in the letter that she didn't know were in her mind.

Dr. Stracks: Yeah. And I'm happy to consult if the person's in Chicago visiting her sister, and happy to get information out to you, Dave, if she's out there. Thoughts about talking with others? People who've gotten better still have trouble convincing other people that this is a meaningful way to get relief.

Dr. Clarke: We wish that people who got better would tell their physicians, for one. I know the common question is, "I've run into somebody at work, or I have a relative who's got these issues, and I really want to tell them how much better I got." We have on the ppdassociation.org website a letter that people can copy or adapt, one to be given to the person's physician and another to explain the situation to loved ones. That was written by several board members of the PPD Association, so it's got a lot of good ideas in both of those. You're not always going to get the response that you would like to get. A lot of people are simply not ready to address the psychosocial stresses that are underlying their illness. I had one patient who very memorably said, after we had our discussion, "Doctor, I think you're right, but I just can't go there right now," and the tears were streaming down her face, and I never saw her again. I hope that she followed up on the suggestions that I gave her and made progress, but at least at that particular moment she wasn't ready. That's certainly the case with a lot of friends, co-workers, and loved ones that we would love to be able to show the pathway that we have followed that's led to progress for ourselves.

Dr. Stracks: I always figure that somewhere between one in ten and one in a hundred people is ready to hear about this as a solution, and hopefully that will continue to increase over time. There are literally hundreds of thousands of people who are eager to hear about this information. That's what Curable has shown. But because of the world the way it is, especially in terms of coronavirus, the odds of standing next to a person who's ready to understand this are small. When you start to expand the community, then you find a lot of people who are ready to hear about it. When people are talking to the person next to them, whether it's a family member or a partner or someone at a cocktail party, odds are that they're not necessarily ready. I also think that people need to hear it oftentimes 10 or 30 or 100 times before they're ready to really move forward with it, and that's why you and I do this work of getting the word out, so that people can hear it more and more often. I also go back to what I was saying a minute ago about boundaries. It's not any of our jobs, even mine, to convince somebody to treat their symptoms in this way. If somebody comes in and wants to know what they can do for a symptom, I'll throw this out there, but if they're not ready, I don't push them in that direction. I use any other tool that they are ready for, food sensitivities or otherwise, to try to help as best I can. I try to keep in mind that my responsibility is to get the information out, but it's not to make somebody understand what they're not ready to understand.

Dr. Clarke: I completely agree, and I would just add that if our viewers try to share this information with people and they get shut down 10 times out of 10, you may be planting a seed. That person that shut you down, 12 months from now, may remember what you told them and start acting on it.

Dr. Stracks: A couple more questions. Inflammatory arthritis or fibromyalgia: any thoughts on either of those?

Dr. Clarke: Fibromyalgia is very well known to be a mind-body condition, and there's not been any other cause found for it. There is research now that shows that a mind-body approach has more benefit than any other. Howard Schubiner, one of your previous guests and well known in the field, along with his colleague Dr. Lumley, has done outstanding research on this and found that people who can identify and express the underlying emotions, what's called emotional awareness and expression therapy, make more progress than with any other form of treatment that's been found so far. So it's excellent for this approach.

Dr. Stracks: Fibromyalgia clearly can be treated by mind-body medicine, as you were just saying, and the studies have shown that. For inflammatory arthritis, if somebody comes into my office with that, I will take a more comprehensive approach. I'll bring up mind-body ideas, but also work on supplements, changing medications around, and what people are eating, so I would rarely treat inflammatory arthritis just as a mind-body disease, even though I think there's definitely a component of that.

Dr. Clarke: That is more likely to have an organ disease as a cause, let's put it that way. In any individual you can't tell if some significant fraction of their symptoms might be mind-body related, but it's likely to be smaller than with fibromyalgia.

Dr. Stracks: Howard and I actually also did an unpublished study on fibromyalgia where we interviewed people about the amount of trauma that they had experienced, and it was literally so unspeakable that I couldn't even figure out how to coordinate the data and start to write it up. Because I've had that experience in that research, I know that if I see somebody with fibromyalgia, I at least need to consider the possibility that there's a trauma component to it.

Dr. Clarke: I had the same shocking experience with my irritable bowel patients. I thought I would see five or six a year that had a history of trauma, and it turned out to be five or six a week.

Dr. Stracks: Any thoughts about triggers? For instance, knowing that sitting in a certain chair isn't the cause of pain, but still can't bring themselves to do that.

Dr. Clarke: The same principles apply, I think. When you are sitting in a chair at work, for example, and you get progressively symptomatic, but you sit in a chair at home and you're fine, you know that is a clear indication that it's not the chair. Then you can use that symptom to focus on, okay, if it's not the chair, what is it? What are the stress issues that are really behind my symptoms? Start working with that. Curable can help people identify them, various books in the field can do that, a psychotherapist can help you with that, and a mind-body trained physician can help with that. If the person doesn't have an organ disease or a structural abnormality that explains why the trigger is causing the problem, then we need to look elsewhere. Symptoms happen for a reason. That's the first line of the new Psychophysiologic Disorders textbook. If it's not an organ disease or a structural abnormality, we need to find the stress that is the underlying cause.

Dr. Stracks: I'm also working on a handout, actually, so if you want to contact my office and get this, it's just about using graded exposure to deal with triggers. You imagine being in that situation and bring up the stress so that you can learn how to deal with it just in your mind, and then very slowly move into those situations, practicing sitting in a chair for three seconds and seeing how you do, and then gradually increasing the amount of time. I think that with triggers we can use some of these cognitive techniques to allow people to gradually experience it and get used to it, so that they teach their body how to be in those situations.

Dr. Clarke: That is a great idea. I didn't encounter as many people with spine issues in my practice, so I like that idea a lot.

Dr. Stracks: Somebody wrote in about a seven-centimeter ovarian cyst and whether this could be a TMS manifestation. I don't think so. I think that falls into the organ disease category.

Dr. Clarke: Yes, I would be hesitant about trying to treat an ovarian cyst with mind-body techniques, meditation, writing, or otherwise. I would probably work with a gynecologist on that to figure out what the right solution is.

Dr. Stracks: Next, decreasing medication when dealing with a GI symptom that's responding well to TMS therapy, specifically this one with inflammatory bowel disease, which is a little bit different than IBS.

Dr. Clarke: Inflammatory bowel disease incorporates Crohn's disease and ulcerative colitis, and it is possible to have irritable bowel syndrome at the same time. Consequently, when a person develops a flare-up of symptoms, it can be a challenge to decide: is it the inflammatory bowel disease or is it the irritable bowel syndrome that is responsible for the flare-up? An experienced gastrointestinal physician can often tell from the nature of the symptoms which one of those two it is, but there's enough overlap that sometimes you can't tell and you have to actually do a colonoscopy or a barium X-ray of the GI tract to find out if the inflammation is active in that person. If it is, you treat that. If the inflammation is not active, then you'd go toward more of a mind-body approach. It can be a very challenging situation for a physician to sort out what's happening there.

Dr. Stracks: I've definitely coached some people through decreasing their medication on inflammatory bowel disease, but it's slow and it can be hard, and there is some risk to it. I don't know that I would necessarily want someone to do it on their own, but I would say that in the right situations I've definitely seen people able to do that. There's a question here about Hashimoto's disease, which is autoimmune thyroid disease. I'll take that, because I do a lot of work with thyroid disease and autoimmune disease in people. Again, it's an autoimmune condition, so I wouldn't treat it just as a mind-body medicine issue, but there are comprehensive plans where I've seen people both manage the Hashimoto's disease much better with thyroid medication and slowly reduce the antibodies. This is part of that, but it's not the only solution. I'm always happy to consult with people with any kind of thyroid issue about what could be helpful for them.

We got down to our last question. The person had a small bowel resection three weeks ago and has some challenges with digestion. Are there any tips for accepting foods into the diet now that they're able to eat foods that they haven't been able to eat for years due to the bowel problems? There's still a lot of fear, and now diarrhea from the surgery. How do you realize that this is a functional issue, not a food issue, and how do you work on the fear of eating now that the physical issue has been worked out?

Dr. Clarke: Depending on the length of the bowel that was removed, if it was a long section, there may be a period of adaptation that the bowel needs to go through so that the remaining bowel can adapt to the piece that's now missing and pick up the slack, so to speak, to do the digestive process that the missing piece was doing before. The key word is going to be gradual. Gradually reintroduce foods that maybe you had trouble with before and see how they're tolerated, and if they're not tolerated, then back off, wait a while, and give your bowel some time to adapt. It can be a months-long process, so you might wait a month or six weeks and then try again to increase what you take in in your diet.

Dr. Stracks: Actually, one last question came in by email from somebody listening on the phone: stinky gas. I get asked that question fairly regularly in this arena. Could that be a symptom of a mind-body issue? Any thoughts about that?

Dr. Clarke: Usually not. What we're talking about with bad odors are very small amounts. They smell like they ought to be huge amounts of compounds, but the things that make bowel gas smell bad are actually very small quantities of very potent compounds, let's put it that way. Those seem to result from certain bacteria that you have in your GI tract that are manufacturing these things. How do you get rid of those? You can try probiotics, you can try yogurt with active cultures, you can try reducing the amount of meat in your diet, and sometimes that will result in a shift. It's not something that medical science has come up with a great solution for, but it's probably not a mind-body issue.

Dr. Stracks: The one thing that I will sometimes give people as an assignment is to try to get an actual check on this, so find a trusted person and get a second opinion if possible. I've had people who have found that, whether it's bad breath or stinky gas or body odor, when they do check it with other people, it's not as bad as they assume it is. Every now and then there's a fear that this is an issue when in reality it's less of an issue than people would imagine.

Dr. Clarke: I've had some patients who were absolutely convinced they had horrible breath, and I wasn't detecting it at all. I asked them, "Are your friends and family complaining about this?" Nope. So it was just something that they were somehow perceiving, and in those cases it absolutely did respond to a mind-body approach.

Dr. Stracks: We will end it there. Thanks so much for being here and spending the extra time telling about your experience in this area and helping answer the questions. Any last thoughts as we sign off?

Dr. Clarke: I'm looking forward to the day when this is a routine part of health care practice, and everybody listening tonight can help with that by teaching their physicians and their friends and family and anybody that they encounter who's got symptoms that might be mind-body. Spread the word about this so that people don't have to suffer for years and years needlessly.

Dr. Stracks: Thank you for being here. This is, as we said, part of an ongoing series, Hope for Healing, that is being produced out of my office in conjunction with Curable. We will be replaying this both from our website and posting it in Curable in a couple of weeks. It has been my pleasure to talk with everybody, to answer these insightful questions that people have, and to be part of a group of people who are smart enough and brave enough to address their symptoms in this nuanced, alternative mind-body way that's so much more effective than so many of the more conventional treatments that we have out there. For those of you listening, please feel free to reach out to my office if you have further questions, want to consult with me, or want to get our regular updates through our newsletter. You can go to my website at [confirm website]. Thank you to Curable for hosting us this evening, and thank you to everybody who's been here and listening and participating. I hope everybody has a great evening, I hope everybody continues to stay safe during quarantine, and I hope to see everybody again soon. Thanks, Dave. Thanks for all you do.

Dr. Clarke: Absolutely. You too, John. Have a good evening.

Dr. Stracks: You too.

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Dr. John Stracks practices mind-body medicine via telehealth nationally and internationally. To learn more about working with Dr. Stracks or the Cormendi Health team, visit cormendihealth.com. You can find more interviews on the Cormendi Health YouTube page.