01 Jul Garbage In Garbage Out.
“It is difficult to get a man to understand something, when his salary depends on his not understanding it.”- Upton Sinclair
This quote is often bandied about when people who believe Dr John Sarno’s story, that most back pain is caused by repressed emotions, want to make the point that he saw something that threatened his salary, bucked the trend, and decided to look more carefully at what was going on. I think we can agree that if one’s tool is a scalpel, they will tend to see things through the lens of their toolbox.
It’s also ttrue that it’s difficult to get any person to understand something if they are afraid to see it. In general, in western cultures we have some fear of being present with our emotions. For example, you won’t hesitate to call in sick if your back is “out”. However, you’re unlikely to call in sick because you are feeling particularly sad or angry. The reason you don’t do this is you know that you’ll be seen as “unprofessional” for letting your emotions get the better of you. In fact, you likely wouldn’t even consider the possibility of calling in sick due to being overwhelmed by your emotional pain.
Due to this cultural aversion to emotions, we tend to talk about them in whispers, only with close friends, or not at all. In fact, the subject is so fraught that in general, just like the person whose tendency to not see that which might affect their bottom line, we’ve all become so afraid of our emotions that we barely understand how much they affect us. Unfortunately, just because we don’t see them, or discuss them, they haven’t ceased to exist. Just like the termites that we don’t see, these unseen emotional have have been doing profound damage to our health, and our health care system. I believe the best way to address the problem is to shine a light on it.
In 2004 we started to make a film about Dr Sarno, “All The Rage”. We spent a few years trying to get it off the ground, but we found such profound resistance to the idea that our emotional life, much of it unconscious, could affect our physical health, that we couldn’t find any funding. We also struggled to articulate what the film would be because it was so difficult to talk about these ideas in ways that people could listen to. When we decided to start it back up in 2011, and I began to do some research, one of the first things I found was an article called “Why Science is Failing Us” by Jonah Lehrer. I was dumbfounded by how directly his article articulated exactly what we were trying to say. A decade later I re-read it and was even more impressed by how well Lehrer had explained everything we were trying to get at in the move. That is, everything except the profound import of our emotional experience. The article hints at why emotional factors rarely included in randomized control studies. However, it doesn’t fully illuminate just how much impact that has on the value of of that work.
Chronic back pain also remains a mystery. While doctors have long assumed that there’s a valid correlation between pain and physical artifacts—a herniated disc, a sheared muscle, a pinched nerve—there’s a growing body of evidence suggesting the role of seemingly unrelated factors. For instance, a recent study published in the journal Spine concluded that minor physical trauma had virtually no relationship with disabling pain. Instead, the researchers found that a small subset of “nonspinal factors,” such as depression and smoking, were most closely associated with episodes of serious pain. We keep trying to fix the back, but perhaps the back isn’t what needs fixing. Perhaps we’re searching for causes in the wrong place.
In this passage Lehrer points out that depression and smoking were more closely associated with episodes of pain than anything found on a scan, but the writing doesn’t go deeper into the emotional factors a play. Later we interviewed Lehrer for our film and talked a great deal about what we can glean from paying more attention to people’s stories, especially the ones they tell about themselves and their relationships. Shortly after we filmed with him, he was beset by scandal when one of his books was shown to have some problematic reporting. A lot of what we discussed this day was just how much we search for causal connections in order to make sense of the world. In this case he got pulled into that same conundrum. His fall from grace was swift and brutal. Still, I am deeply thankful for what I learned from his writing and insights. Part of Lehrer’s strength as a writer and storyteller is how he can see patterns and connections within, and between, different systems. When we look for these patterns we can make sense of data in ways that the people who compiled it might not have seen. We might tell a different story from the same data, if we are looking at it through a different lens. This is largely what his article is about.
When people first started writing code for computers the term “garbage in, garbage out” got used a lot. The idea was, if your code is garbage, then your program will be garbage. The same idea is equally true for science and medicine (and just about anything else really). The data one gets from an experiment will only be as good as the framing for how the data drawn from the experiment is constructed. In other words, we only see what we look for. Jonah Lehrer took this perspective and found a lot of issues with how science was being practiced. While the article didn’t mention Dr Sarno, it did focus on a study that proved Dr Sarno’s theory that what was being seen on MRI’s in regard to back pain was causally connected to their pain. He understood this because the findings he saw rarely correlated exactly with the site of people’s pain, and even if it did, they often had pain in several other places, which indicated that the finding wasn’t accurate. He starts out by writing about how in the mid part of the 20th century there was in increase of back pain. The treatment was to send people home for bed rest, and the vast majority got better within 6 weeks. They didn’t know why it worked, but it did.
Over the next few decades, this hands-off approach to back pain remained the standard medical treatment. That all changed, however, with the introduction of magnetic resonance imaging in the late 1970s. These diagnostic machines use powerful magnets to generate stunningly detailed images of the body’s interior. Within a few years, the MRI machine became a crucial diagnostic tool.
The view afforded by MRI led to a new causal story: Back pain was the result of abnormalities in the spinal discs, those supple buffers between the vertebrae. The MRIs certainly supplied bleak evidence: Back pain was strongly correlated with seriously degenerated discs, which were in turn thought to cause inflammation of the local nerves. Consequently, doctors began administering epidurals to quiet the pain, and if it persisted they would surgically remove the damaged disc tissue.
But the vivid images were misleading. It turns out that disc abnormalities are typically not the cause of chronic back pain. The presence of such abnormalities is just as likely to be correlated with the absence of back problems, as a 1994 study published in The New England Journal of Medicine showed. The researchers imaged the spinal regions of 98 people with no back pain. The results were shocking: Two-thirds of normal patients exhibited “serious problems” like bulging or protruding tissue. In 38 percent of these patients, the MRI revealed multiple damaged discs. Nevertheless, none of these people were in pain. The study concluded that, in most cases, “the discovery of a bulge or protrusion on an MRI scan in a patient with low back pain may frequently be coincidental.”
Since this article came out there have been a veritable flood of studies that repeat this finding. Medical societies recommend that no scans be done for non specific back pain. Those recommendations are largely ignored. There is also no data that steroid shots are better than a placebo, and they can cause damage over time. They are used more frequently than ever before and their cost has increased exponentially. People are being told a causal story, one that they want to believe, but that isn’t supported by the science. I am not a doubter of science. I am a doubter of science that isn’t willing to challenge its own causal story when the data does not support it.
In another post this week I wrote extensively about the definition of pain. This definition of pain, which was established in 2017 by a taxonomy task force of the International Association for the Study of Pain reads, “Pain is an unpleasant sensory and emotional experience that is associated with actual or potential tissue damage or described in such terms.” If it is read carefully it is clear that pain is both a physical and emotional experience, and it is not only associated with tissue damage, but the potential for – or fear of – tissue damage. If you treat pain by exclusively focusing on the physical body, then you are only looking at half of the equation. It’s hard to figure out how one finds an answer if the emotions are ignored. This is why Lehrer’s article struck me with such force. He had the insight to point out that so much science is based on “garbage in”, a causal story that is only looking at a small subset of the data. It’s no wonder that we have an epidemic of pain if both doctors and patients are unwilling, or unable, to examine the role of emotions. There’s no way to develop a treatment method that includes emotional awareness if the causal story doesn’t include it, even when the definition of pain does.
Not all doctors, and not all patients, fail to see the connection. However, it’s a lot less likely that in any given combination, both of them will be on the same page about the import of emotions. Dr Sarno understood the import of this awareness to such a degree that he began to screen patients as to whether or not they were open to they idea that their emotions might be involved in their pain. If they said they were not open to it, he suggested they see someone else. Some people took issue with this, but he pointed out if you went to a physical therapist but refused to do the exercises you were given you’d be wasting everyone’s time.
In the past decade the term “trauma informed” care has started to be heard more frequently. Scientists are finding ways to develop data about the impact of trauma on people’s health. Awareness is growing but the resistance is still quite strong, so it’s going to take some time for it to have a major impact on practice.
I saw a tweet the other day from a woman of about my age who said something along the lines of, “I’m from the generation that came after the one that did not recognize any kind of trauma and before the generation in which everything is seen as traumatizing. That’s a confusing place to be. The tweet indicates that the profound imbalance between those two poles is beginning to get addressed. It also clarifies just how profoundly cultural norms and expectations affect our sense of ourselves and our place in the world. When we draw a dialectical pattern it looks like a wave, but it probably should be represented a bit more like a series of tsunamis.
In some sense this shift probably has something to do with the fact that my generation (gen X) was brought up in an era in which our parents were beginning to try to deal more directly with the emotional needs of their children. However, many of them were not fully aware of just how profoundly they had been affected by not having their needs met, and subsequently they were less adept at figuring out how to meet their own children’s needs than they expected themselves to be.
My father was a psychologist and my mom was a social worker, so they were acutely aware of some of these issues, made efforts to be thoughtful and loving parents, and often failed miserably. One of my first memories is of my father angrily ripping my sheets off the bed in the middle of the night after I had wet the bed once again. I imagine that this shaming helped me to stop wetting the bed, but judging by how it makes me feel to sit with that memory right now, it also had some impact on me.. Yet, when I was dealing with the same situation as a parent, I’m sure I communicated equal amounts of frustration despite my best efforts. Parenting is about the hardest job in the world, and we have very little training on how to do it, except from our own experience. So, it’s not surprising that we unintentionally help our children to experience small traumas that have big impacts on their way of being in the world. Often times people will say they had a perfect childhood. As Dr Gabor Mate points out, this indicates that they most certainly did not. It indicates that they have repressed the less pleasant aspects, which means they’ve learned to do so in order to avoid conflict, or to follow rules in order to get resources.
The good news is, one doesn’t necessarily need to spend a decade in intensive therapy to benefit from the simple awareness that our emotions affect our health. Instead, one needs to start paying a little more attention to how their physical body responds to emotional inputs. When we begin to see how that unfolds we have some agency to begin to address it. Ill leave you with Dr Sarno’s 12 daily reminders. You can also read one of his books, or watch our film. The truth just might set you free.