Complexities of Pain: A Journey with Laura Rathbone in Physiotherapy, Psychology, and Philosophy

Welcome back for this week's episode of the Modern Pain Podcast. This week we're going to talk to a friend and colleague, Laura Rathbone. Laura is an advanced practice physiotherapist working with people experiencing complex and persistent pain conditions and a consultant in physiotherapy for CRPS and neuropathic pain. As part of her work, she collaborates with clinicians to help develop their practice and reach their goals as a clinical coach, as well as through her group and community platforms like Pain Geeks and her own subscription. In this episode we're going to talk a little bit further about her journey and some of the people who've impacted her along the way. We also talk about how she's resolved that conflict that arose for her, like for all of us, when the conception of pain she was taught at university didn't really line up well with the complexity of what she was seeing in the clinic. Laura discusses her strategies to deal with uncertainty she sees in the clinic and also the role philosophy plays in her thinking and practice. We're also going to touch a little bit upon psychologically informed practice and her past training and perspectives on how we can best use it in clinical practice. Acceptance and commitment therapy is another topic we discuss and this is where Laura is an expert. In my opinion, she's leading the way on applying ACT in the clinic and helping other clinicians do the same in her coursework. It was great talking to Laura. I think you're all going to really get some significant value from this episode. Enjoy it. This is the Modern Pain Podcast with Mark Kargela. Welcome to the podcast Laura.

Hi, yeah, thanks for having me.

It is always good to chat with you. I've had the privilege of chatting with you a few times now. We've had you on when Jared and I were doing our learning academy, where we had to do a master class on ACT, and we'll probably touch a bit upon ACT because I know that informs a lot of what you do in the clinic. We'll also probably talk a little bit about your world in the clinic. You've also recently had a major win for yourself as far as finally getting licensure there in the Netherlands. That was a heck of a journey.

I won immigration, now somehow.

I remember talking and we had chatted before this that like two years ago when we first had that master class, you were in the midst of it Recently when I saw that man. That took a bit, but we'll touch upon it, hopefully not get the blood pressure too raised, because I know that was probably a frustrating journey as well.

No, but it has been an interesting journey. Sorry to interrupt you. Just to say registration equivalence across international borders is no small thing, and I think as physiotherapists working within a protected title, we don't necessarily realise just how hard that is. And of course, intersection when we apply intersectional theory we know that it's not the same experience for everybody, and so it's really helpful for us to be mindful of that, but also to recognise that let's not take for granted the freedoms that we have to practise and just how easily that can be taken away.

Yeah, definitely something to be grateful for. I've been around some clinicians who've come to the US and just from a far scene like man, that sounds like it's a pretty intense process. I don't know the exact end notes of it, but everybody I know that's done elsewhere who's travelled abroad has mentioned it's been a challenging process, to say the least. So congratulations on that for finally getting to the finish line. For those of our audience who aren't aware of you, I know a lot of folks see online and do some amazing things, but I'd love if you could just kind of recount a little bit of your background and maybe your journey that brought you to where you're at.

Oh, yeah, sure, Well, I guess my clinical profession. I'm a physiotherapist and I graduated I think I finished my uni bachelors about 12 years ago and I've been sort of on this journey of trying to understand what is not only like, what is pain, but what is the role of a physiotherapist in somebody else's pain experience, and how do we like, how do we draw on all the different and available therapeutic theories and frameworks in order to best support, you know, people that come into our clinic who we don't know and we have to figure out how to get to know them and how to open up a safe space for that relationship. So I'm very interested in that and communication and I guess that the my love of like, communication and relationship building and the sharing of information probably comes from, like my early, I suppose, professional aspirations to be a writer and a journalist, and so I actually trained as a journalist before I trained as a physiotherapist, and so communication study and the sort of philosophy of language, these kind of things were part of how we understood the story and how we, I guess how we understood what it was to have integrity in your writing and what it was to hold a relationship and to try to get to the important points of somebody's story. So that was that's where that came from. And then, since then I worked. Most of my career worked in London, although I'm not from London, I'm from the northwest of England, from a very small seaside town called well it's not very small actually, it's quite big, called Blackpool, which is on the beach and it's mostly like a well, I don't think Blackpool would like me to say this, but it's kind of like a party town. And so I had a great job, I'd had a great young adult life and but then I moved down to London and mostly worked in different types of settings. So I started my practice in private pain, private physiotherapy, working mostly on like injury based insurance cases, which was wonderful because I got to meet lots of people. But it wasn't so much fun because I was constantly feeling the conflict of my ethics and that's challenging. As a new grad, you know, being able to navigate that is quite hard. There's a lot of pressure. And then after that I went and worked embedded within a GP practice which is like a physician, a general physician, I think you call it, and that's obviously what we call it, because it's GP. Gp is anyway, so general practice I've just never thought about what the words might actually be. And then and I worked there, which was really lovely, and I had a great relationship with the, the GPs in that department and saw a lot of their sort of chronic pain and ongoing musculoskeletal conditions patients, which was really wonderful because I got to establish relationships which I like. And then and then I went and did my masters at King's College where I did advanced neuromusculoskeletal physiotherapy practice, which is where we're looking at sort of advanced clinical reasoning in MSK conditions and applying, or I suppose, the. The idea is to try and think across the neuromusculoskeletal systems and we're thinking about patients. And that's where I got to meet Professor Mick Thacker, who taught us our pain module, and so I was very lucky to have that experience. And then he introduced me even more into the word of thinking about pain through different, using different traditions like philosophy or humanities and as well, as you know, a really as well as like being able to integrate the IASP framework for understanding pain in a more sort of, I suppose, neuroscientifically based way. So an IASP is the International Association for the Study of Pain, so they set the sort of baseline curriculum for pain specialized clinicians. So yeah, so I went and worked in a from the GP centers. I then went and worked in an outpatients typical outpatients in the NHS high volume again clinics, and then from there I went to tertiary care, so into the specialized pain system, working in St Thomas's Hospital in London on their inpatient four week pain management program, which is the national, one of the national centers for pain in the UK. And now I'm in Amsterdam just kind of bringing this all together in in my own way and trying to figure out well, okay, after all of that experience, how do I want to practice what? What practice do I want to build and grow and nurture? That, I think, best reflects my integrity, my ethics and my interpretation of the evidence. Thinking about the whole landscape of evidence, not just you know these kind of like the hierarchy and you know systematic reviews and the kind of positivist approach to science, but thinking about what you know how do we honor the experience of each individual person and the sort of the complexity of pain and what kind of a practice would we build if we honored all of those things? And that's where I am now.

Yeah, it's a pretty amazing journey. I think you know definitely jealous to have the opportunity to have Mick as your instructor. I've had you know privilege of having Mick, having a few chats with him and he's been involved in a few things and always come out so much better. Also come out scratching my head and thinking a lot more deeply after you chat with Mickey just obviously is a very deep thinker and has definitely done similar as far as spurred my you know thoughts of looking a little bit deeper and looking at different perspectives of some of the knowledge we have in the world as far as not just from that physio lens of expanding. I'd love to hear a little bit about the conflicts you've had as far as when you kind of considered pain. You know we come out of uni with a thought of it and a very kind of physio educational mindset which I know in the US still getting better. I'm UK pride. I know from my discussions that they're working to improve it as well, but we probably have a way to go. But I'm just curious your conflicts with your kind of conception of pain, not just when you left school but how it's kind of progressed over time. I mean I don't think we ever fully resolved that conflict. It's a very complex, complex topic. But I'm just I'd love to hear what your journey's been with pain and how it's kind of changed over time.

Oh, such a good question. I guess I'm spending a lot of time thinking about it, but maybe not necessarily putting it all together in a timeline. So I spend a lot of time thinking, well, what do I think pain is now? Like? What? What do I understand about it now? But I did a talk recently where I was like hey guys, you know, before you went to university you knew what pain was. You had a really good idea, a good working idea, of what pain was. That you know, made sense to you. And then we go to university and all of a sudden we're like I have no idea what this thing is like. What is it Like? I don't even know if people really experience it like do, and we start thinking that we somehow have some role in judging somebody else's pain, because it gets pulled apart and then it, and then we sort of struggle to put it back together again and I don't know whether we ever really can, because pain just isn't isn't that simple, you know. But I guess you know, before I went into university I knew what pain was. Pain hurt and it was scary and you know, most of the time it was very helpful, but sometimes it was weird and didn't make any sense at all. And my mom had chronic pain, chronic low back pain. So I knew that sometimes it lasted longer than you know. Some pain seemed to last for a very long time, some pains didn't. My dad was a much older father. He passed away 10 years ago but he he, you know, he was an older gentleman. He just lived with pain every day. So I also had this idea that we, you know, when we get older, it's just part of, seems to be just part of life. And then I went into physio school and started getting all concerned with how I could prevent people from feeling pain and how I could cure their pain. And all of a sudden, there, somebody else's pain went from being this thing that seems to be just part of life to something I am personally responsible for eradicating. And that responsibility, I think I felt very, very deeply and I think it it became a part of my identity in some way. As a clinician, I became very much like I've got to be able to understand everybody's pain and find the cause and fix it. And I went on this really big journey into manual therapy because that seemed to be the right thing. And you know needling and trigger points and you know how do we do, like muscle energy techniques and facial release and all this stuff. You know, I went into all of that with this idea that I was supposed to be getting rid of somebody else's pain. And then, as I've as I suppose, as I've emerged from that journey and become more interested in, well, not what works for pain, but why. Why does somebody have pain? And like, why? Why? Why? Why for this person does pain seem to be so, I suppose, without wanting to be too dramatic, but why for this person is pain such an invasive experience, so distressing, so disabling? But yet we can't find anything like why is this happening? And that that question just took me away from those kind of like skills based models of physiotherapy and more into this kind of like clinical reasoning, understanding of my professional role and, you know, trying to fully understand a person's experience. And I guess, where am I now? Well, I'm probably more lost than I was ever. I'm not really sure what pain is. I don't really know what the meaning is of pain. I'm not sure we can say that there is much of a meaning to it sometimes. Why do we? And but I guess what I'm more moving into is this idea that it is? It's more than just biology, it's more than just brain processes, it's more than just one particular, you know neural process. It's a neural mechanism. It seems to be something that we do based on all of the information that we collect over the years and that we sample in the moment, and it seems to be more about how we are in the world than telling us something accurate about the state of our individual tissues or systems. But that doesn't mean that the individual tissues and individual systems are not important in that, because that would be, I think, too big of a statement. So I guess the conflict is still there, but I'm shifting my position, I suppose, and have been on that journey for the last sort of 10 years really, and it's a long one.

Yeah, no, and pain can definitely. I admire your response. As far as I don't know what pain means at the moment, and to me it's a sign of somebody who's a deep critical thinker and clinical reasoner, because it reflects pretty the status of and state of things and pain. But it brings uncertainty and uncertainty is one of those things that I'm sure as you were a young physio, you wanted nothing to do with uncertainty, you wanted certainty. You had mentioned and I remember this very similar journey of like I need to find it and fix it and be the all-knowing person who can take this person into stress and save the day. Yet now you function in a state of uncertainty and successfully you're doing well with, not only obviously clinically, but you coach a lot of clinicians in that uncertainty. I'd love to hear your thoughts on how you get clinicians because you do a lot of great work coaching clinicians who are probably struggling with this uncertainty to find their footing to be successful with people who are in this distress. I'd love to hear your approach and how you deal with it.

Yeah, gosh Well. First of all, thank you for the compliment of saying that you perceive that what I'm doing is successful. I think I do the best I can and I try to always like uphold my own principles of what I feel is right and proper in the way that we do things. But I think sometimes what happens is maybe people might see that as me being super successful in the clinic and always knowing how to best support someone and how to do this thing well. And it's a process and there are often times where I get it wrong and I might overstep a line or say something that's not particularly timed. Well, that brings up a lot of conflict, and I guess one of the things I've done a lot of work on is in forgiving the fact that I'm human and that this other person is also human and that we don't know everything about each other, and so there are going to be times where we step into a direction that might be particularly unpleasant or distressing for somebody else, because I can't see the whole picture. And so just one of the things I've worked on is having that little bit of humility where I just say like hey, I'm really sorry, I didn't realize. And now we know that there's a boundary there. I'm paying attention to that and I'm going to hold that as best I can, whilst also recognizing that I am human as well and full of flaws and make lots of mistakes and get that wrong all the time. And I think that is what helps me build sort of like good relationships. Trusting relationships might be the right way, in that we trust each other enough to allow the benefit of the doubt to be there and to allow flexibility within their relationship, and I think that's what we're looking for really. You're never going to have the best, the perfect relationship or the perfect conversation, but if you can trust each other and you recognize that you're both working within the best interests of the person and that you're authentically doing the best you can, I think there's a lot of space for uncertainty and error sometimes and mistakes, and sometimes they can be the best conversations that come out of that, and so, for me, really getting comfortable with my own fallibility and my own humanity has helped me to build, I think has helped me to build more authentic relationships that honor the complexity of the experience and also the rich life that this person has had before they came into my like before our existence is met. So I think that's one thing that I've spent a lot of time working on and, to be honest, it is the work that I've done with psychologists, the support, the regular supervision and coaching that I get from my psychology mentor, and also the deeper and deeper I go into something like acceptance and commitment therapy and thinking about what it is to be human, and that has helped me enormously to hold that space, because I think we get this. We sort of get encouraged by the model, the very simple linear model, that we're given in in in physio school and I don't mean that in an in an offensive way, because I think teaching physio is an enormously difficult task. You know what do you fit in, how do you guide people through this, how do you make sure people get to the end? This is not an easy job to do and it's not an easy topic to learn, and it's and it really isn't something you learn in three years. You do need to keep investing in it for your career. So it's an enormously difficult task to do and and ultimately what happens is everything does kind of get simplified and made into a kind of linear model, because we're moving through time linearly. So we sort of build it that way. But and you do get kind of caught up in this idea Well, if I ask the right questions and I move through the algorithm and I find the right answers, then I will know the cause and then that the cause will tell me what kind of treatment I need to do, and then the treatment will reduce the pain and then the person will get better, and then I will get a box of chocolates and we'll all move on very happy. And it's that kind of feeling. And I think one of the hardest things is when you realise, yeah, it was very nice, but it wasn't accurate, and now I have to go into learning all over again, almost as if it's from scratch, because now you've got to fill in the gaps. And that's a hard undertaking and can come with a lot of anxiety and a lot of feeling of personal shame, like you have some time, somehow you've got it wrong, somehow you're not good enough, somehow you just don't know what you're doing, especially when we see every like other people, particularly influencers, who seem to have it. So I mean I look at these, you, and I think what are we doing? Two different jobs, like I walk in and it's like I have no idea who this person is and what's going on, and I'm burdened with all of those feelings of fear and anxiety as I open the door and you look on social media and it's so simple and what I think is happening is that people are hitting that cognitive dissonance as they come out of university and they're just like, well, I'm just going to stay over here because this is easier, or this feels more, this feels like I can get more notoriety, this feels like I can push the agenda of my own ego, I mean, which is fine and good for them and we have a wide enough profession for everyone, but it's, I think, for me. It feels like it doesn't convey the real complexity of being human, working with humans in on a very human experience that we don't really understand yet. And so I think if you feel like you don't know what you're doing, you're probably in the right area. Keep pulling on that thread and keep asking those questions and eventually you'll realize why you don't. You feel like you don't know what you're doing because nobody does.

Yeah, yeah, I love the discussion of you know this thought of everybody, I think, views some of the folks we hear on podcasts or social media as they're gonna walk in their clinic and all these people are just getting better. And I always say like if people would follow me, I don't think they're gonna be amazed at you know that I still have people that don't get better. There's still people that I am like not sure what's going on. Like we said, and trying to get comfortable in that space is a major undertaking and I think you give some good examples of just some of the thoughts and the internal kind of discussions we have with ourselves and this feeling of you know, inferiority and imposter syndrome that sometimes pervades even I. There's definitely times where I still feel of walking in the clinic of, and then we have this flip side of social media that presents, you know, the highlight reels of everybody's practice and I agree it doesn't represent some of the challenges and the real the reality of what we face on day to day, because human beings come with a massive degree of complexity and you've done an amazing job just kind of diving deep into that complexity. I want to touch a little bit about your psychology, especially some of your supervision, how you're kind of undertaking that. But I'd love to even back up a little bit to philosophy because and I know this can go deep and philosophy is a massively deep topic. But how did that like enter your world, even just a conscious thought of philosophy itself? Because I know for me it was really bumping into folks like you and Mac and others who are, who are talking about phenomenology and ontology and epistemology, and Matt Lowe's been another one that stimulated my brain in that mode a bit and honestly I had to. I had no idea what those words meant and as I've dug deeper it's really made sense and it's been a really fulfilling way to start really looking deeper, to say what it honors the complexity of what we're dealing with, because there's just so much that informs that complexity and things that we probably don't even consciously think about. That informs it. But I'd love to hear how philosophy kind of entered your world and where it sits now and and how you feel like as as somebody who might be toiling with the struggles that we speak of that how that might be a helpful resource for people.

Yeah, I mean, without a doubt, philosophy became a part of how I understand health care and my practice and because of the relationship that I had with Nick Thacker, who really sort of like Gave me permission to go back into some of the work I had done as a journalist, thinking about social theory, power, privilege, conflict as well, and, like you know all of those things and, and even before that so In my a levels. So what is that? 16 to 18 year old school, I did a topic called communication studies and and you know, we looked at communication theory and we looked at things like Marxism and feminism and post colonialism and, like you know, what are all these systems of Building societies that exist and understanding societies that exist, and I think I had taken that into my journalism world and but I'd never really thought about what that might mean as a physio when I went into physio school and it wasn't until I met Mick and he was like you know, this is, you know, pain is personal and public, you know, and politic it's. It's not just something that's happening within your therapy room or within the houses of people who experience pain. This is, you know, you can, you can understand, you know I was talking to someone this morning saying like actually our clinic is like a microcosm of society. You know, we're seeing social problems on a on a on a massive scale out in society, but we're also seeing them On these like micro scales within therapeutic environments and therapeutic relationships. And who's a philosopher of mind at the time in Edinburgh? And now I think he's believe he's down in Sussex and looking at predictive processing and the embodied mind and the extended mind, and so that's where those conversations came in. But I guess it wasn't actually until I moved to Amsterdam and was taken and was put under restrictions because my license didn't transfer. So this is where these things are important, right, because I moved to the Netherlands and in order to move your license from one country to another you have to, and the equivalency process is very lengthy here. So in the meantime I had to find a way to still be connected to my world and my environment. I was already teaching, so. So then I started thinking more deeply about some of the questions that I'd had around philosophy and around, well you know, social theory and power and discrimination, and you know, over over the years I've been able to meet more and more philosophers, and that's, I think if I hadn't have been put under restrictions and then had to find a new way of understanding my profession and think more widely and had the space to think more widely, I probably wouldn't wouldn't have been had the time to do that, because clinical time doesn't. You know, the clinical system, the framework of that, is not designed to give clinicians space to think. It's designed to get people through a system, which means clinicians are often running Very high volume clinics with lots of complexity, and, you know, having a space to go and read a philosophical paper might not be something that is available to us all when we're in those high volume clinics. And so that's how I ended up in thinking about philosophy. And then, once I opened the door, I was like, oh my god, this is really, this feels really important and exciting. Right, this is changing how I view myself, this is and how I've been practicing, how I understand pain and how I understand it's starting to help me make sense of some of the really challenging personally challenging experiences that I've had in the clinic, and it's really empowering the model I have, the psychotherapeutic framework that I work with him, because it seems to fit very nicely within there. So then I started exploring the philosophy of acceptance and commitment therapy, more thinking about, you know, the functional contextualism and how the environment might afford a certain type of experience and that links very nicely with an activism and embodied cognition, and so we're starting to see I just started to see how these worlds were all coming together and which was very exciting and and rewarding.

The psychology background that you bring to the table with with how you've really pursued that obviously is as you read the literature and what we see out there in the physio landscape. You know psychologically informed care has been a big push. But you know, in To talk about it's one thing but to truly enact it and truly incorporated into practices can be another thing. I think sometimes it gets lip service and then there's not a lot of depth To true application. But you've obviously gone deeper and went into true application where You're working with a psychologist who's given you feedback and mentoring and things. I'd love to hear kind of your perspective on where we are in that whole psychologically informed approach and where you think you know best practice sits. Obviously there's some subjectivity to that, but You're I would definitely consider you someone who is an expert in the incorporation of psychological principles into what we do. I'd love to hear your thoughts on where we're at with that and can how you use it in your practice and get that kind of guidance.

Yeah, oh, wow. Well, first of all, thank you for that, that's very kind to say. I still you know the, the sort of, I suppose, the, the, the, the rookie identity that I still hold on to sometimes would say I'm nowhere near an expert, but yeah, I do. I do call myself a consultant in psychologically informed Physio. I am at that place now where I feel, like you know, the role I take on very often is advisory, it's facilitatory and it's it's teaching. But but there is always just so much to learn and one of the things I love about having a psychology mentor or supervisor is that she reminds me just how much I don't know. That's just a wonderful, like humbling experience and you know, realizing that, you know this is we don't. It's not about necessarily doing it right or doing it well, it's just about kind of understanding and appreciating that the way a person feels, the thoughts that they have, this internal experience and that is private to them, is so much bigger than we, you know, as observers, could ever know, because ours is so much bigger than other observers can ever know of ours. And so what we're trying to do with psychologically informed physio is just try and move towards honoring that and recognizing that that you know pain, if we're saying pain, you know, if we're saying pain is not no reception, it's not just a product of tissue, tissue injury, then and even if it, even if it was mean that, just if we're saying it's not just a biological process they were just saying it's more than sensation, it's an experience then as clinicians working with the experience of pain, we probably Are required, I would say, by our evidence based ethics, to be incorporating more and more of these approaches. And actually, you know, psychologically informed physio isn't anything new. You know, the earliest mention of psychologically informed physio goes back to the 90s with, you know, physiotherapist Vicki Harding and psychologist Amanda Williams working out of UCL and and St Thomas's in London, where I was was fortunate enough to do some work Under the department that Vicki used to work in, and you know like this is and you know. And then we go back to sort of the 2000s, the mid 2010, 11. I think there was a paper that came out I think it was the Georgian lamb paper. That was like you know, we are now at a place in our evidence which says, if you are a physiotherapist and you are not engaging in psychotherapeutic models, you're not Developing your psychotherapeutic approach to integrate into physio, then you no longer evidence based when it comes to pain, and the evidence now requires us to do this. And yet here we are in 2023. I'm still talking about it like it's this new thing that's just arrived recently and that's partly because you know, like you say, how do we fully integrate this into a model and a framework that that was built and predicated upon the idea that pain Is something that happens to people because of some kind of injury and is correlatable to that injury and therefore we have a role in some kind of tissue change and then that would go away, which doesn't necessarily mean. You know, shoulders don't talk about their feelings. So if we're, if we're thinking about shoulders and we're not thinking about people, then then the system that we build around that will not necessarily privilege and prioritize the time and space and environment that people need to talk about their pain, and so psychologically informed physio just feels like a no brainer to me. It seems so obvious that we would be engaging in this but yet, at the same time, so difficult for clinicians and myself, you know, working in traditional models and against traditional time frames, with supervisors and colleagues and mentors and managers who don't necessarily Acknowledge that psychologically informed physio or Physiotherapy practice that looks to incorporate the experience of pain into how we formulate somebody's I suppose diagnosis and prognosis, takes a lot more time and that can be hard on an individual clinician that is dedicated to integrating these things into their practice. And I suppose when I think about it, I think, well, how much time has it taken me to figure out what this thing is and what these things look like? Well, I remember my very first mindfulness-based stress reduction program was like, oh, it must be one or two years after graduating, so 10 years ago, and I had an idea as to how I thought it would be integrated, but I didn't have a lot of people to talk about it. I was in MSK clinics and people were kind of just, oh, you do those patients and I was sort of put in a corner of the clinic and people didn't really ask too many questions because they didn't want to know what was happening. And it wasn't until I started finding really good supervisors who were like, yeah, let's see how we can develop your practice and let's see how we can take you further, and who protected me from the model if I'm really honest and said, yeah, if you need three hours, take three hours, I'll protect you, and that I was able to really expand and be creative and make mistakes and rebuild and try again. And then I went into the tertiary centre where I was working with Lance McCracken Sorry, lance McCracken and I had a psychology supervisor and I was embedded within that and I was like, oh, I see where this is. Actually. It needs to come from the moment the person walks through the door. We need to be thinking in terms of what it's like to be human and what is it like to be me as a human and how do I make space for all of that and how do I manage my own responses and my own urges to act from a place of emotion to what this person who's experiencing pain is saying to me and be able to sort of put that to one side and be able to centre them within that experience. And so psychologically informed physio is not a new concept. It's a very old concept. It's been very well developed and very well thought out in many ways and there's lots of resources there. Physios can go on psychology courses. There's no nothing to stop you from going on a psychotherapy course or going to an ACT course, and the thing that I see most often when I work with individuals is but how does this fit into my practice? How does this fit into a traditional MSK space? And that's very difficult, because now we're talking about identity and systems, so we're talking about power, privilege, discrimination and all of those things that we all experience. But perhaps you know, if you're, if you're living within the dominant group say, your assist, hetero, white, middle class you might not necessarily have experienced power and privilege in that way until you start stepping outside of the box and then, all of a sudden, it becomes very, you become very aware of it and I think having some humility in terms of recognizing this has always been going on. This is, this is a part of how our system is built. And then, and then realizing that if you are moving towards pain care, that is, recognizing the whole person, you're working within a social justice space, and so you better fill in those gaps pretty quickly.

Yeah, yeah, I think you know it's just that deep look at what we're up to and some of the things that inform them. I'm some of the, like you said, power structures and social kind of structures that that we again, I know I personally didn't even consider it, I was just so unsteady, you know, when you come out of school you're just trying to figure out what's going on and get your feet planted somewhat firmly on the ground to feel like you're not failing from a day to day thing. But, as you, you're a great example of somebody whose journey who you know, continues to just realize that humans are never going to give us stability to where we have this like approach, that is, this just algorithmic, linear approach that works with with most of the folks that work through the door. And I think you also bring up some great thoughts on this psychologically informed thing isn't new. This is something we've been talking about for some time, and it gets frustrating because you see the time from research study to clinical floor, but then even more into. Like you know, university classrooms can even be longer, so we still have a ways to go with that. But you know folks like yourself definitely pushing that a bit in a good direction, so much appreciated.

And I'd say that probably we're always psychologically informed, you know, like you know, when you think about the influence of cognitive and behavioral therapy over the years, you know, I mean, this is an approach to understanding the mind and how people experience the world and emotions. This is, this is something that comes out of like the early 1900s. So it's very, it's very, reasonable and plausible to think that physiotherapy has always been psychologically informed. It's been informed by the movement of cognitive and behavioral therapy Always. It's just that cognitive and behavioral therapy has also gone through its own evolutions and changes and we're now moving. You know, we've been in sort of like where we had behaviorism and psychoanalysis and then we had, you know, then these two worlds came together to become like cognitive and behavioral therapy and then we had third wave behavioral therapy, which was the beginning of the acceptance and commitment therapy movement, compassion focused therapy. This was sort of the last 10, 15 years. And now we're maybe moving into another phase where we're thinking about process based therapies. And you know, it's also evolving all the time. And so now I think what's happening is physios are like oh, this, this physio model that we have doesn't, doesn't fit with this new emergence of psychotherapy, this new evolution psychotherapy. Now we need to go into psychologically informed physio. But actually we're just updating the, the model through which we are psychologically informed. You know, maybe we're becoming a bit more aware of it, a bit more cognizant of the influence on physiotherapy. And if you think about, you know, it's very, it's very likely that we've been working within cognitive and behavioral frameworks for a long time. It's, it's in pop culture, it's in pop psychology culture, it's. But now we're just a little bit more aware of it perhaps and trying to think well, how do we do that? If we do that intentionally, are we better at it? And the evidence tells us that physiotherapists, if they do that intentionally, they are better at it and it helps them to build more relationships and it helps them to. It helps them with engagement. People tend to stay on physio longer. They tend to do more. It helps us to to manage our own wellbeing. We start to have less anxiety. We're perhaps less tendencies towards perfectionism. These are all really good signs. That says you know, being more intentional about your learning and integration of psychological approaches and theory into your physiotherapy practice, which will be personal to you as well, as, you know, translatable across people, can not only help you to hold a safer space and a more therapeutic space for people with pain, but it can also help you within your own personal experiences of being a therapist, which is not easy, you know. Yeah.

No, I would wholeheartedly agree, I would testify to that as far as incorporation of psychological informed care has really made me have more comfort in my ability to not always have the answer, to not always be that person who needs to have the cure, the fix I mean things and being able to hold that space with still having confidence that I can do my best to help somebody but also not carry this massive burden of the outcome on my shoulders to where I have to have this outcome that comes out. I'm going to do my best to have the best co-created space and outcome I can have with each person. But I also honor the fact that I can only do so much and there's also so many things that inform you, know that interaction with a person that you know you do your best and there's sometimes it may not come out in the the best, but you're again is we can always be confident that we're doing our best to come together with somebody and make the best outcome possible. But that may need to be things beyond our control that may impact those things. So I really appreciate your thoughts there. The acceptance and commitment therapy you've touched upon already and that's been one topic that you've been a big influence on myself as far as really incorporating it better into my practice. You've done a masterclass for us in the past. We'll link it in the show notes here, but you're also doing some more things on the Act Room. But before we get into your course because I'd highly recommend, if you want to learn how to incorporate it, laura's probably the best person to do so to help you in your practice. But I'd love to hear kind of your view of acceptance and commitment therapy, how it's kind of where you came across it. You've already touched upon maybe a little bit in how you kind of look, you know big picture principles that have helped you better navigate your clinical world.

Yeah, acceptance and commitment therapy is what's called a third wave, cognitive and behavioral therapy. So it focuses less on challenging maladaptive thoughts and beliefs and avoiding triggers, and more on you know how to live well alongside adversity. Acknowledges that adversity may well be a part of somebody's life for longer or shorter periods of time, and that we all experience that. We all go through these periods of distress and difficulty. And so it's about figuring out how to live well alongside those things rather than get caught up in the struggle of trying to get rid of them in order to move on with your life. So it can be particularly difficult. It's not specifically about pain. It's not a pain focused psychotherapy. We're not necessarily even focusing on trying to reduce pain, although I would hold that in my personal practice and interpretation that that is always. The goal is to try and see if pain is reducible or modifiable or changeable.

Yeah, so I think we lost you.

Yeah, I'm back.

I don't know if you can see me again, I got you. I got you so you can I don't know if it keeps recording when I'm still talking, or does it stop recording? It does. It may do on your local machine, I'm not sure. I think I know there's recording going on, probably. It just made the the the ability for us to communicate, and it might still be recorded on, so you can pick up wherever you feel like and I'll stitch it together. You won't even know anything happens. So um yeah, wherever, wherever you feel like. Uh, you, the last I heard you said I would hold, and then yeah.

So I would hold that pain reduction is always something that I'm, you know, wanting to achieve, because I feel like, as a healthcare clinician, committed to, um, you know, doing my bit to, you know, help, I suppose help people not necessarily help people but, um, you know, hold a space for people to experience positive change. Um, I think that's the therapeutic contract that we kind of, you know, we're here to support people in the changes that they want to make in their lives and, and we do the best that we can to be part of that in a positive and helpful way. Um, but acting itself isn't necessarily concerned with changing pain. Um, in fact, it quite explicitly says this is not about, you know, measuring reduction in distress. This is about, you know, uh, working in in ways to make life richer and bigger, um, and doing things differently in order to to make life richer and bigger, alongside some of these experiences. So I guess what it's helped me with enormously is, you know, when pain doesn't necessarily change, rather than, rather than uh, chasing the change in the pain, uh, which can sometimes lead to stigmatizing or dismissal or over medicalization, because then, all of a sudden, we're concerned or frightened that something is more seriously wrong when all of our evidence says this is not necessarily anything sinister or specific. So this is something general and non-specific, um, or primary, like a chronic, primary pain then. Then it allows it sort of allows space for us to be like, okay, we're going to hold pain reduction just here lightly, because obviously we're all that's part of human nature. Right, we want better experiences on the world, but we're going to work towards, you know this thing that we call you, know life. You know what is your life, what are your values? Where is your joy? Where is your feeling of you know having a role in society and being content and doing the things that are important to you and getting your necessary stuff done, even when some of that isn't particularly fun, um, or when it might come with pain. So it's, it's opened up that part of my practice that wasn't completely dependent on pain reduction as being the only outcome for a good therapeutic experience. Um and so, and and that's really quite explicit within act Um, and it teaches us skills. Um, and it teaches. I think the way I mean, certainly the way I teach it is actually it's not a thing we do to people. It's, it's a part of how we understand. You know what it is to be a person that experiences negative and unpleasant emotions and sensations or perceptions, or you know, you know, stuff happens, life, life is sometimes very hard, and and so how do I, how do I best navigate that? Um and thinking about? You know, the framework of act gives us these sub processes to focus on, like you know, and recognizing if you're spending a lot of time in the past or a lot of time in the future, and, just you know, coming back down to the present moment to remember that what, what we can do right here and now, is really all we can actually control. That's really all we can do from moment to moment, and I can't change what's happened in the past and I can't, can't, ensure something is going to happen in the future. The only thing I can do is this moment, this choice, this, this breath, this, this me, this here and then. And one of the ways that we can, we can start thinking about well, what choices do I have in this moment is by being willing to accept that this unpleasant thing is here and I can't necessarily change it, so I'm going to allow that to be here and then I'm going to observe what urges, what habits, what rules, what, what actions seem to be? Do I seem to be moving towards that. I feel like I must like. I feel like, you know, we call it stimulus equivalent. So I have this unpleasant experience and then I want to do this action, and that might be, I have pain and I want to run away, or I want to get away from it, or I want to find out what the cause is. And so, you know, by spending time in the moment and accepting that pain is here, we might not be able to change it. What space does that give me to make a different decision? And if I've got that space, if I can take that diffusion, if I can take that step back, what do I want? What do I want to move towards? You know who am I in the world, and thinking about you know your values, is very important, but also yourself as a context, like what is the trajectory you're moving towards? What do you want to? What stamp do you want to put on the world? And what actions are in line with that? Rather than what is this sort of response, this response to this unpleasant experience? What action is responding to that unpleasant experience? And if you have the choice, even though it's not easy and even though you might not be able to do it to 100% of what you have idealized in your head. What would you do? Yeah, what step would you take? And that might be a small step or a small step in the direction that is meaningful to you can often feel like a small step well spent. Yeah, yeah, no, well said.

I'd love to hear because I know you do some work with some clinicians on this and obviously do some skilled work to help clinicians start incorporating this into their practice, because it is a journey and having someone who can mentor you and kind of give you feedback and talk about cases and what you're seeing in real time. Because there's one thing about you know, having maybe some recorded lectures those are good, not just for the students having maybe some recorded lectures, those are good, nothing wrong with those at all, but having the ability to kind of communicate with somebody who's kind of been through it, who's, you know, working to navigate the struggles of human pain and the things that we see entering our clinic doors. Can you share with everybody a little bit about the course you have on ACT, because I think it's a great resource for folks that are really truly trying to incorporate, not just again watch some recorded things and maybe not get that true application and and steering ourselves in the mirror of what we're doing in the clinic.

Yeah, so I've been developing this online course. I mean, I started teaching it just before the pandemic restrictions were put in place, excuse me, and but then you know. And so essentially what it is is it's a four week course. We meet up once a week and we, you know, we move through discussions about elements of acceptance and commitment therapy that are useful and we practice some skills and we think about what this might mean for your practice, and we spend a lot of time thinking about the framework and about the kind of like what does what does the framework actually mean? You know, like, when we think about acceptance, like what, what actually does that mean? You know, it's very easy to just real offer Acceptance is the ability, the willingness to have unpleasant experiences. Right, okay, that's a sentence. What does that feel like? How easy is it to do that? How are you going to support somebody to be willing to accept the unpleasantness of pain in a clinical space? You know, because that's what that sub process is all about. It's not just telling people oh, now you just need to be willing to accept that pain is a part of your life, like that. I mean, people are rightly angry, patients are rightly angry when they feel that that's what's being said to them, because that's not what we're saying. We're saying how do we get closer to being able to have this really unpleasant experience of pain and also be able to move towards the things that are important and valuable to you in your life? And that in itself is a very hard, is a very hard, challenging process, and so when we start incorporating Acceptance and Commitment Therapy into physiotherapy practice, I think what we have to remember as teachers and as facilitators, is that physios haven't done a five year psychology degree. They haven't spent Time thinking about why am I a clinician? Who? Did I come into health care to fix what? What ills in the world did I feel like I wanted to mean? I know that I had to do some work in Realizing that I could not fix my mother, who had chronic pain when I was younger. I could not get that back. I had to go through the pain of realizing that, although that might be part of the motivating factors for me to become a clinician, it's got nothing to do with what I do as a clinician. Now. You know it really needs to be bracketed away from my clinical environment and these are really hard things for a clinician to go through and your psychologist do a lot of work around different models. They start, they learn all the different psychotherapeutic approaches, but a physiotherapist going on to enact course doesn't have necessarily all of that background. And so when you say To a physio that doesn't have a psychological background or hasn't necessarily been through these processes of knowing themselves in their own personal development and you know, process to is process. Process one is mindful that process to is acceptance. Process three is diffusion, process for itself as a context. Process five is values. And process six is the end, committed action. You know, and it's like we take that very literally sometimes and we might think that it's as simple as just saying, okay, but you know, pain is there, but now what you know, like this, this is not, this is not it. Acceptance and commitment. Therapy is a full psychological model with a, with a philosophy and with a, with a, with a mindset and a personal practice. That is expected of the therapist. That is holding that space. And so when I teach my course I try well, I do the best I can to honor the fact that we also need to fill in some of those gaps and leave a space for clinicians to Question themselves and experience their own, their own conflicts, and actually that's exactly what we focus on. So, instead of thinking about how do we use act to help people with pain On my course, what we do is we think well, look, this is act. What does it mean to you? What are you experiencing? What struggles to you find that you're coming up with? Okay, here's, here's a technique in act that might help you to find some distance from it and to make choices. What does that process feel like for you? How do you go about that and how do you take that experience Into your next clinical experience? And, whilst being underpinned by the theory, so we're drawing on our own personal experiences, were humanizing ourselves within this process In order to hold the humanity of the other person when we go into the next session, rather than just being told this is a list of all the things that you do. So that's how I build this course and you know, that's why I think that four weeks is nice, because we meet, meet every week, we build it up gradually and then we go into a coaching period after that where people come back and we talk about it and we sort of problem solve some of those experiences, just to help people integrate it, because this is not a weekend course enough. You go now you know how to do it. This is a fundamental shift. It's a paradigm shift within how you understand your role and how you hold a space for other people. So that's the course that I do, and then, of course, that is then. So then I, you know, hold this individual clinical coaching space for people who maybe want to take that further, or people who want to further specialize in in pain, informed and rehabilitation spaces. And it's not just physios that I work with, that. You know my books. Right now I have Exercise physiologist, osteopaths, chiropractors, physiotherapists, gynecologists you know it's, it's, it's a. Really I tend to work mostly with people who are Applying their profession in a body situated way To understand how to integrate Across these different approaches. And then what I'm really happy about and what I love doing as well, as I have a small subscription which allows people to come in for, like you know, if you, you know, if you, either you can't access those things or you've accessed them and now you just want a lot ongoing support or you just want, you know, you want a place to keep coming and bringing complex cases. So it's, there's two hours a month of you know, people can just drop in and bring their complex cases or questions and we can have this hour long conversation about it and it's a and that, as well as all the other resources that I've built upon, that, I think, Just help people in that sort of more long term model of working in this space. Because you know, mark, you probably have this as well, but so often I meet people who are super dedicated and committed to understanding pain and and and holding this space in a whole person way better, right, better ways for people. That Is more compassionate and more honoring of the humanity, of what it is to be a person with pain, but they're like the only person in an entire department, maybe even in their entire area, like they might not know anybody else doing this kind of work, and so the feeling of being very isolated and be very lonely and feel kind of feeling Wrong somehow or like out of step or, like you know, unsure. I mean I've got stories of clinicians hiding their practice from all the members of their team, you know, taking patients into into the back of the gym because they want to talk about feelings with them. It's, it's, this is. This is such a it feels like such a toxic environment for emotion and emotion Emotionally minded physiotherapists to be working in, and so I hold this space for people to just come and have, you know, the supervision that they need actually in order to continue that practice and to feel Like they are growing within their appreciation of the full experience of pain, as per the current definition of pain, that it is, you know, a physical and emotional experience Every time, not just in chronic pain, all experiences of pain. And so you know, one of the things that I know has helped me main not not be good at this, right, that's not what I'm talking about here but has helped me to maintain my well-being, safeguard my mental health, prioritize my own personal and professional development, have safe boundaries, reach out and be in the room of people who are experts in this field, who are doing this research. The thing that really made that possible was good support and supervision, and I remember it well. I remember taking this job and Elaine she'll not want me to name her, I don't think, but I love her to bits, but she just was like I don't really know what you do, but it seems like it's the way we need to be going as clinicians, do it, and I will have your back, and that was like that's what we need, because it's not just a paradigm shift, it's not just about information. It's about feeling safe as a clinician to try and to explore and to get it wrong and to you know, all you know, as we move into these new ways of practicing, and that is going to require more than just, you know, a weekend course. That's going to require system change, and so we're all called to action, and now what you see all around the world actually is healthcare clinicians taking action and demanding, you know, better systems, better environments, more, more financial safety in order to do the work that they do, which is important and meaningful, and I strongly hold by this statement that you know, physiotherapists, as with all allied health, therapists, play an important role in the lives of many people who are living with disability, illness, long term conditions and pain, and so we should protect them. I think.

Yeah, yeah, I mean you can just hear in your answer the depth you go and the passion you have for the topic. So I mean those are the type of teachers that I think we need in the world to help kind of get these principles incorporated in the practice. And I would definitively agree that you know the clinical communities that you create with clinicians who may feel very isolated, very alone. That is so rewarding and so kind of comforting when you're in that instability to know that there are other people in the world who may feel like they have to hide their patients in the back of the gym or go to a private room because they're afraid what their colleagues are going to hear about talking about feelings and they're going to have these negative judgments of them. So I think having that opportunity to be in a group of like-minded clinicians who are facing the same struggles like that is so powerful and rewarding. Having had it happen and have the ability to have that in the past, that's how they recommend y'all think about you know, getting involved in that course If you're looking to see how this fits in your world. It's get better at this. The research and science has long since been there that these are processes we need to incorporate into our practice. So definitely take a look at. We'll link it in the show notes, laura's course and where you can kind of get to contact her. But for those, absolutely for those of you who may not watch the show or read the show notes or anything, laura, if you could just let folks know where they can kind of get a hold of you, where they can reach you, and then we'll wrap up.

Absolutely Like. You can get almost all of the information I'm hoping all of the information, since I write the website. But, like on my website, which is laurirathphonecom, and also just to give a shout out to another community that I run with my partner in sort of my partner in pain geeks, christine Petrudis, we run pain geeks and you can find that on pain geekscom community and that is a reading group that really focuses on how we read, what we read and what does this mean to us as clinicians in our practice. So we integrate humanities as well as basic science and social science. So just to say that those things are available. And also, you know, everybody is welcome in the spaces that I hold. You don't have to be an allied health therapist, you don't have to be a physiotherapist. You know this is about people who are working to support people with pain, wanting to understand pain more, and so for me that includes all professions. So, yeah, that's yeah, everybody's welcome, come join. Yeah again.

I highly recommend it. Definitely check it out. We'll have those links in the show notes. And, laura, I want to thank you for your time today. I really appreciate the conversation, always enjoy chatting with you as far as what you're doing and very impressive stuff that you're doing, so keep it up.

Thank you very much. It's always lovely to be here, mark, and thank you for inviting me on again.

Absolutely. We'll have to have you on in the future again here on your journey. Our journeys continue to unfold and then more conflicts will occur that we're having to navigate. I think are valuable for our listening audience to hear and see that some of the struggles are not unique to them, that even that we all deal with some of this uncertainty and conflicts in our world and our practice, and you're a good example of somebody who's navigating it and really putting it out there and helping others navigate their own struggles. So thank you for that.

Yeah, I think if I could say one more thing, and I know that we're coming to the end and I know I talk a lot, but you know, I think what sometimes happens is, when we talk and what I've heard a lot of clinicians say is, well, if nothing matters, then why do I do the job I'm doing? And I just want to end on a note that says you know, what we're saying in the evidence is not that nothing works, it's that everything probably has the potential to work and so your job is really important. And the time that you invest into developing your knowledge and nurturing your interpretation of the evidence and growing a wide practice that has enough skills and space for the human experience of pain, that is really important. And what you know, what we do, makes a difference to the people that we work with. And, yeah, I think this is a really valuable message that sometimes hasn't necessarily come across and it's what I hear quite commonly is people just feel like, you know, I don't even know why I'm doing this, and I would just say that you know, thank you to every clinician out there that listens to the podcast, that gives their time, that invests in the pain, informed communities, because they do not typically survive more than about five to six years. Right, this is the sad thing about the job we do, you know. You know, if we look at the pain, informed communities certainly, since I've graduated I've seen them come and go but for all of the clinicians that do continue to invest in these spaces and to engage with them and to promote them, you know, thank you so much because this is not an easy space to be in, pain is not an easy area to work in and the work that you do, supporting and investing and learning matters. So thank you.

Yeah, no, definitely would concur with your thoughts there it is. It is a tough journey but yeah, it is. There is a lot to be had. I know there's a lot of sometimes cynicism and nihilism about what we're able to do and not do, but there are so much opportunity and so much opportunity for growth, for clinicians to really find comfort in the discomfort and the uncertainty and the distressing situations we find ourselves in the clinic. I actually have renewed my enjoyment for clinic and there was times where, especially when I was in the depths of my manual therapy pursuits, realizing that the complexity chase I had there didn't really pan out the way I was hoping it would did. But then really getting in and chat with folks like Laura and getting to talk with Mick Thackers and have Matt Lowe's and have, you know, chat cooks and other folks, they've really had huge impacts on myself. Yeah, Bronnie Thompson, I mean we could file this off.

She's my soul sister. I think she's a wonderful human being and a brilliant researcher and guide and teacher as well. So yeah, read her book Very much so.

Yeah, and she'll be somebody who will be reaching out again. Bronnie was on gosh, one of our early episodes when I was still figuring this thing out. So we'll have to have her on for another conversation, but yeah, well, I'm gonna. I want to respect your time today, laura, I really appreciate it. We'll definitely have to chat with you in the future.

Yeah, thank you very much and thanks for, like you know, letting me take a very extended goodbye.

Oh, no problems, we appreciate it. We appreciate your time today. We appreciate all you who are listening and who have made it this far Obviously some great stuff today and really appreciate you. If you could pop on and maybe subscribe on the podcast vendors or maybe even on YouTube, we'd greatly appreciate it so Laura and I can get our message out to more folks. But until next time, we'll talk to you all next episode. Bye Around Pain. This is the Modern Pain podcast.