02 Mar how healing works
This is a post about ritual, health, belief, and systems in general. Often, those outside a system have the kind of perspective that allows them to spot the flaws or anomalies within a system, while those who exist within it are often “willfully blind” to these problems. The case of Enron is a good example. To anyone who looked under the hood, the business practices at the firm were illegal and unethical. However, in order to continue working there, everyone had to look the other way. In some sense, they became blind to the problem because seeing it meant they had to challenge it; and if they challenged it, they would no longer be able to be a part of it – and the money was flowing with great strength. Many of those people felt powerless to challenge it without risking their place within the system. On the one hand, it is those who have power within a system that have the greatest ability to address the flaws because those who exist outside of it have no voice. On the other, even those with power and respect within a system often find that they get pushed to the edges, and find themselves discredited and banished if they challenge the fundamental beliefs or practices of that system.
In large part, the subtext of our film “All The Rage” is about how these factors play out in regards to health care, especially back pain, and more specifically how one doctor who gently challenged the overriding paradigm of back pain treatment was in turn pushed to the edges of the practice. In the late 1960’s he recognized the flaws of taking a fully bio-technical approach to the problem rather than a whole systems approach – one that also took into account what was going on in people’s lives, one that recognized how stress affects the body. Despite the fact that he had robust success in treating patients from a mind body perspective, he was dismissed and ignored by his colleagues for his entire career. While his work had very little impact on practice, he saw dramatic results with his patients and published popular books that reached millions. The central tenet of his doctrine was that the vast majority of pain syndromes in America were being caused by the repression of emotions, and his prescription was that simply coming to understand this – and how it played out – was the strongest healing tool he had to give. He postulated that many of these patterns of repressive behavior were formed in childhood, and that this repression of emotions was playing out as pain in adulthood. Forty years later, others are starting to come to understand the profound power of his understanding.
UPDATE: The Lancet just released a series of reports on back pain that repudiate almost all standard care and re-focuses the attention on psychological factors- this is revolutionary and is being covered as such by the main stream press.
CHAPTER 1 – FAMILY
Over the past month, I have been thinking a lot about ideas related to community and ritual, not only in the spiritual sense, but also in terms of the everyday rituals of our life. The ways in which we experience ritual early in life – both in our families as well as in our communities – shape the rest of our days. Some of these rituals are performed with a sense of intention, like rocking our children to sleep each night on a schedule in order to give them a sense of order. Others are less conscious, like habitually expressing frustration when our babies cry, or shaming them for bad behavior. The more we participate in these rituals, the more they become intertwined with our sense of ourselves. While some of our rituals are formed through family interaction, others are experienced through larger social forces like school, religious instruction, media, and everyday public interactions. We tend to associate ritual with religious or spiritual concerns, but just as many manifest themselves in the rhythms and patterns of our daily life and routine. They are interrelated with the complex concentric layers of community: starting with our family, our neighborhood, our city, our state, and our country etc. Further, our sense of our own relationship to these different layers affects our sense of ourselves, and this in turn affects our emotional relationship to the world. It’s a complex stew of interactions and ideas, and we use rituals, both conscious and unconscious, to bring a sense of order to these influences.
These concepts, about how we relate to the world around us, were pinging around my dome last week when I spent some time with my 1 ½ year old nephew. My brother and his wife have been very conscious of setting up a series of loving rituals with their two young boys. While his wife and mother-in-law do a lot of the daily care taking, each morning and evening my brother gives the boys a massage, while also giving them his full attention. It has a somewhat magical effect on them. Even if they are in a fussy mood when the ritual starts, they almost immediately calm down and start smiling back at him. On my second day there, I woke up early because I heard my nephew crying. Remembering how exhausting it had been to get up that early with my own children, I decided to give my brother a break and went out to take over. After he went back to bed, I focused on being radically present with my nephew – meaning I treated it as a kind of meditation. When other thoughts began to intrude, I brought my attention back to my nephew as one might do with their breath during mediation. One reason I wanted to spend that time with my nephew was that I didn’t have the means to be present with my two daughters in the same way when they were young. After meditating on and off for a few years, I came to understand the difference between simply being with a young child and being fully present with one. Since babies can’t communicate with words or gestures, nor understand them, they are much more tuned in to our energy than we might realize. If we are ruminating about work, or responding to a cascade of emails, we have to assume that they recognize the difference unconsciously. They also pick up on the internal tension we feel and respond to it. I wish I had fully understood this when I had my own babies, but you live and you learn. The time spent with my nephew gave me some insight into the power of direct attention.
A few days later, this experience with my nephew helped me to be more aware of how my wife has a tendency to respond with a pattern of resistance to some of our older daughter’s aggressive behaviors and complaints, especially in relation to interactions with her sister. My wife and I talked about how that unconscious response might exacerbate our daughter’s aggression rather than help dissolve it. This discussion didn’t come out of the blue, as we have both been working on being more conscious of the frames of expectation that shape our behaviors. To be clear, I’m far from perfect in this regard and my examinations of my own role helped me to have some insight because I have tried to adjust some of my response and found the results to be positive. My wife did some deep thinking about her reasons for responding in that way. That process led her to confront some difficult feelings she had been avoiding, and also to have some revelations that helped her process those feelings. The next day she was conscious of not responding in that same judgmental way, and she also apologized to our daughter for how she had responded in the past – and promised to listen more in the future. One of our daughter’s main frustrations was that she felt un-listened to, so this response was deeply meaningful to her. Some of her aggression was simply exasperation at seeing enraging patterns play out the way they typically did. This very simple energetic shift paid dividends right away. For the first time in months, our daughter sat in the living room and did homework next to my wife rather than in her room. My wife’s conscious effort to disrupt the negative pattern of response almost immediately had a powerfully positive impact not only on their relationship but on each of them individually. It had a healing effect that involved both the ritual of apology and increasing a sense of family/community connection that left both of them feeling less isolated.
CHAPTER 2 – THE BOOK
Speaking of ritual and community, while I was visiting my brother, he gave me Dr. Wayne Jonas’ book “how healing works” (the title is in lower case on the cover of the book- and I think this is very significant because right from the start it subtly challenges accepted norms- which is dangerous on one level because it might undermine the credibility- but useful in setting a tone of challenging expectations). The underlying premise of the book is that both ritual and community are central to creating an environment of healing. Jonas details how his thorough investigation of evidence-based medicine revealed to him that the vast majority of healing comes from within. In fact, he argues that only 20 percent of healing comes via medical interventions, or the “treatment agent” that the doctor applies to you. Through forty years of seeing patients, working as a trained scientist and through the exploration of many medical systems he found that, “A full 80% of healing comes from constructing a meaningful treatment response, unique to you, which is internal and highly personal, using simple principles and components.” While this may seem like a Molotov cocktail thrown by an anti-science radical, Jonas’ pedigree, and the cover quotes from esteemed colleagues like Dr. Dean Ornish, and former chairman of the Joint Chiefs of Staff, Michael Mullen, should put that skepticism to rest.
For me, it was both a frustrating and exciting read as it confirmed much of what we have been trying to communicate with “All The Rage”, our film about Dr. John Sarno and his mind body approach to medicine. This confirmation was frustrating because the film has been met with a great deal of resistance, and exciting, because Jonas’ book – along with a veritable flood of other books and articles – points to a tipping point in awareness of the need for a more complex, whole-system approach to medicine. In addition to “how healing works”, Johann Harri’s “Lost Connections”, Hilary Jacobs Hendel’s “It’s Not Always Depression”, Andrew Sullivan’s recent scathing look at the opiod epidemic in New York Magazine, and countless other articles about the gun and opioid problems, exhibit profound awareness of how out-of-balance our lives and cultures have become.
All of the discussions point to themes that are also central in Jonas’s book: modern life and technology – in their drive towards clarity and the “scientific thinking” that this involves – have minimized the import of ritual, community, and complexity, leaving many of us lost and cut off from ourselves. The greatest take-away from the book for me is that when one looks at the breadth of the science regarding health, rather than single specific studies, it paints a very clear picture of the importance of ritual, community, and faith in healing. These three factors are heavily woven into Dr. Sarno’s work and our film, and Jonas’ book helped me better articulate even for myself how All the Rage is designed to help people access their emotions in a somewhat ritualized manner.
CHAPTER 3 – DR. JOHN SARNO
Dr Sarno began practicing medicine in the early 1950’s. After a decade of working in a group practice that he helped found, he began to treat back pain at the Rusk Institute at NYU in the early 1960’s. At first, he followed standard care protocols he’d been taught (bed rest, traction, physical therapy, etc.) but found that none of the treatment tools he had been given were very effective. After looking at his patients’ medical charts, he found more than 80% of them had a history of other illnesses that were thought to have a mind body connection (i.e. they were referred to as psychosomatic). He wondered if back pain might be related. After some study and a lot of interactions with patients, he came to understand that many of them were “people-pleasers” who put other people’s needs before their own. He postulated that early in life, they had learned they needed to silence their own needs in order to stay “safe” or secure. When he explained how this unconscious repression of emotions and needs might be causing their pain, many of them recognized the connection and rapidly improved.
Dr. Sarno continued to carefully observe and examine factors that affected his patients’ ability to heal from their various pain syndromes. One of the first things he realized was that if people “bought” the idea that the repression of emotions could be causing their pain, they were much more likely to improve. Those who had a hard time believing that their emotions could have such a powerful effect tended to improve more slowly, or not at all. Eventually he began to screen patients in advance because he found that those who refused to believe that their pain was caused by their emotions were wasting their time when they came to see him. For many people, including other doctors, this created the impression that he was a charlatan who didn’t want to deal with questions about his methodology. However, as he argued, if you were to visit a physical therapist, but refused to do any of the exercises, you would be wasting your time as well. Once he came to see that belief in the idea that the mind might be causing the pain rather than a physical issue, it made no sense to see people who wouldn’t do the emotional introspection necessary to confront the problem.
CHAPTER 4 – RITUALS HEAL
Though he didn’t discuss it directly in his books, I believe that Dr. Sarno also saw the importance of ritual in how strongly-learned patterns of thinking and behavior impacted his patients’ health. What he came to see was that a large number of his patients were perfectionists and people-pleasers, and that these were learned behaviors and ways of being. Further, he saw that the pattern of being a “goodist”, wherein they deferred their own needs to those of others, was often unconsciously enraging. He recognized that one part of their brain was mad as hell and another part was terrified that this rage might rise up and be felt by the conscious brain, and this internal conflict was driving the process that caused the pain. In Dr. Sarno’s framing, the pain serves to create a diversion or distraction from these “unthinkable thoughts”. In order to get around the unconscious resistance to these thoughts, he developed a healing program in which he first ruled out a physical explanation for his patients’ pain, and then educated them about how the mind body interaction could cause such severe pain. He further illuminated how patterns of learned behavior might lead the mind to create protection from these terrifying emotions. In order to connect with the unconscious, he prescribed daily journal writing, and he counseled his patients to talk to their brains in a somewhat ritualized manner – pronouncing that they didn’t need protection from these thoughts and emotions anymore. He understood that they had to create new rituals to overcome the old ones that kept them in the patterns of negative thinking and self-judgment that caused their pain. While his colleagues saw this as unscientific woo, Dr Jonas’ book confirms both the power of Dr Sarno’s methods and the powerful flaws that a purely bio-technical approach to healing entails. The final paragraph of the chapter entitled “How Science Misses Healing” reads,
“Finally, the negative effects of those treatments for the whole person – with all of his or her complex reactions – are frequent, varied, and often poorly recognized. Layer upon layer of uncertainty begin to pile on top of what I had based my whole medical career on, what I had taught to students, what I had used to treat patients. If only a small portion of healing was from the treatments I dished out, and if most patients were getting side effects from those treatments, then was I throwing out most of the healing – and perhaps producing harm – by always looking for the small and particular effects? To make matters worse this type of science is also being reinforced with money – lots of money – from companies seeking to get their products approved even when they might be doing more harm than good. Drugs get FDA approved when they show their benefits go beyond placebo, even by a small amount. This requires very large and expensive studies. Proof now has to be purchased. A “real “treatment must separate itself from the daily process of healing.”
In the next chapter Jonas goes on to explain how these questions led him to embrace a whole-systems science that looks at a web of connections rather than the kind of specific, targeted effect that the use of drug therapies, surgeries, and many other treatments entail. In essence this kind of targeted therapy focuses on symptoms in a way that doesn’t fully explore the complex systems that led to the symptom in the first place. Rather than focus on symptoms a whole-person perspective takes in to account what’s going on in all aspects of a person’s life, not just their physical ailments.
“If we deal with only one aspect of a person – say, the body or the mind parts – we get only partial results, and we produce reverberations (often unwanted) throughout the rest of the person. To fully heal and be well, we need to enhance connections across all four dimensions of the human body, behavior, social, and spiritual. Healing works by making those connections stronger and inducing us to become more whole and responsive in the world.”
CHAPTER 5 – COMMUNITY HEALS
In regards to community, Dr Sarno had his patients come to a weekly lecture so that they could not only get the knowledge they needed, but also get it within a ritualized experience in a group setting. Further, he held monthly panel discussions with patients who had been successfully cured, and he also held small group meetings so that patients could share their experiences. He counseled his patients to be aware that they might face a lot of resistance to these ideas from their community and their families, and that it was important that they be aware of how much this might increase their own resistance to the ideas. He invited family members to the lectures so that they would also understand what was going on. Awareness of the importance of family and community support was central to Dr. Sarno’s practice because he was also aware that it was the pressures that family and community put on his patients – both intentionally and unconsciously – that often were a major driver of the problems to begin with. Dr. Sarno passed away in the summer of 2017, but his methods are not only being carried on by other doctors, but also through online communities in which those who have had success in healing help others work through their own process.
CHAPTER 6 – OUR SENSE OF SELF
We all process information in our own ways. While some of us can’t believe anything unless we see the data to prove it, others are more interested in stories than data, and respond to information based on gut feelings and emotion. One of the strongest aspects of Dr. Jonas’s book is that it relies on available data to construct an expansive and holistic model of complex systems. While he understands the import of randomized control trials, he also has decades of experience using large bodies of data compiled from dozens of trials, to ferret out previously unrecognized patterns and ideas. It is through this work that he has come to see that so much of our healing comes from within.
What Jonas points out is that the rituals that shape our lives are central to our ability to heal, and he uses many individual stories as examples of how this plays out in the world. One story involves an 85-year-old matriarch who ends up in the hospital with a failing heart. For her whole life, she has played the role of caretaker of the members of this extended family, and now they are eager to return the favor. They dote on her in the hospital, but she only gets sicker. As attending physician, Jonas recognized that this love and support ran counter to her sense of self, and that might be part of the problem. He gathers the family and asks them to go in one at a time and ask her for advice and help. Over the course of the day, she becomes more energized and by the following day she becomes well enough to go home. If our life is built around a ritual of taking care of others, having to accept care can devastate our sense of self.
Dr. Sarno was still practicing medicine when he was 88 years old. However, NYU decided to tear down the building that housed his office. Rather than try to re-locate, he decided to retire. His life was built around his work helping others, and within weeks of retiring, he fell ill and was in and out of the hospital with all sorts of illnesses the following year. I saw the same thing happen with my own father. Like Dr. Sarno, he was someone who wanted to take care of and counsel others, and did not want to be taken care of himself. Shortly after retiring, his body started to fail him, and he was told that he might have ALS or rheumatoid arthritis. Within just a couple of years of retiring, he was having a great deal of trouble walking and was hit by a car and killed at 72. A few years after he passed away, my mother told me that on the morning of his death, his doctor had told him that whatever he was doing – yoga, meditation, exercise, and supplements – wasn’t working. Even as I type those words I find it hard to believe that his doctor stole his hope from him in such a direct manner.
In “how healing works,” Dr Jonas recognizes the importance of understanding just how powerful the combination of belief and the ritual of going to a doctor is. If a doctor tells us they believe strongly in a treatment, it is much more likely that this treatment will work. While medicine tends to dismiss this as a “placebo” effect, Jonas came to see it as a healing effect related to ritual.
CHAPTER 7 – MY FAMILY
Like our daily rituals that help us establish some level of equilibrium in the world, it is through more formal community-oriented rituals (including going to the doctor), that we navigate transitions within ourselves and our communities. These more conscious rituals communicate with our unconscious brain, directing it to take action of some sort or another. The daily rituals of church, mosque, and synagogue connect us to our community, and to our faith in a power outside of ourselves. In these institutions, we also perform rituals of transition related to birth, death, and the various stages of life. When we participate in a bar mitzvah, or any other transition to adulthood ceremony, we are presenting ourselves to our community in order to formally change our position within that community. These ritual actions communicate to our unconscious that we are transitioning from one state to another, and this has a powerful effect on our orientation to ourselves and our communities. When we don’t participate in these activities, our life transitions are much less clear, and this can be problematic. When I went off to college, I grew and changed. When I came home for holidays, it was difficult for my father to acknowledge this change because he had not witnessed it, nor been a part of it. This created a level of dissonance that was difficult for us to reconcile.
My father was deeply skeptical and dismissive of organized religion. Only recently, as I approached my 50th year on Earth, did I start to make the connection between my father’s rejection of faith and the trauma his family had experienced. He was a psychologist who grew up poor. His parents were immigrants from Lithuania. While I met his mother a couple of times as a child, his father passed away before I was born. A few months ago, I looked up his parents on a genealogy site and found that they both arrived in the US in 1908. When I did a little more research, I found that they both emigrated near the end of a very difficult time for Jews in Lithuania. My father was born in 1934 in the throes of the Great Depression. When he was around 7 or 8, the Nazis invaded Lithuania in June of 1941. They and their collaborators killed 250,000 Jews, or around 94% of the Jewish population which was close to a third of the inhabitants. While I never had the opportunity to discuss this with my father, I have very little doubt that this trauma had a powerful impact on him and his family. It’s unsurprising that he would strongly reject his religious identity. In addition to growing up in a community of Jewish immigrants who knew that their relatives left behind were rounded up and killed, my father also grew up in relative poverty. While he prospered as a college professor, he had a deep fear of poverty and was reticent to spend money. On some level having money meant having security.
I ended up as a religious studies major in college because I was drawn toward a variety of philosophy, anthropology, and comparative religion classes and accidentally fulfilled the major before I even declared one. In many ways, the study of religion is the study of storytelling. One of the books I read early in my college career was Joseph Campbell’s The Power of Myth which discusses the various myths that shape our cultures and how those myths also shape our stories about ourselves. It is through story that we learn about cultural rituals and rites of passage.
My father was a skilled writer and storyteller, and we bonded over a love of movies. Unfortunately, we clashed over my desire to be an artist and a filmmaker. While my parents instilled a sense of the value of art, my father’s fear of poverty led him to seek safety over passion. After I graduated from college and took on several low-wage jobs in order to focus on music and photography, he shamed me repeatedly for not living up to his expectations. I tried to reason with him, but he was unreasonable. Over time, I came to see that the lack of ritual in our lives was problematic and I suggested to him that we work on a book together called “Transitions”. The underlying idea was that we might look to how ritual functions in order to help parents and adult children transition to a more peer based relationship, one based on mutual respect. We worked on some notes for the book and it brought us a bit closer, but I don’t believe that we had fully completed that transition when he passed away. At his funeral a former student of his handed me his copies of our notes. She had been tasked with typing up notes. Going through those thoughts connected me to him. His memorial was cathartic and I was glad to have the opportunity to think about him, and our connection.
In the middle of the 20th century, the Western World – with its increasing focus on a scientific approach to solving the world’s problems – turned away from the world’s wisdom traditions. My father’s deep skepticism led me to be wary of this esoteric knowledge, and like many others I felt compelled to dismiss it as unscientific “woo”. However, over time, I became drawn towards ideas related to the spiritual even as I remained quite skeptical of religious dogma. Through my work on All The Rage I came to see just how powerful our ideas about ourselves actually are, and these ideas are expressed with great elegance in “how healing works”. It does not appear that Dr. Jonas was aware of Dr. Sarno’s work, but their work is certainly connected.
CHAPTER 8- TAKE AWAYS and All THE RAGE-
One of the reasons that Jonas’ book is so resonant for me is that it tied together many threads I have been toying with- threads that I tried to tie together in some small way with this post. Often, we construct our stories without fully being able to articulate the choices we make. An editor might ask, “Why is that particular detail important? It seems extraneous.” Much of the time the writer doesn’t know “why” it has to be there, but just knows that it does – because it connects to the story in a way that they do not fully understand. That’s art, and it leaves space for the individual to fill in the gaps.
We spent well over a year editing All The Rage, and while we wanted it to inform people about ideas, we also wanted it to be “art” in the sense that it left a lot of room for people to bring their own story to it. Traveling with it for the past year, and observing how profoundly it affected people who saw it in the theater, it’s clear that this kind of metaphorical storytelling allowed people to project their own stories onto the film. Reading Jonas’ book, I was able to articulate that what we wanted to do, and why I fought so hard to get it on screen as opposed to piped into living rooms, was create a tool for viewing as transformative ritual. This was not what we had in mind when we started, but what we discovered as we worked.
As we edited, we struggled with the knowledge of what others’ expected from the film, and what we ourselves wanted to communicate. We were aware of the fact that skeptics of the mind body approach would want data to prove that Dr. Sarno’s methodology was grounded in the science of randomized control trials. When we wove this information into the film, we found that it only made skeptics more skeptical because it raised questions about the data that wasn’t included. So we added more data and that just made them more skeptical and it also made the film boring. Also, we understood that fans of Dr Sarno wanted a film that would honor him in a powerful, almost propagandistic way. While we have incredible respect for him, we knew that this would only limit the audience because those who were not already open to the ideas would reject it out of hand. It was a very thin tightrope we had to traverse.
After the first half dozen rough cut screenings, we decided to strip out a great deal of the information and re-focus on story. As we did more screenings, a lot of the feedback pointed towards adding in more of my own personal journey to heal, as that gave the narrative a forward force people could connect to. We tried to balance that with telling the story of Dr Sarno and his work. One thing we figured out through the countless screenings was that my story needed to be personal enough to draw people in, but not so personal that it became MY story. Based on early theatrical screenings, it seemed like we found a good balance. At our first public screenings, several of the comments were aimed at how “brave” it was of me to put myself in the film. I found the sentiment odd, especially as the film doesn’t get all that personal. However, when the reviews came out, I came to see how that was problematic. Most of the mainstream reviews shamed me directly for being in the film. However, the response at screenings was very different. Packed into dark rooms, engaging in the ritual of the group-viewing experience seemed to deepen the emotional impact of the film, and the Q&A sessions were filled with people wanting to talk about how the film helped them see things about themselves they had not previously seen. Dozens of people have had life-changing experiences while watching the film in a theater.
Reading Jonas’ book helped me to see that with knowledge of the importance of ritual, we can make a film screening an even more powerful experience. Before the next screening we have in Dallas, I plan to explain to the audience that while I am the in the film, it’s really a more universal story about the human condition. Our intent was to make a film that each of them might see themselves in. It is my hope that this might help them to make the journey their own.