Dr. Regina Koepp  0:00  
today's podcast is an important one because today we're talking about chronic pain and the impact of chronic pain on mental health. Today's guest expert is Dr. Jennifer Steiner. Dr. Steiner is a board certified clinical health psychologist and founder of beyond the body health psychology services. It's a private practice in Atlanta that focuses on chronic pain and illness. She also serves as co director of the Center for Mental Health and Aging's continuing education program. And as adjunct professor at Emory School of Medicine. Part of her service includes being a board member of the Georgia Psychological Association Board of Directors and in a couple of other capacities with the Georgia Psychological Association. Dr. Steiner is an expert in the field of pain psychology, she has worked with patients with chronic pain for over 10 years and has published multiple scholarly articles on psychological correlates and interventions for chronic pain. I'm delighted that Dr. Steiner is here imparting her knowledge to all of us for in working with a population that is larger than you might imagine. So thank you so much for being here. Dr. Steiner.

Dr. Jennifer Steiner  1:15  
Absolutely, I'm happy to be here. And it's funny that you mentioned that the population is larger than one might think, because it really is quite a significant proportion of the American population. The most recent study that really looked at this was a survey done by the CDC back in 2016, which of course was five years ago, but that is the most recent. And they found that 28.4% of adults in the United States were living with chronic or high impact chronic pain. And and adults over 65 are actually about 60% of that group. So it's truly a lot more people than we tend to think about

Dr. Regina Koepp  2:00  
what sort of pain conditions are the most common.

Dr. Jennifer Steiner  2:04  
So for older adults, the most common tend to be osteo, arthritis, chronic low back pain, and diseases that tend to be associated with degradation of the joints. I would say in terms of the general population, idiopathic chronic low back pain is high up there, as well as fibromyalgia, rheumatoid arthritis, and osteoarthritis as

Dr. Regina Koepp  2:27  
well. That was so interesting that so many people so that Yeah, I think that I was reading that. That turns out to be like, more than 50 million US adults are living with chronic pain.

Dr. Jennifer Steiner  2:40  
Yes, yeah. It is an unbelievable number of people. And there's good reason why before the current pandemic, we were talking about it as a chronic pain epidemic, because it is, but it's, it's kind of gotten overshadowed for good reason.

Dr. Regina Koepp  2:55  
Why I'm so curious. So as a psychologist, you know, we have lots of different avenues to specialize in or sort of choose from what inspired you to specialize in pain and in health psychology?

Dr. Jennifer Steiner  3:07  
Wow, that's, that's a good question. So in all honesty, I grew up in a family with a lot of chronic pain, a lot of chronic illness and myself included, I grew up with a chronic pain condition. And I, you know, watched how I dealt with it. And I watched how my family members dealt with it. And we all kind of handled it a little bit differently. But the one common theme was that there really wasn't enough support for what we were all kind of trying to get through in our own way. And there weren't therapists or doctors, or anybody really, who could really speak to how it affects the whole person. And I thought somebody's got to do this work. And that's the short version of how I got here.

Dr. Regina Koepp  3:52  
Your direction or your specialty was directed by lived experience, and that noticing that there weren't enough supports for you at the family and honoring all aspects of your holistic self?

Dr. Jennifer Steiner  4:03  
Very much. So I would not be here without the personal experiences. And I think, honestly, I think that's what keeps me invested in this work is I just feel very passionate about helping people learn to live better with this. Yeah. Because because it can really have a very negative impact, but it doesn't have to.

Dr. Regina Koepp  4:23  
Well, I'm looking forward to talking about that more. We'll say more about that. What sort of negative impacts have you seen as a psychologist and also know from firsthand experience?

Dr. Jennifer Steiner  4:34  
Yeah, well, I think that's a really good thing to start talking about. I think there's this common misconception with physical pain, that pain only impacts the physical body and the reality is it that is just not true. I think partly people, you know, kind of default to thinking that way because not everybody experiences chronic pain or they're not familiar with it. And so we tend to think of it for more of an acute or short Return model, because that's what we're used to. So, oftentimes, I think the best way to approach it is to actually think about it from your own experience. And imagine a day that you've had like a really bad headache, or a bad head cold or something, something that's definitely unpleasant, but not long term. And you know, for most people, those types of experiences can interfere with your day or your week, you might have pain that gets in the way of, you know, concentrating at work, or how well you sleep, or just taking care of things around the house. But, you know, it tends to go away after a couple of days, and then you're back to life as usual. But for people with chronic pain, which by definition is pain that's been present for six months or more, almost every day, those experiences become part of everyday life. And so when those type of interferences start to become the day in and day out, it can then lead to a lot of other challenges. You know, for example, just the ability to maintain employment. So if pain is getting in the way of you being able to perform at work, or even to show up to work, that could be a really big issue. And that in turn can affect your finances, or the ability to provide for one's family, or oneself. And when that starts to happen, in some cases, people might notice a change and how they think about themselves. Because if they were defining themselves by their workers, their ability to provide for the family that can really change or shift one's kind of self concept. And all of that can cause a lot of tension in relationships as well. And so it's not uncommon for some of those changes to lead to depression or anxiety or stress. And then all of those experiences really start to feed one another, it gets really messy really quick. So those are some of the ways that I've seen it happen. But I also think it's important to know that that's, you know, what I'm talking about, it's not just based on my clinical experience, or even my personal experience, though, it definitely rings true. The research supports this as well, you know, there's been some research done by Corolla and colleagues in in 2017, actually, and they looked at 40 or 41, I believe, studies that were looking at the experience of chronic pain, and in doing so they were able to come across are determined five kinds of themes. And one of them was this idea of the body as an obstacle. So the body and the physical experience of pain, getting in the way of life getting in the way of doing the things that people want to be doing that make life meaningful, kind of what we were just discussing. And the second thing they came across that I think is really important to mention is this idea of pain, being invisible, but also pain being real. And this is just a huge, important thing to touch on. Because, you know, pain, we can't see it, you know, unless somebody has some kind of an assistive device like a walker or rollator or something, or they're engaging in some kind of pain behavior, like they might be rubbing a joint or limping or a facial display of pain, like a grimace, something to show you to cue you in, hey, there's pain here, we don't see it. And, you know, as humans, we don't really do a great job with things we can't see or touch or measure. And that's the other issue with pain is that right now, we don't have a good, objective, measurable way to determine how much pain somebody is in right now. It's it's largely subjective. And I will say science has come a long way in medical science, and we're a lot closer to coming up with some objective pain measures than we were, you know, even just 10 years ago. But but we're not quite there yet. And so when we ask somebody, what they're experiencing, when it comes to pain, we're reliant on their ability to describe it to us and knowing their experience and their report of that experience. And pain is very, very unique to the individual. And so I think the fact that a we can't see it, and B, we don't have a good way to measure it makes it much more easy to stigmatize. And so people with chronic pain are often experiencing the sense that they're not being believed. And that can lead to a lot of frustration and, and also contribute to depression. So that was something we see a lot, but it was also a theme in this particular study. The third one was this idea of a disrupted sense of self, which I kind of talked about a little bit already, just when pain comes in and takes away some of the things that kind of make you you.

It can leave a person feeling like okay, where do I go from here? Who am I right now, it's not uncommon to hear people talk about that was the knee before pain, or that was my life before this particular illness. This is the knee now it's almost like two completely separate people. And that's the real kind of adjustment for individuals. The fourth theme was this idea of an unpredictability of the condition. So with chronic pain, you often hear people talk about good days and bad days. And the fact that you don't always necessarily know which day is gonna be a good day or a bad day, you know, it's very common for people to feel good and be able to go out with their friends or take care of all of their things around the house, and really feel like they're getting quite a lot done. And then the next day kind of be stuck in on the couch or in bed trying to recover. And it can feel really unpredictable. And while I have found that with some, some guidance, a lot of times people with chronic pain can identify their triggers and figure out which days are going to be up and down and whatnot. That doesn't mean their loved ones or the people that they're around day to day, configure out that roller coaster. And so that unpredictability tends to lead to more challenges with interpersonal relationships and fulfilling commitments, and again, contributes to that stigma. And so those are just, you know, some of the ways in which chronic pain really can kind of grow fingers, if you will, and really start to get into all the aspects of somebody's life. And so to me, it's really not surprising that it would have a big impact on mental health.

Dr. Regina Koepp  11:09  
So let me just review the four themes. One was body as an obstacle. Can you give an example of that?

Dr. Jennifer Steiner  11:16  
Yeah, yeah. So I think the most concrete example would be like, if you want to walk to the mailbox, and all of a sudden pain, the physical experience of pain is getting in the way of you getting to the mailbox to get to your mail, it's, you know, the physical experience of not being able to do something you want to do.

Dr. Regina Koepp  11:37  
That's a great example. So the themes were, one body as an obstacle to pain is invisible, and it's real. The third theme was a disrupted sense of self. And the fourth was unpredictability. And you give some great examples about how that influences relationships. And I really appreciate it also the commitments, like the unpredictability of where will my pain be? And can I manage my commitments on those days?

Dr. Jennifer Steiner  12:11  
Can you make a plan when you don't know how that pain is going to be on any given day? And that's something a lot of people struggle with?

Dr. Regina Koepp  12:18  
Yeah. You brought up an important concept of stigma related to living with chronic pain. Can you talk a little bit more about the stigma that people living with pain experience?

Dr. Jennifer Steiner  12:29  
Yeah, I, you know, I think part of it goes back to what we were just talking about in terms of the unpredictability and the fact that we can't see it. And so a lot of times, because of those factors, loved ones or people that you would associate with may have thoughts like, Well, you were fine yesterday, why can't you do that today, or, but you don't look sick, that's the one I hear all the time is, but you don't look sick, or you don't look like you're in pain. And, and I think, a lot of times, that gets internalized by people who have chronic pain as well, they think it's all in my head, or they think I'm faking, or they think I'm lazy, or that I'm making it up. And sometimes those messages directly are what is being told to the person who's living with pain. And when you know that, that's just not the case that really, really can be devastating to relationships, and people tend to then pull away, you know, if you're getting these messages from people, that they don't believe what you're going through. Why would you associate with these people? Why would you put yourself in that situation, and so you tend to become increasingly isolated, as a result of some of that stigma, and honestly, it happens in doctor's appointments, sometimes, too. I would love to believe that it's happening less with better education, but it still happens, you know, there are still medical providers who are not super well informed about these topics, and, you know, kind of brush it off. And some of that's based on, you know, biases that they may have, which which I do want to talk about a little bit later. And some of it's just based on not being well informed. But there's a lot of stigma there.

Dr. Regina Koepp  14:12  
I can we get into those biases now, because one of the follow up questions I did have was around, you know, because it's invisible or not seen readily. And it really relies on does the person believe us that we're telling how much pain we're in? I think that is directly related to bias.

Dr. Jennifer Steiner  14:32  
You know, and I do think that that's true. You know, there's a ton of research now, thankfully, out there on how biases affect Medical Decision Making specifically as it relates to chronic pain. And a lot of that research points to the fact that when situations are ambiguous, when we're not sure what to do, we tend to fall back on biases whether we realize it or not, and a lot of times I think that's what's happening in the medical field. You know, I don't want to say this. There's a lot of research to support the fact that biases in terms of race, and gender and socioeconomic status and other social identity variables are playing a role in medical decision making for pain. And that can come across pretty much any type of the decision. So it shows up in prescribing habits. So whether or not somebody prescribed an opioid versus an anti inflammatory versus an antidepressant or an anticonvulsant. It shows up in terms of whether or not to refer to mental health. So interestingly, some colleagues of mine at IUPUI, so Indiana University, Purdue University, Indianapolis, I know big, long name, but they do a lot of work looking at biases in the medical decision making around pain. And they have you found that when women present with chronic pain to a female, I'm sorry, let me back up. When women present with chronic pain, they tend to be referred to mental health more often than men, which is probably not surprising. It's aligned with a lot of the other research that's out there. But what is interesting is that they find that that's even more prevalent when women present to a female doctor. So a female physician or provider is more likely to make the referral to mental health for a woman than for a man. And it's interesting, because it's you're not, I guess, I'm not really sure exactly what to make of this. On the one hand, one could argue perhaps these female doctors are more attuned to the potential overarching needs of a woman showing up in their office. On the other hand, what happens when a man presents it to their office, and really could benefit from some support from mental health, but they're missing it, or when a woman shows up and has a male provider. So there's, there's very stark differences there. And that's just based on gender. There's also a ton of research looking at how this affects African Americans and the Latin X population. So the research suggests that African Americans actually tend to report greater pain severity, they tend to report greater pain related disability, lower quality of life, more psychological symptoms, depending on how we measure it, it gets a little bit complicated, but they're not being referred to mental health. And they're not being offered the same range of treatment options, like PT, or OT, or different types of medications, when compared to their white counterparts. And so bias is playing a huge role. Not just in terms of whether or not the person is believed, but also in terms of their actual treatments. It's a big problem.

Dr. Regina Koepp  17:43  
Speechless. Yeah, I knew it was there. I mean, you know, we you and I both do a lot of work and cultural humility and incorporating a sort of social justice frame to the work that we do. And I'm wondering now, you said, and I know we have other things we're going to be talking about. I think this also directly relates to the impact of chronic pain on mental health. Because what message then does that give to, it was clear about the message when we looked at gender was giving to women, it's okay to have mental health needs an additional in addition to physical health needs. Or it could be another interpretation or conceptualization, like I'm thinking about for women, like it's all in your head. Right? Right, which is there's a positive or a negative,

Dr. Jennifer Steiner  18:35  
right. And that's the message they receive a lot of time, I cannot tell you how many times I have talked to somebody and they're like, Well, my doctor just thinks it's all in my head. And, and that's not only an unhelpful message for people to hear, but it can actually get in the way of them getting additional treatment, if they need it, you know, if they're hearing well, they just think I'm crazy. They just think that pain is something that manifesting, they're not going to pick up the phone and call somebody to help them work through it. Whereas, you know, if you tell them, I think your pain is real, and I think it's really affecting the rest of your life and all of these negative ways. And maybe it would help you deal with all of it a little bit better. If you talk to somebody who can help you figure out a way through it. That message is totally different.

Dr. Regina Koepp  19:20  
Yeah, and that I think, you know, the former message that the more harmful one like it's all in your head, you're just crazy. Is not only stigmatizing pain, chronic pain, physical pain, but also stigmatizing mental health needs. Absolutely. And yeah, and then where does the person you know, and it's almost like a punishment rather than a help. And I'm the part that really I struggle with because it feels like it's a double whammy with stigma. And then the referral is more punitive. Yeah, like it's all in your head. When number punished Yeah, and then like you were saying, but the message could be We are here to help you with the physical aspects of your pain. And there's we know that pain has fingers, as you called it, and, and there's help for that too.

Dr. Jennifer Steiner  20:10  
Right? And there's people who can actually work on both. So there's a lot of options if we just talked about it the right way. Yeah.

Dr. Regina Koepp  20:21  
Okay, so now with the that the gender is clear about how that plays out. So can you give an example for African American and Latinx folks who are, so I heard that the consequence of the bias in terms of health care is in treatment like that African American and Latin X folks are not as often referred to mental health care or not as often referred to OTP T or other other supports and managing aspects of pain. And I'm just wondering, then, about the psychological consequence of that.

Dr. Jennifer Steiner  21:00  
Yeah, so

my understanding, and also my experience, is that a lot of times, it just leads to more internalized stigma, it leads to a lot of thinking like, either, maybe I am crazy, maybe it is in my head, or the medical establishment is just going to continue to fail me. And so I'm not going to seek help in any way, shape, or form, I'm not gonna go to my primary care, I'm not gonna go to mental health, I'm not, I'm not going to try because they're not going to hear me anyway. There is a lot of research that suggests that satisfaction with medical care is significantly less for the African American community, as well as the Latin X community. But it seems to be more pronounced in African Americans. And I think a lot of that has to do with a long history of mistreatment of that population by the medical establishment. And we could spend hours on that, and we should spend hours with that. But it tends to lead to more depression, more distress. Yeah. Because if you can't go to your doctor, who can you go to?

Dr. Regina Koepp  22:05  
Right? This also leads me to think about how limited our Latin X statistics might be. Also, if we're only researching folks with documentation, versus folks, Latin X folks who don't have I grew up in Los Angeles. And, and I worked, you know, I went to grad school in the Bay Area and worked with a Latin X population. And thinking how much of a barrier it was to come to treatment if people didn't have documentation status, because of fear of deportation and fear of being found out and, or family members being found out. And so people would just not go right to care or probably not participate in research. That also and also are in higher risk jobs for injury.

Dr. Jennifer Steiner  22:56  
Yes, that is very much the case. And when they do become injured, they don't have as many options. And so the potential negative impact on their overall quality of life, I'm thinking, you know, not just their their physical and mental health, but you know, their ability to provide and their financial situation and becomes extremely limited. And so they either have to work through that pain, or are facing pretty challenging situations.

Dr. Regina Koepp  23:22  
Yeah. I'm thinking about all of the various social identities, you know, in areas of stigma and bias that for 10 years, I worked with people with spinal cord injuries, while I still I still actually have patients with spinal cord injuries, but and just the messages that many people I've worked with, with spinal cord injuries who have quadriplegia paraplegia and, you know, are different levels of paralysis from neck or waist down. Yeah. And just messages sometimes that they get about, Well, you shouldn't be feeling this. You shouldn't be feeling pain, because you're paralyzed is some of the message. And I just think, Wow, that is such a cruel method and unfair and untrue.

Dr. Jennifer Steiner  24:01  
Yes, so much of the I mean, the My first reaction was, can we just get rid of the shoulds? Like, they just have no place here. And it's so untrue, just from like, a physiological standpoint. I mean, then our nervous systems are incredible in the way they can just read. I mean, you know, that's in the way they can rewire themselves and the way that, you know, continued feedback loops allow us to feel pain where we shouldn't that's why we have, you know, phantom limb syndrome for amputees. Oh, wow. That's just the my mind. Not blown. I've heard these things, but it's incredible that we're still people are still sending these messages.

Dr. Regina Koepp  24:36  
Yes, and to populations of people who have heard cruel messages throughout their life. Right. So just the the insult upon injury? Yes. Do you know I know this is a curveball, but since we're talking about social identities, any any stats on LGBTQ identities and pain,

Dr. Jennifer Steiner  24:57  
so there hasn't been a ton of Research. Honestly, I feel like the pain world is a little behind the eight ball and just finally starting to attend to race and gender over the past 10 years. I'm really worried they weren't talking about it before 2016, I'm going to take a tangent to get back to your answer. A colleague of mine presented on race and gender biases in 2016. And at a the American Pain Society Conference, and the room was like in shock, like, it was the first time people were actually really talking about this. And so that was five years ago. So there hasn't been as much on the LGBTQ population, as I would like to see they are starting to do some of that work. And there does seem to be some, some bias present in terms of the medical decision making for pain, it becomes particularly challenging, and I've looked up the research for the transgender population, in particular, when somebody has anatomy or anatomy or organs that they wouldn't otherwise have with their chosen gender identity, and how that gets managed. If they happen to be having pain in those areas, particularly pelvic pain. It is not managed well, let's just say that.

Dr. Regina Koepp  26:24  
Yeah, I have so many images in my mind of what that experience must be like as a transgender or non binary person going in a doctor's office experiencing pelvic pain or GI pain or whatever, sort of pain in the abdomen area, right? Like, just,

Dr. Jennifer Steiner  26:44  
there's so many layers to the stigma, and the bias that they face just trying to address their pain in those appointments sometimes.

Dr. Regina Koepp  26:53  
Yeah, my fear for that, like my fear as a psychologist is retraumatization. And continued rejection or be a little bit or invalidation.

Dr. Jennifer Steiner  27:03  
Right. And, of course, that doesn't lead them to show up again, right, doesn't lead them to seek treatment, if they feel like they're just going to be invalidated and treated poorly.

Dr. Regina Koepp  27:13  
And we know it's already a high risk, mental health population. Right, right, who experiences high rates of trauma from society. And then also, that gets internalized and then high rates of mental health concerns. And then it's they don't get their pain managed, which I know we're going to talk about today is the risk for suicide.

Dr. Jennifer Steiner  27:33  
Yeah. And it is, you know, and I'll just, I'll jump in there. You know, chronic pain is a significant risk factor for both depression and suicide. The most comprehensive literature review on this was done just a few years ago, I think, in 2017, or 18. I can't remember. But it showed that people who have chronic pain are twice as likely to report suicidal behaviors, or to complete suicide compared with people who do not have chronic pain. And that in this group of people, so these people who have chronic pain, suicidality is actually more related to psychosocial factors, like what we've been discussing the the impact on mental health, the impact on finances, and family, and social and stigma and everything we've been talking about. It's more related to dealing with that than the pain itself, which I think is a real important takeaway, because I think most people can think about it as Yeah, I mean, if you're in excruciating pain, why would you want to continue to put up with that, but it's not just that it's really more everything else?

Dr. Regina Koepp  28:43  
Yeah. Well, let's talk about chronic pain and depression. Sure. So how are they connected? And related, but what's the overlap there?

Dr. Jennifer Steiner  28:53  
Yeah. So it's actually pretty interesting. So I think, you know, we've been talking about other ways that pain can affect your life. And so it's not, I think, a hard leap to get to like a Yeah, that could make you depressed. But it also works the other way around. And I don't think people really realize that. So it's really kind of fascinating. So our brains and our body are unbelievably interconnected. And we are hardwired or, you know, biologically programmed, if you will, so that when we're experiencing any kind of strong or uncomfortable emotion, like depression, like anxiety, like intense stress, it causes a chemical reaction in the brain, which then causes several neuro chemicals to be released. And I think most people have heard of the fight or flight response or the fight flight freeze response. And that's the idea that when we're faced with any kind of danger, or even a perceived danger, like a strong uncomfortable emotion, or depression, it can cause the body to react in physical ways. And so what happens is that when our brain picks up on that potential danger or that uncomfortable emotion, the brain activates your stress response. And that usually starts in the hypothalamus. And then that message gets into two other parts of the brain. One is the pituitary gland, which releases the stress hormone cortisol, and the other is the adrenal medulla. So that releases epinephrine or adrenaline. And what happens then is that causes your heart rate to speed up, it causes your muscle tension to increase, which as you can imagine more muscle tension for somebody with chronic pain, not a good thing. And it can also suppress the immune system. And so you know, while those changes can help you deal with whatever the stress or the threat is, in the short term, in the long run, it actually amplifies the effects of chronic pain. And, you know, that's just from having some type of threat, which could be the emotion, it could be the stress. But it's also worth noting that just being in physical pain, can actually set off that cascade associated with a stress response. Because your brain is designed to interpret a pain signal as dangerous. That's why we have pain, it's our it's our alarm system. So just having that daily experience can set off that process. And when chronic pain causes that stress response to happen over and over and over again, it causes a dysfunction in part of the body that are part of our system that we often call our HPA system. And that causes a weakened immune functioning, it causes chronic muscle tension. And in some cases, it actually increases pain sensitivity. And so that's all just from having pain, and potentially having chronic stressor or some depression. So that's that piece of the link, it actually gets a little bit more complicated, because in addition to having a stress response, when we have pain, it another part of the brain actually also takes that pain message, and is supposed to help us inhibit it. But what happens when you have chronic pain and chronic stress, and nothing else is working right? Over time, that system breaks down. And so instead of inhibiting the pain messages, it actually causes another cascade of chemicals, and the system loses its ability to do that properly. And so you've got your stress response, amplifying everything up, you've got chronic pain, basically making it so that your nervous system doesn't actually process pain the way it should. And it just becomes this really nasty, vicious cycle for people. Yeah, I apologize. I got a bit technical there.

Dr. Regina Koepp  32:37  
Now I think it's helpful. I think for for the really invested in this, I think the technicalities are important. And I think for the more beginners in this, I think the technicalities are also important because it talks about the complexity of the pain experience.

Dr. Jennifer Steiner  32:57  
And I think, you know, if we were to put it in kind of a like, what would that actually look like type of way, you may have somebody it's not uncommon to think of, okay, you're having several bad pain days in a row, you might start feeling a little down about that start worrying about, you know, when am I going to get back to, you know, my day to day is this going to affect my job, what have you, and your brain is going to interpret those thoughts as potentially a perceived threat to life as you know it or to your job or your sense of self. And then that would trigger your stress response, causing the person to have increased muscle tension, which would amplify the pain they were already having. So now they've got pain on top of pain. And then they may even feel more depressed and hopeless because now they're hurting even worse. And so because it's chronic pain, and it's been happening for a long time, it would not be unlikely for the brain and the nervous system to have dysfunction and its ability to kind of calm that pain down or stop the pain from amping up. And so that's how that amplification process happens. And you know, at that point, the pain and the depression just start feeding each other and it becomes pretty cyclical in nature.

Dr. Regina Koepp  34:14  
Yeah. What percentage of people living with chronic pain have depression, like would meet criteria for clinical clinical depression.

Dr. Jennifer Steiner  34:23  
So the exact statistic for the general population is escaping me. I know for older adults, it's 13%. So for 13% of adults over 65, they experienced both chronic pain and depression. I think it's actually slightly higher in the under 65 population. But those numbers are escaping me. I apologize. There is some research that suggests that just having pain increases the risk for depression, like basically doubles it. So that would that might give you some thoughts about the prevalence of that

Dr. Regina Koepp  35:00  
Which comes first? Now, you're sort of saying like that there's this bi directional relationship. And there's this loop. So does pain lead to depression or depression lead to pain? Or is it all of the above?

Dr. Jennifer Steiner  35:12  
That's such a good question. And the short answer is, the short answer is, it's complicated. And I'm gonna give you the long answer. So, you know, as we were just talking about, because of all of those physiological changes, it can be hard to tell. And honestly, I think to some degree, it does depend on the individual. And if you can do a quick, good clinical interview with somebody, sometimes you can get the the which came first, but the research is actually a little bit unclear. There's research to support either way. So there's been some work that shows that seems to support the idea that the depression comes first. So Williams and colleagues looked at the general population and found that among those people who were depressed, pain was common and 65% of them. And they took that to mean that pain is a symptom of depression, so that depression must come first. And we also know that depression exacerbates pain. And so some people have taken that to mean that depression, at least has a contributing role, if not potentially a causal role. Of course, we know that correlation doesn't imply causation. And it's hard to do these studies. So we're not really sure. But but there are arguments for that side. There are other studies that seem to really point to this idea that the pain comes first. And so there was a study that gets cited a lot that was done in 2010, that shows that for people who have chronic pain, the most common course of events is first pain. And then the depression naturally follows. And it was found that the depression is usually associated with the pain, lack of sleep, which may be secondary to the pain and changes in day to day life that are secondary to the pain so that there was some pretty clear research to suggest that at least in that population, and in my clinical practice, that's actually what I see the most, you know, somebody, sometimes somebody may have had some stressors prior to the onset of pain, but generally, they may have been handling those stressors pretty well. And it wasn't until the pain started, really getting to the point where it affected many, many different areas of their life negatively that clinical kind of diagnoseable major depressive disorder set in, and then you get that cycle or that bi directional relationship where everything just feeds itself.

Dr. Regina Koepp  37:33  
Yes. You know, this, your mention of sleep is so essential to that we didn't talk about earlier, but I'm glad we're talking about now because I'm thinking, collecting on my clients who are living with chronic pain and have other mental health or demented mild cognitive impairment. And I have one one person has mild cognitive impairment and a sleep issue, but the sleep issue is related to chronic pain. Yeah. And it makes the cognitive issues worse. Pain does and then so does lack of sleep.

Dr. Jennifer Steiner  38:08  
Yes, I often refer to that as like the trifecta, right? Because they all feel one another pain actually can affect cognitive functioning too. You know, it's not uncommon to have a little bit of what I affectionately call brain fog, associated with the pain and pain medication can cause some of that as well. And so between the pain and the lack of sleep, and then not being able to, to concentrate or recall things the way one would like it's just, which is can be frustrating and makes the pain worse. You just, it's a big mess.

Dr. Regina Koepp  38:43  
Yeah, and then and then the lack of sleep also lowers our threshold or lowers our tolerance for distress. Yes. So then, so then we're less able to tolerate all of those stressors, because we haven't had enough replenished. You know, it's absolutely punishing sleep. And yeah, just

Dr. Jennifer Steiner  39:02  
Yeah. And actually, there's been some studies, they're a little old now, but that show that when you you don't have sleep, at least in the appropriate come components, so your sleep architecture is messed up. It can actually lead to chronic pain syndromes like diffuse syndromes, such as fibromyalgia, like symptoms, we don't think that's what fibromyalgia is, but it can recreate the symptoms just from lack of sleep.

Dr. Regina Koepp  39:30  
Yeah, sleep is such a big deal. And so, earlier, you mentioned that there are professionals who can help people with both pain, physical pain management, that physical chronic pain management and also all of the mental health and psychosocial factors. Can you say a little bit about that?

Dr. Jennifer Steiner  39:51  
Yeah, actually, I love talking about this. So this is great. Yeah, so I, I first of all, I want to say that I actually think this is one of the big two challenges for people when it comes to accessing mental health. You know, we already talked about some of the other challenges, but this is a big one. There are lots and lots of really well trained mental health providers who have good experience in depression and anxiety and stress and trauma and all of these other areas that are important. But that doesn't necessarily mean that they have training in working with people who have chronic pain, or that complex relationship between the physical and, and emotional pain. And I find for people who are really caught up in this pain cycle that I keep referring to, they really need somebody who can speak to both in an intelligent and informed way. They need somebody who can help to educate them on how the physical pain and the emotional experience fuels one another because a lot of people don't recognize that in their own experience. And you really need to understand that in order to help kind of break that cycle and do things a little bit differently, so you can cope better, you need somebody who has the knowledge of the medical treatments, or the common experiences that go along with chronic pain. And not everybody has that. So health psychologists or pain psychologists, in particular, are pretty uniquely suited to help people who have chronic pain because they have received specialized training. Typically, these are psychologists who've, who've studied with the intention of working with people who also have either chronic pain or some type of medical condition. And they have training in anatomy and medical terminology, and how to read a medical chart and the psychological interventions that work for people who have chronic pain, because those interventions are not just about okay, you have depression that came after your pain, it's about how do we come up with some strategies that will help you manage your pain triggers? How do we help you do more with your pain without landing you in bed for the next three days? And how do we help you deal with any kind of depression or anxiety or stress or relationship issues that are stemming from from all of this, these challenges in your life. And so they're not treating the pain per se, but they definitely can help to manage triggers and teach you some techniques to reduce the pain or better manage contributing factors. And I think that's why it's important to find somebody that that really does have that background. Yeah.

Dr. Regina Koepp  42:30  
And why it's so important that we're talking about this today, even for the general practitioner, because if 50 million people or more than 50 million people are living with pain in the United States, there isn't possibly enough health psychologists to a common so so even more important, or equally important, is just this dissemination so that general mental health providers, you know, who have sort of a general practice, know some of the basics, some of the fundamentals so that you can help, right.

Dr. Jennifer Steiner  43:00  
And I think even just understanding that these things feed each other can go a long way and just general practice. And it's not hard to find trainings, either. You know, there's some, some good evidence based trainings that if you, if you're starting to see a lot of this in your practice, you can educate yourself.

Dr. Regina Koepp  43:18  
Yes. And I know we have some of those trainings. Yeah. In our in our. So now, what are so you mentioned in terms of bias, what some of the challenges are for people with pain, trying to access mental health care. So some of what you've already described, our bias within the health system, in terms of is the pain believable, based on bias, and then who is getting referred to mental health so women are disproportionately referred, I'm guessing white women are disproportionately referred to mental health care. And Latin X and African American folks are often left out of referrals to mental health care. And so what are some of the other barriers for people living with chronic pain? Accessing mental health treatment?

Dr. Jennifer Steiner  44:07  
Yeah. Well, we've touched on a lot, as you just mentioned, I think I'm gonna come back to this idea of the stigma, not just the bias, but the stigma, you know, when you tell somebody, it's all in your head, they're not likely to show up. And so that in and of itself is a significant barrier. You know, both for mental health care and for pain, and then when you put them both together, it's like, well, I'm not going to do that, if you think I'm crazy. So I think the the real takeaway here is that if we approached, like I said before, if we approach it with a different message, people are more likely to show up and that's one way that we can combat that barrier of stigma is just normalizing. Yeah, pain is very common, and it does affect lots of areas of your life. And oh, hey, by the way, did you know that because you're having a completely human response to this and experiencing some dressed that might be making your pain worse, why don't we help you manage all of it, since that kind of a message I think could go pretty far. So that's that's just to kind of hit that home. I think stigma is a big one. I think finding a mental health provider that has that background is another challenge. And I'm really appreciate that you brought up the fact that sometimes you're just going to be seeing somebody in general practice may be seeing a lot of this because there really are not a ton of health psychologists out there. You know, one resource that I often will direct people to is the American Board of professional psychologists are a bet they've got a directory, and you can search by clinical health psychologist by zip code, but there are not that many. And not all psychologists are board certified, either. So that's not a golden one. Or hold on one, excuse me, but it's a place to start. And then, and then I really think our biggest our biggest challenge is the bias. For sure.

Dr. Regina Koepp  46:05  
Yeah, let's think about some other ways. So to deliver that message that's non stigmatizing. So we already gave two examples of how to do it, like just now you said, how can we normalize it and say, like, Hey, did you know that it's actually very common to have a mental health can experience mental health concerns, and in collaboration with physical pain, that it's common to have one with the other, and we can help you get treatment for that? Or earlier? You? We also had another example, I'm just trying to think like, because I know so many mental health providers will see this just giving a message in a variety of ways.

Dr. Jennifer Steiner  46:47  
Yeah, I mean, I say a lot of times, I believe your pain is real. And it's really impacting you, you know, just in a lot of times, I'll talk to somebody on the phone, and they'll just kind of start telling me their story. And in three minutes, they have to given me this huge list of ways, whether they realize it or not, that their pain is causing some challenges in their life. And also, hey, you know, you just told me that you're, you're not sleeping well, or you're getting a little snappier with your, your partner than you'd like to. It's possible that those things are related to your pain. Wouldn't it be great if we could manage them with that a little bit better? Like, I don't think you're crazy. It's a completely, it makes sense to me that you'd be feeling this way. And I think we can do something about it.

Dr. Regina Koepp  47:31  
Yeah, the message of hope. Yeah, that this is not the end of the pain, journey, or the pain of

Dr. Jennifer Steiner  47:37  
variants. You know, I think I said in the beginning, it can be extremely challenging, as we've been talking about, but it doesn't have to run your life, I think it can be a long process to get to the point where you realize I'm not gonna let this run my life. I don't, it's not going to run the show every day, if you will. There's a way to live with it. It's not an easy way. I'm not gonna I don't want to make light of this and say that it's just get over it, because that's not it at all. But there are ways to continue to live a meaningful life with the pain.

Dr. Regina Koepp  48:10  
Yeah, yeah. And therapy can help with that

Dr. Jennifer Steiner  48:13  
therapy can help a lot with that.

Dr. Regina Koepp  48:16  
I'm also thinking about older adults in the messages older adults specifically get about chronic pain and, and barriers, older adults already have a lot of barriers to mental health, in general, and then pain on top of it. I've heard lots of physicians. And I think this is also changing with education about aging, and health spaces. But I've heard you many of my patients have told me when they experienced pain or chronic pain, their physician will say, Well, you're old, what do you expect? Of course, you're gonna be in pain, you're old,

Dr. Jennifer Steiner  48:48  
which is. So I think hurtful and damaging and invalidating to the person because regardless of age, they're in pain, it's not a pleasant experience, and they still have a life and they still have things that they want to pursue, and the pain is affecting that. And so I do, I think the point you're making is very important, because we do just assume oh pains part of aging. It might be because pain is more common among the aging population. But that doesn't mean it's less impactful or that it's easier to accept and just, you know, get over it. And I think that physicians do forget that there is some data that suggests that as much as we're getting better about screening for depression and in chronic pain, we're less likely to ask the elderly about it.

Dr. Regina Koepp  49:37  
Yeah. And then I also think this comes up, there's some ageism, ableism. And then some stigma with pain, which comes up with in dementia care, and dementia disorders. So I've seen where somebody who doesn't have dementia who's an older adult experiencing pain or limitation, physical limitations or mobility limitations. You'd get referred to physical therapy, I've seen that same profile of a person with dementia, not get referred to physical fancy,

Dr. Jennifer Steiner  50:10  
right? Because it's not like, like difficulties with with memory or cognition should affect how you're physically feeling or physically able to get around, which is what physical therapy is useful for.

Dr. Regina Koepp  50:23  
So yeah, and it could eliminate agitation that comes with dementia sometimes, especially when people with with dementia are in pain. And the physical therapist could train the caregiver on helping do physical therapy tasks beyond. I mean, there are so many ways, but then, you know, dementia is a disability. It's a degenerative condition. And so sometimes it's not seen always as a disability, but it is, and and so

Dr. Jennifer Steiner  50:51  
it's another invisible disability, right, you know, we were talking about pain is an invisible disability, but so is dimension. So somebody asked, you know, until there's a behavior, that's indicative of it, you can't see it.

Dr. Regina Koepp  51:03  
Yeah. And it's hard to articulate pain if you have dementia. So you might just be acting out your pain or being in a bad mood or irritable or so anyway, there. There are lots of barriers with chronic pain management among older adults and adults living with dementia disorders. And even Parkinson's disease. I've worked with some families with Parkinson's who the tremor is creating a tension create a sort of a pain condition and of itself, and just the frustrations and challenges that come with that. Right. And I'm really enjoying this conversation.

Dr. Jennifer Steiner  51:40  
Me too. Me too. This has been great. Yeah. So what recommendations

Dr. Regina Koepp  51:44  
do you have for professionals who work with chronic pain individuals,

Dr. Jennifer Steiner  51:49  
so I'm just going to be at this point home, because I think it's so important, believe them, I mean, I, the most important thing anybody can do is to believe them. Because we've been talking about the stigma and the misunderstanding and whatnot. But, you know, even when we are not sure what the person's the what the etiology of the pain is, or whether it's organic, or if it's not clear, it doesn't matter. They're coming to you because they're experiencing it. And it's likely really impacting them in other ways. And that's all that matters. And so I would say not only believe them, but also I want to encourage providers, especially providers, who are not mental health, to ask about how the pain is impacting the person, not just how it's affecting the physical body or the the physical tasks of the day, like ADLs, like, can you dress yourself? Can you get up off the toilet, those things are important. Absolutely. And without those things that can affect, you know, your sense of self as well. But that's not all. That's important. And I think sometimes we forget that in medicine. And so it's completely appropriate for doctors and nurses and other medical providers to start screening their patients with pain, for depression for suicidal thinking. And I realized that's increasing. But it's not just about screening, it's also saying, how is this affecting your day to day life? It's not enough to just, you know, give a PHQ nine or ask a couple questions about suicide, it's how is this affecting your day to day life, because then then you get a real feel for what's going on. And you can refer to mental health if it's appropriate. And you can do that sooner than just waiting for things to pop up on a screener. So that's for medical professionals for mental, mental health professionals, I would just echo the point we made earlier, which it's completely okay. If you realize, oh, my goodness, I'm out of my league managing this, this person who has chronic pain, there are people who have extensive training and who may be able to help you they're in a consultant role, or you can refer to them, or go get the training yourself. There's lots of that out there. And then, you know, you may feel more comfortable in doing that type of work. And then just talk, you know, having an opportunity to hear discussion like today so that you can at least say, hey, these things affect

Dr. Regina Koepp  54:13  
each other in that pain cycle. If you're if you're looking at the pain cycle with mental health providers eyes, yes. Where is the first place for the mental health provider to start? Yeah,

Dr. Jennifer Steiner  54:27  
so I think that's a really important question. You know, if you if you've got all of these different places that you could potentially target in the pain cycle. I actually, I think, you you couldn't, you could actually hit it from two different ways. So one way that you could hit it from particularly if your person is very focused on the pain piece and a lot of people are is to start with explaining the pain cycle and explaining the stress or depression and pain relation Ship, I will often draw a diagram and explain the biology behind it. Because when you use the physiological or biological explanation in a, in a way that the person can understand, of course, it helps them see, oh, this isn't in my head, this is my body responding the way it's supposed to respond, but it's over responding, if that makes sense. And so I will start with that physical explanation so that you have their understanding and their buy in. And then I usually do relaxation training to help calm down the muscle tension piece and the stress response piece that happens when all of the completely understandable stress and depression are part of the picture. So that's usually where I start. Because then they have a tool. First of all, they have an understanding of what's happening. They feel validated, because they're like, this isn't I mean, it's in my head, because my brain is in my head, but it's not really they have a tool, then to help calm down that response, and to start using almost immediately within the first couple of sessions. And then you can start working on some of the other pieces, like the depression, or the way that it's affecting the family relationships, or how to help them do more, without hurting as much. So that's generally where I start in that cycle is actually a little bit more on the education and physical side. If you have somebody that's really much more focused on like, I just don't feel like myself anymore. I feel completely like this other person, then I'll start more with that, in terms of doing some work on like, well, what does make you you? What are your values? What would you like to be doing more of what would make you feel more whole, unlike yourself again, and go at it from that direction. And sometimes we don't ever even get to relaxation training that may not be important to that particular person. But there are two very distinct ways of dealing with it, depending on how somebody comes. And the nice thing about the cycle is that you really can enter it at any point, like you could enter it from an emotional point, you could enter it from a biological point. And I use my knowledge of the person sitting in front of me to figure out where to start, if that makes any sense.

Dr. Regina Koepp  57:15  
Yeah, that knowledge and a very keen clinical ear. Yeah, you're paying attention to is their presenting description, physical and nature or self concept oriented in nature, or maybe some other,

Dr. Jennifer Steiner  57:31  
right. I mean, and sometimes people will come in, and their biggest issue is, you know, my pain is getting in the way of me being able to take care of my kids or take care of my older, you know, my mother, who's who's aging, or what have you. And so then our focus, our first focus is, how can we help you do more in hurt less? How can we kind of come up with some behavioral strategies that are strategic, so that we can address that before we deal with everything else? You know, the way that the evidence based interventions are structured, there's usually a right way to start. But clinically, I find that it's helpful to look at what what the person's goal is, and start there.

Dr. Regina Koepp  58:13  
Yeah. You mentioned one of the earlier features is after sort of the psychoeducation, about the pain cycle is is a relaxation technique. And some of the things that you talked about with the relaxation technique that I thought was very useful, as you know, I worked for 10 years with older veterans who Yes, when I suggested relaxation training, which may give all sorts of protests and, and lots of skepticism. Like I don't want to do this airy fairy woowoo kind of stuff. And so one of the ways for the skeptics, depending on why they're skeptical, sure about relaxation that I really appreciated about in terms of the way you described it, was it actually the intention for doing it that the intention is that it will help with the the muscle strain or the muscle? I forgot the words that you use,

Dr. Jennifer Steiner  59:13  
I often use tension or or some people will talk about muscle spasms happening. So I'll be like, let's it can help reduce the prevalence of that, or the frequency of that. I'm very clear about it. It's not meditation. And it's not mindfulness. I know mindfulness gets used a lot. And there is a place for that and there's good evidence for that. But when I'm talking about relaxation, I'm not talking about any kind of woowoo we are physiologically trying to access the part of the brain that slows down your body. We're trying to turn off your stress response. And in doing that, we may be able to help release that muscle tension and get your pain to come down a couple of notches. I've when I've explained it that way. I own I mean, I think in the amount of time I've been doing this I may have only had one or two people ever say, Yeah, I still don't want to do it. Most of the time people are like, okay, let's give it

Dr. Regina Koepp  1:00:04  
a shot, please. Yes, yeah, yes. And explaining it like that is so clarifying to me too, as a clinician who's done a lot of work with people with pain and medical problems and life altering medical conditions, that there's all the there's a lot of protests for that, and lack of familiarity with it. Right. And just having the intentionality we do it because of this. And we do it because it's part of this pain experience that we can help target and treat. And it has no side effects.

Dr. Jennifer Steiner  1:00:39  
Right. And you can do it whenever you want. And it takes sometimes as little as five minutes. You know,

it's very hard to argue with that.

Yeah. And sometimes people will find that it takes more practice, but, but I have never had anybody get mad at me for trying it after they've said we could after explaining it that way.

Dr. Regina Koepp  1:01:02  
Well, that's so helpful. Thank you for that. You're welcome. Dr. Steiner, it has been a delight. Learning from you today and hearing about the pain cycle and where professionals, both medical and mental health can participate and provide care and value. I especially love the emphasis on believe them believe that the pain is real, and do your part to reduce stigma and enhance access to care. So thank you for

Dr. Jennifer Steiner  1:01:33  
that. You're welcome. I've enjoyed talking about it. So where can people learn more about you? Um, yeah, so

my company or my practice is beyond the body health psychology services. And my website is www dot beyond the body Psych. So p s ych.com. And I'm also on Facebook and LinkedIn. And you can find out more about me, they're

Dr. Regina Koepp  1:02:02  
great. So we'll definitely link to that and some of the references you mentioned in the show notes. So wonderful. Thanks so much. I can't wait to have you back for another talk on pain or chronic pain.

Dr. Jennifer Steiner  1:02:14  
Can't wait to be here.