Welcome back to the Healing Pain Podcast with Mary Doyle, PT
You’ll learn about a physical therapist who has evolved her work through Pain Neuroscience Education onto Cognitive Behavioral Therapy using Acceptance and Commitment Therapy in the unique environment of a prison. My guest is Mary Doyle, who has been a practicing physical therapist since 1995. Her career started out in outpatient orthopedics. She eventually moved to home care where she treated both geriatric and pediatric patients in the home. Looking for a change from driving and the ever-increasing hurdles of insurance, she moved to correctional facility work in 2016.
She functions in a primary care physical therapy practice within a prison environment. She combines physical therapy with Acceptance and Commitment Therapy for the treatment of pain and other chronic lifestyle conditions. You’ll learn how Mary uses Acceptance and Commitment Therapy to target the important psychosocial variables for prisoners in the prison environment. If you’re interested in learning about combining Pain Neuroscience Education, mindfulness, and ACT like Mary does, make sure to check out my latest book, Radical Relief: A Guide to Overcome Chronic Pain. It is available on Amazon and in most countries. Without further ado, let’s begin and let’s meet Mary Doyle and learn about combining ACT with physical therapy.
Watch the episode here:
Physical Therapy Informed By Acceptance And Commitment Therapy In A Correctional Facility With Mary Doyle, PT
Mary, welcome to the show. It’s great to have you here.
Thanks for having me. I’m excited to be here.
I’m excited to talk to you as well. You work in a specific and distinct practice setting, which is a prison environment. I can’t wait to hear everything about that and the great work you’re doing there. The moment I met you, and I heard about the work you do, first of all, it was moving for me to hear how you embody so much of physical therapy and psychologically informed care. I think about the patient population that you’re working with. I can’t wait to dive into that further. Before we do that, you’ve been a physical therapist since 1995 so this is not new to you. Tell me about the major practice settings that you’ve worked in, what your experience was like in them, and how that led up to the prison environment that you work in.
I’m an athlete. Like a lot of PTs, I tore my ACL and I wanted to go into outpatient orthopedics. That’s where I started. I spent about three years doing that. I got a bit tired of it and wanted to try something new. I had always wanted to work with athletes, but when I switched, I’d tried home care. I loved working with geriatrics. I loved being out and being able to work with people individually, and not having quite so much of a time schedule and time crunch. I stayed in with that. I did a bit of home care with pediatrics as well. That’s doing pediatrics and geriatrics. I did that for fourteen years or so. It was rewarding and interesting.
At the time, I was still doing athletics. I was doing triathlons and I row. I was doing competitions with rowing. I was starting to develop my own pain. I found that driving made it worse. All the notes that we have to do, how particular they are, and how much medication we need was taking up a lot of time. I got an email from a headhunter that said, “There’s this opportunity.” I’m like, “It’s an opportunity. Let’s see what it is.” I emailed back that I would be interested. They said, “It’s at a prison.” I’m like, “Could I work in a prison?” I’ve never had anything to do with anything law wise or criminal wise. I gave it a shot. I went for the interview and they gave me the tour. I’m like, “I’m going from nice houses to this. I think I can do it.” I did it and it’s been great. I love going to work every day.
Tell us what that work environment is like for you. Do you have a physical therapy gym? Where do you provide care for people? What does that look like? You mentioned that you’ve worked in outpatient setting. Most outpatient settings have private treatment rooms and lots of gym equipment. You’ve worked in people’s homes, which is a great environment for working with the people who are aged and the elderly. I’m trying to imagine, because I’ve never been in a prison with regard to physical therapy or anything else. I’m trying to imagine what that environment is like for you.
It does vary from prison to prison. I don’t know a lot of other states have, but I’ve heard from inmates that sometimes they have gyms and sometimes they have a lot of equipment, and they have modalities. I don’t have much of that where I work. I have a treatment room and a table. I have one TENS unit. No hot packs and ice. I don’t do any of that. They can get ice on their own. I do a lot of telling them things that can help them. It’s up to them. As far as equipment, I have some water bottles to use for resistance and a band or two, but I try to use what they have access to so that they can continue on their own. They don’t have a lot of gym equipment in their cells.
Are you seeing people individually in individual sessions? Are you doing group? Is it a mix where you are?
It’s all individual. To give you an idea, to get to my office, I have to go through fifteen locked doors and gates that I don’t have keys to. There’s always somebody overhead watching, and they open the gate for you. Sometimes they see you. Sometimes you have to wait a bit. I do see people individually. I have several places. I work in a fairly large prison and I go to different places in that prison. I have one treatment room in the main park where they come to me, and then I have a couple of other treatment rooms. They still come to me, but it’s closer to where their housing is. There are several levels of prisoners too. There’s a minimum security, there’s maximum, and then there’s supermax. I see all three. There are more officers that need to be closer by when you’re seeing the max and the supermax. They sometimes have to have handcuffs on while they’re in there.
How do these inmates find you? Are they referred to you inside the prison, or an injury that happened when they were in the prison, or something that was pre-existing? Oftentimes, there’s a referral that’s been made to see a physical therapist. Does that work the same in the prison?
Yes, they have referrals. It’s a complex medical system. That’s been a big thing in prisons since the ‘70s. They were like, “Maybe these people need care.” There was a big landmark law case about it too. It’s been gradually improving. It’s a sophisticated medical system. They have a lot of practitioners and nurses. When a prisoner feels bad or they feel like something needs looking at, they put in a sick call and then they’re seen. If they see a provider and the provider decides they need therapy, they send me the referral.
Are you outside of the insurance realm?
We are outside of the insurance realm. That is such a freedom for me. I’m beholden to the person in front of me. I want to make them better, but I don’t have anybody telling me how long I need to see them, how long each session needs to be, what I should be doing in each session for this diagnosis. I don’t have any of that, which is nice.
You’re almost functioning in a primary care capacity within the community of a prison and the inmates that are there.
I get to do a lot of communicating with the other practitioners. I can communicate with mental health. When things are going on, they can communicate with me, and they do often, mental health and the nurse practitioners. That’s good.
What are the challenges of working within a correctional facility for you as a physical therapist and in general?
Some of the things that are a little restricting, there are certain times that you can’t see people because they have count time. They all have to be in their cells when they need to be counted. If anything happens in the facility and it needs to be locked down, then you’re not seeing anyone. You had your day planned and you thought it was going to go one way, and then you need to change up what you’re doing. That happens not super often, especially more on the max side. You won’t be able to see anybody in one certain building, and you have to adjust where you’re going. That can be hard. People move frequently. You thought they were in one place and you needed to see them there, but then they’re in another place. That’s part of the prison system. They try to do a good job of keeping people that can function well together in the same place. It’s complicated.
I’m trying to imagine as a physical therapist coming into that environment, what type of skills did you bring with you that made the transition and the treatment of those inmates and those people easier for you as a professional, and for them with regards to receiving care?
Inmates are interesting people to work with. I had no expectation. I didn’t know what to expect when I first got there of the people that I would be working with. It turned out they’re regular people and they’re here. That was interesting. Once you get to know them more, you start to find out more of their anxieties and the depression. They open up to you a little bit more. You see how much more of that is present in the prison than there is on the outside, the PTSD and head injuries. They’ve all had tremendous trauma in their past. Things that helped me with working with that was I was always the type of person to allow people to be who they were.
I didn’t force my agenda on people. Although as a PT, I was instructing people on what to do. That was what I did. I tried to share my knowledge with them. I respect their differences and respect who they are, that was helpful. Also, being forgiving. If they don’t show up, they don’t show up. I keep them on the schedule. I know that they have things going on in their lives that PT maybe taken a back seat for them. I allow them to do what they feel like they need to do. That helps me. It helps them to trust me more. It helps them to know that I’m going to be there for them no matter what they do. They need that a lot.
The psychosocial variables sounds like they’re quite palpable once you get to know your patients. I’m sure that comes up maybe not in the initial history.
It does take a little time. A lot of times when you first meet them, some of them put up a front and they make everything shiny for you, “There’s not that much I can see going on here, but let’s keep you on. We’ll try this.” After a few visits, then it starts coming out why they’re having so much pain and it’s so persistent.
When you first started using psychosocial skills in combination with physical therapy, what did you first start using?
I always had the skills that we all have as PTs. Allowing people to be where they are and respecting their differences and respecting their anxieties. The thing that tipped me over was I finally went to a chronic pain course, which had that model of the biopsychosocial on it. I was emphasizing that the psycho part is important. I’m like, “That’s a part I don’t address much.” I always steered around it and allowed it, but I didn’t address it. I would read up on people’s past, so I knew what they were coming to me with. I could see where the anxiety or the depression was impacting the things that they were telling me. I’m like, “If I could address some of this, it would help what I’m doing. It would help me be better.” I started looking into that. I took a course on CBT and that was helpful. It didn’t address things the way I acted because it still put them in the wrong like, “Your thoughts are not right. Let’s try to change what your thoughts are.” It would work for some, but some people are wedded to their thoughts.
I liked the way you put that, they’re wedded to their thoughts. That’s a nice metaphor to use. Take me back to the CBT course you took first, because you took a CBT course first.
Before that I took a chronic pain course. That was what opened my eyes up because I hadn’t had pain science before that. I was still on the old treatment model. I was like, “Does everybody know this and I didn’t know?” That took me down a big old rabbit hole. I started looking at tons of stuff. I would talk to other professionals. I’m like, “Nobody knows about this. Why doesn’t anyone know about this?” I started telling everyone about it, teaching the nurses and the practitioners. I’m like, “You need to know this. This is why they’re acting the way they are.” That chronic pain course opened my eyes. I started learning about Lorimer Moseley and all those guys, and how we need stories.
Was the CBT course pain specific or was it more general?
It was pain specific. There was an occupational therapist in there too, but it was mostly mental health practitioners. It was for treating pain specifically. It was great. It was a good course.
Dealing with things like cognitive distortions, intermediate beliefs, core beliefs, all that is common in a framework of a traditional CBT.
They did the motivational interviewing, ANTs, trying to get the Automatic Negative Thoughts, addressing those and gave several techniques to use. I found that helpful.
How long did you run that in your practice? How long did you run CBT before you started touching base with some of the ACT skills?
I was doing pain science and CBT and I was still learning a lot. I was looking at YouTube. I was watching lectures. I was watching things on behavior. I then stumbled on your podcast and started listening to all of that. Your podcast early on had some ACT stuff in it. I’m like, “That sounds like fun.” The doctorate psychologist that was at the prison was doing a lecture. They had a lecture series. They had one every month for a little while. One of them was on ACT. I’m like, “This is it. This is what they need to do.” It was complicated and there were all those metaphors. I’m like, “I know that’s where I need to go, but I couldn’t figure out how to put it in play.” That’s when I took the exposure course first, and then I took the ACT for chronic pain.
When you first come across ACT, especially depending on who’s teaching it, it does sound quite complicated. There are lots of fancy terms, some words that are new like diffusion is not even technically a real word. It’s a metaphorical ACT word. You have this model with all these processes and how do you start to put this into play. What do you find is useful about ACT with working with inmates, and helping them with their either acute or chronic health conditions?
The best thing about it is therapeutic stance. You’re with them on their side. They are not wrong. That was an adjustment for me of trying to figure out what they did wrong, trying to figure out, “What did you do that made you hurt more? No, you’re not wrong.” Getting them to be not wrong. That helps so much, and then not contradicting their thoughts. When you contradict their thoughts, the wall goes up and they can’t listen to anything else. That stance is the most useful thing out of ACT that I’ve gotten.
You’re talking about the ACT stance. Those who study ACT are familiar with it. Was it hard for you to go from CBT to Acceptance and Commitment Therapy ACT with regard to adopting a new stance and how you approach working with your patients?
Yes. I found it a change for me to go from that instructor mode, “I’m the one that knows stuff. Let me enlighten you. If you know this stuff, you’re going to get better.” Sometimes it would work, sometimes it would be okay, and they would be absorbing it. A lot of times they wouldn’t. We’d be at the same place, “Let me tell you about it again. Let me tell you a different way. Let me use this instead.” They still wouldn’t get it because I’m still on the other side telling them what to do, what to think, or how they should be thinking. That’s where ACT helps.
It’s allowing them to get that confidence up that they can help themselves. That’s hard because they walk into the clinic and they expect you to fix them. They expect to be better walking out, but they have a mistrust of the whole medical system, of anything coming from the Department of Corrections. If you’re not saying what they want to hear, they’re not going to listen. They’re not going to do the things that they need to do in order to get better. They have to be able to think of it themselves. I have to be able to guide them so that they can get there.
When I think of traditional CBT and pain education, there’s an approach of, “Let me provide you with some information about what’s happening. I’ll give you some data. I’ll share some of my knowledge and then we’ll change all of this.” Where in ACT, we don’t rely heavily on didactic instruction and sharing of information, although that piece is there. It’s fine to add in a bit of Pain Neuroscience Education into your treatment and combine that with ACT. There’s not a heavy emphasis on modifying thoughts, changing beliefs. You’re working with a population where it could be difficult to change their beliefs not only because of the environment they’re currently in, but because of the entire world they’ve lived in that may have led them up to that.
The only one that they can rely on is themselves. They have to go with what they’re thinking, and they defend that to the end. I try to show them where their thinking is good, where it’s helping them get where they want to go.
It’s to normalize their thoughts first. As you started using these skills, I’m wondering if you noticed a change in yourself. Did the inmates you work with notice that change? How did that start to play out in your work?
They probably did because I try to keep them on. I try to keep seeing my patients until they feel like they’re ready to be on their own. I don’t see them frequently. I’ll see them once a month. With COVID, it was less frequent than that. Some of them I’ve been with for a couple of years, and they would see the changes that I went through. I’m like, “This is what we did before, let’s try something else. What are you thinking about that and how are you feeling?” It was interesting, those patients that I had had for a long time, how they responded to ACT and how it made them change. I know it changed me too, how I was processing my thinking. I’m seeing them change themselves too and knowing that it wasn’t anything that I did to change them. They did it themselves.
What’s been difficult about learning ACT and infusing your physical therapy practice with ACT and the environment that you work in?
I was doing all pain science for a bit and then doing all CBT and then doing all ACT. Sometimes the exercise dropped out back, so I had to re-introduce. Especially with no equipment, I didn’t have any equipment. They didn’t want to exercise, “I don’t want to do anything now.” “Let’s talk a bit, you can exercise when you’re ready to.” I’m integrating it back in. I’m getting it back in so that we’re doing some movements so I can do more of the thoughts and the exposure with the exercise. That was good. That helped me. All the processes getting them all set in and figuring out when to do what. It took some talking with the patients, and then sometimes I would hit on something.
One time I was working with a patient and he was stuck on his pain, “It’s caused by this and I’m never getting rid of it.” I was working on some acceptance work. We started talking about other things. He talked about his celly, and that he didn’t like his celly, but he didn’t want to move him either. He tolerated him because he was tidy and clean. He liked that about him. I hit on that one. I’m like, “Do you think maybe you could sometimes think about your pain that way? It’s necessary. You don’t like it, but it has a function in your life.” We went with that. I’ve seen him for a long time. He comes back often. Sometimes he does a lot better.
You mentioned you’re using your ACT skills as it helps with exposure. ACT in many ways is a type of exposure therapy, which is so important with regards to our work as physical therapist, because we’re exposing people to uncomfortable exercises or at times painful exercises. Even manual therapy can be painful at certain times. You also combine it with some Tai chi as well. I know there were some similarities to ACT and Tai chi. Can you talk about the similarities and how that started?
I teach a Tai chi class in the prison. That came up as a request from an inmate who had heard that Tai chi helps your cardiovascular system. I went and got certified. The more I learned about Tai chi, the more I saw how many parallels it had with the neuroscience that we know, and all the things that we do in ACT which works on your neuroscience. It’s the mindfulness, the slow moving, and working your brain. You have to remember the moves that you’re doing and the sequence of the moves. It’s also about breathing and it’s about being calm. I started to integrate ACT into my Tai chi class, with some of the cues, the noticing things, and the mindfulness. It was helpful. It gave them a lot. I had some regular guys that would never miss a class
ACT has six core processes, acceptance, diffusion, present moment awareness, self as context, values, and committed action. Is there one process you found to be most helpful working with the population you work with each day?
I don’t know if most helpful, is it more that I go back to all the time? I do try to emphasize the values. I go back to their values frequently. Almost every session, I try to take it back to, “What are you here for? What are you working towards?” That’s the thing that’s going to motivate them. It’s going to get them where they need to go. A lot of times they have the most difficulty with the acceptance part and the diffusion too. Those parts I work on, but I always come back to the values. No matter what I’m working on, I come back to the values. What I find is a lot of times they don’t know or they had no idea like, “I have values?” They’ve been so obsessed with all the injustices that are around them, all the injustices that have been put on them. They are angry and always in pain. They lose sight of the things that are important to them. If I get them to refocus, they start to improve.
When you mentioned values, the first thing that comes to my mind is how can someone begin to act on their values if they’re behind bars?
It’s hard. Sometimes I need to give them a little bit of prompts. They feel like it’s such a big barrier. It’s funny because some of them, I’ll give them the bullseye and they’ll be in the center for everything, “I’m doing everything. I’m great.” There are other people, “There is no way I can move on these values. It’s too restrictive.” Everybody’s very individual. We try to figure out what small moves they can make, what little thing they can do, “Can you call this person again? I know you haven’t called them in a long time, but that’s a person that’s important to you. You think maybe you could try it again? Even if they don’t respond, you could write them a letter.” It’s not about that person on the outside responding to them, it’s more about them thinking about that person that’s important, “Write them a letter, even if you don’t send it.”
It’s them acting in line with their values, even though they are in a prison. For example, maybe someone values being a supportive father to his child, but yet he is in that environment. He may not see his child every day, so value seem like they’re distant from him. What you were saying is a phone call, or a letter, or taking care of your health may be a way that helps you with your values with regard to that interaction with family.
Health is important to them. They understand that health is important. They cognitively know what they need to do to get that health, but then all the other stuff, “I want these chips. I don’t want to get up.” Those things come on them and getting them to refocus on their health. Getting them to focus more on those other values too can get them up and moving, which gets them more into the health. They do get up and write that letter. They loved fishing. They used to go fishing. They used to be out in the woods all the time, and now they’re in prison, “We have a lot of outdoors.” I’m like, “When you’re outside, notice what’s out there. Take what you have and use it, and get into the present moment stuff and the mindfulness.”
It sounds like a great environment that requires you to dig deep, get creative, and use all your skills. It’s so fascinating. ACT is an experiential exercise. Experiential is probably easier when you’re in an environment where you have things to work with. You have a little bit less so you’re focusing on that relationship with someone, helping them look at their values and saying, “How can you make that little tiny step now?” It is so important even for people with chronic pain who were outside of the prison system. If you can make that small change, you’re one step closer to something wonderful in your life. If you had to give some advice to a physical therapist who has heard about ACT, but they’re not sure about using psychological informed physiotherapy in general, what advice would you give to them with regard to learning ACT?
First bit of advice is to start using the processes on yourself. ACT makes your life better. I do it a bit with my coworkers too. I find that it helps them a lot. They know that they can come to me. They’re comfortable with me. I’m going to give them that a little bit. There’s a lot of burnout with the workers. They’re super dedicated though. Getting the ACT, going through the processes on yourself, learning what your values are, what is motivating you, why are you going to work every day, where you’re fused to notice when you’re doing things the same old way.
Also, when you’re not in the present moment, when it’s difficult for you to contact other contexts in life and moving into those contexts, even though you may not want to.
Yes, and allowing things to be as they are. Allowing things that you can control, or you feel uncomfortable with. Since listening to your podcast, I started doing my own meditation. I used to think it was a big waste of time back in my youth. I do it every day and it’s important. I understand when I’m teaching these skills to inmates too, and they have such a hard time with it because they’re so distracted. I understand how hard it is. When I first started doing meditation, I did a one-minute meditation and then I didn’t go back to it for a month. Now I can do it every day and it’s so helpful. Knowing who you are and what your part is in the world, they didn’t get that growing up. Some of them did, some of them are intelligent and had a good upbringing, but a lot of them didn’t. They have no idea what their place is. That selfless context helps and then committing to your values. I love the commitment worksheets. I love using motivational interviewing and having them tell me everything to put on that sheet. I’m like, “Now you can do this.”
Mary, you have studied Pain Neuroscience Education, Cognitive Behavioral Therapy, Acceptance and Commitment Therapy. Why is it a radical idea for a physical therapist and other health professionals to use the mind as part of their treatment with regard to chronic pain?
It’s radical because we’re humans and that’s not what we do. We like to go with the status quo and what we’ve always done because it’s comfortable, it’s easy, and we know what we’re doing. There’s a story that I like. I heard it in a lecture that I was listening to. It’s about a doctor in England. This is in the 1850s. They still thought that viruses and disease were spread by miasmas, by what you smell. This was a time in London where cholera outbreaks were frequent. This doctor was Dr. Snow. He was an obstetrician. He had this theory that there were all these people getting cholera and dying right around where he was working.
It was affecting the community and businesses were leaving. He suspected it had something to do with the water supply, but he didn’t have any proof for that. He started gathering it. He started looking at all the people that died and where they lived and where they were getting their water. He started looking at the places that the people weren’t dying, one of which happened to be a prison. He went there and he asked them and found out they had their own well. He went to another place. It was a brewery. They also had their own well. Nobody was dying there. Everybody around them was dying. He’s like, “It’s this well.” He gathered his evidence. He was going to the hospitals and finding out who was dying from cholera.
He had his aunt and her niece died two miles away. He found out that they were getting bottled water from the same well shipped over to them. That’s why they died. He took all this information to the authorities and he said, “You got to take the handle off this well.” It took a lot of convincing and the authorities didn’t want to do it. Eventually they did, and the death stopped. They still didn’t believe him. They didn’t want to make any changes. There were cesspools near the well and it was leaking. There was a Reverend that wanted to disprove his theory that it was coming from the well, because he wanted it to be divine justice. He wanted it to be like God’s retribution. The Reverend started gathering evidence.
When he brought forth his evidence, it all supported what Dr. Snow was doing. He found out the one source of how the cholera got into the well. This is a good 40 years before they even knew what bacteria and viruses were. It took another how long before cities would clean up and have their sewage systems separate from their water systems. People don’t want to change. They don’t want to know that something is new, that it’s not the way that you thought it was. We’re in that same situation. We’re twenty years into this pain science thing. I still kick myself. I’m like, “They knew about this for many years and I didn’t know.” This is where we are. We need to spread this word. Once we get it spread out, then we are all going to be working on the psychological part. The mind and the body are one thing. They work together and they can’t be separated.
It a bit of being uncomfortable as a professional too. We are comfortable learning. That’s inbred in us. We’re good with learning new things, but using something new in practice can be a little uncomfortable. You have to try something new.
It makes it more uncomfortable because they’re not expecting it. People that see us come in with expectations. If we’re not what they expect, they can go somewhere else.
We can’t separate the mind and the body at this point. How can we not take this work and adopt it to clinical practice?
This is what works. Every neuroscience out there that’s putting their work out are saying the same thing. The diet people are all saying the same thing. It all works together. We are figuring out how our bodies work. It’s not what René Descartes thought. It’s not what we always thought it was. It takes people like you getting it out there and making your minions to spread it out more.
Mary, it’s been great talking to you about your whole evolution through pain science, through CBT and through ACT, and the unique environment that you work in. Tell people how they can learn more about you and follow your work.
Make sure to check out her website. Go in there and check out the great things that she’s doing. If you have any questions about the environment she works in, or the things she’s learned, you can reach out to her. I want to thank Mary for joining me. It’s been a pleasure. Make sure to share this episode with your friends and family on Facebook, Twitter, LinkedIn or wherever everyone’s hanging out talking about Acceptance and Commitment Therapy, and other forms of psychologically informed pain care. I’ll see you next time.
- Mary Doyle
- Radical Relief: A Guide to Overcome Chronic Pain