Episode #22 Mind-Body Approaches to Understanding and Healing Chronic Pain with Howard Schubiner, MD
Living with chronic pain can be both physically and emotionally challenging. Nearly 50 million individuals in the US report experiencing chronic pain. The symptoms may become worse over time, spread to new areas of the body, and result in restricted mobility and limitations in daily activities.
Evolving research has demonstrated that for some sufferers emotions can be the source of chronic pain and may be the key to treating the symptoms. Studies have demonstrated that identifying, expressing, and releasing difficult emotions, like fear, can successfully reduce chronic pain.
Our guest is Dr. Howard Schubiner, an internist, pediatrician, and director of the Mind Body Medicine Center. Dr. Schubiner and his colleagues have developed psychological treatments for chronic pain and created a series of studies to evaluate these treatments.
In this episode, Dr. Schubiner helps us to see pain with a new lens. He explains how chronic pain can be protective. He describes how brain-generated pain is different from structural pain.
Dr. Weil and Dr. Schubiner discuss the revolutionary work of the late Dr. John Sarno, a pioneer in treating patients with chronic back pain with mind-body medicine. Dr. Maizes describes how language and common approaches can reinforce a message of disease and perpetuate symptoms. Dr. Schubiner explains how pain reprocessing therapy can help to eliminate and even cure pain and why this therapy offers great hope to people who live with chronic pain.
Please note, the show will not advise, diagnose, or treat medical conditions. Always seek the advice of your physician or healthcare provider for questions regarding your health.
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Victoria Maizes: Hi Andy. Dr. Weil: Hi Victoria. Victoria Maizes: So today we're going to cover a topic that is so critically important in our world, which is chronic pain. It's incredibly common. And while there are many ideas about how to manage the symptoms, we're going to be speaking with someone who believes you can actually cure your pain, that you can unlearn your pain. Dr. Weil: And this is really mind-body medicine and action. And of course mind-body medicine is a really central element of integrative medicine. Victoria Maizes: And while Dr. Schubiner is our guests he really learned this initially from another physician Dr. John Sarno, who was a physiatrist who wrote a book on several books, but it's first one healing back pain, and people would sometimes get better just by reading that book. Dr. Weil: Yeah, his theories were revolutionary. And I think finally they're being put into practice and our guest today is one of the main people doing that. Victoria Maizes: So let's welcome, Howard. Intro Music Victoria Maizes: Dr. Howard Schubiner is an internist and a pediatrician and a professor of medicine, as well as the director of the Mind Body Medicine Center at Ascension Providence Hospital in Southfield, Michigan. Together with Dr. Mark Lemley, he developed emotion awareness and expression therapy, which has been tested in people with chronic pain and found to be effective. He's authored more than a hundred publications in scientific journals and in books. And he's the author of three books, Unlearn Your Pain, Unlearn Your Anxiety and Depression, and Hidden from View. Welcome Howard. Howard S : Thank you so much. You make me sound serious. Victoria Maizes: This is a serious topic [laughing]. Pain is a serious topic for many people. And I'm wondering if we can begin by defining what is neural circuit pain. Howard S.: Yeah, when I talk to people, I say to people you can't understand pain, unless you understand how the brain works. It turns out that all of our senses, all of our experiences are actually generated in the brain. So when you cut your finger, it's not your finger causing pain. It's actually the brain. The brain decides whether to turn on pain or not in pain is always protective. It's something we need. And so, neurocircuit disorder, neurocircuit pain just implies that the brain is creating that pain. But it's specifically saying that the brain is creating that pain in the absence of a structural injury, as opposed to the situation where you, you know, you break an arm and the, and that's triggering the brain to conduct to create pain. But it turns out for the vast majority of people who have chronic pain. They have brain generated pain. And they don't actually have a structural injury and this is a revolutionary concept. Victoria Maizes: It really is. And my understanding is that this was first brought forward as a theory by Dr. John Sarno, who you both knew. And I'd like to go back a little in time and ask you, Andy, how did you know Dr. Sarno and what did you think of his name? Dr. Weil: You know, I, I can't remember how I first came across his work. But as soon as I began reading what he was saying, it made total sense to me because I had seen over and over that there was very little correlation between back pain, especially in the subjective experience and structural correlations as shown on x-rays and scans. And, but his, his idea that pain is created in the brain, although it may localize it area of some structural problem…I thought it was revolutionary. And then I began referring patients to him and the success stories were quite amazing. I've reported, some of them one a good friend of mine, man, who was literally hours from having neurosurgery. I persuaded him to go listen to Dr. Sarno's lectures. He thought it was ridiculous, just thought it was total nonsense and he came home and his pain disappeared. That was without even having met in person Dr. Sarno. Howard S.: It's insane. Isn't it? Victoria Maizes: And that's really a remarkable story. And Howard, I know that Dr. Sarno was a mentor of yours. Could you tell us a little bit more of what you experienced, what you learned? Howard S.: Yeah. Back in 2002 or so, a friend of mine gave me one of Dr. Sarno's books to read. He said, you should be interested in this Howard, you're a mindfulness teacher, you've been interested in mind bodies stuff, you know, throughout your career. And Dr. Sarno is, this has some different views. And I read, I read that book, the Mind Body [00:04:00] Pescription, and I was just so intrigued and I was at a crossroads in my career and I called up Dr. Sarna and I said, Dr. Sarno, can I come work with you? And he said, sure, Howard, you know, come next Monday. And I went to New York. I only spent a few days with them, but it was transformative and seeing how he worked and what he was doing. And I came back to my hospital in Michigan and I started practicing and I started listening to patients intensely for hours on end and getting their stories and reading voraciously about the brain and neuroscience and pain. And you know, then just tried to take his ideas and try to expand them a little bit, try to do some research on them, try to make them really couched in the language of neuroscience that he didn't really have the advantage of working back in the really seventies and eighties when he started doing it. Dr. Weil: Howard, I have two questions for you about Dr. Sarno's work. The first is he was, I mean, he went very far with his ideas. He said that almost all back pain was this mind body problem. He called a tension myositis syndrome. But he said that it was a mistake to deal with the pain on the back and he discouraged people from doing any, any interventions directed at the back, whether acupuncture massage, because he said that reinforced the false idea that the pain was coming from the back rather than the brain. That seemed extreme to me. And I wonder how you feel about that. And the other question, let me just state it, and then you can talk about, it's tricky to explain this to patients because it's so easy for them to hear that you're accusing them of imagining the pain that the pain is not real, that they're making it up. And how do you deal with that? Howard S.: Those are great questions. Well, Dr. Sarno was a purist, you know, he was really, he was dogmatic and and his he was very authoritarian and a lot of ways. And he, his stuff really worked for a lot of people. But to take the components that you mentioned, first of all, he said almost all back pain is of a mind body variety. Well, it turns out he, I wouldn't say all, it's definitely not all. I mean, obviously some people. It drops. Some people have tumors, infections, whatever, but we're doing a study, a large study where we're, we're showing that 85% of the people with chronic neck and back pain when given a full and careful diagnostic evaluation actually do not have a structural disorder. And this is very similar to, with headache, headache. It's 95% of people don't have abdominal and pelvic pain it's in the roughly 90%. Well so but the question of interventions, I think, needs to be moderated because it's basically what we're doing is helping the brain feels safe versus endings. And so, and we're doing a lot of training of physical therapists and acupuncturists and chiropractors and other people who do manual medicine to help teach them how to help reinforce health in the people they're working on, how to show them and use their hands to show them that. And to help them to move in safety with less fear so that they can combine their manual medicine skills with a mind body approach. Because I mean, you can do it the opposite way. It can be kind of counterproductive too, for some, some manual medicine people to keep allude, you know, keep referring to how badly your, how, how your glutes aren't firing, how your core needs to be strong. To change this and that. And they can be reinforcing a message of, of disease which makes the brain feel more afraid, which makes the pain worse. So I think we need to include as many people as we can. We're training people of all stripes in the healthcare field to do this work. Victoria Maizes: I really appreciate that response. One of the central tenants of integrative medicine is how important language is and the language we use can be hexing, you know, it can perpetuate the pain or it can be healing. And Andy, I know, you know, you've sometimes said that you've seen a patient who has responded to you that you were the first person who said, that you believe they could get well again, and I'm sure that that was so critically important in their healing. Body of Wonder General Ad Dr. Weil: And, how about this issue of explaining this to a patient without having them feel that you're accusing them of making the pain? Howard S.: I know. I know we deal with this every single day and I've been accused of being a horrible, I've been accused of a lot of bad things in, in not so subtle language by physicians and non-physicians, but what I try to say to people, first of all, is that you know, anybody who says that the pain is all in your head is either dismissive or judgmental or downright cruel or ignorant about how the brain works, because all pain is real all pain is generated in the brain. And when they say it's all in your head, they're implying that you're, you know, you're faking it or you're imagining it, or it's your fault or you want the pain or you're weak, or you're crazy. And none of that is true. And I've had, I've never had a patient disagreed with me because I'm saying, I can't imagine. And then you have to apply love. Right? You have to be compassionate. No, one's going to listen to us if we're not, if we don't demonstrate love and compassion and caring and you know, and so I'll say, you know, I, I have no idea what you're going…I can't even imagine… you know what you're going through. But I know that it's very real, but there, and let's look at it carefully. Let's see if we can figure out where this pain is coming from, because maybe as Victoria was saying, there's hope. Because the model of healing always includes some kind of explanation. Some kind of an agreed upon explanation that the doctor and the patient or the provider and the patient agree on some kind of techniques that you can do to heal and optimism and hope and love. So when you put that together, I think for most people. They can understand this idea of mind, body pain and mind, body approach. But, you know, sometimes the pain is just so severe that it's really hard for people to wrap their head around and, you know, oftentimes it's going to, it may take some time. I've had people tell me, they took my book. I started reading it and they threw it against the wall and disgust, you know, this is BS, this is ridiculous. You know, year later, maybe they picked it up again. You know, they've been, you know, dead ends of a variety of different, you know, treatment options. Victoria Maizes: I feel like you're alluding to some of the principles and practices of the emotion, awareness and expression therapy that you now deliver, I think in groups to patients. And can you talk a little bit more about that? Howard S.: Sure. If I could just back up just a second. So when we think about like treating, treating people first, we want to make an accurate diagnosis. We want to do a full, complete assessment. If we have a process where we rule out a structural, but we also rule in a neural circuit disorder. And by that, I mean, you can rule in a neural circuit disorder because the pain triggered by the weather or it's, it leaves, it goes away when you're on vacation or it shifts from one arm to the other arm or you know, it's worse anticipating going to work the next day, all these variety of clinical skills that we, that we teach people. And then we educate about the mind body approach and we, and we help people understand predictive coding and how the brain works. And then we're doing, we're trying to make people feel safe. So the third component of as what we're calling pain, reprocessing therapy now, which is our variant of combination of mindfulness plus cognitive behavioral therapy. But it's geared toward eliminating pain. Right. It's, it's geared toward not just coping with pain better, but eliminating it and helping people see that the pain is in the brain. And if they change their relationship to it and fear it less and continue to move. And that's what happened to your friend, Andy, where he is, this fear vanished his fear of the pain vanished and the pain vanished. So those are the first three steps that we're doing with everybody. And the fourth step to victory to answer your question is emotional awareness and expression therapy, which mark Lumley and I who's a brilliant psychologist and teacher and researcher from Wayne State in Detroit, my colleague he and I went to meet Allan Abis who I wrote third book with who is the foremost receipt researcher and teacher in the world on intensive short-term dynamic, psychotherapy, more acronyms, but the bottom line is how do we process emotions? People who who hold on to anger. People who hold on to guilt. People hold onto grief. And not as a choice, it's, they're holding onto it because they don't know what to do with it. Their anger gets bottled up inside because they can feel ashamed to express it and feel like they're being violent, they can't be angry, they can't risk hurting anybody so they hold it in, but it eats away at them. I saw today a young person who's just hanging on to guilt over something that you know, he, he did, that was normal. And you know, and he's thinking of himself as a bad person. So these things drive the danger signal in the brain to create pain. So our model of EAET is a derivative of Dr. Avis work which is a shorter way of helping people to identify express and release emotions, do direct emotional work, and a lot of therapy doesn't really deal with emotions. They're more dealing with cognitive types of skills. Victoria Maizes: Ask a question to bring this into a concrete place. What role have you found for fear in physical pain and what could be done about it? Howard S.: Yeah, well, fear is what drives pain. I mean, most chronic pain is, is derived from from the dangerous signal causing pain pain, causing fear of pain, frustration with pain, worry about pain fighting. Trying to figure it out, trying to fix it, all these apps with fear at the top and their reaction to the pain itself is actually what then drives the brain to create more pain. And so most people with chronic pain, they get worse over time and their pain spreads to different parts of their bodies over time because of this vicious cycle of pain, fear, pain. So it's of critical importance and it's the basis of the PRT model that I mentioned earlier, pain reprocessing, is to help people reduce fear. And so when you put those, these two powerful models together, the fear reduction model and the emotional expression model, you have ways of really helping people be okay with who they are, you know, to be more comfortable in their own skin, to preach, to love themselves more, to, to, to to feel more comfortable with their place in the world and who they are and most importantly, in their body being comfortable with, with what their body is and who they are in their body. And that relieves tremendous tension in the brain, which is actually the driver of chronic pain. And it's not just chronic pain, as I'm sure you're aware. It's chronic fatigue and insomnia and anxiety and depression and addictive disorders and eating disorders and all these, all these things that are really a neurocircuit disorder. It it's, it's phenomenal because when you see people and you talk to them, you spend time with them. They don't just have one thing. Right. They've got this whole checklist of things that have all been driven by, by starting with adverse childhood events. Right? So when you have the, not everyone has that, but everyone has some trauma in their life. And when you have adverse childhood events, which you're, you're setting up the brain for fear and hypervigilance, because your response to these childhood traumatic events is to be fearful is to bottle up emotions. Dr. Weil: What do you find as the acceptance of these ideas now in practices? Is it becoming easier to convince both patients and practitioners? Howard S.: Well, we're training a lot of younger people because I'm not sure where I'm going to see, I'm not going to say, I'm not sure we're going to see the paradigm shift in, you know, in my lifetime. But yes, things are definitely changing. I mean, you're reading more and more about it in the, in the papers and everything. There's a ton of resistance. You know, Dr. Sarno spent his whole career trying to get mainstream medicine to adopt his ideas that hasn't happened. But the drivers of this, and I was talking about this to report yesterday, the drivers of this is really going to be the patients who are the people who care and who are the people who are suffering. It's not really, the doctors, doctors are doing their thing. Sometimes they're frustrated that they don't know what to do with people, but you know, there's a tremendous medical, industrial complex. And you know, there's a lot of financial stuff that goes on and, and inertia and everything, and what people are taught. It's hard to change. You know, I gave a talk to a society of headache specialist, neurologist who all specialize in headache, what am I going to tell them? Yeah. You should totally stop what you're doing. Your whole career. Your whole training is based on injections and medications for primary headache, which are all neurocircuit disorders. I mean, next couple months, I've got a talk for the international pelvic pain society. What am I going to tell them? Victoria Maizes: It's hard. You know, I have to say as someone who was a primary care physician for nine years before I came to practice integrative medicine, I have long had this sense of Mea culpa. Because until, you know, you may have treated people with more invasive, less natural, a more aggressive treatment than was required or would have been helpful. And so it is hard to recognize. There was information out there that might have really benefited your patients. But I think the other thing that has shifted since Dr. Sarno tried to change the world is that there's so much neuroscience now that supports. What you are teaching the central hyper sensitization wasn't known about, we didn't know that chronic pain was different from acute pain. I mean, this is just, and you have been one of the people advancing the research. So I'm wondering if maybe you could just take a little time to talk about some of your research. Howard S.: Yeah, I'd love to we've, we've done a few randomized controlled trials on emotional awareness and expression therapy. In one, one of the large NIH funded trials with fibromyalgia, we showed that it was actually superior to standard cognitive behavioral therapy for pain. In this, in this disorder. And it's the first is actually the first large scale study to show that one psychological intervention for pain was actually superior to another psychological intervention for pain because all the other studies have shown when you compare CBT versus ACT or ACT versus mindfulness-based stress reduction therapies, the results are the same. They're no different in their smaller effects. So we're seeing bigger effects. We've also completed a pain reprocessing therapy, trial, randomized controlled trial in Boulder, Colorado with back pain. And that article is in a submission process now, which I'm sure it will be published eventually showing again, very very significant results in higher, higher results of people going pain-free than any other study that's ever been done so far, and this is with people with back pain, average duration of back pain was 10 years. And then we're doing this other study I was mentioning earlier where we're evaluating back pain. We're finding roughly 85% of people with chronic neck and back pain do not have a structural problem. So those are three of the most important studies. The second two haven't been published yet. And we're really, obviously we're just trying to advance the field, but it's not going to come from a search. You know, the change is going to come from people voting with their feet. You know, people who, who are suffering, people who want something better, desperately trying to get better and looking for anything. And the more and more we build this movement the better off that we're going to be. And it's, and that's part of frankly, I could say it's part of a social, I think it's part of a social justice movement. Because, because it turns out that what are the things which create pain will adverse childhood events creates pain. But on top of that, what creates pain is, is injustice. Racial injustice causes pain, physical pain, because it, it it activates the danger signal in the brain. Prejudice and discrimination on a sexual basis or a gender basis, or you know, the age basis, et cetera, creates pain because our brains create pain when we feel there's injustice in the world. And so linking that, I think can really link to, you know, what Martin Luther king Jr called the arc of, you know, the arc of history bends toward justice. And we have to work on all those levels. Victoria Maizes: That's a really profound elevation of this work. And I guess it seems that it's not just the injustice that is experience. It's the need to bottle your feelings about the injustice that has been experienced. Howard S.: Exactly. I mean, you know, people make fun of microaggressions, but microaggressions, you know, you can die by a thousand paper cuts, right? You have, you have this constant, as you pointed out, you know, feelings of constantly feeling the need to react or can't react or have to hold in everything. And and it's really recognizing the power of our brain and the power of us as human beings, being emotional creatures. Anger is not a dangerous or bad thing. It's just dangerous when you act it out in violence in the world, or you bottle it up inside. But what EAET does getting back to that for a second it's to helps people have a healthy outlet for anger. Which is in fantasy in imagination and allowing that anger to come up in a safe and healthy way, and then dealing with, and then dealing with the sadness and the grief and helping people to allow themselves to feel sadness and feel grief. And then to transform that grief into compassion and self-compassion and compassion for others. And what heals? what heals is compassion. What heals is hope and optimism. Those are the things that heal and that's what we're helping people move towards. So when they get pain, it's not that the pain is the, it sounds crazy right, but it's not that it's necessarily a bad thing. It's a message that their brain is giving to them that something needs to change. And if people can hear that message and act. And make the changes in their life and then in how they see themselves and how they treat themselves and how they treat others. It's a healing for us. Victoria Maizes: So we're moving towards the end here, and I know that our audience will want to know how do I find someone who offers this kind of therapy? What are the resources available to me? I'm hoping you can share some of that. Howard S.: Yeah, we're training people like crazy left and right. If anybody in your audience wants to have any training, please go to my website unlearnyourpain.com. We're doing trainings all over, all over the world of the PPDA it's PPD association.org is our professional non-profit organization, and also a clearing house for information on risk and research bibliography, and a list of practitioners across the world is available on that website. You mentioned earlier Victoria, we were talking about some videos, some simple animated videos that we've put together to help explain this to people. And those are available on YouTube, but through my website, unlearnyourpain.com. So the TMS Wiki is another excellent site TMSwiki.org is another, it's a patient run site for information about this model. And it goes back to Dr. Sarno cause it's DMS, which was 10 tension myositis syndrome that Dr. Sarno coined his term in the first place, back in the seventies and eighties, Dr. Weil: Howard, what would a typical course of treatment look like in terms of time and also money and as a covered by insurance? Howard S.: Yeah, it all depends on the person and you know how people are doing it. You know, there's a, there's a whole raft of, of neurocircuit specialists psychotherapists who do work remotely. A lot of them are not know, are not taking insurance. So that can be pricey, you know, in my own practice, I just bill insurance, you know, I just bill insurance, I see people for two hours for a first visit. And then I see them for one hour after that. And You know, it may take a few weeks to get better a few months somewhere on that order. And but there's physicians, you know, around the country who are also who also doing this work Victoria Maizes: Well, thank you so much. Giving hope to people with chronic pain and creating methods for people to find novel approaches and empowering approaches that can really change their lives. We appreciate the work you're doing Howard S.: It is a it's an honor. And it's a pleasure to be here with you guys. I've admired your work for many, many years, as I've said.