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FC2O Episode 21 - Nick Penney
21 Plays4 years ago
Using mindfulness is not just some philosophical or pseudo-spiritual discipline. In this episode, Dr Nick Penney explains how he applies mindfulness and other aspects of a biospychosocial approach to achieve some quite extraordinary results with people experiencing persistent pain.
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Transcript
Understanding Life and Pain
00:00:00
Speaker
I think the question, the telling question that I've always or I've come to recognize is most important is not really asking people what have they done, but it's more a question of what's going on, what's going on with you in terms of pain, what's going on with you in terms of your life. And so my case history would include the sort of standard biomedical, biomechanical
00:00:27
Speaker
questions to rule out that there's particularly any sign of any underlying pathology, but would very quickly move into how the pain and the injury has impacted on the individual and how it's impacted on their life or interfered with their life.
00:00:58
Speaker
to order.
Dr. Nick Penny's Journey and Insights
00:01:18
Speaker
This week we're joined by Dr Nick Penny who has some incredible results in working with people experiencing persistent pain which I know is a hot topic both in professional circles and has been voted as the leading topic people want to hear about here on FC2O. Nick originally trained at the British School of Osteopathy here in London in the UK then went on to do his PhD at the University of Queensland in Australia where he investigated the biopsychosocial model specifically looking at obstacles to recovery.
00:01:45
Speaker
Nick came to realise that you can't separate out the mind from the body. You have to consider both and help patients and people understand how the mind and body talk to each other. Nick went on to train in and to practice mindfulness, getting both first-hand experience and expert insight into how mindfulness can help people to transform themselves.
00:02:05
Speaker
Nick began to integrate an understanding of neuroplasticity, or how the brain can rewire itself, the influence of epigenetics, or how our genes can be switched on or off by our lifestyle choices and thoughts, and the bidirectional communication between body and mind into his clinical work.
00:02:22
Speaker
Nick found that attention can often be hijacked by pain or distressing thoughts and that mindfulness training helps us understand that we can have a choice on both what we pay attention to and what meaning we give it. The purpose of mindful medicine, therefore, is to help you understand that we have this choice and how to be aware of it and to engage it. So join Nick and me as we travel through Nick's journey to help more people move from a life of pain to a life of meaning and happiness. Enjoy the show. Here we go.
00:03:04
Speaker
So welcome to another edition of FC2O with me, Matt Warden, and my guest today, Dr. Nick Penny. Hi, Nick. How are you doing? Very well, thank you, Matt. How are you? Excellent. Yes, very good. Very good. It's quite early here. So I've got my espresso with me. So hopefully that will fire things up and you might need something to keep you awake at your end. Where are you based? Based in Auckland in New Zealand. So currently we are about 11 hours in
00:03:31
Speaker
11 or 12 hours in front of you, I'm not exactly sure. Yeah, something like that, something like that. Yeah, pretty much polar opposites anyway. So yeah, yeah. So Nick, I know that you trained originally as an osteopath. And so can you explain your sort of career trajectory where you started? And obviously, you're your most well, we'll get through to your most recent research and the way you're practicing now. So sure.
Biopsychosocial Approach to Pain
00:03:56
Speaker
So I originally trained, as you say, as an osteopath at the British School of Osteopathy in London, and next year will be the 40th year of our year group graduating. We graduated in 1980. And I started my practising career as an osteopath with
00:04:19
Speaker
Kim Burton, who was an osteopath in Huddersfield in West Yorkshire, who very rapidly transited into ergonomics and research. And for the first nine years or so of my career, I practiced with Kim and on my own account as an osteopath in Skipton in North Yorkshire. One of my early associate osteopaths once
00:04:48
Speaker
remarked to our receptionist when she was told that she would be seeing one of my patients that she really hated seeing my patients because she never knew where to start. And when the receptionist asked, why is that and she said, well, I really don't know what he does, I think he kind of talks them better. And that was the thing that turned out to be quite true with my later career. So I left
00:05:17
Speaker
the UK in 1989 and came to New Zealand. At the time I was almost in transit to join the osteopathic school at the Royal Melbourne Institute of Technology in Victoria, but I washed up in New Zealand and it took me another 10 years to get to Australia. Right. Practised as an osteopath in New Zealand.
00:05:41
Speaker
but was also ahead of the osteopathic association in those days as we were seeking statutory regulation for osteopaths, much as occurred in the UK. And as a result of that, being a stakeholder, we were involved with the first clinical practice evidence-based guidelines for the management of acute low back pain. So back pain has been present for three months or less.
00:06:08
Speaker
Yes. And this was the point at which my early associates' prophecy came to pass when I started to become aware of what are called the psychosocial factors, which are things that prevent people from necessarily recovering from acute low back pain. And New Zealand was the first country in the world to produce guidelines that included the assessment
00:06:36
Speaker
of these factors, stress, distress, anxiety and depression, seemingly a long way away from the sort of basic osteopathic model, but something which I clearly observed a lot in my patients over the years. And as the guidelines were produced, it was clear that
00:06:58
Speaker
lots of people didn't really understand what was involved. And I was, got very interested in this and the work of Professor Gordon Waddell some years ago. That led me to leave New Zealand to pursue a PhD, a doctorate in musculoskeletal medicine, specialising in this biopsycholus social approach to pain, which I completed
00:07:26
Speaker
in 2009 at the University of Queensland. So that's probably the positive history of my career. I continued to work as an osteopath during the time of my studies and then relocated back to New Zealand where I've been practicing more in terms of pain and specialising in pain.
00:07:51
Speaker
and running a multidisciplinary integrative practice to help people
00:08:00
Speaker
better understand and manage pain. Right. Right. Fantastic.
Patient-Centered Pain Management
00:08:03
Speaker
Fantastic. So I know this is probably a very, very difficult question or impossible question to answer, perhaps. But what would your normal process be with a patient? And I guess the reason I prefaced it with it being tricky is that, of course, it's going to vary patient to patient. But presumably, there's some kind of loose thread that you would go through in terms of an outline when someone comes in with, let's say, with a persistent pain issue.
00:08:29
Speaker
Sure. Maybe the slight difference between what I do now and what I used to do was that as osteopaths, we work more in terms of primary care, taking people off the street, getting referrals, people self-referring. In the pain medicine world where I work now, our patients are all referred. So they come with a history attached to their case.
00:08:59
Speaker
But I think the question, the telling question that I've always, or I've come to recognize is most important is not really asking people what have they done. Um, but it's more a question of what's going on, what's going on with you in terms of pain, what's going on with you in terms of your life. And so my case history would include the sort of standard biomedical biomechanical
00:09:27
Speaker
questions to rule out that there's particularly any sign of any underlying pathology, but would very quickly move into how the pain
00:09:39
Speaker
and the injury has impacted on the individual and how it's impacted on their life or interfered with their life. Right. Right. And so this is reflecting that kind of biopsychosocial view. So you're interested in the biology as you say, but also in particular the impact on their sense of wellbeing, their sense of self and how that affects their relationships as well. Is that kind of
00:10:04
Speaker
Absolutely. Well, it covers a multitude of things. We know that pain and depression are basically two sides of the same coin. So when people come with pain that's persisted more than three months or so, then it's already starting to show its impact on their mental health and their mood. It's very often
00:10:29
Speaker
Aggravating perhaps underlying anxieties and as well as all the anxiety that's generated by the pain and what people fear they might have done and and.
00:10:41
Speaker
they fear for their future. When people come in with this persistent pain issue, you have a sense that there's likely to be these kind of comorbidities that are psychological in nature. Then where do you go with it from there? You want to know about
00:11:01
Speaker
what's going on for them in their lives? And that's a kind of very open question, presumably that allows them to really talk about what's important to them. What, you know, what's my story? And often people don't get much of a chance. And it's one of the things that's always I've always enjoyed about osteopathic medicine is
00:11:24
Speaker
that we have the luxury of time to be able to sit down and allow people's stories and histories to gently unfold rather than being time pressured into saying, so what's the primary symptom? And let's deal with that rather than dealing with the person behind the symptom. You know, as to William Osler who died almost a hundred years ago in
00:11:52
Speaker
once said a good physician treats the disease, a great physician treats the patient who has the disease. And I think that's very pertinent to what we do.
00:12:03
Speaker
Yeah. And I think didn't Hippocrates say something along the same lines, or at least he was attributed or credited with thinking about the person that has the disease or the disease that has the person, something like that. Yes. And I think 80 still said something along the same lines. These things always have a thread, you know, all the way through them. But I just like the idea that what's going on is really allowing people to
00:12:30
Speaker
broaden out all the areas of their health and their well-being that may be a concern to them and also allows us as clinicians the opportunity to gently explore things that the patient may not realize are impacting on their ability to recover. Yes, yes for sure.
00:12:55
Speaker
So do you, do you have any examples of, um, or, you know, hypothetical cases where someone comes in with this persistent pain? Um, let's say it's low back pain because that's a, you know, obviously a very, very common one. Um, they've got a little bit of comorbidity in terms of, uh, some, some depression. Um, where, where would you go with that? Obviously they're going to tell you what's important to them. What's, what's the next step as far as you're concerned? Figure out how much the pain is.
00:13:25
Speaker
interfering with their life. So pain interference, you can classify or is defined as a way of measuring how much the pain impacts on people's cognitive abilities, their abilities to think their emotions, their physical activities, which includes sleep and enjoyment of life. So we may often see instead of just asking somebody to rate how much something hurts from zero to 10,
00:13:55
Speaker
Um, you know, an average patient may say, well, you know, it's the pain severity is maybe four or five out of 10. If you ask them how much it bothers them, then the answer can often be, well, eight, eight or nine out of 10. It's, it's impacting a lot on me and my life, which of course is why they're seeking to try and do something about it in the first place. We don't, I don't see, um, depression.
00:14:24
Speaker
or anxiety or diabetes or any other kind of diagnosis in terms of a medical comorbidity in inverted commas. These are all part of the patient's life experience. So how does all of this fit together?
00:14:46
Speaker
You know, is their diabetes well controlled, for instance? If they, and we use screening measures to help us assess if people are clinically depressed, A, are they aware of that? Often people are. And then, well, how's this being addressed? What's the evidence behind managing depression? Are they getting enough exercise? Are they getting enough sleep? If they've been prescribed antidepressants, are they taking them? Are they engaged in talking therapies?
00:15:17
Speaker
It's about looking with a broad-angled lens to sift out the factors that may be pertinent to this individual person.
Impact of Psychosocial Factors on Pain
00:15:30
Speaker
If you take an example of actually neck pain, there was a study done some years ago of women in the workplace suffering with neck conditions.
00:15:39
Speaker
And the researchers looked to find what was the single biggest factor that predicted women being off work with neck pain. And everybody sort of jumped at the thought that maybe it's sitting in front of computers, sitting too much, and came out with a whole raft of different things. And the answer turned out to be the biggest predictive factor of a woman having time off work with neck pain was an unsupportive management style at work.
00:16:09
Speaker
So something out of left field, a standard clinical assessment, nobody would think to ask about how do you enjoy your job? How long have you been there? How well supported do you feel and valid in what you do?
00:16:28
Speaker
And it's surprising then how that will then potentially open up a conversation. Yeah, that's fascinating, isn't it? I just recently did an interview with Brony Lennox Thompson, who, of course, I'm sure you'll be aware of, and there's an occupational therapist. And so talking about occupation, not just in terms of jobs, but in terms of what people are actually occupying themselves with, it was a fascinating conversation about just how important that is and her whole concept of living well with pain.
00:16:56
Speaker
Absolutely. I saw that. You've got several videos on your site, which are great. They're nice short videos so people can just get bite-sized chunks of your experience and wisdom. One of those videos was your Six A's approach. I saw a few connections there between what you were expressing and what Bronnie was expressing on her podcast with me.
00:17:20
Speaker
So would you be willing to go through that six A's approach, starting with the apprenticeship A?
00:17:28
Speaker
Now you are really going to test my memory because I can't say I've looked at that in some considerable time. That's why I said, you know, starting with apprenticeship. So, okay, let me just run through the list. So it's apprenticeship, application, attention, awareness, acceptance, which of course, you know, is the, it made me think about it. And then that action as well. So when you say apprenticeship, what are you kind of pointing to there?
00:17:59
Speaker
learning about pain education, really about understanding pain as a sign of threat, not necessarily as a sign of damage.
Mindfulness and Pain Science
00:18:10
Speaker
So as an apprentice, we're really just
00:18:13
Speaker
learning the ropes and learning a different way of looking at these things that trouble us in our lives. Pain science has moved on a long way from the idea that damage is necessary in order for us to experience pain. What's your experience with patients that are there, they're in pain in front of you and you explain to them that pain doesn't necessarily correlate with damage?
00:18:43
Speaker
Do they sit there in disbelief, some of them, or are they quite open to it?
00:18:50
Speaker
I think it comes as quite a surprise to a number of people, but it allows the consultation to move to this idea that hurting doesn't necessarily mean people are harming themselves. So one of the big factors in preventing people recovering is fear of pain and fear of movement or re-injury. So if people can come to understand that hurt doesn't mean harm,
00:19:22
Speaker
then that also then allows you to help them recognize that movement may be something that is therapeutic and helpful to them. With some people, this takes time and does a deal of patience that can be necessary in order to help people shift the beliefs about pain that they've been brought up with. And of course, the difficulty with that is it's very easy for them to go
00:19:52
Speaker
and seek another opinion where somebody will tell them that it's all about the damage that they can see on their X-ray or their MRI scanner. Yeah, that's a really important point. I think probably most of us that are online should have an awareness of that, but that's this idea of having a no-seabic effect through the language that we use and the ideas that we put in patients' heads. Yeah, absolutely. Research done at the George Institute in
00:20:21
Speaker
Sydney concluded that really, we should be very careful who are offering scans too. Because once you put up a picture, it's a very difficult image for somebody's head to get around that it's that may not be that may be a complete red herring. And also that people who
00:20:42
Speaker
are subjected to MRI scans are more likely to be offered invasive techniques, surgery or injections for say low back pain. And their evidence actually showed that far from reassuring somebody by taking a scan, you often actually put their pain score up a little by taking a scan and then demonstrating the wear and tear that we can see in everybody over the age of 18.
00:21:09
Speaker
Right. Yeah. Fascinating, isn't it? And, you know, I suppose, yeah, yeah. Well, one of the things that I've come across in discussions in the past, because I think, you know, migrating from that more biomechanical view of the body into this awareness of, you know, greater awareness of pain, science, pain, neuroscience, and so on.
00:21:33
Speaker
One of the papers I've been aware of for many years was this paper by Booz et al, which was from 1995, and it was showing that in that particular paper they found 76% of asymptomatic people had disc injuries. Yeah, and it was very good. Demonstrable bulges in disc, in that, invertible discs, yeah. That's it. Yeah, yeah, yeah. Do you know the study? Have you, have you seen it? Yeah, yeah, yeah. Great.
00:21:55
Speaker
And so, you know, what I had used that study to explain when I was training, you know, sometimes lost your pass, but quite often fitness professionals as well, is to say, well, look, you know, if we know that three courses, the people that are coming in have these disc bulges, irrespective of pain, you know, with no history of pain, then we just need to be careful with our technique.
00:22:17
Speaker
And it makes sense that we should teach people optimized lifting technique and all this kind of thing. But this is kind of quite counter to the way the whole pain neuroscience field has moved. And they've used that figure actually to say, well, not so much that there's danger in those 76% of people that have these disc bulges, but more that actually it's a normal thing and most people can get by without any pain in spite of the disc
00:22:45
Speaker
So, I mean, this is something that obviously, you know, I imagine you've had to work with people that have a degree of knowledge, they've read around it, and they've heard that these disc bulges cause problems, or that, as you say, the scans show these bulges.
00:23:03
Speaker
And what I was thinking was an interesting sort of crossover with some of your other work is that these ideas are quite powerful, aren't they? So they're really mind viruses or memes. And so do you have any techniques specifically to work with that, or was it just a case of education?
Mindfulness Techniques in Practice
00:23:31
Speaker
It depends on some of the other factors. If somebody is very high in what's known as pain catastrophizing, pain catastrophizing being the more we freak out about the pain, the more it hurts, really. We know that people who are high in pain catastrophizing and Sullivan in the 90s produced what's called the pain catastrophizing scale, which we use as part of our battery of outcome questionnaires.
00:24:01
Speaker
If you have somebody high in pain catastrophizing, pain catastrophizing doesn't respond to simple education and reassurance. So you have to do something fundamentally different to be able to alter that, that pattern of behavior, that belief. Yes. Yeah.
00:24:19
Speaker
And so that then brings in the idea that somehow we have to have some other tools to be able to work with. And you mentioned acceptance, which is obviously something that we work a lot with. And we work a lot in my practice with mindfulness-based cognitive therapy and mindfulness-based stress reduction. And the basis of these practices is learning
00:24:49
Speaker
to pay attention to our actual experience. Yeah. Not the story that my mind tells me about my experience, which is what usually catches all of us. Right. Right. And not the negative emotion that then therefore comes from the story rather than the experience. Yes. Yes. Okay. When you can teach people enough mindfulness skills to be able to do this,
00:25:19
Speaker
then they're able to disengage from those catastrophic thoughts. There are lots of little techniques and one of the simplest sort of take-home ones that we can use today is taking a single thought like my back's damaged. That's what the scan says. So we sit there,
00:25:49
Speaker
And we ask somebody to close their eyes and sit there and just allow that thought to percolate around in their mind. They're not trying to do anything with it, but I'm just sitting there for about 10 cycles of breath with the thought that my back is damaged. After that minute or 10 breath cycles, we ask people to prefix my back is damaged with
00:26:19
Speaker
I'm having the thought that my back is damaged. And we let them sit with that for a minute. And then finally, the third minute is other prefix. I notice I'm having the thought my back is damaged. And by doing that, and I've done it in quite large groups in various presentations,
00:26:48
Speaker
we start to put a little distance between
00:26:51
Speaker
the thought that my back is damaged. And by the time I'm having the thought that my back is damaged, there's now a bit of a question in my mind. Is my back damaged or is it just a thought? Yes, yes. That's fantastic. Very simple drill, isn't it? Really good. It's the simple drill. It's known as a diffusion technique from acceptance commitment therapy, which is really just a way of trying to see that my thoughts are thoughts. They're not necessarily facts.
00:27:20
Speaker
their thoughts, their mental events, and they've perhaps been put in there by a well-meaning clinician who hasn't understood that I'm quite fearful about the idea that my back's damaged because
00:27:32
Speaker
My father's back was damaged and he ended up having surgery and was never quite the same again. Yeah, yeah, yeah. Very interesting. For instance, yeah. When I was doing, I don't know if you know much about my background, but I did the osteopathic training and then did some training with the Czech Institute and went through their whole sort of gamut of training from 2001 to 2005. And the last level of the training is quite a lot about people's beliefs. And we had a guy come in who's a sports psychologist more than anything.
00:28:01
Speaker
but he did a half day with us. And he gave this, I think it's a fairly standard kind of concept, but it's the idea that you're sat watching your life play out on the stage and you're totally engaged in it. You're in the front row, totally drawn into this situation that's unfolding on the stage. And it might be a painful situation, could be physically painful, emotionally painful, et cetera.
00:28:29
Speaker
And he says, but then what I want you to do is I want you to, so you know, he kind of takes you into this relaxed state and you're, you're looking at something that's been very stressful for you. And he asked you just to step up, you know, just to stand up and to go up to the back row and to look down on yourself, watching yourself.
00:28:48
Speaker
on the stage so you're going you know so you get embodied essentially you got up to the back row you're looking down absolutely yeah and it strikes me it's a very similar kind of concept to what you were just uh it is another diffusion technique and it is designed to put some distance between
00:29:07
Speaker
my experience and my perception of my experience. There are 101 examples of them and they are quite effective. The other thing is if you have a very troublesome thought or emotion you can identify it and sing it to yourself
00:29:28
Speaker
probably under your breath to the tune of Happy Birthday for a minute. It's very hard not to end up laughing at yourself when you take this painful sorter emotion or if you can do a Donald Duck voice in your mind, you do it in a Donald Duck voice and it just provides enough separation
00:29:49
Speaker
for us to disengage, which is all we're after. Fantastic. Now, okay, so we started on this 6A's process. Apprenticeship application is the second part of that 6A's process, which I think we started. Yeah, if you've got knowledge, you have to be able to apply it.
00:30:08
Speaker
Yeah and so examples of that obviously I mean that drill we just talked about the diffusion drill is an example of applying that knowledge but what other examples would you give?
00:30:21
Speaker
Well, if you take the hurt isn't harm example, then we'll often find out to people what their capacity is. Well, I can walk for 20 minutes, but if I walk for 20 minutes, my back's really getting quite sore.
00:30:39
Speaker
Okay. So we're not doing any harm here, but what save we, if we're getting sore at 20 minutes, what if we walk for 15 minutes? So we get close to the point where our structure might be starting to complain or we might be building up with pain. And then we're starting to retrain the nervous system that in fact was safe.
00:30:59
Speaker
to move within this capacity. So having understood that pain is a sign of threat, the application is, can I now start to train my system that I'm safe to move, that I'm safe to stretch? And in fact, pain towards the end of, say, a range of movement might be a sign of safety. It might not be a sign of danger at all.
00:31:21
Speaker
might be the body saying, this is enough. Right, right, right. Yeah. Yeah, fascinating. Okay. And so then attention is the next one. And I guess that is about being present and not being distracted. It is. But it's surprisingly difficult to do. So attention is really, yes, paying attention, but learning how to pay attention without the mind telling me
00:31:49
Speaker
the story about what it is i'm paying attention to yes yes so this whole thing about the story again yeah yeah i noticed on one of the videos on your site you had um uh i think was a kind of form of mindfulness where you're taking the the individual down to their feet i think it's the first video actually on your site yes it is and um so obviously you know just take a few deep breaths and then focusing attention into the feet um
00:32:13
Speaker
And again, just really being present and holding the attention there and then recognizing that perhaps they've spent a few moments not thinking about their pain. And I thought that was an interesting because of course there's attention, but it's attention or something other than the pain or other than the story. Correct. Yes. But it's not only it's focused attention, it's by choice. Yes. OK. So we have a network
00:32:41
Speaker
of neurons in our brain, brain cells called the salience network. And this is now what we used to call the, the neuromatrix sort of a pain neuromatrix.
Pain Perception and the Brain
00:32:53
Speaker
Well, salience means the brain figuring out what it is I've got to pay attention to. And most of that is done automatically. But at the point that I choose to pay attention to my feet,
00:33:09
Speaker
I've now taken over, consciously taken over my salience network and said, um, you know, I don't care what else is on the cards as to what you think we should be paying attention to at the moment. We're just going to pay attention to our feet. Ask the salience network. But what about that thought about what's going to happen tomorrow? Yes, I can observe that, but I'm going to bring my attention back to my feet. What about that pain in my right knee? Yep. I'm aware of that.
00:33:36
Speaker
but I'm actually just focusing my attention on my feet, changing the way the system reports the information to us. Do you ever get people that would say, but what if I'm supposed to be paying attention to the pain? Because isn't there that sort of potential? Of course, a lot of people experiencing pain will have high levels of anxiety quite naturally. And if you're saying to them,
00:34:03
Speaker
essentially ignore the pain, focus on something else, which I know is a bit of a clumsy way and a non-technical way of saying it. No, it's pretty close actually, but I'd actually, what I tend to do is I put it the other way, which is, well, is it helpful? Yes, yeah. Is paying attention to the pain helpful? Pain is designed to grab our attention. If I am talking to you in the kitchen and I
00:34:29
Speaker
with deep in conversation, I put my hand down on the hot plate that only just been turned off. The pain will immediately disrupt my train of thought and the conversation with you. And I will remove my hand and curse and swear. Yeah. And so there's the protective element of pain. That's something I need to pay attention to. Because if I don't,
00:34:52
Speaker
I'm going to incur more damage in my body. And that will always override at the point that it needs to. So one of the things that we learned many years ago with pain is that the brain does have the capacity to shut pain down to zero. If at the point we're feeling pain,
00:35:16
Speaker
the pain is likely to stop us being able to survive. So this is primarily in sort of warfare and highly traumatic situations. You know, people talk about being in horrendous accidents and not being aware that they'd really injured themselves. Because at that point, when a threat to survival is so great, the brain has the capacity and the drugs on board what's called the endogenous opiates.
00:35:44
Speaker
to cut the pain down to zero. Yeah. Yeah. Later on, we're going to feel a lot of pain. So what we're doing is really trying to leverage that a little bit. Yeah. Yeah. Yeah. I was going to say shock bites is a, an example of that, isn't it? Quite often you hear people just think something's brushed past them and then they realize how they're like missing or whatever. Yeah. Um, absolutely. Yeah. Yeah. Um, so
00:36:08
Speaker
something that you mentioned there just caught my attention because I think you said something like pain is designed to grab our attention and in an editorial I wrote last year for the Journal of Body Work that I had an image in there and it was
00:36:24
Speaker
essentially you know kind of schematic of the nervous system just really spinal cord and the reptilian sort of concept of the brain you know but the idea and they had a little finger just poking the cortex and the idea was that the finger was representing pain and it was saying that you know a lot of pain is from the unconscious processes or the autonomic automated processes of the body just giving the cortex a nudge to say hey this needs some attention
00:36:53
Speaker
I was wondering, does that kind of fit with your way of thinking to some degree? Yeah, absolutely. I think it's designed to tell the Salience Network this is potentially a threat it needs to be paid attention to until we can determine whether we need to fight, run away, or in fact whether there isn't such a great threat there after all.
00:37:20
Speaker
And the brain's remarkably good at doing it. And in fact, the problem is it gets so good at doing it that it learns how to do it. So the more, the longer we're in pain, the easier it is for the generate the pain to be generated by the brain, the brain and spinal cord literally learns pain.
00:37:40
Speaker
And the longer we're in pain, the better it gets at it. So in fact, our pain levels often start to creep up as the nervous system adapts. So this is kind of the process of facilitation as described. Do you know if that, because I forget the exact definition, but it's something along the lines of each time an impulse traverses a given set of neurons to the exclusion of others.
00:38:02
Speaker
the resistance becomes smaller on each future occasion. So something like that. Is that kind of still relatively current, as you say? Absolutely. The more you use a circuit and a synapse, the easier it is to use it. In effect, you strengthen it. Well, this makes it very pertinent that it's important
00:38:26
Speaker
about what we pay attention to. Well, one of the things that struck me when I was listening to that meditation we were talking about or mindfulness focusing the attention into the feet is one technique that I've used with pain patients is toe tapping.
00:38:43
Speaker
and so it's a similar kind of idea that you can lay down so you're you know you're unloaded you're rested and so I guess the the level of threat is perceived to be lower but often they're still feeling pain and then I just get them to tap their toes together and this was just a technique I picked up from
00:39:04
Speaker
from a kind of martial arts background and the idea again was that it takes you out of your head because you're putting your attention to your feet and just by gently tapping the toes together in a rhythmic way that's kind of somewhat hypnotic then that was you know what I termed the way I described to the patient was that this is a distraction technique and I was but I was I kind of used it as a
00:39:27
Speaker
you know, broke down the word. So it's, it's, it's just action. You know, it's like, you've got to do something different to be linked with pain. And distraction is a valid technique, particularly for people in, in really severe pain at that, at which point any, you know, you do anything you can that works. It's just that by distracting
00:39:52
Speaker
we're avoiding. And so avoidance is a very useful short-term strategy to us, but it's an absolutely hopeless long-term strategy. So one of the difficulties in dealing with people with persistent pain is that their avoidance strategy is now no longer working. I've had my treatment, I've taken my drugs, I've had my acupuncture, I've tried to distract myself, but now that isn't working. So it can then be very hard for people to understand that
00:40:20
Speaker
The way that they get their system to settle down is by actually acknowledging and back to one of the A's, accepting that this is my current situation.
Acceptance and Mindfulness in Pain Management
00:40:35
Speaker
And at the point we do that, we stop struggling with it.
00:40:39
Speaker
And at the point we stop struggling with it, it starts to dissipate. And so this, I think, leads nicely into the sort of paper that you sent me. It was more of a report, I think, which is your, let's see, it's the epoch. Right.
00:41:00
Speaker
collaboration. And yeah, so you essentially sent me this this paper, which documents one number of different factors, but actually showing how your approach helps people that are experiencing persistent pain. Because one of the things that triggered me to think about this was you saying that, of course, the pain when someone's experiencing pain, it can
00:41:24
Speaker
seem to become perhaps a hopeless situation and actually a lot of the literature out there suggests that people should just you know accept the pain and live with the pain but actually you've seen significant clinical improvements with your work and so how do you first of all how do you frame that up to the patient when you are working with them?
00:41:51
Speaker
Say something similar to what you say that, you know, the general view of this is teaching people to live well with pain, but I'd prefer to teach them how to live well without the pain. Yes, okay. And if we accept that persistent pain comes about because of what's called neuroplasticity, the nervous system's ability to rewire itself.
00:42:17
Speaker
It makes no logical sense that it can only rewire itself in one direction. Yes, exactly. Yeah. If I've become and develop persistent pain over time, the consensus, the sort of standard accepted wisdom is, well, now you're stuck with it. Well, surely if we create the right environment,
00:42:37
Speaker
nervous system where we rile itself in the opposite direction. So this EPOC, the Electronic Persistent Pain Outcomes Collaboration is part of a group called the Australian Health Outcomes Collaboration which is based at Wollongong University in New South Wales in Australia and all the pain services
00:43:04
Speaker
that provide pain management across Australia and New Zealand are signed up to this service. And the idea is it gives us some objective measures of what we're actually doing. So rather than us just going, well, Mrs. Jones seems to be feeling better and Mrs. Jones says she's feeling better. Here are a range of objective outcomes that are taken when we start with the patient.
00:43:27
Speaker
They're taken at the end of the process, and they're then taken three months after that as well, so we can see that the change has been sustained. And there we can see, and in fact, at the last meeting that we had, the administrator of the New Zealand arm of this
00:43:48
Speaker
collaboration came to me and said, well, based on the latest international classification of disease definition of chronic pain, there's a high proportion of the patients leaving your service no longer meeting that definition. Yeah, that's amazing, isn't it? Which is fantastic. And even better that it's
00:44:13
Speaker
seen by somebody else based on the statistics that are produced. We just upload them into a database and they do the statistical analysis and they send us the statistics back. And the hope is that providers will then talk amongst themselves, find out what's working well, find out what's not working so well, so that we can potentially improve
00:44:40
Speaker
And just to put a bit more of a biopsychosocial spin on it, one of the comments on the report is that you noted that a third of your patients come from the
00:44:50
Speaker
the highest quintile of socioeconomic disadvantage, whereas the other services that were also included in this report had only 21% of their patient population from that quintile. Can you explain that in terms of putting a biopsychosocial view on it?
00:45:10
Speaker
Yeah, sure. It's a good question. Pain, persistent and chronic pain positively discriminates towards lower socioeconomic advantage. So the more that life is a battle and a struggle, it's just great that pain also then becomes part of that struggle.
00:45:34
Speaker
Yes. And so one of the things that is known worldwide is that this is a population who can be very difficult to shift their health outcomes. They're the population who are slow to take up the message about stopping smoking. They're the population that are slow to take up the message about exercise and dietary modification so as not to
00:46:03
Speaker
to move towards high BMIs and becoming obese.
00:46:09
Speaker
to take a population to have such a high proportion of our patients from that population and still develop the results that we're getting, provides me with a lot of joy and hope. And of course, it also is quite rewarding that we are getting to work and offer these skills and this knowledge to people who would normally not be able to access it through
00:46:38
Speaker
fee-for-service type of arrangement. Because our service is 100% funded through what's called the Accident Compensation Corporation in New Zealand, which is the local government insurer, which covers people for pain and injury as a result of personal accident. That's it. Yeah, I remember it. I remember it well.
00:46:59
Speaker
Yeah, it's got its limitations. We're the only country other than Norway to have such a system. But the trade off is that you cannot sue for a personal injury in New Zealand. So you are automatically covered and
00:47:17
Speaker
treatment and wage related compensation can be provided if you can't work. Yes, yes. And look, I want to just sort of try and convey to the listeners that the results that you're getting are quite, from what I can see, they're quite extraordinary. And so what I'll do is I'll put these graphs
00:47:36
Speaker
into the show notes if you're happy for me to do that so people can see the outcomes that you're generating. And what would you put that success down to? So go on, go on, you want to say something? Well, yeah, I'd be happy for you to do it. Thank you. I think we put it down to the understanding of people from this biopsychosocial perspective. And I know it's a long word and it's banded around, but a lot of people don't really understand
00:48:06
Speaker
And when you look at the literature, it's not something that is routinely integrated into medical care from whatever discipline. But the evidence is clear that this works.
00:48:23
Speaker
The founder of the model was a fellow called an American physician called George Engle. And in 1977, he suggested that we were getting even then caught up with treating data, with too busy treating scans and blood tests and things that were abnormal in the patient. And that clinicians should really be able to
00:48:47
Speaker
consider the psychosocial, the psychology and the social aspects of somebody's existence and the pathophysiologic variables, the biomedicine, if you like. A clinician should be able to do that simultaneously. And so that's what we attempt to do. So with some patients, it would be very much more a biomedical
00:49:11
Speaker
kind of approach with others that may be more psychosocial kind of approach.
00:49:18
Speaker
And the thing that I think we do very differently is the integration of mindfulness and acceptance commitment therapy just into the whole treatment paradigm. You posed the question to me earlier about how do I see this fitting in? Is it an add-on or is it something different? It's all of it.
00:49:44
Speaker
It's all intertwined with it as best it can be. Right. Right. Yeah. So it's sort of interwoven in the whole sort of. It has to be interwoven. Yeah. Yeah. Yeah. OK. OK, great. Now, one spin on what we were just talking about in terms of the lower socioeconomic advantage and how this is consistently correlated with increased propensity to develop persistent pain and so on.
00:50:10
Speaker
One thing that I've been aware of is, and I can't remember the references right at the moment, but I can probably dig them out for the show notes, is that that trend towards increased propensity to developing persistent pain. I think that's only true of industrial nations and non-industrialized nations. I'm not sure that that's still the case. Have you seen anything on that? Because my understanding was that this is a kind of real
00:50:41
Speaker
fascinating twist because it seems that you can go to nations that have a very low GDP and a lot of poverty, perhaps people mainly working in the fields and this kind of thing to just essentially grow their own food. And in spite of that, what we would classify as a very low socioeconomic status, the back pain instance is actually less there than it is in industrialized nations.
00:51:10
Speaker
Have you seen anything along those lines? Yeah, I think more recent research tends to suggest that it may just be that chronic pain is very under-reported in these nations. But there was a study done in Australia, and I can't think of the author's name off the top of my head, but they looked at chronic back pain amongst Aboriginal people.
00:51:39
Speaker
And they found that Aboriginal people, just the same as everybody else suffered with chronic back pain, but they saw it as being part of life. Right. And because they saw it as being part of life, they modified their activities a little bit. And back to one of those days, they accepted that this was their situation. Yes. As it was then.
00:52:06
Speaker
but they didn't have this belief that it was going to last. So maybe, and it goes back to our discussion a little bit about intervention, maybe by intervening and showing people how damaged and broken we think they are, perhaps we're potentially disabling them by doing that. And of course, a lot of this work has been around the
00:52:31
Speaker
the idea that we've over-medicalized back pain to the nth degree and it's become a huge industry. Yes, yes. So you mentioned the A's. I think I skipped past awareness. So we went apprenticeship application attention. I think I skipped over awareness. And is there a clear distinction between attention and awareness? Because they sound quite similar from a linguistic perspective.
00:52:59
Speaker
Yeah, I think there is quite a distinction because this is non-judgmental awareness. So can I bring my attention into my feet? Can I notice and teach mindfulness to children as part of the UK's mindfulness in schools project as well? And when you teach adolescents to put their attention into the feet,
00:53:23
Speaker
they're absolutely astounded that there is all this sensation in their feet, which they weren't aware of until they started to pay attention. Yeah, yeah. Isn't that amazing? Damping it down that much that we go because it's there's lots of kind of drills aren't there where you put a raisin in your mouth as a classic one, isn't it? And feel the contours and the raisin and then slowly to it and all that kind. And we just are so oblivious to so much of the potential sensory awareness that we have.
00:53:50
Speaker
Yeah, because we're living in our heads and we're living with the threats and the anxieties that 21st century living has brought us and we're losing contact with what we actually feel. So awareness is nonjudgmental awareness. Can I notice what I'm feeling without my mind telling me the story about what it means? Yeah, yeah, yeah. So, you know, there's a lot of
00:54:20
Speaker
crossover. I imagine for you as a clinician, how do you find it? Because of course, there's a lot of new age or spiritual disciplines that have talked about these kinds of things, you know, very similar terms. I mean, one of the things that struck me earlier is that, you know, when I first qualified as an osteopath, I remember Caroline Miss had just brought out her book Anatomy of the Spirit, and then she did one on sacred contracts. And I was quite intrigued by that. So I read those books, and I went to see her speak. And she was always talking about
00:54:48
Speaker
your biography becomes your biology. And, and it's kind of, you know, that's kind of what we're saying about the story that we're telling ourselves. There's that, you know, if we tell ourselves a story that there's issues and there's pain and, and so on, then we really need to rewrite that, that story.
00:55:05
Speaker
in order that we thereby affect our biology. Absolutely. If we give it oxygen and we pay attention to it, then we can believe
Changing Experiences and Emotional Suffering
00:55:14
Speaker
it. There's a wonderful researcher, Lisa Feldman Barrett, who published a very good book early this year called How Emotions Are Made. And one of Lisa's sayings, which I like a lot, is if we change our experience today, we can change who we are tomorrow. Yeah, yeah.
00:55:35
Speaker
which basically goes back to what you're just saying. We can rewrite our story because there's a lot of scientific research and thought that the brain basically is just a very predictive organ. It spends all its time predicting what my experience is going to be based on the only thing it's got, which is past experience. So if I change my experience today, I can view it more
00:56:04
Speaker
neutrally, it's not freaking me out. I'm not catastrophizing about it. I'm not fearful of it. Then tomorrow.
00:56:12
Speaker
The only thing that my brain can predict how I'm going to feel is based on how I felt today. Yes, yes. So I noticed in one of your papers, sorry, do you want to? Well, it's because in one of your papers, I don't know which one it was, I think it's the 2010 one that you did for the International Journal.
00:56:36
Speaker
Yeah, it's a general perspective medicine. So, but you mentioned in there that pain is an emotion or emotion can be
00:56:45
Speaker
Yeah, it's a sensory and emotional experience. Yes. And so I wanted to ask about this, because I've, I've looked into this in the past. And of course, it makes sense that it is emotional in many ways, I think, you know, that that just is logical. But at the same time, some people when when I've studied emotion, and I've looked at various people's models of emotion, pain often isn't considered one of the core emotions or the primary emotions. So can you just elaborate on that a little bit?
00:57:16
Speaker
Well, yes, the emotional experience is pain suffering, if you like. So we will have pain as a severity of pain and it's inevitable. We all experience pain at times in our lives. But the suffering, the emotion that comes with the pain, we talk about that as being entirely optional.
00:57:40
Speaker
So it pain generates emotion, but it's not a primary emotion. Right. Yes. Okay. And again, um, I think, um, Feldman Barrett's work is suggesting that maybe these so-called sort of built-in primary emotions aren't really built in at all. They're just built. So it's life experience.
00:58:05
Speaker
that tends us to feel certain things in certain situations. And it takes work. This is not something that's easy to necessarily change around for ourselves. It takes time and patience and persistence, but we have the potential to change that. As long as we're aware of it and we're acknowledging it and we're accepting it and we're not avoiding it. And for some people,
00:58:34
Speaker
that's quite a challenge. And you need skilled teachers and clinicians to be able to guide you through that pathway, really. Yes. Yes. OK. So we've done the first four. So we've done apprenticeship, application, attention, awareness. We've also talked about acceptance. Is there anything in addition that you would want to talk about other than that? Yeah. I think the one thing to say about acceptance is it doesn't mean being
00:59:04
Speaker
hopeless and helpless acceptance in this situation means accepting that this is actually my reality at the moment yes and if i'm accepting that this is my reality i'm not struggling with it and i'm therefore open to the possibility that it might change right yes yes the other thing i think to to talk about acceptance is
00:59:33
Speaker
It covers a lot of ground in lots of different ways, but there are points at which acceptance is not the right thing to do. If somebody is living in an abusive relationship, then acceptance of that abusive relationship clearly is not the right tool. So I tend to say to my patients as best I can that we are
00:59:58
Speaker
working towards the idea of acceptance. And we don't do this early on in a process because it's too confronting. We work our way through to get to this, which is why it's down the list a little bit. And I say whilst acceptance is really what we're after, we have to remember that there is no negotiation with terrorists. Yes. Yeah. So at the point or if the pain is
01:00:22
Speaker
is too much to bear is too strong, or there is a lot of nerve root pain, a lot of pain shooting down an arm or a leg, then there is a point at which acceptance is not going to work. And at that point, we may need to step back and deal with it in a different way. We may need to look at intervention or we may need to look at some pharmacology in order to get that pain back under control. So it's not blanket.
01:00:49
Speaker
It's not blanket acceptance. Yeah, okay, okay. That's useful clarification. Because I think, you know, at first glance it can seem, and this was my concern when I first heard about it, was that
01:01:03
Speaker
you know, there's many things, as we all know, that can contribute to the pain experience from all the stuff we've discussed today. One area we haven't really discussed is nutrition so much. We've talked a bit about lifestyle sleep. But things like even, you know, breathing pattern, which
01:01:21
Speaker
If you look at Leon Cheto's work, then of course it ties in with a lot of the work in pain neuroscience from the perspective that the moment your anxiety level goes up, well then so does your autonomic nervous system switch.
01:01:37
Speaker
Yeah, absolutely. And very recently, the Zidane lab in San Diego, fatal Zidane, who's a neuroscientist doing a lot of work in mindfulness research, their group showed that slow deep breathing in the face of acute pain is actually
01:01:56
Speaker
better in terms of pain control than a single dose of morphine. Really? Wow. It's amazing. So clearly in experimental conditions, but clearly there is this inbuilt capacity
01:02:11
Speaker
to be able to deal with pain much more effectively than we have possibly been led to believe. Yes. Well, and this actually brings up a point that I wanted to raise with you is that, of course, you're training people in mindfulness as part of what you're doing.
01:02:30
Speaker
And so this, for example, there's the drill on your site with the feet, which is freely available to anyone who's got an internet connection. And isn't it amazing that so many of these things that are being found to be really important in terms of optimal management of a pain experience?
01:02:51
Speaker
are free you know it's things like meditation or mindfulness breathing sleeping you know those kinds of things moving you know absolutely don't need a gym membership to move um so yeah it's it's fascinating do you um do you get any resistance from your patients in terms of making these kinds of lifestyle changes or bringing mindfulness into their daily lives um
01:03:18
Speaker
I'm quite happy when people are sort of healthily skeptical when we start. And with some people, we might spend a lot of time talking about the neuroscience and the education and the how this works or the why this works. Ultimately, people have to experience it. So when you start with this work and again,
01:03:43
Speaker
Fadle's work shows that you can change people's experience with a relatively small amount of attentional training, mindfulness training. And that can be enough to get people's interest. Yes. May I share a very
01:04:05
Speaker
interesting story of a patient that we're working with at the moment. There's a lady who actually lost the lower part of her left leg in an accident. Right. And we've just started with the process. So she gets a lot of phantom limb pain. There's pain where the limb is no longer there. And a lot of what's called phantom limb sensation. Right. And we did a basic relaxation exercise the other week, which was that bringing the attention down into the feet just
01:04:32
Speaker
breathing away any tension and then gradually working up the body. And afterwards, I said I deliberately said feet, not foot, right? She has obviously a prosthetic lower leg. And she said, No, I'm really glad that you you did that. Because when I didn't tell you before, but I get phantom limb pain in my toes where my toes were, right?
01:04:57
Speaker
As I breathe down into it, I could feel the pain in my toes and the pain in the instep of my, where my foot would be. Yeah. And as I was instructed to breathe it away, it disappeared. Wow.
01:05:16
Speaker
So at that point I thought, well, okay, we're going to make some progress here. So we were both fascinated with the idea that not only was she feeling pain in the limb that wasn't there, but when she chose to breathe it away and let it go, it disappeared.
01:05:30
Speaker
Yeah, that's amazing. Which just shows the potential strength of the work and we've met a number of people with phantom limb pain and it's fascinating to see that you can make changes and that because that's very much
01:05:49
Speaker
cognitive reorganization in the brain, phantom limb pain comes from the brain struggling to understand why there's no feedback from this limb. And so by engaging in this work,
01:06:02
Speaker
you're actually changing the way that that system is operating. Yes. And would someone like that then potentially use that as an exercise themselves at home that they would take themselves through that same meditation? Yeah, absolutely. We provide guided narrations because it's important that people do this work for themselves pretty much day to day. The more
01:06:24
Speaker
If we want the system to change it's like getting fit. If we're going to do 10 bicep curls once a week, we're not going to strengthen our bicep very much. We start doing 10 bicep curls a day.
01:06:37
Speaker
then we're going to see some change. And we know from the neuroscience that in terms of mindfulness work, we're really looking for, you know, an optimum 20 minutes a day as a minimum, as a bare minimum really of focused practice.
01:06:56
Speaker
yeah okay okay and is there any risk of over training you know like there would be in the gym could people become obsessed with it have you seen that at all or is that not really seemingly a good question um you can't really over train it but i think you can end up striving to try and create change as quickly as possible which yes in that way you over train and
01:07:25
Speaker
it's not going to work. And I think sometimes people will do a lot of practice without necessarily good focus. And Tiger Woods said many years ago that his father had been very criticized highly for making him hit golf balls as a very small boy. And he said, but it misses one fundamental fact is the small boy's got to want to do it.
01:07:51
Speaker
and focus on it because anybody can stand there and hit golf balls, but if they're not focused, paying attention to it, they won't improve. Yeah, for sure. So it takes a bit of mental application in all of these, whatever these skills are that we're trying to learn. Yeah, it's a little bit like, I know Paul Chek has a phrase where he says, repetition is the mother of skill, so long as there's skill in the repetition.
01:08:14
Speaker
Right. Yeah, good. I like it. Yeah. But no, no, one of the one of the areas that I know that we've we've touched on. And I think that was essentially what we're just talking about was mindfulness based cognitive therapy. Is that is that what you were just describing with the lady with the phantom? That was relaxation based cognitive therapy is
01:08:37
Speaker
A derivation of mindfulness based stress reduction which was developed specifically to. Aid people with relapsing depression so the research was based on people who had had.
01:08:54
Speaker
three episodes of clinical depression. They were currently in remission when they were part of the research project. But by just adapting mindfulness-based stress reduction just a little bit more to the ruminative, repetitive thoughts that people develop with clinical depression, Teesdale and Williams were able to
01:09:21
Speaker
demonstrate that just short of 50% of the people that you train didn't relapse back into depression. And that is better than the drugs. And this is once you've learned it, you learn it and you practice it. It's self-care, it's self-help. No more treatment, no more prescriptions, no more trips to the therapist, just paying attention in this particular way.
01:09:51
Speaker
Yeah, that's amazing. And now there's a lot of research around pain. There's some very interesting research that's being done in the US to help people not over or abuse their narcotic opiate based medication for persistent pain. And the researchers there are showing some really interesting work that by doing this, people don't get caught up in the cues
01:10:21
Speaker
that make them abuse whatever it is that they're abusing. So you teach them mindfulness, which alters a subconscious drive.
01:10:34
Speaker
to take the substance. So they're unaware of the fact that you've altered this, but you see it because their consumption of the opiate decreases. Right. Right. Yeah. Rocket science. I think it's just extraordinary. It is. It is. Again, it kind of touches on the whole idea of the unconscious or subconscious functions, which, you know, I know probably it's an area of contention, but I've seen figures that suggest that the
01:11:04
Speaker
percentage of cognitive function that is conscious is actually very small. It's somewhere in the region. About 10%. Yeah. Or less, I've heard. So then a lot of our habits and a lot of our ways of being and thinking and behaving seem to be just regulated unconsciously, which is, which is, if you think about it, it's quite common sense because if you had to think about everything that you did, it would be a huge mental drain. So there's this... Unbreathed. Unbreathed. Unbreathed.
01:11:35
Speaker
Heartbeat. Yes. And I know that one figure that I saw is that the unconscious nervous system is able to process 40 million bits of information per, now would it be second or minute? I think it's per second probably. Yeah, it must be per second because... Yeah, it is. Yeah. And then the conscious is about 40 bits per minute. Absolutely. Per second rather, per second, yeah.
01:12:01
Speaker
So it's essentially about a million times quicker processor. So what aspects of what you're doing in your approach are working with the conscious mind and what's working with the unconscious? Is that difficult to say? I think it's slightly difficult to say but I think
01:12:23
Speaker
that the work of choosing to pay attention means that we're getting a glimpse of what's going on in our subconscious by the way that it's making us feel or think. So the sensations that we feel, the emotions that we feel, and the thoughts that percolate out from the subconscious. So by paying attention,
01:12:50
Speaker
it gives us a window of recognizing that, as I put it, my mind's down there rummaging through the garbage again. And so then I've got a choice about bringing my awareness back to a conscious level. This is what I'm going to choose to pay attention to.
01:13:10
Speaker
And another thing that I teach my patients a lot is from my own experiences, when I noticed that my mind's got very caught up in negative stories, pain, whatever it might be, I close my consulting room door at work or the bathroom door at home because it's the only place you can get some privacy in my house. Like most people, I guess. I'd say to myself, out lied. All right, Nicholas, what are you thinking?
01:13:36
Speaker
I'm known as Nick, but I was always Nicholas when I was in trouble as a little boy. So, all right, Nicholas, what are you thinking? Well, I know what I'm thinking, but I need to challenge it because it's no use telling myself not to think it because I already am. What are you thinking? Pause. Next moment. Second question. Is it helpful? Yeah. Well, I know the answer to that as well. That's why I'm doing it. But again, I'm now making myself aware
01:14:04
Speaker
that what I'm thinking in the context that I'm thinking it is not helpful to me. Now you're telling myself not to think it, so what do I do then? Well, just like we said, I close my eyes, I just drop my attention down into my feet. It's as far away from my head as I can get. Pay attention to the feet on the floor for maybe 30 seconds. Now I've got my attention back because if I can feel my feet on the floor or I can notice my breathing, I have to be in the present moment, I can't be anywhere else.
01:14:33
Speaker
So then that allows me to move on. And I think by doing this enough, it means that another of these networks called the default mode network in our brain, often called the me network, the thing that's chatting on about me and my life and what's wrong with it and why I should have done something else with it. When we practice formally, the default mode network goes quiet.
01:15:02
Speaker
When you stop practicing, when you've become a little bit skilled at practicing, the default mode network does not come back online to the same degree as it was before we did the practice. So this, we, we practice mindfulness to become more mindful, just more aware of our present moment situation. And then that potentially, I think decreases the drive
01:15:32
Speaker
from the subconscious, which is back to our ancestors. All our subconscious are really interested in three things, which is food, shelter, and a mate. Yes, yes, exactly. And watching for threats. Well, if I'm paying attention to my present moment, maybe there isn't any threat here.
01:15:54
Speaker
And therefore there's no need for my physiology to wind up to meet a threat which is more imagined and being driven by subconscious than its actual reality. Yeah, yeah, yeah. Fascinating.
01:16:09
Speaker
I think we've done five of the six. So the last A in your list of six is action. And I assume, is that fairly self-explanatory that it's really... It is, but I think it's a bit like we talked about focus, it's committed action. Yes. It's putting what we've learned into...
01:16:27
Speaker
um, into play and accepting the fact that we're not going to master it. You know, if we take somebody down to the basketball court and show them how to throw a free throw, we don't expect them to be able to peel off three baskets one after the other.
Mindfulness in Addiction Management
01:16:44
Speaker
So we have to be accepting that we're going to fail, but this is committed action to really towards values rather than goals.
01:16:55
Speaker
And I'm sure Bronnie would have talked a little bit about that. This is really about just moving towards the values of things that bring value and meaning and joy to us as individuals every day. And of course, they're different for everybody. Yeah. Yeah. And so that's where this sense of purpose is so important as well, presumably. Absolutely. Yeah. Yeah. Yeah. Critical, really. And do you coach
01:17:21
Speaker
your patients or clients through that? I mean, is that something that is a formalized part of the process? It can be. Again, we don't have a way to go process as in everybody goes through every step. We take people through as many steps as we need in order for them to
01:17:42
Speaker
be able to grasp what's going on and then put it into play for themselves. But yes, in some of the longer term cases or where people are really struggling to identify what their values are, because we get separated from them by pain and anxiety and depression, then yes, there's a formal
01:18:04
Speaker
a formal process that we can do to help people identify and even in group work can do the same thing, help people identify what their values are and then how they're going to take some action towards meeting those values.
01:18:18
Speaker
Yes, yes. Okay, okay. Great, great. Now I noticed in one of your papers, you referenced Daniel Siegel, who I'm a fan of, you know, read several of his books and listened to various audio books. And there are a couple of couple of things that I know he talks about that jumped out when you were talking earlier. So so one of them actually what we were just talking about in terms of when
01:18:48
Speaker
Well, he describes the different cortical layers, saying there's six cortical layers, and you've got information that can come descending through the top layers. And essentially, it's in the middle layers where we make sense of that information, or ascending coming up from the bottom layers. And so when it's coming descending through from layer six down towards the middle layers,
01:19:16
Speaker
What that is essentially coming through is our kind of filter of prejudgment, our experience, et cetera. But when it's coming up from the base, so when it's coming up through layers one, two, three, and reaching that kind of midpoint again, that's more like a kind of beginner's mind and more like a kind of, I guess, to me it seems to correlate somewhat with what we're attempting to achieve when we're using mindfulness is this sense of non-judgment.
01:19:45
Speaker
And is that something that you've thought about? Yeah, I thought you would have done. Yeah, and I think you summed it up quite well. If we're on automatic pilot, as we talk about, then that descending information can be very judgmental. It's all about my expectations and how this relates to me and my experience.
01:20:13
Speaker
And the ascending information is then processed against that backdrop. And we can come to some quite strange beliefs and perceptions about our existence by doing that. And mindfulness and sort of integration, as Dan would talk about, is really more about choosing and observing
01:20:41
Speaker
without the baggage of my previous experience to notice exactly what is. I don't necessarily need to be able to overthink this particular sensation or this particular input. And I think this ties in a lot with
01:21:05
Speaker
Stephen Porges theories of the vagus nerve and this the idea of what he calls neuroception that the Vegas is basically sending information up our gut sensation. And then it's the processing of the brain that turns that into something that
01:21:27
Speaker
potentially we find very stressful. Right. Yeah. Yeah. Makes sense. Yeah. And I suppose the other thing that I was thinking of in relation to Dan Siegel's work is he makes a comment. I'm sure he's not the first or the last person to make the comment, but he says that the brain is the one thing that can grow itself by thinking about itself.
01:21:52
Speaker
And I was actually listening to a podcast with Dawson Church last week and he's, I don't know if you've heard of him, but he's written a book called Mind to Matter and he's got some stats and these are just from my memory recall, so I might be slightly off, but he was talking about doing
01:22:10
Speaker
a group that did meditation just for 14 minutes, one four, 14 minutes, I don't know why 14, but that was the duration, and across an eight-week period.
01:22:20
Speaker
He said, they saw growth in various structures within the brain. And unfortunately, my memory is not good enough to remember exactly which structures they were, but they're related. In general, you start to see a little increase in the gray matter. In the gray matter, right, yes. But he said one of the structures, which in particular is associated with a sense of well-being and happiness, grew by 24% in eight weeks.
01:22:46
Speaker
Wow. And he said, this is just extraordinary. And I'll have to again, I'll have to dig that out and put it in the show notes so that people can can actually look into it if they're interested. But it just struck me that I mean, even if those figures were slightly overinflated, you know, that's still incredible that you can grow the brain through thinking in a certain way and using a certain. Yeah, absolutely. They did some
01:23:10
Speaker
studies at University College in London of London taxi drivers doing the knowledge and they did some brain scans at the point that they started and then at the point where they finished the knowledge and takes them about three years and you could see an increased volume of the hippocampus in the brain and this is the area that's associated with navigation.
01:23:31
Speaker
So as they were learning the hippocampus, they were exercising, it was growing. And within reason, the longer somebody carries on driving a London taxi cab, the greater the expansion of this area in the brain is. We talk about it being a remarkably plastic structure, it does it, it evolves and it changes.
01:23:55
Speaker
quite literally with every experience that we have, which is why this idea of being careful about what we pay attention to makes so much sense because if we spend a lot of time paying attention to lots of negative things going on in an environment or a lot of negative self-referential thinking, well then we're just growing and strengthening that area of our brain, it makes it easier for us to do it. Yes, yes. So where do you see...
01:24:22
Speaker
I was going to say it just happens so quickly. If you blindfold somebody so that you take all the light out of their optic nerve, the visual cortex starts being recruited by other areas of the brain within 24 hours. The brain kind of goes, we've got this huge chunk of computing power that's idle.
01:24:43
Speaker
Let's shift it and do something else with it. Yeah. Yeah. I was going to ask, you know, where you see your work overlapping with spiritual, the spiritual kind of side of life, people developing either spiritual philosophy or following spiritual pathways, because much of the advice that has been passed down that, you know, people talk about wisdom, traditions, this kind of thing.
01:25:10
Speaker
And of course we know about the religions as well and we know that there's issues with some religious thought but that equally there's a lot of wisdom interwoven in there as well. So how do you see your work integrating with that side of things? I refereed a paper a few months ago where somebody was talking about, the authors were talking about the biopsychosocial model
01:25:38
Speaker
rather ignored the spiritual aspect of somebody's existence. And I tended to actually disagree because I don't think that it does. It's about attending to our experience as it is. And that these practices in this work will allows us to pay more attention to the things that are meaningful to us. And if that happens to be a spiritual belief,
01:26:06
Speaker
then that's fine. So we'll often say that these types of practices, if you have very strong spiritual beliefs, will potentially enhance them, not detract from them at all. And I'm very careful to point out that I do this work very much from a neuroscience pain perspective.
01:26:31
Speaker
not from any other perspective at all. This is all about what the science and the research tells us that we can achieve by utilizing these approaches.
01:26:43
Speaker
But is there a danger in some people's belief systems? I guess this is where you could get very controversial because of course it is by its nature judgmental. But if you've got a belief system that disempowers, and this was the point that I made in the Ghost in the Machine papers that I wrote, was that
01:27:04
Speaker
A lot of our traditional, you know, monotheistic religions, of course, place the locus of power outside of the individual to an external authority figure in the sky. It's unseen, you know, and, and it's quite paternalistic through the storytelling, quite paternalistic and quite forceful. And, you know, you could even say vengeance in some of the stories. Yes. Yeah.
01:27:29
Speaker
And even though I think many people that have been through the formal education, they could perhaps look at some of those stories and decide for themselves whether or not they sound plausible, whether they sound helpful. There is this kind of underlying current of
01:27:49
Speaker
beliefs that have been passed down across the generations. And this kind of comes back into the whole biopsychosocial thing is that you've got a whole society, if we were to take the UK as an example, you've got a whole society there that was based on, you know, a Christian belief system, and all of those values
01:28:06
Speaker
even though they are not explicitly described as necessarily, you know, coming from the Bible, a lot of those, a lot of those values are still present implicitly in our behaviors. And I think there's been quite a lot of research into that, which, which shows that as some of them are probably not that helpful to us.
01:28:27
Speaker
No. And I think, you know, pain science, for many years, was seen very, very strongly through the lens of Christianity. Really? Okay. Yeah. So it is it's intertwined in all of these things. And my, my kind of view of it from an individual perspective is and you know, in the pain science, we, you can see,
01:28:50
Speaker
people discussing the idea that praying or, as you say, putting your belief in a higher power is what's known as a negative coping strategy. But I think it depends how you do it. Yes. So I generally
Respecting Patient Beliefs and Conclusion
01:29:12
Speaker
believe that we have to meet our patients where they are, and who they are. And at the moment, and we're a very diverse multicultural society in New Zealand like you are in the UK now. And I
01:29:27
Speaker
I've had the fun of meeting people with strong Muslim and Islamic beliefs, which I really knew nothing about. And we've had some very interesting conversations interweaving their faith with the work that we do within a pain context. And I've learned a lot and learned to respect their beliefs, but I wouldn't challenge them.
01:29:55
Speaker
Yes, it's about trying to make...
01:29:59
Speaker
a sensible pathway that is coherent and makes sense for that individual to be able to move forward. Yes. Because it could be equally as destructive to question their faith or because essentially then you're questioning again on the biopsychosocial level, you could be ostracizing them from their tribe essentially. Yeah, you're not you're not validating their experience.
01:30:26
Speaker
I think the difficulty can be when people see pain as somehow as a judgment on them. And so again, that has to be carefully and culturally considered as part of a biopsychosocial
01:30:47
Speaker
yes approach and you know gently tested where it it can be but not dismissed out of out of hand yeah yeah okay so i guess linking in with this to some degree is the idea that your work can be preventative because if you've got the right kind of models in place in your mind
01:31:12
Speaker
and you can practice this mindfulness. As you say, you engender the neuroplasticity and then the life experiences associated with an altered outlook on life.
01:31:29
Speaker
How much have you attempted to apply this preventively? Because I think in your reports, don't you mention about prehabilitation? Yeah, again, there is some evidence that if you can modify people's beliefs, particularly if they're going towards some kind of orthopedic procedure, and there are a number of factors which
01:31:56
Speaker
are obstacles to their recovery, if you can modify those factors.
01:32:04
Speaker
before they have the intervention, then clearly you're gonna help them recover afterwards. Yes, yes. It's actually much easier to teach people some of these skills if they don't have a backdrop of a lot of life stress or a lot of pain or distress in their life. And that was one of the things that drew me to the mindfulness in schools charity in the UK.
01:32:29
Speaker
Yes. There's a very large study going on in the UK at the moment, the Myriad study, where the charity has just taught three and a half thousand, 11 to 14 year olds, the 10 week course, and another three and a half thousand acting as the control group. And it's been funded by the Wellcome Foundation, and they're being followed for seven years. Right.
01:32:55
Speaker
and they're looking at outcomes in terms of mental and physical health and wellbeing, academic achievement, interaction with the criminal justice system. So a whole range of different outcomes. And so what they're essentially looking to see is, so if we teach people these skills in adolescence when the brain is going through this massive rewiring process, can you set them up
01:33:23
Speaker
for different experiences as they move into adulthood.
01:33:28
Speaker
Yes, yes. Fascinating. It is fascinating. It'll be very, very kind of interesting to see where that goes when and what comes of it because there have been some other studies like this, which have shown quite incredible in the real sense of the words, you know, you wouldn't give it credit if someone suggested to you results. And so, yeah, I'll really look forward to hearing more about that. So I guess that's going to be what sort of year would that be 2025 to 2025? I think
01:33:58
Speaker
going to be publishing the results as they sort of come to hand. The pilot study that was published in the British Journal of Psychiatry showed that the pilot group
01:34:12
Speaker
They particularly looked at their stress levels around the end of year exams. And they found less, less stress, less anxiety, clearly enough to make us say this needs to be looked at. Right. Yeah, over a longer period with a highly powered trial.
01:34:32
Speaker
Yeah, that's very exciting, isn't it? Yeah, absolutely. Yeah, yeah. Yeah. Excellent. Excellent. Well, maybe we'll have to if podcasts are still a thing in six or seven years time, we might have to do another one. Fantastic. Well, Nick, I know it's getting late there for you. So so let you head off. But if people want to get hold of you, where's the best place to? Well, I know your site, but do you want to just shout out the URL?
01:35:04
Speaker
It's quite simple. DrNickPenny.com. I don't look at it very often myself. Let me look. I will tell you because I was on it earlier. It's DrNickPenny. It's DrNickPenny. N-I-C-K-P-E-N-N-E-Y. That's it. You got the spelling right. I've been practicing a lot.
01:35:30
Speaker
Yes, fantastic. Well, thank you so much for sharing all of this, you know, really fascinating information. I'd love to have gone on for another hour or so. I just was aware that the time was creeping late. But yeah, hopefully our paths will cross. I'm out in New Zealand in March. So who knows? We may get to cross paths then. Absolutely. Look us up. Yeah, that'd be great. Thanks so much for your time. You're welcome, man. Cheers, Nick. Bye bye. Cheers. Bye bye.
01:36:02
Speaker
Well, I think you'll agree another fascinating series of insights from a master in their field, helping us to identify order from the chaos. And I think what really impressed me the most is that Nick's work really achieves that, not just in his theories, but in the results he gets with his clients, which you can see in the show notes on mattwarden.com.
01:36:21
Speaker
By now you may have gathered I will be in Nick's stomping ground Auckland in March 2020 to explain how mindfulness, the biopsychosocial approach and many other modern clinical modalities can be contextualised and prioritised by being placed into a larger evolutionary model.
01:36:37
Speaker
As John Holland says, a good model repays decades of research and provides accurate predictions into the indefinite future. So that's what I'll be presenting, hoping to contribute my two penithworth to help move us from chaos towards order. Bye for now. See you at the next show.