Welcome back to the Healing Pain Podcast with Joe Tatta, PT, DPT And Annette Willgens, PT, EdD

Welcome back to another episode of the show. We’re going to do something a little bit different in this episode than I typically do. Typically, I’m interviewing a guest or an expert about a piece of research that they conducted or an investigation, maybe a clinician who’s doing some interesting work or wrote a book. In this episode, what I’d like to do is give you a sneak peek into our monthly coaching and mentorship calls. We call them our community coaching calls. They are mentorship and coaching calls that center around the courses and learning activities here at the Integrative Pain Science Institute.

Before we do that, I want to thank everyone who showed up in San Antonio, Texas for the 2022 Combined Sections Meeting for the APTA. I want to thank the APTA, the American Physical Therapy Association for inviting me and some of my other colleagues here at the institute, where we had an opportunity to present five sessions on lots of different topics related to chronic pain, physical therapy and the promotion of health and well-being for the patients we see.

San Antonio is such a great city. If you’ve ever been there, it’s a great walkable city. They have that river walk. It’s this little rolling river that runs through the center of the city. They have all these restaurants and bars that line that river walk. I didn’t have too much time to hang out at the bars and restaurants but I did have an evening where I connected with one of our instructors here at the institute whose name is Jeremy Fletcher. We chatted a lot about PT and where we should go as a profession.

We also had the opportunity to connect with Carey Rothschild, who is here at the institute as well, who teaches our Pain Education course. I want to congratulate her because Carey was awarded the Academy of Orthopedic Physical Therapy James A. Gould Excellence in Teaching Award specifically for teaching orthopedic physical therapy. She’s a professor at the University of Central Florida.

I got to attend her award ceremony, which I was super excited for her. I met some of the students who are going to school at the University of Central Florida. They’re in their DPT programs. I want to give them a big shout-out and say hello. I’m super excited for all of you to move into the wonderful profession of physical therapy.

The last time I was at CSM was before COVID, which was probably back in 2019. There was a big conference that year in Denver, Colorado. There were about 17,000 people. In 2022, I believe CSM was a little bit smaller, maybe around about 11,000 or so. I noticed that the overall theme of our conference has changed over the years.

It used to be very focused on joint structure and function, which is important but there’s a progressive movement that’s happening in physical therapy where people are embracing the bio-psycho-social model not just for chronic pain but for many different types of chronic health conditions, acute health conditions and through all the different specialties that we have as physical therapists and other licensed health professionals.

When I was there, I had the opportunity to interact with a lot of DPT students because they attended a lot of the lectures that I was giving on various topics like nutrition and Acceptance and Commitment Therapy. Quite often, they’d asked me about the courses like, “Do you offer any type of mentorship at the institute?” It was for when they graduated, what opportunities are there to interact with me and the wonderful staff we have here at the Integrative Pain Science Institute.

For this episode, I want to share a sneak peek with you into one of our monthly mentorship and coaching calls. We hold these calls once a month on a Saturday. They’re typically about 90 minutes long. It’s a live Zoom call. It’s an opportunity for people to ask questions but more importantly, we usually focus on a clinical case or we practice some type of new technique or bio-psycho-social skill that requires more of an experiential approach where we have to practice and reflect on what we’ve done.

We also invite the institute faculty to come and talk to our course participants and share what they’re doing about projects and research. Oftentimes, they’re teaching different types of skills related to the course that they teach here at the institute. In this episode, I want to share with you the monthly mentorship and coaching call we did with Dr. Annette Willgens, where we discussed mindfulness. She teaches the mindfulness-based stress reduction course here at the institute. We talk about mindfulness and how you can use it with its various implications.

One of the other reasons why I want to share this with you is because mentorship is one of the things that changed my life and career as a physical therapist. When I first graduated from school in 1997, one of my earliest mentors was the director of physical therapy at the in-patient rehab I used to work at. Her name is Pam. She’s a wonderful PT who took me under her wings right out of school. Then, I had more advanced clinical mentors.

There used to be a physical therapist whose name was Jeffrey Ellis. Unfortunately, he already passed. He was a wonderful manual therapist who had all these courses developed around orthopedic manual physical therapy. I took about 4 or 5 courses with him in my 1st couple of years out of school. He was an advanced clinical mentor of mine.

I’ve had business mentors and personal mentors. Sometimes, they’re friends or colleagues but oftentimes, they are people I’m paying for services to mentor me around. I’d be like, “How can I have these business ideas or goals? What do I do? How do I put this in motion?” They hold you accountable and set you with strategic planning. I’ve even had a spiritual mentor. There’s a particular individual I work with who has a Ph.D. in Psychology and Divinity from Yale University. I started working with him a few years ago because I realized the chronic pain space.

There’s a big, spiritual component to chronic pain and something there that we should all start to explore both how we help our patients and what is the deeper meaning for me as a practitioner and founder of an institute. He has been great to talk to about the deeper work sometimes that we have to do. In this episode, I want to share with you Dr. Annette Willgens. She’s going to talk about mindfulness.

She’ll guide you through a couple of different exercises and then you’re going to hear the interaction between the participants who are part of this mentorship call. They’re all people who have signed up for various courses here at the institute, whether it’s our nutrition course, motivational interviewing, ACT, trauma-informed pain care or pain education. Everyone is in this group going through all these courses and learning.

We talk about self-report measures you can use about your initial evaluation and then what happens when you get stuck as a practitioner and your patient’s not progressing. It’s how do you start to integrate all this in a seamless way for your practice. I hope you enjoy this episode. There are some experiential exercises because it’s a mindfulness call, so if you’re driving in the car or walking on the treadmill, you may want to pull over to the side and take the opportunity to experience the exercise. That is great with delivering mindfulness.

There is going to be lots of Q&A. If you have any questions about anything we do here at the institute and in the courses that we have, any of the sessions that I presented at Combined Sections Meeting or our mentorship and coaching calls, send us an email. It’s [email protected]. Without further ado, let’s begin. You can read a sample monthly mentorship and coaching call that I delivered with professor Annette Willgens. Enjoy. I hope you’re doing well. I’ll see you soon.

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Mentorship & Coaching Opportunities For Integrative Pain Care With Joe Tatta, PT, DPT And Annette Willgens, PT, EdD

Free Monthly Practitioner Training For Next Generation Pain Professionals

Annette, welcome. We’re super excited to have you here.

I wanted to begin by saying welcome. It’s so good to be here. Thank you so much for having me. I’d like to know how you’re doing on a scale of 1 to 10. One means you’d rather go back to bed and pull the covers over your head and not come out for a very long time and ten means you are actively engaged in whatever is coming your way and feeling fully capable of addressing it. I see some 8, 7, 8, 10s, a 6, a couple more 8s, another 6 and a 5. I get it. I’m at about a five myself. There’s also a seven. That’s good to know.

With that wisdom and knowledge, let’s move forward into this. Let me talk you through a brief meditation. I invite you to blink your eyes closed. I’m going to be here doing the very same thing with you. We begin by blinking the eyes closed or if that’s not preferable, then a downward gaze. Begin to tune into the fact that you are here and you are breathing.

Perhaps feeling the breath coming in at the tip of your nose, the coolness of the air entering the nostrils, perhaps tracing it down your throat or perhaps you feel the breath more at your chest. If I’m feeling extremely distracted, I like to put my hand right on my chest and then another hand on my belly to feel the physical presence of my breath. There’s nothing to change or do. We’re simply noticing air coming in and out.

I invite you, as you breathe, to scan your body. Uncross your legs and plant your feet wherever they are. Stretch your spine and begin at the base of your toes. Lift your toes and spread them out. I’m hoping your toes are in some yummy slippers or maybe even without socks, but wherever they are, spread them out and make space. Wiggle them and place them down.

Notice the ball of the foot and the arch. Notice the center point of each heel bone, the calf, the front of the shin and sense of the knees. Notice the density of long bones, of the legs and their weight or maybe any feeling of coolness or warmness inside, outside, front or back of the thigh. Notice the sit bones get heavy. Allow the pelvis to melt into the support surface.

Notice the low back, the thoracic spine and then trace up to the base of the occiput. Soften the jaw and the space behind your eyes. Allow the belly to be soft. Notice the space of the shoulders. It’s okay to wiggle and maybe rotate them a little bit, inviting them to soften, get a little heavy or a little dense and then scan down the space of the elbows, the forearms and then the hands. Notice where you’ve chosen to place your hands. Palms down is more of a grounding posture. Palms up is more of a receiving posture but notice the space of the palm wherever it’s landed and then come back to this inhale and exhale.

If you are new to meditation, know that the thinking brain is normal. I’ve enjoyed learning meditation myself and most enjoy encapsulating thoughts in clouds and watching them float away. You might label things that come into your brain space like thinking, planning, worrying. The cloud takes a hold of it and it floats on by. You return kindly and gently to this inhale and exhale. Notice any sound, the felt sense of the body and the life of the mind always returning the anchor of the breath.

Notice where the mind wants to go. We gently, kindly and compassionately draw it back to the present moment or the moment that’s right here, right now. It’s the only moment we have any control over. Breathing in, I know I am breathing in. Breathing out, I know I am breathing out. Again, scan the body from the tips of the toes, feet, lower legs, upper legs, the weight at the seat, the length of the spine, the felt sense of the front body hugging the back body, the space at the shoulders, arms and hands. Unhinge the jaw and soften the forehead. There’s nothing to do.

I would like to share one study that came out in the Journal of Medical and Biological Engineering. I’m not into medical and biological engineering but this study caught my eye. It’s a 2021 study by Moraes. What they did in this study was looked at the effects of mindfulness meditation training and electrophysiological signals recorded during a concentration task. We talk about how easily we are distracted.

What these researchers did is looked at depression, anxiety and stress but there is a good deal of research out there to support what we’re doing, why we’re doing it and how it can have lasting effects on the physiological state of the body. At this time, I’m happy to take questions and comments. Is there anything anyone would like to share? What courses are you taking? How are they resonating with you? What’s new in your practice? Where are you in your practice?

I’m in a little different situation. I’m retired but I’ve been discussing doing some mindfulness classes and some of the things with neuro op.

 

I strongly encourage you to continue whatever journey you’re on toward either a mindfulness certification that’s psychologically informed or the certification that Joe is talking about. There are so many different avenues out there but my suggestion for you is to cultivate your practice. That can be challenging and exciting. I tend to do it as the last thing before I go to sleep every night.

I sit up in bed, do my meditation and prepare my body for sleep. I’m not a good sleeper. I tend toward anxiety and not-enoughness, so my mind starts to go a bit crazy when I go to lay down and try to sleep. That’s the time that I found that’s best for me, so choose that time, commit to that practice and then keep noticing and being aware. Did I address your question, Ellen?

Yes. Your encouragement is great. I’ve been a long-time meditator. Any group would be appropriate in and outside of a medical setting. It has been a lifesaver for me. Thank you.

The most important thing that we can do for our patients and the people that we have direct connections with as we share this practice is to ask people, “What is your story?” By that I mean, what is the story that you tell yourself regularly? I shared a little bit of my story. When I do this work with my doctor of physical therapy students, I always start with, “This is my story. I’m a kid of immigrant parents that put a lot of pressure on us and loved us to death but there’s this constant feeling of not-enoughness and unworthiness. There’s this constant striving and it can get a little bit ugly and graspy.” I have to continually rein it in. I can be very competitive. I have to notice that and continually check in about intention. What’s the story that you tell yourself? Is there a story that informs who you are?

“Thanks, Anne. This feeling that it’s never good enough. A helper. A people pleaser.” Does that resonate with you, Mary? “Everybody else comes first and me last.” That’s Joe. “Take care of everyone. A recovering perfectionist.” I love that. There is no such thing as perfection. I would say that perfectionism is always maladaptive. “Putting others before yourself. All of the above.” Well said, Ron. Ditto. I love it.

When we know our story or the default mode of the brain, we can catch ourselves much more easily and that happens pretty nicely in meditation. I frequently find myself going, “I should. I need to. I have to.” If you notice, all of those things come from a core place of I, so it’s all about me all of the time. It’s very self-centered and self-focused. When I step away from that, that’s where I can find space and that shift that needs to happen, so with that peeling away the layers of the onion, I can find the core of what’s going on in the present moment.

Betsy asked a great question. “Do you think our stories change as we heal through healthcare?” Our stories do change as we grow, mature and end the cycle of the maladaptive patterns that no longer serve in our youth. The more we meditate and do the hard work to uncover that truth, that’s the key to shifting that story.

One of my favorite authors, Dr. Hawkins, out of the University of Michigan, says that we like the small part of ourselves. There’s this small part of ourselves, the small S, that’s attached. It’s very familiar. No matter how painful, inefficient or maladaptive it is, this small self enjoys this negativity and impoverished life that goes with it, like feeling unworthy, invalidated, judging others, judging ourselves, being inflated, winning, being right, grieving the past or fearing the future.

You know what this sounds like in all of our patients and sometimes ourselves. Craving assurances, wanting certainty, it’s all of those things but are we willing to imagine a big S self? Are we willing to show up and be truthful so that we can find joy, love, inspiration and feel okay with exactly the way things are in the present moment? Mary has a question.

I work in Delaware at a prison and I do these all the time. I’ve been through the ACT course and the mindfulness course, but every once in a while, I come upon someone who has spent their life running away from who they are and every feeling, always making up this story about themselves and trying to be that. I was wondering. If you have those particularly hard-shelled patients, do you have any tips for getting in?

What a service of love that you are doing. The word dissociation, does that mean something to you?

Yes.

We dissociate all the time. I did it when I was worried about not being able to sleep and for this talk, I was like, “Is anybody going to come? Is it relevant? Does any of this matter anyway? Who do I think I am?” All of that is my story. It’s that self-doubt that sits on this shoulder regularly. I dissociate, go to Amazon and need a pair of boots. I don’t need a pair of boots but that’s my way of dissociating and it works. If you can call out that individual, it’s easy to make excuses, dissociate and share your story.

 

I challenge you not to do it. I challenge you to sit with it and call them out on that dissociation. Sometimes, dissociation is helpful and necessary but more often than not, when we dissociate, it’s about that familiar. It’s the small self. If that familiar is what you’re attached to, it’s going to be hard to come face-to-face with the truth and the truth is that there’s more right with you than wrong with you à la Jon Kabat-Zinn.

We need to take a fundamentally non-contentious attitude toward whatever we are experiencing in the present moment. Name it, call it out and label it. When we see it and label it, it stops being the subjective thing that takes over our sympathetic nervous system and becomes this more object of thing that we can see. Not only that. We can see it among others. I’m happy to share my story because I know you all have a very similar story.

Who in this room doesn’t have self-doubt that follows them around regularly? There are certainly different degrees and origins of it but we are all more alike than different and that individual wants to stay different. It’s serving him some purpose, so I would ask him, “What is it serving you? What is the purpose of you continuing to be different and tune into your small self?” What do you think?

It’s hard because they have these patterns that are so ingrained. The people that are the hardest don’t want to share, so it’s hard to get them to even tell you their story and then there’s this huge mistrust of anyone that’s trying to give them care but then they blame everyone for not getting the care that they need. There are lots of layers.

The worst thing that we do is that we hide and you might even start a conversation with that statement. Hiding is shame and shame is the most destructive of all emotions. I used to think it was fear but I’ve decided it’s shame because shame doesn’t even allow somebody to talk about fear. You might talk about what shame feels like in the body, where it lives and the effect it has physiologically on inflammation, blood vessels and right down to the cellular level.

If you truly want to change your life, looking at the place where shame lives is a good start. It’s scary, it sucks and it’s hard but the only way out of anything is right through the middle. I probably have not answered your question completely and it’s not that easy but addressing things like shame, fear, dissociation and wanting to be with the familiar, it is why women choose men who harm them because it’s familiar and they’re unaware. I don’t know. What do you think?

That all rings true. When you start to ask them to look in, they won’t do it but they won’t accept any labels from you either.

What labels do you offer?

I’m going back to what you were saying before. If you could look at your fear or shame, I am not afraid of anything and there is nothing that I’m ashamed of.

If there’s no shame and fear, what is there?

It’s everything that is someone else’s fault.

It’s blame. Blame is grief so maybe talking about grief is a good place to begin. What is grief? What does it feel like? What does it look like? What does it smell like? What is its color? Where does it live in your body? The grief of what has been done to you, that’s from a trauma-informed care perspective. Thanks for working that out with me, Mary.

I have a question. I work with veterans. I’ve worked in the VA system for many years. I love it but it’s extremely challenging. I mainly work with chronic pain patients. I have a program called Pain University, which was developed on TOMA initially but I brought it to our facility and it was going well until COVID hit. You all know how that is but I’m getting it back up and running.

 

It drew me to meditation because here I was telling my patients, “Meditation is a great thing,” and I wasn’t doing it myself, so I did the whole, “I’m going to do it for 1 month for 15 minutes, twice a day.” I did it and it was amazing. My kids spot the difference. I could take that pause and breath, not feel like I’m going to one million or zillion directions at once. Thank you for getting me back into it because taking this class got me back into that.

I had a couple of specific questions. In the VA, we deal with tons of chronic pain, PTSD and anxiety. The whole blame thing that you talked about, I feel like so many veterans blame the VA and the military for their problems. They feel like they’re broken. They have a mistrust a lot of times with the system because the system hasn’t always been great, especially because we tend to work in that biomedical model. They’ve had the injections, surgeries, medication and none of it has worked for them and here I am trying to bring on these other things and there’s a distrust. Also, part of it too, is they’re afraid of getting better.

It’s the familiar. To break away from that is terrifying.

I had a veteran who lost it. When I even suggested the possibility that she could improve upon her pain, she pretty much said, “I’m out of here. You don’t know what you’re talking about. You’re all the same.” She left and went to a patient advocate and complained about me. She said that I was threatening her. That was a tough one.

As far as bringing meditation in, I’ve heard that sometimes with PTSD, certain meditation cannot be the right one to do and I was wondering which one may be better for PTSD versus chronic pain. I’m not sure if a body scan is good for chronic pain because then do they focus on their pain. Do you have any guidance on that? Almost chronic pain and PTSD are great together.

Before you answer, can I hop in on one comment that Anne had?

Please do.

Welcome, Anne. I love the work that you’re doing. I’d love to hear more about it. For us as clinicians, we oftentimes look at the VA as a place where innovation can happen and we’d love to have a little bit more of that in the private sector, which we don’t, so I welcome your input. I don’t know if you have done the ACT course or not but in general, in ACT, when we approach people, we don’t approach people as pain being the one thing that we’re after so when that patient was like, “You’re not going to alleviate my pain. You’re full of beeswax. I’m out of here,” it’s interesting to think of it from her perspective. We don’t know her history or diagnosis. Some people do live with pain their entire life.

As professionals, we have to get better at saying, “I’m going to help support your life as best as possible in all the various different ways.” That’s part of an integrative approach to pain. For some people, when you do approach them with the idea of pain relief, there is a wall that goes up for a couple of reasons. One is they’ve tried things before and they failed. They’ve lost trust in the system. Our system causes pain and trauma to persist in many ways, so it is weird because all of us are a part of a system that is causing this to persist, but we’re also a net that’s working from the inside trying to change that system.

Saying to someone, “I agree with you 100% that this system is broken,” I’m working from the inside taking the steps to change that system. You and I are part of that change. With regards to pain relief, the reason why it might scare some people away is that they don’t want to be let down again. It hurts to be let down again when they enter in with all the energy of their mind and body and it doesn’t work.

Pain relief, for me, is always the last aspect of things. I’m talking about pain. We’re not going to ignore the elephant in the room but what else can we improve upon? How can we improve upon your stress? How can we improve upon sleep? How can we help you manage your thoughts and emotions better? If pain is in the middle or the center, if we work along the outside of that, eventually, the pain will get better but hanging the shingle of pain relief can be quite challenging for us as individuals and the system in general.

I like that. That’s helpful. One of the things that she also mentioned was, “You’ll take my disability away if I get better.” That was part of it, too but I love that going from the outside in. That’s a great approach. Thank you.

That’s very wise. Thanks, Joe. As the mindfulness faculty member on staff, everybody sees me as the weirdo and the students see me as the person that they can come to so my office becomes this revolving door of, “Nobody knows this but I have an eating disorder. I have anxiety. I have depression. My parents split up. My boyfriend of eight years walked out on me.” These are all things that these young twenties have.

 

There’s a lot of mistrust and it’s not just in the VA. It’s everyone. We all have our armor on. There are a few things that come to mind to close the loop here and one is asking people if they would like to come from a position of strength or a position of weakness. We have to make that choice daily multiple times a day. It can be something like deciding to leave an unhealthy relationship or whether or not you want to grab the ice cream in the freezer at that moment in time. Those are both real.

When you come from a place of strength, you can’t be wrong. When you come from a place of weakness, there’s a lot of emotionalities involved in that. I’d like Joe’s input on this. I tell my students, “You will with intention and consequences or you will not with intention and consequences.” Those are the two ways of being. That’s it. It doesn’t have to get much more complex than that.

Less and less, I look at my job to find the deficit in someone and instead, we’re on a strength finding mission. What are the strengths of someone? How can we build upon those strengths? Even someone that you might identify as having major depression still has some strength there because there’s something that is allowing them to even move or be with that major depression. What is that strength?

In healthcare, we’re so good at screening and identifying all the problems. Patients see this in the self-report measures. They realize, “Here’s a diet questionnaire. They’re asking about food. Here’s a stress questionnaire or trauma question. They’re asking about my history.” They realize here are all the things that are wrong in life but how do we start to move people toward the things that are working for them and start to build that out?

There was a podcast of the parents from the Sandy Hook massacre shooting. It’s a heart-wrenching story. The interviewer was asking them, “How do you fill the hole in your heart that is lost that your child is gone?” They say, “I can’t fill the hole in my heart but I can make my heart bigger. It may never go away but as I make my heart bigger, the hole starts to become less.”

I thought it was a beautiful metaphor for chronic pain and trauma as well. What can we empower people with? What can we enrich in someone’s life? What goodness can we instill that will help fill that gap? We may never be able to take someone’s pain away and that’s okay but if we can build the other aspects of their life, that’s potentially more valuable to their quality of life in the long-term.

This is Lisa. I have a lot of patients who are on the autism spectrum. I see adult chronic pain but I happen to have several patients that are on the autism spectrum and sometimes some of these things are difficult. Do you have any suggestions? The autism spectrum is not a homogeneous term but do you have any suggestions?

In terms of the neuro-typical versus neuro-atypical, one of the biggest challenges is for autistic folks to be embodied. They are very much in their heads and they’ve never been taught to be in their bodies, so for them, that body scan is extremely helpful. I would keep it short and interesting that the parts of our body have color, texture and different temperatures. To get them to be very curious, they have weight, density and coolness. These are all sorts of wonderful ways to get more embodied. There’s an OT out there, Kelly Mahler and she does fantastic work. Look her up. She has got some great resources.

Thank you.

Kelly was on my show a couple of episodes back. I love Kelly’s work. Most of her work is in the pediatric realm and she does have great pediatric resources. Check out her website. Read the episode, where we focused on interoception but coming from a mindfulness aspect. I want to piggyback on some of the things that Annette was talking about with body scanning and helping someone open up to things like texture, temperature, density and sensation in the body.

If you think back to the practice that she led us through when we opened up, she was leading us through a body scan. However, she would dip in and out using 1 hand on the chest and 1 hand on the belly. That was super powerful. It was touching into the body. She said at some point to notice the density of your thighbone. What I like about what she did is she was bringing in all these different aspects of how mindfulness works, both the mind, the mental aspect or the cognitive aspect, as well as the body aspect.

As you’re new to teaching meditation, you may stick with, “Session one, I’m going to teach a body scan. Session two, I’m going to teach mindful emotions.” As you get better, you weave all these skills together and that’s okay too. There’s a place for targeting one thing and a place as you become more skilled to bring them all in together. Another thing I liked in that meditation was the part with the clouds, which if you’re a traditional meditator, you identify as decentering. ACT causes a diffusion. They’re very similar and practically the same but bringing that component in, you saw that come up in the practice, which was great.

In terms of our neuroatypical folks, it would be the same for PTSD. That population is going to have a hard time closing their eyes. I encourage that population to take out a child’s pose up against a wall. A child’s pose uses hands and knees. The knees are wide, the big toes touch and then place the head down onto a mat. It’s a posture of inviting openness in the hips where a lot of stress and negative energy is stored. It’s a posture of surrender. You don’t have to close your eyes. If you’re up against a wall, you’re not concerned about somebody walking up behind you. Those are the key concerns. Some gentle yoga would be wonderful for any of these populations.

 

With some of these populations that we’re talking about, schizophrenia, PTSD and even chronic pain, it’s okay to be brief at the beginning like 1 to 3 minutes with eyes open or when eyes are open, we gaze down 1 foot or 2 in front of us. 1 to 3 minutes is plenty for some people. It’s for the PTSD crowd and those with psychiatric conditions but sometimes, you’d be surprised. It’s for people who have undergone a lot of stress or have a difficult time with meditation. Meditation is not easy for some people.

I don’t find it easy at all. I need to do some pretty intense yoga to be able to sit and be still at the end of my practice, which is another place where I do it. The other thing that you can do is work with cues while you’re invited to meditate. One of my favorite cues is noticing the pause at the end of the exhale. As you’re breathing in and breathing out, notice the pause. Keep repeating that cue. It keeps people focused on the breath because it gives the mind something to do.

That works early on. The other is alternate nostril breathing. You have to focus the mind on the changes in the air going into one nostril exiting the other. I invite people to do this without their hands and then sit quietly. Air is going into both nostrils but you’re focusing the mind on only one. Interestingly, it does give the mind something to do for those people that have a lot of trouble.

The other thing I’ll add to that is to remember with any type of meditation technique, there’s an open focus and a centered focus. The centered focus is the breath. For a lot of people, especially those who are high in the anxiety realm, focusing on the breath can be anxiety-provoking, especially when someone’s tight, they have poor posture and they’re already constricted. With that mentioned, she likes to do yoga first.

If you’re a PT, you can do some stretches before that. That’s okay. The other thing is if the breath is a place that causes anxiety, then frequently moves outwards during the meditation. For example, you start focusing on the breath and Annette did this during her meditation, then focus on the sound. Come back to the breath and then focus on your leg and then come back to the breath. Do you then see any light coming through your eyes if your eyes are closed? You’re moving someone’s awareness in and out rather than staying stuck in one place.

If someone has a hard time focusing on the breath, then have them focus on one body part. Maybe it’s their hand, foot or whatever body part is comfortable for them. The other thing is that there are different places you can focus on the breath. For some people, that spot below your nose and above your lip where you can feel the air entering and exiting is a nice place to focus. For other people, it’s in their belly. You have some choices and areas to play with. If you find people have a hard time staying focused on the belly, which is oftentimes where we start, we have flexibility. We can modify this as we go on.

I have a question. In the course, you talked about trauma related to the act of breathing. Could you give some examples of that?

Are you talking to me or Joe’s trauma course? I’m sorry.

That was in your class.

Concerning the breath, the breath is naturally a parasympathetic regulator. It’s the vagus nerve. It allows the body to calm down, especially the out-breath but when there is trauma, the breath can be anxiety-provoking. The most important thing for survivors of trauma and you and I know about the ACE score, is to recognize that there needs to be the space to be able to escape, come back, touch away and touch back in. If you’re guiding a meditation, an open-monitoring meditation would be much more helpful to a person who has experienced trauma.

Yoga as a moving meditation can be critical. We need to discharge energy that was intended for threat and stress. The only way to do that is through activity and the vinyasa or the series of poses. To activate that energy, we can release some of that tension. We can practice being still and then a safer relationship with the mind, body and breath.

It’s so much of a challenge because so many of the patients that I see are so debilitated physically that some of the poses for yoga, you can barely even modify them, which is challenging but moving towards a sitting yoga and that thing would be the way to start anyway.

I put in the chat thread a framework that I use in my mind. It appears in Annette’s course and all good mindfulness courses. What you’re working with is mindfulness of the mind. That’s the ability to notice and observe thoughts. That’s nonjudgmental. Mindfulness of the breath is anchoring to the breath. Mindfulness of the body could be a body scan and then mindfulness of emotion.

 

You’ll see those four in very traditional contemplative approaches but they also show up even in the psychotherapeutic literature around looking at how “mindfulness works.” Mindful walking or mindful movement is the other one that is part of that, so that could be part of mindfulness of the body but the mindful movement is another one that’s in there.

With wheelchair users, if you can even get them to do a pushup, it’s going to activate the co-contraction of the muscles and parasympathetic nervous system because you are quite pushing and using the muscles in a way that helps to activate the system. As the release happens, you are releasing some of that excess energy. All of these folks that are the fidgeters or can’t be still, I’m one of those people.

Don’t put a pen in my hand because I will break it. I will take the thing off. It drives me crazy. I’m working hard on that but I’m a fidgeter. You can see them right off the bat like, “That person needs to move before any of this is going to land in their body or before the mind is going to trust the body.” Not to overly characterize or categorize but thinking of it that way is a way to get in without causing more trauma.

There are also little ways that you can work mindfulness into your session. For example, you can say things like, “Before we start this session, what’s the one emotion that’s most present with you? Before we begin this exercise that’s new for you, is there any emotion that comes up for you? Are you noticing any emotion present with us in the therapy room as we begin?” They are simple little cues to turn people toward their experience. For some reason, mindfulness has this approach that we have to sit, cross our legs and be there for 40 minutes to 1 hour. We, especially in the institute here, are learning to move away from that.

If you want to develop a course like that, teach that and that’s part of your therapy, that’s fine but realize that might not be necessary and it might not be what someone needs to get started. It’s like taking a runner and putting them on a marathon first by having them sit for 40 minutes. Even when you start to look at some of the literature, some of the most adverse reactions that people have toward mindfulness is the longer 40-minute plus sitting meditation styles. That’s when people oftentimes report the most adverse effects. You hear things like, “This retraumatized me. I disassociated during the meditation process. My pain became bad during it.” It tells you that we have to learn how to dose and grade this like everything else that we do.

The magic happens between the 8 and 15-minute mark. That is where you start to get the neural changes in terms of gray matter, white matter, telomere length and strength. There’s a great article by Tang and colleagues, 2017. It’s the first article that looked at the dosing of mindfulness meditation. What’s the minimum? What do I have to do to get some of these important changes? The state of the research is telling us it is between 8 and 15-minutes.

They say to begin with the present moment and move forward from there. That’s what it’s about. It’s beginning with whatever you have here in the present moment and then building on that.

Another great author and researcher is Jack Kornfield. We all have heard of that name. Tara Brach is another one. She does a lot of great work with STOP. I love Tara Brach. She has a website. There are lots of free meditations. The STOP acronym is Stop, Take a breath, Observe and Proceed. She also does RAIN, which is Recognize, Accept, Investigate and Non-attach. It’s like taking a STOP and adding to it a little bit for that investigative piece. Not to mean that we need to investigate in great depth but where does this live in my body? How does this show up for me? That can be very helpful. These are very brief and short practices that are extremely beneficial.

If you notice, most of the meditations that are in Annette’s course, the ACT course, the mindfulness-based pain relief course where I did a ton there, STOP and RAIN are in that course as well, I’ve made them intentionally brief because I realized, for most people coming into our courses, they’re working in clinical practice where there are other things we have to do and achieve besides the mindfulness aspect. Brief works well for our patient populations, typically in the beginning. We’re going to start to wrap up but we want to make sure we have addressed everyone’s questions, so if there’s anything that’s on your mind about the course, the content or anything here at the institute, let us know before we head out.

This is Ron. I have a question regarding seeing a lot of people who are speaking Spanish. Are there any resources or things that you can recommend? It doesn’t work well with an interpreter. Is there something that I could play that is in their native language that would help?

I don’t have any resources off the top of my head but I’m sure there are meditations in Spanish.

Are you able to do any?

Am I able to lead a meditation in Spanish? I probably could. Not too many on this call would understand me. My Spanish is pretty fluent. I probably would do a little bit of brushing up on it before I lead that.

 

I would appreciate it if you would do it or maybe that would be incorporated. I’m not the only one who is probably seeing that population.

Are you asking me to record them in Spanish?

If that’s possible as part of the course.

That’s a great challenge for me. That way, I can practice up on my skills but I’ll tell you, I’m sure there are resources out there that have better accents and are more understandable than what you’re going to receive from me.

Ron, I found one on YouTube. I had a guy that had very little English and I had very little Spanish. It had nice waves in it. With the little bit of Spanish I know, I could tell that they were saying the right things in it. If you do a little bit of looking on YouTube, it’s there. That stuff is out there.

Anne said Insight Timer has a Spanish version. Insight Timer is a nice place to go for that. That’s reliable. The other thing on that topic is I’m working on a presentation for CMS as well on eHealth and technology. We’re all excited about technology. It should make our lives easier but realize before you start directing people toward apps, downloads or whatever it is, make sure that you go through it first on your own.

I don’t mean just playing it for ten seconds. If you’re going to give someone a meditation, listen to the entire meditation. This is the other interesting part of some of the trauma research around meditation. The two places where trauma responses with meditation happen are with the longer meditations and when people are using apps on their own.

I’m not saying an app is a bad place to go. I’m saying that we have to dose it correctly and know what the particular meditation is teaching. I recommend playing, experimenting and listening to them on your own. Don’t just send someone on a deep dive into whatever app it is because, as you know, these apps sometimes have hundreds and hundreds of different meditations that might not be appropriate for your particular patient or person you’re working with.

That’s why I was asking because I didn’t know what the content was. I know it’s out there but I don’t know if it’s appropriate for the patient.

The better thing is I’ll listen to some in Spanish. The other thing is some of the research I’ve been looking at, which is interesting as well, is that most of the eHealth apps that are out there rarely have a clinician on board that is helping them develop the content. This is not just for meditation apps. There are tons of apps for other things related to pain, health, general diet, exercise, pain science and all those sorts of things. You’ll realize it either might not help the person or there’s always a potential for harm, so you have to do a little bit of research on your own.

Someone’s asking about a reimbursement-related issue. Mandy, are you asking about reimbursement related to meditation specifically? What I recommend there is that you should be using some type of patient self-report measure that you’re providing someone at the initial intake. There are lots of different mindful and acceptance-spaced self-report measures you can use.

They’re in the ACT program. In our mindfulness programs, we can put some into the Facebook group if you want but use that for pre and post measures and then all the questions in those self-report measures become your goals for your short-term and long-term goals and that’s how it becomes measurable.

What’s nice is if you use more than one, then you have more ammunition about documenting, tracking progress and providing information to the insurance company that helps you with reimbursement with continued care. Heart rate variability is another one, so you can use HeartMath for that in tracking heart rate variability. Is there anything you want to say to wrap up, Annette?

I wanted to end with a little poem. I wanted to thank everyone. There’s an option to close your eyes or do on a gentle downward gaze but I found this great poem that I love and I wanted to share it. Thank you so much for joining us. The poem is Charles Wright and it is from Black Zodiac. “Take a loose rein and a deep seat. John, my father, would say to someone starting on a long journey. Meaning, take it easy, relax.”

 

“Let what’s taking you, take you. I think of landscapes, mountains, rivers or lost lakes where sunsets rise and fall. The scald of summer wheat fields, light-licked and poppy smeared. Sunlight surrounds me and winter birds doodle and peck in the dead grass. I’m emptied, ready to go. Again, I tell myself what I’ve told myself for years. Listen to John. Do what the clouds do.” I wish everyone a wonderful holiday season and don’t hesitate to reach out if there are any questions at all.

As we wrap up, what I want everyone to do is to put in the chat thread where you are on that scale of 1 to 10. Let us know where you are after doing some of this work, talking and collaborating. Let us know the difference that you notice.

This is wonderful. This is the sense of community. This is the Sangha.

If you noticed, I’ve even changed some of my language where I used to call these group coaching calls group mentorship calls and then I call them community coaching calls. I can lead and we can lead but all of us are leaders at this phase. All of you that are taking these courses at the institute are way ahead of so many professionals, not just in the PT world but even in some of the other health professions as well. We want you to be leaders. We’re not forcing you to be leaders but we do think there’s that leadership aspect in all of you where you’ll take this work and deliver it to your patients. You’ll inspire your colleagues at work and your friends and family.

As you know, this is lifelong learning once you start to move into this realm. We appreciate you all being here. The community coaching calls happen once a month. I’ll post the link in the Facebook group. In general, they’re at the same time. That’s where you’ll see us once a month. Sometimes, it’ll just be me. Other times, we’ll invite speakers in from the faculty from the institute and I’d like to bring some other people from the outside in as well to be special guests. Those will be people who both are already part of our community and who are from outside our community. They’re special speakers that only will be accessed through our community coaching calls here.

If you haven’t taken Annette’s course, you can find it on the institute’s website. It’s called Mindful Stress Management for the Healthcare Professional. It’s a 6-week course and in 3 months, maybe toward the mid-end of March 2022, there’s going to be that smaller, briefer but powerful course that Annette’s going to lead with two other colleagues on how to teach this to a PT student who maybe you’re supervising. Annette, do you want to talk about that for a moment?

The Mindful Clinical Mentoring course is geared towards instructors in clinical settings. If you are accepting students, post-docs or even volunteers, this would be a great course. It’s taught in 3 to 4 modules. The fourth module is a case study in which we unpack some challenging students. It’s a way that the clinical instructor can learn aspects of mindful presence, mindful teaching and then the student can benefit from that teacher. It’s not just about one or the other. It’s about the student-teacher dyad and the challenges of being a young person in a very stressed-out world. There are some new data and neuroscience in it. It’s nothing overwhelming but it’s interesting stuff. I hope you’ll join us.

It’s only about 3-or 4-hours total. It’s intentionally meant to be brief and applicable to use in practice. Although, if you have children, teenagers, kids in college or friends who have challenges, all of it starts to become useful. The reason how this developed is a lot of PT programs are reaching out to Annette saying, “Can you please come to our program and teach us this? We have stressed out PT students who are having challenges. We want them to graduate and be good PTs. We need some help.” That’s where this is all developing from.

Annette’s doing some work where she’s going into the PT school directly and educating the staff at the DPT program, as well as the clinical instructors in the field that are coming in and receiving this training as well. You can take it as an individual course if you want, but I’m going to talk to Annette about including this to be part of the psychologically informed certification. Once you’ve embodied all this work, this is the course where you take it and teach it to other people. That’s what I was saying before about the leadership aspect. I do think that once you’re able to teach this to other people, that’s where the magic starts to happen.

The course intends to have you leave feeling like you could lead a patient, a student, a volunteer or some young person through a brief meditation, body scan or some other way of increasing mindfulness and PTA programs as well.

There’s more to come, happy holidays to everyone. Happy New Year.

Thanks for all you’re doing. You’re amazing.

Thank you too for being here. Come see us at CSM if you are in San Antonio, Texas. We’d love to meet you. If not, we’ll see you on the next community coaching call. Everyone, thank you so much. We’ll see you soon.

Important Links:

• 2022 Combined Sections Meeting for the APTA
• Jeremy Fletcher – LinkedIn
• Carey Rothschild – LinkedIn
• Dr. Annette Willgens – LinkedIn
• [email protected]
• Kelly Mahler
• How Awareness Of One’s Body Affects Physical And Mental Wellbeing – Previous episode
• Jack Kornfield
• Tara Brach
• YouTube – Insight Timer
• Insight Timer
• HeartMath
• Facebook – The Integrative Pain Science Institute
• Mindful Stress Management for the Healthcare Professional

About Annette Willgens, PT, EdD

Clinical Associate Professor at Temple University. Her teaching includes clinical management of the pediatric patient, introduction to mindfulness, teaching & group dynamics, pediatric development, and group dynamics. Her research interests include mindfulness for graduate student success, stress management, and clinical practice.