May 25, 2025
Whole Person Physical Therapy Is Here | Matt Erb on Mindbody Integration
Send us a text Pain Practice OS Waiting List Matt Erb returns to the show for an insightful and wide-ranging conversation on the future of physical therapy. We cover the limitations of the biopsychosocial model, practical mindbody strategies, billing within the system, trauma-informed care, and how clinicians can advocate for real change—both in their practice and the communities they serve. 📃 Article - Advancing Physiotherapy in Mental Health: Guiding Principles for Whole-Person Care ...
Matt Erb returns to the show for an insightful and wide-ranging conversation on the future of physical therapy. We cover the limitations of the biopsychosocial model, practical mindbody strategies, billing within the system, trauma-informed care, and how clinicians can advocate for real change—both in their practice and the communities they serve.
📃 Article -
Advancing Physiotherapy in Mental Health: Guiding Principles for Whole-Person Care
📕
Integrative Rehabilitation Practice
- Textbook Co-Edited by Matt
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WEBVTT
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Before we start this week, I have a question for you.
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If that speaks to you, go to modern pain care.com/pain program and jump on our waiting list so you can be the first to know when the program launches.
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Now onto today's episode.
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a whole body of research demonstrating that the social environment, the social mileau that we're, that we find ourselves in co regulates inflammation.
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I.
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So just by changing social environments can change inflammatory states in the body,
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That is Matt Erb, someone who's not only changed the way I think about mind body care, but who's also doing the real work of bridging physiology, psychology, and social context into clinical practice.
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This episode is for every clinician who's ever asked me, how do I actually bill for this?
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How do I document nervous system regulation, breath work, or trauma-informed care in a system that's built for sets, reps, and manual therapy?
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Matt and I unpack all of that today.
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We'll walk through how to frame and code this work with the current system ethically, legally, and effectively, while keeping your care aligned with a truly whole person model.
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If you've ever felt stuck between what you know patients need and what your EMR wants you to write.
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This episode will give you clarity, confidence, and practical tools to move forward.
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We'll also cover how to interview from a trauma-informed lens, how to navigate the trap of reductionism and what it really means to support healing through presence, physiology, and empowerment.
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Let's get into it.
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Matt, welcome back to the podcast.
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Thanks.
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Good to see you, mark.
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It's always good to have a conversation with Matt.
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Matt is somebody who's really had a big influence on my career, really, as far as broadening my viewpoint on mindbody medicine.
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We'll talk about if those of you have listened episodes back.
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Ways back.
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Matt came on and talked a little bit of his work.
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We have a paper he authored that I think is great, and we'll link it in the show notes.
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He's gonna discuss a little bit of that.
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That just gets into the mental health and really integrating that into physiotherapy care.
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But Matt, I'd love if you could talk a little bit about the stimulus for that paper as far as you've been in the physical therapy field for a bit now, and you've seen things evolve and maybe a lack of evolving that may have stimulated paper more.
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If you can discuss a little bit about what stimulated your writing in that paper.
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The paper really is.
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Has arisen out of my entire career, 27 years in now with a passion for mindbody integration.
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Know how many years ago I, when I first came across the world, phys physiotherapy the International Organization for Physiotherapy and Mental Health, thought, why isn't the US engaged in that scene?
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How much more developed it was in a number of European and.
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In Eastern countries, and of course we are now several of us got together Ellen Anderson and I and a number of others, Marlisa Sullivan, and.
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Helped the A PTA officially join that group a few years ago, and it's a loosely organized group.
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But out of that and some invitations to speak at the Latin American Conference on physiotherapy in mental health care I was invited to consider putting my presentation into a paper and that's the result.
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And it's a great paper.
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That kind of gets into the, some of the issues we've had as a profession of true integration.
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Where would you see, because I think you, you've put some rightful criticisms about maybe some fragmentation versus truly embodying.
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A whole person way of getting it.
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Where do you feel this paper kind of tugs at some of those issues we've had with maybe bio psychosocial versus a more integrated, truly integrated whole person approach?
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Yeah, I think that the reductionism is so entrenched in, in, in our training in general, in biomedical.
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One of the things I like to start with on this topic is that.
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There's a tendency to think that the psychological domain of our life and or the social domain are not represented by neurophysiological or biological correlates.
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And there are in fact underpinning.
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So just the three words un unto itself is implying that there are three separate things, and I know there's been a lot of publications on this area, but when you look at things like and I can't remember if I referenced it in the paper, but Naomi Eisenberger's work out at UCSF.
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She's done a whole body of research demonstrating that the social environment, the social mileau that we're, that we find ourselves in co regulates inflammation.
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I.
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So just by changing social environments can change inflammatory states in the body, we tend to go toward immediately towards you.
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What are you eating?
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And of course that's important'cause we know that ultra processed foods is a major source of inflammation.
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In our system with the gr gut brain axis, but we don't often tend to look at the environments that people are bathed in.
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And so the social environment as one thing, and then we each of course have the individual mind body connection, which is our individual psycho psychology, our personality.
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But all of that also is found to have, biological underpinnings.
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so just that alone, helping people to understand, not to distinguish the biological or biomedical domain from the social and psychological elements, psychosocial stressors, for example, of people's lives is something I say over and over to help people change their thinking about the relevance of that.
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I love how you connected the neurophysiology to it, right?
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I think there's this thought that there's this nebulous factor out there of social and when you can really put it into biology, where we embody our social world, like you said, the social world we're bathed in and that context that we operate in that have constant influence on how our systems are regulating or dysregulating.
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I don't want to get too deep into this topic'cause it gets a little contentious with, but this thought, there's still folks that think there's gonna be some biomedical breakthrough that's just gonna, and if we just can learn to, and the new thing seems to be the nociceptive apparatus where it's just this biological island that it just maybe I'm probably maybe misrepresenting a little bit, but it still seems to me like we're still looking there.
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There's certain pockets and I've had discussions with various clinicians who, you know, and that's okay.
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They can have disagreements.
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I think that's healthy.
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But where do you sit with this thought on this like nociceptive apparatus and that it's just a matter of a biomedical breakthrough that's gonna really really unlock some improvements in pain.
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Do you think we're missing a biomedical breakthrough or are we still just missing the big picture as it comes to pain?
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I will remain ever hopeful that the biomedical model can come up with breakthroughs that alleviate suffering, that alleviate the experience of pain.
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I think that I tend to take the non-dual approach of both.
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And when we look at pain reprocessing therapy and this messaging that, it's relatively or entirely produced by the brain.
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And so changing brain structures through psychological processes, through mental cognitive, emotional awareness and expression is the solution.
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I don't negate that or distinguish it from the research that's showing that if you have chronic non diffuse or non-specific low back pain, that there may be non-identifiable on structural imaging, but neuro immune and neuroinflammatory and cellular changes that are activating it.
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I don't make a distinction that if that's the case, that negates the relevance of it, of offloading the allostatic load.
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Psychosocial stress addressing upstream determinants to their health so on.
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I see that there, it's a both and for me addressing the tissues, the health of the tissues locally, and addressing the neural networks that communicate, from the tissues of the body to the brain simultaneously.
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It's great points you bring up.
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'cause I do think sometimes, we tend to jump to the, or, approach with things.
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And I, and there's definitely been my experience with some of the pain science things early on where I jumped way into the psychosocial without.
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Recognizing the interplay of biology and that, like you said, let's definitely hold hope for biomedicine to have some breakthroughs that can ease suffering and help people out.
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But we also need to understand the biology, the connection of the psychosocial in our biology too.
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We can to me, treat it all and maximize all aspects of things instead of just trying to segment people in the categories.
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Now in your paper you highlighted the mindbody medicine approach as part of your framework, which you've done some great work and really worked with some, pretty impressive groups and folks with that I'm wondering if you could elaborate on what the mindbody medicine kind of approach looks like in a practical day-to-day physical therapy setting as far as how does that look like day to day?
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Maybe, how you're average day caseload might interact with that.
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'cause I know it can probably vary depending on the person in front of you, but I think sometimes physios hear mind body medicine and they don't really have a view on, what does that look like?
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And obviously you don't have to get into the exact details of detailed intervention strategies, but maybe how you, how that looks in a just a day-to-day approach.
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I think it starts, out of the gates with a psychosocial oriented interview.
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That is also trauma informed.
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So I think what is smart and safe in terms of developing a relationship, knowing that the populace is just as entrenched in the splitting of mental health, psychological social factors from what's happening in their body.
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And so questions, just give me a little bit of a sense.
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I'll say, I'll preface it with a one line education.
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We know that.
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stress can increase, inflammation can predispose us to all kinds of ill health issues.
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So I'm wondering if you could give me a sense if you're, you feel like your stress levels, whether it's, social or occupational, are they low, medium, or high late?
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So questions like that or I'll ask questions like even if you.
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Don't think it has anything to do with the problem you're here for.
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And I'll say to you right away that I don't make any assumptions about relative causality, but I'd like to get to know a little bit about what your body, and your nervous system has been through any history of any accidents, injuries, or traumas, even if they're not physical traumas, psychological.
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So I might ask a question like that.
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And of course it's pretty easy in my practice'cause most people are referred knowing that they're coming to a mindbody integrated, whole person practice.
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Many of them are referred by mental health professionals because they have co-occurring depression.
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Diagnose PTSD or trauma history.
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So it's easier for me in that setting than I think the average practitioner.
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But there's ways with simple education to begin to open the conversation about stress as a pretty safe entry point for most people.
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I would agree.
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I don't think stress is something that's very taboo per se.
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Now.
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Your practice as well when you're working with some of these people.
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Interventional strategies, obviously you did, you're talking assessment and some of the great things we do to get to get, peel away the layers of all the things that are surrounding.
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What comes in as a script is a low back pain thing where we often try to obviously get to know a little bit more the whole person thing.
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What kind of like interventional strategies?
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I know there's very either variety depending on the person in front of us, but I wonder if you could discuss a little bit of how maybe trauma-informed care and a little bit more of how mindbody medicine looks in a day to day, like as far as some interventional strategies what kind of interventions you might be using and that you think.
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As physios, we should be more comfortable, at least delving into that to best serve our patients.
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I'll start just with a, an example of trauma-informed care.
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The provision of choice.
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Is critical.
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there's, I can't cite the author off the top of my head, but I know when I was first studying this, I can say that there's research around two to three choices, supports, I'm gonna call it the biology of empowerment.
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Too many choices will overwhelm, but just automatically assuming this is what we're gonna do without providing some options for choice, is an example of helping support.
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A sense of autonomy or agency within the care experience, and I consider that part a trauma-informed care.
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When I look at the broad field of mindbody medicine, which is really built off psycho neuro or is Candace pert, person who discovered the mu receptor said psycho, neuro, endo, immuno, keep adding it in because really we do function as whole state.
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system, patterning, that's why I put a lot of emphasis in mind body medicine, on nervous system regulation.
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I try to get some basic assessment out of the gates, for example, I'll take a look at hand and foot temperatures.
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Colder hands and colder feet generally indicate higher sympathetic dominance.
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I'll take a look at a heart power spectrum analysis and heart rate variability to get a little bit of a sense of the autonomic profile as is acting on heart rate variability of the time in an initial evaluation with the population I'm working with, and I guess most people coming to a health care appointment, there's high sympathetic dominance in the heart rate variability pattern.
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And so I begin to look at my sense of how regulated, physiological, regulated, what's the arousal or activation level, is this person in a state of hyper vigilance?
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And I'll start to work with guided mind body practices that build on body awareness, breath awareness, breath regulation neurocognitive principles that arise outta mindfulness.
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And like somato emotional awareness.
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How does this pain experience make you feel?
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And I'm asking that, not because I'm suggesting it's causing your pain, but I'd like to get a sense of the impact this is having on your life.
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Does it bring up frustration or sadness or These types of questions provide permission to as an entry point into the hole that each person really is, and a lot of people are surprised by it.
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I had worked with someone recently and I asked a question about.
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Similar to that tears pretty quickly.
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And I said, what's happening?
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And the response was, grief.
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I've lost so much since this started in my life.
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And then I
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Yeah.
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Yeah.
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I acknowledge grief is probably one of the most under-recognized aspects of living with chronic pain.
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More tears.
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So it's just simple acknowledgements.
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It's how you relate, it's how you respond, it's how you preface it.
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And then weave in practices that I use the analogy of a radio dial, so as your nervous system, central autonomic axis together dialed up in arousal.
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Ooh, what's that?
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Ooh, what's that?
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Things are more biased to be interpreted as foe or unpleasant, or.
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Novel, pay attention, right?
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There's a vigilance baseline.
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And then I teach people how to dial that back down and you'd be amazed when this becomes the focus of what you're looking for, how people will experience a physiological shift and automatically they demonstrating shifts in commitment.
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actions, cognitive framework.
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The behavioral set widens naturally without me having to do any sort of lifestyle or motivational interviewing or suggestions for home program.
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It's, what's your committed action?
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What's your takeaway from today?
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It's not me telling them what it should be, but that opens up when I can help them.
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Through co-regulation, so the regulation of myself, the training of self-regulation, physiological self-regulation skills.
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I went on for a while, but I'll
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That was great.
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I think I love,'cause you ex exuded it you just demonstrated it.
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It's very much a more Socratic guided discovery process with these type approaches.
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It's not, we just had a podcast episode on this topic of how we have this struggle as PTs.
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We want to grab the steering wheel and drive it and in a direction and we don't open up that self-discovery process, like you said, where I think it's fascinating that you've seen.
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Patients where when you open a door to this physiologic change that it just opens up the door.
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I've really gotten into the habit of helping people do a mindfulness activity just to learn that right off the bat, just to start kinda calming the system down.
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I don't, I maybe haven't used the exact thought process or terminology you use, but I've definitely found it much more easy to have them start opening discussions and moving in areas and being able to like maybe work when you start helping them regulate things.
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But I'm wondering if you can speak to some of the.
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Communication skills that are involved in kind of that guided discovery approach instead of, it's, to me, it's, you're not giving them the answers.
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You're not, you're helping them come up with their own answers, not just telling them the answer of the question.
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Would that be accurate or how do you view kind your communication approach when you're trying to help people maybe connect the dots with some of this stuff?
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I'll start with the phrase phenomenological heuristic, which I get criticized for daily for using in my household.
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No one knows what that is.
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It's enabling people to come to know themselves better and to arrive at their own answers and decisions.
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it's a, it's really a subjective based approach.
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And to not go into it with assumptions, and the work that I've done with this nonprofit in Washington dc we do a wide range of body skills, like simple drawings.
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So I'll give you an example.
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Draw yourself with your biggest problem.
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Crayons, piece of paper, what comes out.
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I did a group when I was first getting certified in this with chronic pain and chronic migraine and headache patients at the hospital I worked at in Minneapolis back in 2009, I think.
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we did this with all of them, and probably only half of them drew.
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Their biggest problem is their pain, even though they signed up as chronic or persistent pain patients.
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So that alone gives you a sense that there's more going on here, right?
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I think a lot of open-ended questions.
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Tell me more.
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I'm curious about, I do a lot of observation, so when someone's telling me their history, I can, I try to watch body language and if I notice a shift based on something that's said, I might make a comment like.
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Anything you notice happening in your body as you're just telling me about that.
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So they're getting real time cues to tune in to the mind body connection because they're, they may be meant cognitively fused if act right cognitive fusion with the storyline about the accident, but they're not aware that just relaying it to me is dialing up that arousal level.
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So I try to be really cautious about not.
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Invading someone's unconscious, but there are open-ended questions that facilitate that present moment of tension on what's happening, physiologically in the body when they're sharing or processing something more cognitive.
00:19:59.737 --> 00:20:13.527
It gets into, I've been diving a little bit into this whole default mode network of, that humans operate under, where it's just this kind of neurophysiologic, kinda, I guess the soundtrack that plays and sometimes we get so ingrained and identified, like you said, fused to this.
00:20:14.307 --> 00:20:23.606
Mind track of how our, what it is and how we identify ourselves and almost sometimes identify ourselves so deeply with a past experience or the pain and all that's come around it.
00:20:23.606 --> 00:20:34.646
That it's having the skills to have somebody almost step back from that experience and look at it from a, like a, almost like a outside perspective, which is a lot what act and mindfulness does, is to help people be.
00:20:35.112 --> 00:20:40.031
Instead of ruminating or future past kind of mindset where they can come into the now and stuff.
00:20:40.031 --> 00:20:42.961
And I've been just amazed how that has been so helpful for people.
00:20:42.961 --> 00:20:44.102
And I completely agree.
00:20:44.102 --> 00:20:56.251
I've seen people where I noticed sweating and I noticed like just, body posture and things changing when they're starting to go over some of these tough situations and stories, obviously emotions, like you mentioned with your patient there coming out as well.
00:20:57.406 --> 00:21:10.186
One thing I wanted to make sure we touched on too and this discussion, the framework to this whole person support, and one of the components of it you discussed is this capacity to be present, to learn from dis discomfort.
00:21:10.727 --> 00:21:13.307
And to me, that is so hard.
00:21:13.307 --> 00:21:19.997
I think for, and I know it was for me, I understand, I think about, I'm gonna have you get deeper into it, but there's this.
00:21:20.747 --> 00:21:22.037
It could be cultural too.
00:21:22.037 --> 00:21:28.067
I'm sure it is cultural where like pain is something not to be experienced and we have to eradicate and escape it at all costs.
00:21:28.067 --> 00:21:33.376
Yet when we look at life, it's probably an inescapable reality of the human condition.
00:21:33.376 --> 00:21:35.386
We're gonna bump into some of these things.
00:21:35.386 --> 00:21:44.836
I'm wondering if you could speak to what you mean by that capacity present and learn from discomfort and how you might help a patient kind of explore that with themselves.
00:21:46.194 --> 00:21:47.180
That's a big one.
00:21:47.569 --> 00:21:49.670
A few weeks ago I gave a presentation.
00:21:50.369 --> 00:21:52.950
University of Arizona Center for Integrative Medicine.
00:21:52.950 --> 00:22:02.009
It's a subsidiary of the College of Medicine, but it's funded by the Andrew Weill Center on just introduction and overview to Persistent Pain.
00:22:02.009 --> 00:22:02.039
I.
00:22:03.359 --> 00:22:19.859
Pain biology, integrative care for pain, and I put up a graphic showing the rates of chronic pain around the world based by country and the top three countries with the highest rates of reported chronic pain, or the uk, Australia, and the United States.
00:22:20.819 --> 00:22:25.319
And I present the question to the audience, what do you all think might be behind that?
00:22:26.190 --> 00:22:32.460
I get a lot of different, very interesting answers, some of which have led me into new avenues of insight.
00:22:33.539 --> 00:22:44.065
But in the end, I often will say I wonder at a sociocultural level that we have cultivated a society with a very low tolerance for unpleasant of anything.
00:22:45.230 --> 00:22:47.029
We want it fixed.
00:22:47.059 --> 00:22:48.650
We, we don't want to be bothered.
00:22:48.650 --> 00:22:53.000
There's this sort of, and I usually get mostly nods around that.
00:22:53.900 --> 00:23:01.934
I sometimes, when I talk about sociocultural phenomena, talk about a series of three papers and whiplash, for example.
00:23:02.414 --> 00:23:03.980
And there was a paper looking at.
00:23:04.424 --> 00:23:07.934
The concept of whiplash and Lithuania versus in Norway.
00:23:07.934 --> 00:23:10.964
And in Norway, they have whiplash support groups all around the country.
00:23:10.964 --> 00:23:14.894
But in Lithuania, they don't really have an equivalency to the idea.
00:23:14.894 --> 00:23:19.845
And the rates of people seeking care for pain or headache are much lower.
00:23:20.805 --> 00:23:23.355
and the idea is that we have collective beliefs.
00:23:23.414 --> 00:23:28.035
We have individual beliefs, but there's collective or societal beliefs that are drivers.
00:23:29.204 --> 00:23:30.494
To what we experience.
00:23:31.365 --> 00:23:36.464
so comfort with discomfort for me is just helping people, temper that.
00:23:36.464 --> 00:23:41.525
So it can start really simply with notice the area of pain.
00:23:41.704 --> 00:23:46.025
I'll get people lying down, get'em as relatively comfortable as they can be.
00:23:46.835 --> 00:23:48.095
your attention to it.
00:23:48.394 --> 00:23:51.125
And I call it self-regulation in the face of pain.
00:23:51.950 --> 00:23:58.730
I'll say this supports natural resilience, that you're not going anywhere and I'm not going anywhere, at least not in this moment.
00:23:59.720 --> 00:24:05.299
So can I dial down some of the outputs that come with the pain experience, that protection?
00:24:05.690 --> 00:24:11.980
Can you notice some subtle holding or guarding, either locally in the area of the pain, or maybe it's upstream.
00:24:12.700 --> 00:24:16.309
You might be clenching your jaw, your, you got shoulder earrings on.
00:24:17.119 --> 00:24:18.529
The pain is in your back.
00:24:18.559 --> 00:24:19.910
Can you disarm that?
00:24:19.910 --> 00:24:21.200
Can you drop the shoulders?
00:24:21.200 --> 00:24:22.640
Can you unc unclench the jaw?
00:24:22.640 --> 00:24:25.130
Can you holding the breath?
00:24:25.789 --> 00:24:31.220
And I'll say, this is what I mean by beginning to develop a greater degree of comfort with discomfort.
00:24:31.849 --> 00:24:34.549
And I'll say, this'll build on your natural resilience.
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