Brain vs Body? How Emotions Shape Pain – With Dr. Mark Lumley

Mark Lumley (00:00)
Descartes still haunts us to this day. Psychologists and other mental health people need to be a lot more open to bodily based things.

And similarly, all of our colleagues in nursing and in physical therapy and the like could be doing so much more with the stories of patients with their disclosures, with their traumas and whatnot than they currently are.

Mark Kargela (00:17)
This week on the Modern Pain podcast, we're diving deep into the fascinating and often misunderstood relationship between pain, the brain, and our emotions. My guest, Dr. Mark Lumley, is one of the leading researchers in emotional awareness and expression therapy and has been at the forefront of exploring how unprocessed emotions can drive persistent pain. We'll unpack the origins and evolutions of EAET and pain reprocessing therapy PRT, exploring how these approaches overlap and differ and tackle some of the biggest barriers, both cultural and systemic,

to integrating emotional work into pain care. Whether you're a clinician looking to expand your skills or someone navigating your own pain experience, this conversation will give you new insights into how addressing emotions can open powerful pathways to recovery.

In this episode, we dive into the transformative world of emotional awareness and expression therapy with expert insights from Dr. Lumley. We discover how EAET helps individuals become aware of and express emotions that have been avoided, reducing physical symptoms like

therapy's roots, its evolution alongside pain reprocessing therapy and its promising results in treating conditions like fibromyalgia. Join us as we unpack the emotional and relational dynamics that drive pain and learn how EAET is making a difference in the lives of many.

Now, on to the episode.

Mark Kargela (01:35)
I want to get right into it with some of the discussions we've had, Howard Schubiner on our podcast, talking about pain reprocessing therapy and a lot of the promising results that we've had in some research

I'd love if you could kind of maybe unpack the this whole interaction between what is PRT? What is emotional expression and awareness therapy and kind of how they all correlate?

Mark Lumley (01:55)
Yeah, and it's a challenging one and it's evolving as we talk. So Howard and I go back till 2008 or so, but before then I was doing a lot of research on emotional awareness, this idea of alexithymia, which is the idea that some folks have difficulty knowing what they feel, being able to put into words, expressing their feelings, and that's sort of a risk factor for pain and lots of other problems. So I was doing work on that. I was doing research on emotional disclosure or expressive writing.

sort of the Jamie Pennebaker paradigm and applying that not just to college students, but to people with rheumatoid arthritis and fibromyalgia and headaches. So doing a lot of that work. And then I meet Howard, who is a close colleague who lives and works just a few miles away from where I live and work. And we found ourselves to be kindred spirits and we're working closely. We meet every week and talk about things and we do research together and we teach, do trainings together for health professionals.

Howard came out of a different line. He was coming out of the John Sarno line of as a physician, diagnosing people with mind, body pain or neuroplastic pain, and then giving them a strong message of the pain is in the brain and it's connected with emotions. We started working together on several research studies and put together a team to do training of health professionals around 2015, 2016. And this team included Alan Gordon, who's a social worker and developer.

of PRT out in California and his colleague, Christy Wepe. And the four of us started putting on trainings for health professionals here in Detroit for several years in a row before COVID hit. And it's important to take a look at that training because what we did is we focused on something that didn't even have a name yet. It was sort of a little bit of Howard's unlearn your pain, a little bit of emotional processing, a little bit of Sarno, give people a new model about where your pain's coming from and educate them.

And we put these trainings together, but from those trainings emerged what I think is sort of a split. And the split was that Alan, along with Howard, especially became interested in the concept of changing people's beliefs about where their pain is coming from and how best to do that, to take them from a body-focused view to a brain-focused view of their pain and develop some techniques to do that, including somatic tracking.

And that evolved, we actually had this conversation for half a year, what to call that focus. And Alan came up with the idea of pain reprocessing therapy, which we blessed and said, go for it. And that evolved into a study that he and Howard did with Tor Weger and Yoni Ashar at the University of Colorado Boulder, which became a famous study of pain reprocessing therapy and showing really strong positive results of that. Meanwhile, my background has been in emotion.

and the role of emotion and stress and trauma in pain and other problems. And a bit of a split was that I continued our interest in emotional awareness and emotional expression and emotional processing more generally. We got a grant, Howard and I did, along with colleagues at the University of Michigan to study that approach in fibromyalgia. And one of our thoughts was that fibromyalgia is well known for having a lot of psychological challenges and...

childhood issues and relationship difficulties and emotional processing problems that seem to be driving it. It's recognized as a brain-based condition, fibromyalgia. And we thought to ourselves, what is needed in fibromyalgia is processing of these longstanding problems in relationships and emotions, often dealing with the traumas and the conflicts that are in the lives of these people. Not so much trying to convince them that it's in the brain.

Actually, lot of these patients already know that it's in their central nervous system. And so we did that study and found pretty nice results of this thing. We actually didn't know what to call the thing we were doing. And we came up with a name when we wrote the grant to the NIH. We called it emotional exposure therapy. Three nice little letters, E-E-T, though if you spell it out, it looks funky, eat. But also, it's more than just exposure like the behavioral folks do when they try to treat a phobia.

It's more about processing emotions. And we borrowed a little bit from Sarno, which said, help people to become aware of their emotions. In my background, in Alexithymia, that said we need to help people become aware of their emotions. And then one of the strongest ways to work through or process emotions is to put those emotions in the language and give them some expression with your words, with your muscles, with your voice, and especially the emotions that have been avoided. So we're doing this big study funded by the NIH.

I couldn't get on board with calling it a three-letter acronym. And I've got this interesting thing I've been tracking, which is our field loves three-letter acronyms. We've got CBT and DBT and PRT. I've actually got a list of about 130 different psychotherapy three-letter acronyms that have been developed. And I resisted getting on that Kool-Aid train of three-letter acronyms. And I said, let's try some four-letter acronym. And we put together this thing that

that we all struggle with, E-A-E-T, like what the heck are those? Too many vowels, four letters, it's complicated. And in retrospect, I wish I had stayed with a three-letter thing, because it's easier for we humans to do threes than fours. Nonetheless, we've called it emotional awareness and expression therapy, because it really captures the key pieces. Become aware of what you've been unaware of and give some expression in some way, language, body, fantasy.

to those things that you've been fearfully avoiding. And our belief is that doing so reduces physical symptoms, including pain. And we've got probably, I was keeping track now, 14 or 15 trials showing that, and three or four of them showing superiority to cognitive behavioral therapy. So we've got a bit of divergence now between PRT, it has its own training program and a set of studies going on, and then EAET, which has its own training program and a set of studies going on.

Though we're in close contact, both Howard and I, with Yoni Ashar, who's sort of taken the lead in doing research on PRT, with Alan Gordon, and trying to figure out where the boundaries are between the two. And it's become blurry, quite honestly. You talk with some of my PRT colleagues and they'll say, well, emotions come up so we need to process them. We need to hear their story. We need to help people be not afraid of them. I say, yeah, yeah, that's what we've been doing for 15 years now. On the other hand,

Howard and I are currently running a trial with other colleagues of back and neck pain, a big NIH funded trial. We're comparing what we're calling EAET. We're comparing it to CBT and acceptance and commitment therapy and a treatment as usual in people with back and neck pain. But we've started EAET with a session or two that focuses on what looks like PRT because most people come in with their MRIs and saying, I've got this problem in my back. Here's the image to show it. And we have to...

loosen their belief systems about the origins of their pain, shifting them from their body to their brain, or otherwise they're stuck there. And so we've included some PRT components at the front end of our EAET. So both camps, as I'm looking at it, are sort of merging. And Yoni, Ashar, and I have had number of conversations about something that might be unifying, like neuroplastic recovery therapies. But

Currently, my thinking is that PRT, and Howard and I wrote a paper in 2019 suggesting that PRT is sort of the starting place with many patients. Help them see where their pain's coming from, educate them about the brain versus the body, give them some techniques, whether it's somatic tracking or what we like to do is provocative testing. Have them imagine bending or lifting or twisting or doing other pain inducing behaviors and see what happens to their pain. And then given them some calming self statements or affirmations and see if it

reduces their pain while they imagine doing those behaviors. But we could do that in real life too, have them bend or sit or twist and see what happens to their pain and use their mind to reduce that pain experience. Those are cool PRT components and valuable. then emotions almost always come up even in PRT. So was speaking with Yoni Ashar recently about our most recent trial and his therapists are saying, yeah, two thirds of the time patients are revealing secrets, they're sharing traumas, they're crying in session.

they're accessing anger, they're going home and they're working on relationships in a new way. I don't actually call that PRT, might call that EAT. So I think the boundaries are blurring, which by the way would have made John Sarno our guru, pleased because if you think about what he said, John Sarno he said, chronic pain is a combination of it's your brain, not your body, and it's repressed emotions like repressed rage.

Mark Kargela (09:30)
Yeah.

Mark Lumley (09:46)
There are the two parts. It's your brain, not your body. Evolves into PRT. It's repressed emotions like repressed rage. There's your EAT. He said them both.

Mark Kargela (09:54)
I'm wondering with some of the challenges we face culturally, especially when it comes to emotions, I think sometimes there's some difficulties of folks really wanting to confront those, think, some tendencies in the testosterone-laden male culture of maybe that's not something comfortable to express or talk about or looked well upon to talk about. I'm wondering what barriers you find. And also, think healthcare system, right? I think we have a healthcare system that

is much more comfortable looking at your MRI and your x-ray and talking about your pain than sitting down and having a conversation. Some of that systemic barrier is probably time, productivity demands and all these things. I'm just wondering what you see as some of the barriers that you guys are challenged with to have this approach, whether it be healthcare system or just kind of cultural barriers that you face.

Mark Lumley (10:39)
Yeah, so that question has a lot of pieces to it. There's the larger system issues. If we're talking about emotions in particular, emotions are in many places given second or third thought and often reduced and minimized. Most of our therapies, like cognitive therapy, tend to reduce emotionality. They see somebody who might have some anger there or some sadness there or some shame there, and they will give people strategies to stop feeling those things because they seem to be pain drivers.

So there's that piece, even within our own field. Certainly at the level of systems, healthcare systems, it's hard enough to shift people from a model that says it's in your body, let's find it and fix it, to your brain has something to do with it and your brain is the place where emotions and beliefs are active. So we have to do some work there, it's hard. I think probably the biggest challenge is that most of us as humans have developed fears of our emotional experiences.

by virtue of our cultures, our gender, our religions, our families, we don't go there. It's painful. It's hard. It's scary. Yeah, it's scary is the key piece. Anger is the key emotion that seems to be the most common conflicted problem one. Most of our patients have good reasons to have adaptive, healthy, appropriate anger. They've been hurt. They've been used. They've been abused. They've been rejected. They've been constrained.

They've been pressured into being something that they don't wanna be or to hide stuff when they don't wanna hide it. And they should feel angry about that. That's a normal, healthy emotion. But by virtue of lots of forces, that has been transformed into blaming themselves, turned into sadness, turned into guilt and shame, all sorts of things. And it manifests, I think, through the brain's neural circuitry in bodily symptoms as well, like pain. And so helping people

develop their capacity for experiencing first, becoming aware of and experiencing and eventually expressing in some way, we'll come back to that probably, in some way expressing those feelings are important. It's not just anger. You mentioned guys, for example, might be really taught to not do emotions. Well, guys are taught to do anger actually. They don't do the vulnerable emotions. And so in my mind, there's three big categories of emotions. There's the ones that say that are autonomous or

agentic or empowering. That's often anger. That says no, that says this is my boundary, that says I will protect myself. But there's also these connecting emotions, Tenderness, love, sadness. Those emotions connect people. Those are ones that guys, on average, have more trouble doing. On average, and I don't want to make too more out of generalizations about gender here, but on average,

We see women often having trouble with anger because that's been shut down in their development very early as a threat to connecting emotions, as a threat to relationships. But truth is, many people have problems with both of these spectrums of emotions, both the connecting ones and the empowering ones like anger. And I'll add briefly just a third set of emotions that Howard Schubiner and I are increasingly recognizing and appreciating, which is the positive self-emotions like pride and self-compassion.

A lot of people have trouble doing that too, giving themselves a pat on the back, saying, I've done okay. It's okay to not be 100 % or not be perfect. A lot of folks need help with those emotions as well.

Mark Kargela (13:41)
I work with persistent pain quite a bit as well. And it is a delicate dance to take somebody from a system that is again, much more apt to point out MRI findings and x-ray findings and really pathologize the body. And yet you're here trying to connect somebody to a really different thought process where, know, what's going on in your emotions, what's been going on in your experience and your

psychosocial being around these symptoms. I'm wondering if you could share a little bit about how you all approach kind of that. You mentioned a little bit of some of PRT techniques already with in that first session to kind of open the door. I'm wondering if you could share a little bit about how you all go about helping people kind of make that consideration in that kind of movement to where maybe it's more than just, you know, my degenerative disc or my, you know, again, my MRI that we bring in and

and point to that this is why I'm in this type of pain.

Mark Lumley (14:31)
Yeah, there's a bunch of techniques we have, some of which are sort of educational. As we do a pain history and we see what happens with their pain and where it moves and that sort of thing, we'll say, isn't it interesting that you have this bad disc here, but you're feeling pain over there? Or isn't it interesting that the pain shows up a lot when you're going to your parents' house, but not when you're leaving your parents' house. Isn't it interesting that?

And so there's a lot, you hear people's stories, you'll hear a lot of anomalies to their stories that suggest it's more than just this particular injury or structural issue. So that's a piece of it. We give them some stories, some classic stories like, why is it that a person, the classic construction worker who jumped off of a platform lands on a nail, it goes through his boot, he's in screaming pain, but upon removing the boot, they see that the nail went right between his toes and didn't hit his skin, his foot, yet he had pain.

and stories in the opposite direction too. There's lots of stories we share which usually loosen their thinking. But some of the classic things we do, this provocative testing I mentioned earlier, so I won't get into too much detail, but simply having them imagine pain inducing behaviors. I'd say 60 to 70 % of the people will start to have some sensation happening in their body just upon imagining something that induces pain. And the flip side, if you use some calming self statements, my back is healthy, this is my brain, not in any danger to my body.

Most of those patients will find some pain reduction right then and there. The fun thing for me becomes when we switch to emotions. And here there's two ways I like to go. One of which is to hear their stories about their lives and get them interested. Many, many people will tell a story if you ask deeply enough, tell me about your pain's onset and when it's become worse. And it's often connected with something. I was going through this really tough time in school. I was bullied.

I heard a patient the other day said, yeah, my pain started around six or seven years old. I was bullied a lot, but the doctors told me it was, and then she came up with something biological. I'd say most of the people we run into have a story in which the onset of the pain is associated maybe with an injury, but also with some strong emotional things going on in their lives. And pain exacerbations or reductions are also sort of tracking things that are emotionally important.

And then there's also what happens in the daily life. And this patient recently said, who's got back pain and she's in our clinical trial, she said, you know, it's strange. If I'm home alone and I bend over, I don't hurt much at all. But if my husband's home and I bend over, I hurt a lot. What a great flag that is that there's something in that relationship. And upon further exploration, we find out that husband is a cheating guy and she knows it and she's very angry with him. And we hear these stories all the time of things that'll happen. We had a patient in our trial right now.

and her pain disappeared upon hearing the new model and doing a little work. And then it skyrocketed just before the next session with her therapist. And part of that issue was she realized that in talking to the therapist, he's gonna be leaving the therapy with her in a few more weeks. And she sort of connected to him and she's angry that he's gonna be leaving and all of sudden her pain skyrockets again just before the therapy session. Those things are big flags that it's emotional issues going on.

And then the other thing we do a lot of is as we talk with patients about emotionally salient things, tell me Mark about that story with your father. What happened there? How are you feeling? Tell me, Dawn, about your discovery of your husband cheating and what feelings there. And as people start to talk about these stories, they will often, right then, right there in front of us, have a pain experience. Pain will start to go up. We draw attention to it. What's happening in your body right now?

I'm feeling this thing happening and my gut is feeling sick. I'm feeling tension in my chest and my neck is starting to hurt again. Okay, as we talk about this topic, let's track your pain as we do this emotional work. The majority of patients have bodily experiences as they tackle emotional issues. And that becomes a big light bulb that says, my gosh, this stuff matters. My emotional life matters. And then we have to take them to let's work on helping you feel more comfortable with those emotions so they don't scare you.

threaten your brain, activate your danger alarm system. That is your pain.

Mark Kargela (18:18)
So that sounds like the awareness component, right? You're bringing people's awareness to these emotions and having these experiential activities where they see when these emotions come to the surface, what changes in their body, right? How everything gets embodied. I'm wondering how then are you looking at the expression piece? I know you mentioned a few things already, but I'm wondering if you can unpack a little bit about the expression piece as far as how you're having folks kind of manage those, express those in ways that as you mentioned aren't going to...

create some of that sensitization of the whole system.

Mark Lumley (18:46)
Yeah, that's an important piece. I want to flag the word you just used a moment ago, manage. Because this idea of I have to manage my emotions or manage my pain is a word I'm flagging. We use it too much. It reflects the need for control and it's going to get out of whack and it's going to blow up. And yup, people are afraid. They're afraid of their pain. They're afraid of their body being injured. They're afraid of their emotional lives. They're afraid they're going to destroy relationships. They're afraid they'll pick up an Uzi and shoot everybody if they start to tap into anger.

So we have to be thoughtful about not falling into the trap of reinforcing that fear. Because that stuff doesn't happen. It's stunning how rarely the fears come true. But how do we do the emotion, the expression piece of it? There's probably three directions we're working, one of which is disclosure. Putting an experience simply into words and...

This is in our therapy, we have them do it in writing at home, like it's a homework exercise, expressive writing, to take what has been residing in their head and put it out into some language on a piece of paper, for example. In session, we have them tell a story as much as they can about things that are hard to tell stories about. So we're actually looking for things that are hard to talk about. And those flags are pretty easy to see when a person starts to balk or change topics or get nervous or tense. And then there's an invitation that says, would you give it a try?

to talk about that thing that's hard. And you'll usually will hear stories. People will share their stories and the stories have parts they're leaving out and parts they're bringing to it. And we look for the parts they're leaving out. What else happened? How else are you feeling? And so that's part one, some disclosure about things that have not been disclosed as much or they're hard to talk about especially, or hard to write about. And then when it comes to other forms of expression,

we do two things. And we make a judgment call whether the expression should be imaginal, like in their mind, or out loud so the therapist can actually see and hear. We usually start inviting it out loud, and it goes something like this. This thing that happened with your dad, this time when he just told you you were a loser, and he didn't want to talk to you more because you didn't score a goal in soccer, and that still haunts you to this day, right? Take yourself back there.

I'd like you to picture that experience and notice what was happening. Now notice what's happening to your body. What do you feel bubbling up within you? You'll hear some signs of anger bubbling up mixed by tension that tries to block it. What is it that you wanted to say? There's a party that wants to say something and do something to your dad. And by the way, this could be to your spouse, to your boss, to your neighbor, whomever you're.

And by the way, the number one thing that comes out as people replay this experience and imagine themselves there is they start with the question, why? Hear this 80, 90 % of the time, they'll say, why are you yelling at me? Why did you leave me? Why did you cheat on me? Why didn't you care enough about me? Why? And if you think about that question, why, it's a good start, but it's still pretty passive and helpless. And so we take them to the next step, which is

inviting them to drop the why and tell them how they feel. And that often goes into the next direction, which is sometimes pretty aggressive. You should have never done this. You're an asshole. I hate your guts. I wish you were dead. And that becomes sort of a vicious outburst, which is more powerful than asking why. But we often want to help people move in a direction that's not just destroying the other, but having some sense of power in a relationship.

And so we'll invite them eventually to get to the point where they're telling the other person that the other person was wrong and they owe them or they should have never done that. connected to the words are often an envisioned action. So this is an important piece. It's not just using our language, but most people connected with their emotional experience have something they'd like to do.

And by the way, if what they want to do is run away, we usually say, no, that's not a good thing to do. That's, you know, avoiding the problem. What is it that you want to do your body? And it ranges from, I just want the person to shut up, that other person in my imagination. I want them to sit down. I want them to listen to me. I want them to apologize. Two, I want to hurt them badly. I want to, you we see this especially with abuse, with rape, with other sort of assaults. They want to revenge and hurt the other person, which by the way is okay.

to have those beliefs and wishes and fantasies and to hear them as a therapist and to support them. So we invite an image of what they'd like to do. And oftentimes the body gets activated right then and right there. The hands will start to clench, they'll start to hit the table. They'll start, the jaw will start to get clenched up and we'll say, what is it that that body wants to do? And they'll actually literally sometimes push away. We'll invite a patient to stand up in the room and say, what does your body want to do? I want to knock the person down. want to push them against the wall. I want to slap.

Okay, let me see your hands do that. What we're looking for is expressions that are hard to do. Feared expressions. If it's too easy, it's not the right one. We're looking for what is hard to do, and that's the key. Because some people will punch a wall. Bad idea, the wall is not the person who hurt them. And also it's too easy. Some people will yell and scream. If it's easy, it's the wrong direction. There's something that's missing. We're looking for the hard or emotionally uncomfortable expressions.

to move towards those instead. Many patients will do this expressive work out loud. Sometimes it's too scary. Sometimes, by the way, it doesn't fit the situation. Like, I've got my daughter in the next room. I don't want her to hear this. And so we'll say, can you play it out in your mind? What are you doing with your mind, this expression towards the other person? That can be very powerful for people. So we often do a lot of that first, then we'll sometimes say, what did you just do in your mind to that your mother, your father, your...

your sibling. Sometimes people feel like it's a bit of a show if they do it in front of a therapist. So again, we'll have them practice this expression in their mind's eye first. Sometimes that's just sufficient in itself. What's cool about the expression, by the way, is it often moves from one emotion to another. So anger is a starting place for many, but that opens up this sort of guilt over their anger expression towards maybe a loved one. And that opens up connecting feelings. Maybe tears will come next.

or a sense of love or empathy for that person or longing. I wish my dad wouldn't have been like that. I wish he would have been a better dad. And I'll say, tell your father directly, as if you're talking to him right now, what you long for from him. And the person will start to communicate not the anger of just a few minutes ago, but the wish for a closer, more loving dad. And that combination of anger, often through a little bit of guilt, through some connecting feelings like grief or love,

is a beautiful transition. We see it a lot. And it is sort of the healing transition that many people need to get both of those sets of feelings, angry feelings and connecting feelings into one person and recognize and experience fully. And it does wonders for the body and the experience of the body.

Mark Kargela (24:55)
you

Yeah, I'm wondering, because you've all in your research looked at neuroimaging, and I would not pretend to be an expert in fMRI and the intricate details of brain neurophysiology. I'm into a basic extent, of course, but I'm wondering if you can kind of speak to a little bit of some of the neuroimaging findings of as we're doing some of these interventions, what we're seeing happening in the brain and in the nervous system that might signal some of the work you're doing.

Mark Lumley (25:24)
Mark, I'm glad that you mentioned you're not a neuroscientist. Let me quote you. I, Mark, am not a neuroscientist. That works for me too. I'm gonna punt on this one, I think, because it's a bit beyond me. Though I will comment, know, the study you're referring to is the study on pain reprocessing therapy that Yoni Ashar was the lead author on, and Toro Weger was the senior author who's the world famous neuroscientist. And that study started out, by the way, as a study of...

Mark Kargela (25:30)
you

Mark Lumley (25:50)
Yoni Ashar's doctoral dissertation was going to be looking at brain signatures of the open labeled placebo effect. He was going to study what happens if you give people an injection in their back and people with back pain, what happens in their brain if they get that open label or they're told it's a placebo, that's open label, they're told it's a placebo, what happens to the brain? And he shifted his ideas around when Howard Schubiner and Alan Gordon approached them to add another arm to that trial of pain reprocessing therapy arm.

And so the fMRIs were going on at the time and then we were able to kind of do an fMRI on this thing. I do know that the effects in that study and one other study that we've published recently with another group on virtual reality pain work and people with back pain. did similarly, it came out of TOR's group also with Marta Chekhov, who's the first author there. And we did a study here and she was looking at brains pre and post. It is hard to find the signature. It's hard to find the brain changes. They're subtle.

You have to dig a lot in the data and explore it. It doesn't pass the test of interocular trauma. You ever heard of that test, Mark, the test of interocular trauma? That's when you're looking at the results and they jump off the page and smack you right between the eyeballs. It's so clear. Nope. These fMRI studies that I've been involved with are usually hard to see the results and you have to work at it quite a bit. So I just wanted to put that cautionary note out there that

Mark Kargela (26:54)
I have not.

Mark Lumley (27:09)
The clinical effects, people's reports of pain and that sort of thing are much stronger than what we can measure thus far with our brains. We got to believe the brains are changing. We certainly believe that, but we're not picking it up as readily or as easily as we might hope.

Mark Kargela (27:22)
I'm wondering, because some of the criticisms you hear out there on PRT and some of these type of techniques is that it's extremely brain and neurocentric. And there's folks that say kind of misses the whole biologic components to it too. And obviously I don't think we're trying to get people back to the ages of like, let's just all identify via x-ray and MRI. I'm wondering where you sit with some of that, how you respond to some of that criticism of this is way overly brain centric, neurocentric from folks.

Mark Lumley (27:48)
Yep, I usually start by saying, good point. You're right there in some ways. The larger field of pain diagnosis has broken things down to primary versus secondary pain. There's a whole bunch of pain problems that look like they're largely driven by structural bodily pathologies. Though even in those cases, the brain has to get the nociceptive or neuropathic signaling from the body and do something with it. And it creates a pretty accurate representation of the body's problems.

called pain. But most of the patients are not that way. Most of the time, the brain is doing more of the work independent of what it's picking up from the body and creating an experience that's probably not too reflective of what's happening in the body. And so I don't mind starting there and seeing what can be changed, but being mindful that we might not be able to make, well, first off, I know we can't make the change in everybody. We can't make a brain-based shift in their pain.

My current thinking is that in the larger field of pain management, we'll grab that word from that second management, you know, you've got the classic cognitive behavioral approaches to manage pain and rehabilitation management approaches and acceptance and commitment therapy, which says, even though you're living in pain, let's live better according to your values and function better. Those approaches might be best suited for people whose pain experiences largely being driven by bodily pathologies.

I don't do much of this work with people with rheumatoid arthritis or inflammatory bowel diseases or neuropathic pains or sickle cell pain, though even in all of the cancer-based pain, though even with those pains, there can be another component that shows up, which is more central, which is more brain-based. There's a study out recently out of Iran of people with breast cancer and pain, and they used EAAT with great success. And I thought breast cancer pain. Well, it turns out you could have

pain related to a tumor, but you can have lots of other associated pains throughout the torso and the chest that are probably secondary. I'm sorry, they're developed after this thing, partly as a function of the trauma of having cancer and treatments and all that kind of stuff. And those pains might be much more responsive to these brain-based approaches. But I'm cautious, partly I'm cautious because I'm a psychologist and not a physician. And so I don't know the brain.

in the body, especially as well as some. Quite honestly, I encourage many of us to take an experimental approach, which is let's see how much your pain is responsive to these brain-based approaches, keeping open the possibility that they're not, or they're only minimally appropriate. And maybe your pain is being driven by a lot of other things. We have a number of people in our current clinical trial who have back neck pain and pain in their knees.

which might be more driven by osteoarthritis. And we can see people often whose backs improve and their knees still have a lot of pain. I think that's okay, that there can be these different mechanisms going on.

but let's not give up the brain just because, you know, pain often starts with an injury or there's some pathologies that are found on scans or whatever.

Mark Kargela (30:32)
Yeah. And I think it goes to that clinical scientist role. Like if when you're in the clinic, there is a little bit of an N equals one with every patient of like, let's try some interventions and see how much these things impact. So if we're going to take more of a brain neurocentric approach, then we should have some process to see, this making change? But again, if you can have those experiential activities like you're doing in the EA, ET work to help patients see that yes, in fact, my pain changes when I start engaging.

these emotions and things to where it kind of validates that that's probably at minimum a solid component of what they're dealing with. So yeah, I can definitely see that, you know, cause I think some folks want it to be all or none or one or the other. And that's never going to be the way, with the complexity of pain. There's just a lot of, a lot of factors that go into a pain experience. A lot of this, as I hear it and have read a bit about it, it's, it's delivered in it's obviously has a huge psychology background.

my always concern with like good pain programs in the world is that they're very few and far between as far as like our communities and the ability of people in our communities to get access to good, solid pain rehabilitation services, be it PRT, EEAT, ACT, whatever it is, that there's just not a lot of it out there. So I think having the ability to have

Because the other thing I've seen in very short supply are psychologists who want to specialize in pain. Apparently, it's not the most popular route for psychology graduates to go into. And I get it. It's a tough, probably, tough entry into maybe their profession. But I'm wondering where you sit with practitioners outside of traditional psychologists delivering these type of interventions with folks. Like, where do you see some concerns? Do you see there's some possible

you know, openings for that. I'm wondering what your thoughts are on that.

Mark Lumley (32:12)
Yeah, this is a hot topic right now. I'm talking with colleagues in my psychology field, concerned that pain reprocessing therapy is being taught to everybody under the sun. Coaches, high school graduates, and they're out there opening up their clinics and their services. And I'm really torn. I don't want to just be guided by turf issues or guild issues, like I'm a psychologist, you too should. I'm quite confident.

that many, people with lesser degrees of education than a doctorate degree can be excellent practitioners. We know that. Where the boundary is, I'm not sure. And when we should be trying to protect the public, I don't know. The pain reprocessing therapy folks have been a little more open to training coaches of all sorts and others. The work we do in EAET feels a lot more like depth psychotherapy, and it is more challenging. It's trauma work.

And so we've tried to put a higher bar in terms of our training of people. I don't really want people just going there and saying, and opening up whatever the gates are to emotional stuff that could be difficult and not knowing what to do with it. And so I've been a bit more cautious about the emotional work. But this is a tough one. I, average, I mean, when we do our training, when Howard and I do our training, we might have a hundred people taking the course. We'd get 30 or 40 psychologists. We'd get a couple of 20 or 25.

counselors, people usually with master's degrees in counseling, 20 or so social workers, a smattering of others, physical therapists, people who have less mental health background, and even some people who've had some coaching training and been accredited or certified by a particular body of that, that we usually make those on a case-by-case decision. But it is, on average, I'm not believing that it needs to be psychologists. Also, psychologists are few and far between, as you noted.

My university graduates about 10 psychologists and 230 social workers a year. There's a huge difference there. And we need to help the people with master's degrees, master's in psychology, master's in social work, master's in counseling especially, become frontline practitioners of this and lots of other behavioral and psychological therapies. So, yeah.

Mark Kargela (34:00)
Yeah, I've always had this concern or wonder, you know, as science and our understanding of pain has really taken off, you know, in the last 20, 30 years, we've obviously recognized that it's much more than one profession's purview as far as like that it's not going to sit in biomedical. I often wonder like, are the professional boundaries that we created when science was where it was back in so on when we couldn't, you know, the mind body separation, all that stuff.

I'm wondering where you sit. Like, do we have, like, are we kind of in need of professions that are more broad in scope that are able to, and I know a lot of doctors are doing a lot of this stuff too. So, I mean, I think Howard's a great example of a physician who's very much integrating these, but then there's always the discussion of, you're escaping your scope and all these different things. And obviously we don't have the massive change that it would need to take to get policy changes, especially with our governments and how

efficient they tend to be or lack their efficiency. But I'm just wondering what your thoughts are. Like, do you think there's in need of maybe some professions that are a little bit more well-rounded on this whole, you know, mind-body, you know, we're going to be able to treat both, you know, not just and or type thing, or what are your thoughts?

Mark Lumley (35:11)
Yeah, I mean, think so one issue there is the split between mind and body. You have the mental health professions and you have mental health coverage and insurance. And most of those people, including myself and other psychologists are fearful of doing anything with the body. Maybe we'll do a relaxation exercise. We won't touch the body. We won't direct the body. won't have, even when I have patients, you know, stand up and do something with their body in a session, I get some oohs and ahs and gasps from my psychologist colleagues, like you should just be talking to them, you know.

anything above the neck only. And forget dance and other sorts of things. It's like, no, that's strange. Or the physical therapists who are like, I don't know that I can talk to a patient about their stuff. I can only do physical things. I really think we need to move away from that split, that dualism that Descartes introduced still haunts us to this day. And so psychologists need to do a lot more work. Psychologists and other mental health people need to be a lot more open to bodily based things.

And the bodily based people need to be a lot more open to the psychological mental based things. And I hope the field does move in that direction and gets rid of this taboo. Partly by the way, it's scope of practice, partly it's taboo. It's like, we better stay away from the body. That's going to be scary. know, how unfortunate that is that we've lost focus and lost some attention to the body.

And similarly, all of our colleagues in nursing and in physical therapy and the like could be doing so much more with the stories of patients with their disclosures, with their traumas and whatnot than they currently are.

Mark Kargela (36:32)
that's definitely something we're trying to help clinicians with because as coming from a physiotherapist, physical therapist background, that's where we're trained, right? We get a little bit of a smattering of, yeah, and these people might have some psychosocial issues and you can identify them, but we're not going to give you much in the way of any really, know, clinically relevant ways to kind of help patients connect the dots and make some headway on their pain with it. So it is a massive struggle for sure.

Getting back to EAET, I'm wondering if you can discuss kind of where you think things are headed. I know you're probably in the midst of some work right now, as you mentioned, but I'm wondering where you think things are headed and where you'd like to see things go as far as applying these things at maybe a bigger scale.

Mark Lumley (37:11)
Big scale. my hope is that there's increasing recognition of the role of emotions and emotional processes in pain. I personally am not a big fan of trying to have yet one more therapy enter the battleground of therapies. And they have 131 rather than 130 therapies competing for turf. And I don't have particularly much ego in the game either in terms of like naming something.

I actually didn't want to name our therapy anything because I know that when you name it, then it gets reified and gets affiliated with somebody and you have to then have all the things that come with a name. And it just enters this battleground. Nonetheless, by the way, we ended up having to name it because there was a recognition that nobody would know what to call it and you couldn't search it and research and you couldn't quantify it and meta-analyze it and everything else that you do. So I named it something.

But my bigger wish is that we recognize that it's more than just thoughts and behaviors, it's also emotions and relationships, because emotions almost always happen in the context of relationships. So if we start to move from thinking about your pain or understanding where it's coming from or having a new belief system about your pain, appraisals, it's more than that. It's usually emotion-driven things in relationships that are most important. And so my hope is that that becomes a commonly recognized contributor to pain.

and a direction that we could go to address it.

Mark Kargela (38:26)
I'm wondering if you let us in a little bit on what's coming down the pipeline of things you maybe you can share. I know there's maybe some things in progress, but like what kind of work is currently in progress with with EAT and related interventions?

Mark Lumley (38:38)
Yeah, there's attempts to make it briefer. We've actually done several studies having a single session, recognizing that, as you were saying earlier, we're not gonna have enough professionals to do this work. Related to that is we're not gonna have enough accessibility to eight, 10, 12, 15 session therapies. What can we do briefly? So we've studied a couple of places. Can you do have a single session, like in a medical clinic with patients with pain or other functional somatic syndromes or somatic syndromes?

Can you do good work then? And the answer is yes, you can. Even though it scares people like, oh no, you're gonna open a Pandora's box of emotional trauma stuff with our patients. Patients value it and they have some improvement when they get such a single session interview. Right now we're looking at different, we're starting a study looking at different single sessions. Like if you do a session of PRT focused stuff versus a session of emotion focused stuff versus a session of cognitive behavioral stuff, what are the differences?

We're also interested in who benefits from what. Every time we do a study, there's a set of people who get better and a set of people who don't. We have great difficulty predicting who that's gonna be. We don't know why. And so, continued work on trying to figure out who is it that gets better from these approaches and who doesn't is a way to go. We also don't really know what changes. There's a lot of stuff happening, for example, when you do EAT.

You have a therapist who cares deeply and explores a lot about a person's story. They're very different than a CBT therapist who might be following a manual and being structured with skills training, for example. EAT is much deeper, it's much more profound. Many, many of the patients who have an eight-session course of it in our clinical trials want more. Probably half of the patients are asking for more, often to stay with the therapist. This doesn't happen in our CBT arm of the trial. Nobody asks for more.

something is happening at the relationship. And so we don't really know how much of it is the relationship with a therapist, how much is it the emotional processes. We've said, we've hypothesized it's becoming aware of emotions and expressing emotions. We hypothesize that, but not quite sure that's really all that it is, or that's the key parts. We hypothesize that it's overcoming fear of anger and overcoming fear of connecting emotions. Maybe, but so.

Big picture, looking at mechanisms or the processes that are actually happening is another piece of this. I've got a colleague who's trying to do more of this in terms of self-help, build platforms that take this on the net, internet, and have people work through modules more on their own, maybe with a little bit of input from some therapist or something, but mostly self-guided. Daniel Maroti in Stockholm, Sweden has done several studies on that of EAAT built on the internet with nice success. So those are some of the directions.

I think another piece will be, know, limitations of the type of pain. Is it the case that these approaches PRT, EAT, really don't have much success with pain that's more secondary to bodily pathologies? Or if those things also involve the brain, as they probably do, because most are all pain is being driven by brain, even if the brain is registering a lot of bodily pathology, a lot of bodily nociception,

Can these approaches change how the brain is experiencing what the body is sending, the messages the body is sending? That's an unknown.

The other thing we need to do is to try different populations. So you'll note that the big study on pain reprocessing therapy published in 2022 that I was a part of, but Yoni Ashar and Tor and Howard and Alan Gordon and Christy Weepie took the leads on, that used community volunteers from Boulder, Colorado, almost all white, educated, open-minded, interested in brain and stuff because they were getting these MRIs as part of the study.

That's an ideal setting. And the therapists, by the way, were ideal, excellent therapists, both Christie and some of the best therapists I know, who've also, by the way, recovered from their own pain problems. That's public knowledge. That's sort of an ideal setting. What happens when you take any of our therapies and you transport them into some frontline rehab clinic with broken patients who are on disability, who have lots of MRIs showing all sorts of pathologies, who have...

physicians telling them what's wrong with their bodies who've had multiple surgeries and they're going through lots of life struggles and dealing with bad relationships and poverty and loss of job and racism and you name it. How do we do in those populations when we go into those populations? I won't give the full story, but I know that some of the attempts which have not been talked about much have not been very successful getting into those kinds of populations. It turns out that the patients are not as on board as

Patients in Boulder, Colorado are the ones that we're recruiting right now on our trial. And they have lots of other stories going on and other beliefs about their pain and lots of crap in their lives that interfere with engaging fully in these approaches. So we really need to look at those other populations, other locations to do this work rather than just recruiting community volunteers.

Mark Kargela (43:03)
I think you bring up a good point. think that's the tough thing is like a lot of the folks volunteering for these studies aren't going to be often the folks that are in the midst of some very difficult life challenge. Maybe I'm not saying there isn't some of the folks that did, but I agree. think the general frontline clinical practice, especially in different socioeconomic circumstances and all the different circumstances that we find different clinics and cultures and things. And I think if we can see interventions that have some durability across that, that would be

amazing. And I think obviously, you know, there's just going to be hard silver bullets for anything and not that we're expecting that but it's, I think to be able to adapt our techniques and our interventions to, you know, the unique uniqueness of each setting that we find and we're trying to, you know, use these interventions with folks with. I'm wondering, Mark, if you can share where if somebody's interested in receiving some training in this to kind of further their

understanding of EAET and related interventions. How can they go about doing that?

Mark Lumley (43:58)
Yeah, we don't have built a great website yet. Howard Schubiner writing the book for the American Psychological Association on this for practitioners. My website, which is just my personal website at the university, which you can find by Googling my name, it pops up really easily, Mark Lumley. But I've got some free materials, some patient manuals and patient workbooks and therapist manuals from some of our studies that's freely available and some other materials there. Howard Schubiner's website.

unlearnyourpain.com is a pretty good resource for a fair amount of this. I also recommend his book, which, you know, he's unlearn your pain has got a lot of this material in it for it's a patient workbook, but a lot of practitioners find value in it. Let me suggest probably the best organization for this work broadly is the it's now being called the Association for the Treatment of Neuroplastic Symptoms, ATNS. You can find it by Googling symptomatic.

symptomatic.me. This organization is a very cool group of practitioners, some researchers, patients and patient advocates coming together to further mind-body medicine for the treatment of these so-called neuroplastic symptoms. There's a lot of resources for patients and providers on that website. So that's symptomatic.me, the Association for the Treatment of Neuroplastic Symptoms.

I think that's probably the best place for both patients and providers, clinicians to go.

Mark Kargela (45:13)
We will definitely link all of those in the show notes for those of who are listening or watching. can kind of check any of those resources out, and hopefully there's some good resources for your patients. Mark, I wanted to thank you for your time today. I really appreciate the conversation. It was great to talk to you and finally meet you virtually. And again, thank you so much for the work you're doing.

Mark Lumley (45:31)
Mark, it's been my pleasure. Thank you for letting me chat with you and the rest of the audience out.

Mark Kargela (45:35)
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