Chronic Pain Care: Why “Not Knowing” Makes You a Better Clinician

Faith Stokes: [00:00:00] I don't have to be the expert in the room. They are the expert in their experience. And so if I try to sell myself as a pelvic health expert, if I try to sell myself as someone who does lifestyle medicine, if that's not what they need from me, I may make them feel like they're not in the right place.

Mark Kargela: If you've ever felt the pressure to walk into a session with a perfect title, the perfect plan, and the perfect answer, this episode is here to disrupt that in the best way. Today I'm joined by Faith Stokes, MSK, and Pelvic Health, physical therapist, manual therapist, trauma-informed and psychologically informed clinician, and in her words, most content, simply being faith.

And that's not a branding choice. It's a clinical strategy because when you work with complexity, rigid labels can trap both the clinician and the patient in a narrow script. In this conversation, faith shares what it looks like to lead with curiosity, set of certainty, and why not knowing can be one of the safest, most effective places to start.

We talk about how clinicians default to quick solutions when their own nervous system is overwhelmed. How to [00:01:00] stay present when a patient's story is heavy and why acknowledging what matters sometimes simply is saying a loved one's name can change everything about the rehab process. We also dig into what trauma-informed care actually looks like on the ground.

Building physical and emotional safety plans, getting clear consent, co-regulation in the room, and knowing when and how to connect patients with the right mental health support. Without reinforcing a mind body split. If you treat persistent pain, pelvic health, or any messy case that doesn't fit the textbook, you'll walk away with practical ways to show up.

More human, more grounded, and more effective now onto the episode.

Announcer: This is the Modern Pain Podcast with Mark Kargela.

Mark Kargela: Faith, first off, great to have you on the podcast, and I look at your work online and one, that's why you're on the podcast. I have great respect for it, and I think it'll be a great conversation for folks to see your perspective. But I see musculoskeletal physical therapist, manual therapist, pelvic health physical therapist.

I see trauma-informed clinician, [00:02:00] I see psychologically informed clinician. How would you define yourself to somebody who's getting to know, like how do you define what you do? To somebody who maybe isn't aware of you and your practice.

Faith Stokes: That's a really good question. I honestly have reverted back to just being faith and it's an interesting thing that happened over time because my colleagues would see someone that presented with a specific cluster of things. And when we consider these patients that have all of these things going on they tend to have syndromes.

And I wouldn't really call myself a syndrome specialist, but that tends to be the approach I take. And even when they try to describe me, they're like, you're just gonna need to meet faith. So it's probably much more eclectic and I maybe need to work on my identity, but I am most content when I am just my name.

Mark Kargela: And it's a good approach too. It shows that you have that shared expertise in the room. You're not. Dr. Stokes who rises above and pain sains people and things. No, I, and it's that kind of, [00:03:00] like you said, shared narrative that you have with people. I think that whole clinical chameleon approach, you find yourself just much more adaptable with that mindset to, to be able to meet situations.

You work with a lot of complexity, obviously, in your practice with the nature of your practice. I'm wondering if that serves you well.

Faith Stokes: It does, and I think that's something, we've both done a fellowship that I picked up from Fellowship. I don't. That's been liberating for me as a provider. The whole you know when people say, give me your like elevator speech, panic, attack, central. I'm like I don't know. What do you wanna hear in the next two minutes? Because that's what I do all day in the clinic.

Mark Kargela: Yeah, and it, to me, it's we never get trained on sales, right? But the whole point of sales is to understand the problems of the person you're trying to help,

I'm just wondering because we tend to have this like sometimes preconceived notion of what we're gonna offer

A patient as a clinician. 'cause we're defined ourselves so rigidly sometimes, especially early on in our career of this is the package I offer versus maybe suspending this like preconceived [00:04:00] expertise that has to dictate the nature of this interaction where I can be okay to have a somewhat of a sales exchange of what are the problems you're dealing with. Here. Let me listen to that, hear that, validate that, and then let's propose a tailored solution to you now that I know you and your unique human condition and the unique humanity that you're bringing to the equation. I think that's a, that's such a hard switch that I found from my practice and, talking to others, I'm wondering how it's been for you.

Faith Stokes: I think for me, I realized it's okay to not know what to do, and when I come in with those preconceived biases, it's usually because I'm feeling overwhelmed. And if I take back control quickly, then I can manage my own nervous system. And I realize that's my own, that's my own nervous system need needing reassurance, and it's removing me from caring for this patient.

A beautiful example of that was a patient I treated last year. She came in with fibromyalgia, chronic. Cervical, thoracic [00:05:00] and lumbar pain. Pelvic pain was being investigated for multiple comorbidities and she was depressed and anxious. Her yellow flags were through the ceiling. And I sat down and one of the questions we asked in fellowship is like, what do you think is going on?

And she looked at me and she said, my 18-year-old son was murdered five years ago. And all of this started after he was murdered. Every time I go to the doctor, I tell them his name and I tell them that's why I'm sick. And they tell me that's not the case. And so my first question was, what's his name? His name was Tristan.

And so we said Tristan's name at the start of every session. We found some way to speak of him, like she had shirts and key chains, like her child was everywhere. I just made it a point to notice some part of what she was wearing that day and say, is that Tristan's favorite color? Is that his favorite shade of green?

And then we just slowly progressed through the [00:06:00] idea that for you to recover from all these things you, you have to physically move, you have to take better care of yourself. You have to heal this part of you. And she was willing to regimentally walk through lifestyle medicine, approaches to movement and nutrition and sleep.

We said his name and I did not need to educate her on the comorbidities. I did not need to lecture her on physical activities. I said, let's go walk on the treadmill, and I want you to tell me your favorite memory of Tristan as a child. I had her walk and talk about him, and she would walk for 15, 20 minutes because she would get to talk about her child.

And had I not asked that or understood that I don't know where I would've gone with education with this patient, but she just needed her child acknowledged. Then she was willing to go through the process of healing with really minimum support. She was self-driving herself. 'cause she's said, I can't live like this forever.

I know I have to do something, [00:07:00] but this is where I'm stuck. So that's the gift of letting them be the expert is they will tell you where they're stuck and then that's all you have to do is remove that barrier.

Mark Kargela: Such a great example of one, frustrating example of home medicine and biomedicine and not just in physician 'cause it's still in, in physio and other related professions too, where. We are so afraid to delve out of our security blanket, which is our biased professional training, which often doesn't position us well to manage these conversations and allow that to come into the room and give it space and validate it.

I have had similar patients who had just come off a hospice situation, caring

for their loved one in and of life care and their body has this major reaction from it. And

same thing, and this was at probably one of the more preemptive healthcare institutions in the world. The ologists are just bouncing back and forth of all, 'cause of course this disregulates

human beings.

'cause you know when your body's going through a massively emotional, destabilizing experience, lo and [00:08:00] behold it shows up in your autonomics and your GI and various other things. Yet we still piecemeal. Is that still how bad do you still see that problem in your world? I know it's d different and there's different Definitely. Examples of multidisciplinary groups and healthcare systems. So I'm not trying to be too doom and gloom on things, but I still think there's such a limit of us just swallowing our professional ego and just being a human being. Faith being Mark

in a room this to man, what was his name?

Tell me some, yeah. I think that's just an amazing intervention too, to have her. Walk in a context where she's sharing, something like that. I think that, but where are you seeing that? As far as our, we got a long ways to go, in my opinion. What do you think?

Faith Stokes: we do. And if I'm being honest, I'm still guilty of it. I am most secure in prescribing physical activity. I am most secure in manual therapy, putting my hands on someone. And I did put my hands on this patient, but in my mind, I wasn't fixing her joints. I was helping regulate her nervous system because it was so [00:09:00] dysregulated.

She needed the comfort of another human being, having physical contact with her. Recognizing that, that may produce a result. I am not necessarily sure what it's going to look like, but in the world that I work in, obviously her experience, it's not that unusual. And something I've learned to share with patients is that we work a really long time to become who we are.

I went to school for a total of eight years. I've been practicing for nearly 10 now, so that's, nearly 18 years of investment into me. And to go into a space where I don't know what to do. It's human for your ego to get in the way. It's wrong, but it's human. And so I don't I wanna be careful in criticizing people who are struggling with that because I know I wasn't given all the resources I needed.

But I think, like I say, it's been helpful to step back and say, the patients [00:10:00] don't expect you to walk in the first day and know exactly what to do. They know they're messy. They know they have 10 things going on, and if you can give them something, that's fine, but I've honestly found that many of them get relief when I look at them and say, I really don't know the answer to that question.

Can you give me a second to dig on that? Shoot me your email. Let me look at this for a minute. And they'll verbally say, what a relief. Someone's just not making something up. So I think there's a lot of pressure we can take off of ourself to not have a perfectly wrapped answer. And in the medical system, like the colleagues that I work with, I've talked to them, they have five minutes with this human, like I, I would suck as an md.

I would never get through my day because I love to talk to people too much and to have five minutes to figure out her it's never gonna happen. So that's where I've learned to say, you know [00:11:00] what? I am, I have the gift where I work to sit with these humans for an hour and really talk to them.

Understand what might be going on. So if you have five minutes, please send them to me before you send them through extensive testing. Let me be with them through this testing. And that way we have a better opportunity to actually get to the root of things that are going on. Cause I think we work in a medical system that's just not set up to be patient centered.

It's just not. We have to find our piece, our part, and try to fix that part. I hope, I think a lot of smart people are working on that solution. They're working on education to train us to be better at what we do. But I would be lying if I didn't try to admit that I make things as bio MEChA bio mechanical as I can and try to find a reason to do manual therapy or put my hands on someone versus just be curious what they need from me that day.

Mark Kargela: And just listening to you, I can hear and it's [00:12:00] usually the characteristic of somebody who's fellowship trained is like this whole metacognitive really conscious. Thought process of thinking about what you're bringing to a, to an encounter from a personal bias and clinical bias standpoint. There's and how we train too in some of our programs is the best person to do, act, for instance, on is yourself because it helps you deal with

these difficult voices, this inner critic, this person that's gonna be screaming your, in your head, figure this out and fix it. You need to have a solution for this person. I'm wondering like, what are the, 'cause you've already spoke to this a little bit of you've been able to like pump the brakes and recognize what you're bringing and like almost pause and take perspective on yourself before you start launching into things. I'm wondering like, if you could talk about like that, unpack that a little bit for people who are listening who might be earlier in their journey of kind of this whole metacognitive reflective practice component where you're almost slowing your thinking down so you can pause. Catch a breath and meet a human where they're at versus maybe doing what we tend to do as clinicians early on in our careers. I wonder if you can unpack that a little bit.

Faith Stokes: I had the gift [00:13:00] of doing some mentorship in my practice with Dr. Christian Marson during fellowship and when I was in fellowship. Just for context, I was traveling to other people to get mentorship and I emailed Mark Shepherd, who's the director and said, this isn't working for me. Their people don't look like my people.

I need someone with me, with my people. And so Christian came to my practice, bless him. He is not a pelvic health therapist, so I threw him right out the deep end with that. And I remember one day we went to see a really difficult patient. It was such a tough case that I I walked out of the room, I walked straight back past Christian.

I went straight to the bathroom to go cry. Like I, I didn't even tell him what I was doing. I just left. And when I came out, he was so compassionate. He looked at me and said, what are you doing? And I was like I didn't have an answer. I didn't have something to do to help her. And he goes if you're in your head and you're beating yourself up, do you have access [00:14:00] to the parts of your brain that can fix this problem?

And I thought about it and he's if you wanna be creative, like what part of the brain do you need to use? And are you using the prefrontal cortex? If you are listening to a bunch of inner negative dialogue. I thought to myself, no, I have no access to that part of my brain. My amygdala is thumping right now.

And I thought about that and I've started reflecting on when I am with a patient that's more challenging if I find myself becoming anxious. If I find myself framing what's happening as negative oh my God, I am not gonna have time to do this or something, that's my pump the brakes, because I'm like, oh, I am gonna lose control of my prefrontal cortex and I will not be able to help them today.

And so Christian and Mark both gave me the word curious. How do you become curious? And I think my label for metacognition is curiosity. [00:15:00] When someone says a sentence to you, did they say a full sentence? Can you ask a question about it? The patient that said her son died and no one said his name, I wanted her to say his name.

But when I'm curious, my, my brain is alive like it's on fire. I am thinking like 10 thoughts and I'm so excited and I am so engaged with the person in front of me. 'cause I'm like, whoa. Oh am I so excited? I think I have some solutions for you, but I'm gonna sit here and I'm gonna finish listening 'cause I want this.

Customized and it means I am like with that person in front of me so deeply and so engaged 'cause we're having this experience together. And so that would be my tip. When you're trying to work on metacognition, if you find yourself feeling more anxious and negative you're using the tool wrong.

If you find yourself curious, if you find yourself leaning towards that person and fully engaged in what they're saying. You are still hearing the same number of voices. I don't [00:16:00] know how many are in my head, but they are going really fast. But your feeling, your emotion is different. And I think especially for these complex cases, I don't think we realize what our body language does.

When I'm feeling anxious, I tend to lean back away or lean away from them. Or we might cross our arms or we might become quizzical. And someone, particularly people with trauma histories, may interpret that as withdrawal. And if you notice when you do that, like they lean in and they start to get louder and they start to try to convince you of things and it's because they think you that you're going to miss what they're saying.

They're trying to amplify it. And so if I'm curious, I can lean towards them and they feel that engagement and they get quieter and they speak slower. And when they see me get excited, then they ask what are you thinking? You have an idea. And then that reciprocity happens. So that was a huge shift in my thinking process for metacognition is what [00:17:00] emotion am I feeling right now?

The more positive emotions give me better access to the parts of my brain that can actually fix the issue.

Mark Kargela: Do you think the negative voices go away per se? Do you still and I say that because.

Faith Stokes: Yeah,

Mark Kargela: The one thing that's helped me personally, and I can't speak for yourself of course, 'cause I'm not inside your head. You wouldn't want inside my head, I'm

Faith Stokes: no

Mark Kargela: it's dangerous

territory

Faith Stokes: always.

Mark Kargela: Yeah. But I've, and where I think ACT has helped me personally is recognize one, that it's human to have these negative

critics, these inner critics and these

Faith Stokes: yes.

Mark Kargela: Are gonna push you to have the answer, to have the solution and have these things. And it's not that and how we work with patients too.

It's not that these are gonna go away or that you need to push them away, or you need to like tussle with them. The whole skill of it is can you be okay? Can you sit with them? And still be able to engage in something that's valuable where I can engage with this human who's uniquely positioned, I'm uniquely positioned to help, but I'm gonna first listen.

I'm not gonna let these voices put me in a tug of war and then push me to cutting this person off and trying to drive a solution that the patient isn't ready to [00:18:00] hear yet. 'cause they haven't even expressed their situation. I'm wondering just 'cause I think sometimes clinicians have this. Maybe feeling that faith never has these negative voices anymore.

She never has these inner critics anymore. She must be, just, her brain must be devoid of any of these things. What would you say?

Faith Stokes: It's the opposite of that. And I think, so I did a I did something called positive intelligence, which has this idea that we have inner critics and judges and we all have dominant inner critics that say certain things to us. And I bring this up because one of the tips to manage the voices is name it.

So when I hear myself saying that I've done it in the clinic, I'll say, judge, to make the thought stop. And once I know that's my inner judge defining me, that helps me like say that's not my inner sage. And so I think the voices are there, but they get a lot quieter and they have less effect on you.

[00:19:00] And. I think there's a perspective I've gotten over time. This is something less I have been, I've been less able to help myself with more. So really sitting back and saying, my husband who you met earlier is this how Joey would talk to me and. No, that's not how Joey would talk to me. So I think we all struggle with that.

I think we all hear those inner voices, and I have had to ask myself, am I holding myself to this unrealistic expectation? And I had this wonderful psychologist teach me this phrase, what's the feeling under the feeling? The feeling you're feeling is judgment and frustration. But the feeling under that feeling is, I actually care about this person and I want to help them.

And these negative feelings that I'm sentencing on the top are because I feel like I might not be able to love them or help them the way that I want to. And in psychology, that's what she told me. She's you don't deal with these. You focus on [00:20:00] this. So when I hear those voices and they can be very loud I will focus on the feeling, under the feeling and say, I care.

I'm showing up. And I think as I've studied that I've realized, you've spoken to connection. It's not that the person is always helpful, if we think about a toddler that's trying to help with things, like they're not helpful at all. But you don't get upset at them because they're feeling their goal is to love you and to help you.

And so when we are willing to sit with a patient and just be present, it's enough to be, to acknowledge their experience and that you want to help them. But man, I wish the negative stuff would go away. I actually mentioned that to my therapist and she was like, faith, you will always be anxious as a person.

You will just get better with living with it. And I was like that was harsh, but probably necessary feedback.

Mark Kargela: Totally get that too. I've had to come to terms with and [00:21:00] accept that there are certain characteristics I have as a clinician and as a human. It's a human condition, that we

deal with that. That is just something that once you recognize one, that faith deals with it, mark deals with it. And I guarantee you all people on Planet Earth deal with it.

It's just are they living well with it? Which is the whole point of like positive intelligence Act approaches and things like that is to

Faith Stokes: yes.

Mark Kargela: To take perspective and have some awareness of it so you can manage it well, which is what we try to do with patients with some of the negative, and they often come with a lot of negative things. Now this discussion gets, obviously we're getting deep into the psychologically informed components of what we do. Early in my career when I was like chasing my latest certification in manual therapy. Like

that stuff got shoved way to the side. 'cause man, when am I gonna learn to lock things out from 16 different planes and cavitate one single facet? And I honestly, I wish that was a joke, but there was a point in my career that was exactly where I was at

Faith Stokes: I am laughing out of empathy.

Mark Kargela: Yeah. I appreciate it. This is this these conversations are almost like support groups for me as well. So that's why I have [00:22:00] these

Faith Stokes: Yes.

Mark Kargela: But there's this false dichotomy out there that you're, it's this, either or like you're a manual therapist or psychological inform and obviously bellin's fellowship,

which you went through. And that's hopes to debunk and dispel that 'cause you can't, the humans demand that we're not in this dichotomy. How do you reconcile those two together when you and can live both roles? Roles? I can have a manual therapist you spoke to how. You've reconceptualized what hands do and how it can still bring value in your practice.

How do you reconcile both of those kind of co components of what we do? Because I think there's this false dichotomy out there that I get a feeling from you obviously, that doesn't exist in your practice, that it's an or thing. It's an and thing,

Faith Stokes: I think for me, the shift was accepting it within myself as not an either or thing, because. I separated it in my brain in buckets. Like these are things I talk to my PT about. These are things I talk to my counselor about instead of realizing the [00:23:00] overlap in those two. And I integrate my own psychologically informed care for myself into my practice.

And. For me I am not a neurosciencey person. Like I still have a picture on my phone during a neuro exam from a my DPT program where I was so freaked out by the test, I misspelled my name at the start of the test. It didn't do great on that exam. So for me, like I had, it took a lot of focus for me to really try to get an understanding of the nervous system, but.

I did the curiosity approach with my mentor. I have three steps that I integrate my own psychological care into my practice. So the curiosity approach, what is my emotion? I use the positive intelligence approach where you hyperfocus on a sound or something you're looking at for at least 10 seconds.

And I do that on the patient. So it's my own version of a mindfulness practice. It makes me more [00:24:00] present in the moment. It makes me calmer. And when you do that, when you focus on your own calmness, the patient regulates you. You start to co-regulate with this person and your nervous system gets on the same wavelength.

And then the third way I incorporated that is actually into my manual therapy. I have a mindfulness practice with my manual therapy, meaning. I hyper focus on my touch during palpation, so I do a lot more palpation than I used to and force myself to regulate my own nervous system when my hands are on another person.

And so that's probably where it started for me because I was really struggling with negative voices and anxiety in my practice I was. Mid heat of fellowship where you're getting evaluated at every turn. And that started really calming me down. But the flip side of that was that I noticed my patients were getting calmer.

They were relaxing into me. They [00:25:00] were slowing down their speech, they were falling asleep on the mats. And I thought to myself, these are not separate things. I'm doing what I've done, but I have shifted my, the way I frame this, and I am taking care of myself while taking care of them. In fact, it became such a big part of my mental health that the very first time I took a vacation, I got up on Monday and I was like, oh no.

What's a mindfulness practice when you don't have patients? I didn't practice that, so I had to think about what to do. But again, that was my own self-care and it made me a better pt. And I thought to myself, if it had such a powerful influence on my practice as it stands, how do I give them the same tool?

How do I help them regulate their own nervous system without me? And that's where I started, was just teaching nervous system regulation. Most of my patients have a past history of like ACEs or adverse [00:26:00] childhood events where they were not raised in safe environments and were not taught emotional regulation or coping strategies.

So being able to give them that, being able to give them a safe relationship where they could co-regulate and then giving them the ability to do that independently shifted We, me way towards this idea of what else is there out there? What's the psychology world doing to manage these things? And then when I started studying and that, I was like, oh, we do that.

Oh we do that. We just call it something else. So I think again you and I were talking before we started recording about how pelvic health and orthopedic overlap. A lot of what we do really overlaps with the psychology world, and I don't think you can separate it, but I have learned that it's the intention that you put into it and the way that you frame it.

And once you identify it, it makes the tool more reproducible.

Mark Kargela: And it's so powerful when you can understand the psychological underpinnings of what you're doing when you lay hands on somebody and to take, [00:27:00] like you said, pause. Regulate yourself, but also regulate yourself when difficult emotions come into the room, when somebody's flared up and they're unhappy with you, and your tendency is to take the defensive mode and instead of just like leaning into that and really having an honest, validating discussion of and owning it, 'cause I've definitely,

I've just flared that just had a conversation like that Thursday where, obviously not purposely we attempted some things and it did not go well for of the patient, but. Leaned in and we were laughing and joking by halfway through just because, and that was not something I felt capable of doing.

'cause I would just immediately get into defense mode as a clinician and not be able to control my emotional reactions to some of those situations. 'cause to me that was, I'm a failure. I suck at this. All these voices that show up when we're having those things. So I think that emotional intelligence. All these different positive intelligence and act based approaches are so powerful as a clinician to help you manage your own self as a clinician. But then, like you said, to really be able to best manage a relationship with a unique person and tailor yourself, be it with your hands or not [00:28:00] your hands, to that unique neutral in front of you.

What do you think?

Faith Stokes: I honestly, what I related to with what you just said, and I'm sure you see it in your practice, and I know when I mentor people, that's what they see with complex people is like we do often mess it up because there's such a unique individual. I can say my best evidence says to try this, and then my best evidence lit it on fire.

And I'm like back to the drawing board. But because I know that happens now, I have those conversations on the front end. I'm interested in your symptoms changing. Even if it swings the wrong way, a system that is, that will be, can be changed, can heal. So if it swings the wrong way, that tells me I'm in the right area, wrong dose.

So it's important that you tell me if something is wrong, and that's not my goal. But I want you to understand that as we try to help you, you don't fit in a textbook, so I'm going to depend on you to give [00:29:00] me feedback, and then you ask for consent in a very different way because. To give a patient example, like I've been working a lot on with veterans and soldiers who have been in IED explosions.

And what I'm finding is that first and second rib mobilization produces flashbacks really commonly. And I was fortunate enough to get that feedback from one of them that had increased his nightmares and made his flashbacks come back. And so I give that disclaimer. I need to work on this area. It might cause this.

I need you to tell me if you start to feel your mood shift or if you start to feel uncomfortable or unsafe in the room. 'cause that's not what I'm interested in doing. It means I'm in the right area, wrong dose. And I don't know about you and your practice, but I found if I have those conversations in the front end, early in my career, I'd have been like I'm gonna summon the demon if I talk about it.

Now I'm like, no. They deserve to consent to what might [00:30:00] happen and be part of this conversation. And then when it does happen, they can be like, you were right. That did not go great. So what's plan B? And we get our therapeutic alliance back a lot faster versus them feeling like I was surprised by what happened.

Mark Kargela: When the unknowns are known, I think it just makes it easier for a patient, right when you lay it out there. 'cause I definitely do the very similar, I say, we're gonna be trying things and we're gonna be experimenting it with some things to see if we can shift your system in the right direction.

You and I are gonna work together and you and I probably gonna have sessions where we feel like, man, we had a really good session. And sometimes you're gonna, your system's gonna say not so well, maybe later that day or the next day. We're not gonna obviously work for that and try for that, but that's probably the reality of how these systems work as they're regulating and moving themselves in a positive direction. But the good news about that is it gives us a learning experience, right? It gives us the opportunity to see what's working and what's not, and then

tailor our work to you based on that. Like we're not just droning the same. Tech running you through the gym on the same program over and over again, which we won't get into that setting.

'Cause that's [00:31:00] a whole nother ax to grind and discussion to have. Which we won't go to. But I think there would be some huge value for you sharing a little bit of your approach with trauma. You've already shared a little bit of it, of how you've approached it with that patient, but I'm loving if you could help clinicians just maybe have an ability to bring that into the room and maybe obviously recognize when it's beyond what we should be. Working with and when you need a teammate, be it in the behavioral mental health arena to, but how do you make that part of your practice that 'cause I just don't see with some of the patients, especially working with person's pain, if that doesn't get in the room, that part of the reason that person's in your room seeking.

Some fix through a manipulation is they're not addressing the elephant in the room, which is they're not really working with this problem that's been going on, and it's not my job to, to diagnose it, but I am somebody who can make them aware of it and plug them into the right person to process that and work through that.

And then obviously we can incorporate some trauma informed skills as we're working with somebody. What would you recommend to a clinician who's like trauma? I don't know how to even go there. What would you say to them?

Faith Stokes: Oh there's a [00:32:00] number of things. 'cause this is a topic that gets me excited. One, first and foremost. I think in those moments it's okay to be human. And in fact that's what they need you to be is human in your response. And one, I think the hardest thing people come up with is what?

What happens when they tell you something happened to them? It's okay to say, I really wish I knew the perfect thing to say to you right now to make this better. I really wish I knew the one thing I could do that would fix this. I don't know what to say or do. That will help. Can. Can you guide me?

What do you need to hear from me right now? And that's where just showing your hand is better than saying something. Placating. Let's go back to my gentleman where I was doing his rib mobilization, where he called out a work for three days. I didn't know until he came back. He was like, yeah, I don't know what happened there, but we don't need to do that [00:33:00] again.

And I talked to him about it. And so that's my approach now is I needed to know before I if there's a risk for that, that they have a physical and emotional safety plan. So that's something I talk to these patients about if they share a tra a trauma with me. I say part of my screening process is making sure that if we provoke any symptoms in session, that you have the tools and the resources you need at home to cope and manage this.

So what's your physical safety plan? If you have a massive exacerbation of your pain, what do you do to calm it down? Can you do that by yourself? Then the emotional safety plan in his case he had shared issues with having suicidal thoughts in the past. We talked about that. I have images that I share that has all of their, like suicide hotlines and all of that on it, and I gave that to him and we actually programmed them in his phone so he didn't have to remember.

[00:34:00] Them or where the paper was and we saved it under a code word. So he didn't have like suicide hotline in his phone. It was help number one in his phone. So if he started to have a crisis, he could hit help, number one. But I don't proceed in trauma cases unless those two things are present, because I don't wanna trigger something.

They then have to go home and figure out how to cope with by themselves. So physical and emotional safety plans. Then much of what you were talking about with graded exposure when I am working, let's go with assault victims. I want them to tell me like the color a person wears, that, that's comforting to them.

So what's your mom's favorite color? What does she wear all the time? If I'm able, I actually try to wear those colors when I'm treating them. I wanna create safety in the environment. We change the lighting, we change the sense in the room so that their nervous system realizes they're somewhere else if the pain is reproduced.

And then we talk about doing that at home. If you are [00:35:00] having your pain, let's make sure you feel as far away from this situation as you can. But then the idea is if I have a safe environment for you to come to, can we change the context of your pain? Then can we provoke it in a meaningful way and teach you, provoke it, learn to cope with it, provoke it, learn to cope with it, provoke it, and they get to the point where those memories like soften and don't become as harsh for me if they're in a very acute stage.

So I do work with I work very early in the process with assault victims. And for them, like I need to know they have a counselor or a hotline that they can talk to because it produces very emotional things. But you're gonna have a lot of patients who don't do well with counseling. And I progress them a little bit slower because they don't have the safety netting.

And I do find they will become more comfortable with counseling because they'll say. [00:36:00] Faith, if my counselor was you, I would talk to them and I said, there are counselors out there that are better than me. We just may have to fire a couple to find the one that works best for you. So once we have that therapeutic alliance, if we progress a little bit slower, we can successfully get people in counseling.

But I think. Realizing that a lot of what we do helps them process their trauma because they're with you and they're safe with you, and they can get exposure to pain that reproduces emotional memories and then learn how to get that pain to go away or change it that can help them cope at the same time.

So that's just been some approaches that I've taken. But then the other thing I will say is there are a lot of amazing books written by people, by authors who have experienced trauma that can be incredibly guiding to clinicians. One I'm reading a lot right now, his name is Pete Walker. He went through Dr.

Peak Walker. He went through extensive childhood abuse. And treats only [00:37:00] complex PTSD. So PE people who have grown up with so much abuse, they even have trouble relating to other human beings. And his books are amazing for understanding the way someone thinks or feels or interacts, and where they might struggle with therapeutic alliance and accepting that they may never really be able to trust you as a human because trust and safety are the most terrifying things they've ever experienced.

Taking the time to read personal experience of people who've recovered. And then he has patient facing books, and I love the way he talks to patients. And so I like listening to the way that he speaks to them and learning to like frame words that way can be incredibly helpful.

Mark Kargela: Yeah, we'll have to put his books in the

Faith Stokes: I will.

Mark Kargela: And if you can share those, that would be awesome. 'cause I know the

audience will be interested in that. I'm wondering what your experience is with 'cause I'm definitely a hundred percent on board with referrals to counselors, mental health, psychology and stuff. My only issue sometimes is that referral, [00:38:00] sometimes people get into this, it just exposes dualism of the issue that still exists out there. I love, I wish there were so many more pain psychologists 'cause they don't necessarily fall into this, but sometimes folks that maybe not as much in chronic pain and maybe folks are in rural settings where this psychologist is working with all the things and trying to do their best and doing an amazing job, of course, but still struggles to put a narrative together of how their work equals.

'cause I think there's still this lack of understanding of how a person's mental and psychological world is embodied in how they. Present themselves in a musculoskeletal domain and vice versa. You can't separate the two. I'm wondering, there's some amazing mental health behavioral health folks who help patients make the connection. I just sometimes still see that. It seems like we're islanded we're in our little siloed buckets where Yes, I'm working on the mind part and you're working on the body part where we're working all of it together. What's been your experience?

Faith Stokes: Similar in my area, it's very rural. A good patient example of this was I often will work with people who are about to go into the [00:39:00] courtroom and have to efface their attacker for the court case and their counselors are not teaching them coping techniques. How to calm their nervous system or control their nervous ness.

So that's something that I teach them to do is nervous system regulation. How to incorporate mindfulness when you're being cross examined and you're sitting across from the person who did this to you and in my area, they're not allowed to leave the room when they're on the stand. They have to stay there.

They're forced to sit in a situation where they, where their nervous system is going nuts and try to regulate. And I've run into a number of therapists who struggled to give them coping tools and I'll tell them, go back to your therapist. They've worked with you since this happened. Ask them coping tools and they don't have guidance on that.

And so that's a huge gap. My favorite piece of advice, and I, it's where I don't like when we look at therapeutic disclosure. I have been in counseling since my [00:40:00] twenties. I have had four therapists. I obviously fired three. You are going to need different therapies or different therapists based on the stage of your life or based on what happens to you and.

Just like there are different types of PTs, there are different types of therapy and like educating a patient on that, that because they had one negative experience, it means that person wasn't the right fit for them. And my favorite mental health resource right now is actually Sonder mind. It is a beha.

It's a, a platform. And when you sign up for an account, you tell you tell Sonder mind what you need. And Sonder mind matches you with multiple therapists. You get a free 15 minute interview with those therapists and I tell them, go with the one you vibe with, but Sonder mine will fire your therapist for you.

If it's not a good fit and help you find a new one. And because it's a platform, you can go in person or virtually. So I've pushed people more towards the [00:41:00] virtual route for the reason that you're saying because it's given them access. To, again, one of these patients was struggling with this and they found her, someone who actually worked in the court systems with people trying to do these things.

They found her a counselor who did that. It completely changed what was happening for her because this person knew exactly what was going to happen that day and could talk her through it. So I think that's where, as a clinician, I've had to get creative. But again, as soon as I disclose, I've gone to therapy.

I have fired therapist because they were not meeting my need and allowing me to get to the next phase of healing. And when we talk about that. I support them through the process. I've sat there and helped them set up a Sonder mind account. We have to find the barrier and remove it for them because I know that's the healthiest thing to do, but they don't know that they have the ability to fire anybody on their medical team that is not taking care of [00:42:00] them.

And that's unfortunately something we don't normalize in medicine.

Mark Kargela: No, I think patients should be the CEO of their own healthcare and sometimes they are like getting drug around and

not knowing they have any say in the matter of being that person who can hire fire and, promote people within their healthcare team. For sure. Faith, I know you're involved in, residency, fellowship training.

You're involved in national organizations and things. What do you think are the big issues? Where are we falling short as far as training? Early clin, early career clinicians on being able to manage this stuff in clinic, at least at a basic level, especially for someone who's gonna go practice in a rural setting where they don't have access to. Some of these, services and things you've already mentioned some great digital, virtual things, which I think are amazing. What do you think we need to be teaching these folks early career that would help them, that we're not doing right now?

Faith Stokes: So I, I have to give a complete shout out to the up and coming generation of PTs because I get to work with them [00:43:00] and they have such a beautiful foundation of humanity and they have been taught completely differently as far as acceptance of other people. So they come into these situations hungry to talk about this stuff.

They bring the topic to the table. And so I think this is where I had to jump through a lot of barriers and a lot of hoops to feel comfortable talking about my own mental health, going to counseling my own, past issues. And they don't have that barrier. They're comfortable with it.

So I think for me, it's been embracing and letting them lead the charge and recognizing they're going to pass me at some point because they are not fettered by the same things, but they need the time and experience that I have with certain patterns that I've seen with patients. And what we're starting to learn now.

About [00:44:00] exercise and how physical activity helps us manage traumatic memories, and the fact that putting our hands on a human being is not changing, the tissue underneath. However, it can reduce anxiety and it can stop panic attacks, and it can change someone's autonomic nervous system and empowering them that while this evidence is new.

It's emerging and so to watch it, and I really think they're going to lead the charge on that because their comfort level with the topic is so much better and they don't have my long list of biases with it. So I think just allowing them to have curiosity and say, wow, that's not my strength. If you could guess what direction we should go with that.

Where do you think we should go? And then just listen to them because we do have barriers talking about this right now, and they just don't have them. So I don't know. Maybe they need to be in charge.

Mark Kargela: Yeah, [00:45:00] seems like a logical approach, although one we don't necessarily consider, as a clinician, especially early on when we're so set on being the CEO of that whole interaction, which I think you've demonstrated that humility and the ability to be faith and sit, equal across from an expert who's the biggest expert in the pain experience, which is the person who's experiencing it as we know.

Faith, I could probably talk to you for about two more hours 'cause I've thoroughly enjoyed this conversation. We'll probably have to have you on again if I can bother you again to come on again to.

Chat on some more topics, but for those who, for those of the folks who are listening, where can they find you?

Faith Stokes: I'm on Instagram and LinkedIn. It's at the pH fellow, at the Pelvic Health Fellow for both handles. Like Mark said, I share different things that I'm working on there but also try to put educational resources on there to support you in making it a little bit easier to start these conversations.

Mark Kargela: Definitely check that out. We'll make sure we link that stuff in the show notes so you can follow faith if you're not already following her to get some good. [00:46:00] good. content on this stuff because honestly, social media, when you're following the right stuff, can really be your best content, some of your best continuing education when

people are sharing their cases, sharing some of the research that's coming out, sharing all that stuff.

So it's great to finally get to talk to you, faith, and thanks so much for your time and thanks for all the amazing work you're doing.

Faith Stokes: Thank you for having me.

Mark Kargela: Alright. For those of you who are listening, make sure you subscribe. If you're watching on YouTube, we'd love to subscribe there. If you're working with clinicians who are struggling with some of these issues, or you're maybe struggling with it yourself, make sure you share it too, if you could. That helps us get some more Reach for the podcast.

Helps us get this information. Other clinicians who might be struggling with this stuff, but we're gonna leave it there this week. We will talk to you all next week.