13 Mar The Simple Sarno Answers (from my perspective – not his)
This morning I got an email from a friend who recently read Dr. Sarno’s Book “Healing Back Pain”. He expressed appreciation for the book but he also had some relevant questions. I get asked questions like this a lot, so I thought I’d answer them in a post.
His first question was, “Dr. Sarno stated that if his method doesn’t help, it could be from being only 90% sure that it’s right- that holding onto even 10% dis-belief that it’s a physical problem. He tolerates no doubt? Devout Christians aren’t that religious.”
I think it’s important to point out that he is not taking the type of religious orthodoxy approach the question implies. When he speaks of “believing 100%” he is not referring to believing each individual idea presented in the book, or that he has discussed with his patients. Instead I think he is referring to the most basic idea at the core of his treatment method; that the primary cause of the vast majority of pain syndromes is emotional rather than physical. Once the patient has been examined by a qualified physician (especially one who understands the relationship between mind and body), and that a physical cause has been ruled out, he believes that it is essential to let go of the focus on the physical issue and the pain. As he sees it, the pain distracts people from uncomfortable thoughts or emotions. In order to break this pattern its important to retrain the brain to deal with directly with these feelings rather than repress them. Focusing on the physical pain keeps people stuck in the same pattern. For this reason he implores people to think emotionally rather than physically when they experience pain. He also urges them to resume physical activity as soon as they are able. This is not to say that the pain is not real pain, nor that people never injure themselves.
One of the important things to recognize when reading any book is the cultural context within which it was conceived and written. It’s also important to imagine the audience it was written for. At the time that Dr. Sarno wrote “Healing Back Pain” the culture, and the medical system, had developed a profound sense of faith in “modern medicine” and the power of science. The United States had recently put a man on the moon, and with the advent of vaccines and antibiotics doctors had many infectious diseases on the run . There was an increasingly powerful faith in the the power of science to eventually solve any problem. President Nixon declared war on cancer and there was an sense that it too would be defeated in short order.
At the same time, physicians like Dr. Sanro who were focused on rehabilitative medicine had begun to see an increasing number of patients with back and neck pain that they had great difficulty recovering from. The patient’s belief that their problems stemmed from a physical injury, even when they sometimes could not recall the injury taking place, was so ingrained that when these patients did not heal, they often became despondent. In fact with each doctor they visited, and new diagnosis they got, the more pain they felt, and the more helpless they felt. Often times by the time they reached Dr. Sarno’s office they had seen half a dozen or more specialists who had been unable to help them.
Dr. Sarno was deeply frustrated by his lack of success in helping patients heal. An avid fan of Sherlock Holmes, he began to look for clues that others might have missed. The first thing he did was look for literature that supported the standard care that he had been taught. He was hard pressed to find any convincing evidence for the effectiveness of treatment methods like bed rest, physical therapy, heating pads, ice, or electric stimulation. He also looked more closely at the diagnosis of disc herniation and found that it rarely was an accurate predictor of pain. For example, a patient might come in with a diagnosis of a herniation at the L4 vertebrae, which would indicate pain down the side of a patient’s leg. However, the patient might have pain in a variety of places that had nothing to do with the herniation. Further the patient would often explain that sometimes the pain would come and go, or would even move from place to place. These facts contradicted the diagnosis of a herniation as the cause of the pain. This was very clear when he examined me. I did have pain that lined up with the hernation that was shown on my MRI. However, I had pain in a lot of places that could not be explained by my scan.
He then looked at his patient’s charts and he found that 80% of them had two or more symptoms, or issues, that were thought to have a mind body connection. Health problems like colitis, eczema, migraines, uclers, and dizziness were accepted as being related to stress at the time. It was an “ah-ha” moment for him when he realized that there may be a connection between the mind and back pain. He began to talk to his patients and he quickly saw a pattern. For the most part the patients that came to his practice were perfectionists who pushed themselves to perform at a very high level. They often acted in a selfless manner that indicated that they had lost some consciousness of their own personal needs. They were people-pleasers who hated to let anyone down in any way. This often put them into conflict with the feelings of anger and rage that they were supressing. For example he had one patient who left work early to eat dinner with his mother and then hurried home to have dinner with his wife and child. He couldn’t bear to disappoint either of them, and in the process put on dozens of pounds. Despite his efforts to make both his wife and mother happy, they were both mad at him much of the time. He attributed the back pain to the weight gain but Dr. Sarno saw it from a different perspective. He postulated tat when we repress our needs and desires to such a degree that we lose awareness of those needs, the ego fights back. In Freudian terms, the id, or child like part of our inner consciousness rages against these self imposed restrictions. In an effort to make sure these unthinkable thoughts stay below the level of consciousness the brain activates the autonomic nervous system, causing the pain, in order to keep the attention away from these dangerous thoughts. When i originally read the book in the early 90’s I immediately related to the issues that he talked about. I was able to banish my own recurrent bouts of back pain for a decade.
Some people have trouble accepting the Freudian framing that Dr. Sarno uses. This is understandable as different people use different tools to understand the world. In the end though I don’t think it’s necessary to understand exactly how the process is happening or even exactly what emotions are being repressed. What’s important is to become aware of the process because when it goes on without our consciousness of it then we have no means, or understanding, by which to change it.
After treating patients for decades he came to see how important it was for his patients to “buy” the diagnosis. I filmed a scene in which a psychiatrist came to speak with him about incorporating Dr. Sarno’s methods into his own work. During the conversation it came out that this man’s mother was carried into Dr. Sarno’s office by his father as she had not walked in years. She walked out of his office. Subsequently Dr. Sarno’s name took on heroic overtones in his household. He went into medicine himself and in last week of residency he hurt his back while diving to help a very heavy patient that was falling off a gurney. He suffered with pain for months and his father urged him to call Dr. Sarno. He did, and talking to the doctor helped. However, he found it difficult to fully embrace the idea and he had trouble fully recovering. Eventually he father asked him to think about how profoundly Dr. Sarno’s work had helped his mother. When he was able to connect the pain to the stress of finishing school and entering into a new phase of life, he was finally able to overcome his pain.
As I was writing this response I got an email about a piece that Dr. Howard Schubiner just posted to his blog on Psychology Today’s site. It does a great job of illuminating how pervasive the mind body interaction is in relation to pain, and how readily we ignore it. The important thing is to pay attention to the message that it is sending us.
Dr. Sarno began to explain this perspective to his patients in general terms. While pointing out that the physical diagnosis that they’d been given didn’t sense medically he also gently explained the patterns of thought and behavior that he believed might be the more powerful causative factor in their pain syndrome. Some saw the connection right away and others resisted, some angrily. After a while this gave him another clue. He found that those who could see the connection most readily tended to improve most rapidly. Those who could not “buy it” did not get better. I was recently told by a former colleague of my father’s, that around this same time, another colleague of theirs in the psychology department at UNC ran a study that highlighted how powerful this sense of belief can be. Working with the state workman’s compensation board he randomly assigned 50 applicants to workman’s comp and 50 were denied. A year later those who had gotten the compensation were generally still in pain, and those who had been denied had mostly improved. This could indicate a number of things. One might interpret it to say that the one’s who got it were invested in being hurt. Or, one could say that the power of belief is powerful, and that those who were told that they were so injured that they needed compensation adapted to that belief. They saw themselves as someone with a bad back, and that belief was hard to overcome.
Now to get back to the initial question, I think that to say he doesn’t “tolerate” disbelief doesn’t accurately describe the situation. Instead, I would argue that through his experience, and his role, Dr. Sarno came to see that doubt had a corrosive effect on the ability of his patients to get over their issues. Since the cultural understanding of back pain stood in such powerful opposition to his suppositions he found that he needed to be equally as forceful with his ideas if they were going to overcome the built in resistance. He wrote the book to appeal to general audiences, as well as doctors who might be open to the idea. He bristled at the idea that his theories were “alternative” and insisted that he was basing his diagnosis on careful observation, while it was standard medicine of the time that was unscientific. I think it’s safe to say that science has borne out a good deal of what he suggested. Each week there are more studies coming out that connect neurological imaging to the emotional processing of pain, as well as the powerful effect that stress and the repression of emotions play in overall health.
Over the years he developed more complex theories as to how and why the pain syndromes manifested themselves as they did, as well as more detailed treatment methodologies. There are people who focus intently on the minute details of both what Dr. Sarno said, and whether or not their symptoms are improving. Both of these activities serve as a distraction from the very simple truth at the heart of his book; that the mind and body are intimately related, and when we separate the two, and only focus on the physical body we are missing the heart of the problem. Given the time that he was working within, where the medical system embraced Cartesian dualism and basically said “give us the body and the psychologists can deal with the mind”, Dr Sarno struggled with how to communicate the idea that the mind and body were not separate systems but instead part of a larger whole. In fact he later decided to use the term “mindbody” rather than “mind body” to make this more clear.
The next set of questions are a bit run together so I’ll just post them here and try to answer it one go.
“If there’s any doubt problem is physical, one should see a “regular doctor.” But wouldn’t they say it’s physical?”
“He says pain can start with injury, but where are his injured patients? I’d expect most people seeing a rehab doc had an injury. Where are his car crash patients, sports injured, wouldn’t his method be great for injured vets? People have pain after permanent injuries but years later go months without pain, couldn’t he help when they do get pain?”
In some sense the answer to all of these questions is yes. Dr. Sarno wrote his books because he knew that he could not treat everybody. At the same time he makes it clear that it’s best to make sure there’s nothing like a tumor, or a broken bone, that is causing the pain. However, if the doctors tell people that the pain is caused by a herniated disc, he’ll point out there is no strong science to support that claim. In fact there’s a lot of science that calls this diagnosis into question and the ACP suggests that MRI’s be avoided when people have back pain.
There is now a lot of neuroscience research coming out that illustrates how pain is processed in different parts of the brain. Injuries certainly can cause pain. However, the body heals itself, and when pain becomes chronic after an injury it is likely that the brain, and how we process pain, is involved. Of course, since much of the chronic pain epidemic has to do with a myriad of factors including, stress, anxiety, fear, emotional repression, class issues, etc the same principles of finding the connection between mind and body, rather than severing it, can be useful in all situations involving health care. Science is making this more clear every day.
One thing I want to be clear on here is that Dr. Sarno never said, nor implied, that the pain is “all in one’s head”. Instead he recognized that the brain is extremely powerful, and that the mindbody interaction has a great deal to do with how we experience symptoms in our bodies. Like his patients Dr. Sarno has dealt these issues all of his life. We all do, some of us just pay attention to it, and some of us ignore it. His most profound point is that is dangerous for doctors to ignore this connection.