Welcome back to the Healing Pain Podcast with Dr. Les Aria, PhD
For a lot of practitioners, medical and psychiatric patients are difficult to treat, approach, or figure out. Dr. Les Aria is a rehabilitation and pain psychologist with over a decade of experience in working with patients with chronic pain and other types of chronic diseases. He specializes in treating complex medical-psychiatric chronic pain patients, when others suggest nothing can be done. His love for the brain and pain has helped him develop a unique style in helping patients who are suffering by helping them retrain the mind to rewire their brain and body. Dr. Aria explains what adverse childhood experiences are, how they relate to the development of pain and poor health, and what you can do to prevent or treat them.
We have another interesting and informative podcast that I can’t wait to share with you. Before we begin, just a reminder that if you’re listening to this podcast and you have not yet signed up to be a subscriber, hop on over to www.DrJoeTatta.com/Podcast and enter your name and email address so you can receive a new episode directly to your inbox each week. This week on the podcast, we are discussing how adverse childhood experiences in early life can lead to the development of chronic pain syndromes in children and later on in life as an adult.
Now, to get us rolling you may be asking what is an adverse childhood experience? An Adverse Childhood Experience or also what is known as an ACE is defined as a physical, mental or sexual abuse in early childhood, emotional or physical neglect, a violent home environment, a household where there is some substance abuse problem, exposure to a parent with a mental illness, the experience of a parental separation or divorce or the experience of a parent that was incarcerated while you were a child. The data from the pain literature shows us that if you’re exposed to these adverse events as a child, it can lead to chronic pain conditions such as headaches, fibromyalgia, autoimmune disease, and painful musculoskeletal conditions later in life.
Here to speak with us about the psychological, cognitive, and social aspects of Adverse Childhood Experiences is Dr. Les Aria. Dr. Aria is a rehabilitation and pain psychologist with over a decade of experience in working with patients with chronic pain and other types of chronic diseases. He currently works at the Integrated Pain Clinic at Kaiser Permanente in Sacramento, California. Dr. Aria will speak with us about Adverse Childhood Experiences, explain what they are, how they relate to the development of pain and poor health, and what you can do to prevent or treat them. If you’re interested in obtaining your own personal ACE score, I’ve included a free download to the Adverse Childhood Experience Quiz. By downloading and completing the quiz, you’ll be able to find your own ACE score, which can help shed some light on how early life experiences may have affected your health. To download the quiz, all you have to do is go to www.DrJoeTatta.com/87Download or you can pick up your cell phone and simply text the word, ‘87Download’ to the number 44222.
This podcast is sponsored by the Heal Your Pain, Heal Your Life Program. If you’re looking for the fastest way to reverse pain using integrative and functional medicine principles right from the comfort of your own home that takes into account your nutrition, stress and emotions, mindfulness and movement, simply go to www.HealYourPainHealYourLife.com and sign up now. This seven-week guided how-to program includes videos, audios, and PDF handouts as well as a live members only training call that meets twice a month that I personally facilitate and guide. Susan, a longtime member of the program says that, “This program has been life-changing for me. It’s like having my own pain survival guide. I’m humbled by the knowledge, wisdom, and compassion I receive from everyone in the group. Thank you so much from the bottom of my heart, for showing me a path to a life with less pain.” I’m excited to speak with Dr. Aria about pain and Adverse Childhood Experiences. Let’s begin the podcasts and let’s dive in.
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Pain Psychology: A Paradigm Shift In Treating Pain with Dr. Les Aria, PhD
Les, welcome to the Healing Pain Podcast. It’s great to have you here.
Thank you. It’s great being here.
Les, the reason why I wanted to have you on is because you’re a pain psychologist and you’re known for treating complex medical and psychiatric patients. Patients that a lot of other practitioners feel like they are difficult to treat or approach or figure out, tell me how you wound up in those really important shoes?
It’s an interesting short story in the sense that I didn’t want to treat chronic pain patients. I was doing a clerkship which is a first year rotating through clinics for my grad school and I basically said I’d never want to work with chronic pain patients. I started to pursue neuropsychology and I found that more intriguing, but what was interesting is I discovered that some of more chronic pain patients, they were nice people who are struggling. Ultimately, I basically fell in love with chronic pain and started to develop a specialty. That’s how I came into this contact with the specialty.
It’s a beautiful story because we know that a lot of people with chronic pain are misunderstood. There are people, whether it’s their family, friends or a practitioners they’ve seen that because you can’t see pain, you can’t touch it and you can’t feel it on your own that oftentimes are understood and they’re looking for people like yourself who take an interest and they can see that there’s a life on the other side of their pain. Tell me about where you currently work and what that’s like?
I work for a very large healthcare organization, Kaiser Permanente in California, Sacramento. The department we have is very integrated with multiple disciplines. For example, acupuncturists, biofeedback therapists, pain physical therapists, and a large group of pain psychologists.
The truth is there’s not a lot of integrated practices out there like that. How does the patient finds that clinic you work in and what are they likely to experience once they step in the front door there?
One of the ways patients get to us is through a referral through Kaiser Permanente primary care doctor or a specialist like a spine doctor or a neurosurgeon and we get the referral. To tell you the truth, most people don’t want to come to us. One of the reasons why they don’t want to come to us because they have a medical condition and they look at us as, “You’re placating my physical symptoms because you’re telling me now it’s all in my head, which is far from the truth,” but that’s how they usually get to us is through a specialty referral.
Once someone finds you, what happens? What’s their care typically look like?
They are referred to an orientation program, which basically means we introduce them into the region they were referred, what we can do for them and the science behind our treatment. They enter an orientation program and at that point, they get to select whether they want to come into a department and not, and we get about an 80% selection rate. The 20% are usually looking for what I call them, the holy grail, the search for the medical cure, and those folks, we don’t let them just leave. We contact them a week later to see if they’ve thought about it. This way not to pester them, but encourage them that we know they’re suffering.
About 80% of the people decide, “I’m going to give this a shot,” and the other 20% as we say just aren’t ready yet.
They’re not ready for several reasons and at some point we could discuss that says it’s the belief they hold about their pain and that’s where it is. If you believe it’s physical and just purely physical, which is what the typical world believes, that’s where the problem begins.
Obviously, as a pain psychologist, you are starting to chip away those beliefs and unpeel the layers to it. How do you first start to have those conversations? They’re difficult conversations to have and oftentimes it can take a number of sessions, if not months, sometimes.
I tend to do in one session. Not that I’m an expert at it, you just get good at it up to some point. I use a lot of motivational interviewing questions. I would hate to come to a doctor’s appointment or to any appointment and when someone’s telling me what I must think. I think that’s the first thing. I’m very respectful of patients and everyone in our department is. We basically start with just, “What do you think is going on? What’s your concern?” Then at some point I’ll ask if they’re willing to hear some of the information I have, the latest science information. I call it brain science and that’s where I start, but I usually want to hear their story first.
Tell me about the groups that you have there and how those run and what they’re all about for patients?
The whole group can be couched under one theme, which is basically mind-body medicine. We run three kinds of groups or three kinds of treatments. One is what we call the pain workshop, which is very psychoeducational but people often believe, they’re just coming to hear a lecture. It’s not lecture-based. That’s a small portion. I got to tell anyone who entered my workshops, “I’m always calling on you asking questions.” It’s very didactic and interactive. One of the things I often like to do is someone in the group, usually what I’m doing with one of these educational groups, they’ll tell me they cannot stand or they cannot sit too long and how long is this workshop? What I do is at that point I start an experiential exercise. I might tell them to go towards their pain. We do the pain workshops, we do group therapy using ACT and mindfulness. I know you’re very familiar with that and perhaps our audience too. The other thing that we do is individual treatment, a one-on-one consultation also using ACT. Sometimes I’ll use CBT and a variety of other interventions.
There’s a psychoeducational pain group, there’s group psychotherapy which sounds like you’re using ACT as the foundation for it and then there’s individual counseling. What’s the difference between a psychoeducational group versus a group therapy?
The psychoeducational group is not therapy in the sense. We’re parting information and we’re getting them to experience what it feels like to dial down the pain intensity. It’s a lot of experience. It’s very interactive. We’re not talking about deep feelings, we’re not talking about more personal things. It’s very general basically trying to part a cognitive shift, meaning that with information based on science. In comparison what group therapy would do, is there’s a lot of processing and deep unearthing roots, with unfinished business and again using ACT’s framework which is beautiful and wonderful.
How many weeks and sessions are those group therapy?
We have ran data and we found that that patients can get all they need in four weeks versus the typical of eight and twelve. How I did that was I asked myself, “How long would I like to sit in a workshop?”
When you said that, did you mean you as a practitioner or you as someone in pain?
I have chronic pain myself so anything I ask my patients to do, I do myself. I asked you to meditate, I meditate, to exercise, I exercise, dietary. In that same sense, I tested out eight weeks, twelve weeks and I found out something interesting. It’s four weeks we have a greater retention of folks and their attention span is far greater.
People want things to be short, concise, and they want to take them and bring them into their world and see how they work.
The key message there is practicality.
Knowing that in the realm of pain psychology, we started to talked about pain, you mentioned like individual therapy and group therapy and going more into emotions and past experiences. There’s a lot of research around Adverse Childhood Experiences as maybe being a trigger that can lead to someone having chronic disease and without obviously chronic pain. Can you first tell us what Adverse Childhood Experiences are?
Typically, the average public or even professional know only just a handful of them and the typical ones are usually sexual abuse, physical abuse, emotional abuse, and neglect and to tell you the truth, that’s just the part of it. There are more to it. Adverse Childhood Experience, it was a study that was done in the mid ‘90s by a Kaiser doctor by the name of Dr. Felitti. A wonderful individual, a preventative medicine doctor in San Diego, and he found something out by accident. He found out that there was a correlation between those who struggled with childhood issues, not just sexual abuse, physical abuse. We’re talking also violence at home, mental illness, incarceration, those and physical abandonment, emotional abandonment. It’s about ten categories of Adverse Childhood Experiences that he found out, and then what he did was he did a correlation.
He found out that we could predict with some sense of accuracy on who will develop cardiac disease, who will smoke, who will exercise, who will be obese, and who is most likely to get depression. This Adverse Childhood Experience was a phenomenal landmark epidemiological study and in fact, I haven’t talked to Dr. Felitti. One of the things that I discovered was he was at an obesity conference talking to surgeons and they didn’t quite believe that these variables were impacting. The person who was sitting next to you was the CDC director who was overseeing research and he said, “If you believe in this, let’s do a study,” and that’s how this all came about. In 1998, I believe he published the studies and to date, we’re starting to pay attention to what happened to you in the past wires you for what’s in the future.
Should that be something that every clinician ask younger patient or even someone who’s older, in their 40s and 50s?
We’re starting to do that more. It’s still not recognized as you and I know that medical research takes decades before it gets to a practical level. The answer is absolutely yes. In fact, if you happen to look at my clinical notes in the past few years, you will see somewhere in the body of my clinical note, my intake is ACE score of and then you’ll see a number. Since you brought that up, one of the things is with ACE scores, if you score a four or greater, which means that you’ve got physical abuse, sexual abuse, mental illness, incarceration, divorce, something like that that the child experienced when they’re growing up, when you have a four plus, you’re at a high risk for cardiac disease and at risk behaviors, that is. If you have a six plus score out of ten, you have a 3,000% risk of suicide. It’s a crazy percentage. What these numbers and it might not mean a whole lot to the average person, but what it lets us practitioners know is the higher your ACE score, you’ll likely to have chronic medical conditions. One of it is most likely chronic pain. That’s why I think it’s important for everyone to take a look at it.
You said something interesting there, Les. You said that as the score increases above a four, that you’re more likely to have behaviors that lead to chronic diseases. That’s an important distinction because if I wasn’t listening so carefully, one might say, “If I take this test and I’m over four, it means that I’m going to get this type of disease versus I might have behaviors.” There’s a distinction there that’s important if could talk about it.
That’s what it is. One of these things when we look at studies, it makes it sound it’s doom and gloom. I do want to let everyone know and I’m glad you brought that up because we have a choice and not to get too much into ACT, but that’s why I like ACT is we notice our thoughts, but we have a choice on how do you wish to live your life. This should get us all excited including our audience and professionals that, “Let’s take a look at it.” We have something very important. We have choice in our behaviors, independent about DNA, independent of what research says. That’s the take home message.
It’s interesting because even if you scored high on the ACE scale, it doesn’t mean that you’re going to have diabetes or heart disease or chronic pain necessarily. We found other things about resiliency. ACE was good at showing us, “If someone’s had these types of experiences, alcoholic parents, physical abuse, sexual abuse, that you were more likely to develop behaviors that are not going to help you cope in life and it’s going to lead to disease,” however, it’s also started to unearth things about resiliency and how resilient we can be as human beings. Can you talk about that?
I’ve been in practice for fifteen years, Dr. Joe, and I love seeing patients because every time I see them, it’s like a textbook. I’ve learned something here and the more I hang out in this field, I’m realizing is we have the ability to heal. We have so much ability to heal that we give power away. Research is showing us there’s something called the resiliency zone. We can develop it and how do we develop it? We develop it by not running away. It goes back to the basic tenets of our treatment, be aware. The cornerstone of recovery is self-awareness.
Be aware of where you are in your mind. Be aware of the amount of avoidance you’re using and unhealthy choices you’re doing. The other cornerstone of recovery is to be able to do behaviors that move you in the direction of healing. Some of the things you speak in your book and some of the things that we talked about and one of it for example, is learning to de-stress. To dialing down that pain intensity and what we call it in brain science or in pain psychology, we call it bottom up processing. What bottom up processing basically saying is, drop into your breath, in simplicity. Dial that sympathetic system down. How we develop the resiliency is paying attention to what’s going on in our mind, in our body and then making that choice. It does help with resiliency.
As people are exposed to these adverse conditions, there are also might be other conditions in their life that are supportive. How they think about or confront some of those situations has a lot to do with how these things start to piece themselves out or develop as we go forward in life.
That’s part of the thing is putting the patient back in the driver’s seat is to be able to give them that opportunity to say, “Here are some scientific proven techniques, here’s what you need to do.” It’s not always about exercising, it’s not always about nutrition, it’s the integrated approach of the person with the pain and all the things that we recommend. Resiliency is not psychological, it’s the people around them, it’s the support, it’s the environment and the choices they make.
I’m going to ask you maybe a little bit of a challenging question in the world of psychology. A patient comes in, you give them this ACE test, it’s ten questions. I get a score and you look at it as a professional and the obviously the patient’s looking at it and they see it, “Dad was an alcoholic, mom left me and I was raped in high school.” As a psychologist who incorporates a lot of different types of techniques, how do you not give over attention to the negative, especially when you are employing a type of therapy such as ACT which does not spend a lot of time focusing on the negative? It’s a tight rope to walk with patients sometimes.
It is. Not too long ago, I was working with a patient and one of the things that I do want to send a message out, the type of patients I see, the complex medical and psychiatric, these are folks like both of us. It’s great folks, but they have a very strong and traumatic history and to answer that question, here is this. I do not invalidate them. I validate them and one of the things with traumatic patients with chronic pain is that they tend not to be validated. One of the things they are used to is the outside world rejects them and they reject their body and everything else.
Even though I’m an ACT therapist and a mindfulness guy and I love all that stuff, I go back to being just human. What that means is, I validate their tough experiences and I say, “You’ve had a tough life and childhood,” and often than not, the response I get is, “Yeah, but that’s the past.” I usually break into a smile and say, “Absolutely and that’s a part of why I want to talk with you about it is I tell patients that the past steps into the present,” and the brain power I’m talking about is the amygdala. Every time a patient who struggles with pain does not know how to deal with it, we opened up the door of the past.
I wanted to mention something here is that when I keep saying the past steps into the present, I basically mean as same sensations of lack of control, different context, in a sense that when the pain becomes so overwhelming, you feel controlled and manipulated. If you are manipulated as a child, you might experience that same sensation, except in the sensation of physical pain. Walking that tight rope is to be able to validate them, but I don’t spend a whole lot of time in the past, but I do bring whenever someone feels extreme pain in the office, I basically say, “Let’s drop into your breath. Let’s observe that and let’s go to it,” and that’s the big key message there, “To heal, you need to get better at feeling.”
It’s an interesting question because I get a lot of emails from people who follow me asking me questions about trauma. “Could I have my trauma treated, my trauma dealt with?” I think probably what you’re saying is refreshing in some ways. A lot of people don’t want to go back to that emotionally and/or physically painful part of their lives. They want to be able to move forward, but they want to be able to move forward in an informed way of what’s happened in the past. It’s probably a welcome message to a lot of people because I wouldn’t want to go back and visit some of the traumas that happened in my life. I don’t have that many traumas. I’m sure people have many more. I think they are important things to talk about and discuss.
Two comments on that one is, two-thirds of us in the United States, this is going back to the ACE study, have at least one trauma. That could be divorced. It’s the most common thing. Also, another message I want to emphasize is that we are constantly visiting the past except we don’t know it. For example, when someone experiences pain or emotional upset, those memories are embodied and coded and that’s why I love working with pain and trauma because it’s a fine line, but the reality is most people do not want to go back and talk about the past. There are a group of them that do want to talk about the past and they need to work on that.
Very often, if the trauma is very, very severe beyond my expertise, I have several colleagues who are trauma therapist and that’s all they do. That is a skill. What they do is they do trauma therapy then they come back to me and we work them through the program. Through the education, the groups and the individual therapy and strengthen them. By the time we get to the individual therapy part, I usually get them to choose something. I usually say something silly. If anyone’s worked with me, they know I’ll say something silly like this after they’ve been hanging out with me a while, pick three, six, nine or twelve, those are months, and basically I ask them how long they’d like to heal. I ask them and very often I get six months to nine months and to tell you the truth, it’s unbelievable when patients get to the point where they’ve dropped in 50% of their pain. That is very rewarding.
Tell me about a success story. We all have those patients that stick out in our minds, either recent ones or ones that came across our map that looks like they’ve tried everything and all of a sudden they turned the corner.
Someone distinctly popped up in my mind the moment you said that. Let me explain her. She’s in the late 60s and she’s a former director of nursing at a very big place and she’s retired now. Her thoracic was fused, her lumbar was fused, and a doctor referred her to our department, and she reluctantly sat in class. I remember distinctly. She sat up front with her arms crossed and she was frowning at me. By the fourth week, she approached me and she said, “Do you believe everything is saying?” I said, “Absolutely.” She said, “I’m going to test you out.”
Eight months later, here’s the end result. She unearthed that she did have trauma, but she’d been avoiding it and she broke down. She will tell you the pain is there, but it doesn’t bother her. She says she doesn’t quite understand that, nor does she care to understand it. She is a success story because she is now driving. She’s traveling on her own. She is off all opioids. She practices ACT. She meditates a minimum of 45 minutes a day and she’s now preaching the word that pain can be reduced. In fact, you can live a pain-free life. She picked up your book and she wanted me to mention this to you. She loves the nutritional part, which she never got on any other pain management book. She’s a wonderful recovery story. We’re off meds, she was severely depressed. The depression is barely there and she’s very functional.
I wish her the best and thanks for sharing that story and just so she knows if she listens one day, my mom was a director of nursing too. My mom was a nurse. My mom and her, I’ve talked about these issues with my mom in other places, but my mom is one of my inspirations to work with patients. She had an issue with chronic pain and some anxiety and as a kid, I think instead of looking at it like an adverse effect in my life, it put me on a path to wanting to help people and serve people. Les, how has treating people with pain informed your life?
This is what I called silent sufferers in the sense that it’s informed my life that we all suffer at different levels, not just because we cannot see it. Very often, the ones I treat and see basically acknowledged they have pain, but they don’t realize they’re suffering deep down inside mostly, nor do they have the skills. I have a saying, I say is that, “The most important skills are never taught to us, the most important life skill.” One of it is basically, “How do I deal with this thing called the mind?” That’s why, not to beat on this drum too much again, but ACT teaches you tons of thought and it can become symbolic. If you attached to those words and what it says and what your mind says. Ultimately, it’s informed me that one, people, they don’t have the mental skills and two, a lot of people are suffering who continue to believe that pain is just physical. I made my lifelong mission to help people reduce suffering.
How has treating people with pain helped you be a better person?
I used to be quite an impatient person. I’m embarrassed to tell you that, but in the fifteen years that I’ve grown, it’s taught me to be more patient. With the practice of a daily mindful practice, it’s helped me become very aware of my judgments. It’s taught me to be more compassionate.
Why should someone see a physical therapist if they have pain and they’re scared?
One of the things I love about physical therapy in the sense that is they are well apt to help rehabilitate someone. I’ve mentioned this to you as the gal I work with, Christy, and she’s a physical therapist and she basically uses ACT and physical therapy. I think people should see physical therapists because it’s one of the foundations of recovery and pain management.
Les, it’s been great chatting with you. I’m glad we had this opportunity to connect. Can you tell everyone how they can learn more information about you?
A couple of ways to get to me, there’s a website called Myndfulness.io and that’s one way to get to me or you can just email me at [email protected].
I want to thank Les for being on the Healing Pain Podcast talking about all things pain, but most specifically talking about how you can become more resilient in your life and live beyond the pain. You can find more information out about him at Myndfulness.io. At the end of every podcast I ask each of you to click the like button and share it out with your friends and family on Facebook, Twitter, LinkedIn, wherever you like to be social. Thank you all for joining me.
About Les Aria
Les Aria is a Pain Psychologist, who has been practicing for the past 15 years with a large healthcare organization in Northern California, and will be offering his unique online training program on Mindfulness Meditation in May 2018.
Les specializes in treating complex medical-psychiatric chronic pain patients, when others suggest nothing can be done. He completed two specializations, fellowships. One in Neuropsychology and the other in Pain Management. His love for the brain and pain has helped him develop a unique style in helping patients who are suffering by helping them retrain the minds to rewire their brain and body. His interventions includes: Hypnosis, EMDR, EFT, Biofeedback, Trauma-Therapy, MBSR, and his other two loves: Mindfulness Meditation and Acceptance Commitment Therapy (ACT).
The Healing Pain Podcast features expert interviews and serves as:
A community for both practitioners and seekers of health.
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A catalyst to broaden the conversation around pain emphasizing biopsychosocial treatments.
A platform to discuss pain treatment, research and advocacy.
If you would like to appear in an episode of The Healing Pain Podcast or know someone with an incredible story of overcoming pain contact Dr. Joe Tatta at [email protected]. Experts from the fields of medicine, physical therapy, chiropractic, nutrition, psychology, spirituality, personal development and more are welcome.
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