#62: Understanding Pain and Pain Management with Dr Amber Johnston

Ever wonder how chronic pain impacts not just your body, but your mindset and life? 

This week I'm joined by Dr. Amber Johnston, a leading Clinical Psychologist and Neuropsychologist, to unpack the science behind pain. We talk about breaking the cycle of fear and avoidance, how stress amplifies pain, and practical steps to reclaim your life. 

Whether you’re battling pain or supporting someone who is, you’ll gain actionable strategies to feel empowered and hopeful again. Listen in and discover how changing your relationship with pain can change everything.

Highlights include:

04:13 Acute vs. Chronic Pain
08:26 Chronic Pain's Impact on Social Plans
11:36 Subjectivity of Pain Perception
15:49 Brain's Complex Pain Processing
18:59 Perception's Role in Chronic Pain
22:10 Understanding Fear Avoidance Cycle
25:21 Rethinking Pain Signals
30:18 Impact of Lifestyle on Health

Want more?

Head over to Hello Therapy's Substack for an EXCLUSIVE mini interview where I ask Dr Amber why she specialised in pain and what her personal, go-to pain management strategy is. Watch HERE.

This week's guest:

Dr Amber Johnston, a practicing clinician specialising in Clinical, Health, Pain Management, and Neuropsychology, offers her expertise to individuals facing a broad spectrum of challenges - from those with mild stress looking to build healthier emotional tools, to those with more significant clinical diagnoses that need formal, specialised treatment. Amber also works with individuals who do not meet clear psychological or medical diagnosis, those requiring cognitive assessment or emotional support following a neurological injury or stroke, those with complex chronic medical conditions, and those with medically unexplained symptoms/Functional Neurological Disorder including health anxiety. In her capacity as the founder and director of Healthy Mind Psychology, Amber leads a team of over 26 doctoral-level Psychologists. Her mission is to expand understanding of the mind/body connection and emphasise the important message that psychological understanding is important for everybody.

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The Hello Therapy podcast and the information provided by Dr Liz White (DClinPsy, CPsychol, AFBPsS, CSci, HCPC reg.), is solely intended for informational and educational purposes and does not constitute personalised advice. Please reach out to your GP or a mental health professional if you need support. 

Transcript

Dr Liz White 0:02

If you're looking to improve your mental health and well-being, then keep listening. I'm Dr Liz White, a consultant clinical psychologist with over 20 years of experience. Whether you're a frazzled parent, a stressed out professional or finding your way through the challenges of midlife, you're in the right place. Through a mix of solo episodes and insightful conversations with expert psychologists and therapists, I'm bringing you evidence-based tools and strategies to help you navigate life's ups and downs with confidence, clarity and compassion. With confidence, clarity and compassion this is your space to feel seen, supported and empowered. Welcome to Hello Therapy.

Dr Liz White 1:01

If you have ever experienced physical pain for any length of time, you will know just how difficult it can be for your body and your mind. This week, I'm chatting to Dr Amber Johnston, clinical psychologist, neuropsychologist and founder of Healthy Mind Psychology. We explore the complexities of pain and the psychological impact of living with chronic pain. Amber explains how pain is processed in the brain, how psychological factors influence the perception of pain and how this understanding can help in the management of pain day to day. I personally found our conversation fascinating and I'm sure you will too. Please share with anyone you know who is living with chronic pain, as there are so many great insights and tips in this episode. Don't forget to check out an exclusive mini video interview with Amber over on Substack, where I ask her, amongst other things, what she would never do if she herself experienced severe pain. The link is in the show notes, so let's dive in. So, amber, thank you so much for joining me on the Hello Therapy podcast. It's great to have you here.

Dr Amber Johnston 2:14

Thank you for having me. It's great to be here finally.

Dr Liz White 2:17

I know we've been trying to do this for quite a while, so, yeah, it's great to have you here. So we're talking this week about all things pain. I haven't talked about pain yet on the podcast, but before we get into that, do you want to tell our listeners who you are and what?

Dr Amber Johnston 2:34

you do. Sure, I'm Dr Amber Johnston. I'm a clinical psychologist and work in neuropsychology. So I have worked for many years in brain rehabilitation for those with accidents, injury, stroke, that kind of thing. But I came into private practice about five years ago or so and within that have really specialized for those that are still within hospital systems, that are having a whole host of different medical conditions that potentially have a stress element to them or just the fact of going through treatment and diagnosis and everything else. The psychological impact, the impact on family, that's what we really specialize in. But then we see a whole host of other things and there's a lot of trauma that comes up.

Dr Amber Johnston 3:20

So I do work especially with EMDR and trauma-based practices brilliant, okay, and I'm sure there's lots of trauma in the pain experience as well indeed, pain is traumatic for anybody, and those in particular that have had a serious injury, an accident, a surgery, those who have not followed the traditional medical expectation of recovery, all of that can feel very traumatic because pain is an alert in our brain. It's telling us something is wrong.

Dr Liz White 3:55

So if we keep getting those signals, that feels traumatic for somebody going through it so can you give us a bit of context, because there are lots of definitions that I think get banded around. So can you tell us the difference between chronic pain and acute pain?

Dr Amber Johnston 4:15

Sure, I mean acute pain. There is some different ideas of when that line is, but normally we expect if we've had an injury, if we've had a surgery, if we've had something happen, there's a normal expectation to get better and across the board we generally say three months or so. Now that might be different depending particularly on the specific of that individual and their condition, but in a generalized sense, three, maybe up to six months of, you know, expecting a recovery to happen in a way that can be predicted. And normally the guidance during that acute medical phase is you need to rest, you need to let your body restore, you need to do all the things that your body needs to help the immune system go through that recovery process, that your body needs to help the immune system go through that recovery process.

Dr Amber Johnston 5:08

So when something then starts to become chronic is when we've passed over that time period or when there isn't necessarily a clear precipitating factor that began the pain experience. So those are some of the things that start, meaning that we're in this different phase and actually a chronic pain is something that is very different, in terms of how we manage it, than what we would be advising with acute pain, and that's where things can go really wrong, because some people who are going on and on and on with their pain experience might still be using acute pain strategies and end up in a long termterm condition of avoidance of resting but finding their life very empty, losing their ability to exercise, they're not sleeping well and there's a whole host of different things that happen then when we're using the concepts we learn basically as children for how to deal with acute pain when we're in a chronic pain condition.

Dr Liz White 6:06

Yeah, and obviously the. The impact on mental health is huge when you are experiencing chronic pain. So when you've been in pain for many months and what you're saying, there is a, there is a line, isn't there of a. You know, the six month mark maybe, but I'm guessing that's quite arbitrary sometimes, but it's very arbitrary.

Dr Amber Johnston 6:29

Yeah, again, we're kind of not trying to really pinpoint where that spot is. You know, if somebody has been having, you know, three, four or five months in recovery, we're still going and, and you will see that shift in the medical community too. You know physiotherapists getting involved, you know they will start to be pushing, to be doing more, so coming away from just the rest and restoration back into you come and let's. Let's see what we can do, let's see how we get the body moving again. Um, sorry, I've interrupted no, no, no, no.

Dr Liz White 7:02

It's just really interesting because I was just thinking that I've worked with a lot of clients over the years who have had injuries, say, and are, yeah, many months, sometimes years, into their post-injury chronic pain experience, and there is definitely there can be a bit of a vicious cycle that can get set up, isn't there? You mentioned avoidance before, but can you tell me a little bit about the mental health impact? I know this is a huge question, but just off the top of your head, you know, how does chronic pain affect mental health and vice versa?

Dr Amber Johnston 7:38

I mean it affects it in every aspect because it's going to be everything from sleep being disrupted. That's a big one. If we're not getting the proper sleep, we do not have the energy and the resources to be able to do our best with our management of emotion or with other condition. It affects our sense of identity. A lot of people feel that they aren't who they used to be. There's a lot of sense of loss, grieving a previous life that they used to lead, that they now can't do things. So a lot of the paying clients that I work with are rethinking things like career, thinking what kind of role they can play in society. What are they capable of doing. It often affects people socially. I mean.

Chronic Pain's Impact on Social Plans

Dr Amber Johnston 8:21

One big thing with that is that people say I can't predict if I'm going to be okay enough to go out. So if somebody's saying you know, let's make plans for Saturday evening, I have no idea how I'm going to feel Saturday evening. So people will often say so I just say no because it's better than constantly canceling on people, which is such a shame, because you can empathize with why they wouldn't want to feel like they're messing someone around, but at the same time, if you're just predicting you're going to be in pain. You know that has a big role in our pain experience and we can talk about that in a minute all the brain and the pain, but I think also then the fact that your body is in this hyper state. It's going to be in a hyper intensive state as it's managing the signals that it's interpreting. So you're going to be using a lot of energy and resources just by the management of interception what's happening, the feelings of what's happening inside. So in a lot of ways, people completely lose what life is supposed to look like, how they feel they can or can't participate, the concept of engagement and what that looks like.

Dr Amber Johnston 9:22

But I think most importantly, people think I don't look like I'm in pain. I don't look like I'm sick or ill. So there's this concept that people are incredibly sensitive to, which is who's going to think that it's all in my head, or that I'm making this up, or the concept of an invisible illness. You know you can't show and I will have chronic pain. People say I wish that you know my arm was cut off because then you could see that there is a problem, as opposed to me walking around and having the fact that chronic pain is not consistent necessarily, so you'll have good days and bad days. So people will see you on a good day and have no idea what bad days look like. So I think that's another part that becomes really challenging for for somebody in that condition oh, it does, doesn't it?

Dr Liz White 10:15

and I was just reflecting there on I? I had a couple of years of pain from a back uh prolapse disc and it was not fun and it was very, very painful and the thing that I experienced a lot was hopelessness, like not knowing is this going to get better? Am I going to be left like this? How's that going to impact my work, etc. Etc. And that uncertainty can be really tough, can't it as well?

Dr Amber Johnston 10:44

definitely and that's kind of what I'm saying about the friend stuff people feel like how do they make plans, how do you know what the future can hold for you when you're dealing with that uncertainty? So that can be really tricky for people to have hope when they feel like they can't just put things in place.

Subjectivity of Pain Perception

Dr Liz White 11:01

That yeah so so can we touch a little bit on. Obviously you're a neuropsychologist, so you know all about the brain and and pain. So, um, one thing I wanted to think with you about is this idea of high or low pain tolerance, because that is something that I think does get talked about. This idea of, oh, you've got low pain tolerance or high pain tolerance, is that? Is that even a thing um and and or what can explain people's differing experiences or perceptions of pain? I mean, it's I.

Dr Amber Johnston 12:16

I don't want to just definitively negate something, but pain is all about interpretation. Pain is all about context, understanding, signaling and so many other factors about what's happening within the body. It's subjective and that is the definition of pain, is that it's an unpleasant sensory sensation, but that is subjectively understood, which means we are completely unable to compare one person's pain to another. And it's funny because we have those little checkboxes that you go to a doctor and it's on a scale of one to 10, what's your pain? And people have no idea how to fill those out. So they can kind of fill it out based on comparisons with their own experience, but then might feel really invalidated that they feel really their pains of four, but that four is probably like a 10 to their partner who's not used to it.

Dr Amber Johnston 13:15

So is that a difference in pain tolerance or is that simply that somebody has learned some strategies so their confidence in managing pain might lead to a higher pain tolerance?

Dr Amber Johnston 13:26

And I guess that's where we try to help people is not about putting some kind of label or judgment on it, but simply, you know, what is it that can help make your tolerance of your experience move, that dial up a little bit or down a little bit, and are there's little ways that we can see what happens naturally in our day to day that might move it up or move it down and and encourage that and it's it's all about one's own perception of that and within that too you might be getting similar signals. But when you are exhausted, when you're ill, when you don't have the resources, when you are exhausted when you're ill, when you don't have the resources, when you're low, you're not necessarily that there's. There's studies will show that in those circumstances people report of a painful stimulus is higher than others who are in a better kind of conditioned state. Um, so we know that we can see these subjective responses will change with different body states.

Dr Liz White 14:23

Yeah, because that was my next question was to think about specifically stress and anxiety, which are things that you know, we all experience at various points, but when you are someone who also experiences chronic pain, stress and anxiety can really exacerbate it, can't it? Can you sort of speak to, maybe like the brain mechanism around that? If you could, yeah.

Dr Amber Johnston 14:50

I think the first thing is to understand that pain is really weird and there's a really great book I think it's called that pain is weird.

Brain's Complex Pain Processing

Dr Amber Johnston 14:58

There's also some really good ones that I like to always just put out there for people, and one's called the Painful Truth by Monty Lyman, and I think that's a really good resource, because it does go into a lot of just study about how unusual pain is, and the concept of pain being perceived is key. Now we want to be really careful, knowing that people already feel invalidated, that people can't see their pain, that it can't be objectively measured, that we are not invalidating somebody's experience of distress Nobody wishes that they have that condition, nobody. So if we can start with that premise, we can then say it doesn't mean, though, that there isn't a role that we can have in our thinking patterns, in our lifestyle, in working with our brain that might make some difference. Now we're not saying it's a panacea, we're not saying there's quick fixes or quick tricks and tools, but we are saying that there's more than just a surgery or a pill that potentially can help, and we know about you know the opioid crises, and we know that people might go chasing surgery after surgery in hopes that that gets a fix, and actually, studies will show that really kind of makes things a lot worse over time. So we just want there to be some hope that there are other options that people might have more control over, and one of the things there is that I can't remember the exact numbers in one of these books, but, like I think the pain is, I think it's like 17 different areas of the brain are involved in the processing of pain. So we're not talking about one pain center and it's either working or not working, or how do we, you know, jiggle that around somehow. We're just speaking about how pain signals come up through our spinal cord and they go in through brainstem and they go to different areas that will locate where the pain is and it will interpret the amount of sensation that's coming through. But it also very much goes into the limbic system of our brain, which, which is the part that's about emotion, and it goes to our frontal lobes, which is all about understanding and making reason, the context. Yeah, all of these areas are going to be heavily involved in what's going on in our body and making sense of it, and that means that our brain can get things wrong. Now this has happened. So this has happened to me.

Dr Amber Johnston 17:23

I talk about this little anecdote because when it happened I was like, ah, that's exactly what I've been reading about, it makes so much sense. Where I was stirring a pot on the hob and I remember just having this thought to so much sense. Where I was stirring a pot on the hob and I remember just having this thought to myself of like I'm gonna touch that, it's gonna hurt the side of the pot. I don't know why, it was just a thought I had like don't touch the side of the pot, that's gonna hurt. And then my son came in and I turned around and I was interacting with him for a minute and, sure enough, I touched the side of the pot and it hurts and I, like sprang back. I was like oh, and I looked down and there is no mark, nothing to indicate it, and I recognized the way that my hand was. I didn't touch the pot, I touched the cold tile.

Dr Amber Johnston 18:09

But what it was is that our body registers um, during something called nociception. It registers changes in temperature, changes in pressure and changes the chemicals that are within it. So again, if you get cut, you have a rush of chemicals that go in to assess damage and start an immune system response. Yeah, but I had a change of pressure and temperature by putting my hand against the cold tile, with my interpretation already set that I was going to get burned on this pot and I had a pain perception. I had a genuine pain experience for a second until I worked it all out. And that's one of these things where these studies are showing all the time how much this happens. This is real. It doesn't invalidate the experience I had. And now, in chronic pain condition, people are having real experiences all the time.

Dr Amber Johnston 18:59

But there will likely be, depending on the situation, some very complex interplay between the actual injury, the illness, the condition, the nerves. If there's been damage, there will then be a sense of interpretation, threat, response. There will then be the state with which our body can manage that, and all of that is going to be having a full interacting effect on what those signals are doing. It means that they can grow. So we often see that where pain will change, they will move. So we often see that where pain will change, they will move. It'll get bigger, it'll get smaller.

Dr Amber Johnston 19:36

There's things that can happen that often we can refer back to a number of processes. Another one is our brains making meaning of where it's finding the threat. So if it's having a signal that keeps coming from a certain area, it's located. The area it's located, the sensations around it, and now our attention, which is now being put into that area, because we have determined that's threatening, that's upsetting, we don't want this. Is it there? Let me check. And through neuroplasticity we can end up pairing sensations from a certain area with a threat expectation, the expectation of hitting the hot pan, to then be increasing the interpretation of all signals coming from that area as being painful, as being something we suffer from, and that's how these things can potentially grow.

Dr Amber Johnston 20:27

And again, this is when people get into difficulty because doctors are saying, well, there's no reason for that pain, it must be in your head, you know, it must not be real. You don't really hear doctors say it's in your head, you don't really hear them say that. But they will just say things that feel invalidating or that is disbelief. But they don't sit down necessarily and talk people through the neurophysiology of why. And I think when people have some of this understanding, at least they can hold on to something a little bit more than being told well, it shouldn't be this way. Or, very simply, are you under stress and that doesn't mean that it feels dismissive, you know.

Dr Liz White 21:11

In that sense, so you're saying that the pat, yes, the power of the mind. Isn't it that we can, through our minds, amplify our pain? But also we can, we can, modify our pain so that it's less painful. Is that what you're saying?

Dr Amber Johnston 21:25

it's all possible.

Dr Amber Johnston 21:27

Now what the other thing we really don't want is for somebody to feel blame and responsibility for their pain, and there will definitely be times when there are true medical situations.

Understanding Fear Avoidance Cycle

Dr Amber Johnston 21:39

You have, you know, nerve based pain. That is very real, it very much hurts. But then you know there will also be the concept of, even within true medical clarity of condition, that our mind can still do a lot to help with the movements even small movements but potentially really big movements and in the way that we are interpreting or thinking about our pain signal because I think, just thinking about my own experience, I know that when I was really in the thick of my back problem that I did not want to move off the sofa because I did not want to make it worse yes and I was scared that I would make it worse and I was scared that there would be another disc that would pop out or this would happen or that would happen, even though there were people telling me or you do need to sort of keep moving around, but when I moved around it was so, so painful.

Dr Liz White 22:37

So you do get. You get very stuck, I think and I'm using the example of back pain. Obviously, there's lots of different types of pain, but it's very complex, isn't it?

Dr Amber Johnston 22:47

completely and again, that's why I think that you know I love what I do and I love the colleagues that work with me, because we can really help somebody feel the support of truly understanding, being validating of their experience, yet also helping them understand the science and maybe beginning to push some of this. You know, what you're talking about now is the fear avoidance cycle.

Dr Amber Johnston 23:10

And this is really real. You know, why would you be pushing yourself when you have the potential of feeling like you're going to maybe crash, even burn even more and have to get, of course, normal? That is normal brain response to recognizing a potential threat and trying to stay away from it. But the difficulty is that, yes, the brain could be potentially incorrect and if it's, if it's predicting a potential consequence. That might not be the case. You know, the same thing happens with phobias, where you know very real conditions where people are terrified of approaching something that the brain has given to them through a bunch of chemicals. It is told that this is unsafe, you can't just approach it, so they work hard to avoid that. And the same thing can happen with the, with the avoidance, fear, response in pain, and what it can lead to is the muscles getting deconditioned. You know us feeling much more isolated, not having the hope of how this is ever going to get off of the cycle, and that increases more stress.

Rethinking Pain Signals

Dr Amber Johnston 24:12

Now, stress within the body. Stress is cortisol, it is adrenaline. Normally, after you have adrenaline peak, you then have cortisol coming up to kind of keep an eye out for things. The other thing that happens when you're in stress and adrenaline cortisol is that you have a hypervigilance, so all your senses become more tuned to what's going on around you because it needs to be aware of the danger that's there. But that includes your interoception, the sense of what's going on inside your body. So if everything's heightened, including your own recognition what's happening internally, you know, you can see that those pain signals become amplified when under that stress, heightened threat response state. Additionally, long-term cortisol release that creates inflammation. So inflammation within the system is naturally going to be influencing and irritating um some of the nerve receptors that are traveling to the brain to create more signals for the brain to be potentially interpreting as threatening and painful so it's a complex interplay, isn't it, between lots of different things, and I think the the question that I get asked a lot by people is what can I do?

Dr Liz White 25:28

how do I reduce or manage this pain that I'm in? So do you have some like go-to strategies that I obviously I recognize that the work that you do is always based on assessment and formulation of a person, but in terms of and everyone's different, but in terms of some like key things that people might be able to do to, to sort of help their pain, what would they be.

Dr Amber Johnston 25:57

So I have a little bit of a triangle as again that really generalist model that we then need to make, but the triangle starts with helping people think about their pain signal. So instead of just going into, you know how to live well with pain or that kind of thing we start with the concept of how to think about your relationship with your signals itself. So you know, when you were just saying that you were on the couch feeling afraid to be able to move, you know that's a really important relationship you are having with this pain signal. So one of the things that we spend time doing is actually inviting in the pain. Now this is the work of Alan Gordon, who's over at University of Boulder and he does pain reprocessing therapy and what he talks about is how much we are fighting against the pain signal and the interpretation of what it is, and that fight and that push away response and that fear of it coming out and trying to avoid actually creates all the stress response and the hypervigilance and the hyper focus on something that creates the interpretation which leads to the pain signal. So that's that cycle. So he's always talking about and I've had this work with a lot of clients where we start to invite in. Let's really spend time thinking about the signal itself. So spend a little bit of time really calmly, and that's the key, instead of the natural pushing away, getting rid of it, panicking.

Dr Amber Johnston 27:26

For here's another little anecdote when I'm going through all this, I think about it in, you know, acute ways. But I cut my finger with a knife and the immediate response was that ah, like throwing down the knife and trying to run over and, you know, holding it and putting it underwater. And I had this moment that I said okay, no, no, no wait, let me think I'm going to explore these signals rather than just that ah response. And I would just had my thumb under the water. I was feeling the feeling of water on it, I could feel it hot, I could feel it pulsing, and I noticed that when I was breathing in, I was feeling the pulse of, you know, a sharpness, and when I breathed out, it was completely gone. So I was having this pain come in. When I was breathing in, it was completely gone. When I breathed out, it was a sharpness. It went through, like with the pulsing of my blood.

Dr Amber Johnston 28:25

That was moving and it was just thinking about this concept and suddenly it moved from being this threatening kind of chaotic high stress state experience to something really calm and much more inquisitive and curious and that can begin to start to shape your thoughts around your pain. Because if you feel a little bit more like oh no, okay, I actually can tolerate this at least for a bit. You know, we know that it's exhausting and we get drained, but if we're starting to change our relationship a little bit, some of that chaotic kind of panic stress response can be reduced around it. There's other things people will do where they think about how to describe their pain and put visualizations on it so that they can almost do the opposite the breathing, really relaxing body and muscle. That can be difficult, depending on the location of pain, to working too much with the somatic, but it is possible it could be effective for some people.

Dr Amber Johnston 29:24

But that concept of really trying to think about the role of stress and cortisol in your interpretation and trying to reverse some of that can make a big, big difference. And then also noticing when what's happening. When is it more likely that your pain signals feel higher? What is naturally happening when your pain signals feel lower? What is it that distraction can do? What kind of distraction, you know. Are there times that you sleep or you eat that make a real difference? So so there's lots, lots.

Dr Liz White 29:57

That's where it becomes more individualized okay, and in terms of that triangle you were talking about, what are the other two points?

Impact of Lifestyle on Health

Dr Amber Johnston 30:07

so when we talk about so coming down from the middle, like the immediate, thinking about the signals themselves and trying to turn down the threat response in response to the signal, we then start to come into that concept of biopsychosocial formulation. So this becomes a little bit more in depth and the way I like to describe stress is that we know stress is the psychological stress that everybody knows of and, given interpretation, we know how important and relevant it is in pain. But there's also physical stress and our body will need energy sources to manage physical stress and that could be the immune system is being knocked. There's virus going on, there's something that's happening we're never really aware of. When viruses start, when our immune system really gets going. We often don't know Sleep, how much sleep and restoration. We're getting things like the gut microbiome, what's entering into our system and what kind of stress our microbiome is under based on, you know, food or toxins or pollutions or whatever else is in our environment. These things can impact us on a cellular level. They can impede mitochondrial functioning, they can impede the glial cells which are in our brain and they help restore and take care of neuronal health. And if some of these things are not working as well, that there's inflammation across the system. That's all stressful for our body and that's a different type of stress. So, thinking about some of the lifestyle factors that are involved, not just the psychological stress, that's all part of the true biopsychosocial formulation. So we start personalizing that and setting some goals about anything that maybe needs some consideration.

Dr Amber Johnston 31:50

And then the last level is the fact that we have a huge amount of evidence of the fact that adverse childhood experiences, big traumas, have quite a massive correlation with people who suffer from health condition and chronic pain symptoms. There is something very real about the things that we go through in our childhood. Now this is tricky because we have big traumas and we have little traumas, and you'd be surprised how many people don't count. Even the big traumas are not truly recognizing that. No, this were things that were really significant, that shouldn't have happened and they did. And you're a survivor and you got through. But your body had to get into survival mode and it learned over time that the world is threatening and therefore it needs more hypervigilance and more resources. And there's a cumulative wear and tear effect across our body where things just don't work as they should and that can lead to those being more vulnerable to chronic pain conditions or the non-hypertensive medical trajectory of recovery following a real condition.

Dr Amber Johnston 33:01

Now somebody like Alan Gordon and a few others you know will start talking. Gabor Monta, you know there's a group of big name clinicians and therapists and scientists that are saying it can go much deeper. This could be about you know unconscious or you know subjective previous experience. But to make more sense of that, what they mean when they say unconscious, it's just that the majority of things that we think about through the day we don't have conscious awareness of, because we couldn't possibly.

Dr Amber Johnston 33:33

You know, we have very little conscious awareness of what our brain is processing. So all of our experiences have shaped the way that the brain interprets things that are going on around it and what it considers to be threatening and what it prepares you for to have to cope with, based off of previous experiences that we may not fully have conscious awareness of, because that would take too much energy to constantly know all this stuff, know all this stuff. So in that way, yeah, we can behave and we can respond and we can have certain personality characteristics that are based off our past. Um, and we know through alan gordon's work and that of others, that things like perfectionism, people pleasing, catastrophizing anxiety um first and fourth I can't think of it right now are certain personality characteristics highly associated with these pain conditions.

Dr Liz White 34:28

Again, because of the heightenedness of that expectation and the wear and tear and the exhaustion that happens, okay, over time fascinating and in terms of someone who's listening to this, who is a chronic pain sufferer, are there any kind of daily habits or maybe lifestyle changes, based on what you said, that might be helpful in their perception of pain or their experience of pain?

Dr Amber Johnston 34:56

You know I think what we don't want is for anybody to feel like they have another thing you know that has to add to their list. So any change should take some time. You know any change should be slow steps that are done over time. You look at what you want to achieve in a year and break it down into you know 15 steps rather than you know just try and jump ahead and make those changes too quickly, especially when you know when you are in pain and your resources are down, you'll be more prone to go back to old habits because they are easy. They don't require much brain energy to make new habits.

Dr Amber Johnston 35:36

One of the things that I have like a pain workbook and one of the things that I talk about on it in there is like the wheel of life, and I know that you can Google wheel of lives all across, you know, and they'll they.

Dr Amber Johnston 35:49

What they do is they just break down our whole concept of life into different triangles that represent family or work or spirituality or hobbies or, you know, exercise, and it's almost like that's just a good place for people to start where they can just think about what aspects of my life am I still feeling pretty confident with you know and some people will in chronic pain, will still feel pretty good about their ability to relate to their children.

Dr Amber Johnston 36:18

That's what they save energy for. And then there'll be other areas where they're really longing to do more, and that might be a way to start helping somebody think about what areas are the most meaningful for them. Not that they just have to tick all these boxes and have this giant list, but what areas would mean the most impact for their authentic well-being if they could just increase a little bit more and more, and that, I think, is a good place for somebody to start. The other thing I would say is to read about pain, just read up on it, just learn about the science and the understanding of it. It's so much more complex than what we learn as children. Whereas you fall over, you know, you bump your knee, mom comes over and rubs it, makes it better and then off you go, and that's not what chronic pain is.

Dr Liz White 37:08

Yeah, and what would you say is one of the sort of biggest myths or misconceptions about pain that you really wish that you could change. That's out there.

Dr Amber Johnston 37:21

I think the biggest thing is about the patient journey. You know, the patients often feel so invalidated, that sense of invisible illness, that sense of feeling like the concept of it's all in your head. I mean what I want to say to that when people are like, oh, I just hate that concept, it's all in your head. I'm like, well, of course it is. Everything is Hunger is in your head. I'm like, well, of course it is. Everything is Hunger is in your head. You know, thirst is in your head, but everything's interpreted in your head. So, instead of seeing that as something really invalidating and shameful, we say, well, no, duh, of course everything is in our head, but that doesn't mean that it's not just as real as absolutely everything else that's being processed by our bodies and therefore you know it almost.

Dr Amber Johnston 38:06

I feel like when people are more open to psychology this is the second thing I'd say I think people often feel like they have to choose between medical community and psychological community. So if they are going to see a psychologist for pain, are they then abandoning the medical journey because the doctors will just dismiss them? It's all in your head, you're seeing a psychologist, and I actually find that to be really untrue. I feel like patients that have a much greater understanding of the science and what they are and aren't doing to help themselves can actually have much richer conversations with their, with their medical doctors about their understanding and different options. Um, so I find that that patients who do engage in the psychology aspect feel more empowered to be able to still continue medical investigation and treatment options. Um, it's not a one or the other, yeah well, amber, that has been fascinating.

Dr Liz White 39:06

Today I've learned so much about pain in the brain. Thank you so much for coming on well, thanks for having me.

Dr Liz White 39:12

It's a passion, I think you can see thank you for tuning in to this episode of hello therapy. We'd love for you to join our growing community over on Substack. You can sign up for free or become a paid subscriber for access to exclusive perks like never before seen video interviews and downloadable guides designed to support your mental health. If you enjoyed this episode, make sure to subscribe so you never miss a new release. And if you got value from this episode, it would mean the world if you left a five star review. As always, check the show notes for my full disclaimer. Thanks again for listening.