From Pain to Possibility
Episode 2: The Biopsychosocial Model with Marylsa Sullivan
Intro: You're listening to From Pain to Possibility, with Susi Hately. You’ll hear Susi’s best ideas on how to reduce or even eradicate your pain and learn how to listen to your body when it whispers so you don't have to hear it scream. And now here's your host, Susi Hately.
Susi: With this episode, I'm delighted to introduce you to Marlysa Sullivan. She's an assistant professor at Maryland University of Integrative Health, where she teaches in the integrative health sciences and yoga therapy departments. She's developed courses in the yoga therapy curriculum, as well as being the founding clinical director for the Masters of Science in Yoga Therapy program at Maryland University. She's got a strong passion for understanding both modern and scientific understandings of the body and mind, and integrating this information with the ancient teachings, philosophy, and practices of yoga. She believes in teaching from an experiential place, that the teachings and practice of yoga must be felt to be understood and to be integrated into caring for our clients. She's excited about the potential that yoga therapy can bring to our current healthcare climate and bringing more of the scientific and ancient teachings into the education of our future healers, teachers, and practitioners.
So, welcome. I am delighted to be having my guest for this episode being Marlysa Sullivan, and we have a bit of a history through the IAYT and as yoga therapists. And today I want to dig into this conversation that's a growing and an important conversation about polyvagel theory. But before we get there, Marlysa is a physical therapist. And before we started to record, I asked her, I said “Were you a physical therapist before a yoga person, or how did that happen?” And she quickly said, “Well, actually, that's not exactly how it happened.” So how was your path, moving into or combining this physical therapy and yoga perspectives?
Marlysa: Well, thank you very much for having me part of your podcast. I'm super excited to be talking about these topics with you. And I started off, actually, when I was first in college, in the field of medical anthropology. I was really interested in how our beliefs and spirituality impacts our views of health and healing. And then through my process, I ended up meeting a physical therapist who had a very biopsychosocial perspective, and she became my mentor. So I became a physical therapist just because I loved her work so much, and it was really exciting to me. And then after becoming a PT, I became a yoga teacher. But I was always really interested in the more, like, chronic pain type of clients and how their emotions and mood and beliefs intersected with their healing and resilience and wellbeing. So whenever I studied yoga, I tended to go towards more the teachers that were speaking about the philosophy and the spirituality to integrate that into clinical care.
Susi: So you were really blending this yoga model with a biomedical model.
Marlysa: Yeah, I would say from the beginning of my PT career, I was interested in a more of a biopsychosocial/spiritual perspective. And yoga was my way of really recognizing, studying that and kind of actualizing it in my practice.
Susi: That's interesting because there's other physical therapists—and as they're known here in Canada, physiotherapists—who are interested in yoga, that are saying something very, very similar of how yoga’s provided that way in. And there's a physician, Jennifer Ireland, that I'm interviewing, and for her, she's been using acupuncture as that way in. So it's an interesting theme and pattern for people who have training on both sides of the fence.
Which leads me into asking you about polyvagal theory. Now, this is a huge, huge topic, but one that's really interesting in how we're understanding more and more about the nervous system and the nervous system and healing. And also, I mean, for me, I remember back in—was it the ‘80s?—where there was some research out of Harvard on the relaxation response. I think was Herbert Benson. And there's sort of these seedlings towards polyvagal theory that were at least from the ’80s. I'm sure the history of this is even further before that. But I knew back then the necessity for what I simply called relaxation. And then now there's just a greater understanding between these roles of our sympathetic and our parasympathetic nervous systems.
So let's just start from sort of a 50,000-foot view. How would you describe, in a big-picture perspective, what polyvagal theory is?
Marlysa: The first thing that I thought about when you were saying that was the way that I use polyvagal theory, because it is kind of like the essential components. But I’m going to also just go a little bit bigger than that, like you said. So I'm going to start with this idea. So one of the findings that Dr. Porges, who developed polyvagal theory, found was that the vagus nerve had two origination sites so that the motor component of the vagus nerve actually had two different functions, depending on which group of brainstem nuclei it was coming from.
So there is one part of the vagus nerve, the myelinated vagus, that is responsible for what we consider the relaxation response, like that good heart-rate variability, slowed respiratory rate, blood pressure, and those things. But then there's another part of the vagus nerve that helps us slow our systems down, and this has been really interesting for the people that study trauma, because it really is a demonstration of what they've seen clinically. So it was science really showing clinicians something that they had seen and giving them an explanation for it. And it was this idea that under life threats, this other part of the vagus nerve becomes more dominant in its response, and it's a slowing down of the resources to the bare enough for survival. So this is like a shut down or a death feigning.
So because of these different functions of the vagus nerve, what polyvagal theory gives us is this idea, that the thing that I think is one of the most fascinating things about it, is that the autonomic nervous system is a shared platform for physiological, psychological, and behavioral response. So as we all kind of can understand, when our sympathetic nervous system is activated, when we detect threat, we're going to have a physiological response from mobilization, but we’re also going to have an emotional response from mobilization, whether that's excitement or fear or anger. And we're going to have a behavioral response that's aligned with that, of the fight or flight.
When our autonomic nervous system comes into that optimal relaxation response, that part of the vagus nerve that's also part of that, then physiologically, we're at rest in restoration. We have optimal heart rate, heart-rate variability, breath rate, blood pressure, and so on. Emotionally, we have more access to things like calm, contentment, peace. And then behaviorally, we have more ability for social engagement and social connection, that we have more ability to perceive safety around us and to interact with our environment from those cues of safety. When our autonomic nervous system is in that life-threat response, then physiologically all of our resources are shut down to the bear needed for survival. Emotionally, we're in more of a shut down kind of a state, even to, like, behavioral states of dissociation.
So what I think is really just remarkable about the theory is it helps us as clinicians take a more integrated biopsychosocial view because instead of addressing this physiological symptom, this psychological symptom, this behavioral symptom, we're looking at instead, let's shift the autonomic nervous-system state to then begin to catalyze upon that state to cultivate certain behavioral and psychological emotional states.
Susi: So, in a nutshell, and this might be oversimplifying it, so let me know if I've done that, when we're in a mobilizing force type of state, that would be more like a sympathetic nervous-system state. And then the other two, which is the save for the simplified way of the, like, rest and digest, that would be one side of the parasympathetic response. And then almost a helplessness or a shutdown or a dissociative state would be that other side. So, is that right?
Marlysa: Yeah, exactly. It's like this continuum. And so part of this is instead of looking at the autonomic nervous system as dichotomous—one is on, one is off—there's actually a continuum that we have.
Susi: Yes. In the past, before I knew anything about the vagus nerve or that piece of the puzzle, someone taught it to me like brake pedal and gas pedal. And so we need to have gas, and we need to have brake. And so it's this back-and-forth dance that we're working with and playing with. And then if we're getting heavy on one of the elements, then the system won't be, essentially, in balance. And so it's like this dance that is occurring. However, my question for you, though, is that can we get, if we're in a sort of a shutdown dissociative state, can we get stuck there?
Marlysa: Yeah. And I think you could get stuck in probably any of the states. And one of the ideas of those stuck states is that we often need a little bit of that sympathetic arousal to move from that shutdown state into the relaxation response, which is really cool because it has a nice parallel to yoga, where they talk about these concepts of the gunas, or the qualities of nature. And when we're in that more what they call tamasic or shutdown, lethargic, obscured state, instead of just moving to clarity, they talk about using rajas, using activation, in order to pull someone into sattva, into that clarity. So in those perspectives, both yoga and polyvagal theory, getting stuck in those kind of dissociative, lethargic, fatigue states often requires a little activation to get there.
Susi: So, let's have a chat about gunas, because there'll be people who are listening to this who are very familiar with gunas and people who are like, “What? A huh?” And so let's have a, first, a conversation about what are gunas, and then we can transfer that back into a, how this can help you with maneuvering through polyvagal and just our systemic physiology. So give me your take on gunas.
Marlysa: Okay. So in yoga philosophy, everything that is material nature is anything that moves or shifts or changes. So my body is made up of material nature, my mind is, but so is everything in the environment, like the trees, the earth. It’s anything that shifts and changes is material nature or what they call prakriti. All of nature has three qualities: it's either the quality of activation, which is called raja guna; or it's the quality of stillness, tamo guna; or the quality of clarity, which is sattva guna.
So in your body right now, there's places in your body that feel clear and lucid and vibrant, and those are places where sattva guna is dominant. There's places in your body that might be tense or agitated or activated. Those are places where raja guna is predominant. And then there's places in your body that might feel really stable or even still or dull or numb, and that would be tamo guna, so that all the gunas are present within our body, our mind. We have certain thoughts and emotions that are more activating, or raja guna; clear, sattva guna; or more stable or still, tamo guna. And then we can look at everything in the environment and see the properties of the gunas within them.
So in these gunas, it’s similar to this idea of the autonomic nervous system, there's a continuum. So raja guna is anywhere from the healthy activation, like excitement, motivation, creativity, all the way to anger, agitation, worry, fear. Tamo guna is a continuum of stillness, from stillness, solidities, stability, all the way to dullness, obscuration, deep fatigue, and lethargy. Sattva guna, you could even say, has that continuum of clarity and buoyancy all the way to kind of dissociative, kind of spiritual-bypassing-type states.
So in tying this into the nervous system a little bit, we could say that the gunas are broader than the autonomic nervous system. But when we activate a guna like sattva guna, which is this clarity, then we're likely to be reflected with that, with the parasympathetic nervous system that is a relaxation response. When I’m activated in raja guna, when I have more of that mobilization force inside of me, then that's going to be reflected in my autonomic nervous system as sympathetic. When I'm more in that dullness or obscuration, that's going to be reflected in that tamo guna. And vice versa. When I'm in a sympathetic nervous-system state, then I'm probably activating raja guna inside of me. When I'm in that relaxation response, I'm activating sattva guna. When I have that shutdown state, then I'm activating more tamo guna.
Susi: So then the gunas can become really a process by which one can use to explore what states they're in, in whatever part of their system they want to explore.
Susi: And then that can give them some understanding of just where they're at along in their recovery and their healing process.
Marlysa: Yeah. And I think what's really nice about these two models of polyvagal theory and gunas is that they show that we can work with clients from a truly yogic perspective, but we can also put it in language of the autonomic nervous system so that people can conceptualize it a little bit more tangibly. And we can also look at research to see what research kind of goes along with that and helps to support what we're doing. So from a yogic perspective, instead of treating symptoms, we’re looking at these underlying states, whether it's the autonomic nervous-system state or looking at the guna state, because by activating different gunas or autonomic nervous-system states, we're going to affect physiology, psychology, and behavior.
Susi: So when you're working with a client in the early stages, and they don't know anything about gunas, and you want to introduce this idea of qualities and introduce this idea of being curious about these qualities, because that I find is ultimately when we're playing around with the guna world, there's an exploratory curious space. And how do you work with a client? Do you—of course, this is going to depend on the client, I know. But what would be a common or a tendency that you might have with how you start the conversation with a client around introducing them to gunas?
Marlysa: I would say that in general, I start the conversation by first giving people a few experiences over a couple sessions of sattva guna, or that relaxation response. I want them to first see and feel and experience that when they shift their states, that they have a different quality of life and a different sense of well-being. Then once they've experienced that in their body and they see that they can access those relaxed states, then I can talk to them about—it depends on who they are, of course, but I’ll either start with the autonomic nervous system and talk about how we're cultivating this relaxation response and that ultimately we want to notice if we can be with states of activation but come back to states of relaxation, which gets more into the resiliency that you talking about.
I'll use the language of the gunas, also, if they're open to it. And I do find that sometimes the language of the gunas can be really helpful, in that, because a lot of the people I see are in the U.S. because I'm in the U.S., that they are unfamiliar with the gunas. It's not part of their culture and where they came from, so there's less judgment. So instead of saying, “I'm feeling anxious,” or” I'm feeling grief,” they can begin to say to themselves, “Oh, this is raja guna,” or “This is tamo guna,” and it doesn't have the same judgment as anxiety or fear or worry or depression.
So I, too, find that teaching them to notice the sensations that arise and that those sensations that are more activating are raja guna and those that are more still, all the way to lethargy or heavy, are more tamo guna has been helpful for them in noticing as these qualities arise in their life and how they can begin to work with them.
Susi: Do you find, then, that once they see and are working with qualities—and as you said, there is sort of a less judgmental state of it because the qualities are kind of like colors in a way, that it’s blue and red and purple. There's nothing bad or wrong about any of the blue or red or purple, per se—that then they're able to see symptoms in a similar way?
Marlysa: Yeah. They're able to have the experience of pain, but to disconnect from it in a healthy way, to speak about it in a more objective way. Same with things like anxiety or grief. They're able to look at it different, and then they become more receptive to changing those underlying qualities to change their relationship with those sensations.
Susi: So that's what's really cool about this yoga and biomedical model is being able to bring these pieces together.
I was speaking with a grad trainee of mine who had done some work down at the Duke Integrative Medical. And there were a number of professionals who had come through who are PhDs or M.D., PhD types that had specialties within their particular field in medicine, but also were either lovers of meditation and yoga. And they were saying on some level, and I'm paraphrasing what she said, but how I interpreted what she said was that the quantitative measure that tends to be the measure that's used in the biomedical model, they knew had a certain space, and there's a limitation to it. And then there's this qualitative measure, that yoga really is supportive of and that this qualitative measure can bring a lot more detail or direction, if I can use that term, to support someone's process. What do you think about that?
Marlysa: Yeah, I totally agree with that. And to just add a little bit to it, at least in the field of orthopedics, it's known that radiographic evidence of things like arthritis or disc herniations are not always correlated to the people that have pain or limited function. So that objective measures, while important and great and they have their place, for sure, they're not always indicative of the person's state of health, well-being, or function.
So even in the studies, like the Harvard studies, about purpose and meaning, which is a particular passion of mine of studying, that being connected to meaning and purpose is related to decrease all-cause mortality, independent of things like comorbidities, physical activity, diet. So, these qualitative measures are important objectively and subjectively for health and well-being of the individual, and I think we're beginning to see that more and more in the medical communities and have more and more research supporting the importance of those measures.
Susi: So, what are some ideas that if a person listening to this is a medical professional, because I have a number of medical professionals who are following me, and they have an interest in yoga but aren't really sure about how to take the next step, and granted, depending on their profession, how they integrate these concepts is going to be different, but what are some ideas of starting points where, like, they might not know what gunas are, for example. And so to go there, they wouldn't be ready for that yet. But what are some examples that you can provide them of ways they can at least start integrating some of this idea or just thoughts to think about as they move towards integrating? I'm just thinking of people who like that there's an integration between an alternative way of looking at health and well-being and working with people with pain. Then there’s that integrating with a biomedical model, but they're not quite sure about how to go about doing it.
Marlysa: It's a complex question. I think with this idea of the autonomic nervous system, and I can talk about resources of learning, but to contemplate the truth of that for you, meaning that noticing how your state of your autonomic nervous system and its expression of either safety or danger impacts your thoughts, your emotions, your interactions with other people, the way you eat, the way you go about your day. So even journaling about that, how does the amount of sleep impact your relationship with yourself, your relationship with others, your work? How does your sense of relaxation or ease or stress—that's another way to look at it, too. So if you were to wake up each morning and to rate how rested you felt and how stressed you felt, and then you were to journal about how that affected your thoughts, your emotions, your relationship to your body, your ability to perceive your body, your interactions with others, you would begin to see how these underlying states impacted that. And I think once you realize that in yourself, then you're able to teach that to other people. So more from a personal-growth perspective, that's what I would say.
As far as reading and conceptualizing, in Frontiers of Human Neuroscience, I have a paper with—it’s just an open-access journal. I have a paper with Stephen Porges on this idea of polyvagal theory and gunas. Dr. Stephen Porges has a website that has many of his podcasts and information on that. What are some other sources? We have our Yoga and Science in Pain Care book that talks a lot about the pain science from this biopsychosocial-spiritual perspective, as well as I have a new book coming out called Understanding Yoga Therapy that talks about this. And then you could even do books like—there's really great books, like Mindy Eisenberg has a great book about adapting yoga. So you could look at things like the Accessible Yoga Community, or Matthew Sanford, to name a few. Does that answer your question?
Susi: Yes, that does, because I’m finding where there's a lot of people who know that there's limitations in a biomedical model but aren't necessarily sure of where to go or where to start and how to navigate it, really, because it's not like there's a direct cause and effect and there's not a direct linear process. I do find that the people in the medical community that I've worked with, the consistent factor, which goes along with some of the resources that you were—the first resource you mentioned in terms of a self-awareness exercise—is that they’re all interested in their own personal development and their own growth and so that there is a bias for self-awareness anyway. And so that's a usable technique that they can play with. And as they get more experience with utilizing it, then that's something that just naturally is shared organically with their clientele.
Marlysa: Yes. Yeah, and I think there's some really nice tools out there to look at this more perspective. Like, there's a Harvard longitudinal study about meaning and purpose, and Steven Cole is a researcher with NIH who has done that. So you can look at some of those other concepts.
Susi: Now, when you're talking about yamas and niyamas, how do you integrate those pillars into the work that you do?
Marlysa: Yeah. You know, I was going to mention this other concept, and then I wasn't sure, and now I get to. Thanks.
So, in this research about this more holistic view, there's research on this concept from Aristotle that’s called eudaimonic well-being, and it's this idea of living a well-lived, well-purposed life in alignment with your values. And there are studies that look at the effect of eudaimonic well-being, especially meaning and purpose, on longevity, immunity, inflammation, pain, interference, function, all those kinds of things. So, in that work, a key piece of that work is the idea of ethical inquiry, so really understanding alignment with our values.
And what's another cool concept in yoga is this idea of yamas and niyamas, which are these ethical principles of yoga. In the yoga text, there's the Mahabharata, which is this huge ethic, and it speaks about the ethical principles, these values, being doorways to what they called dharma, which is this ability for us to live in inner and outer harmony in a way that sustains both us and the world around us. So it's an understanding of meaning and purpose that's not individualistic. It's an understanding of meaning and purpose that comes from a deep reflection of values in a way that supports yourself, those around you, life, the world.
So I use the yamas and niyamas very purposely in my sessions. And you can start it very simplistically as, like, what intention are you wanting to cultivate in your life? Are you wanting to cultivate patience, peacefulness, cheerfulness, friendliness, compassion? And then, through the yoga practice we begin to inquire into how do you understand that quality in your body? So like, where do you notice compassion in your body? What are its qualities of things like heaviness or lightness or openness or closedness? Are there postures that help you contact that value and connect to that value? And what are the movements and positions that help you to actualize it?
Susi: And then out of that exploration physically, then how does that—there's a circle there that then starts to be completed.
Marlysa: Mm-hmm. Yeah. So then it's like—so once you really understand what that value means for you, so one of the things I love about Aristotle's teaching is he talks about the values on a continuum, from an excess to a deficiency to the optimal balance. So the idea of ethics isn't rigid or someone telling you what to do. It's more like, how do you know when you're centered in your expression of compassion that supports you and those around you? So once we know that for ourselves in our body, we can begin to look at, how do I interact with—probably easy, first—how do I interact with my animals, my closest friends, my partner from that quality? And then how do I interact with a more difficult situation or more difficult person with that quality so that we can begin to reflect on how this quality is going to show up in different circumstances from those that are easiest to more difficult.
Susi: And so then, how—and this is probably pretty obvious, but I still want to ask the question—how does that then circle back to polyvagal theory?
Marlysa: It’s often really difficult if you're in an overly sympathetic state or shutdown state. The idea of connecting to compassion or patience or acceptance is not only difficult, but it might be unhealthy to do in those states. So in in this idea of polyvagal theory and the gunas, what we want to do is cultivate this parasympathetic nervous-system state, that social-engagement system, relaxation response, sattva guna, from which the qualities of compassion and patience can be more healthily reflected upon. So when we reflect on things like the yamas and niyamas, it's really like a two-way meeting, where from the body I'm going to do it by cultivating this social-engagement system. And then once that's cultivated, I can enter in through the mind to purposely bring in these values and these ethical increase.
Susi: So, then, what you're doing is you're basically pinpointing someone on where they might be in terms of their state on the spectrum, is polyvagal theory.
Marlysa: Correct. So based on how they're presenting with the kinds of thoughts, emotions, energetically, and even from just assessing the body, I'm looking at, are they in overly sympathetic, or rajasic, states? Are they in more shutdown, lethargic, fatigue, tamasic states? And whichever one of those they're in, I'm going to find practices, whether it's movement, breathing, or meditations, that pulls them into sattva guna, or the social-engagement platform.
And it can be kind of complex because their mind can be more in that activated state, and their body can be in that really fatigued state. So you have to see. Like, I'm going to try this practice with a person to see if it helped cultivate a slower breath rate, more ease and relaxation in the body, more calm in the mind. And so those are like—if I had to say, what are the things I'm looking for to see if the practices I'm providing them are bringing them into that social-engagement system, or sattva guna, I'm looking for the ability for their body to be calm and relaxed. I'm looking for the ability of their breath to be slow and deep. I'm looking for the ability for them to really be in a relaxed posture and to feel a sense of comfort or ease.
Susi: Awesome. So that, then, as complex as it can be, it becomes simple, and as you practice it, simple, not easy, but simple in the way in terms of this result that you're seeking. And then you start to develop a bit of an art of where you start and how you start and then how you continue.
Marlysa: Yeah. And you can get a little sense of that even for the person. Like, what is it that relaxes you? What is it that tends to bring a sense of ease? And they might say, “Working out really hard helps me to relax.” So then I know I need to kind of burn their energy off a little bit and activate them a little bit before we come into relaxation.
Susi: Well, that's great. This is a great place to wind this down. And I think we could probably keep talking and talking and talking. Marlysa, I think this is such a good topic, and the way you describe it integrates it so nicely with the biomedical and the biopsychosocial model. So it's terrific.
So, if people want to find you, you've got the book that you've done with Shelly and Neil, et al. And we'll be putting notes for that book that's available. You've got your new book that's coming out. If people want to connect with you, what's the best way for them to reach out to you?
Marlysa: Probably Facebook. And then I have a website, marlysasullivan.com, as well. But Facebook or my website, or I’m on Instagram, too.
Susi: Okay. So, we will have those connections in the notes so that people can easily find you. Thank you so much. This has been really terrific.
Marlysa: Thank you. This has been a great conversation. I’ve really enjoyed it.