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Clean Pain vs Dirty Pain
Episode 2425th July 2022 • Stress-Less Physician • Sara Dill
00:00:00 00:21:51

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How we experience emotional pain in life is connected to the source or cause of the pain. This birthed the concept of clean pain vs dirty pain. But what exactly is clean pain? What is dirty pain? And do the differences between them hold a key to how we work through each type of pain?

In this episode, I want to share the powerful concept of clean pain vs dirty pain. I have personally experienced empowerment in how I handle emotional suffering by understanding and framing pain through this concept. The core difference lies in how concrete the source of the pain is. Is the pain something specific you can name that happened? Or is the pain in how you are thinking about what happened? Let’s examine this together.

“We think that sometimes by spending a lot of time worrying about something or thinking about something, we can somehow solve it. Or even prevent ourselves from feeling the discomfort or pain. But what it does is prolong it.” – Dr. Sara Dill

What You’ll Learn 

  • What is clean pain?
  • What is dirty pain? 
  • Defining pain
  • Responding to pain

Contact Info and Recommended Resources

Connect with Sara Dill, MD, The Doctor’s Coach


I’m Dr. Sara Dill, and this is the Stress-Less Physician podcast episode number 24. Welcome to the Stress-Less Physician podcast. I’m your host, Dr. Sara Dill MD. Using my unique combination of coaching and mindfulness tools, I will teach you practical ways to reduce your stress level, feel happier at work, and create a better balance between your medical career and personal life. If you are a busy practicing physician who wants to design a life and medical career that feel good to you, you are in the right place.

Hey everyone, welcome back to the podcast. I have actually spent the last couple hours coming up with lots of things I wanted to talk about. And so today, I’ve decided to talk about this idea of “Clean Pain Versus Dirty Pain.” And this is something that I find super helpful, I just came up in a coaching session actually last week.

And I was just sort of thinking about it this weekend, because that’s what I do. I think about coaching, and coaching topics, and the ideas that have really helped me transform my life are the things that I want to share with you. Because not everyone wants to read as many books on the subject as I have, or go to all sorts of workshops and trainings and do all the stuff that I find fun in personal growth and development.

So, the point of this podcast is sometimes just to share with you the things that I think are very helpful or useful and can save you some time if you don’t want to spend a lot of time in the self-help aisles of your favorite bookstore, whether that’s literally or more metaphorically.

So, clean pain versus dirty pain, is something that I first got introduced to by Martha Beck, I think. So, maybe about eight or 10 years ago when I first started getting into this. And it’s an idea that I believe actually originates with a psychologist named Dr. Steven Hayes, who started a kind of therapy called Acceptance and Commitment Therapy. So, I want to attribute it to him. I hope that’s correct. But Martha Beck was who first introduced me to it.

And he and she both described this as a way of understanding our emotional pain or our suffering that we experience, our emotional suffering. And so, clean pain is the emotional suffering or emotional pain that we experience when something more intrinsically hurtful or stressful happens to us. So, this might be something like a bad medical diagnosis, could be something like a death or a loss, a relationship breakup, getting fired, or let go from a job, an accident or ill health. It could be the disappointment that you might feel over a cancelled vacation, or it could be something like just my frustration I felt last night, for example, when my puppy peed all over my bed as I was trying to get some sleep, right?

These are things that most of us would think it’s pretty reasonable to have a stress response. These are situations that trigger a natural stress response, and then we feel upset or stressed out or angry or sad, whatever it is for some time, right? That’s clean pain. There’s a concrete objective cause and an effect and the pain or the suffering has a limited duration.

Dirty pain however, stems not from an objective situation or an event, not from the facts of something that happened, but from our subjective thoughts about the situation or the event, and this might be real, or it might be imagined. So maybe something unpleasant happened, right? So, say “my puppy peeing on the bed last night,” that happened, that was factual. And then I might start thinking about if it happens again, is he going to keep barking all night? All sorts of things. I’m going to start ruminating in my head, projecting into the future, maybe I have thoughts about “I’m doing something wrong, this is my fault. Maybe I think about how I shouldn’t have gotten a puppy or how I’m going to be tired the next day, I might not be able to work very well.

All of those thoughts are what I would call dirty pain, right? They are unnecessary to the situation and they’re adding to my suffering, they’re sort of extenuating it, continuing it, making it bigger. So again, dirty pain stems not from an actual situation or something that actually happened, but it’s from our thoughts about a situation or event that might even be imaginary, right? It might be us worrying about something in the future or regretting something in the past. So rather than just dealing with whatever happened and moving on and letting it pass, we start spinning all kinds of stories and worries and other things, it just escalates it.

So, dirty pain is always based on our thoughts, our interpretations and our projections about something. So again, it might be based on a real objective event that has happened in the immediate past, it might be something that could happen in the future. But our body can’t distinguish between a real thought and an imagined though, right? So we get this emotional response either way. And then the more we think about it and the more we continue to feed it with our thinking and our mental narrative, the worse it gets, and typically the longer it sticks around.

So again, the distinction is that as humans, we feel sort of what I would call clean pain, when something hurtful happens to us. It’s in sort of the immediate experience of it. Dirty pain is the result of our thoughts about how wrong it is, how it proves maybe we aren’t doing something right, or we’re bad, or life is bad, or things are just going wrong.

The vast majority of our unhappiness, I would argue, also probably comes from the secondary response, not from the pain of reality or the pain we perceive in reality, but from our painful thoughts about reality. And I know I spend a lot of time—probably most of the time on this podcast talking about how all of our emotional response comes from our thinking, that all of our stress is in some way mental, right?

That facts are neutral and facts don’t hurt, and I think that that’s very helpful. And yet I also think that as humans, right? Sometimes we want to feel what I would consider stress like sadness, like fear, like disappointment, right? And so it’s not that the goal of coaching is to feel neutral about everything. For one, I think that could be incredibly boring. And two, I think that it might almost be an impossible goal. But the goal of coaching, as I see it, is to know what you’re feeling in the moment, to have self-awareness in the moment, and to know and notice how we are causing it or perpetuating it.

So, I might instinctively feel some sadness or some fear, if I find out I have a diagnosis about something, or I hear that someone I love died. It may not always be the case, but I would say for most of us. And yet, is that just the clean pain of the immediate reaction or am I then spinning out with a lot of additional stories and narrative that is making it even worse?

So, how do we go about dealing with clean pain versus dirty pain? Before I mention that I wanted to just take a moment and discuss, again, sort of the lifespan of an emotion. Jill Bolte Taylor is a Harvard trained neuroanatomist, who had a haemorrhagic stroke and actually found herself in a sort of blissful state after that.

She wrote a book called My Stroke of Insight. That is excellent, and has also done Ted talks, and has a new book out now, definitely worth checking out. But what I learned from her and that she explained is that: the lifespan of an emotion of just sort of a naturally triggered emotion is 90 seconds. So, she discusses that when a person has a reaction to something in their environment, there’s a 90 second chemical process that happens in the body, after that any remaining emotional response is just the person choosing whether intentionally or unintentionally to stay in that emotional loop.

So something happens in the external world, we have this chemical or neurochemical response, goes through the body, causes a variety of physical sensations, and then those chemicals get flushed out of the body in approximately 90 seconds. So next time this happens, you could watch this, right? Next time you’re aware of being angry or upset, you could actually just check out your watch, notice the process of it sort of happening, peeking, and then dissipating.

The reason why I’m introducing this in this podcast episode is that: this is also how I think of clean pain versus dirty pain in a more scientific way. And so, clean pain is that first 90 seconds of a response to anything. I’m someone who has a very high startle response, I startle very easily, I startle myself very easily. I startle myself, I think I see something, I get sort of panicked or afraid very quickly and then within 90 seconds, I’m back down to my baseline and I sort of know this about myself. So you could just notice this. Often, if we are feeling grief, maybe we’ve lost someone that we cared about, right?

It’ll come in these waves. Those waves are approximately 90 seconds when we don’t get involved with more mental stories, right? When we don’t get involved with adding to the narrative, when we don’t add more sort of dirty pain onto it. So, we often will keep re-triggering the emotion over and over again, and we do that with our thoughts, with our thinking.

The other way I’ve heard this explained is with a Buddhist parable called, “The Two Arrows.” So, the first arrow that hits us again is - an unexpected event or a situation, an illness, a death, is the arrow that causes pain, hardship, and it hurts us, it wounds us. The second arrow is our own reaction to this pain and hardship, right? The second arrow is often called: suffering in that tradition. So, the first arrow causes sort of what I would call clean pain, right? It causes pain. And the second arrow—our reaction to it, causes suffering.

So, the invitation here is to notice how much of your distress, how much of your unhappiness, how much of your negative emotional reactions come from the secondary response, come from dirty pain, come from the second arrow, not from the pain of reality, right? Or I would say the challenges of reality, the nature of reality, but from our painful thoughts about reality. And how do we work with this?

So, why is this a helpful topic for me and for my clients? How does this idea of clean pain versus dirty pain tie into self-coaching and basically, reducing our stress, reducing our suffering and feeling better, overall. And what I would invite you to do here, is to notice am I feeling clean pain? Am I feeling the pain of whatever has happened? Or am I adding to it? Am I resisting it? Am I arguing with it? Am I fighting reality? That basically is dirty pain. Am I making it mean a whole bunch of other things that are not necessarily true or useful?

How do we surrender to the fact that life is challenging, and life often presents us with situations and events that we don’t like, we wouldn’t have chosen, right? We aren’t fans of them. That’s sort of how I narrate it to myself. What you can do is to surrender to the fact that this is happening, right? Surrender to reality, allow it, accept it, acknowledge it, you don’t have to love it. And how do you surrender? What that looks like is observing compassionately, right? With compassion for yourself, or maybe for others, acknowledging that sometimes life is hard, sometimes things happen that we don’t like.

So the first step in any of this work is always to acknowledge what you are experiencing, what you are feeling, what you are thinking. And can you allow what you are feeling, right? Name it, allow it, maybe notice if you can just be gentle with whatever you’re experiencing, and especially if it’s particularly painful.

And then you can start to ask yourself when you’re upset or angry or hurt or sad or overwhelmed or stressed. Am I dealing with clean pain? Am I dealing with the first arrow, with the challenges of life? Or am I reacting to the second arrow? Am I creating unnecessary suffering? Am I creating a lot of dirty pain for myself?

Again, never in the way of judging or blaming yourself, but getting curious, right? You could ask: am I creating some unnecessary drama here? Am I sort of adding to it? Notice what happens for you when you are continually running through dirty pain kinds of thoughts, right? Worst case scenario, arguing with reality, blaming yourself or other people, or just spinning worst case “What if” scenarios in your mind. Notice the result for you. Is that the result that you want? You can always check in with what are the actual circumstances, what are the actual facts? What’s actually happened? Notice what you’re choosing to make those facts mean. Maybe you’re going to the worst-case scenario in the future, maybe you are using it to make yourself wrong or someone else wrong. Those are sort of the optional areas to let go of.

Notice how often the drama and the dirty pain, the second arrow—It’s really not necessary, it creates unnecessary suffering for us. And typically, what it does is it stops us from finding solutions or moving forward or moving on. We think that sometimes by spending a lot of time worrying about something or thinking about something, we can somehow solve it, or even prevent ourselves from feeling the discomfort or the pain, but what it does is prolong it, right? So, I always come back to this example of getting a flat tire. I don’t love getting a flat tire, it’s happened to me a couple times.

I can spend a lot of time making that very dramatic, right? Making it mean all sorts of things, worrying about the consequences, or I can just solve it. It can allow myself to recognize that I’m usually not particularly happy when it’s happened, right? It means, I might be running late, I have to take a series of other actions that I hadn’t planned on. But if I want to solve it and move on, I can do so.

I know that a flat tire is not nearly as painful as some of the other things like: dealing with death, dying, illness. The disappointment of not having a vacation or having plans work out of a lot of what we’ve experienced in the last couple years with the COVID pandemic, and yet, the principle is often the same, right? Can we allow ourselves to experience that first 90 seconds and then notice, are we continuing to make this more difficult for ourselves? Where are we adding to our own suffering? Or causing it unintentionally or unconsciously, but that’s where our power lies, right?

We can’t control the world—as I’ve talked about in a previous podcast, we can’t control what happens, yet, we can control how we decide to respond to it, how we want to think about it, how we want to either make it worse or make it better, by the way we think and respond to it. That’s the beauty of this work.

That’s where our power lies. We don’t have to control the world, we can’t. But what we can do is decide, can we allow ourselves to experience the challenging things, the pain of being alive sometimes. And can we minimize the unnecessary suffering, the dirty pain… or thoughts about a situation or event that basically cause us to spin out, make it more unpleasant, more dramatic, basically worse.

That is what I have for you this week. I hope this is something that if it’s new to you, it’s been helpful. Again, as with anything I talk about on the podcast, just check in with yourself, test it out, put it to the test in the real world, in the wild and see if this is a concept that’s helpful for you.

So again, when you’re feeling some intense emotion or just any emotion you can just notice, am I reacting right to just the events in the world? Or am I reacting to the second arrow? Am I creating unnecessary suffering? What is the part of this unpleasantness that I can drop and not add to? And how do I want to approach the events of my life? All right, can’t wait to talk to you next week. Again, feel free to reach out to me anytime with questions or comments. Sara, S-A-R-A, Talk to you later, bye.

If you are a busy practicing physician ready to start feeling less stressed, enjoy work more, and learn how to create a more balanced and sustainable medical practice and life, sign up for a consult call with me at That’s It would be my privilege and pleasure to work with you.