Foundations of PRT: What Is Pain Reprocessing Therapy?
Video: Watch the full session here → https://www.youtube.com/watch?v=zfnkIyc_Li0
Dr. Stracks: Welcome, everybody. Good afternoon. Many of you know me. I am Dr. John Stracks, a physician in the Chicagoland area and nationally on telehealth, specializing in mind body medicine. It's great to be with you today. I am here with my special guest and colleague Erica Walker, a psychotherapist and pain coach with us at Cormendi Health. As a brief introduction, Erica is a world-renowned pain reprocessing therapy therapist. I refer to pain reprocessing therapy as PRT. She's been with us here at Cormendi Health for about four years now and has extensive experience in this field. She was previously the clinical director at the Pain Psychology Center in Los Angeles. Given her expertise, experience, and success in helping clients deal with physical symptoms using PRT methods, I've asked her to help me create this primer on what PRT is and how it's used. I think there's a lot of interest in PRT and also a lot of confusion about what it is and what it isn't. So, Erica, I am beyond thrilled that you are here with me today to talk about this. Welcome. Did I miss anything in my introduction?
Erica: No, that made me sound like a superstar, so I'll take it.
Dr. Stracks: You are a superstar. I'm super glad you're here, and like I said, I've been amazed at how successful you are working with people with physical symptoms over the years. So that people have a little background, can you tell us more about who you are and how you became the therapist you are today?
Erica's Background: From Massage Therapist to PRT Therapist
Erica: Yeah, thanks. I'll start from the beginning. In my undergraduate degree I had two majors: pre-med and psychology. During that period I had the super high privilege of being able to dissect two human cadavers, which got me so fascinated in anatomy and physiology that it rolled me into becoming a massage therapist. I went to a school called the Institute of Psycho-Structural Balancing, meaning the mind and the body. So I started my mind body career on the more body-oriented side, but we were focused very much on the emotional housing, how we hold emotion in the body. My adulthood started off with an understanding that the mind and the body are not separate entities and that they affect one another.
Dr. Stracks: When you were working as a massage therapist, which you did for a while, did you ever see that in action? Did you ever see yourself working on the body side and entering into people's emotional world?
Erica: Yes. There are two examples that have stuck with me because they were so beautiful. I was working with a young man who was about to be married. I met him and could just see the nervousness on him. During the massage I could tell he was very tight, with a lot of tension in the body. So I did an energy hold, which is a hand on the head and a hand on the heart. I just held there for a moment. It sort of mimics being held by someone who cares about you. He started weeping, just profoundly weeping. We weren't talking at all. I didn't say anything and he didn't say anything. It was this huge emotional release, and the tension just released from his body.
The other one I remember was really amazing. It was a woman I would see regularly. She was a cellist for the LA Philharmonic, a really high-achieving, high-level musician, and she would come over to my house. I would work on her forearms and hands, where she held lots of tension. When I worked on them, she would laugh, this profound, wild laughter, until she would cry, and she would feel so great afterwards. It was so touching to me to be part of that experience with people.
Dr. Stracks: In the mind body medicine world, we frequently think about the power of the mind to influence the body, and those are really good examples of the body influencing the mind, and of you working on the body to influence the mind. I don't know any other therapists in this world who started out by dissecting cadavers, and I think that gives you a unique perspective.
Erica: I do think what is unique to me is that I'm fearless with talking about people's bodies and symptoms. You cannot freak me out. I am not intimidated by this. I'm extremely confident. Tell me what's going on in your body. What are you experiencing? I want to know.
Dr. Stracks: I've talked to a lot of psychotherapists over the years who are the opposite of that. They learn in therapy school that their job is in the mind and the physician's job is in the body, and there's not a lot of overlap, or any overlap, there. So that's one of the things I appreciate about you, just how comfortable you are in that physical world.
Erica: Thank you. I appreciate that.
Dr. Stracks: Me too. So you worked as a massage therapist, and at some point you made the decision to switch tracks and become a psychotherapist. Eventually you found your way to the Pain Psychology Center, probably 10 or so years ago, and that is where you were first introduced to the concept of PRT, correct?
Learning PRT at the Pain Psychology Center
Erica: Yes. That was a really special time at the Pain Psychology Center, because it was still very mom-and-pop. We were hanging out in Alan Gordon's apartment, me, Christie Uipi, and some really amazing therapists, and we were having this think-tank experience, with case consulting. I was learning PRT from Alan and Christie and the others, and this was my world. It wasn't like I was doing a one-off training in PRT. It was my whole world. We were having conversations about PRT as it continued to be refined, as Alan and Christie were doing the Boulder Back Pain Study, and as Alan was working on his book The Way Out. I was there for all of that. I was in on the ground floor of bringing PRT in, not just as a modality but as a way that I work with clients, and of asking how I can adjust it with each of my clients. What makes sense for them? I'm constantly assessing what strategy or tool this particular client might find useful and meaningful.
Dr. Stracks: As you were spending time there, learning about this and working with what today are giants in the field, along with you, what really resonated with you? What made you say, "This is my calling, and this is the kind of work I want to do"?
Erica: With all of the steps I've taken and all the decisions I've made in my life, it didn't occur to me that I would end up here working with you. I was just following what was interesting to me. And I like results. I'm a person who likes results. I like to see what works. What is working, what is not working? Let's put that on the shelf if we think it's not going to work right now. Let's lean into what does work. At this point in my career, I have seen it work over and over and over.
Dr. Stracks: Ahead of our talking, I asked several clients what some of the things are that have worked really well for them, and there's an extraordinary amount of overlap in what people say. We'll talk about some of those today, and we'll talk about some of those next time you and I talk.
How PRT Differs from Psychoanalysis
Dr. Stracks: A lot of people have come into this work by reading, say, Dr. John Sarno and The Mindbody Prescription. Back when Dr. Sarno was practicing in New York, in the 1970s and 1980s, there was a lot of psychoanalysis. It would be, "Okay, read this book, understand this message, and if you're not better, we'll send you to an analyst and do therapy three times a week for many years until we sort out what's at the bottom of this." PRT is not that.
Erica: No. I think of psychoanalysis as more of a bottom-up process, and PRT is more strategy and structure. What I like about PRT for our clientele is that by the time a client gets to me, they've been through dozens of doctors, physical therapists, and medications. They've tried it all. I've had clients try things I haven't even heard of. They're exhausted, frustrated, overwhelmed, and scared. They get to me and say, "I need you to just tell me what to do and how to do it, because I can't keep talking about my childhood for the rest of my life and expect that it's going to somehow shift the experience I'm having in my body."
Danger vs. Safety: How PRT Works
Erica: When I think of PRT, I'm thinking danger versus safety. Picture an analog dial: the volume goes up on the nervous system, and we start pitching towards danger. We start pitching more towards a fight, flight, or freeze experience. Everything in PRT is in service of bringing that volume down into safety. Through all these different strategies, we create opportunities for the brain to appraise, "I am safe right now. Therefore, it's not necessary for me to continue to use the same old neural circuitry to send out signals of pain and danger and sensation into the body."
Getting Started: The Evidence List
Dr. Stracks: You've gone through this process with, I'm going to say, thousands of clients over the years. Say I'm a new client and I come in dealing with a physical symptom, whether it's back pain, migraine headaches, fibromyalgia, chronic fatigue, or stomach issues, all of which I know you've seen in our Curable clients. I come to you, like you said, having talked to a dozen different people: psychologists, physicians, physical therapists. How would you get started with me? What happens when I first come to see you?
Erica: What I first want to know is the client's working knowledge of neuroplastic pain. What have they read? What's informing them? And why do they think this applies to them? Most of the clients who come through Curable have already read something. They've been on Curable. They've probably read Sarno. They've probably read The Way Out. So they have some working knowledge, but I want to make sure we really solidify what this means to you and how you fit into it.
Then we roll into what's called an evidence list. What are the pieces of evidence that cause you to think this is more mind body and less structural? Some of the obvious physiological pieces of evidence are things like, "I had an MRI that was relatively unremarkable. I had blood work done and they didn't really see much. I've seen doctors, and medication really hasn't helped me all that much. PT hasn't been as helpful as I would have liked it to be." All these things that I've tried have not been as effective as one might think they should be, and here I am. We know it hasn't been effective because they're coming to see me. We might also look at pieces of evidence like the symptom or sensation moving around, having several different symptoms, or having been a child who had a lot of tummy aches or ear aches. So there are lots of physiological pieces of evidence we can point to.
Then there's the more psychological element. Did this happen to show up during a period of stress? Does this show up when it's not a physical trigger, but more of an argument with your partner, or an estranged parent reaching out to you out of the blue?
Dr. Stracks: Is this a conversation that you and I would have? Is it a homework assignment that you'd give me to take with me? Is there an actual evidence list that I'm writing down, or is it a way of thinking about whether these symptoms may be based in my psychology as opposed to my body?
Erica: Right out of the gate, we're bullet pointing and writing down what the pieces of evidence are. I'll ask questions and give prompts. Some of the questions I might ask are: Do you find yourself to be perfectionistic? Do you find yourself to be a people pleaser? Do you have any history of anxiety?
Understanding Anxiety in Mind Body Pain
Dr. Stracks: Let's unpack anxiety for a moment, because from time to time I'll talk with people and they'll say, "No, I have never had anxiety in my life."
Erica: I would argue that no one has never had anxiety in their life. Anxiety can sound like a very clinical term. Anxiety is that agitation we might feel in our body, that chest tightness, that tension in the body. It's worry. It's obsessive thoughts. It's catastrophic thinking. It's rumination, nervousness, stress. I hear this a lot: "I don't have anxiety, but I've had a lot of stress." I'd put anxiety in the category of fear, that which we fear. So we're going to spend a little time unpacking how that shows up and what quality of anxiety shows up. Is it more obsessive? Monitoring the body: is it there, is it gone, is it worse, is it better, I need to pay attention to this at all times. Is it more worry: what if this happens? Is it more catastrophic: I'm the one who can't figure this out, I'll never be out of pain, this is the rest of my life? We hear a lot of that.
Dr. Stracks: I was just going to ask how many times you've heard people say they understand the theory and they see how it will work for other people, but they're worried it's not going to work for them.
Erica: That's right. Probably the most common fear.
Dr. Stracks: Say I come to see you as a client. Is this anxiety piece something you're trying to assess right away, to see how much it's in play for me?
Erica: Yes, absolutely. I think that's really critical.
Perfectionism, People Pleasing, and Boundaries
Erica: With perfectionism and people pleasing, we hear this a lot. Sarno referred to this as being the goodist. Not many people bring that term up these days, but I do like it. I think it really encapsulates perfectionism and people pleasing. When we're thinking about people pleasing, we're talking about boundaries. Are you saying yes when you'd rather say no? We want people to like us. We're biologically hardwired to want to stay in a group, because the group is safety. So we navigate our lives in a multitude of ways to keep people from disliking us. Sometimes that can pitch into not having strong enough boundaries, which is not a judgment. This is usually learned behavior. We want people to like us. That's a good quality. It means we're nice. We don't want to abolish that, but we want to think about to what degree we're taking care of ourselves within our relationships.
Dr. Stracks: When we're thinking about PRT in general, how it works, and what people can expect, help me understand how this all fits together. So far we've talked about understanding that the symptoms are not necessarily physically based, and understanding our own tendencies towards anxiety, people pleasing, and perfectionism. How does that help me ultimately to start to get better? Why are we starting there?
Erica: We want the evidence to be irrefutable. Let's say it's physical, something like "my MRI was unremarkable." We know that information. We want to notice these psychological elements as well. I want people to write them down, bullet point them, and if something else comes up that they remember, add it to the evidence list. So we're not going to be in an argument with the evidence list.
The reason this is important is that what many clients will tend to do is start going, "But it could be structural." "No, I don't think it is." "But something might have been missed." We go back and forth, and this is anxiety. This is chatter, chatter, chatter. If we have an evidence list and this starts happening, we can look at the evidence and say, "Okay, but my MRI was unremarkable. Okay, but I do characterologically fit the role here. With perfectionism, I'm navigating my life so that I don't screw up, because if I screw up, I might disappoint somebody. So I need to stay really vigilant with how I navigate my work and my relationships. If I stay perfect, then people can't hate me. I can't get kicked out of the group if I never screw up." That's so much pressure.
Dr. Stracks: So with the evidence list, there's the physical part, why a physical explanation doesn't 100% make sense, and then also the psychological part: I have these traits, and I am the kind of person described in books, and these psychological traits in me can lead to the development of pain because I'm trying to use this to stay away from disappointing people, or from feeling like I'm not enough, or like I'm not going to get what I want. There are so many different pieces to it, correct?
Erica: That's right. These strategies of perfectionism and people pleasing are usually developed very early on. If a child grew up in a chaotic household, or in a household where parents or guardians were unpredictable, so they didn't quite know what to expect when they got home from school, then what a lot of kids do is learn to pull their feelings inside. "There's not space for my feelings in this house. I'm going to stuff that down, and I'm going to do my best to navigate the circumstances I'm in." For a lot of kids, it's, "If I just get the gold star, if I don't get my name on the board, if I get good grades, if I work really hard and kind of stay out of the way, then that keeps me safe." That's what we learn as kids: what is safe and what is dangerous.
Dr. Stracks: And the downside is that if that strategy just worked, if we could keep everything inside forever, there wouldn't be a problem. But we can't stuff everything down forever. It eventually needs a place to go. What I say to people all the time, and I think probably what you say too, is that until we learn otherwise, we just assume that physical symptoms are about physical problems. And when you really dig into the research, that's not what the research says. You can have lots of physical issues in your body without any pain or symptoms, and you can have lots of pain or symptoms without any kind of physical damage. So pain really isn't about damage, it's about the sense of danger. And if emotions become dangerous, then when we have the emotions, in order to deal with that danger, we produce these physical symptoms.
Erica: That's right. I think a lot of us learn that really early on and then just perpetuate it, because it was a strategy that worked. Kids are very smart. They go, "Oh, okay, there's going to be yelling. I'm going to remove myself from the situation. I'm going to go to my room. I'm going to make myself as small as possible. I'm going to make myself invisible." That's a smart strategy. As we develop and become adults, we still employ these strategies that have worked for us in the past, and then we might get to a point where that's not working for us. Say I'm saying yes to everyone instead of saying no when I want to. I'm going to develop a lot of resentment. I will still look very nice. I will still smile. I will still be generous. Everyone will like me. But inside, I'm going to be harboring this anger that is not a safe emotion for me, so I'm going to stuff that anger down.
Dr. Stracks: So as part of this PRT process, at least at the beginning, you're trying to assess what's going on under the surface that's leading to the symptoms, correct?
Erica: Right. Exactly.
Tracking Your Wins
Dr. Stracks: As you're getting to know somebody, you're trying to make sure they understand and are clear in their own mind where the symptoms are coming from, and you get a chance to learn where you think the symptoms are coming from. What happens from there? What else happens in this PRT process?
Erica: In the first session there's a lot of territory to cover. I want clients to always leave the first session with some kind of strategy, something they can use. They've already been through it. They've already answered every question about their body. They just want something to hold on to. So I do a couple of pieces of homework or strategy right out of the gate. The evidence list rolls right into tracking your wins, which is another PRT strategy. It's keeping track of the things that are going well. We are survival-oriented beings. We are profoundly skilled at keeping track of the things that we don't like. We might even expand them: "I stubbed my toe this morning, which means this day is ruined." So we want to keep track of what's going well.
What I mean by tracking your wins is very client-specific. It's unique to each client. It could be something like, "I went to a restaurant. I knew it was going to have some hard chairs. I had to sit in a wooden chair, and that scares me. In spite of it scaring me and in spite of having some anxiety around it, I went to the restaurant. I did it anyway." Maybe I experienced some discomfort. Maybe I was super engaged. Either way, that's a win. The chair isn't dangerous. The chair has become avoided. So it could be anything clients are doing: "I bent over and tied my shoe." "I went to Target. It was loud and bright and there were a lot of people, and it was a little overwhelming, but I did it anyway." It could be, "I went to my nephew's bar mitzvah and ended up seeing people I hadn't seen in a while, and I felt really great and wasn't paying attention to my body all that much."
Now, the wins and the evidence might overlap. That last example might be a piece of evidence: when I'm experiencing profound joy around people I love, I'm not paying attention to my body that much, and therefore I'm not noticing sensation. That's not a structural event. If I'm experiencing joy and not noticing pain or sensation or symptoms, that's not structural.
Dr. Stracks: If people want a hard list that they can use, they can get in touch with us at Cormendi Health and we can send them the tools we have. But with the evidence list and the tracking of wins, are you asking people to literally write these things down and keep track of them?
Erica: Yeah, I want people keeping track of them. The evidence list can continue on, and tracking your wins is a weekly exercise. I want people showing up to our next session with what has gone well this week, what their wins were. These don't have to be huge wins. They can be small things, like, "I'm usually only able to walk a third of a mile, and yesterday I was able to walk half a mile."
Dr. Stracks: And like you said, we're hardwired to look for the negative and look for the threat. We really have to practice seeing the positive side, because if we don't get excited about the things we're doing, there's no reason to keep looking for those wins. That's why I think it's such an important strategy. I have a client who has done really, really well. She had terrible foot pain and was in a wheelchair, and she has done great for 10 years. She told me a story once about taking her child, who was probably five or six, to Disneyland. She didn't think she could go and was worried about it, and she called me and said, "I went to Disneyland for a week and it was great. I walked around the whole park, and I sat for about 10 minutes on one of the days, but otherwise I was there with my family. It was so much fun." Then she paused and said, "When do you think I'll get better?" I said, "You did. You won. You got better. You had to sit down for 10 minutes over the course of the whole week." But she saw those 10 minutes as proof that she still wasn't better, and missed this entire picture.
Erica: That's why I push hard in the opposite direction. We spend a lot of our lives in this direction of what's dangerous, what's threatening, what don't I like. It's not our fault. We're biologically hardwired, and we're oriented towards threat. So we go hard in the opposite direction: what's going well? That could be the smallest thing. I want people mining for that. "I ate a cupcake and it was delicious." That's fine. Anything that you find to be a win for you is a win.
Dr. Stracks: And it's so tempting to say, "Yes, but I had this win, but I'm still in pain. Yes, I had this win, but I'm still not sure I can do this."
Erica: Yes. With tracking the wins, I will often have to scoot people back to what we're doing. I'll hear, "I had this really great day on Wednesday, but then Thursday was a total mess," and now we're stuck on Thursday. Let's go back to Wednesday. What was happening on Wednesday?
Dr. Stracks: This is a common occurrence when people are working with you, right? They'll try to bypass the wins. They'll bring their list with them and move through it really quickly and want to go into what's not going well. Will you stop them and come back and say, "Hey, no, we need to look at this a little more"?
Erica: It depends on where we are in our therapeutic relationship. It's been so wired in that I need to be focused and fixated on this pain, and I need to let you know how bad it is. I don't want to dismiss that, because I know it's bad. I know it sucks. So I do want to make sure we spend some time with it, but we're building on strategies. We're always building on: what's your strategy? Okay, so Thursday this came up. What were you able to employ in that moment?
Somatic Tracking vs. Cognitive Tools: Where to Start
Dr. Stracks: So you're starting with the assessment, the evidence list, and keeping track of wins. Is there one more tool that you'll frequently hand out in the first or second session?
Erica: Yes. In my first session, as I'm going through this assessment phase, I'm making the decision of whether I want to start with something more cognitive or something more like somatic tracking. Those are two tools I use right out of the gate. But I want to make sure that someone can tolerate somatic tracking. If the level of fear is quite high, then we're probably going to start off with something more cognitive.
Dr. Stracks: To interject for a second, you and I have talked on camera about somatic tracking, so everybody who's listening may or may not know that there's already an interview on our YouTube channel of the two of us talking about that. I think somatic tracking is an important part of PRT, but like you said, not everybody is ready to do that right from the beginning. If you find somebody who has a little too much fear to really settle into their body, you'll work at the level of the brain first. Correct?
Erica: Yes.
Dr. Stracks: I wonder if we can drop that video in the comments so that people can have access to the somatic tracking video.
Erica: Yes. It is an integral piece of pain reprocessing therapy. I will drop that into the chat.
Dr. Stracks: And how do you start to use some of those more cognitive strategies? How do you think about employing them?
Erica: When I was at the Pain Psychology Center, I developed a tool that's specific to people who experience chronic pain, because we know, because we've witnessed it, that people who experience chronic pain have a tendency to be hard on themselves. People who have been at this for a little bit and have listened to some things will sometimes pick up on the idea that "I'm not supposed to have a negative thought." People tend to be really hard on themselves, and often they don't even realize it, because it's been so habitual throughout their lives. So this idea of "Oh no, I'm not supposed to have a negative thought, there's something fundamentally and uniquely wrong with me" speaks to that catastrophic fear: "I have negative thoughts, so that means I'm the one who's not going to get better."
Thoughts are thoughts. We have about 70,000 thoughts a day, and roughly 90% are the same as yesterday. We tend to gravitate towards the ones that we either really, really like or really, really fear. What if this fear-oriented thought is true? We'll spend long periods of time going back over that thought. We've had the thought "What if I'm the one who's not going to get better?" thousands of times, I could argue. It has not been of service. It hasn't changed anything. That looping thought is emotional suffering, and it's bringing the volume up on the nervous system. Like I said earlier, everything we're doing in PRT is in service of bringing the volume down.
Dr. Stracks: The volume of what?
Erica: Up here is fight or flight, and we want to transition a little more into rest and digest. When that analog volume is up, we pitch more and more towards fight or flight. The breath gets shallow, the heart starts racing, and the body becomes tense so that we can effectively get away from a grizzly bear. That's what fight or flight is designed for, to keep us alive. But most of the time we don't need to be in that state.
Dr. Stracks: Got it. And yet, because of who we are and our need to look for the threat, for our ancestors it was better to mistake a stick for a snake than a snake for a stick. So we produce all of these potentially catastrophic thoughts just to try to keep us safe. How do you start to work with people on that?
The Three C's: Catch, Compassion, Carry On
Erica: This technique, I call it the three C's. I will often do this in the very first session so that a client can leave feeling like, "I have homework to do. I have a strategy that I can use." I want this to feel useful to clients instead of just "tell me about your childhood" and then our time is up and you're on your way. Clients are going to leave thinking, "I just told you every horrible thing that's happened in my life, and what am I supposed to do?" I've heard that over and over from people: "I need you to tell me something to do." Okay, I will. I'm fine doing that. I'm a pretty directive person.
The three C's stands for catch, compassion, carry on.
Dr. Stracks: Okay, I got it.
Erica: This is relatively simple, but I'm going to really unpack it, because I know our clients sometimes have a lot of fear that they're not doing something correctly. "Am I doing it right?" That's just another anxious thought. That's just another fear-oriented thought.
Dr. Stracks: Is this a common CBT technique that got invented somewhere? How do you know about this?
Erica: I've studied a lot of CBT, but I did this specifically for our clientele. The catch part, getting out of battle with the thought, is the cognitive behavioral piece. The compassion piece, I think, is really crucial for our clients: can I be more gentle with myself? The carry on piece I will expand on with clients I've been working with for a while, but for right now it's just: what's going on with my breath? So there's a somatic piece in there as well. There's the cognitive, the self-compassion, and then the somatic piece. I pieced this together from different interventions, so it's specific to what our clientele presents with.
Dr. Stracks: So this is your own technique that you developed specifically for working with clients who have physical symptoms.
Erica: Correct.
Dr. Stracks: Got it. Let me help you unpack this a little more so that people have a good sense of it. And again, if people are interested in the handouts and worksheets that we have, you can get in touch with our office and we'll send those on. For the first C, catch, what am I trying to catch? The negative thought, or any thought?
Erica: Let's say the thought is, "I'm the one who's never going to figure this out." You might be 45 minutes down a rabbit hole of looping this before you recognize that that's what's happening. But the first piece is that we've got to come into awareness that that's what's happening, so that we're not getting overwhelmingly hijacked by these thoughts that show up and we're not taking them as truths. We would never go around in the world saying, "By the way, everything that I think is true." We know that's not accurate. But we do this privately, so no one sees that we're looping: "I'm never getting better. I'm never getting better," over and over and over.
In old-school pop psychology, they talk about thought replacement: if you have a negative thought, you've got to replace it with a positive thought. Here's the problem with that. We're back to "Yes, it is. No, it isn't. Yes, you will. No, you won't," and now we're at a higher level of anxiety. So what I ask people to do is just notice the thought. Just notice, "Oh, I'm 45 minutes down a rabbit hole with this thought."
Dr. Stracks: And I'm sorry to interrupt: the types of thoughts we're going to catch. "I'm never going to get better." What are a couple of other common thoughts people have that this would be useful for? "I'm not in the right place. This is really a physical issue. It must be physical." Is that another one?
Erica: Right, the battle of "is it structural, is it not structural," which is not really of service once we have a solid evidence list going.
Dr. Stracks: "Erica won't be able to help me." Is that another one? Or "this isn't the right type of treatment for me," or "I'm uniquely damaged"?
Erica: Yes. All those thoughts come back to the same place: "I'm the one who can't get better. I can't figure this out." And this can apply to other looping thoughts too, like "I'm going to lose my job." I had someone who was always convinced that he was going to lose his job. "I'm going to lose my job. I'm going to lose my job." It's not valuable. It's just suffering. It's just bringing the anxiety up. So all we're doing with this first C is catching it. We don't need to do anything with it. We're just noticing there's a thought. We've got to be in awareness to be able to affect change. We can't affect change if we don't know what's going on. I'm making it sound more challenging than it is, but I'm going to show you how to use it. "Aha, there it is."
Then this next one is the hardest for people to do, and I do a thumbs up with it. This is the compassion piece: "Good, I'm getting better at this." Why do I put this in here? Because people have read, or at least interpreted, that they're not supposed to have negative thoughts. So what will happen is they'll say, "Okay, there's that really scary thought. Why do I keep doing this to myself? There must be something so uniquely wrong with me that I'm having all of these scary thoughts, and now I'm really never going to get out of pain." What we've done is what the Buddhists call the second arrow. It's basically kicking yourself while you're down. "I'm bad. Now I really can't figure this out." So going back: "Aha, there's that scary thought. Good, I'm getting better at this."
I have literally had some clients who will give themselves a physical thumbs up, which I think is great because it's kind of goofy and kind of funny and light-hearted. But we've got to go in this direction as opposed to that direction, even if it feels totally unnatural. People will get good at the catching. The compassion is going to be harder, because the mind is going to say, "I don't know. Erica might really not know what she's doing. Dr. Stracks might, but he doesn't know me that well." The mind is going to keep trying to pull back into that protective, threat-oriented state. So it's, "Aha, there it is again. Good, I'm getting better at this. I'm not getting hijacked as often as I maybe have in the past."
Dr. Stracks: And the compassion is about giving compassion to ourselves for working on this, practicing it, and getting better and more quickly finding the thoughts. That's the big part of the compassion piece, correct?
Erica: Right. And the mind is going to keep trying to pull back. That's not a fail. It's just a habit. So it's, "Aha, there it is." Maybe it's the 400th time in the last hour. "Good, I'm getting better at this."
The third C, for the purposes of this lunch and learn today, is what's going on with my breath. Let's carry on and check back in with what's happening with my breath. If I've been marinating in this scary thought and suffering over here, the odds of my breath being shallow, my heart going a little faster, and my body having pretty high tension are good. Put your hand on your belly and just breathe into your hand, and slow the breath down. We don't need to do a fancy breath technique unless you already have one that works really well for you. So it's, "Aha. Good. The brain's going to pull back. Caught it again. Sneaky. Good. What's going on with my breath?" I know we spent a lot of time unpacking this, but it should be a relatively easy thing to pick up.
Dr. Stracks: Is that what you find with people, that after you explain it and they practice it a few times, they feel, "A, I can do this, and B, it's useful"?
Erica: Yes. Typically, right out of the gate, most people are going to find that useful. Some people who have really high anxiety might go into the fear of "But I'm not doing it correctly." And all that is, is another fear thought. Then do-over. It's going to take some practice. It's not automatic, because this flight of thoughts has been going on for a long period of time.
Dr. Stracks: As you're getting started with people, and this is one of the reasons you like PRT, there are very specific, concrete strategies and skills that we can employ.
Erica: Right. By the time clients get to me, they're looking for structure. They're looking for someone to say, "Here's what I want you to do and here's how I want you to do it." That how piece is going to become important, and it takes shape over time. We don't want to attack our healing process with intensity or treat ourselves like an equation: "If I do this technique and I do it the right way, then I'm going to be out of pain." How I do things is probably going to be the bigger shift than what I'm doing.
Dr. Stracks: Just thinking about what we've talked about, because I know we're starting to run short on time and there are a couple of questions that people have asked: at the beginning of this process, we get clear in our own minds that our body is not damaged, that it's not the source of the suffering, and that the symptoms are coming from our minds, not our bodies. Then we understand where the anxiety and the personality traits are coming from, make sure we're paying attention to the things that are going well, and start by watching our mind, understanding that just because we have these thoughts doesn't mean they're true, and that there are things we can do.
Erica: Exactly.
What's Next in PRT: Self-Compassion
Dr. Stracks: That's approximately where our first session starts. You'll be back with me in about six weeks, on Monday, June 1st, I believe, for the next time we do this. As a very brief preview, what are some other pieces that make PRT effective as you go along?
Erica: I use PRT in my own way because I've been doing this for years, so I will pepper in things that I think are really important. One of the things we may end up talking about, and you and I can discuss what we think is the best use of our time when we meet, is self-compassion. How does self-compassion fit into chronic pain? It's part of being really hard on ourselves. I normally tell people we can be mean to ourselves or we can get better, but it's really, really hard to do both.
Dr. Stracks: Right. And going back to that perfectionistic trait, we tend to believe that if we motivate ourselves through harshness, that's going to get us to where we want to be.
Erica: Well, that may have worked in the past. "If I just keep putting pressure on, I'm going to be successful." That may have worked really well, but it's pressure, pressure, pressure, and the nervous system can only deal with so much pressure before it says, "Okay, I've had it. Something's got to shift here." A case needs to be made for self-compassion being very relevant to this work.
Dr. Stracks: Yeah, for sure.
Audience Q&A
Dr. Stracks: I think that's a good place for us to leave it today. A couple of people have put a few questions into the Q&A, and you have a couple of minutes to stick around and answer a few before we sign off. For those of you who are watching, if you still have additional questions, feel free to ask. We'll get to as many of these as we can in the next few minutes.
Audience feedback
Dr. Stracks: The first question, which is more of a comment: one attendee says she's been moved to tears listening to you describe your message, and that your empathy and intuitiveness come through so powerfully. I just wanted to give that feedback to you.
Erica: Ooh, that made me a little misty. Thank you.
Do people see dramatic decreases in symptoms once they understand what's going on beneath the surface?
Dr. Stracks: The follow-up here is about talking and journaling through these processes. When she feels warning signs in her body, it's astonishing how instantly a symptom can disappear once we figure out what's going on under the surface. She also notes that the political chaos can sometimes be a catalyst. Do you find that once people are able to recognize what's going on, they can see a dramatic decrease?
Erica: Yes, quite often, actually.
What are good long-term strategies for changing personality traits like perfectionism and people pleasing?
Dr. Stracks: Another question: "Thank you so much for this talk and for being here. Doing PRT made a lot of progress both with the fear and the doubt and the symptoms. My question is about longer-term work regarding personality traits. Are there good strategies for changing these? I've heard that you set boundaries. I'm wondering if there are other techniques or ways to approach the longer-term challenge." Like we were talking about a few minutes ago, there's a lot in there: boundaries, perfectionism, self-compassion. Can you give people one self-compassion resource that might be helpful as they start to think about this and unpack it a little?
Erica: When you said boundaries, the first thing that popped up for me is a quote by the author Prentis Hemphill, where she says, "Boundaries are the distance at which I can love you and me simultaneously." I like that. It's something I've played with over and over. When I think about whether I would rather say no, that's okay. In terms of self-compassion, there's so much to unpack that it's really its own lunch and learn, at least. It's something I work with on an ongoing basis: how can I be a little gentler with myself? For the person who's asking, if you can watch the somatic tracking video, there's a lot of gentleness involved in the way we do somatic tracking, through a meditative perspective. Can I just notice myself through a lens of kindness?
Dr. Stracks: And that somatic tracking video that we did, I put it in the chat, but it sounds like the chat maybe didn't get through to everybody. Cormendi Health has a YouTube page, and Erica's and my somatic tracking videos are on it. If you can't find it, just message our office at info@cormendihealth.com and we will send you the official link.
How is PRT relevant if I have a physical condition like polymyalgia rheumatica or inflammation?
Dr. Stracks: A couple more questions. "I've struggled with PMR for many years, and my inflammatory markers are high. What can I do if I have a physical condition? How is PRT relevant for someone who struggles with something that's physiologically going on in their body?" PMR is probably polymyalgia rheumatica, so an inflammatory issue. This is a great question, and I had wanted to address it today, but I think we had a lot to unpack. It's such a powerful question.
Erica: How can it help you? When I think of inflammation, I'm thinking of the immune system, and I'm thinking of the volume being up, going a little more towards danger. I've seen people, and you have too, I know, and we've had clients overlapping, who've had autoimmune conditions and have been able to bring the volume down just by being less reactive. I probably should have said this right out of the gate: when I think of pain reprocessing therapy, I'm thinking about whether I can learn to respond differently to sensations in my body. That is possible. It is a big ask, but it is possible: to respond to the sensation differently as opposed to going into that reactivity of "Oh no, here it comes," because now it's shallow breath, racing heart, and a bracing body.
Dr. Stracks: One of the things I'll say to people is that we talk about all these systems in our body, the immune system, the nervous system, the cardiovascular system, and the endocrine system, to make it easier for our human brains to understand what's going on microscopically. From the vantage point of the body, there are no systems. It's not like our immune system will say to our nervous system, "Hey, I'd love to take care of that for you, but I'm the immune system, not the nervous system, so I'm off duty right now." It all is just part of one big system. When we understand that the immune system and the nervous system are essentially one entity, then we can see that inflammation, which is the immune system being on high alert, calms when we calm our nervous system, and the rest of our system starts to calm too. We had a client with inflammatory arthritis who worked with one of the other therapists here, I don't think it was you, Erica. She did therapy for about six months and her inflammatory scores went down by half, working on the psychological side.
Erica: Absolutely. I absolutely believe that.
How do I handle the urge to figure out what's triggering my symptoms instead of working to recover?
Dr. Stracks: One more question: "Any advice regarding the instinct to try to figure out what's triggering or causing the symptoms versus not working so hard to try to recover? Sometimes it feels like a chicken and an egg."
Erica: We can actually use the three C's with that. It might be an impulse to Google. It might be an impulse to read a Sarno book 40 times, which I've heard from clients. It might be a need to consume massive amounts of content. That's more the how. We were talking earlier about the what and then the how. I'll say to people, you don't need to somatic track your face off, and you don't need to read every single thing. If you're noticing that kind of obsessive impulse (I'm not sure that's exactly what you're asking), it's just, "Aha, there's that impulse. Okay, good." And then, what's going on with my breath? We want to bring some of that intensity down, the "I'm going to attack my healing" intensity. That's where finding the balance comes in, and it might take a little time to find that balance. But notice that impetus to get really intense with the healing process itself.
Dr. Stracks: For a lot of our clients, that's the strategy that has helped them be successful in the world. I was talking to somebody this morning who's a high-level corporate attorney. He didn't get there by being completely Zen, and it's a strategy in the working world that frequently works great. Just when we're trying to heal, whether it's emotionally or physically or anything else, we need different strategies that we learn as adults. So what you're saying is that we can observe ourselves being intense in that way and then learn just to catch it, for starters.
Erica: Right, just for starters. That's a longer conversation.
How do I find a local therapist, or do you work with people on telehealth?
Dr. Stracks: Good. Somebody asked how to find a local therapist, or whether you work with people on telehealth.
Erica: I do work with people on telehealth.
Dr. Stracks: If people are interested in working with you, they can contact our office. We'll put them in touch and they'll be able to take it from there.
Closing
Dr. Stracks: It is the top of the hour here in Chicago, and I assume everywhere else around the world as well, so we are going to end there. Thank you to all of you who've been here with us, listening, asking great questions, and sharing them with us. Erica, thank you for being here and sharing your expertise and what's made you such an effective PRT therapist over the years. If you want any of the handouts we used to work on the PRT techniques, go ahead and get in touch with us at info@cormendihealth.com, or go to our website, cormendihealth.com, and contact us there. Erica and I will be back in about six weeks, on June 1st, to continue the conversation and pick up with self-compassion and how that is part of the PRT process. Thank you all for being here and spending this time with us. Thank you, Erica, so much, and we'll see everybody in about six weeks. Bye.
Erica: Bye.
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.