Tune in the part two of this interview with President of the Psychophysiologic Disorders Association, Dr. David Clarke. In this episode, he highlights the value of self care and talks about the benefits of emotional awareness and expression therapy.
“All of us need that ability to put ourselves on the list of people we take care of.” -Dr. David Clarke
In episode 164, we hear part two of Dr. Jen Barna’s fascinating interview with Dr. David Clarke. In the second part of this interview, Dr. Clarke explains why self care is so very important in our lives. He also highlights the importance of processing our feelings in order to prevent and/or treat stress induced illness. Then, he answers Dr. Barna’s question on how to explain the Boulder Back Pain Study to people who have questions about it. He speaks about the paradigm shift in pain management due to the effectiveness of Pain Reprocessing Therapy and its implications in healthcare.
Dr. Clarke is a gastroenterologist, President of the Psychophysiologic Disorders Association and author of They Can’t Find Anything Wrong! Psychophysiologic disorders are somatic illness symptoms induced by hidden stressors. When he began his practice as a GI doctor, Dr. Clarke noticed a large number of his patients had symptoms, some so severe they resulted in multiple hospitalizations, with no identifiable underlying cause. This observation was the beginning of his journey toward identifying these patients and connecting their physical illness with hidden stressors, and then treating them with what is known as Emotional Awareness and Expression Therapy with tremendously successful results.
David D. Clarke, MD is President of the Psychophysiologic Disorders Association. He is also Assistant Director at the Center for Ethics and Clinical Assistant Professor of Gastroenterology Emeritus both at Oregon Health & Science University (OHSU) in Portland, Oregon, USA. As Faculty Associate at Arizona State University and at the Cummings Graduate Institute for Behavioral Health Studies, he teaches graduate courses on Psychophysiologic Medicine. His book for patients, They Can’t Find Anything Wrong!,(Sentient Publications, 2007) was praised by a president of the American Psychosomatic Society as “truly remarkable.” He was also the lead editor for the professional textbook Psychophysiologic Disorders (KDP Publishing, 2019) which has sixteen contributors from five countries.
He is board-certified in Gastroenterology and Internal Medicine and practiced Gastroenterology in Portland from 1984 to 2009. During that time he diagnosed and treated over 7000 patients whose symptoms were not explained by diagnostic testing.
Dr. Clarke is a graduate of Williams College (Phi Beta Kappa) and the University of Connecticut School of Medicine where he received the Mosby Award for Clinical Excellence. He completed internship and residency in Internal Medicine and fellowship in Gastroenterology at Harbor/UCLA Medical Center in Los Angeles. He has been a Visiting Professor at the Royal Children’s Hospital in Brisbane, Australia and at Oxford University in England. Dr. Clarke has lectured extensively on Psychophysiologic Disorders to health care professionals and the public across North America and in Europe. He has appeared on over 100 television and radio broadcasts throughout the U.S. Dr. Clarke’s websites are Stressillness.com and PPDAssociation.org.
If you are interested in learning to diagnose and treat PPD patients, here is Dr. Clarke’s advice:
There are numerous options now for any physician (even a psychiatrist) to become skilled at PPD diagnosis and treatment including books, online courses and recorded or live conference presentations. The http://EndChronicPain.org/ website has access to many of these. As one Family Physician put it, “these ideas put the joy back into my practice.”
Some references related to Emotional Awareness and Expression Therapy and Pain Reprocessing Therapy:
They Can’t Find Anything Wrong!,(Sentient Publications, 2007)
Psychophysiologic Disorders (KDP Publishing, 2019)
The Curable App: https://www.curablehealth.com/
A documentary film about a radical cure for chronic pain
THIS MIGHT HURT
How therapy, not pills, can nix chronic pain and change the brain
Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial
Yoni K Ashar et al. JAMA Psychiatry. 2022.
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Podcast produced by: Amanda Taran
Please enjoy the full transcript below
Dr. David: All of us need that ability to put ourselves on the list of people we take care of.
Jen: Welcome to DocWorking: The Whole Physician Podcast. I’m Dr. Jen Barna, founder and CEO of DocWorking and cohost of the podcast. Thank you so much for joining me today, where I’ll be continuing my conversation with Dr. David Clarke, president of Psychophysiologic Disorders Association and lead editor of Psychophysiologic Disorders, a monumental publication from 2019 that was written for healthcare providers and is often prescribed for patients. His seminars to healthcare professionals have been described as life changing in the field of diagnosing and treating unexplained physical illness caused partly or completely by hidden stressors.
If you haven’t heard Monday’s episode with the first part of my conversation with Dr. David Clarke, please take a look back and listen to Monday’s as well. And thank you for joining us today. Dr. David Clarke, welcome back to DocWorking: The Whole Physician Podcast and let’s continue the conversation.
Dr. David: Thank you, Jen. It’s great to be with you.
Jen: One thing that we talk about fairly often on the podcast is those types of tendencies leading to perfectionism, and guilt, and shame, which may lie around this tendency to care for others and neglect oneself. When you’re talking with healthcare providers or others, who have those types of personality traits, what would you suggest that someone could do if they identify that in themselves and consider themselves to be at risk?
Dr. David: Well, those character traits, we need them to be good professionals. It’s only when we’ve taken them too far, when we have difficulty putting ourselves on the list of people we take care of, that it can lead to physical symptoms and other problems. If it’s gone that far, then I ask people to look back to when they were growing up to see if they, at that time, might have learned things about themselves that aren’t true to me. Did they learn that it was their job to focus on the needs of other people in their household to the exclusion of themselves? Kids need to have time to be selfish. They need to have time to do nothing, but focus on their own needs, to spend time in activities that have no purpose but their own joy. When something stops being joyful, they drop it and move onto something else that gives them joy.
When kids are doing that, they are learning self-care skills that turn out to be essential for us. If my patients, who are healthcare professionals can look back and see that they were characteristics in their early environment that prevented them from learning those skills, that can help them recognize that that’s a skill they need to learn. All of us need that ability to put ourselves on the list of people we take care of. And then I ask people, “If you’re going to learn how to do this, you need to carve out some time.” And ideally, regular time, every week, for several hours, if you can, a full afternoon, probably even better, and just to do some trial and error to get out of the house and do something that you think will be fun. If it turns out, well, it wasn’t fun, that’s okay. You’ve still learned something about yourself that you didn’t know before. And that will inform you the next time you try something.
One of my patients was a champion athlete as a girl, but she did her sport before school, after school, and on weekends from age four to age 18. She never really got to be a kid, just to have some time to be carefree and self-indulgent. As an adult in her early 30s, she was working full time, her husband was working full time, had two kids, she was coaching the two kids in her sport, she was coaching other people’s kids in the sport, she was on the board of directors of the Athletic Club, and she was driving kids to out of state competitions. I asked her, “What she did for fun?” She really had to think about it. Maybe she got out to the movies with her husband every other month. There just wasn’t any space for her and she just finally hit the wall with it and developed acute abdominal pain. I met her for the first time in the early hours of the morning in the ER. All the diagnostic tests had been normal and they didn’t know what to do next. It turned out the solution for her was to take an afternoon a week just for herself. But she had to overcome some guilt about that, just the very concept that she was going to do something for herself was a foreign idea and she couldn’t think of much to do except for going for a walk in a park. Just the idea, “What am I going to do with that time, a whole afternoon a week? I don’t know anything fun to do for myself.”
But while she was walking, she was thinking and eventually, she hit upon the idea of taking piano lessons, which was a surprise, because she’d never done anything musical before, but she absolutely loved it and that was the key for her. Her pain went away after that, she had learned how to do something with no purpose, but her own joy. Whenever her stress level got too high in the future, she had that activity she could call upon. It’s a process. It takes time. It takes many of my patients months to learn how to do this. But once they learn that skill, they’ve got it for life.
Jen: From what I understand, a number of the patients that you described have been through multiple providers who have been unable to identify what is causing their problem and they have often come to you feeling that they’re at the end of their rope? My one question is for those who might be listening, who have had a similar experience like that and have not encountered a provider who could help them identify a solution, which potentially may be related to a stress-induced illness, what do you suggest for them in terms of finding a way out?
Dr. David: Well, there are fortunately a ton of resources out there now that I didn’t have access to when I was starting in this field. But the Psychophysiologic Disorders Association is a nonprofit that I chair and we have an online webinar-based course on there. It’d probably take about five hours to go through and that can bring clinicians up to speed on these areas. But we deliberately kept it jargon free, so that patients can use it as well. This being the 21st century, there’s an app now, it’s called Curable. Their website is curablehealth.com, and they have scooped up myself and most of my colleagues that do this work and have experience with it, as scientific advisors, and they’ve been very good about putting only evidence-based concepts into their app. The user interface is very easy to use and they’ve been getting excellent results with that, many people find it helpful.
There are a number of evidence-based books out there. My own, obviously, we’ve mentioned, but there are a number of my colleagues that have written books as well and we list those on the PPD Association website. One of the links, it’s easier to remember, is endchronicpain.org and there are resources on there. The textbook, in fact, Psychophysiologic Disorders is also written without jargon, so the medical people can read the psychological stuff, and vice versa, and not get lost. Because it’s jargon free, the more scientific oriented patients out there can also read it. Many of them prefer it to some of the other books, because they liked the science.
There are lots of ways to learn to incorporate this into your practice. Because one of my patients said, I think I mentioned this earlier, that it brought joy back into her practice to be able to have success treating this population. At the beginning, you’re not going to be all that good at it. I was, I’m sure, terrible at it. I would hate to have to watch myself 40 years ago struggling with this patient population, even having had a framework taught to me by a psychiatrist at UCLA. I was getting decent outcomes, but it was still very, very difficult to think my way through this. But it’s like anything else in medicine. The more you do it, the better you get.
Jen: As you’re teaching up and coming healthcare providers in different areas of professions within healthcare, are you seeing that this is now being incorporated into medical education in a way that it wasn’t in the past? Because as you mentioned, you weren’t trained in this area, I wasn’t trained in this area, and from what I have observed in conversations with other providers and people in this field, many of us were not trained. So, I’m hoping that perhaps this is starting to shift.
Dr. David: Yes, it finally is. We’re finally reaching a tipping point. In medicine, if you want to change practice, you need to have research. In order to have research, we had to convince the researchers that this was a valuable approach. Just really in the last five years, we finally have randomized controlled trials, including one in Boston that was published last September, and another one, the Boulder Back Pain Study from Colorado, and a few others as well that have used these techniques, and they’ve achieved better outcomes by far than cognitive behavioral therapy, than placebo injections. But a whole bunch of different control groups have been tested against this. The impact of what we can call Emotional Awareness and Expression Therapy or another term for it is, Pain Reprocessing Therapy, these have a lot of overlap with them, the impact of these is just far and away better than what’s been available before. That’s finally convincing people to not only incorporate this into their practice, but to add it to medical education. So, we’re definitely seeing a tipping point and I’m looking forward to more randomized control trials stimulated by these first four or five that have been published.
Jen: Yes, absolutely. And one question that I’ve had come up in discussions with people about, for example, the Boulder Back Pain Study that came out, Alan Gordon-
Dr. David: Yes.
Jen: -was involved in, that has been, what is the difference between the placebo effect, and the Pain Reprocessing Therapy effect, and how do they differentiate between those? I wonder if you might be able to help me better answer that.
Dr. David: Well, there certainly was a difference in the outcomes of the patients. The average pain scores started out around four or five. And in the Pain Reprocessing Therapy group in the Boulder Back Pain Study had dropped to about one and it dropped maybe half a point in their placebo control group, which was pretty powerful. It was an injection into the spine. Short of surgery can’t get a much more powerful placebo than that and yet it had almost no impact. Psychological treatment, which was just eight sessions, it was two sessions a week for four weeks, not only did it drop the pain scores to one by the end of the month, but the pain score was sustained. It stayed at one for a full year of follow up. So, what is going on that this new form of psychotherapy is so much better?
It gets back to the idea of expressing emotions in words. People have a lot of fear about the damage that’s going on to their bodies when they’re experiencing these symptoms, because they don’t understand the process. But the key concept is that, yes, a lot of symptoms are generated at the place in your body where you feel them, but there’s a whole other category, which is symptoms that are generated in your brain and they are generated there because the neuroanatomy is different, and we’ve seen this in fMRI studies of groups of patients with fibromyalgia, for example, or irritable bowel. When you inflict pain on them, the area of the brain that lights up is different than what lights up in healthy people under the same circumstances. So, there are actual neuroanatomic differences that underpin this and the Boulder Back Pain Study did before and after MRIs on the brain and found that the brain actually changed in response to psychotherapy. Just by talking to people, we are changing the way their brains are wired, so that they’re not experiencing the signals from their body as pain nearly so much anymore.
Why is that the key for me? What I’m seeing, and I’ve seen a number of videotapes of the psychotherapy sessions, is again this idea of taking emotions that people didn’t recognize were there and putting them into words. Reducing their fear level about their symptoms is one, but also giving people a chance to think about what might be going on psychologically, what emotions they might have about people from their past or present that they can now talk about, use their cognitive skills to process better, makes a huge difference.
You’re getting at the real root cause of these patients’ symptoms in a way that hasn’t been done before. The outcomes that you see are just extraordinary. I don’t always cure people with a one-hour conversation, but even the people that take longer, they know they’re on a pathway. They know that they are finally on the road to recovery and their healthcare utilization tends to go way down after that.
Jen: Yeah, it is remarkable. In the wake of the opioid epidemic-
Dr. David: Absolutely.
Jen: -and the devastating effects of that, which I think relate to our training, uninformed training and treating pain and chronic pain with opioids. This is revolutionary and can really change the lives of so many millions of people. So, thank you so much for coming onto the podcast and talking with me about all of this. We will link in our show notes to all of these various resources that we’ve discussed, so that if you’re listening, you can easily check out the show notes and click to explore all of these different resources that Dr. Clarke has described to us. Thank you again, Dr. Clarke, for taking the time to come and talk with us today.
Dr. David: It’s been a pleasure.
Amanda: I’m Amanda Taran, producer of DocWorking: The Whole Physician Podcast. Thank you so much for listening. Please don’t forget to like and subscribe, and head over to docworking.com to see all we have to offer.