Pain Speak
Pain Speak
Pain Reprocessing Therapy Part 1 - Pain Protection and Safety
What if chronic pain isn’t a sign of damage — but a learned alarm the nervous system can unlearn?
In this episode of PainSpeak, I’m joined by Caroline Davies, a specialist pain physiotherapist with over 25 years of experience working across the NHS, the US healthcare system, and now in independent practice in the UK. Caroline’s work sits at the cutting edge of modern pain care, blending deep physiotherapy expertise with contemporary neuroscience and emotion-focused therapies.
Together, we explore one of the most important — and often misunderstood — shifts happening in pain medicine today: the move from viewing chronic pain purely as a problem of tissue damage, to understanding it as a problem of persistent threat signalling in the brain and nervous system.
From Physiotherapy to Pain Reprocessing Therapy - This episode follows close on the heels of the Channel 4 documentary on 8th Jan featuring Dr. Rangan Chatterjee - The drug Free doctor as he interviewed a patient with chronic pain who had used Pain Reprocessing therapy to reduce her pain significantly. Of course this has given us the chance to understand in more detail what PRT is and isnt!!
About Caroline Davies
Caroline began her career in traditional musculoskeletal physiotherapy, working extensively with complex pain presentations including CRPS, pelvic pain, cancer-related pain, and trauma-associated pain. Over time, she noticed a familiar pattern many clinicians will recognise: people whose scans looked “reassuring,” whose tissues had healed, yet whose pain continued — sometimes worsening — despite doing everything they were told.
In this conversation, We talk candidly about the limits of conventional approaches, the frustration clinicians can feel when progress stalls, and the curiosity that eventually led her to train in Pain Reprocessing Therapy (PRT), Emotional Awareness and Expression Therapy (EAET), and more recently, Internal Family Systems-informed approaches.
As always on PainSpeak, the aim is not to tell you what to think — but to help you understand pain differently, so that change becomes possible.
Disclaimer:
This podcast is for education and general information only and does not replace personalised medical advice. If you are e
Disclaimer:
This podcast is for education and general information only and does not replace personalised medical advice. If you are experiencing ongoing pain or distress, please consult your healthcare professional.
Please provide a feedback and comments on the podcast and any questions that you may have.
If you enjoyed it please rate and leave a review on Spotify/Apple podcasts and tell a friend about this show.
The Pain Speak podcast is presented by Prof Deepak Ravindran, a NHS Consultant specialising in Pain and Lifestyle Medicine. Dr Ravindran is also the author of the book, 'The Pain Free Mindset'
Get in touch:
Twitter: @deepakravindra5
Instagram: drdeepakravindran
Website: www.deepakravindran.co.uk
Linktree: https://linktr.ee/DrDeepakRavindran
Youtube Channel: https://www.youtube.com/@drdeepakravindran5361
For Clinical Queries and consultations, please go to Berkshire Pain Clinic
Order a copy of the Pain Free Mindset here
For Season 1 and 3:
Mixed and edited by Rob Cao at...
This is PainSpeak with Dr. Deepak Ravendran.
SPEAKER_00:Hello and welcome to PainSpeak. I'm Deepak Ravendran, consultant in pain and lifestyle medicine, honorary professor at the Teethide University, Director of the Barkchair Pain Clinic, and author of the Pain Free Mindset. In this podcast, I bring you the science, the stories and the strategies that are transforming how we think about and treat persistent pain. You'll hear from leading clinicians, researchers, and most importantly, people living with pain as we explore what truly helps. From neuroscience and nutrition to trauma recovery, sleep, movement, and mindset. Together, we'll uncover practical insight, the most advanced neuroscience understanding, and fresh hope for a life beyond pain. I'm glad you're here. So let's begin today's conversation. Hello, welcome to Pain Speak, conversations at the cutting edge of pain science and human experience. In today's episode, I'm going to be really delighted that I'm joined by Caroline Davis. She's a specialist pain physiotherapist with over 25 years of experience in working both in the NHS and the US healthcare system, and right now in independent care. And I'm proud to say that a lot of my patients who have required pain reprocessing therapy-based approaches in recent times, I've had the opportunity to be supported by her for my patients. So and with PRT now being in the news in the last couple of weeks with a few articles and work by Dr. Langan Chatterjee, I thought this would be a great time to actually dive deep into the whole treatment approach and what it means. And I'm really glad to be joined by Caroline. So, Caroline, thank you so much for the work that you do, where you're able to bridge the deep physio expertise that you've accumulated over 20 years with this kind of modern neuroscience and the various approaches that I'm hoping to sort of unpick in today's conversation. Thank you. Welcome to Pain Speak.
SPEAKER_01:Nice to be here. Thank you for having me.
SPEAKER_00:Brilliant. Well, Caroline, first things actually, in terms there, I touched very, very briefly on the wide experience that you have and your original training is been as a physiotherapist, I think, in the UK, if I'm not wrong. What drew you specifically to complex and persistent pain? What's your journey been like?
SPEAKER_01:It's so interesting how you do take a journey, don't you? And you don't always realize where your destination is. But I think I was at the Royal National Hospital for Rheumatic Diseases in Bath, and I was working in the Department of Rheumatology to start with, with lots of complex cases there. And then I had an opportunity to work in one of the national CRPS that stands for complex regional pain syndrome programs, which also had a sort of an occasional also program for people with complex late effects cancer pain. And so I had, I just suddenly realized I was literally surrounded by people with complex pain. And yet that was the challenge, that was what I'd loved. I've worked in the past with people with pelvic pain, which probably also got me started, and um also working with uh US veterans who had a really complicated history of psychological, physiological, every kind of trauma that you could imagine. So it all ended up making sense that I would want to become a pain physiotherapist, and it was the challenging people that I really most wanted to help.
SPEAKER_00:Fantastic. And does it mean that the traditional MSK model that you would have been taught in your physio school, is it more the fact that because your occupational experiences were all with complex pain that drew you there? And do you find that at odd now? Do you find the traditional MSK model being quite incomplete then in terms of what you understand about pain science now?
SPEAKER_01:I don't, I think it's so fascinating. You know, I had many years working without the knowledge about pain reprocessing and without the understanding about the neuroscience of pain and the brain, but I still was able to help people. Um, you know, the majority of people would get better with exercise or maybe some manual therapy. But what I do know is that there were people all throughout my career who I would see on my list and I would have a sinking feeling. And it was because I had that sense or had that experience with them that all of the things that I was trying were still not going to be able to help them. So I think I knew that I was missing something. Um, so it was sort of a hole that I was aware of that when pain reprocessing therapy, when I came across it, I was just so delighted to find something which I feel like I've been looking for for a long while.
SPEAKER_00:Well, absolutely fine. And and and uh is that how or why you trained in reprocessing therapy? Run it for us as to how you, with your wide experience of so many complex conditions in the run-up to understanding about PRT, you talked about the hole that you felt was there. Um, how was recovery like then before PRT? And and what was that timeline? When did you hear about PRT? When did you say, aha, that's what I need to learn about?
SPEAKER_01:I remember exactly when I first heard about PRT. I was sitting upstairs at the hospital in Bath. I was in the program working with people with complex regional pain, and I would so often see people coming in who had, you know, hugely difficult experiences. We were helping them, there were some exciting therapies that we were doing in the program. And at the same time, I felt like there was something missing that we were not able to fully explain why this had turned out the way it had. And um, that was really the pain reprocessing piece that was missing. I also felt from some of my own difficult, painful experiences, which were perhaps more of the emotional kind that I'd had um earlier in my life, that there were there were times when just sitting with difficult emotions could be like the most important way to get through them, to process them, to understand what you were going through. And so when I heard about pain reprocessing, it rang a lot of very similar bells. The idea that you might be able to find a way to sit with your pain and even understand perhaps a greater meaning of it, um, it really, really made sense. And it really felt like what we had been missing with many of these complex pain uh people that we were seeing.
SPEAKER_00:Absolutely. No, I agree. And I would this have been what 2020, 2021 thereabouts, or earlier than that?
SPEAKER_01:Actually, no, it was a little bit later. I think it was 22, 23 when well, it's 23 when I took the training. So I think it was 2022 when I first heard about it.
unknown:Yeah.
SPEAKER_00:Yeah, no, I agree. And I think so. When I did my training around 2021, 22, exactly, I think for the same reasons I I found the work of uh Howard Schubner to be really uh useful. I'd come across his work even earlier, and then when I knew he was one of the collaborators for this project and with the board of study, which we will talk about soon, um, I felt the same as well. I think PRT offers a very different look and it ties in and complements in very well with the newer theories uh of brain neuroscience and predictive modeling, everything that to me it made sense as well. So this is obviously now talked about a little bit more in the traditional media because uh Dr. Rangan Chatterji interviewed a patient uh and talked about pain reprocessing therapy. He actually had uh Howard Schubiner in his documentary as well. For those of uh people who still don't know what it is, do you want to help us sort of dive deep into it? What exactly is pain reprocessing therapy and how is it therefore different from what we traditionally offer for pain in the UK in terms of CBT, which is cognitive aerial therapy, and ACT, which is acceptance and commitment therapy?
SPEAKER_01:Yes, absolutely. I think the biggest difference is that it starts out with a different goal. You know, I'd always struggled with pain management. I always felt like if I'd been in chronic pain, um, I wouldn't be that interested in someone helping me to manage it. Um, I'd only really be interested in someone who might help me to get rid of it. And so I had that sort of like a um skepticism, you could say, about even the whole term of pain management. Uh so pain reprocessing therapy, even if you notice how you might feel in your body when you say that word, when someone with chronic pain might think of reprocessing my pain, that just sounds slightly more hopeful. And that that exactly is the direction that you start out with. And so for me, that's the first important difference. We start out with the aim of helping to help someone to a pain-free or more pain-free life, and it is a possible goal. So that's a you know, that's a lofty goal to start with, and I think it's very normal for people to feel skeptical. I always tell people if you're not skeptical, then that would be a surprise at this point.
SPEAKER_02:Yeah.
SPEAKER_01:But but what we then set about doing in pain reprocessing therapy is really a sort of shared education. I want to learn about whoever I'm working with, you know, what journey they've been on, all the different things they've tried, what's going on in their life around the time they have their pain. And at the same time, I'm gonna be sharing my knowledge and insight about the brain, about what we understand about pain now. And that's literally the first stage that can take several sessions. Um, you know, I'm learning about them, they're learning about pain. And from there, we, you know, even during that process, that's literally going to be changing neural pathways in their brain. So that's like the first stage that we really want to really get on a shared understanding about pain. And we've learned a lot in the last decades about it. So there is some really important new messages to convey. The next stage is we move into practice, and it's you know, a set of tools that comes with pain reprocessing therapy. People who've done a little reading about it might have heard of somatic tracking, and we can talk a bit more about that. But there's other things that are important too, leaning into neutral sensations, being open about including emotions that come up. And, you know, I with my physiotherapy background know that at some point in the practice uh segments we want to get people moving again, you know. So there's a really lovely part of helping people to understand that even if they are feeling pain when they're moving, you know, they're no longer got that sense that they're damaging their bodies further. So there's the practice phase, and that leads into some more sort of confidence building. And at this point, we're starting to hopefully see some changes in their pain. This takes them then perhaps to the step where they start trying new activities they haven't done in a while. Maybe they start getting back to work or working longer hours. And with getting back into that, there's always going to be some setbacks, some challenges that will come along. And that's a really actually another important part of the therapy is learning how to deal with the setbacks. So we get into that confidence building stage, and that can lead towards recovery, you know, and it's it's a sort of period of time that we can't ever say exactly how long that's gonna take. Um, and it is it's so different for everyone too. We might emphasize more on the emotions for some people, some people it might be more about the movement, other people it might be making really some significant life changes in their work or family or relationships. So it's it's different for everyone, but that's a sort of broad overview of the steps that we might take.
SPEAKER_00:That's really helpful. I think, and I think at the outset, when you outlined that primarily our goal is different, I so agree with you because we have traditionally taught and suggested both CBT and ACT. Now, CBT for me is a form of cognitive challenge and restructuring, whereas ACT is a form of cognitive flexibility approaches, but both, exactly as you said, are at the level of cognition and are at the level of saying, let us learn to embrace further values while accepting your pain, or let us learn to challenge those beliefs and accept the pain. Whereas the fundamental goal of PRT is that re-appraisal, is that reprocessing. So we are aiming towards a different future and one that is much more hopeful than what we've ever been able to give in our pain neuroscience. So I think that is really clear that PRT's goal is different there. And I think of these as a hierarchy. And clearly the question that presents itself is uh it's not exactly physical rehab because the somatic tracking is a body component, but it's also uh threat reappraisal. So how or what role does the brain sort of threat system or emotion system play in this kind of ongoing pain?
SPEAKER_01:Uh a key role. Absolutely key role. So anytime, you know, sometimes after I've given, you know, after we've talked a lot about the brain and neuroscience, I'll show people a slide that um is very simple. It's like a seesaw, and you know, on one eye one side is a red arrow going up, and it says anything your brain thinks is a threat will increase your pain. And on the other side is a green arrow going down, anything that helps you makes you feel safer will decrease your pain. So it really can be that simple. If we feel threatened or anxious, and you know, it may not be the typical things that we might think of, it can even be like an internal pressure that we're putting on ourselves. This literally will change the route that our neural pathways will take and make it more likely that our brain might come to the conclusion that we should be alerted with pain because there might be a need to get our attention. And that pain is one of the best ways that our brain can get our attention.
SPEAKER_00:Okay. In some ways, you're almost describing the predictive processing approach, isn't it? How would you do you bring that uh model now? Just for some of you listening out there, the most accepted or the latest theory right now in how the brain works is around what we call as a predictive processing model. Um but I'm curious, Caroline, do you bring that model into PRT, into discussing with your patients? How do you approach that in daily practice?
SPEAKER_01:Yes, I will spend a whole session uh discussing predictive processing.
SPEAKER_00:Wow, okay.
SPEAKER_01:And it's because I think it's a really, for me, it's a key element in understanding how pain reprocessing works. So what I will do, because it is, it can be very elusive, you know, it's so hard to even imagine that we have these automatic predicted programs that we run every day in in every part of our lives. So I'll sometimes come up with some examples of when they don't work. You know, like you're if you ever going on the subway or the underground and you get to the escalator and the escalator isn't working, have you noticed how there's a slight glitch in what happens next? You know, because normally you go smoothly up, you're just used to walking up or standing on an escalator. But when it's not working, your automatic program for going up an escalator is suddenly interrupted and it doesn't quite make sense. And that you know, even myself knowing this, I can try and eliminate that glitch, but so hard. So that's an example. Maybe if you've ever been on a boat for a while and you then your your brain is adapted to the swaying of the boat, you get off the boat, and again the land is nothing's quite making sense. So these are small examples that I can use to remind people, you know, this this is so it's so sublimable. Subliminal I don't want to say that word, but subliminal. Thank you. It's that it's it's so under the surface that it's hard to really believe it exists. Um, but it it it's there for all the reasons that um we were actually chatting about before we started this podcast for protection, so that if we might not be paying attention, our subconscious brain is noticing that we're in a similar situation to before when we got hurt or injured or were perhaps with someone who might be a bit threatening. Um it's there for efficiency. Our brains want nothing more than to keep everything working smoothly in our bodies, and if we are having to pay attention to everything all at once, all of the time, and re-redo things all the time, we're going to be exhausted by the end of the day. So it's it's so integral to how we work, and then you know, then you say, Well, I'm afraid the other uh point of going into the subject is that our brains can get into the subconscious habit of pain. And I really want to emphasize the subconscious part because no one in their right mind is going to consciously um set about creating a habit of being in pain every day, you know. So I don't mean that in any way at all, but our brains can, through um, for all kinds of reasons get stuck kind of on that uh repeat loop. And this is um, you know, without going on too much about this, um, I'm very passionate and interested in it. And I think this is exactly how pain reprocessing could be explained, how it how it actually works.
SPEAKER_00:Fantastic. In a way, the bedrock, what you're saying of PRT is again the newer understanding, the neuroscience of predictive processing. And again, it does make sense. And to me as well, that part of how to explain PRT, you've given us some really fantastic examples. I think I'm going to pinch that in my explanation to patients. That escalated glitch is something very real. You're right. Absolutely. When I think about it now, that is something, even though I know it's suddenly not working, the first one or two steps is a little bit of a change when I take that first two steps because I almost think it's going to stop off. My brain's ready for that, and then it realize, well, you know what? You know what? Sorry, you just get your exercise by walking up the escalator that doesn't work. Well, this is fascinating. So when you go through your sessions there, what are the examples? You know, can you give us some change examples that you've had or experienced or helped your patients experience?
SPEAKER_01:Um, yes. Do you are you still thinking along the lines of the predictive processing and how talking about the BLT itself? Actually, PRT, yeah.
SPEAKER_00:Okay. PRT itself, what examples do you feel uh deploying this whole PRT approach? What are the changes you've noticed?
SPEAKER_01:Yes, I'd love to share some of those. And and maybe I also feel like I should go back and perhaps finish up a little bit more explanation of linking predictive processing with um PRT. So in in pain reprocessing, one of the sort of principal techniques that you will do is somatic tracking, where you sit in your body and you actually go towards the sensations of pain in a new way. Now, this will interrupt the predictive pattern of your brain. Okay, so this and this is when your brain will pay attention. It will pay attention that you are now sitting, noticing or feeling that pain, but in a maybe a calmer way, in a different way to normal, and it will kind of start logging that away. Maybe it will be starting to think, oh, maybe this low back pain isn't such a problem as I thought. Um, or maybe maybe my shoulder might be okay. And if you keep practicing, being in the moment, interrupting that predicted programming, then that can be how you build new pathways in your brain. So I just wanted to add that. Um and now I'm gonna need you to remind me what your question was. What were you what was your question, please?
SPEAKER_00:Any change examples working with patients, yeah.
SPEAKER_01:Yeah, so um I've just had such a uh complete range of people coming to see me. And I think, you know, I've had lots of people before I knew about pain reprocessing, and I think I can look back to some examples there of where perhaps I really could have used some pain or even emotion reprocessing. Um but since I trained in pain reprocessing, which is now three years ago, I can think of well, many examples. Um, in the earlier times, I was working with someone who found it extremely painful to sit down, which is in our modern day like a really restrictive problem to have. You know, we work most, not everyone, of course, but anyone with a sort of computer-related job is going to need to sit. You know, we sit in meetings, um, we sit to travel, uh, we sit to relax. So, you know, if you have pain when you're sitting, it can be really challenging. So we worked together using pain reprocessing, and this person was able to get back to uh a normal working hours, able to travel, um, able to get over all of the fear that she had that she was literally damaging her body by sitting. Um, so that was perhaps one of my first um examples of using PRT. Yeah. There's I've tended to see a lot of people with foot pain, and I think our feet are a very interesting part of this. I think if we have, you know, for one thing, they get a lot of wear and tear. For another thing, uh, we will worry if we have any problems with our feet, because literally they are what take us around to do things. You know, that's what we use when we're exercising, when we're exploring. So our feet are really important. So I've worked with lots of people with um foot pain, starting with someone I will help who'd had heel pain for four years. Um, every time he would go out walking, he would um experience this pain, and we worked together going through the different stages. You know, there's always some interesting situations that go on in people's lives when this foot pain starts, and that's a really key aspect to explore and understand. But um, you know, six months later he was um back to doing his you know as much walking as he liked. He loved walking all over London, and he was able to get back to running without any pain. So it's it's lovely to see that, you know. That's why I do this job, of course, is to see these things, you know.
SPEAKER_00:Yes, and I think that's the biggest thing, isn't it? Where in patients like this, if you can get that reappraisal, that somatic tracking, the steps that you describe, you're almost achieving that potential of reversibility. I agree it's not a guarantee in every person, but that's that reversibility is something that genuinely hasn't been really possible or even probable in the pain literature up to now. So that that is fantastic to hear that, and definitely I do have some stories. And I think a couple of patients that we've we've seen as well, isn't it? Like, for example, I might be patients with really refractory eye pain, sort of corneal uh neuralgia type, and I think uh you've seen some of those kinds of so two ends of the body as well have been possible, isn't it? So PRT has that wide application. I'm going to actually take a little segue now because we talked about emotion, you talked about emotion being a key part there, you know. So before we go on to the practical deployment of PRT, I want to look into another specialist skill set that you have, which is this newer technique that's also becoming relevant for pain management called emotional awareness and expression therapy. Um do you want to explain EAET to us and you know how does emotion play a role in that part? What what can you tell us about EAET?
SPEAKER_01:Well, first of all, I absolutely love that we're finally getting emotion on the table, you know, to discuss. This was always uh a sort of bugbear of mine going through um school and then all the different jobs I've had that you know, invariably at some point during our sessions, people would have strong, difficult feelings that they'd want to share with us. And yet it always felt like they were kept, you know, in a traditional sort of environment, they were kept outside the room. It wasn't included in our remit, you know, emotions mental health, yeah. Yes, scary, difficult, and so on. And so when I came across um emotional awareness and expression therapy, well, I was really excited. I'd had an interest in emotion, a personal interest in difficult emotions for many years, and I've been studying them. And um, so the therapy, I think, just come just actually does something that we should have had all along, is includes it includes emotions in the room. It actually says that emotions that aren't expressed or that um are suppressed or you know, not sort of um given the time uh can really hold up our recovery from illness and pain. And so if we bring them right into this therapy approach, which uh EAET does, um, we can actually make significant progress. And and it really is encouraging if you start looking into the research evidence for EAET. It's actually been going for quite a bit longer than PRT, and they've got quite a lot of studies now, 17 or 18. Quite a number of them are RCTs or randomized controlled trials, and they're really they're really showing significant improvements for people in complex pain. You know, some of them are working with veterans, um, some of them working with fibromyalgia, another complex pain condition. So it's a very exciting field. Um, I probably haven't fully explained it, but it, you know, obviously I'm very uh I'm very passionate about it. And I went and did the training. And um, you know, I I know that for not everyone is comfortable talking about difficult emotions. You know, sometimes it's even harder to talk about difficult or feel difficult emotions than it is pain, which is really saying something. So, you know, I don't say this lightly, and this isn't necessarily not everyone will want to sort of go to that level, but it is sometimes necessary for people to take that courage and take those steps in a therapeutic safe setting to fully recover from their pain, because undoubtedly it's it's an emotional experience having pain. And at the same time, often there's a lot of emotional experiences going on earlier in one's life, preceding the time the pain showed up, or around the time someone had an accident or illness, or even as a result of having an accident. You know, if you're if you're a driven person and you suddenly break your arm or leg and you think you can't do all the things you've got on your list, or you're not going to be able to do your exercise, it usually keeps you calm and centered. That can induce a lot of fear. Um, and all of this needs to be included in any of our treatment approaches.
SPEAKER_00:Absolutely. And I think it is a tricky the way you describe it. We know that it is so integral to how we feel and function and perform. Um, and yet you're right, we somehow seem to separate it out. I'm always curious, do you then find having trained in both of these treatment approaches, do you find that it complements PRT? Do you think it's something that someone as a physio or a healthcare professional trained in both can deliver it? Or does it have to be someone that you link up with a psychologist who delivers it? What are your views on that? Do you have any thoughts?
SPEAKER_01:That's great questions. Um, I I think it's really important to say that emotional awareness and expression therapy and PRT very much overlap. So pain reprocessing therapy is definitely inclusive of emotions and in itself, um perhaps people who are very keen on pain reprocessing therapy and uh you know the founders as well would would say, yes, emotions are included in this, and I and I thoroughly agree it was in my training. But what I think um Schuminer and others, and Professor Jans have done, a psychiatrist who's working in this field, is they've really put a light in an area that's been very dark. And I think focusing on emotions as a therapeutic approach is very powerful and might even be really necessary to have it sort of in the headline so we fully do include them. Um I know there was a second part to your question. Oh, oh yes, do you think this is in the sort of remit of a physio? Do we need psychologists?
SPEAKER_00:Um, you know, I think this is this could be just that it doesn't become too overwhelming for either the clinician or the patient. So that's what I was just thinking. Yes, from an NHS perspective. Sometimes I've seen uh these days that a lot of my physiotherapy colleagues talk about this concept of psychologically informed practice. So they are much more psychologically informed than probably what the MSK training would have given them. But I was just wondering how do we try to reduce overwhelm and support both the clinician and the patient if emotions are strong?
SPEAKER_01:Well, I I've really thought a lot about this. Um, you know, especially if my training is in physiotherapy, not in psychology. Um, you know, we could have another whole conversation about how we've how what a mistake it was to divide us up in this way, you know, that physiotherapists don't get to include psychology, and psychologists may not be including the body or the you know the physio side of things. So, you know, I ideally we'd have we'd meet in the middle and we'd both feel comfortable and confident doing um including both of these things. I on a personal level have um always made a note to be in touch with psychologists, to um if I start to feel uncomfortable that there may be something that I don't have all the skills for, I will refer people to psychologists. Um so I have a great respect that that is their, you know, that's their strengths, maybe in the same way that they, if they're working with someone with pain, might refer them back to me.
unknown:Yeah.
SPEAKER_01:And I just want to finally say though, I think we all have been over afraid of emotions. In in all the EAET emotional awareness and expression therapy studies, there have been no recorded harmful side effects of expressing expressing strong feelings. Okay. It is safe, you know, providing we're not expressing them in a physical way, you know, it's it's safe to talk about anger and to become angry, but it's obviously not safe to start throwing things around or harming yourself. So we've we've got to have some kind of safe container, but we also must allow people to be able to express their feelings and not feel so afraid. But the really interesting interesting thing is that starts with feeling as a practitioner, that starts with feeling safe, feeling your own feelings and it's being able to express your own emotions. So it sometimes, as we all know, and I'm sure you know this DPAC, the work starts with us. We have to do some of this healing, recovery, and exploration first before we feel comfortable to do it with others.
SPEAKER_00:No, absolutely very well said, and I couldn't have put it any better there. You talked about that strong negative feeling, but what emotions you've noticed sort of sitting under the pain patients when you deploy EAET? You know, does it does it also include positive emotions or or you know what just give me some examples of emotions that you would name?
SPEAKER_01:Everything, every kind of emotion could could lead to pain, even as as you said, positive emotions. You'd be surprised the number of people I've had whose chronic pain has started around the time of them getting married or organizing a wedding. Um yes. There's also, I would say, a high degree of um both anger that can, you know, anger is a very difficult one. I don't think as a society, you know, again for understandable reasons, we've suppressed anger, but I don't think we have safe or accessible ways to talk about that. So anger is a very common one that underlines pain. And, you know, I think I always like to say to people, yes, anger is very appropriate at times. Anger is a way that we stand up for ourselves, anger is a way that we might see that something unfair is happening. So, you know, um, and anger is a frequent and very understandable reaction going through trying to get help for chronic pain. So that's a big one. You know, grief, loss, those can be dreadfully difficult, loneliness, shame, guilt, you know, all of these. None of these are easy emotions to have. Um, and for a lot of us, uh, it's easier to, you know, yeah, bury them is a sort of euphemistic term, but you know, it is easier to often bury these really difficult emotions than be able to do anything with them. And and that's very common. That's very human.
SPEAKER_00:And in some ways, and in some ways, I think as Bessel van der Kok said, the body keeps a score, isn't it? All those emotions then start to present in different ways, and and that manifestation can be that protective output of of pain as well. Well, thank you so much for that. That's a really, I think, a good overview. I know that we have just barely scratched the surface of techniques like EAT. I wanted to scratch the surface of uh another technique before we come back to a more practical implementation of PRT. And this is looking at another uh approach that you're trained in, and which is definitely something I'm hearing a lot of my practitioner colleagues across the UK and in the US talking about in the context of pain, which is internal family systems therapy, so IFS. Um how would you describe it or you know what drew you to that, and how do you integrate that with your PRT and EAET experience?
SPEAKER_01:Yes, I'm gonna start with your second question. What drew me to it? I, after probably a year or two of practicing pain reprocessing therapy, honestly, it was working fairly well. Um, most people were getting significantly better, but I had maybe one or two people and you know, seeing some reflection of this in others who I just couldn't quite get all the way, or we couldn't get as far. And what I was noticing was um that they were very self-critical. Yeah, they had a strong inner critic. And this led to a very interesting observation of myself. Well, how am I going to help them with their strong inner critic when I have a strong inner critic sitting in the room with me? Um, and at that same time I started, it was sort of like a drumbeat. I kept hearing about internal family systems therapy. I had a friend that would periodically just send me emails saying internal family systems therapy, you should check it out. You know, this was over a few years because it had helped him so much. And then I'd come across it in other courses. Schubiner mentioned it, Charlie Merrill, who does a really great class on PRT for physios and manual therapists, he mentioned it. Um, so I went and did some. I took the therapy myself, and I found it perhaps to be the most transformative therapy that I've had um throughout my life. And then um, you know, I won't profess to be an expert in internal family systems, but I have now completed a training in it and I'm using it with um patients, and it's very exciting work. So coming back to what is it, you know, we can make all the changes in our external lives, our external environment, we can balance our work, we can do the exercises, we can change or improve our relationships, ideally. Um, you know, we can sort of practice mindfulness and relaxation, but we may still have the biggest challenge sitting inside our heads, like a little voice that says, you know, oh, you're not good enough, or you what, you know, whatever. We all have our own version of this, right? So our inner critics can actually be the threat that is keeping us in pain. And I find that a very ironic, interesting possibility that we actually, the voices in our head and that coming deep from our subconscious from our earlier experiences, could be so um impactful on our pain experiences. So, yes, this is why I got really excited, went to do the training, and I'm finding it to be extremely useful so far.
SPEAKER_00:Okay, and in some ways, when you talk about it, it makes me appreciate that when you talk about the inner critic or there are parts inside that can be a threat, in some ways that also can fit into the predictive processing model because effectively your threats or the voices are your priors, they are the ones maintaining the beliefs or the prediction model that there is danger or threat somewhere, and you are constantly therefore reacting. And so it's a very strong argument for again saying that IFS tackles those uh inner critics or protectors or exiles, and you know, there are so many things, and I think that deserves a separate pod episode on its own. Thank you so much for that introduction. It's amazing that you've realized that you still need to be learning and improving and adding some more sort of uh arrows in your quiver because we know that our pain patients present with so many different layers and shades there. Coming back to PRT, so with pain reprocessing therapy and and you know what it might actually look in practice, what does a treatment journey for someone wanting to access PRT look like?
SPEAKER_01:Well, what I would say is first of all, you have to hear About it, right? And that's what's so great about this episode last week on Channel 4 with Dr. Chatterjee. It's still probably not getting across, but I hope that it will be changing or is changing as we speak. I think the searches for pain reprocessing went right up. And I certainly had some new inquiries, which was nice. So, first of all, people have to know about it. And then I think we need to be uh, you know, the process is of course in whether this is something you can do yourself, whether you could read a book, you know, such as I've got a few book recommendations, including the book that you wrote, DPAC. I really have been enjoying reading that recently, The Pain-Free Mindset. Thank you. And I just think that um we need to appreciate that this is going to be a different journey for everyone. So some people might be able to pick up either Alan Gordon's book, The Um The Way Out, yeah. Or there's another really nice book, um, a workbook that's been developed by Vanessa Blackstone and Little.
SPEAKER_00:Absolutely, yeah.
SPEAKER_01:It's a it's a the pain reprocessing therapy workbook, really nice sort of to do on your own at home.
SPEAKER_02:Yeah.
SPEAKER_01:Um, so for some people that might be enough. They might be able to work through that, they might be able to listen to the podcast. You know, there's some great apps now out there, curable, free me for more fatigue symptoms. There's absolutely a huge number of growing um YouTube channels on this. So, some people that might be enough. For other people, they might get stuck at some point. And often it's this trying to do the somatic tracking on your own or sort of understanding the big picture of how this all happened to you. And that's where I always say two brains can be a lot better than one. Yeah. And it can take some courage and then sort of encouragement to get through some of the difficult stages, you know. So we start with the education, like I was saying, and we can sometimes be sitting there in the room, and someone's saying, I get this, I really get now that my pain is more about a predicted pattern. I'm safe, I get that my um, you know, my body isn't as damaged as I thought it was, but I haven't actually seen the pain change yet. So that's sometimes where we need to just have someone else who's been through the process with other people to encourage us and say, yes, this is normal, this happened sort of at this time. It's because we're learning a new thing in our brain. And you know, like learning anything, if you learn and go to learn a new sport or a new job, it isn't always instant, you know, it can take repeated practice, and then one day you show up to work and everything goes smoothly, or you go on the pitch or the field, and you literally it you got your flow. And that's the same thing with pain reprocessing. So there's the learning, there's the practice stage where you can, you know, run into some issues. Um but for a therapy, you know, for coming in to see a therapist, what you will benefit from then is that perspective, that perspective on what this might all be about, what the meaning of you know, how this has all happened. And I think that's such an important point that I've come to realize with um any approach is that if you can make sense of what's happened to you, it's a huge step towards your recovery. Um fantastic.
SPEAKER_00:Yeah.
SPEAKER_01:And that can be a good thing.
SPEAKER_00:I think that understanding pain isn't just literally, yeah, absolutely.
SPEAKER_01:Yes. So that can happen at any point along that way. And then, you know, as you get towards perhaps, I don't know, eight to ten sessions. Hopefully by then you would be seeing some progress. Um, we can start stretching out the appointments. They don't, you know, I start once a week just because it really helps to have some sort of building of momentum towards making these changes, but you can spread the appointments out as you get into the process, as you're seeing the changes, you know, and then it's about integrating it and going off and doing this. And at some point you're gonna have, you know, if you're working with me or another practitioner, you're gonna have enough to just then go and explore and try this on your own. So this isn't about someone coming to see me forever or always needing to see me. This is about helping you through a journey that gets you to a recovery where you don't need to see uh a pain reprocessing therapist anymore.
SPEAKER_00:Absolutely. And I think you've answered that other question how long can it take? And listening to you describe that eight to ten sessions and spacing as they take on more and get more comfortable. It's almost like what we want to do is it's going to go over a two to four month period probably of support that's going to be there. And and from a behavior change and from again a neuroscience perspective, we do know that for these habits to form, these this consistent maintenance of these techniques that you described, the somatic tracking, the appraisal, that all requires time to practice. And then at one point, as you said, it just falls in place and you go smoothly. We know that that varies. Some people it can happen as quickly as you know 21 days or 30 days. And I think in the literature, for that kind of thing to happen on average in some other patients, it can take as long as 245 to 250 days. So that's almost six to eight months. So we know that that is the duration it can take, but you're right. Okay, so you at least provide that support for three to four months, which is very much. You talked about sometimes the challenges or the sticking points. So, what do you feel are the common sticking points or challenges you've noticed when your patients start to engage with and move through the various steps of your recovery process?
SPEAKER_01:Well, the first step is actually getting in through the door or you know, considering something. Um, you know, because most people who have chronic pain, whether it's months or years, will have tried a whole number of things already. Okay, so that's the first challenge. Is it it's very hard to accept that you've done all of these different things and yet still you're not better, and that there could be one more thing to try that could be the final thing. You know, even just having hope can be difficult or even painful for people. So that's the first challenge. Like I said, it is challenging, it's not an instant fix. Um, it does require some sort of reflection, looking at yourself, understanding, thinking about how different things in your life might have affected how your brain, you know, your sense of your brain's protectiveness. Um it can be that you perhaps need to reappraise some parts of your life and how you've been doing things. So, you know, it is not like a band-aid approach. This is can be deep, it can require some um kind of difficult appraisals of things, but hopefully, you know, I'm often surprised how often I end up laughing with people. You know, things can also be enjoyable in the process of doing this. Um but the challenges I think then come, you know, of course, there's that midpoint where perhaps you haven't quite seen it happen yet. And then what I will say now, I used to not tell people about setbacks, um, but now I'll say, look, it's inevitable. Some point you're gonna be doing really well, you're gonna feel like, oh, I think I think this is pain reprocessing is really working. Uh, I've been able to go and do this or that, and then something will just slam into you. It might be an event completely outside of your life, it might be that you did actually do slightly too much. Um, it could be any number of things, but you will then feel like you've gone back to the beginning, like you've slid all the way down that snake and the snake's in Leather's board, and you're, you know, you'll feel hopeless and terrible, and everything that all your doubts will come rushing back. Now, that is normal. It's a normal part of recovery. And what we have to do is that's the point when you lean in, we come back together, trust the process, just employ all the things. Pick yourself up, remember all the things you've learned, just put the things into practice, and and invariably you'll you'll find that you'll start coming out of it within a few days, you know, something that perhaps in the past might have taken a few weeks or a few months to get over. Now you're coming out in a few days, or maybe a week or two at the most.
SPEAKER_00:And then putting that systems in place again should enable a faster recovery from setbacks than being set, you know, left for a longer in a pain flare, isn't it? That makes sense. So, probably the million-dollar question then is uh pain reprocessing therapy right for everyone? You know, which groups of patients or what examples you can think of where you've said this might not be the right time or even the right approach for you? Because I know that you do a discovery call, so you do have that kind of an initial catch-up with patients. So have you give us some examples of when PRT may not be right, either the timing or the approach itself?
SPEAKER_01:Yes, it is the million-dollar question. And I don't think I think we need to be very pragmatic. You know, pain reprocessing therapy is got is a wonderful concept. It's still a bit early, it needs some more evidence to come out, you know, there's more trials being done. So, you know, it's a little bit early to say this is it. Um, it's it's not a panacea. And yet I would not want to be not using it. You know, if I had um, you know, if someone said, well, you can do pain physio, but you can't use pain reprocessing therapy, I'd say, oh, I'm sorry, I just can't do I'm not interested anymore. So it's um valuable enough to most people, but what I want to stress is that people come to us with, you know, some serious underlying conditions. You know, I see people with who've been diagnosed with uh complex regional pain syndrome, other people who've had nerve injuries, multiple surgeries, maybe inflammatory conditions. So we want to be realistic, you know. If, like as you write so lovely so well in your book about no susception, i.e., sort of like the damage information that's coming in up to the brain, the brain gets to decide on the pain. We know that there may be still either some damage that's uh there, present, um, ongoing. So we don't want to be ever um simplistic about this and say this can help everyone get all the way better. And so, but what I do, I do work with these group of people, and we still see improvements. And I think that's really nice. There may be a level of inflammation that's going on, there may be still some recovery or some structural issues, but there's still always going to be that margin, you know, that margin that makes a difference when you know more about pain, when you know more about all the things that influence pain or that you can do about it. So, yes, it's not for everyone, um, but I do think most people can could benefit from that approach.
SPEAKER_00:Um, there's no uh no absolute contraindications per se in your book as such for PRT, you would consider at least that conversation to see what aspects can be changed or improved or or or benefited from.
SPEAKER_01:Yes, and but there are a few important caveats to that. If I feel that someone hasn't had something fully investigated and there are any doubts at all in my mind, I would want to send them back to someone like yourself to rule it out or their GP for more tests or scans. So, yes, it's I'm always mindful that I do not want to ever miss something. And if someone hasn't gone through a very thorough route to check things out, then that would be a reason to go back and have more tests, more consultations. More costs. And then perhaps one other um one other situation that has occurred a couple of times is if I find that I'm working with someone who really is struggling mentally, you know, maybe even having some suicidal thoughts or ideation, that would be a point where I would um connect them back with their GP and psychology um services to help them with that person, you know, give them the encouragement to come back to me, but there could be something just anxiety that's through the roof, or you know, those are the things where I might just say, yeah, let's come back to this, but let you know, these we need to help you get the right help um for these other issues first.
SPEAKER_00:Okay, fair enough. And I think that's that is going to be very sensible. And it's all about safety, isn't it? It's about ensuring that everyone's safe in the process. So we're reaching the top of the hour. I'm gonna ask a few sort of shorter, more rapid fire questions out here. One, can people teach themselves PRT? You did talk about initially giving people some resources there, but can it be something that's self-taught?
SPEAKER_02:Yes.
SPEAKER_00:Okay, okay. That's too short, a little bit expansion, maybe.
SPEAKER_01:Yes, and actually there was a study that came out last year that I just found out thanks to a colleague of mine, and it was on a brief pain reprocessing therapy. I don't know if you've heard of it by Sturgeon et al. Tell us more, yeah.
SPEAKER_00:Tell us more, yeah.
SPEAKER_01:Okay, and they did three or four sessions, or no, I think just three actually, fitting into pain education, somatic tracking, and probably some sort of further understanding of steps that they could take and made some significant gains. Um, and I've also found in some short-term help that you can make a difference. Reading a book by yourself can actually heal some people. We call it the book cure. Um, so it is a it is a yes. And I want to say, you know, I know not everyone can afford or might be able to find accessible pain reprocessing therapy, but there are books that can help. And there also are some groups that are starting uh group programs. I'm hoping to start a group program that will be a bit more accessible for people. Yeah, I really still want to just say yes because I don't I don't think we ever want to make ourselves indispensable. People can learn, people are getting smarter all the time. You know, with AI and Chat GPT, people are coming to me already with more and more knowledge. Now that that doesn't mean to say everyone, some people will get stuck and need more help.
SPEAKER_00:Yeah, absolutely. I think yes, you can you can have your AI PRT coach slash somebody in your pocket, but you're still going to need the human connection at some point. Okay, thank you for that. Second shorter question then, is somatic tracking difficult to do or learn?
SPEAKER_01:Yes, it can be. That's because in general, like we've been talking about, we like to say in our predicted processing programs, we don't necessarily like to do new things, especially if they might involve pain or difficult emotions. So, yes, somatic tracking is a counterintuitive thing to do. It can sound easy when it's described, but people can be left with a lot of questions of whether they're doing it right, are they doing it enough? And even the approach or the way that you do it can influence the outcome. It's very important to not be trying to reduce your pain through doing it. There's a lot more I could say about that, but yes, I would say somatic tracking can be a bit tricky.
SPEAKER_00:Tricky, fair enough there. So, in closing then, um, if someone listening today has has really found this, and I hope you do, and I've really found it helpful to hear from a PRT practitioner, but they're also scared to believe that this could work for them, Caroline. What would you want them to hear or take away?
SPEAKER_01:I really understand how they're feeling. Let's start with that. And then I would just say that if I had anyone that I knew, a friend or family member, and they came to me, as long as I was sure that sort of the normal things that we might worry about causing pain had been ruled out, I would really encourage them to um try pain reprocessing therapy. Now, friends and family members aren't always the best people to take up your advice, as I found.
SPEAKER_00:Yes, tell me about it, yes.
SPEAKER_01:But no, I would be very encouraging for anyone out there who might be having some doubts. You know, to have doubts is normal, it's human, it's how everyone starts. Just give it a try, pick up a book, listen to a podcast, just just plant the seed and consider that this this could actually be the one thing that you've been missing and that could really help you get out of pain.
SPEAKER_00:Fantastic. Thank you so much for that. So, where can uh Caroline, where can people find you? What's what where do you work? Well, how do you work? Just give us an idea.
SPEAKER_01:So I'm working a mixture of in-person in London, uh, in Farrington. I have a clinic that I go to every week, and I'm also working online, so I can work with people who are either you know in too much pain to come in or further away and can't make it into the centre of uh of London. And then my website is called reprocessyourpain.com. Um, I'm also hoping to bring in call. Sorry, yes, that's right. That's my U US background there, slipping in. Um, thank you for that. And uh I am doing uh half-hour free discovery calls, which I think is a great way for you to get to know me and me to get to know you. So you can book one of those on my website. Um I'm hoping to bring in another therapist to my practice this year. I've made a really great connection with an occupational therapist in Bath, and um her name's Karen, and we've been talking about pulling ourselves to pulling our um sort of shared skills together. Perhaps in the future it'd be really nice to work with a psychologist as well. I'd really like to build a little team uh of people to um work together because I do think there's lots of complementary skills that can be helpful in helping get people out of pain.
SPEAKER_00:Brilliant. Well, thank you so much, Caroline. There, I'll have all the other sort of access details in the show notes as well. So thank you once again, Caroline, for the time that you spent today, for the clinical insight into pain reprocessing therapy, and also for clearly the humanity and the skill that you've brought into your work with so many years there. Um, as always on Pain Speak, I think my focus with this podcast over time, and I'm hoping to make this a much more routine affair in 2026. It isn't about quick fixes. There's so many new things that we want to talk about in pain science. And it's important to have that open mind, that curiosity to know the understanding of pain, but always from a patient perspective, it's about safety, it's about hope and possibility. And that's what I want to bring to in this podcast. So if this conversation has resonated for you, please do share it widely with someone who needs this hope. And remember, pain is very much real. I think none of us are ever going to say that we're making it up anymore. But the reality of this conversation and treatments like PRT is that recovery is possible, genuine full recovery is possible. So thank you, Caroline, for today and uh wish you all the very best. Thank you so much for joining me on Paint Speak. If you found this conversation helpful, please share it with someone who might benefit. And don't forget to subscribe or leave a Short review. It really helps others discover the show. You can find more resources, talks, and updates about my work at my website deepakravindran.co.uk, or connect with me on the various social media platforms I frequent LinkedIn, Instagram, and YouTube, and certainly subscribe to my YouTube channel. Until next time, stay curious, stay compassionate, and remember, small steps do make big changes on the journey to a pain free mindset. I'm Deepak Ravindran, and this is PainSpeak.