Welcome back to the Healing Pain Podcast with John (Drew) Sturgeon, PhD
On this week’s episode of the Pain Science Education Podcast, we explore the concept of pain resilience with our expert guest Dr. Drew Sturgeon. Dr Sturgeorn is a fellowship-trained licensed clinical psychologist and clinical assistant professor at the University of Michigan School of Medicine Department of Anesthesiology. Dr. Sturgeon shares his journey into pain resilience, influenced by his mentor Dr. Alex Zoutra’s work on adult resilience and adaptation in chronic pain. We discuss the growing interest in pain resilience and its distinction from pain vulnerability. Dr. Sturgeon emphasizes that resilience should be viewed as a process rather than a trait, highlighting the importance of sustainability, recovery, and growth in the face of chronic pain. We explore the idea that resilience involves actively pursuing meaningful goals despite pain, rather than merely tolerating it. Dr. Sturgeon explains how positive emotions, acceptance, and cognitive-behavioral strategies can enhance resilience by helping individuals reframe their pain experience and maintain functionality.
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Welcome to the Pain Science Education Podcast, where we discuss ways to treat and reverse persistent pain. I’m your host, Dr. Joe Tatta, a licensed physical therapist and founder of the Integrative Pain Science Institute, where we train practitioners on whole person pain care. This podcast also serves as a public health campaign to support those living with chronic pain. This podcast is for informational purposes only, and it’s not intended to be a substitute for professional medical advice. Hey there, friends. Welcome to this week’s episode of the Pain Science Education Podcast. I am your host, Dr. Joe Tatta. It’s great to be here with you for another week. On this week’s episode of the podcast, we’re talking about the concept of pain resilience. My expert guest this week is Dr. Drew Sturgeon, who is a fellowship trained licensed clinical psychologist and clinical assistant professor in the Department of Anesthesiology at the University of Michigan School of Medicine. He also has a focus on pain psychology, which we often talk about on the pain science education podcast. Dr. Sturgeon’s clinical work focuses on the combination of cognitive behavioral therapy, acceptance and commitment therapy, mindfulness and emotion focus approaches for the reversal of chronic pain. His research interests include how we can help people adapt and become resilient in the face of chronic pain and experience growth throughout the process. On today’s episode, we talk about the growing interest in pain resilience, in pain recovery, the difference between pain vulnerability and pain resilience and ways you can help your patients build pain resilience in chronic pain management. Okay. Without further ado, let’s begin and let’s meet Dr. Drew Sturgeon and learn about the importance of pain resilience. Hi there, Drew. Thanks for joining me this week on the pain science education podcast.
Thanks for having me. Glad to be here.
Understanding Pain Resilience
We’re going to talk about a new topic today on the podcast, which you’ve had kind of touched on here and there. We haven’t spent a whole episode on it really. And that’s the idea of pain resilience. I think you’re well aware of the literature and we look back kind of at the chronic pain literature. We have a plethora of information on pain vulnerability. Really decades from multiple resources. But we have little on pain resilience, so to speak, but a growing body of literature, which is good. But I think a good place to start to kind of warm us up today is how did you become interested in pain resilience, knowing that so many things are focusing or pointing toward vulnerabilities?
So, I guess what I would start by saying that I was, as a graduate student in a lab, my primary mentor, Alex Zoutra, did a lot of work in adult resilience more generally. And he also had a line of research in sort of adaptation in adults with chronic pain. So chronic pain had been an area of interest of mine for a long time. It’s actually what I sought out to go to grad school. And soon after I landed at Arizona State, I had the opportunity to sort of apply some of his broader adult resilience models, sort of this implicit understanding that there’s no way as a human being to avoid, you know, stress or adversity. But to adapt that specifically to chronic pain, which can have devastating effects on people’s lives. So, understanding that even though pain itself can be a huge, huge burden, that some people still do seem to adapt effectively and continue to live their lives in more or less the way they’d want to, even if that pain signals are.
Yeah. So of course, important to, you know, talk about our, our mentors and people that came before us who really studied resilience more generally, it seems like, and now we’re starting to look at, okay, is there, um, something about pain specific resilience that, um, I guess in and of itself is specific. How do you like, how have you started to look at resilience, um, versus kind of more the general resilience versus what we’re now moving toward today, which is pain resilience.
So, I think I’d probably start by saying that there’s sort of a misunderstanding, I think, about what resilience to pain is. There’s a broader expectation that maybe it’s a trait, that either you have it, or you don’t. And I think what we’ve kind of come to understand is it’s better to understand resilience as a process. And so, the first publication I ever had, was adapting, again, Alex’s sort of adult stress resilience model, and you sort of break it down in a temporal way, so across time. So, if you think about something like pain as a stressor or a barrier, the first thing that it can do is immediately interrupt your ability to do things that are meaningful. So, one way that people are resilient is when pain is present, they show sustainability, the ability to pursue meaningful, functional things, even as pain is present. But that itself doesn’t tell the whole story. And then even in some cases, pain may deplete your ability to keep doing those things across time, or they might disrupt your sleep or mess up your mood or challenge your relationships. And so, a second piece of that is in those instances where maybe we don’t handle a stressor like pain perfectly, how do we bounce back? So, recovery from the negative impact that something like pain can have. And then in the longer, you know, many people with chronic pain will say, look, this has been a net negative in my life. But many people who have still adapted effectively will say, with that being said, I still learned something. I’ve learned more about myself, I’ve learned more about my body, I’ve learned more about the relationships and what I should prioritize in my life. So, there’s this idea of long-term grief. Even in the face of something that is a major stressor, a major source of adversity like pain, people still sometimes come through and say, well, I am wiser in some ways, even though I would really just rather not have this. So, thinking about pain less as, you know, some people are just better at handling pain than others and more about how do you, how do you adapt? How do you learn? And even if it is a continued presence in your life, what are, sometimes you can find ways to still function.
There’s a lot to unpack just in that kind of 122nd minute summary, which is, I think, a brilliant summary of pain resilience. So, a couple of things that come to my mind, which maybe we can touch on. And I know some of these may have kind of like yes or no answers, and some of them maybe we’re not sure, and some maybe, well, here’s what we know currently. So, let’s start here. Is resilience, or from what the literature says, is resilience a state or a trait that people have?
The answer is probably both. So, there may be inborn differences or characteristics of the person that in some way make them more resilient. You know, so genetics or your physical fitness or the sort of resources that you otherwise have in your life to help you get through adversity. Some of those things might be a little bit more stable, but at the same time, it is a state, there is a state component. That’s sort of why treatments, you know, play a role because we can’t change somebody’s genetics, but we might be able to give them more resources they can draw on in the moment to adapt more effectively. So, any model of resilience should sort of say that we can acknowledge that there may be stable contributors to what make people more resilient, but also at the micro level, some things that still move around that we can, we can use a little more dynamic.
Okay. And then the idea of resilience being a process, which I think is subtle, but very important in the sense that people are very interested in including clinicians into, okay, what is the thing? What’s the one new thing? That is going to reduce significantly or eliminate someone’s pain, right? A very somewhat reductionistic way of approaching pain, and we know that we really should be approaching pain from a more whole perspective, so to speak. But talk to us about the idea of pain being a process, or sorry, resilience being a process versus resilience being an intervention, so to speak.
All right. Well, I usually sort of use an analogy. So, anybody here is familiar with experimental pain research? One of the things we’ve used a lot over the years is called a cold presser test, where people will be brought in and asked to submerge their arm in a bucket of ice water. And so, we use this as a measure of pain tolerance. So, I’m going to just ask you a question here, Let’s say that you bring somebody in, you ask them to submerge their arm in a bucket of ice water, and they do it forever. Is that a resilient person? What would your answer be?
I would say probably not knowing that being in ice water for a long time just makes you numb, essentially. So, you feel nothing.
Right. So, they might be tolerant to pain, but they’re not necessarily resilient. So why do you think that’s not resilient?
Why is being an ice bucket not resilience? Yeah. I would say because they haven’t either applied the skills that they have or maybe learn new skills to apply to the situation that they’re in currently.
So absolutely. The other piece to it is, I mean, a lot of people, if you pose this question and ask, well, why are the, why is there arm in a bucket of ice water in the first place? That if you’re, if you’re experiencing pain, and you’re trying to accomplish something, what is the goal? You know, when we bring people in and ask them to submerge their own, you know, that’s not a thing people do in their everyday lives, unless you’re, you know, spearfishing in Alaska or something. Yeah. So, Pain that you tolerate without a purpose or a goal in mind isn’t particularly resilience. It’s just tolerance. And tolerance is an important piece. You can’t tolerate pain, there may not be a whole lot you can do, but resilience is about pursuing a goal, even though pain is there. Whether that’s maintaining good function or staying healthy or, you know, keeping a good relationship, whatever it is, resilience is applied to your efforts in a context that involves an adversity like pain.
Interesting. So can we say that pain resilience is more of an active process where pain tolerance, just sticking your hand in the bucket, so to speak, and just kind of gritting your teeth and burying it is more passive and that’s not necessarily the behaviors that we want to cultivate in people.
Yeah, to a degree, although I don’t know. I put my arm in a bucket of ice water. It actually does. It takes some active work. But at some point, you do question, well, why am I doing this? Right. So, yes, absolutely. The bigger piece here is not just that we’re trying to grit our teeth and push through, which, again, if we get to chronic pain, ends up being really problematic. It’s that we do it for a reason, that when I, you know, there’s a very popular idea amongst sort of people with lived experiences of chronic diseases, generally the spoon theory. You know, that if you’re, you only have so many resources to devote to any activity that you have to do during the day, so you have to prioritize. Pain forces you to do that too. So, resilience is often about identifying what those goals actually are and then finding the most effective way to get to them. You know, tolerance is a piece of it, but if you’re missing the goal context, it’s really hard to be resilient.
So, let’s take maybe a quick turn maybe into the brain and nervous system. I don’t want to spend too much time there because it can kind of get very technical. But what is like some, you know, neuroimaging and starting to kind of look into the brain and nervous system? Are we starting to see that potentially as people build resilience is something different happening in the brain or potentially are people who are more resilient at the start have aspects of their nervous system that are different than people who are developing chronic pain?
Neuroimaging and Pain Resilience
Well, I’ll start by saying I’m not a neuroscientist, so I’m going to give you my sort of dumbed down version of this. Again, the answer is likely both, you know, that some people come in with sort of there may be genetic factors that lead people to be more resilient or more vulnerable to chronic pain. If we think about the idea, though, let’s take there’s been some pretty well-regarded studies in neuroimaging before and after, say, cognitive behavioral therapy for that you can see changes in the morphology of the brain, so sort of the structure and shape of the brain, as well as connectivity of different regions of the brain. And so, if people respond to a frontline behavioral treatment like cognitive behavioral therapy, what we tend to see is that almost that they have sort of a strengthening of their ability to regulate emotions and to plan their behaviors, to identify goals. Again, it’s the, you know, there’s been, I think, a pretty strong interest amongst the neuroimaging community in pain to look at reward processing. So, a key piece to this is even as something really negative is happening to you, you can still identify something in your environment that’s rewarding that keeps you going. So, a lot of the broad psychology literature on pain resilience has talked about positive psychological constructs like optimism and hope and goal setting and these other things. And that’s an important piece here. But it sort of the argument that I would make is that you have to take a balanced view, that you’re looking for those goals, but also recognizing that it’s in a challenging context. So, your ability to maybe filter out or take pain out of the driver’s seat and then reorient your efforts somewhere else is probably the best way to encapsulate that process. So again, my ability to tell you what discrete brain regions do, I’m probably not the right guy for that. But functionally, downregulating the sort of the affective response or the sometimes-paralyzing effect that pain can have on your ability to function, If you can shift your attention quickly and set goals and continue to proceed, even if things are challenging, that’s probably what we’re, what we’re mapping like at the neural level.
So, this is really interesting, and I think it’s also very impactful for people, because for so long, the message has been people with pain are anxious, people with pain are depressed, and now you’re bringing these other words in, like hope, optimism, things from positive psychology, growth, resilience. I think a lot of these things actually do bring hope to people, and as far as shifting the perspective away from that there’s something wrong with me physically, obviously my brain and or my body, that maybe there’s nothing necessarily wrong with it, but I can leverage these other positive aspects that can kind of overshadow those, what we know as vulnerability factors. Do you feel like we put enough emphasis on that currently in pain care?
I think it’s hard partially because there is, there aren’t many symptoms where we get less uniform agreement across professionals about what a signal means than pain. So, a lot of the really promising pain neuroscience education approaches that have come out have sort of reformulated pain as a protective response and an active, adaptive, protective response by the brain. And this is not speaking to the severity of damage to the body one way or the other. It’s that when pain occurs, your brain has identified something in the environment as threatening to you. And so, whether that’s driven by tissue damage or by central nervous system sensitization, the pain signal itself is real. So, we should understand first that that signal serves an adaptive function. And then what the brain’s really doing is deciding between. Do I protect or do I let up so that we can still proceed and do something else in the environment? And to some degree, you can kind of make the same argument about depression and anxiety. At a micro level, they do have an adaptive function. If I’m being chased by a tiger and the tiger disappears, anxiety in that moment is actually very adaptive to me. But if the tiger then disappears entirely and I’m still anxious a year later, well, that’s not adaptive anymore. It occurred for a reason, but it’s no longer helping me survive. There are signals that have kind of gotten out of hand. But luckily, if we give the brain new feedback, the hope is that it’ll incorporate that new feedback and maybe those alarm signals come down. So, I think that that’s not often where people come into clinical care. They don’t come in with that level of understanding of what these signals actually mean. In fact, a lot of times what people are told in the medical system is, you have pain because your body’s You know. And that’s a very reductionist and often inaccurate view of why they have pain in the first place. And it doesn’t lay out a plan for how to get better.
So, there’s a lot of research. Yeah. Versus when we bring in the concept of resilience and some of the constructs that you kind of stacked on that, things like hope, optimism, positivity, really what you’re saying is those have the ability to enhance your reward system, which starts to change your brain. In a more adaptive way, which has an impact on your behavior is what we hope, obviously at the end, right?
Yeah. So, you know, let’s take one of the kind of the prominent areas of focus and resilience and pain literature, which is positive emotion. So, the sort of salutatory, the health enhancing effects of positive emotion So, for example, that your nervous system bounces back from stress better, if you maintain positive emotions better. There was even a famous study about 30 years ago on how positive emotions boost your immune function and makes you more resistant to the common cold. So, you can sort of tie a discrete mechanism like positive emotion to better overall health. And so, I think there is a coherent story to tell people, which is, look, as much as we want to just, we want to reduce pain as much as we can, but that often doesn’t do the job by itself for any number of reasons. So, we have to broaden our view. We also want to give your nervous system some fuel to change. So, one of my favorite studies in the last 10 years, if you think about pain as a conditioned response, that the brain learns from cues in the environment how to protect you, positive emotions help you reverse or change some of that fear learning that can develop. So, if you want your brain to learn to send you less pain, you have to give it positive emotions as a means of speeding that up. So, I like that model a lot, because we’re not saying the brain is doing something wrong, necessarily. There is a level of pain we need to have. But at this level, it’s not serving you that far. So, let’s find the ingredients that help you move in a new direction.
I think that’s really helpful for a lot of people who are very focused on pain education specifically, because that’s a very cognitive intervention, very thinking thought based. But what you’re saying with positive emotions is potentially and let me know if I’m kind of tracking with you in the right direction, that just the cognitive piece is less likely to change the nervous system when we know that there are emotional factors involved in someone’s pain experience.
And behavioral factors. So, one of my favorite things as a clinician in the last 10 to 15 years is the idea that pain itself is a safe signal. As awful as it feels, pain can’t necessarily damage your body. It’s a signal your brain uses to let you know when you’re in danger. And so, knowing that often really almost never is enough to make people better. We can tell them that, and even if they believe us, it doesn’t make the pain go away. But it needs to be a more active retraining process. So, if I want to think differently, if I want to feel differently, I need to train my brain and my body. I can know exercise is good for me, but the first time I get on an exercise bike, my legs and back might be screaming at me. So, there’s a process by which my brain and body need to adapt to that. And so, the safety, the reward, all those things are nice in the abstract, but they really only have true benefit when we’re doing that, when we bring them into our lives in a more active way. And that’s what a lot of the current psychological therapists for pain do. So, they’re focused on that idea. Don’t just think you know the answer. Try it out and see if it makes a difference.
Right. So, take your knowledge and put it into action in some way. Test it. I mean, behavioral testing is a big part of, I think, what all of us do in pain care in some way. Absolutely. Yeah. What other type of, um, you know, psychological constructs or, or mechanisms, um, help people build resilience to pain.
Acceptance of Pain
So, my, my favorite, and it’s maybe the least favorite of my patients, but the one that I like the most is acceptance of pain. And the reason, let’s start with the fact that there is a pretty bad misunderstanding about what acceptance of pain actually means. So many times, this is delivered to people sort of as a message, you need to resign yourself to the fact that you’ll always have pain. And that is not what the idea here is. Instead, the idea is acceptance of pain means recognizing that you have pain right now and stopping ineffective attempts to stop it. So, as an example, my back hurts all the time, and my way of solving that is by laying in bed for 22 hours a day. Is that actually working? And even if it is, what am I losing by doing this? So, some of the research that comes out of acceptance commitment therapy for pain, and more broadly, just this idea of acceptance, really what it is, is flexibility. Is understanding that, you know, this may have worked before when I had acute pain. When I threw my back out and gave myself a week and that went, then the pain went away, that was fine. But I’ve been at this for two years. The pain’s not better. What else can I do now? So, learning to adapt and learning to be flexible, even as the pain is giving you these really frustrating and confusing messages about how to move forward. That’s, it’s maybe the single biggest piece. I wrote a paper several years ago, where I sort of concluded the construct that is the closest to resilience that’s specific to pain is acceptance. Because it allows you, so the way that construct is broken down is it includes a willingness to experience pain, and an orientation towards doing things that are personally meaningful. So, engagement in what’s meaningful. So, I’m willing to tolerate things that are painful in the service of what’s meaningful. You know, I think if you want to break down encapsulate resilience and sort of a brief way, which if you probably noticed, I’m not very brief. That would be it.
Yeah. And these are not brief topics. These are, you know, oftentimes in-depth topics. So, would you, would you say, um, and this is maybe I’m putting too much emphasis on this, but would you say that, um, developing that acceptance or willingness to, to work with pain, um, from, uh, I guess a pain psychology perspective, do you find that to be more impactful than even something like cognitive reappraisal?
I think there, Cognitive reappraisal is a skill in a toolbox. I’m a sports fan. The way I like to describe cognitive reappraisal is if I’m about to shoot a free throw and those thoughts get to be too much for me, if I think if I miss this shot, I’m going to lose the game. Cognitive reappraisal is my best friend. But often if you just present people with this idea that you can talk again, you know, kind of talk back to your thoughts, they go, well, great. I mean, I have to talk back to every negative thought I have for the rest of my life. So, the idea of acceptance here is a little more broadly, not even just specific to pain is the idea that I’m going to have negative thoughts and emotions and physical sensations like pain sometimes. And I can still recognize that I don’t have to ignore them. I don’t have to deny them, but they also don’t have to take control of my life. So, the two things do not, they’re not mutually exclusive by any stretch. I think that they’re employed differently. I think that this acceptance is maybe more of a mindset, whereas cognitive reappraisal is something you use micro in the moment.
In the moment, that’s interesting, especially knowing that acceptance has a big mindfulness component to it. I mean, awareness and acceptance is a lot of ways wrapped up in the definition of mindfulness. So, it’s interesting to see how these kinds of processes start to come together to support people in their pain recovery process. So, we have CBT as a gold standard. broadly accepted by most professionals as gold standard care for chronic pain. Would you say traditional CBT as it’s kind of taught and delivered, does it have an impact on pain resilience? Has that been measured in the literature specifically, or do we need to add other components, other processes to traditional CBT to make sure we’re cultivating a resilience to pain?
So let me first speak to the gold standard thing, because this is one of my favorites. CBT, the reason it’s the gold standard is because you can apply it in basically any pain population and expect an effect that it will have positive effects on certain things.
Same effect?
Some effect. Yes. It’s above zero. It’ll probably be it benefits mood and it benefits function and it benefits pain a little. But that’s really valuable to have, you know, because in many, many treatments, we don’t have anything. But for many people, it’s often not enough. So, CBT, the way it’s, I don’t know that there’s actually a lot of people out there that do strict CBT for pain anymore. I think oftentimes it’s been infused with either acceptance and commitment therapy, sort of the values, goals, other things like that. Or it’s been infused with things like mindfulness. Or in some cases, it’s been infused. So, my colleague here at the University of Michigan, Afton Hassett, sort of has studied adding some of these positive psychology interventions alongside CBT. So, I’d say that what makes it difficult is I’m sort of skeptical that you can fully assess resilience via self-report. And that’s what most clinical trials base their findings on, is self-report. So, if you ask somebody how resilient versus or how resilient are you in terms of pain? Those can just be hard questions for people to understand in the first place. And I don’t know that it’s the most valid way of getting to it. So again, based on this idea that it’s not so much a trait that you can sort of capture in the same way. I don’t know that we do a good job. Because as much as anything else, it’s also about context, the context in which somebody is living, what their actual goals are, what they need to be, and we often don’t capture that in clinical trials anyway.
Do we have good tools or self-report measures to measure pain resilience? I know we have general resilience measures. That’s been around for quite a while. But how are we doing on the pain resilience front as far as having psychometrics to evaluate and track that over sessions?
There are some reasonably well-validated instruments. So, there’s a pain resilience scale. It was done by my colleague, Max Sleepian, who’s now, I think he’s in Canada now. They generally, the psychometrics of them tend to be acceptable. Like they’re perfectly reasonable measures to use. But when you look at their correlations with sort of meaningful function, it’s not always as high as you’d want it to be. And it may be that, for example, that these are mutually influential, that the more you get somebody functional, the more likely they are to endorse some of the things that would otherwise look like resilience. So again, back to this idea of process more than a trade. But there isn’t any, and along those same lines, given what I just said about acceptance, there are long and brief versions of the chronic pain acceptance questionnaire that are well-validated. So, think of them as one potentially useful data point, but they often don’t tell the full story. They get at more maybe attitude about how people understand their pain and then like elements of self-efficacy maybe that the extent to which I feel I can live my life the way I want to even though the pain is there, how well I maintain my mood, how well I maintain my relationships, you know, I can still live a meaningful life even though pain is there. So, but if you think about those things, each of those items, those can be really hard to sort of boil down to a one to five response scale, right? That’s, you know, we’re never going to be perfect in that respect because people’s lives are a lot more nuanced to them. I want to be clear. I’m not saying don’t use the scale but understand that they’re just a building block.
Yeah. I think all of us understand that a 10-question self-report measure oftentimes lacks a lot of personal context that we gather just during our evaluation and assessment process, whether you’re using a self-report measure or not that’s validated. But what I’m hearing you saying is that in some way, pain resilience, you can use a specific tool, or it probably should improve and track alongside pain acceptance and or psychological flexibility it sounds like in some way.
The other thing here is I would say that if we’re talking about assessment more generally, I think we’re often well served not trying to cast too broad a net but using more discrete measures. So, for example, we want to know how maybe quote unquote physically resilient somebody is. Ask about their discrete physical function, like their ability to do specific activities. you know, there’s a there’s a really nice brief resilience scale that is just focused on recovery of stress. So, if you narrow the focus a bit and focus, you know, just on a sort of a sub construct, it gets a little bit easier to feel confident of what you’re capturing is valid. You know, and acceptance and resilience scales have a function. But they don’t tell the full story. And so, we see this when we look at, say, cross-sectional or longitudinal research. They don’t necessarily do a great job of predicting how people are doing, especially perspective. There’s a relationship, but it’s maybe not as strong as you’d want it to be. That doesn’t mean they’re not valid. It means there’s probably a lot more going on than what we can just access by itself.
Behavioral Resilience vs. Cognitive Resilience
Right. And then, you know, as we’re talking about this, I’m listening to you talk about behavioral, and you’re also talking about the cognitive pieces of it. Should we look at pain resilience, both do people, I guess, ask ourselves as clinicians, am I seeing here a cognitive resilience to pain or a psychological or an emotional resilience to pain, as well as a behavioral resilience to pain? And are those, of course, interrelated, but are they different in some way?
That’s a great point. So, this is something that we brought up a lot in prior publications is the idea that you might consider resilience domain specific. So, it’s not too far outside the realm of possibility that say for somebody who has chronic pain that they go to work every single day. Right, that that could be a form of resilience. But if that same person has left all of their relationships in their life deteriorate, you know, so they’re going to work, but everybody hates them. Is that a resilient person? It’s really hard to answer that question, isn’t it? Because in one domain they are and in another they’re not, you know. And so, thinking as a clinician, there are different treatments for me to use if somebody’s got a lot of interpersonal issues than if they’re struggling to go to work. But they’re not perfect. They’re not by any means perfectly overlapping. And again, back to spoon theory, people often say, look, I just don’t have it in me to maintain everything at the level I did before. So, you know, we want to be sort of mindful of the fact that this is, again, where we’re getting at, you know, a lot of the acceptance and commitment therapy work. So, one of my favorite books of all time is The Happiness Trap by Russ Harris. You know, he talks about the dartboard, the values dartboard. So how close are you to the center? for any one of these things that might be valuable to you. And if things are less valuable to you, then maybe you don’t have to be as close to the center. If my engagement and leisure is not that important to me, but my time with my family and my health are, then being close to the center on those is way more important than what I’m doing in my free time. So, again, this is this idea, and I actually, of all disciplines, I think PTs do this better than anybody, where you start by asking people, what do you want to be doing? You know, you build functional goals that way. My PT friends taught me that might give three or five things that you work on in the course of treatment. I love that model because it’s got resilience baked into it.
Yeah, when I look at, you know, there’s certainly a lot of professionals who approach pain from an impairment perspective, which we know is not what should be done. But even still, even if they’re approaching it with an impairment perspective, there’s still, I think, in some indirect way, they’re probably not aware of it, helping someone build in that sense of physical or behavioral resilience. But I think the point you’re making of helping people identify the specific domains of their life that are important to them and then resourcing them with the tools that they need in those specific domains that are problematic is a much different conversation than if I just give someone a little bit of education about how their brain works, and I do something to reduce their catastrophizing, that they’ll recover from pain, so to speak. And again, it’s that kind of one side of the coin is vulnerability, the other side is resilience. And which side of the coin are we working on? And do they have overlaps sometimes, I guess? Are they interrelated constructs at times?
I think they have to be. I don’t know that you can. So, it’s very fair if somebody just talks to you about resilience and they never acknowledge the problem that you’re having, then they’re being Pollyanna. And that’s probably not going to serve the term. You know, we have to acknowledge the difficulty. I mean, resilience, by definition, implies the presence of adversity. You know, if your whole life is tremendously easy, then there is no resilience. There’s nothing to be resilient to. So that’s why this construct can be difficult at times to sort of define, because we’re saying pain itself is a real adversity, but that’s not the entirety of your life, right? At least we don’t want it to be. I’m guessing you don’t want it to be. What else is there? What else can we build back up for you? And knowing that in some cases, building back up is part of the process of how you get better. Our best model, I think, for a lot of forms of chronic pain is still rehabilitative. That rebuilding function improves mood and improves sleep and stress. And I even published a paper with my colleagues from University of Washington a few years ago. Pain is what we call a lagging indicator. So other things improve before pain does. Function, mood, sleep. So, these are all sort of things that sort of clear the runway for people to get more pain relief in the future. So, I think there’s a coherent model for that. So don’t just myopically focus on the positive, but also don’t myopically focus on the negative, right? If somebody said to me, if somebody, you know, in the course of treatment planning, if somebody said, well, I can do everything but skydive, but I don’t go skydiving. I say, then your treatment’s over. You know, you don’t need, you don’t need to be in a physical capacity to do a thing that you don’t want to do anyway.
Right. That’s right. That’s what that’s where they are. That’s where they are, essentially. What do you think the future of pain resilience will look like? I still think we’re kind of at the beginning of this. I think more people are becoming aware of what pain specific resilience is, which I think is exciting. It is starting to change the conversation a little bit away from maybe this idea of giving people just education to change their behavior versus there’s all these other domains that we can work with, so to speak. But what do you see happening in the future?
So, we just published a paper on this, actually, for our rheumatology reports, that there’s a lot of things that remain to be done. One, reliance on self-report, like we said, is not a great idea. That can be part of the picture, but it’s not the whole thing. So, for example, broadening the focus to physiological metrics or brain metrics of how the brain adapts under conditions of stress, that’s another thing. The other thing that is a big problem across fields of psychology is that almost all the research has been done predominantly in white college-educated people. So, this idea that resilience looks like what, you know, a college student at a, you know, a mid-tier university looks like is a terrible assumption to make. And so, people would, there’s a lot of people with very different lived life experiences where resilience takes different forms. There’s different things they have to overcome and there’s likely different things that they prioritize. And we don’t, our current models don’t really acknowledge that at all. So, there’s a lot of Resilience research, like a lot of forms of pain research, a lot of psychology research, has been weak in the area of showing diverse perspectives. So, we can’t just rely on self-report. We can’t just rely on the report of people who normally would show up to do a survey study, that we’re only getting a very small slice of what resilience actually looks like.
So, these are important topics that we’re talking about health disparities, which we don’t talk about enough in pain. So, is your recommendation that we should be looking at? Is there potentially a pain specific resilience in, let’s say, people of color or in people who live with LGBT experience or people who are diverse? Are there resilience factors that are different in those populations specifically?
Future of Pain Resilience
I would say so again, think back to where we have to acknowledge both the negative or the vulnerability side and the resilient side at the same time. People with different lived experiences, whether it’s a congenital condition, whether it’s, you know, being from a minoritized group, they overcome different things. And so those things very well can factor into how they experience or process or seek treatment for pain. But they also may have different priorities. Their goals may be different. This is kind of an extreme example, but there’s been some research around survivors of female genital cutting in sub-Saharan Africa, and the way that tremendously high rates of pain But the way that they experience that within the context of the culture, and if they immigrate to the United States, and then they’re now navigating sort of an, you know, kind of an alien healthcare system that is much more hostile to it, there are layers of challenge that they now face that they never had before. But the distress they feel about it is very different when they’re in a community of people like that’s not viewed with that same, necessarily the same harsh social view. And so, we’re clear. It’s an extreme example, not one that we endorse in this country in any number of ways, but we don’t want to take people’s agency away from them either. That if whatever it was that brought them to a pain condition, we have to assume, especially if it was voluntary, we have to assume that there was some intent there, that there was a reason they did it, that we can’t assume by saying, we can’t start by saying, well, we know better than you don’t do this anymore. So, the, the way people process a severe medical condition of any type factors into how they manage the symptoms and how they, how they think about their lives moving forward. So most, most cases are not quite as extreme as the one I just described, but it is, it is useful to illustrate. Pain can come from a lot of different things and people view pain through a very different lens. There’s some really good work by a group in Minnesota. I’m interested in sort of what the cultural implications of all this, they’ve actually done some very interesting work on resilience in this group.
Yeah, the cultural implications are important. It makes me think, cause you know, we’re, we’re so focused on, um, patient care, one-on-one patient care. Okay. Someone comes into your clinic, your office, how can I help them become more resilient bounce back? Maybe even experience growth by the end of their care or when they leave us. You know, a lot of times those processes continue, but should we start to think about how we can, um, become socially. More resilient to pain or culturally more resilient to pain. Because if obviously, if so, if socioculturally, if there are factors that are affecting pain, sometimes very strongly, should we be thinking much, much broader in the case of what can we do as a society to build almost everyone’s resilience almost at once, so to speak?
So yes, I think we should. First, the thing that I wish everybody understood is that having pain is not a choice, and it does not mean that you’re crazy. It’s amazing how often I have to have that discussion, where I have to reassure a patient I’m treating, I don’t think you’re crazy, and I don’t think you’re doing this to yourself. By and large, people don’t do that. So, let’s start with the fact that the medical system really doesn’t do a bang-up job of that. And on top of that, so this idea that it’s somehow a character flaw or whatever it is, that’s one piece that we need to get rid of. Another piece is that pain itself is actually a part of life. And that not all pain has to be feared. It’s a brain-based signal that’s not necessarily harmful to you, particularly if you can keep it within frame. So, there was some really interesting work done. And I think it was an Australian group looking at a public education campaign around whiplash. I think you know what I’m talking about. Yeah. It’s a great model for if you’re in a car accident, your body will heal. This is not necessarily a sign of irreparably damage. It actually did reduce what I understand, I don’t know if it was workers comp claims or something along those lines, but as soon as they stopped. the public education campaign, though, all those improved metrics went right back to where they were. People need this reminder over and over and over again.
It’s almost so much chilling, so much chilling to think that once they remove that message, that, you know, rates of pain, chronic pain, so to speak, increased again.
Well, I am by nature very repetitive, and so my patients almost always tell me they don’t mind that I repeat myself, but I’ve come to appreciate that people may need to hear that message more than once. And often they need to hear it from everybody that’s treating them, right? The pain is real, but it’s not dangerous. Right. And if you don’t get that reassurance, it’s really hard to move like really, really hard. And so that’s the, if we could get people, if we could stop this sort of treatment of people with pain, whether it is though there, you know, that they’re crazy or that they’ve somehow done this to themselves, that would be a great start. And then on top of that, I think the medical system and more broadly, we need to start modeling that pain is a thing that can be treated. And it’s, you know, this is not inherently something that has to destroy your life.
Right. It can be treated. And for some people and many people, it’s actually curable.
Yeah. Yeah. That’s probably a different place. Yeah.
Drew, it’s been great talking to you about pain resilience. I know we covered lots of ground, everything from the cognitive behavioral aspects to a little bit of the neuroscience and psychology. And at the end here, even working into maybe some of the sociology and cultural aspects, which are important. Tell us how we can learn more about you and follow your work in this area.
So, I don’t have my own website necessarily. You can certainly find me on the University of Michigan website, which is my current employer. I have LinkedIn. I don’t know what it is, but I’m pretty easy to find. And on ResearchGate, if anybody uses ResearchGate, it’s one of my favorites for disseminating research. Or keep listening to this podcast, I suppose. Lots of ways to follow good pain research, not just mine.
So, we will include all those links over on the page at the Integrative Pain Science Institute, to Drew’s LinkedIn, to his ResearchGate, and at the University of Michigan. You can reach out to him. He’s got some great research that you can read. We will link to the paper that he mentioned as well. It was a good review that was just done on pain resilience. It’s worth a read because it’s a good history and overview of the current state of pain resilience and where we’re going. At the end of every podcast, I ask you to share this information with your friends and family on Facebook, LinkedIn, or Twitter. Anyone who’s interested in pain recovery and of course, pain resilience. Stay tuned for the next episode. I’m Dr. Joe Tatta. It was great being with you here this week. We’ll see you next week. Thank you for listening to the Pain Science Education Podcast. To subscribe to the podcast and learn more, visit IntegrativePainScienceInstitute.com. That’s IntegrativePainScienceInstitute.com. Sign up to receive weekly updates and learn about our continuing education courses. If you enjoyed this episode, leave us a review on your favorite podcast platform and share this episode with your friends. Please join us next week as we share more science-backed solutions for treating and reversing chronic and persistent pain.
John (Drew) Sturgeon is a fellowship-trained, licensed clinical psychologist and Clinical Assistant Professor in the Department of Anesthesiology at the University of Michigan School of Medicine. He completed his PhD in clinical psychology at Arizona State University and postdoctoral pain psychology fellowship in the Department of Anesthesiology, Perioperative, and Pain Medicine at the Stanford University School of Medicine. He has been extensively trained and continues to treat people with chronic pain using a combination of cognitive-behavioral therapy, Acceptance and Commitment Therapy (ACT), and emotion- and meditation-focused approaches to pain management. His research interests include contributors to individual resilience in chronic pain, comprehensive statistical modeling of adaptation to chronic pain, fatigue, social factors in the experience of pain, and novel and disseminable behavioral interventions for chronic pain. Dr. Sturgeon has published 80 peer-reviewed articles and book chapters in the areas of resilience and vulnerability factors in chronic pain and stress, psychological interventions for chronic pain, and the broader role of psychosocial factors in chronic pain.
Important Links and Resources
Dr. Sturgeon’s Research Gate Page
Sturgeon, J.A., Zubieta, C., Kaplan, C.M. et al. Broadening the Scope of Resilience in Chronic Pain: Methods, Social Context, and Development. Curr Rheumatol Rep 26, 112–123 (2024). https://doi.org/10.1007/s11926-024-01133-0
Sturgeon, J.A., Zautra, A.J. Resilience: A New Paradigm for Adaptation to Chronic Pain. Curr Pain Headache Rep 14, 105–112 (2010). https://doi.org/10.1007/s11916-010-0095-9
Sturgeon, J.A., Kraus, S.W. Resilience in Women’s Sexual Pain After Female Genital Cutting: Adaptation Across Time and Personal and Cultural Context. Arch Sex Behav 50, 1891–1895 (2021). https://doi.org/10.1007/s10508-019-01536-6
Sturgeon, J. A., & Zautra, A. J. (2016). Resilience to chronic arthritis pain is not about stopping pain that will not stop: Development of a dynamic model of effective pain adaptation. In P. M. Nicassio (Ed.), Psychosocial factors in arthritis: Perspectives on adjustment and management (pp. 133–149). Springer International Publishing/Springer Nature. https://doi.org/10.1007/978-3-319-22858-7_8
Tatta J, Pignataro RM, Bezner JR, George SZ, Rothschild CE. PRISM-Pain Recovery and Integrative Systems Model: A Process-Based Cognitive-Behavioral Approach for Physical Therapy. Phys Ther. 2023;103(10):pzad077. doi:10.1093/ptj/pzad077
