Welcome back to the Healing Pain Podcast with Deepak Ravindran, MD

We’re speaking with Dr. Deepak Ravindran regarding the association between post-traumatic stress disorder and chronic pain. Dr. Ravindran has more than twenty years of experience in helping people overcome pain. He’s one of the few consultants in the UK with a triple certification in musculoskeletal medicine, pain medicine, and lifestyle medicine. Dr. Ravindran is a full-time NHS consultant in pain medicine, as well as anesthesia at the Royal Berkshire NHS Foundation Trust and Redding and the lead for the pain service. In this episode, we discuss how to provide trauma informed pain care, as well as Dr. Ravindran’s book called The Pain-Free Mindset: 7 Steps to Taking Control and Overcoming Chronic Pain. If you enjoyed this episode, make sure to take a screenshot on your phone and share it over to Instagram and tag me. My Instagram handle is @DrJoeTatta and I’ll be sure to tag you back. Let’s begin and let’s learn about a pain-free mindset and the connection between trauma and chronic pain.

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Understanding Posttraumatic Stress Disorder (PTSD) And Chronic Pain With Deepak Ravindran, MD

Dr. Ravindran, welcome to the podcast. It’s great to have you here.

Likewise, Joe. Thank you for having me. It’s been great to be here with you.

I’ve been looking forward to chatting with you. I read your latest book, which is out, which we’ll talk about throughout this episode and I want to point people to it. It’s called The Pain-Free Mindset: 7 Steps to Taking Control and Overcoming Chronic Pain. It’s a wonderful book because it’s integrative, holistic, multidisciplinary and interdisciplinary. It’s a great resource for both professionals and people living with pain. You’ve been practicing now for more than twenty years. Most of that is within pain management. I also know that even though you wrote a book on pain, your sights are starting to point toward the intersection on trauma and pain. Also, what that means for us as professionals and the spiral that people may get caught in who have trauma, co-existing trauma, or who are maybe traumatized by inadequate or poor pain care. It’s a good place to start and talk about that.

The way I try to provide pain care in my practice is what I call Trauma-Informed Pain Practice. A lot of it is almost regular work that’s been done in many parts of the US and in the UK in the criminal justice system, education and social care. It has become common to know that everyone, all of us have some form of trauma that we’ve experienced in the past. The earlier you experienced the trauma, the more of an impact it has on your developing nervous and immune system. Over the years, the immune and nervous systems get more intertwined with each other and how they manifested. If we are to accept the neuro understanding that pain is fundamentally a form of protection, then you could always say that the nervous and immune systems are working in tandem to provide protection. If at any time they have been exposed to a threat, danger or trauma of any kind, whether that be that developmental trauma, an adult trauma, or a pandemic as we are in now. All of that will impact our nervous and immune system and that could manifest in some people as pain. Pain from a particular organ or structure.

Trauma-informed means that at least we are always aware that everyone could have trauma. We realize that, we have to recognize that, and we want to respond to it. Most importantly, in the UK we call it secondary care, but in the US, it would be hospital system care, it would be that inherent need for us to resist re-traumatization in our communication, in our talk, in our manners, in our way of therapeutic relationship. How can we ensure that we don’t re-traumatize them? That’s what I bring to my pain practice as well.

When you mentioned the word trauma, the first thing that comes to mind for a lot of people is ACEs or Adverse Childhood Experiences. You mentioned those. In 2020 and 2021, people have started to focus on, “There are more than those basic Adverse Childhood Experiences.” All of us, at some point in some way, may confront a trauma. The Coronavirus pandemic is one of them and all the sequela out of that. Are you perhaps positioning it to a place? Because we know that all of us still have a long way to go with regard to safe and effective pain care. As practitioners, should we start to look at the system that we have right now for pain as, in some way, traumatizing people and adding potentially to the pain that has developed?

Absolutely, Joe. Both the US from what I’ve heard on your podcast before from your guests and from what I know from my colleagues, friends, and relatives in the US and in the UK here, and for that matter in other developing and developed countries. The way we do pain care does need a large-scale change. The paradigm of how we look after our patients has to change. My USP is looking at it from a trauma-informed to be integrative, to be across the community, and locally in my area of Berkshire in the UK, that’s what I’ve done. We’ve helped set up a community pain service wherein you’ve got psychologists and physiotherapists espousing these values. You’ve got the secondary care service trying to keep that in mind. We need to have a different journey, but we still have incentives and funding of healthcare systems that are often skewed towards procedures. There is often that factory line approach of doing one thing and sending it to another specialist. You’ve got the separate joints and separate organs siloed approach and that doesn’t help. I would agree that pain care does need a radical change or of a kind.

Along your journey in this 22 year or so history with medicine and specializing in pain management, was there a particular watershed moment where you realized, “I’m not only involved in medicine. I’m not only involved in the care and management of pain, but I’m also involved in the care of trauma?”

Usually, with all these things, it comes a little late in life. My first eleven years after I finished my undergraduate in 98 hours, I was qualified in India. In my post-graduate, I specialized in anesthesia and critical care, and pain medicine in India in one of the tertiary institutes in Pondicherry. I came over to the UK in Oxford and in London to further do some training and qualify in pain medicine fellowship. I started out as a consultant, and like any other pain physician consultant, I felt that as long as I had a good arm and a nice long needle, I potentially could block anything. With my superior knowledge of opioids, I thought I could practically use medications and interventions to solve all pain problems.

Pain was exciting because it looked that’s where the research in the neuroscience was still to be done. I had a great belief that medicines and interventions could solve the problem, but rapidly within the first 2 or 3 years within my own practice, I was realizing that I was achieving any credible success with my medications and interventions in only about 30% of patients. It was starting to become a problem for me because the patients would get some relief, they go back into the community and they come back again. This rolling chair didn’t work for me because the wait list were getting high.

There was not much funding and one of the things I started realizing around 2013 to 2015 was that patients will be coming back. The volume of notes would be getting higher and higher. I was starting to see a trend in a few patients wherein they would have visited orthopedics, probably a few specialties within orthopedics. They would have then been to the neurologist, gastroenterologists, internal physician, and rheumatologists. They would be getting a diagnosis of fibromyalgia on the way, but they also have osteoarthritis and other autoimmune problems.

One such patient, I shall call her Debbie, was the turning point for me in 2015. It was probably about the sixth time I’d been seeing her in my pain clinic over that 2.5 or 3-year period she was with us. I had done epidural and facet joint injections. Because she’d had back surgery with some sciatica, I’d sent her off for a spinal cord stimulator. Sod’s Law, it was infected so the implant had to come out and there she was back again with general widespread pain. When I saw the three volumes of notes, I asked, “What do you want, Debbie?”

She wasn’t able to engage in a pain management program because she was a single mom. She said she couldn’t make time. Her son was autistic and he was needing care. When I unraveled it, I suddenly realized that many of my patients are having these long sets of notes. There are so many Debbies and these Debbies were not just in my chronic pain clinic as an anesthetic. I was doing still one day of anesthesia practice in a theater setting. I was seeing Debbies in the preoperative clinic. I was doing inpatient ward rounds throughout my hospital system and I was seeing Debbies in the in-hospital ward rounds admitted with a rheumatological problem.

The pattern was there. They were seeing multiple specialists getting multiple diagnoses. What was evident was that they were all having a history of some form of trauma, often developmental, but then a series of adverse life events as well. I did an audit in my practice in the pain clinic. I randomly said, “For a ten-week period, I’m going to ask everyone who comes into my clinic, about 150 patients over an eight-week period, ‘Would you be willing to fill out the ACE score and a resilience score to see where they are?’” I was gobsmacked to a certain extent when I found that 45% of the patients who came to my secondary care pain clinic had Adverse Childhood Experience scores of 4, 5, 6 or 7 with emotional abuse and neglect being the predominant ones.

I realized for a pain clinic that is sitting in secondary care or for that matter, any pain clinic, if 45% of the patients coming to a service have had some form of developmental trauma or ongoing trauma issues leading to such high volumes, the service has got to reconfigure itself such that the specialist knows how to manage that group. That’s when I realized that the last few years of my practice here have been spent in attempting to go upstream. I’m trying to position and say that as pain physicians or for that matter, trauma-informed clinicians, we should not be so downstream as seeing patients 3, 4 or 5 years in their pain journey. We should be seeing them early on upstream, close to after their primary care physician so we can prevent further trauma from happening, and then try to see if we can change some of what has already happened.

I love that you took patient notes and did your own little experiment and investigation. Often we think, “I have to run an entire randomized controlled trial and it has to be published in a paper.” As professionals, we know so much and we have so much information. The constraints of our training have made us think, “I can’t change anything within my own practice,” but I liked that you took that into your own hands. You did a little investigation and started looking at the data on your own.

I love that you mentioned you use the ACE score as well as the resiliency score, because so often people use the ACE which may or may not show the entire picture. Sometimes people are resilient. What you found with five ACEs that’s almost double what the limit is as far as what people say. 1 or 2 ACEs are okay. Anything beyond three, we know that the nervous system becomes primed and the immune system becomes primed as well. That’s when central sensitization and nociplastic pain and all the things that we’re talking about developed.

As you are telling me this story, I’m a physical therapist, and I believe all of us in pain care have a tremendous responsibility for us to serve people well. As you’re talking about trauma and all these Debbies that are in your clinic, and you’re starting to take action and change your practice and change the way you’re looking at these downstream effects. I’m wondering how much of the vicarious trauma that you’ve become aware of yourself that all of us as professionals are a part of. Vicarious trauma is a well-known theory that’s been looked upon in the field of pain medicine and medicine in general and how it affects us as professionals. The healing container that we’re creating, if we’re doing it the right way in and in an open way, we’re bringing people into this space to help them heal. Sometimes there can be some vicarious trauma that we take on as well.

I’ve had to think a lot of my practice to see how I can escape that. Before I go ahead, can I clarify? Would you be open to also saying vicarious trauma would be how much of an impact it has on the practitioner in terms of listening to that history in that sense? Is that what you mean by that?

Yes. It’s the impact that it has on us to work with people who are suffering every day and how it affects both our physical as well as mental health.

To a certain extent, I’ve tried to dilute the defect by innovating the trauma-informed care. It allows me to slightly move away from there because although I have a questionnaire that asks for this history, and it allows me to become aware of someone who comes in with an ACE score of 4 or 5 but with chronic pain in my practice, I don’t delve into the trauma itself. I use that as a standpoint to say, “How can I tailor my discussions with this person in front of me? How can I be compassionate and talk about opioids if that’s what they come there for or talk about interventions, if that’s what they are looking for?”

I place it in context because if I know that it’s an ACE score of six, who has not worked for some time, but got chronic pain with a bundle of notes and 5 or 6 consultations, but MRI scans don’t show much. My conversation is different from someone who might have the same ACE score of six but comes with a clear focal structural issue or a clear idea of, “This is what I want, doctor. Could you give this to me? Can you do this for me?” That allows me to tailor my discussions and my practice. I won’t delve too much into the history until I do need to talk about it.

I try to shield myself from that vicarious trauma issue there. Where it does happen, I’m blessed in the sense that where I work, I’ve got access to good psychologists and physiotherapists. I practice within that environment. I have access to nurses, physiotherapists, and psychologists. We’re all trained in motivational interviewing. To a certain extent, we work with the patient in front of us and we try to use it as almost a debriefing thing. If I do have those feelings, I talk it out. I’m also blessed with the fact that my wife is a psychiatrist at home. Sometimes I can get home therapy as well if needed. If nothing else works, I’ve got mindful running.

In your book, you talk about the pain-free MINDSET. It’s a little acronym, which is great. Tell us about that holistic approach to pain management.

With this story of Debbie that I mentioned, in terms of medications and interventions, that wasn’t working for a lot of my patients who are coming up there. I realized, fundamentally one of the things that the general public have to understand and we in the pain community are aware of this distinction between nociception and pain. I realized even my surgical colleagues, a lot of my GP, primary care colleagues still don’t or weren’t getting the nuance of what we were trying to say. I thought I’ll use that as a USP of saying, “What is the neuroscience you need to know and how can you build upon that?”

Thanks to your wonderful course on nutrition and chronic pain, I realized how much of the role nutrition could play in alleviating pain in that sense and where we can bring that in. Matthew Walker’s book came out around 2016 or 2017 about why we sleep and he had a big role in looking at the research around sleep and pain being a more reciprocal bi-directional thing rather than one after the other. For physical activity and movement, we had a few books from Kelly McGonigal and a few other folks coming around how exercise and physical activities are much more than that.

We’ve always had behavioral therapies which have been used in many different fashions, but then the research was coming out about the benefit of yoga, Tai Chi, meditation and mindfulness. All of those therapies, which were considered complementary or allied, we’re now having the bunch of evidence in the last years to say that they probably had as much a role to play or probably a better role to play than medications or intervention. I suddenly realized that there was this opportunity to put it together into an easy-to-remember acronym.

That’s what the M and the I are for. Medications and Interventions. N is Neuroscience of stress, which is where traumatic stress came along, and D was the Diet and nutrition. E is for exercise. I would have preferred physical activity, but the acronym wasn’t working out with that. T is for Therapies of mind and body. That’s how the MINDSET approach came along. It is as much a paradigm change as well because I’m asking my fellow colleagues, my healthcare professionals once you realize that the nervous and the immune system are interlinked and that traumatic stress or stress has a pathophysiological output, you cannot go back to practicing biomedical dualistic medicine, the Cartesian Model like we are doing. In that sense, it’s a mindset shift that’s required both from the public and the healthcare professionals. That’s what worked out for the publishers as well. They like that USP.

Tell us the acronym for that MINDSET again and what the letters stand for.

The M is for Medications, anything that we have in pain. I is for Intervention. That can be injections, surgery, any form of intervention. N is for the Neuroscience of pain and stress, particularly traumatic stress. D is Diet and nutrition, the microbiome. S is for Sleep. E is for Exercise and physical activity and T is Therapies of mind and body.

With regard to the therapies of mind and body, I know you’ve studied a number of them like ACT Acceptance and Commitment Therapy, mindfulness, CBT. I know you did a lot of research on Pain Neuroscience Education, which is more or less a mind and body therapy in some way. As a physician who specializes in pain management, what are your thoughts? They all have positive research around them. They’re all beneficial to certain people in certain ways. I’m wondering as a physician, how do you categorize them in your mind and how do you start to talk to patients and refer people on toward a certain therapy?

I’ve thought long and hard about this. It’s exactly as you said. I looked into the behavioral therapy literature. I bought the Pain Neuroscience Education book by Adriaan Louw and I looked at how he approached it. The reality is that we are all living in a healthcare system where a lot of these mind-body therapies are still struggling to have the quality of evidence that’s behind them to back the state funding it at infinitum. We are going to struggle with acupuncture, Reiki or yoga being given on tap for patients for as long as required.

Wayne Jonas with the Integrative Healthcare Model in some of the VA centers has been able to introduce that on a long-term basis for the veterans probably, but in the UK, certainly and most parts of India or in Africa there, a lot of these therapies are going to be left out of the mainstream. They’re always going to be looked down as the next step or could be thought of in the background. You can add it in or not. I’ve tried to take a pragmatic approach in the sense that there are some approaches that are done for you like acupuncture or for that matter, a lot of chiropractic care, osteopathic care. You go down, you lie down, they massage it and they do it so it’s a DFY.

You have the done with you model, which is all the pain management programs, a few of the Pain Neuroscience Education, pilates, and all these other exercise therapies, which is to a certain extent you can be doing it with someone to learn how to do it. You have the DIY approach where you get on and do it yourself because of mind-body scan techniques or things that you can learn off YouTube, and you can do that. The reality is that in the UK, at least everybody’s being pushed. All patients are being empowered. Everybody’s being asked to take activation and take a little bit of control in their hands and they feel more empowered to take control.

My thought process is, how can I present all these therapies of mind and body, which are very important, but they do have a placebo response component integrated into them? There is an element of how a good CBT practitioner probably will achieve as much improvement as an ACT practitioner, as an MBCT practitioner, or a pilates trainer. The aim is how do you enhance therapeutic relationships? I’ve taken the pragmatic approach to say that as a physician, as a pain guide, what I can tell you is if you come to me asking for pain management advice, I will talk to you about medications and interventions if they’re appropriate. I’m going to give equal importance or equal weight to the other five aspects of the mindset, which traditionally physicians don’t talk about or just say, “Look it up.” I’m going to pay attention to that.

When it comes to therapies of mind and body, I’m going to say, “How far away is it from your house? These therapies are mind and body. You need to look them up the way you do exercise. You need to do them regularly. You need to make it a habit. You need to know how to make it easy, attractive, good to do habit that you can incorporate as part of your lifestyle.” Therefore, if it means that you can’t do it yourself. You can’t meditate. You want someone to massage you or do acupuncture because that works better for you than exercise, then decide who the acupuncture practitioner you love, how far away they are, and how often you can afford them. The reality is you might live in an area where your healthcare system will give it to you on tap, but more often than not, they’re going to say you have four sessions and off. How are you going to afford it for the next 5, 10, 15 or 20 years of your life? It’s a pragmatic decision that I ask them to take and I laid out as a guide to say, “These are your choices. They all are excellent. Find the right person, find the technique, and off you go.”

How are you overcoming the stigma with regard to the psychosocial therapies in practice when you’re talking to people about pain? You’ve studied Pain Neuroscience Education so you know the concept of the reconceptualization of pain and you’re familiar with Cognitive Behavioral Therapies. All of those involve talking to people about the influence of the mind and the nervous system. As a physician, you’re their first point of contact before they get to a physiotherapist, a psychologist, an OT or anyone else. How are you destigmatizing this process and certain aspects of that mindset, which they’re now hearing for the first time? What are those because so often we think that the stigma exists in telling people that Cognitive Behavioral Therapy will help them. However, I’ve come across people who felt stigmatized by talking about nutrition. It’s not only the mindset part of it or the Cognitive Behavioral Therapies. I think it’s unique to the person.

I have tackled this in two ways. One is the fact that the book offers one option of saying that and laying it out and saying, “If you want to come and see me, this is what I believe in. This is already out there. This is our practice.” The second step is as physicians, we are the first port of call, whether it’s a primary care physician or a secondary care physician. We have the responsibility and opportunity to make these behavioral therapies attractive. We, physicians, do not sell them adequately well enough because sometimes we don’t know enough about them to sell them in an attractive fashion to our patients. That’s part of the reason why I wanted to read about it because if I had to encourage my patients to say, “Please talk to my psychologist, because what they do for you is valuable, the way they will approach it is valuable,” I have to make it sound appealing and worth it to do that.

Marketers know how to promote a product that’s useful. Physicians can take a leaf out of the book to say your mood will influence and that attempt at changing the mood, whether it’s challenging the mood or accepting the mood is important. Sometimes it requires someone with better skills than a doctor to do it more effectively and in a sustained manner. In physiotherapy, you’ve got this concept of psychologically informed physiotherapy practice. There might be a reason to have psychologically informed physicians as well who can understand how to encourage patients to do it. That’s what I’ve tried to do in my practice. What’s made it easier for me is in a way long COVID or the pandemic of COVID has made us realize that there is such a huge overlap between the nervous system and immune system in terms of how symptoms come. It’s the same that happens with our understanding of pain and nociplastic pain and central sensitization.

I can show them that the nervous and immune systems are hugely overlapping. Eighty percent of your dopamine or serotonin is produced in your intestine, then it goes into the immune system and travels into your brain. When you’ve got such a huge overlap between your nervous and immune system, we need to find different ways of dampening the immune system in your nerves, in your brain, and your spinal cord. We can use drugs or injections, which act from the bottom down to dampen it. It may or may not work but it got side effects. What about therapies that could act from the top down, which could dampen the same nervous and immune system? That’s what my colleagues will do with you. This is not about saying it’s in your head but it’s saying, “How do I dampen the nervous system, calm it down and protect it?” These colleagues of mine do a much better job. They will be able to see you in between this, “Let me refer you to a video. Why don’t you watch this video? Why don’t you watch this resource?”

Much of what I’ve learned from that literature around digital advice is you’ve got to provide 7 to 10 touchpoints to a potential patient before they can start accepting what you’re saying. What I will say is one. My physiotherapist will say the same thing. I’m encouraging my GP and my primary care colleagues to say the same thing. They may look at a few videos or listen to a few podcasts. By the time they are coming to see my psychologist, they have had enough information to say, “This is what I want. I’m interested and I want to do it with you.” I’m hoping that that would help in destigmatizing in the long run. It’s still some way off but that’s my approach.

Professionals ask me all the time, how do you get people to engage with nutrition? How do you get your patients to engage with mindfulness? Because when I talk to them about it, they won’t do it.” I always say to them, “Show me your website. Show me your intake paperwork.” It’s all those touchpoints that you were talking about. Before someone comes to me, they’re on my website. They see all these different topics I’m talking about. They see the intake paperwork where I’m asking about the nutrition, their mood, thoughts, feelings, emotions, fears and things like that. We’re talking about it during the session. All these touchpoints and the touchpoints before they get to you, before they’re in your consultation room are so important. It helps you do your job better. It makes your job easier versus when someone comes to you and all they know is you treat pain, but they have no idea how you treat it. They have to figure out, “What is this? How does it work? Do I want this?” Some people don’t necessarily want nutrition and in that case, you say, “That’s fine. We’ll cross off the N on the mindset as you have in your book but I have all these other tools that can help you as well in similar ways.”

What I found useful is understanding this concept of behavior change by Prochaska and DiClemente, the Transtheoretical Model of Change. That made my clinical practice less strenuous for me because if people are in the precontemplative phase, I should not feel bad that they haven’t listened to my advice and haven’t taken the drug or aren’t doing what they’re doing. They are just not in that phase where they’re ready to change. My role is to increase awareness, make them aware of the choices and leave it to them to decide. If I can change and provide the touchpoints such that when they come, they’re headed in the contemplative phase or in the planning phase. That’s where they’re ready to take my advice, ready to act on it and give it a whirl. If they can put it into action, if I give them the pain management program, that’s the action phase, then all they need is the maintenance aspect of that.

It will relapse again and make them aware that they’ll relapse but that process is what I’ve tried to take through in my book as well to say, “Try to assess where our patient is in that journey. If you find them in precontemplative, don’t spend time putting them in a pain management program, making them wait 4 or 5 months. Give them the resources, give them the information, let them think about it, and let them come back because we are not living their life. They are living their life. They know their pressures and they’ll come back when they’re ready.

This is an important topic that I thought you touched on that I want to talk about. I brought this up with a distant colleague of mine and her response was, “All of these patients need to be in multidisciplinary pain programs.” I said, “First of all, we don’t have enough. Even if the funding was there, we don’t have enough professionals to staff it.” We have a problem with staffing with regard to qualified professionals. We have a problem with regard to funding of these programs, but that the point that you touched on is probably the most important point. We can’t take people and throw them into a multidisciplinary program, which takes a lot of work and time for an individual. Sometimes they’re an inpatient, sometimes they’re outpatient, but it’s a significant amount of time that people have to spend. If they’re not ready for that, we potentially could be wasting everyone’s time and money, and the patient may relapse because they’re not necessarily ready for it.

However, what you’re saying is you’re recognizing that precontemplation phase. You’re saying that potentially the most important point, the pivot point, the choice point that happens is one caring human that can shift it for them. Once that one caring human shifts something for them, maybe it’s the multidisciplinary program. Maybe they need two professionals. Maybe they need another professional that’s more specialized in something. It’s an important point you bring up because I’ve seen some things start to pop up about, “We need multidisciplinary pain programs.” I’m like, “We do. We definitely need more of them, but I don’t think that’s the solution.” The solution is how do we take the one person who they’re coming to, that could be a physician like yourself, a physical therapist, or a psychologist. How do we optimize that one encounter so it’s successful for the patient?

You hit the nail on the head in that. This is an American tool. I forget the lady but I don’t know why Dr. Hibbard comes to mind. She apparently started a tool called the Patient Activation Measure, PAM score. That was brought to her and it has been adopted in the UK by the NHS England and NHS Improvement as a tool for understanding long-term condition management in the UK. The PAM score is a set of thirteen questions which is similar to the Patient Self-Efficacy score, the PSEQ we have in a broad layout. It spits out a number out of a hundred for those thirteen questions that somehow are average and logged out to a number. That is divided into four levels. If level 3 and 4 means that people are scoring 60 or 70-plus, that means they are quite health literate. They are motivated to take control of their health and make decisions for themselves.

Level 3 or 4 in my area, I’ve got the approval locally to say those people would be suitable for a digital program. Thanks to the pandemic, we’ve now got a digital pain management program, wherein you don’t need that huge resource implication of having multiple practitioners, physiotherapists, psychologists, and OTs being involved. You could stratify patients to say, “High activated levels could do a digital program with a bit of light touch physio, a physical health coach or a minimal touch to treat them through,” but then you have the intermediate phase wherein your score PAMs of level 2 or level 3. wherein they are a little bit hesitant. They’re not sure. They want some coaching, support and motivation. That is where probably the multidisciplinary programs that you talk about, wherein you bring the group effect, accountability, and habit formation. You give them some directed smart goals, which they can do. You then scale it up like atomic habits, small habits and build it up there.

For the level one, the ones who are quite low in their activation, that might be someone whose social support systems and resilience is not great, who has been deeply traumatized, who’s got ongoing mental health issues or family issues or comorbidities. Those might be the people where we need to give our most resources and say, “You need a little bit of social care rather than a big fancy program. You need something else. You probably need your employment sorted. You need something job security sorted. You need some food stamps or food insecurity looked at and poverty taken care of in some way.” That stratification is important if we need to allocate resources properly as healthcare practitioners.

I appreciate what you said because it tells me that you have a system in your mind of how to triage someone in a way who has pain. I know the UK system is a little bit more structured than the US system is. We don’t have that closed system the way that you have it in the UK. We’re definitely lacking that. Although as we know in pain, we have a lot of room to develop in the pain world pretty much in every country. Part of that development process I believe is creating patient-forward material that people can access and read about. Your new book is one of those. It’s called The Pain-Free Mindset: 7 Steps to Taking Control and Overcoming Chronic Pain. You can find it on Amazon and in many bookstores near you but Amazon is always a great place. As we close, tell people how they can learn more about you and how they can learn all the great work that you’re up to.

My website, which is my name, DeepakRavindran.co.uk. It’s a UK website there but otherwise, I’ve become a little bit more active on the usual social media handles of Instagram and Twitter. My Twitter is @DeepakRavindra5. A five for some reason. Don’t ask me why. It just happened.

We’ll make sure you stay active on there because we’ll be sharing your episode out quite regularly. That website you can reach to www.DeepakRavindran.co.uk and you can find all of Deepak’s work there. You can find his book, The Pain-Free Mindset online and on Amazon. I want to thank him for joining us, talking about integrative chronic pain and the intersection between pain and trauma. Make sure you share this episode with your friends and family on Facebook, LinkedIn, Twitter. Tag him since he’s new to social media. Keep him busy and tell him how much you liked this episode and how much you’re enjoying his book. I’ll see you soon.

Important Links:

• Dr. Deepak Ravindran
• The Pain-Free Mindset: 7 Steps to Taking Control and Overcoming Chronic Pain
• @DrJoeTatta – Instagram
• Pain Neuroscience Education
• Amazon – The Pain-Free Mindset
• Instagram – Dr. Deepak Ravindran
• @DeepakRavindra5 – Twitter
• https://www.Facebook.com/DrDeepakRavindran

About Deepak Ravindran