A New Prescription

What Role Can Therapists Play in Addressing Chronic Pain?

Howard Schubiner • 11/17/2018 • 3 Comments

Sixteen years ago, tired of the academic rat race of striving for yet another grant and another publication, I left the only job I’d ever had as a physician. I went from being a well-established teacher, clinician, and researcher at Wayne State University to practicing medicine at a community hospital, where I thought I’d just coast along, helping people feel better, until my retirement. But the shift turned out to be less gratifying than I’d anticipated. I found that my frustrations with academia were soon replaced with the irritations of dealing with the modern medical bureaucracy—issues with documentation, billing, electronic medical records, practicing defensive medicine to try to avoid lawsuits, and pressure to see more patients in less time.

Most frustrating, however, was that as an internal medicine specialist, many of the patients I saw regularly suffered from chronic pain conditions that seemed impervious to medical treatments. And it wasn’t just happening in my small office: the number of people with chronic pain was exploding across the country. Often prescribing opioids was the only way to help. We were at the beginning of the opioid abuse epidemic. Clashes with patients about their dosages became increasing frequent, and I wondered at times if I was one of the many doctors being scammed and contributing to widespread addiction. Physicians, insurers, and the patients themselves were all at a loss. Although I had no particular desire to delve into the specific issue of chronic pain, which I figured must be one of the most unsatisfying areas of medicine, I just couldn’t avoid it.

Then a year into my new position, a colleague suggested that I read The Mindbody Prescription by John Sarno, explaining that a close friend of his had made a remarkable recovery from chronic back and leg pain after reading it. Knowing that I’d started to practice and teach mindfulness meditation a few years earlier, he thought I’d enjoy the book’s exploration of the role our minds play in the production of pain.

As a rehabilitation physician at New York University, Sarno saw hundreds of patients with back pain every year. He noticed that the degree of pain and the likelihood of recovery appeared to be unrelated to the degree of abnormalities demonstrated on X-rays, CT scans, and MRI exams. In other words, many people whose imaging studies appeared normal had severe and chronic pain, while others with significant abnormalities had little pain and recovered quickly. In fact, most people have “abnormal” X-rays and MRIs, even those with no pain at all. A study published in 2014 by Waleed Brinjikji from the Mayo Clinic showed that 50 percent of pain-free 30-year-olds have evidence of disc degeneration on MRIs, and 40 percent have evidence of a bulging disc. Those numbers are 80 and 60 percent, respectively, for pain-free 50-year-olds, and they rise from there. A study published in 2009 evaluated more than 1,100 people with acute back pain and followed them for one year after the pain started—only 1 percent of them were found to have a significant structural abnormality in their back.

These were eye-opening facts to me. Few people in the medical profession were looking at the disconnect between pain and structural abnormalities in the body. I was intrigued. Could it be that we were attributing the vast majority of back pain to disorders like scoliosis, degenerative and bulging discs, and poor posture when the pain had a different source?

Sarno dug deeper. Interested in exploring the role of emotions in causing physical symptoms, he offered a relatively simple approach: recognize that most people with chronic pain have a psychosomatic disorder, change their mindset about the pain, and deal with the emotions that caused the problem. His goal was to cure pain, rather than just manage it. The results were startling. The recognition that back pain could be caused purely by stress and unrecognized emotions—meaning there was nothing wrong with the back itself—led to remarkable recoveries for many of his patients. Some of them didn’t even need to deal with the stressful situation or process their underlying emotions, as they naturally started to adjust their thinking and see the pain as irrelevant.

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My father always told me that if something seems too good to be true, it probably is. But I was captivated enough by Sarno’s work with his patients that I wanted to see if I could replicate his results in my own medical practice. So when I returned to Detroit, I asked my boss if I could set up a pilot program for a few patients with chronic pain and other symptoms that hadn’t responded to medical treatments. I had no idea what I was getting into, but I had the presence of mind to do two things: read everything I could find on chronic pain, and listen carefully to the medical histories and life stories of people who were experiencing it.

Even though the field of neuroscience was exploding with findings that definitively linked the brain and the body, most physicians and therapists remained separated into silos: we treat the bodies, you treat the minds. But as I read articles and books by Joseph LeDoux, Timothy Wilson, Daniel Wegner, Antonio Damasio, Edward Shorter, and others, the line between medicine and psychotherapy began to blur for me.

It turns out that our brains generate all our internal experiences, based on feedback from our bodies and a process termed “predictive coding.” Our brains predict what we should experience on a moment-by-moment basis. When I had low-back pain several years ago, I felt it every time I bent over. After I figured out that the problem wasn’t due to a structural abnormality in my back, and that my brain was creating this pain as a conditioned response, I consciously changed how I thought about it. I started bending over very deliberately without worrying about the pain, reminding myself that nothing was wrong with my back.

This simple process worked to reprogram the predictions my brain was making, so that I eventually stopped having back pain when bending over. Therapists might recognize this as the well-known process of graded exposure and desensitization, which has been used for decades to treat phobias. But most doctors would be shocked to find how useful it can be for chronic pain when the cause isn’t a structural disorder in the body but a neural circuit that’s been learned.

A New Prescription

One of my first patients was Mary, a woman in her 50s, who’d had facial and head pain for 17 years. Her pain was constant and debilitating. After seeing many pain specialists and trying more than 20 medications and several procedures, such as injections and surgery, to try to decompress her facial nerve, she’d given up any hope of recovery. Her only option, she’d been told, was to cope as best she could with a chronic and incurable condition.

When I asked about her upbringing, she told me that while her mother was mild mannered and caring, her father swung unpredictably from being calm and respectful to being demanding, highly critical, and abusive. She recalled him grabbing her by the collar once and yelling into her face, “Why can’t you do anything right?”

Still, Mary had no problems with chronic pain until the day she’d received glasses with a new prescription. Within seconds of putting them on, she got a sharp pain on the left side of her head and face, which persisted—for 17 years. Her adult life had been good. She’d been in a healthy marriage and had healthy children. The opticians and eye doctors tried many different glasses and prescriptions, all to no avail.

I asked whether some kind of stressful event had been going on in her life when she’d gotten the new glasses. After thinking about it, she remembered that it was around this time that she’d been assigned to a new boss: he was demanding, micromanaging, and he yelled at her almost every day. My eyes widened. It seemed that the new pair of glasses had nothing to do with her pain, except that the moment she’d put them on—in the midst of a stressful time that her subconscious linked to a frightening childhood with a highly critical, male, adult authority figure—is when her brain chose to activate the alarm signal, pain, which had become learned as a neural pathway and then conditioned.

None of her other doctors had seen the bigger picture of how her life circumstances might have led to brain-induced pain. But could this insight about the mind–body connection really make any difference? What could I offer Mary that she hadn’t already tried? After all, she’d already consulted with a pain psychologist, who’d used several therapeutic interventions to address the anxiety and depression caused by her pain, taught her mindfulness exercises to help her cope with it better, and offered advice to help her cognitively reframe it.

Click here to read the full version of this article...

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Howard Schubiner, MD, is an internist, researcher, and director of the Mind Body Medicine Program at Providence Hospital–Ascension Health. He’s a professor at the Michigan State University College of Human Medicine, the author of Unlearn Your Pain and Unlearn Your Anxiety and Depression, and coauthor with Allan Abbas of Hidden From View.

This blog is excerpted from "Chronic Pain Reconsidered," by Howard Schubiner. The full version is available in the September/October 2018 issue, Psychedelics: The Future of Talk Therapy?

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Topic: Mind/Body | Trauma

Tags: 2018 | biomedical model | body | body and mind | body psychotherapy | child trauma | childhood trauma | childhood traumas | chronic pain | emotional pain | Medical tests | memories | memory | mind body | Mind/Body | Pain | pain control | pain management | painful experiences | Trauma | traumas | treating trauma | unreleased trauma

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3 Comments

Sunday, November 25, 2018 1:28:15 PM | posted by Robin Bilazarian, LCSW
Great article. It is important in this serious time of the Opioid epidemic to find other ways to quiet pain. I practice, teach nationally , wrote a book (on Amazon --Tapping the Mighty MInd-Simple Solutions for Stress, Conflict, and Pain) and run occasional hospital based groups on non-medication pain management using the Emotional Freedom Techniques aka Tapping. It is self applied acupressure for the emotions and particularly, using this and metaphors (ex. leg pain feels like a steel rod shooting hot bullets), the pain diminishes quickly. Possibly the metaphor is hitting both sides of the brain and the amygdala.

Monday, November 26, 2018 4:47:37 PM | posted by Drew Bednar
I am a senior academic spine surgeon and this article reminded me of much that I might tend to forget and that I know my colleagues are almost never educated in, and it taught me a good bit besides. Thank you for presenting this excellent piece which would likely do well as reprint into one of the lead spine surgical journals.

Tuesday, December 4, 2018 10:29:44 PM | posted by Mark Harfenist
You write, "A study published in 2009 evaluated more than 1,100 people with acute back pain and followed them for one year after the pain started—only 1 percent of them were found to have a significant structural abnormality in their back." I cannot make sense of this statement. If half or more of pain-free people have structural abnormalities in their spines--as you also state--how can it be that only one percent of people with acute pain have the same abnormalities? Are virtually all spine abnormalities concentrated in people with no pain, while those who suffer have, overwhelmingly, nothing physical wrong? Perhaps a reference or two.....?