Video: Watch the full session here → https://www.youtube.com/watch?v=jPhQgvTteKE
Dr. Stracks: Welcome, everybody. We'll get started in about 60 seconds. Erica, nice to see you.
Erica: Nice to see you, too. Thanks so much for having me back.
Dr. Stracks: You are welcome. I like that book in your background.
Erica: Thank you very much. Dr. Howard Schubiner.
Dr. Stracks: Dr. Schubiner's new book, Unlearn Your Pain, came out last week. He's our colleague here at Cormendi Health and a mentor of mine for many, many years. He worked on this book for three, four, five years. It's the sum total of what he's learned in the mind body medicine space over two decades. Nurali will put the link to the book in the chat for those of you who are interested. It's on sale through the publisher and anywhere that you get books, and it's a great addition to the literature on mind body medicine.
Dr. Schubiner is normally in the Detroit, Michigan area, but he's going to be here in Chicago on Friday signing the book and talking with people. So if you're in the Chicago area or nearby, Friday at 5:00 Central, Dr. Schubiner will be here talking a little bit and doing a book signing. Nurali will put the link in the chat so you'll know how to get in touch with us if you're interested in attending. That will be super fun, and we are super excited. Like I said, he's been working on this for years, so it's great to have it come out.
Everybody's here, so let's get started. Erica, nice of you to be here with me today. For those of you who don't know me, I'm Dr. John Stracks, a physician with an office in the Chicago area and worldwide on telehealth, specializing in mind body medicine. I'm here with Erica Walker, a therapist and pain coach in our office at Cormendi Health who specializes in pain reprocessing therapy, which I will call PRT. She has been doing outstanding work in this area for well over a decade, has treated thousands of patients for mind body medicine disorders, and has agreed to be with me in this series of lunch and learns to talk about the fundamentals of PRT. Erica, thank you for being here.
Erica: Thank you so much. I'm happy to be back.
Quick Review: What Is Pain Reprocessing Therapy (PRT)?
Dr. Stracks: We were here about a month ago talking about an overview of PRT. You and I discussed this ahead of time and thought that a quick overview would be helpful for people. What we started to talk about last time, and then we'll move on into next steps, was just what PRT is, correct?
Erica: Right. PRT is designed essentially to help break the fear-pain cycle. Think about it like a loop. The fear is fueling the pain, and the pain fuels the fear, and we can get stuck there, but we can also get out of it. PRT offers a lot of strategies for how to respond differently to unpleasant sensations and pain in the body. PRT can be used for any mind body symptom. There's a lot of literature on musculoskeletal pain, back pain, and joint pain, but we've seen people with kind of every symptom under the sun. If I had to list all of the ones that I've experienced, I would literally have to start with my head and work my way systematically down my body. So we can get out of chronic pain. It is doable. It's not easy, but it's relatively simple at the same time.
Dr. Stracks: When we were talking last time, we talked about three specific strategies that you tend to recommend essentially as soon as you start to work with people, right?
Strategy 1: The Evidence List
Erica: Yeah. Right out of the gate, I want to start off with an evidence list, especially if people are on the fence. I think of this like chatting back and forth and getting into an anxiety argument. Is it structural? Yes. No. Yes. No. We go back and forth and can spend lots and lots of time doing this chatter box in our head. It is, it isn't, it is, it isn't. And when pain goes up, it tends to pitch more towards the idea that there's got to be something structurally wrong with me.
So with evidence, I'm asking people to literally write down and bullet point what makes them think that this is mind body. Where's that information coming from? Is it unremarkable testing? Is it that this shows up when I'm under a lot of duress? Did this come about after we had our first child? What are the pieces of evidence that are supporting the mind body explanation? We're not going to go fully into that today because we already did these three strategies in our previous video, so we can drop the link.
Dr. Stracks: Right. We'll put the link in the chat, and people can find that on our YouTube page. So that's keeping an evidence list, keeping our understanding about why we think these pain issues are more related to psychology than to anything wrong in our body.
Strategy 2: Keeping Track of Your Wins
Dr. Stracks: We also talked about the ability to keep track of our wins and when we're doing well. How do you explain that to people when you first see them?
Erica: This is one of my favorite things, because as humans we are phenomenally skilled at being oriented towards threat. We're survival-oriented creatures. Some people call it a negativity bias. I don't really love that phrase because it kind of sounds like I'm doing something wrong. We are organically designed this way. We need no more practice with keeping track of the things that we don't like. What we usually need practice with is keeping track of the things that go well.
It could even be something that feels small to say out loud, but it's big to me and it's big to them. Like, "I tied my shoes without help for the first time in a year." Or, "I did an activity that I didn't think I could do, and I did it." Even if it wasn't perfect, that's okay, because we're just steering the ship towards wellness.
Dr. Stracks: How do you help people understand that those wins are important even if it doesn't feel that way? That was a really good example: "I tied my shoes without help for the first time in a year." A lot of my patients over time would say, "All I did was tie my shoes." How is that a win?
Erica: Yes, and this happens a lot. I'll give the homework of keeping track of your wins this week, and invariably people will come back and say that it was small, so I try to flesh that out a little more. Did you sit and watch a movie with your partner and not get up the whole time? That's huge. What people in pain might think is a little win is, to me, critically important in the healing process.
Dr. Stracks: And so one of the things you do with people is help them to see that. Like you said, we're so good at looking for threat and at looking at the negative. It takes a lot of intention to find the positive.
Erica: It does. That's why I have people either type it out or write it out, and it's how I like to start a session. It's pretty much the homework from the first session: keeping track of your wins. Then I want the client to start off the session with what has gone well. There's certainly going to be space to talk about what's maybe not going ideally right now, but I want to encapsulate it this way because those wins help you pitch into safety and out of fear. The mind is going to go back and forth like this for a while. Am I safe? Am I not? It's just part of being human.
Dr. Stracks: When you're working with people individually, is that literally how you start the sessions, by finding out what went well since the last one?
Erica: Yep. That's what we start with.
Dr. Stracks: I like that.
Strategy 3: The Three C's (Catch, Compassion, Carry On)
Dr. Stracks: The other thing we talked about last time was the three C's, which is a specific strategy that you developed over time. Can you give a brief overview of that too?
Erica: Okay, this is the three C's. I'm going to jam through this because we did a lot on it last time. It's called catch, compassion, carry on.
We can't change something if our thoughts are just running a narrative and we're buying into that narrative. "Oh my gosh, this is true." We would never go around saying everything that I think is true. We know that's not the case, but we get really caught up in the thoughts that scare us the most. So we want to start identifying them. "Oh my gosh, that's the scary thought that I've had. That's the catastrophic thought that I've had a million times." I'm just going to notice it without getting into battle with it. Old-school psychology talks about thought replacement: get rid of the negative thought and add a positive thought.
Dr. Stracks: It's too much work.
Erica: It's just too much work. Let's simplify it. Just, "Aha, there's the thought that scares me."
This is the compassion piece. I know this looks kind of silly, but I actually have clients who give themselves a physical thumbs up. "Good, I caught this. Excellent. I intervened on my own behalf. I caught this when I was 32 hours down a rabbit hole with it, but then I figured out, wait, this is just scary thinking. It doesn't mean that it's true. I don't have to engage with this scary thought." And then we want to be kind to ourselves. This is the hardest part, because what people want to do is say, "Oh my gosh, I'm having that negative thought. I'm not supposed to be thinking negative thoughts. It's all my fault. Now I'm doing it to myself." We don't want to kick ourselves while we're down. So, "Good. I'm getting better at this. I'm on the right track."
That's the hardest part. This is not organic to us. So if my negative thought is, "I'm never going to get better," I see that I'm saying it, I catch myself, and then I say, "It's okay that I have that thought. The thought isn't necessarily true."
The carry on part, for the simplicity of this talk today (I will stretch this out more when I'm working with somebody individually), is just noticing what's happening with my breath. The breath is shallow. The heart's going to be a little faster. Muscles are going to get tense, because the brain is preparing us to go into fight-or-flight mode so that we are safe. This is a really primitive function and we're grateful to have it, but we mostly don't need to be in a state of fight or flight.
Dr. Stracks: Got it. So that's what we talked about last time: the evidence list, keeping track of your wins, and your specific strategy of the three C's.
Somatic Tracking and Interoceptive Exposure
Dr. Stracks: You and I also did a video previously, I can't remember, six months ago or a year ago, talking about somatic tracking, which is an exposure technique. That full video is available and I can link to it as well. Let's briefly review what exposure is, why it's important, and why we spent all that time talking about somatic tracking.
Erica: Essentially, exposure is confronting the things that scare us. Exposure work is challenging. It's also incredibly rewarding when you get the hang of it. Somatic tracking is what's called interoceptive exposure.
Dr. Stracks: Interoceptive exposure.
Erica: Yes. You're welcome for the nerdiness. It has a clinical name to it.
Dr. Stracks: Interesting. Okay. Got it.
Erica: This is paying attention, without judgment and on purpose, to the sensations in the body that we find scary. It sounds kind of counterintuitive, because the goal here is for the pain to go away, but in order to do that, we've got to get closer to it. It's not easy, and not everyone is ready to do that right out of the gate.
Dr. Stracks: Say I come to you and I've got terrible back pain and I hate it. I just don't want it to be there. I want it to go away. And you tell me to feel it. I don't want to feel it. Can I get away without feeling it?
Erica: You're trying to ask me a trick question here. No. The reason is that we have to learn how to reduce the fear around the sensation, because otherwise we're going back to the beginning, the fear-pain cycle. Somatic tracking gives us an opportunity to take a break from all of the judgment and the fear and the negative fixation. We can just be with that sensation while we're breathing, noticing when it's moving, when it's a little louder, when it's a little quieter.
People will often say to me in a first session, "I tried somatic tracking, but I think I'm doing it wrong." You hear this all the time, right? The only way to really do it wrong is to be doing it with the thought, "I've got to make this go away," because that approach already hasn't worked. So we've got to shift gears and come towards the body so as not to be as scared of it.
For example, if someone is scared of escalators and stops riding them and never wants to get on one again, they don't have to. But the only way to get beyond the fear is to ride the escalator, to be with it and reduce the intensity in the body. So I really walk people through it. It's an entire session for me to go through somatic tracking and try it. We just dip our toes in and see: are you ready to do this or not? Do you like it? Do you hate it? Then we can shove it aside and come back to it. If it's too much, if the fear is too high, then we've got to work on the fear first.
Dr. Stracks: How quickly do you bring this up with people? We talked last time about getting started, people meeting you, and what to do initially. Does the concept of somatic tracking, or interoceptive exposure, come up pretty quickly when you're working with someone?
Erica: Usually, yes. We're communicating with one another, so we're dipping our toe in. Let's see how this goes. If the intensity starts to rise, then we get really calm and slow things down together. It's easier to do somatic tracking when you're with somebody else, because the client is just listening to me and not anticipating what I'm going to say. They're actually paying attention to my words, which can be really soothing and calming.
One of my favorite strategies with somatic tracking, and I know this isn't necessarily the focus of what we're talking about, is that sometimes people will come in and tell me how much they hate it and how terrible it is. I say, "How do you do it?" And they say, "Well, I know it's so important, so I sit down every morning and I do this for 30 minutes until I can't take it anymore." I say, "Okay, great. Let's try three seconds."
Dr. Stracks: Exactly. You don't need to somatic track your face off.
Erica: Right, because it's still having that same intense pressure. It shifts the pressure to "I have to heal, and it has to happen right now." We hear this from clients all the time: "How long do you think this is going to take?" We don't know the answer. I tell people we'll move forward as quickly as you can and as slowly as you need to.
Dr. Stracks: It's different for everybody, which is hard. You and I both want everybody to be better in 24 hours. I don't want anybody to suffer at all. But I know there's a process to it, and for some people that process is a little bit longer and for some it's a little bit shorter. I think one of the advantages of talking with you or with me is that people will come in and say, "It's been six weeks and I'm not better, and I'm slow," and I'm thinking about how quickly they're actually moving forward. There's so much information out there that suggests this should be instantaneous. It's a process of getting better.
Erica: It's a process. And as we talked about last time, the what is probably even less important than the how. We're going through specific strategies here, but the how, the energy we bring to something like somatic tracking, matters. If we're closing our eyes and thinking, "I'm doing it. I'm doing it. Where's the pain?" then we go into that really fixated space again. We want to shift that, and it's okay that it takes time for that intensity to shift.
Dr. Stracks: Because when we're not feeling well, we spend so much time focusing on not feeling well. Do you ever try to bring people to different sensations in their bodies?
Erica: Yes. Let's say they're having neck pain or something like that, and we're noticing it, and as we're doing somatic tracking together the pain starts to get louder. Then I'm going to take us to another place in the body that's more neutral. A lot of times that's going to be the hands or feet, or it could be something else, like touching your face. Just notice what this feels like. We're titrating back and forth so that this is more tolerable.
Dr. Stracks: Because when there's pain all the time, it gets so big that we forget there are other parts of our bodies that feel okay or neutral.
Erica: People do tend to enjoy that distraction, like mimicking walking. So curling your feet, and then I'll start calling out parts of the body. Notice this ligament area here and how it tightens. Notice your ankle and how it gets a little bit tight. Your calf, your knee even, might be activated.
Setting Goals and Graded Exposure for Activities You Fear
Dr. Stracks: There's a whole separate video that we have on somatic tracking, covering the introduction and the exposure. So what happens next? What else is involved with the practice of PRT that helps people to move forward?
Erica: I like setting goals. Probably in the first session I'm going to ask what you're doing for exercise, what you might be avoiding, and what activities you used to enjoy and are now avoiding. There are several types of exposure that I do. We've talked a lot about the walk-jog. We get tons of clients who are fearful of running, and this could be from any sensation in the body. If their goal is to get back into running, often what I'll do is have them put on headphones so we're not even on Zoom together. We can be, but it's kind of challenging. We start by walking for one minute, and then the jog part is literally the slowest jog you've ever done in your life. There is zero way that you can harm yourself doing that. So do a minute of walking, then four steps of jogging, and then back to walking.
We want to introduce these things in a way that's reasonably palatable. We don't want to retraumatize anyone. It's not just "you have to go out for a run." We don't want to go from zero to ten. It's too much. I know a lot of people think that pushing themselves is part of the healing process, but that's still that intensity. That's still somatic tracking your face off.
So we start out slow. If someone is afraid of using a machine, say they've avoided their recumbent bike, then we'll do it together. We take a few minutes and just describe the machine itself: there are the wheels here and the handles here. Great. Breathe. Then I have them get on it and we just hang out on it and talk. Once we start to move, it's kind of like, "Raise your hand if you're noticing some anxiety coming up," and then we pause. So again, we want to titrate with exposure. Thirty minutes of somatic tracking is pretty excessive, I would say.
Dr. Stracks: Without a doubt. And I've known you to literally be on a Zoom call with somebody as they're working out or going out for a walk or a jog. That's part of what you'll do.
Erica: Yeah. I think it's really helpful, because it's hard for someone in pain to explain to someone who has never experienced chronic pain that doing a mild jog is incredibly scary for them. Doing it with me, because this is what I do all the time, really reduces the fear and reduces the self-judgment.
Dr. Stracks: I think that's so important too. I get a lot of people who say, "I used to run marathons and now I have trouble running a block. How is that important?" But you can't get back to the marathons without first doing the block, and people miss that point frequently.
Erica: Right. For a lot of people who have become phobic of a myriad of things, there's this idea of, "I haven't driven for a year, and in my mind's eye I'm thinking, 'Oh my gosh, I need to go get on the 405 right now,'" one of the busiest freeways in California. No, we want to drive around the block, and do it enough that you're comfortable with driving around the block.
Pain Is About Danger, Not Damage
Dr. Stracks: Let's talk about this idea of danger and safety. We're talking about getting back to activities that we used to be able to do, with the concept of somatic tracking, making sure that we feel like these sensations in our body are safe. What I say frequently to people when we're talking about pain is that pain is not evidence of damage in our body. It's evidence that our brain is sensing danger somewhere. It's not about damage, it's about danger. So one of the big antidotes to the pain is being able to create this sense of safety. That is much, much easier said than done in my experience.
Erica: Absolutely.
Creating Believable Messages of Safety
Dr. Stracks: One of the things you and I have talked about a lot, and I hear this very often from clients, is that some people love telling themselves, "I'm safe," and they can buy into that. Many people, though, don't believe that they're safe. So what do we do with that?
Erica: If we're telling ourselves "I'm safe, I'm safe, I'm safe," and we don't believe it, we're gaslighting ourselves, and that's going to lead to us feeling bad about ourselves. So with messages of safety, I want people to have creative license to figure out how to embody that sense of safety a little more. If "I'm safe" isn't working, that's okay. You're not doing it wrong. You just don't believe it. Other options are "I can tolerate this" and "This is temporary."
Then one of the most creative ones I've ever heard came up recently, and I do have permission to use this. I'm not going to use the client's name. Check this out, I love it: "My body is fine. My brain will align."
Dr. Stracks: Say that again.
Erica: "My body is fine. My brain will align." It's kind of getting the body and the brain to sync up and be on the same team.
Dr. Stracks: This idea of safety comes up quickly when you work with clients. When people move forward quickly, what's the thread that helps them? My answer almost always is that my patients who have done really well, really quickly, lose the fear very quickly. They manage to figure out ways to create safety in places where it wasn't previously. So how do you help people with that? Say I come to see you and this idea comes up, safety and danger, not damage, and I say, "I just don't feel safe," or maybe what you said, "I tell myself I'm safe, but I don't really believe it." How do you start creating messages of safety that are believable?
Erica: I've been preferring lately "I can tolerate this," as evidenced by the fact that I already am. I didn't like it. I hate it. I'm still able to tolerate it. We're combating that catastrophic thinking of "I'm never going to get out of this. It's going to get worse and this is the rest of my life. I'm going to be disabled." We want to combat that, and we're using the three C's there.
Then there are times when the body gets so activated that the three C's aren't really available. As anxiety rises, we cognitively go a little bit offline and get kind of stuck. We want to trust in the breath. It's always going to be on your side. Even if it feels uncomfortable and it takes minutes to get the breath to slow down, we're going to get the heart going a little more slowly and relax the body a little more.
I've gotten really creative with messages of safety before. If "I'm safe" doesn't work, if "I can tolerate this" doesn't work, if "this is temporary" doesn't work, how about: what am I good at? I worked with a client years ago who said none of those words worked. She said, "I don't at all believe it." I said, "Okay, so what are you good at?" She took a moment and said, "Well, I'm a good gardener." "Okay, what are you good at in gardening?" "Oh, I have this beautiful tomato plant." That's going to be your message of safety until we can get closer to "I can tolerate this." I'm a good gardener. I'm a good tomato farmer.
Dr. Stracks: Let's unpack this a little because I think it's really interesting, and I know how effective it can be. A lot of our clients have a lot of experience in not being safe: safe in their bodies, safe in their environment, safe in their families. So for a lot of our clients, there's a lot of past history that helps them understand that they're not safe. Now we're saying, "No, no, part of what makes you better is learning to create that sense of safety." What you said a few minutes ago, that if you don't feel safe and you tell yourself you are, it's the same as gaslighting yourself, is right. Our brains are too smart to believe something that's not true. A lot of people start with the strategy of "I feel safe, I am safe," but frequently that's not super effective. So you said the next step is "I can tolerate this." Tell me a little more about that, because I think that's a true statement for most people.
Erica: It's evident in that you're on the planet. You were able to get to the other side of this.
Dr. Stracks: Yes. So tolerating, to the extent that it essentially hasn't killed us. We're still here and we're still doing this, and it doesn't necessarily feel good and we don't necessarily want it there, but we are tolerating it. Help me make the link here. How does that help build us towards feeling safer?
Erica: We're wanting to build resiliency. There's a lot that goes into the first couple of sessions, and I'm talking a lot in those sessions. What can you associate with feeling safe? Is there anything in your life? Your dog? Does your dog make you feel safe? What about having your screen saver be your dog? I'm really getting to know someone on a personal level and figuring out what helps them feel specifically safe. A lot of the literature and video content that's out there online says you need to tell yourself that you're safe. Literally half the time, people come in and say, "This does not work for me. I don't believe that to be true. In fact, I know it to be untrue."
Dr. Stracks: Let me hold that there. I'm still trying to unpack this a little in my own mind too. The idea of "I'm tolerating it" is not a direct measure of safety necessarily, but it's much more authentic. It brings people away from the idea that they have to tell themselves they're safe, and reframes it as: this is where I am in the process, and this is a true statement about my experience. Do I have that fairly accurate?
Erica: Yes, exactly right. That sense of authenticity, like, "This makes sense to me." Is it safe? Maybe not.
Dr. Stracks: Okay. So you're reframing it and helping create authenticity in people's minds as they go through this process, and then you're starting to look for places where, if you're not feeling safe in your body, you do feel safe. That's where somebody's dog may come in, for instance.
Erica: Right. In EMDR therapy we call that outsourcing the resources. If we're not feeling safe in our body, telling ourselves "I'm safe" almost turns into yelling at yourself. "I'm safe!" The frustration starts to build, and now we're yelling at ourselves.
Dr. Stracks: Which is never helpful. Are there any other examples you can come up with? The dog and the screen saver are one. Any other common ones, where people start to recognize that there are some areas of safety in their lives?
Erica: This is one that I use. It's a rose quartz heart. I've had it for years, like decades. I find it soothing. It's a self-soothing practice, and there are a lot of different self-soothing practices. It might not even be words. It might be touch, physical touch. When we put our hand on our heart, it's said to elicit some oxytocin that mimics having a hug. You're the medical doctor.
Dr. Stracks: Correct. When we talk about self-compassion, which we will later on, self-touch actually elicits that, as if somebody else is giving us a hug.
Erica: And we're making sure that we're breathing, that we're not up here, but with the rise and fall of the chest.
Using Your Strengths to Build Safety
Dr. Stracks: You asked your patient earlier what she was good at, and she said gardening. I'm starting to see how that's part of this, but can you unpack that a little more? Why look for people's strengths? What does that do?
Erica: I think it makes them feel good, first of all. They like sharing with me because I'm not going to see their garden. I'm not coming over to their house. Unless they take their computer outside and show me, I likely won't see it. So they get actually pretty excited about telling me. They've got this private garden thing going on and people largely don't see it. "I'm really good at growing tomatoes," and in that moment it feels good. We can come up with something that we know we're good at.
Dr. Stracks: So thinking about what we've been talking about in terms of safety and exposure, you're bringing people's strengths to light and helping them anchor in the good feeling of that. That's a good way of putting it.
Erica: If you ask someone to list their strengths and they say, "Oh, I don't have anything that I'm strong at," but you know that's not really true, then I'll ask, "Okay, what would your spouse say? What would your kids say? What would your friends say?" Usually we can get a pretty good list going, and I think it helps bolster confidence to share that, to acknowledge that they know it about themselves and that other people know it about them too.
Dr. Stracks: Do you ever have people who are shy about telling you their strengths? How do you work with them if somebody says, "I don't really have any strengths. That's the whole problem," or "I used to have strengths before I had pain and now I don't anymore"?
Erica: I'll prompt people. Are you a pet owner? Do you take good care of your dog? Yes? Okay, so do you like animals? Okay, so you're good to animals. There's a big compassionate space for animals. Or do you like walking in nature? "Oh, I love the tall trees, and there's this meadow over here that I like." Okay, so you're a person who's connecting with the earth. It can be challenging to just sit here and have you ask my strengths, and I'm like, "Oh, I'm funny. I'm hot. I'm smart." It's a little awkward.
Dr. Stracks: Right. And it ties back into celebrating the wins, too, because one of the important parts of this is to recognize pieces of our recovery that seem small.
Erica: Yes. That's why we're still talking about messages of safety, because we want to expand it. People might start off with, "I'm safe, but I don't feel it." I want people to have a myriad of options for how they can message safety back to themselves and be on their own side. "I'm a good gardener" is cool. It's a good brag.
Dr. Stracks: And for those of us who aren't good gardeners, it's super impressive that people are.
Erica: Some of my friends say, "Erica's the best chef in the world." I'm not. I'm pretty good, but in LA most people don't really cook. Everyone's going out to eat. So I can roast a chicken and people are like, "This is the best thing I've ever had."
Dr. Stracks: Anything else about messaging of safety that you think is important for people? Let's see if we missed anything. I know we're covering a lot of territory today.
Erica: Messages of safety and self-compassion really overlap. All of these pieces overlap.
Self-Compassion in Pain Reprocessing Therapy
Dr. Stracks: Yes. Let's spend a little of the time we have remaining talking about self-compassion, and then hopefully there will be a few minutes for questions after that. There should be a Q&A button for those of you who are listening, and you can type your questions in. We'll leave about 10 minutes at the end to try to get to some of them.
The three C's are about compassion, safety is about compassion, and recognizing our strengths is about compassion. You and I have both seen lots of people who are extraordinarily hard on themselves. I say this to people, and you probably do sometimes too: we can be mean to ourselves, or we can get better, but it's very, very difficult to do both. When I said earlier that my patients who do well quickly lose the fear of the pain very quickly, there's also this compassion piece. If we don't learn how to be kinder to ourselves, I think people can really struggle in moving forward. If we're talking about danger and safety, and we're constantly being down on ourselves in our minds, that's not a very safe place.
Erica: I love your visual. Mine was similar, but yours is better, so I'm going to steal it. Imagine someone walking around right behind you chattering in your ear all day, saying, "Erica, you're not good at your job. You should have gotten that email out sooner. You really dropped the ball. You don't look very nice today." I'm going to feel terrible very quickly. I'm imagining myself crying. That would be so horrible. But we do it to ourselves internally, and no one's witnessing it. This is again where we can get stuck on that chatter loop, and where we want to use the three C's to intervene on our own behalf.
Self-compassion is really just about: can I be kind to myself? I think most of us, especially our generation and up, grew up when there was no space for compassion. That wasn't part of the story at all. The story was pull yourself up by the bootstraps, be tough, and get out there and be successful.
Dr. Stracks: No pain, no gain. Wasn't that the mantra of our teenage years?
Erica: Totally. No pain, no gain. How compassionate is that? Most of us learned that in order to motivate ourselves we put pressure on ourselves. We've got to work harder and do it more. No space for compassion whatsoever. Part of that is that we have succeeded in the past from putting pressure on ourselves. We got the A on the exam, we got into college, grad school, whatever. Then we get to a certain point where the nervous system says, "Okay, I'm hearing this constant chatter of how bad I am all the time." It could be smaller than that. It's not necessarily "Ugh, you're a piece of crap." It could be this ongoing background noise of "I can't get everything done. I'm never going to get my to-do list done." The truth is you're never going to get the to-do list done. You cross something off and immediately replace it with something else. So we've all got to be a little gentler with ourselves about that to-do list, especially in this day and age.
Dr. Stracks: You and I both see people come in who say, "Oh yeah, I'm sort of hard on myself," and when we really unpack it, people can say really, really unkind things, and it's kind of constant in the background. Say you find out that that's a big part of what's causing people's pain and discomfort. How do you start to help them change that around? Or let me ask first: is working on the self-compassion aspect part of what you do with people?
Erica: Absolutely. I feel like you and I found our way into the self-compassion world roughly around the same time, maybe a little under 10 years ago. I love it when our brains are synced up even when we're not talking. Sometimes we'll have the exact same thought.
Here's the very basic science version. The amygdala is part of the process of the brain going into fight-or-flight mode. It's critically important to that. Fight or flight is really helpful if we're getting chased by a grizzly bear. It is not useful if we're trying to get our emails out.
Dr. Stracks: Right.
Erica: When the amygdala lights up, it's not the amygdala's job to know where the messaging is coming from. It doesn't know if it's this person over here or this person in here. When we are continually harsh, critical, and pressuring with ourselves, we're lighting up that amygdala. We're pushing towards fight or flight, and we want to go the opposite direction. We want to move towards self-compassion and away from pressure and criticism. This circles all the way back. It's partly why I have people track their wins: you're going to feel safer if you can acknowledge that you're doing things that are moving you towards health and healing.
Dr. Stracks: For a lot of people, the self-criticism goes way, way back. What are the beginning steps? Say it's early on, you've seen somebody two or three times, and this starts to pop up and you recognize the messaging they're giving themselves. What do you do next? How do you start to work with people to help them move towards compassion?
Erica: For years now I've used with almost every single client the Mindful Self-Compassion Workbook by Kristin Neff and Christopher Germer. It is so user friendly. I'll say, "I want you to do the first two chapters." That's about eight pages.
Dr. Stracks: That's it.
Erica: Right. We're just going to slowly move through where the resistance is to being kinder to yourself. What's at risk? "Oh, well, if I don't put this pressure on myself, then I won't be as successful as I want to be." Well, you will be in pain and you will be miserable. This compassion piece might actually be the most important part, and it's probably the hardest part. With the three C's, that second piece, compassion, is always the hardest part for people. They'll say, "Oh, I caught the thought, and then I dropped into my breath." What was happening in between there? So again, it's all overlapping.
Dr. Stracks: Mindful Self-Compassion Workbook. If Nurali can put a link into the chat, that would be great. Say the names of the authors again.
Erica: Kristin Neff and Christopher Germer.
Dr. Stracks: And the title is just The Mindful Self-Compassion Workbook.
Erica: That's right.
Dr. Stracks: When I've looked at it, it has like 13 different meditations and 38 different exercises. I think it's important to recognize that self-compassion is a skill.
Erica: That's very well said.
Dr. Stracks: Even if we're not good at it, even if it's a new concept, which I think it was for me at some point as an adult, we can still learn how to do it. I'm a child of the 70s, so it was all about harshness and being on your own. I was taking a class in somatic psychotherapy, a training, and I had to leave town every couple of months for it. One time I was getting ready to leave town and I looked at my schedule in my office and I was totally booked for the day I was at the training. I immediately tried to blame my staff. "I told you I was going to be out of town." They said, "No, you didn't." Then I immediately attacked myself. "How could I do this? How could I be so stupid? Professionals don't do this, and I'm never going to be a successful physician if I can't even control my schedule."
Part of that training was learning about self-compassion, and I specifically remember, 12 or 15 years ago, sitting there berating myself, and I stopped. I said, "You know what? We don't talk like this around here anymore. If there's not something nice to say, then we don't need to say it." The process of doing that interrupted the cycle of me yelling at myself. Then it became clearly apparent: okay, we're in this situation, and we've got to do something about it. There were about 15 people on my schedule, so the staff called some and I called some. One person got kind of irritated, and the rest were like, "Oh, that's no problem, we'll just switch it." The people I called said, "Oh my god, Dr. Stracks, that's so nice of you to reach out and call directly. That's so wonderful that you did that." So that's an important first step, just realizing in the three C's that we're doing this and figuring out some way to interrupt.
Erica: And I've got my own self-soothing object. I've got my stone here. When I was growing up, we had horses, and we took in this rescue horse who was so sweet and beautiful but had been abused and was just terrified. We had to move really, really slowly with her. Once she let me touch her, I would pet her down the head (their heads are super long) until her eyes would soften, and I would say, "Easy, girl." It's really simple. That's what I do for myself if I get into that frazzled mode, which still exists. I probably am not going to be able to abolish it. It shows up as part of my personality sometimes to get into that perfectionistic way of being. But as soon as I recognize it, I'll just say, "Easy, girl, easy, girl," like I'm talking to this really sweet, scared horse. That's a technique that just developed over time. It's nothing wildly profound, and it might not be meaningful to anybody else, but to me, even just stroking my arm, I automatically think, "Oh, that's right. I can be kind to myself."
Dr. Stracks: Right. Just recognizing that that's an option is such an important part of getting started with it.
Erica: It's huge. It's such a big part, and it's challenging for people.
Dr. Stracks: Without a doubt, huge.
Erica: It's a long process. I think there are 22 chapters in this book and we're just doing two at a time. That is weekly homework.
Audience Q&A
Dr. Stracks: It's ten till the hour, and there are a couple of questions that have shown up in the chat that I want to go over. There's probably more we can talk about with self-compassion, so we'll pick up there with some other specific strategies next time, because it's such a critical piece of people's improvement. Let's take a couple of questions before we sign off. There's one message in the Q&A saying the chats aren't coming through. That may or may not still be true. If it is, we'll sort that out and email all the links that we've talked about to everybody later today or tomorrow.
Can focusing on a different part of the body help with interoceptive exposure while running?
Dr. Stracks: "I've noticed with high-intensity intervals with the local running club that the sensations of pain in the calf and numbness in the foot became less on the second and third intervals when I focused on the sensations in my opposite leg or opposite foot, or focused on the runner just ahead of me. Is that on the right track for interoceptive exposure?"
Erica: Yeah, that sounds great.
Dr. Stracks: It's doing a couple of different things. It's taking our focus away from the negative and focusing some on the positive, or, like you said, oscillating between one and the other: noticing what doesn't feel good and then noticing what does. Just recognizing that we don't have to focus only on the negative sensations is really good. Yeah, that sounds great.
How do you work on safety when the world feels less safe?
Dr. Stracks: "How do you do the work with safety during times when the world is feeling less safe? Violence, environment, viruses. What is the impact of that context on our ability to feel safe in our minds?"
Erica: This is such a good question. I think it's fair to say that in my lifetime this is the internationally highest level of anxiety in the ether. I do not want to leave this out, and I'm so glad you brought up this question: limit your content consumption. Stop Googling your symptoms. It's got to stop.
Dr. Stracks: You and I have been talking a lot about Googling our symptoms, and this question is a little different. This is the external world. But what I was saying earlier, that we can be mean to ourselves or we can get better, I'm starting to wonder if we can Google our symptoms or we can get better, and doing both is really difficult. The Googling and the searching constantly reinforces the danger. That's what the algorithms do.
Erica: And all those terrifying headlines that show up in the newsfeed get scarier and scarier because they want clicks. Then you open them up and you realize nothing's really determined. They're just throwing out an idea. The news is not great. I really limit my news intake, and I think of it in terms of capacity versus capability. I'm capable of being on the news thread, but do I have the capacity for it right now? I'm not talking about sticking your head in the sand, but really taking some days to say, "I'm going to take a break from this." The good news doesn't really make headlines, but all the scary stuff does. All of that scary headline messaging continues to drive the volume up on the nervous system. We're getting more and more dysregulated.
Dr. Stracks: I've been thinking about this concept, and I think you and I have talked about it: humans evolved in times of scarcity. The biggest place of scarcity was food, so our bodies are designed to eat as much food as we can whenever we get the chance. As long as food was relatively scarce, that was a really good strategy, because during the summer, during times of harvest, we could eat and eat and eat, and then winter would come and there would be less food, and we'd lose those calories and expend the energy on staying safe during the winter until that process repeated. That's a good strategy. But 50 years ago, food became plentiful rather than scarce, and our strategy is still to eat and eat and eat. We've made ourselves sick by not knowing how to limit, because we never needed to before. The rise in obesity and the rise in diabetes are linked to this switch from food being scarce to food being plentiful. Now we all need different strategies to make sure we don't get sick.
I heard somebody say recently that information is in the same category. Historically, information has been scarce, so anything we could do to get our hands on it, like talking with people or getting information from other villages, helped us get ahead of potential danger and stay alive. Then, with the advent of the internet 30 or 40 years ago, all of a sudden we switched, before we could evolve for it, to information being plentiful. Now, if we consume as much as we possibly can, it's no longer particularly useful. We need a different strategy to make sure we're not taking in too much.
Erica: That's an amazing way to put that. Exactly. We have seen clients who are on a device any moment they're awake.
Dr. Stracks: Yes, and younger generations even more so. So figuring out how to manage that and how to balance our need to look in other places is important. One other answer, and then a couple more questions: the idea of gratitude, of looking for the positive in our lives and in our world. There have been multiple studies at this point on how helpful that is in so many different ways. Making sure that we spend at least a little bit of time each day focusing on the positive is super important.
Erica: Absolutely.
If my brain caused fascia and muscle tightness for a year and a half, is it real or neuroplastic?
Dr. Stracks: "If my brain is causing fascia and muscle tightness and sensitivity, and then it causes compensation patterns and misalignment for a year and a half, is that considered real or neuroplastic? And can I still get out of it? It feels like my muscles have been beaten all over." That sounds like more of a you question.
Erica: I think that one of the places I see people get into when they're doing this work is that what we're trying to explain is that thinking psychologically about the pain is frequently more useful than thinking physically. Even when my patients say, "Okay, there's stress in my life, the stress is causing muscle tension, and the muscle tension hurts," that's still a way of getting into physically based thinking. What I really encourage people to do is think of these sensations in psychological ways. Where's the stress? What's going on in our lives? What's happened in the past? And try to leave more of the physically based thinking aside.
What I say to people sometimes is that we don't have a tensometer. We can't put a thermometer in our muscle and see literally how tense or tight it is. It will feel super tense, and people will say, "Every time I go to the massage therapist, they say, 'Oh my goodness, you've got marbles in here.'" That scares us. But in reality, there are people whose tensometer reading would be much higher who are walking around feeling just fine. So I don't think the muscle tension and the tightness and the patterns are really where the issue is. When we focus on that, we miss the opportunity to see the psychological parts that are causing issues for us.
Dr. Stracks: It sounds like the person posing the question may be doing some of that back and forth: is it structural, is it not? This is when we start getting into problem solving, which is a great trait when it is necessary but can be problematic when we turn ourselves into an equation that we're trying to solve.
Erica: Yes. You're not a problem that needs solving.
Dr. Stracks: You're not a problem to be solved. Yes.
How do I handle a to-do list and email inbox that never end, especially when self-employed?
Dr. Stracks: It's the top of the hour, so this is the last question, and then you and I sign off. Someone said one thing that really resonated with her is that the to-do list is never done. "Zero unread emails would be great, but it never ends. How do you overcome this? I'm self-employed, so I can never clock out, and the emails always stress me out. How do you let yourself live in a world where the tasks are never done?"
Erica: You kind of have to just be okay with it. It's taken me a while. I love to-do lists. I will put even super small things on my to-do list, like brush your teeth.
Dr. Stracks: Take out the garbage. Yep, take out the garbage is on my to-do list.
Erica: Yes. It feels so good to get through it, but it's not going to end. So I have some rules with myself. Once I leave my office, I'm not allowed to think about work. This is not easy, but I trained myself this way: if I start thinking about a case conceptualization or something, I have to come back into my office. My office is the least comfortable room in the house, so I want to be out there. I can only be in here if I'm thinking about work.
Dr. Stracks: The self-employed part is important too, because you never clock out and the work never ends. We'll talk more at some point about the information age versus the industrial age. But supposedly there was a study in the early days of the internet where they put up two identical websites for a consultant. One said, "Contact me here for information." The other said, "Contact me here for information between 9:00 a.m. and 5:00 p.m. or by appointment." Which of those do you think got more clicks?
Erica: Probably the appointment.
Dr. Stracks: Exactly. The one that had some limits on it got more clicks. People respect limits. People admire limits. When we put those limits in place, we do a couple of things. The clients who are important will understand that limits are important, and frequently people will say, "Oh yeah, I should do that." It also knocks out people who have unrealistic expectations. None of us needs to be on call 24 hours a day, seven days a week. I know the world works that way, but that's not good for our mental health and it's not good for our physical health.
Boundaries, which we haven't really talked about yet, are a hugely important part of PRT, and they're useful here. Think about where we want to put the boundaries and how we put them in place, not to offend people but to take care of ourselves. As we take care of ourselves, we're better able to take care of other people too. Strategy-wise, if this person has really felt like they're on the clock 24/7, they can start by initiating boundaries with clients: "Hey, I'm shifting to do things a little differently, so my working hours are going to be X to X, I'll be off on the weekend, and I'll get back to you between these hours Monday through Tuesday." As we continue to unpack parts of PRT, that would be on the list to discuss.
Closing
Dr. Stracks: We're a couple of minutes past the hour, so we will end here. Erica, thank you so much.
Erica: Oh, thanks so much for having me.
Dr. Stracks: It's so much fun to talk with you about all of this. We'll be back in another month or so, in early July, to talk more. Thank you to everybody who's here and listening. If you're interested in working with Erica directly and seeing how PRT can help you, or how her expertise can help you, go ahead and reach out through our website. We hope to see you all back here next time we do this in July. If anybody is in the Chicagoland area and wants to come to Dr. Schubiner's book signing on Friday, we're more than happy to host as many people as want to come, and we'll email out all those links that may or may not have gotten to you. Erica, thanks so much, and thanks to everybody who's watching. I hope everybody has a great rest of their week.
Erica: All right, thanks so much. Bye, everyone.
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.