Reset your brain and body for a pain-free life.

Joe Tatta, PT, DPT


Marlysa Sullivan: The Social Domain of Pain and Health – Connecting Science with Treatment

Welcome to Episode #6 of the Healing Pain Podcast with Marlysa Sullivan!

What is the biopsychosocial-spiritual model for pain? And how does it differ from the now archaic biomedical model that many struggling and without answers?

The biopsychosocial-spiritual model is the newest trend when it comes to developing effective programs for those struggling with pain and other chronic health conditions. We now understand the complexity of pain syndromes and how it affects life on every level, including social interactions, emotional stress and even spiritual health. In this interview, Marlysa Sullivan, MPT will provide you with a solid foundation to understand the biopsychosocial-spiritual model, how you can integrate it into practice or help find a practitioner who embraces this new model of care.

In This Episode You Will Learn:

  • The biopsychosocial-spiritual model of health and how does it relates to pain.
  • How to define the social domain of health and its relationship to the other domains.
  • The connection between the social domain of health to pain and supporting research.
  • The physiological basis for looking at and understanding health in the social domain.
  • How yoga, meditation and physical therapy to work with improving social health, connection and the physiological underpinnings of pain and social isolation.

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Hi Marlysa Sullivan. Thanks for being here for the Healing Pain podcast. It’s great to have you.

Thanks. It’s great to be here.

So, I wanted to have you on cause you have a really unique background as a physical therapist, as a yoga instructor as well as obviously you teach now at the … Is it the University of Maryland you teach at? Or where do you work?

It’s Maryland University of Integrative Health.

Right, Maryland University of Integrative Health. And I know you teach up there therapeutic yoga program there so it’s great to have you here. And we’re gonna dive in and talk about the biopsychosocial aspects of pain today. So tell us, how does … You know I think we’re looking at kind of the, if I should be so bold, the death of kind of the biomedical model when it comes to pain and even our health in general. But what is a biopsychosocial model because a lot of people have talked about it on my podcast and I think if you’re a clinician you have an idea what that means but if you’re someone who struggles with pain, or if you have another health condition you like “What is this biopsychosocial model mean and what does that really mean to me as a patient.” You know – Can you just expand upon that for us to start.

Yeah. The biopsychosocial, and sometimes it’s called biopsychosocial spiritual model, is helping us to understand the more dynamic nature of who we are as human beings. So in our lived experience we’re not just these physical entities separate from all out other entities. So it’s looking at the physical, the mental, the psychological, the social and the spiritual as this multi-dimensional and multi-layered experience of the human experience. So whether I’m in wellness and health and vitality, or if I’m in disease or suffering or sick or pain, the root of that suffering is about this connection between layers. It’s about this dynamic and complex experience of what’s happening. Not just what’s in my physical body, but what’s happening in my mind, what’s happening in my social relationships, and my social connection and even my spiritual connection.

So sometimes what I often use this example with chronic pain. And chronic pain is such a beautiful way for us to really understand this cause it is so obviously more than one facet of who we are. So, from a physical standpoint if I someone who has chronic pain, say like chronic low back pain, then I’m going to have some tightness in certain muscles. I’m going to have weakness in certain muscles. I’m going to have changes in my nervous system that I think you’ve had other people talk about. All of that will create and experience of anxiety, or depression, or a different mental state. We’ll also then create a feeling of isolation. Like I can’t participate in the activities I use to participate in. My friends are changing. I’m not connected to my life meaning and purpose.

So that’s like this one direction of seeing it. But we can also look at the biopsychosocial model to see that any of those avenues are doorways for us see. So for one person it might be primarily this physical root. But for another person they might have a lot of anxiety and worry. And because of their anxiety they’re gonna hold like their hip flexors really tight of their glutes really tight and they’re gonna get disconnected from their abdominals. It’s gonna create nervous system activation that’s gonna create the nervous system changes. It’s going to create isolation.

And then what we’re gonna talk about more today is really how this social avenue is another doorway for us to look at all of this coming from. So if I feel disconnected from people around me, it I feel disconnected from my life and from purpose, then I might have an experience of anxiety or depression. If I feel anxious I’m going to start breathing differently in my body. My nervous system is gonna go towards sympathetic activation. My muscles are going to tense in a way that congruent with that. So if we work with someone and we just fix the muscle an balances, or we just work with nervous system information, or even just work with the mental state, it doesn’t get to the root of that piece of connection that’s also missing.

So you did a great introduction of describing what the biopsychosocial aspect is and how it relates to pain. It also relates to other aspects of health of course. But how long have you kind of focused on would you say a biomedical model? We’ve really kind of missed out some of those certain aspects of kind of the social, the spiritual or the emotional part of it. And you know with that obviously over the course of those decades certain patients have not gained positive aspects or have only come so far in their health transformation because those parts have been missing.

Yes. I think I missed the first part of your question.

So my question was I guess you know we’re now seeing that there’s kind of a new model out there basically.


What was the previous model? And what should like a patient be aware of when they’re going to a practitioner that may still be practicing solely on an older model?

Okay. The previous model, like the more biomedical model, was to try to find the organic causes. Try to find like – The biomedical model was really good at thing like … If you think about what the biomedical model’s really great at is it helps eradicate diseases that we don’t have to worry about anymore. So it’s really great at finding the organic cause of disease and treating that organic cause.

With chronic pain and chronic disease and chronic illness the body experiences changes in ways that are not so easily solved. So when you go to someone who has a more biomedical approach they’re not going to look at … They’re not going to ask you questions about your state of your mind. About your experience of sleep, your experience of anxiety or depression. If you’d had any significant emotional upheavals in the last few years. Like some loss of friends or loss of family. Someone who’s not coming from a biopsychosocial background might not ask you what you do for fun. What are your creative outlets. How you experience joy. How do you experience connection. So they’re gonna stay with their questions being like “what’s weak?”, “what’s tight”? You know – Doing objective measurements verses that more qualitative piece of “Well how are you living?”. “What is the quality of your life?” “What is the quality of your experience in the world?”

And obviously from one physical therapist to the next there’s still a place for the bio, meaning that sometimes it is a muscle that’s weak or a muscle that’s tight. And sometimes we do have to focus just solely on movement cause that may be the one piece or the biggest piece that’s missing from your life. Although we’re now learning that there are other pieces that are a part of the puzzle.

Well, and I think not only that but sometimes all of the psychosocial stuff is so intangible that the biological piece and the movement piece is incredibly tangible. So if you take someone that feels like weak from life, like they don’t have efficacy that they can create change, or efficacy that they can get better, and we give them an experience through movement of being strong or being in control, then they now have this experience of being strong to hold against their experience of being weak. So we can use the physical body.

What we can really do as body centered practitioners, as physical therapist is not get in the story of why there’s issues in the psychosocial experience, but to get out of the story and to say how is this showing up in your body. And how can we use your body to give you a different experience. So if someone has in their session with us an experience of being strong or and experience of being completely relaxed and open then that shows them that they have the potential for that in their life. So the body can give us a really tangible way to allow patients to experience that.

Interesting. So tell us about the social part of the biopsychosocial. Spiritual we’ll talk about later on but, tell us about the social aspect. What does that mean? And how can a clinician start to be aware of that more?

This social domain of health is, to me, it’s just fascinating right now because of what I’ve been reading about it and what I’ve been finding about it. So, the social domain of health has to do with how we feel connected to our social world. Meaning our relationships with others. But even it kind of gets blurry with that spiritual as far as connection to life.

So it doesn’t have to do with how many friends you have. It doesn’t even have to do with if you’re introverted or extroverted. You can have one friend or one person you talk to everyday or even an animal and you feel socially connected. So the studies on social connection all have to do with perception. Perceive social isolation or perceived social connection. And the finds that they found is that over many years they found that feelings socially isolated is correlated with pain. It is also people who have pain have a greater experience with social isolation. But people who have social isolation also report greater disability.

So in one study on lower back pain and were socially isolated had greater levels of disability. The other findings that I’ve been reading about with social isolation is the changes in gene expression so that when I feel socially isolated my gene activation changes towards having an increased inflammation in my system and decreased immune response. So if you think about cardiovascular disease and cancers that piece of social isolation is correlated with that piece of it, as far as increasing inflammation, decreasing the immune response. So the – So working with someones experience of loneliness and someones experience of isolation is going to have that emotional benefit. But it’s also going to have a really tangible experience in the body as far as inflammation, immune response, heart rate, blood pressure, digestion, all of those.

And the interesting thing you said is that it doesn’t necessarily mean you have to have a group of twenty or more friends. It’s your perception on your own isolation that’s actually important.

Yes. Yeah.

So can we talk about that for a minute? So obviously you may be fine with just having one friend. But obviously if you have a chronic condition or you have chronic pain you may be more likely to be in your home or less mobile or active in a community. So what are some options that people have for trying to create a social structure that may not involve being in a group of, you know, twenty or more people at a time.

So I want to answer that two ways. One way is the … One experience in social connection is having people around you that you feel connected to. So if someone is unable to leave their home then, especially today with internet, there are things like discussion boards for different diseases. There are – I’ve read things even on people who are trying to adhere to physical activity where there’s like Facebook groups that are bout helping people to stay motivated towards their physical activity. So finding an online forum is one way that people can be socially connected.

The other thing about social connection that I think we could have a really big impact on through yoga and physical therapy is what is called vagal tone. So the correlation between the nervous system and the feeling of isolation. So vagal tone is the state of the nervous system that’s been called the social engagement system. And it’s that state where we feel relaxed. It’s a state of the parasympathetic nervous where we can restore and come into balance. And increasing vagal tone, increasing that relaxation of the nervous system and the hear rate, and the blood pressure has been correlated with a greater ability to read facial and emotional ques. So being better able to atone to others. But even more interesting is that vagal flexibility, meaning the ability to activate my nervous system and relax my nervous system appropriately, is correlated with less loneliness. So when we teach someone how to relax and how to build resilience they experience the capacity to have less loneliness … A less lonely experience.

Interesting. And I wanna get a little nerdy about vagal tone for a second. Maybe go back to anatomy and physiology, but can you describe what vagal tone is? And I guess you really should start and just give us a little brief and tell us what the vagus nerve actually is and how that connection and that vagal tone help us with kind of modulate not only our fight or flight response system, but you know also you know finding a state where you can live in a healthy way.

Yeah. So the vagus nerve is a primary conduit of the parasympathetic nervous system. And there’s a branch of the vagus nerve that connects the heart to our vocal cords, to our inner ear, to our muscles of facial expression. And it’s that part of the vagus nerve that’s responsible for relaxing our heart rate from a sympathetic state. And it’s that part that when we think of what the relaxation response is it’s when that part of the vagus nerve has it’s input and control over the heart. What was the second part of your question?

No, I mean that’s great right there. So basically you’re saying that when you have a … When you feel supported, or when you have a social structure, or when you feel like your social structure is adequate and fulfilling, you’re more likely to modulate your own nervous system in a way that can help your health.

Yes. And what’s interesting is the idea of going the opposite direction. So instead of trying to create social connection I can also help someone create vagal tone and create resilience in the nervous system, which automatically creates a sense of connection. So one of the ways that yoga has been found to help pain is that it does create greater connection. Is that it creates greater capacity to traverse difficult times in a relationship, but it also improves vagal tone and social attunement. That ability to read facial and emotional ques. So simply by doing meditative movement we’re helping someone cultivate the experience of connection verses just going out and trying to be connected to other people.

Interesting. So the physiologic basis behind vagal tone, what are some of the signs and symptoms someone might see get better as they become, you know, more in tune to their own body and help to kind of balance out their nervous system?

Well being in vagal tone helps you decrease your heart rate, it decreases your blood pressure. It can improve being in that relaxation state can improve digestion. It can also help you relax muscles because when you’re in a relaxed state you’re gonna have a better capacity to go inside and relax. And if we think about this idea of creating vagal tone to help with social attunement its like when I help someone create a state of relaxation we’re helping them create a sense of safety and a sense of peace and a sense of connection inside of themselves that they can carry with them out into the world. So the idea of doing that on the yoga mat or in the physical session is that they can build this kind of reservoir, this capacity or this foundation of finding connection within themselves which ask to enhance their ability to feel connected to the outer world.

And what’s really interesting is I think when you mention things like heart rate and respiration, the average person thinks they don’t have control over that. That it’s just their anatomy that dictates that or their own genetics. But even things … I think the most important thing to talk about is hypertension. You can have control over your own blood pressure basically.

Yeah. Yeah. So we through working and the breath is really the most direct way of going right in and working with that. One of the ideas or frameworks of how yoga works to do this and what we can do as physical therapist is called top-down regulation and bottom-up regulation. This idea that we fan use meditation and mindfulness to use my mind to relax my body. So when I think of a word or an image that creates a sense of peace or calm, that’s gonna have a direct effect on activating that vagus nerve and vagal tone, which then creates a decrease in heart rate and respiratory rates.

But practices like yoga also have this bottom-up capacity where we kind of touched on it before with moving the body, but I can also use the breath to regulate. So when I breathe deeply and slowly ane elongate my exhalation that decreases my heart rate right away. When they measure vagal tone, they measure it through heart rate variability, which means that when I inhale my heart rate goes up a little bit and when I exhale my heart rate goes down. So if we take advantage of that and really lengthen exhalation, we decrease heart rate, we decrease blood pressure through the breathe or through the body.

And then another way we can do this in a bottom -up way, it’s like if you’ve ever been really nervous, or really anxious, or really worried and you just try to sit down and relax it’s impossible. So we can actually use movement to help us. We can use movement to kind of burn off the excess energy. Instead of trying to sit still and meditate we can do some breathe based movement to take us from a heightened nervous system state to a relaxed nervous system state.

So how would someone know if they should approach themselves and their own health more from a top-down or bottom-up approach. So, what do you advise your patients? Do they need to move a little bit more? Do they need to maybe focus on the mediative, cognitive aspect of things.

That’s a nice question. I would say … Typically I’d usually probably do a little of both but if someone – I was working with someone who had a lot of anxiety and a lot of panic. And for her the idea of sitting down and using the long, slow, deep breathes and coming up with a nice word or image is like really activating because it’s just impossible. So for her, of course, movement is what is indicated. So if she moves a little bit and is able to move with the breathe enough, then that begins to allow her to come down to a relaxed state. Verses someone else who … I’m trying to think of an example of when I would just use the breathe. Sometimes when someone has like a lot of lethargy or there’s like a lot of fear of movement, like with chronic pain, that there can be a lot of fear of movement. So helping someone come in to just a comfortable position in their body to find that word, or image or way of breathing that helps them feel calm. And then I can gradually introduce movements.

So if I work with someone who had fear of movement, because movement has always hurt them so they have a good reason for having fear, that we create like a mantra. Like a work, an image, something that helps their body create a state of relaxation. So then when we introduce movement they can always come back to that state of relaxation. So that we can introduce just a couple bits of movements and they can move from a calm state and then come back down. A lot of times with movement and chronic pain if someone has all of these areas of tightness and weakness, and their nervous system is activated and we try to have them move on top of that is just going to exacerbate everything. So if we help some create a vagal tone space, a relaxed space, they’re gonna be able to be more connected to their body. They’re gonna be able to activate muscles more appropriately or more accurately and to find a way they can move pain free.

I think that’s a great point. So what’s you’re saying … And I thinks it’s important for people out there who are listening who have chronic pain and they may have been told to go see a physical therapist or to go right to a yoga class. What you’re saying is that there’s a way that you can start to heal without actually moving first.

Yeah. Like so when we –

And obviously not to downplay the movement aspect. Eventually someone has to move cause you can’t live in our society without moving. You have to be able bodied and be able to engage in your social life and your work life. But in the beginning when fear is an issue there’s another way in to the healing process.

Yeah. So for someone when there is a lot of fear and the fear is understanding that the fear is rightly there because it does always hurt them that if you spend time, and that means like days, months, year, on creating a relaxed nervous system. A place of like where they can feel … I’ve heard it called different things like inner resource. A sense of safety, a sense of peace. But a way for them to access what it would feel like pain free. Or what it would be like to be at peace and at home. That sense of safety. And then when you being to cultivate movement you can either try to keep that sense of peace or inner resource with you as you move or you have it to come back to. So that you can being to activate. And that’s the building of resilience. Like activating a little bit and coming back down to that state of peace. And that would very much be more coming from a we’re gonna began top down and gradually bring the body in to it.

Excellent. So can we take a big leap and talk about the spiritual for a second.


Obviously, you know for most patients they’re going to probably the orthopedic physician. The doctors probably not asking them about their spirituality and how it relates to their pain. But can you give us and introduction into the spiritual part of your practice and how it can help someone with chronic pain.

Yeah. So spirituality can of course be defined so many different ways. And there’s this importance to really distinguish the spirituality verses religion. And spirituality is really about meaning and purpose. How do I find meaning and purpose in my life. How do I feel connected to the world in a way that there is purpose.

So a lot of times in questions about like ideas of spiritual health are about does someone have access … Like when I have access to my spirituality and my connection, my purpose, I can be creative. I can experience joy. I can fully relax. I have a purpose and meaning. So asking people questions about do they have outlets for creativity. Do they still experience joy. Do they have … Even very directly connected to meaning and purpose. And we can easily bring that in to this practice we were just talking bout so that when someone creates a word or an image or a felt experience of purpose and we allow that to be kind of the intentions throughout the practice.

So when I’m connected to that meaning and purpose I’m going to have a certain state of my nervous system. I’m going to have a certain of my mind. When I feel really connected to my spirituality my thoughts are going to be different. My emotions are different. My whole physical body is different. I move differently. So if we spend time helping someone connect with their purposes in life, to connect to their sense of joy, to their sense of creativity then we can allow that connection to come out through the practice.

So if I’m a patient and I’ve listened to your interview and I’m starting to understand what a biopsychosocial spiritual aspect of healing entails. When I go out there into the world and I really find that most practitioners are unfortunately still practicing in kind of a silo. You know the therapist are kind of doing the movement. The psychologist doing the psychology part about it. You know – To find the spiritual peace you have to completely go somewhere else. And you know it’s very difficult to intertwine all those things together, which we’re starting to do it more and more as our healthcare system kind of evolves. But if I’m a patient how do I start to go about finding those types of practitioner? Or what should I be on the lookout for?

The International Association of Yoga Therapy is an organization that has a listing of yoga therapist. And there are the … The field of yoga therapy is pretty new. But their website has a list of yoga therapist. It also has places where there are healthcare practitioners. Like physical therapist, occupational therapist, doctors that are also that integrate yoga into their practice. So that’s one place to go is the International Association of Yoga Therapy.

The physical therapy world there are different organizations that are looking to bring this out. So if anyone is like a physical therapist or occupational therapist or healthcare provider listening we do have a Facebook page called Bridge Builders to Awareness in Healthcare. And there we have a directory of other healthcare practitioners that are doing this work. But I would say for a patient when you’re looking for someone – If you can’t find it on the IAYT reading someones bio. Reading someone’s bio. Reading about what their training is in.

So one of the yoga training that I’m doing right now if Richard Miller’s “I Rest Yoga Nidra”. And it very much focuses on everything we’ve been talking about. So he has a integrated restoration institute and a lot of his graduates are also licensed healthcare practitioners. Do that would be another good place. It’d called Integrative Restoration Institute. And they done a lot of work and a lot of research in chronic pain and PTSD. So that would be another good resource. So, but looking about someone’s bio and seeing if they have something like the the IRES – Integrative Restoration. If they have a background in yoga therapy. If they have a background in meditation … Some kind of meditative practice.

So typically I’d find someone who’s a licensed healthcare practitioner, like a physical therapist, and they may have another certification or some kind of integrated approach to the care of they take toward a patient.


Or, and maybe a facility that offers not only physical therapy but you can also access other aspects of care basically.

Yeah. Yeah so if finding like where I work in Atlanta. I work in an acupuncture office where we have acupuncturist. We have access to psychologist and then physical therapy.



So I want to thank you for the interview today. But can you tell us how people can learn more about you and your information. Your website. I know you do some trainings.

Yeah. My website is So I’m part of the center for integrated yoga studies where we have a 200 hour and a 300 hour yoga teacher training with a therapeutic or mediative focus. I also work at Maryland University of Integrative Health. I’m an assistant professor there. So the best way to find me is on my website. And so if you go to integrative you can go to ask Marlisa and you can get on the mailing list from there. That would probably be the best way.

Excellent. So I want to thank Marlisa Sullivan, physical therapist, for being with us on the Healing and Pain podcast. Please check her out on her website and at her university where she teaches. And please stay connected to the Healing Pain podcast each week at Well have new practitioners from every profession of medicine, physical therapy, psychology, spirituality. Everyone talking about how to heal a chronic pain in an integrated way. And we’ll see you next week.

About Marlysa Sullivan, MPT

Marlysa is an assistant professor at Maryland University of Integrative Health (MUIH) where she teaches in both the integrative sciences and yoga therapy departments. She founded the yoga therapy clinic as part of the Masters in yoga therapy program at MUIH as well as teaching anatomy, kinesiology, physiology, the effect of physical activity on all domains of health, yoga for the chronic pain, orthopedic and neurological client and yoga perspectives in health and disease. At Emory University she teaches physical therapy students a course on integrating yoga into physical therapy practice. Her interest is in research and teaching the integration of yoga and meditation into health, specifically with chronic pain, orthopedic and neurological conditions. She has a private physical therapy and yoga therapy practice in Atlanta, GA.

To learn more about Marlysa Sullivan, MPT visit


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Amber VilhauerMarlysa Sullivan: The Social Domain of Pain and Health – Connecting Science with Treatment
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