Interview with Howard Schubiner, MD

image of Howard Schubiner,_MD

Howard Schubiner, MD is the Director and founder of the Mind body Medicine Center at Providence Hospital in Southfield, Michigan. He was a full Professor at Wayne State University in Detroit for 18 years. He is a fellow in the American College of Physicians, the American Academy of Pediatrics and the Society for Adolescent Medicine. Dr. Schubiner’s research areas include adolescent health, ADHD, and stress reduction. He has authored over 60 publications in scientific journals and books and is on the Editorial Boards of the Journal of Adolescent Health and the Journal of Attention Disorders. His book, Unlearn Your Pain, was released in March 2010. Dr. Schubiner completed the first Randomized Controlled Trial, published in a peer-reviewed journal, on the effectiveness of PPD treatment in Fibromyalgia cases.

This interview will be published in three segments: 1. General information on Dr. Schubiner and PPD, 2. Developments in his research, 3. PPD treatment. Several prominent PPD practitioners participated in the interview including Eric Sherman PsyDAlan Gordon LCSWBarbra Kline LCSW, and Colleen Perry.

General Questions about Dr. Schubiner

TMS Wiki: Before beginning to study PPD, you had a successful career as a researcher in the fields of adolescent medicine, ADHD, and stress reduction. For example, you are on the editorial boards of the Journal of Adolescent Health and the Journal of Attention Disorders. I would think that switching your focus to PPD must feel like a big transition. How did you first learn about PPD, and what about the field led you to refocus your career in this direction?

Howard Schubiner: When I was in college, I was very interested in mind body interactions. After becoming a doctor, I studied hypnosis, meditation, and acupuncture. However, I had little time for those interests during my 30s, while I was working to build a career as a researcher. However, when I turned 40, I realized that I needed to get back to meditation. This led me to become a mindfulness meditation teacher, which opened the doors back to my roots. When I finally left the University for Providence Hospital, I happened to hear about a friend’s experience with severe hip and back pain that was basically cured by the methods of Dr. Sarno.

This occurred at a time when I was ready for a new passion and I started reading voraciously. I read all of Dr. Sarno’s books, worked with him for a few days, and found as much research as I could that related to the connection between the mind and the body. I began to realize how important this area is and how this is a key to understanding so much human misery that is unexplained by modern medical science. The vast majority of doctors do not understand that mental events can cause true and real physical pain. That simple statement, that simple understanding is missing in modern medicine. We call it modern medicines‘ blind spot. I started interviewing people and the more I paid careful attention to their stories, the more I really began to understand the depth and breadth of this disorder. Since I was used to teaching mindfulness meditation courses in small groups, it was only natural that I’d develop a TMS program that I taught to small groups once a week for several weeks. I have tried to be innovative by incorporating elements of mindfulness meditation, therapeutic journaling, and many concepts that I had learned from my earlier training.

I am not a strong believer in fate, but I do believe that when opportunity knocks, you should pay attention and respond. I feel that this work is the most important work that I have done.

Wiki: You have a strong background in mindfulness meditation. How do you think that your background with mindfulness informs your approach to PPD and to medicine in general?

HS: Mindfulness is a powerful tool for living. In my opinion, everyone should learn these techniques, and they are easy to learn and implement. The hard part is remembering to implement them, especially in times of stress. Mindfulness teaches being in the moment, being able to gain perspective, understanding that everything is transient, learning to deal with strong emotions and negative thoughts. Brain studies show that mindfulness practice activates the DLPFC area of the brain which is important in inhibiting pain. It is also associated with improved immune function and overall contentment.

With regard to pain and TMS, mindfulness is an invaluable component for recovery. Although pain can clearly be triggered by emotions that have been primed from stressful events in the past, the pain is occurring in the present. And it continues to be triggered by emotions in the present, even if they were learned in the past. Therefore, while it is important to understand the effects of the past and deal with them, it is also important to live in the present and deal with current stressors and current emotions. Mindfulness practice helps people to observe, accept, learn from, and let go of things that occur on a minute by minute basis. Therefore, when unwanted thoughts, emotions, or pains occur, this gives us an opportunity to observe them, accept them, learn from them and let them go. It allows us to not be afraid of strong emotions or pain because they are seen as transient phenomena and they can’t hurt us or harm us if we don’t let them. It teaches us not to resist these feelings, but rather to embrace them, become one with them, and allow them to pass.

Mindfulness also teaches us that we need to make good decisions—it is not enough to simply be passive and watch life go by, it is important to engage with it and decide how to improve our lives. It is frequently not enough to simply understand life stressors and write about them to recover from TMS. Often, people must make some changes in their lives and mindfulness practice helps people step back and make good decisions about how to proceed.

Wiki: You studied with Jon Kabat-Zinn and Saki F. Santorelli. Can you tell us about their work and its relevance to PPD?

HS: They were my first meditation teachers and I respect them greatly. They taught me that mindfulness is, at its core, an inquiry; an inquiry into the depths of our being and our reality. It’s a simple process that when practiced seriously, can make huge differences in people’s lives. During my years as a mindfulness teacher, I was impressed how many people found it to be helpful in resolving a number of stress-related problems in their lives. However, one thing puzzled me about it. During my sixteen years of teaching mindfulness, very few people had dramatic recoveries from TMS-like symptoms. It was only when I started to fully understand TMS and educate people about it that mindfulness became an approach that helped to create dramatic recoveries. The combination of education and interventions is powerful, while only one of the two is often not enough.

Wiki: Are there any ways in which your experience of studying with them affected the meditation portions of your PPD recovery program?

HS: Often meditation approaches tend to be cerebral and people tend to think of meditation as a relaxing, passive way of observing reality and our situation. However, Jon and Saki also emphasize that mindfulness practice requires us to engage in reality, in all of its ups and downs. A key concept in understanding TMS is that emotions are often suppressed and these emotions can be expressed as pain and other physical symptoms. Therefore, learning to recognize and express these emotions is part of PPD recovery. Mindfulness practice is one way to deal with strong emotions and I have recorded a meditation specifically for this purpose. It’s entitled, Embracing Emotions, and is available at no cost at

Wiki: Have you found that people with PPD have any inhibitions or specific difficulties with practicing mindfulness? Also, how do you discuss meditation with patients, and have them agree to meditate?

HS: I have not had many difficulties in explaining mindfulness or in getting people to engage in it. The techniques are clear and easy to grasp. They don’t contradict tenets of religious beliefs. Mindfulness exercises can be done while sitting in a quiet place or while engaging in any activities, such as work, leisure, or exercise. People who engage in mindfulness exercises generally benefit greatly. The difficult part is often getting people to remember to practice and continue that practice.

Eric Sherman PsyD: Did you ever encounter professional ostracism/ridicule/ or marginalization for espousing your views on psychophysiologic disorders? If so, how did you deal with it?

Howard Schubiner: I haven’t been exposed to anything resembling ostracism or ridicule as yet. I hope I don’t! Several professionals have questioned my ideas and we have debated them in a professional manner. This is an important way to sharpen my concepts and correct any areas that aren’t clear or correct. One day, I was giving a lecture and after presenting a brief patient vignette, I asked what I thought was a rhetorical question, “Does that make sense?” Immediately, a physician in the audience shook his head “No”, and walked out of the lecture hall.

ES: What have you found to be the most compelling argument to pique the curiosity of fellow physicians who were on the fence, that is, not completely antagonistic to your ideas about psychophysiologic disorders?

HS: The most compelling arguments are the presentation of data. Some people immediately understand these concepts from powerful stories that describe PPD. However, others need to see the science. I try very hard to create a case for the legitimacy of PPD by presenting a cogent argument based on scientific studies. I have been fortunate to work with some excellent researchers to conduct studies that demonstrate that this approach actually helps people.

ES: Have any of the physicians who might have rejected your ideas in the past come around? If so, how do you understand their ‚conversions‘?

HS: I’m not aware of anyone in this category, but a typical “conversion” would occur when a patient responds completely to this approach or the physician sees this disorder in someone in their family.

Wiki: There seems to be several different treatment programs each of which has different approaches. As you were developing your own treatment program, what factored in to your methodology? In other words, why did you choose the techniques that you did.

HS: I have been a physician for many years and have worked in the area of stress reduction and management for a long time. Over the years, I’ve been exposed to many forms of treatment and these have informed my choice of therapies for PPD. In my program, I focus on therapeutic writing because there is solid research showing its benefit and it allows people to explore many issues in a safe and useful format. Mindfulness was a natural choice given my background. The affirmations were something newer to me, but I’ve found it to be an essential part of the program. Finally, moving forward in life, encouraging exercise, and emphasizing positive emotional health were aspects of the program that just seemed to make sense. I am constantly evaluating new forms of treatment that may help people with PPD because not everyone responds to the same interventions.

General Questions on PPD

Alan Gordon, LCSWDo you think that the physical symptoms serve as a distraction from painful unconscious emotions or are simply a consequence of painful unconscious emotions?

HS: That is a difficult question, but both concepts might be valid. It’s often difficult to understand the “motivation” of the subconscious mind! It seems clear that we are designed to protect ourselves. Pain and other symptoms seem to serve as an alarm much of the time, therefore they can easily be seen as a consequence of subconscious emotions. Fatigue typically occurs in the setting of someone who is totally overwhelmed in their life. Therefore it seems to serve to create a “time-out” for someone who needs it. On the other hand, there seems to be an interesting relationship between pain and anxiety. I’ve frequently seen people who have severe anxiety that reduces when pain occurs or vice versa. This suggests that pain can be seen as a way of covering anxiety when the anxiety is too uncomfortable. It is also an example of symptom substitution.

AG: Why do many people find it so difficult to let go of the physical/structural explanation for their pain even in the face of overwhelming evidence that it’s psychophysiologic?

HS: This is a good and important question. Of course, everyone is different, but one of the problems that I frequently see is that the “evidence” for PPD may not be overwhelming to them. That evidence primarily consists of scientific studies, a paradigm that is often foreign and new, and connections between pain and psychological events. These are relatively easy to ignore or not fully understand. In addition, there is often “evidence” of a physical/structural problem from other doctors and from lab tests or X-rays/MRI’s. It can be difficult to ignore that information. Secondly, there is the oft mentioned problem of “Are you saying that it’s all in my head?” This line of thinking is powerful in resisting a psychological explanation because it is often perceived to place blame on the patient. In addition, it may be rejected because it also places responsibility on the patient. Now the cure is in their hands, rather than in the hands of the physician.

Wiki: Have you seen any pediatric cases of PPD, and would you diagnosis them in a different manner than adult patients? Does PPD appear in different ways for children than in adults?

HS: PPD is a common phenomenon in all people and therefore we see it in children, adolescents, as well as adults and the elderly. The manifestations are generally the same at all ages, but children may not be as capable of looking at their emotions and their subconscious motivations as are adults.

Wiki: Can anxiety and depression be manifestations of PPD or are they the cause of PPD? Have you had success treating them with this approach? What about insomnia?

HS: In working with people with PPD, I encounter anxiety, depression, and insomnia on a daily basis. It is clear that these issues can create augmented pain responses and increased pain often increases anxiety, depression, and/or insomnia. I also see that these disorders can alternate or substitute for pain on a regular basis. In addition, anxiety, depression, and insomnia are triggered by the same life events as are PPD pain responses. It is these experiences that lead me to state that anxiety, depression, and insomnia are commonly manifestations of PPD. Just as with pain, it is essential to rule out medical conditions that can cause these disorders. However, when no medical condition exists to create them, I treat them in the same way that I treat pain due to PPD.

Wiki: I read several statistics that say more women then men suffer from PPD, specifically in cases of Fibromyalgia where women make up almost 90% of the cases. In your opinion why is this? Is the reason more genetics or cultural? How could understanding this help in understanding PPD as a whole?

HS: There may be some genetic factors involved, but those have not been shown to be a significant factor in this discrepancy. There are data to show that women are more likely to have been victims of sexual abuse and other forms of abuse. Women are also more likely to be conscientious, to worry, and to be less selfish than men in large international studies. They are more likely to be primary caregivers for children and aging parents. In my opinion, these factors combine to produce PPD in a higher proportion in women. Understanding this helps us to realize that the people most likely to be affected with PPD are the “good” people of the world who care for others, try hard to please, and are responsible. It should help to decrease the stigma of having PPD.

Wiki: I’m interested in some of the specifics of various „PPD equivalents,“ such as TMJknee problems, dizziness, GI conditions, dermatological conditions etc. Are the same central sensitization mechanisms at play here or are there different mechanisms? Is there a structural (i.e. non mind-body) component for some of the diagnoses? Do you find yourself using different approaches in treating them?

HS: For all symptoms, a medical work-up should be completed. This will include a good history and physical exam, and necessary lab tests and imaging procedures. When these data are reviewed, one can make a determination about the cause of the symptoms, i.e. whether each symptom is purely PPD, purely a structural/physical cause, or a combination of the two. Central sensitization mechanisms are the cause of PPD, no matter what specific symptom is manifest. The approach to treating PPD is the same, no matter what symptoms have been produced.

Survey Response: Barbara A. Kline, LCSW-CSince current theory supports a genetic/biological cause of bi-polar disorder, do you agree with this or do you believe bipolar disorder is another manifestation of PPD? I haven’t noticed this mentioned in any of my readings or lectures I’ve attended.

HS: That is a difficult question. I have avoided it for some time, but it’s an important issue and I’ll try to give a reasonable answer. Many people have a tendency to describe potential PPD symptoms in dichotomous terms, that is, either it is PPD or it’s structural/genetic/physical. There are obviously many disorders or symptoms that are a combination of the two. These can present complex issues for both the therapist and the patient. It may be that bipolar has components of both PPD and a genetic problem. On the other hand, it is my belief that psychiatrists are currently over-diagnosing bipolar disorder and therefore many people who carry the diagnosis do not have the “genetic” version of it, but rather a “learned” version that is caused by the same underlying events as PPD. This will have to be sorted out on a case-by-case basis to understand how to best treat people with bipolar disorder. Of course, treating bipolar with a combination of medications and PPD therapy can make a lot of sense as well


TMS Wiki: Are Randomized Controlled Trials (RCTs) important to the wider acceptance of the TMS/PPD approach? If so, why?

Howard Schubiner: There is no question that research findings will be necessary for this approach to be validated and accepted. There are a variety of types of research studies that will be needed, including case studies, outcome studies and RCT’s. RCT’s are recognized to provide the most valid scientific data, so those studies are most important in moving this field forward.

Wiki: In 2010 you published a study called „Sustained Pain Reduction Through Affective Self-awareness in Fibromyalgia: A Randomized Controlled Trial.“ Would you please give an overview of this study?

HS: In this study, we enrolled women with fibromyalgia and randomized them into an intervention group and a wait-list group. The intervention group received an initial visit with me of 2 hours in duration followed by the treatment program that I have developed (and published in my book, Unlearn Your Pain) in a small group format. The initial visit consisted of a medical history, a physical exam, a detailed psychological history to elicit connections between stressful events and the onset of PPD symptoms, and an explanation of PPD. This interview is also published in my book (Chapter 5). When you conduct this kind of interview, it is almost always successful in obtaining a clear understanding of the life events and stressful situations that triggered the onset of PPD symptoms, including fibromyalgia.

Wiki: Can you describe the treatment techniques that were used in the study and why you chose those specific techniques? Clinicians may wish to use this study to validate their own approaches to colleagues and patients. To do so, they need as clear an understanding of the differences between this program and their own treatment as possible, so please be specific. Also, how did the program in the study differ from the program in Unlearn Your Pain? Do you have advice for anyone who would want to set up a program similar to the one in the study?

HS: The treatment approach can be broken down into seven steps and is taught in a 4-week program (see Chapters 7-11 of Unlearn Your Pain). The program that was tested in the research study was of 3 weeks duration. These are:

1) Understanding PPD: The body is normal and does not have a physical/structural disease process. The symptoms are real and can be severe, but are caused by learned nerve pathways that have been triggered by subconscious processes.

2) Hope/Positive Expectations/Confidence: Hope and positive expectations that resolution of symptoms is possible and confidence that one can accomplish this.

3) Writing: A series of therapeutic writing exercises were designed to help participants learn more about their underlying thoughts and emotions about life events and cope with them better.

4) Meditations: Mindfulness practice is taught and other meditations were developed to heal both mind and body.

5) Self-talk: A series of powerful affirmations are used to help align the mind and body towards health and empowerment.

6) Changes: Looking carefully at one’s life to discern what changes are necessary to create health and well-being.

7) Love: Participants are asked to practice kindness to self, increase self-worth, take time for self, and be assertive.

Wiki: How did you measure the effectiveness of the treatment? What made you choose those measures? Did you do a follow up after the treatment was complete?

HS: We measured a variety of outcomes, such as pain, overall physical health, locus of control, sleep, fatigue, number of painful regions, and tender point sensitivity. There were dramatic decreases in pain, number of painful regions, and in physical health. Locus of control shifted from reliance on physicians to reliance on self. The sensitivity of tender points was reduced thus demonstrating an objective measure of efficacy. There were no changes in sleep or fatigue. The measures that improved showed statistical significance at a 6-week follow up and that level of improvement persisted to the 6-month follow up even though there was no additional treatment after the 3-week program. This finding suggests that the treatment induced a lasting effect.

Wiki: Were there any limitations to the study that readers should be aware of?

HS: One limitation of the study was that the sample size was relatively small, however given the small sample size the fact that the results were strongly statistically significant shows that the intervention was powerful. Another limitation was that the control group did not receive an intervention of similar intensity.

Wiki: What were the overall findings of the trial? Given the study’s strengths and weaknesses, what do you believe this teaches us about the PPD treatment approach?

HS: This study is the first randomized, controlled trial to study a PPD treatment approach. It demonstrates that this treatment approach is effective for a disorder that is generally considered to respond poorly to any form of treatment. Since individuals with fibromyalgia are likely to suffer with a variety of other psychophysiologic disorders, it shows that this approach is also effective for those disorders, i.e. irritable bowel syndrome, headaches, back and neck pain, etc.

Wiki: Some may argue that exercise helps fibromyalgia independent of psychological interventions. How would you respond to people who said that the psychological interventions merely made people more willing to exercise, and that it was the exercise that led to the improvements?

HS: My clinical experience suggests that exercise is only effective when it is combined with the other elements of the PPD program. Exercise alone may have limited value, but the key to dramatic improvement is understanding why one is exercising, i.e. to undo the emotional fear, to break the conditioned responses of pain that have been associated with exercise, and to prove to oneself that one is strong and healthy.

Wiki: Fibromyalgia can create different symptoms in different people. Did you find any difference in outcomes between participants who also had IBS and ones who had migraine headaches? The study mentions that you did not exclude patients who were in psychiatric treatment or who had other psychiatric disorders, such as anxiety, post-traumatic stress disorder, or depression. Did you find any difference in outcomes for patients receiving other treatment or who had a comorbid diagnosis?

HS: In an attempt to understand some of the factors that might predict successful treatment, we expanded the study to 40 individuals with fibromyalgia who were treated with this program. However, we did not find any useful factors or predictors so we abandoned that additional study.

Wiki: You have recently been awarded a grant from the NIH. How will the new study differ from the study that we have been discussing above? Should we expect one study or a collection of them?

HS: The new study will compare 3 groups of women with fibromyalgia in a randomized fashion who will receive an 8-week intervention in a small group format. Group 1 will be a control group and will consists of an educational program to explain fibromyalgia. We will use the traditional medical model for fibromyalgia. Participants will learn that fibromyalgia is a chronic painful condition with no known cause and no known cure.

Group 2 will consist of a cognitive-behavioral therapy intervention. The model will consist of graded exercise, learning to cope better with pain, and reframing anxious and catastrophic thoughts.

Group 3 will consist of an emotional expressive intervention. This model links pain to emotionally difficult life events and asks participants to uncover and process emotions in order to recover from painful symptoms.

Wiki: People will want to know when they can hope to see a new article being published. What can you tell us about when you hope to be conducting the trials? Could you give an estimate of how long it might take before results begin to be published (or at least a lower bound)?

HS: Patience will be required. This study will last for 5 years, so we won’t have any results for quite a while.

Wiki: Do you have any thoughts for research that you would like to conduct in the future, after the grant?

HS: We are currently analyzing data from an outcome study of patients who have been enrolled in the 4-week treatment program that I run in Michigan. We have enrolled about 60 patients to date and we expect to publish that data soon.

Treatment and Therapy

Wiki: During patient meetings, what are the most important ideas that need to be communicated to a PPD patient? What language do you find helpful in communicating these ideas?

HS: There are several critical concepts to convey to patients. They may have been told that their pain isn’t real, that it’s all in their head, or that they are just anxious or depressed. They are often very sensitive to feeling invalidated and stigmatized. These are the points I try to make:

  1. Their pain is absolutely, 100% real. All pain is real, of course, so that should be clear to everyone. I let them know that I know how much they are suffering and that I truly want to help them. I tell them that the most important thing we can do is identify the true cause of the pain, in order to reverse it. Covering up pain with medications and injections can be necessary, but it’s certainly not ideal. Most people are happy to know that you take their pain seriously and you want to help them get rid of it.
  2. Pain is often caused by learned nerve connections. If the doctors they’ve already seen haven’t been able to help them, it may be because they are looking in the wrong place. In other words, pain can occur in a part of the body even though there is no disease process going on there. I tell them that we are going to work to identify the underlying cause of the pain and that if we do, they will have a good chance to conquer it.

Wiki: Using the following diagram, please explain the roles that you believe the depicted brain structures play both in PPD pain and in PPD pain relief.

An image of Schubiner Diagram
An image of Neurologic Mechanism for Mind Body Syndrom

Diagram credits for both diagrams: Howard Schubiner, MD.

HS: THE PATHWAYS THAT PRODUCE AND PERPETUATE MIND BODY SYNDROME: These pathways can begin due to an injury or stressful event that produces strong emotions in the amygdala. Once the pain begins, nerves that send pain signals to the brain become sensitive over time and send repeated signals even when there is no tissue damage in the area where the pain is felt. These signals go to the amygdala and then get amplified by both conscious and subconscious emotions, which trigger activation of the anterior cingulate cortex (ACC). The autonomic nervous system (ANS) activates the fight, flight, freeze, or submit mechanism, which produces nerve activation, muscle tension, GI/GU spasm, and/or CV activation that worsens the physical symptoms. These pathways get reinforced over time, and this creates a vicious cycle of pain and increased emotional responses. A variety of triggers (such as certain physical movements or positions, places, weather changes, foods, or situations) can act as conditioned responses and add to the neurologic pathways that perpetuate pain. In the conscious portion of the brain, the dorsolateral prefrontal cortex (DLPFC) area can act to diminish and break the cycle by overriding the activity of the ANS and by deactivating the ACC.

Wiki: I’ve heard that in brain science, what we know is dwarfed by what we don’t know. I know that there is some controversy around the exact mechanism behind PPD. However, many medical conditions are successfully treated before the underlying mechanism is completely understood. How confident can we be about the models described above? Which rest on the most solid foundations and which rest on the least solid foundations?

HS: I definitely agree that there is a great deal of controversy in many different arenas of mind body medicine and what are sometimes called “medically unexplained symptoms” in the medical literature. For example, fibromyalgia is clearly a form of PPD from my point of view. However, the literature is full of many divergent theories on the etiology of fibromyalgia. Of course, most people are going with some sort of physical disorder, which is common in the era of modern medicine’s blind spot to the fact that psychological issues can (and often do ) cause real physical pain.

Anyway, it is difficult to know the exact mechanism of PPD and I will address that topic in the next question. However, I think we can be very certain that psychological mechanisms underlie PPD. From a psychological point of view, we don’t know if emotions are suppressed or repressed; we don’t know if PPD is a distraction or an alarm signaling danger; and we don’t know if the Id and the Superego are playing major roles. We also don’t know to what extent social factors play a role such as social contagion. Cultural issues may also be very important, as seen in so-called “culture bound syndromes” such as voodoo and, I would add, whiplash. But we do know that some or all of these psychological, social and cultural mechanisms are the cause of PPD symptoms. I happen to believe that PPD has the same underlying psychological mechanisms to PTSD and to what is known as conversion disorders (such as psychologically induced paralysis or inability to speak). And virtually all physicians and psychologists agree that psychological mechanisms are the cause of PTSD and conversion disorders. Another area of controversy is the role that genetic factors play, but that is the topic of yet another question (that I cover in the book).

Wiki: What is your view of the exact mechanism of PPD? Is it an overactive ANS? Oxygen deficiency? Allostatic loadCentral sensitization? Could you tell us a little bit about each of these models and help us understand the differences between each?

HS: Now you’re really asking difficult questions. But here goes. The ANS is clearly overactive in animals who were abused in infancy and people with histories of abuse tend to be “hyper-vigilant” and to respond to perceived danger with heightened anxiety. However, the data on the ANS in disorders such as fibromyalgia does not support the ANS being “overactive.” In fact, there are lower cortisol responses to stress in people with histories of abuse. Studies of the ANS in fibromyalgia patients suggest that it is actually dysfunctional in some ways, not necessarily over- or under-active. Furthermore, an overactive ANS implies an “all or none” phenomenon. In reality, the ANS is very specific in terms of which pathways are activated to cause differing PPD manifestations.

I have not found evidence for the oxygen deprivation theory. There is one study which supports that in fibromyalgia patients, but that hasn’t been confirmed. In addition, oxygen deprivation would theoretically occur on a micro-level caused by vaso-constriction. Stress doesn’t always produce vaso-constriction, for example, having one’s face turn red with embarrassment is due to vaso-dilation. Oxygen deprivation is purported to explain musculo-skeletal pain, but if that’s the cause of PPD, one would have to find different explanations for fatigue, tinnitus, diarrhea, urinary frequency, anxiety, tachycardia, and other symptoms that I see as being all part of the varied manifestations of PPD. Furthermore, when one invokes oxygen deprivation, people often get the idea that they need to breathe more deeply or somehow increase their oxygen levels and neither of these is true from my point of view.

Allostatic load is an attractive theory as it suggests that stress builds up and finally boils over to create physical symptoms. In many ways that makes sense, but I haven’t found that a good fit with what I see in my patients‘ lives. Allostatic load theory might work for disorders like asthma or inflammatory bowel disease where there is pathology induced by the buildup of stress. However, I don’t see PPD that way. I see PPD as being induced by very specific stressors that psychologically trigger emotional and pain memories from earlier in life. It’s not an accumulation of stress, but moments when certain situations create the onset of specific symptoms and then these symptoms can quickly disappear. The allostatic load model is really a disease model and I don’t see PPD as fitting a disease model.

McEwen, BS. “Stress, adaptation, and disease. Allostasis and allostatic load.” Ann NY Acad. Sci. 1998. 840: 33-44. [Abstract] [Cited By] [About Bruce McEwen]

Central sensitization is closer to the model that makes sense to me. People like Yunus who have written about central sensitization suggest that a wide variety of disorders can be lumped under this mechanism, which makes sense to me (including fibromyalgia, fatigue, PTSD, and other PPD syndromes). However, the people who write about central sensitization have not linked the onset of these disorders to stress and emotional reactions. They just consider the central sensitization to occur for unknown or genetic reasons. If you combine central sensitization with the psychological mechanisms that I discussed in the last question, I think you have a pretty good model for PPD.

Yunus, Muhammad. “Central Sensitivity Syndromes: A New Paradigm and Group Nosology for Fibromyalgia and Overlapping Conditions, and the Related Issue of Disease versus Illness.” Seminars in Arthritis Rheumatism. 2008. 37: 339-352. [Abstract] [Cited By]

I think of PPD as being caused by learned nerve pathways. This is similar to the nerve pathways we learned in order to ride a bicycle, speak a language, or throw a ball. These pathways can learn pain or any other PPD manifestation. They can be initiated by an injury or can be induced simply by emotional reactions. The manifestations can be present one minute and move or disappear in the next minute because the nerve pathways can be activated or deactivated by the brain very quickly, as described in one of the earlier questions.

Wiki: From the psychological point of view, what do we know about why people develop PPD symptoms? Is it to distract them from emotions? To suppress emotions? To alert them to danger? Scientifically speaking, what do we know about how we get from the unconscious mind wanting something to actual physical changes in the body? How does this relate to the mechanism and structures described above?

HS: As I mentioned above, we really don’t know too much about the psychological mechanisms. I tend to think that the body reacts to danger with an alarm system that is built in from our evolutionary heritage. I don’t think that the majority of PPD symptoms occur when the body is reacting in order to protect us from emotions or to distract us from them, however there are times when these theories seem to fit pretty well. It does seem pretty clear that people who tend to suppress or not even notice emotions are more likely to experience PPD. However, the body can react incredibly quickly to an emotional event that we don’t even have time to recognize the emotion. This is also part of our evolutionary heritage and has been shown by Joseph LeDoux in The Emotional Brain. How the mind produces PPD symptoms appears to be related to activation of very specific pathways from the ANS to the body and activation of very specific brain pathways. These pathways can produce activation of the nerves, muscles, GI tract, GU system, cardiovascular system, blood vessel constriction or dilation and these fibers can create all of the PPD symptoms. ANS activation can also produce a submit or freeze reaction (as it does in animals who freeze or play dead in the face of danger) and it seems to me that these reactions are what causes fatigue and depression. The bottom line is that the brain is pretty complicated. It has long term memory for specific childhood events and emotional memory that lasts forever. Most of our thoughts and emotions actually reside in subconscious portions of the mind and the body is controlled (via the ANS) by the subconscious part of our minds. When we encounter situations that trigger our emotional speed dial, responses occur with lightning speed in the brain and the body can react even before we can be aware of our emotions.

Wiki: Is it important to believe in the PPD concept? Can one be skeptical or doubt PPD and still recover? What does this tell us about the mechanism behind PPD? Can you relate your answer to the structures described above?

HS: As I mentioned above, it is generally not enough to engage in the therapeutic tools for PPD (such as mindfulness, expressive writing, affirmations, and counseling) without the understanding about PPD. I think that people need to understand that they have PPD rather than a medical disease and that they can recover. I understand that many people find it very difficult to believe that PPD can cause such severe pain or such varied symptoms. But it’s a critical element of recovery. When people doubt the diagnosis and continue to worry that they have a physical problem, it impedes their recovery because doubt leads to fear and fear leads to persistent pain by activating the ACC. It’s common to be skeptical that the program will work, but usually people begin to see responses when they start it and that helps to convince them. Since the mind controls the PPD symptoms, it is helpful to believe that you have PPD, that you are capable of getting better, and that you can cure yourself. A positive attitude activates the part of the brain that decreases pain, the DLPFC. The other activities that activate the DLPFC are kindness, love, hope, confidence, laughter, and awe—all good things to cultivate.

Wiki: What research studies do you find helpful to summarize during patient meetings?

HS: 1. There’s an important study done by the U of Michigan group that clearly show that the pain of fibromyalgia is real.

2. The same group has also shown that the pain of fibromyalgia is caused by central sensitization or central amplification; and that people with low back pain also have central sensitization/amplification of pain.

  • Giesecke T; Graceley RH; Claw DJ; et al. “Central Pain Processing in Chronic Low Back Pain. Evidence for Reduced Pain Inhibition.” Schmerz. 2006 Sept. 20(5): 411-414, 416-417. [Abstract]

3. Studies of phantom limb syndrome indicate that pain can occur in a part of the body with no disease and that this pain is associated with cortical reorganization.

  • Flor H, Elbert T, Knecht S, Wienbruch C, Pantev C, Birbaumer N, Larbig W, Taub E. „Phantom-limb pain as a perceptual correlate of cortical reorganization following arm amputation.“ Nature. 1995, 375: 482-4. [Abstract]

4. A study by Derbyshire, et. al., demonstrated that pain created via hypnosis was identical in terms of brain structures activated (ACC, insula, somatosensory cortex) as pain induced by placing a hot object in a participant’s hand. And pain that is imagined does not share those structures. The brain can create real pain.

  • Derbyshire SWG, Whalley MG, Stenger VA, Oakley DA. „Cerebral activation during hypnotically induced and imagined pain.“ Neuroimage. 2004, 23: 392– 401. [Abstract] [Cited By] [About SWG Derbyshire]

5. Studies of MRI’s in people without back pain show abnormal MRI’s.

  • Borenstein, G; Boden, SD; Weisel, SW. „The Value of Magnetic Resonance Imaging of the Lumbar Spine to Predict Low-Back Pain in Asymptomatic Individuals: A 7-year follow-up study.“ Journal of Bone and Joint Surgery [American]. 2001. 83-A: 1306-11. [Abstract] [Cited By] [About the Author]
  • Boos, N.; Rieder, R.; Schade, V; et al. „The diagnostic accuracy of MRI, work perception, and psychosocial factors in identifying symptomatic disc herniations.“ Spine. 1995, 20: 2613-2625. [Abstract]
  • Jensen, MC; Brant-Zawadski, MN; Obuchowski, N; Modic, MT; Malkasian, D; Ross, JS. „Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain.“ New England Journal of Medicine, July 14, 1994. 331(2): 69-73. [Abstract[Full Text] [Cited By]

6. A sham car accident caused neck pain in 10% of people 4 weeks later; those with the most stress. Castro.

  • Castro, WH; Meyer, SJ; Becke, ME; Nentwig, CG; Hein, MF; Ercan, Bl; et al. „No stress – no whiplash? Prevalence of „whiplash“ symptoms following exposure to a placebo rear-end collision.“ International Journal of Legal Medicine. 2001, 114: 316-22. [Abstract] [Cited By]

7. Subconscious mechanisms control the body and alert us to potential danger.

  • LeDoux J. The Emotional Brain: The mysterious underpinnings of emotional life. Touchstone Books, Simon and Schuster. 1996. New York, NY. [ Page] [About LeDoux]

8. Most thoughts and emotions are subconscious and these trigger brain structures (ACC and ANS) that cause and amplify pain and other PPD symptoms. We can activate the DLPFC, which inhibits the ACC and pain, by understanding the underlying causes of pain, by mindfulness, by therapeutic writing, by affirmations, by enhancing gratitude, love, forgiveness and by enhancing self-esteem and self-efficacy.

  • deCharms, R. C., & Zador, A. „Neural representation and the cortical code„. Annual Review Neuroscience. 2000. 23: 613–647. [Abstract[Full Text PDF] [About deCharms]
  • Schmahl C, Bohus M, Esposito F, Treede RD, Di Salle F, Greffrath W, Ludaescher P, Jochims A, Lieb K, Scheffler K, Hennig J, Seifritz E. „Neural correlates of antinociception in borderline personality disorder.“ Archives of General Psychiatry. 2006, 63: 659-67. [Abstract[Full Text] [Full Text PDF]
  • Lieberman MD, Jarcho JM, Berman S, Naliboff BD, Suyenobu BY, Mandelkern M, Mayer EA. The Neural correlates of placebo effects: a disruption account. NeuroImage 2004, 22: 447–455. [Abstract[Full Text PDF] [About Lieberman]

Colleen PerryAs a physician, how do you help the childrenwhen you suspectthe parents are the main cause of the PPD? How do you explain PPD to parents?

HS: Children get PPD of course, just as adults do. I explain the process in the same way, i.e. as real physical symptoms triggered by stress and emotions. PPD commonly occurs in children after traumatic events or difficulties with teachers, siblings or other children. However, the most common causes are difficulties with parents. If the child is old enough to separate from parents and begin to make their own decisions (usually at least a teenager), then I may primarily work with them. For younger children, it is necessary to help the parents change their behaviors.

Wiki: There are several people on the wiki now who are in the 70s, and have chronic pain. What are the challenges in diagnosing elderly patients, and do you adjust your treatment for these patients.

HS: Older patients can present difficulties for several reasons. They are more likely to have medical and structural disorders that can make the diagnosis of PPD less certain. They may be more “set in their ways” making significant changes more difficult. They may have to deal with isolation and mortality. These issues can complicate treatment considerations. It is important to go slowly, review all of the medical information and make decisions carefully about the diagnosis. Similarly, treatment often takes longer and requires a significant amount of effort on the part of the patient.

Wiki: I have found that a large percentage of people who recover from PPD have, at some point, a relapse and gain new chronic symptoms many years after the initial recovery from PPD. Do you find it more difficult to treat patients with PPD relapses? Are there any unique problems or issues that people having a PPD relapse have, either accepting the diagnosis or in treatment, that are not prevalent in people just learning about PPD?

HS: One might think that someone who has successfully overcome PPD in the past would have an easier time when a “relapse” occurs. This is often the case; however, at times people in this situation can struggle to get better. Sometimes they begin to worry that they aren’t getting better quickly enough and begin to “count days,” which only leads to more worry. The PPD symptoms are often different from the original ones and this can lead the person to a fruitless medical workup. The most important thing to offer people in this situation is reassurance.

Wiki: How do you approach a patient who rejects the PPD diagnosis?

HS: Sometimes people in this situation need more medical testing or a more thorough explanation of the lack of medical findings to explain their symptoms. Sometimes they need patient explanation of the neurological mechanisms that underlie PPD. Sometimes they need to hear stories of others who have overcome similar problems. And sometimes there is little one can do but wait until they decide to take the PPD path or another path.

Wiki: Should patients stop taking all medications? Can that be difficult or even dangerous? Must patients also stop physical therapy?

HS: Regarding physical therapy, I never mind if patients continue that as long as they see it as building strength and flexibility. I have problems with physical therapy if the patient is frequently reminded that there is something wrong with their body. I never recommend stopping medications early in the course of PPD treatment. I prefer to allow patients to stay on their medications while they work at getting better. Once they are better, it is much easier to wean off their medications. If one stops the medications too early, it can lead to increased pain for a couple of reasons. One, the medications may have been helping to alleviate the pain and two; the mind can “use” the lack of medication as a reason to ramp up PPD pain.

Wiki: Once people discover how the PPD approach can change people’s lives, they tend to see it everywhere. It’s crucial, of course, that practitioners don’t leap to a diagnosis of PPD when something more serious is going on. What are some important conditions to rule out with someone complaining of back pain? Of FMS? Of RSI? Of TMJ?

HS: It’s too complicated to delineate all of the potential medical disorders that need to be ruled out in various conditions. In general, if a reasonable medical workup doesn’t demonstrate a serious condition, the diagnosis if likely to be PPD. Once a diagnosis has been made via the traditional medical route of fibromyalgia, migraine or tension headaches, irritable bowel or bladder syndrome, or chronic fatigue, the actual diagnosis is PPD.


„Du bist alles, was ist, deine Gedanken, dein Leben, deine Träume werden wahr. Du bist alles, was du zu sein wählst. Du bist so unbegrenzt wie das endlose Universum.“

-Shad Helmstetter

Gedanken können einen erheblichen Einfluss darauf haben, wie sich Menschen fühlen. Wenn jemand ständig denkt, dass er seine Schmerzen nie heilen wird, wird er sie wahrscheinlich auch nie heilen. Aber wenn jemand seinen Verstand so umprogrammiert, dass er glaubt, er habe keine Schmerzen, kann er geheilt werden. TMS-Patienten haben ihren Verstand so programmiert, dass er Schmerzen erzeugt, wenn sie sich in bestimmten Situationen befinden. Mit Hilfe von Affirmationen kann eine Person ihren Verstand so umprogrammieren, dass er keine TMS-Schmerzen mehr erzeugt. Um TMS zu überwinden, ist es äußerst wichtig, dass eine Person ihre Selbstgespräche erkennt und ändert, wie sie über ihre Schmerzen denkt.


Einfach ausgedrückt sind Selbstgespräche die Gedanken, die Menschen bewusst oder unbewusst über sich selbst denken. Jeder Mensch hat Gedanken über seine Stärken und Schwächen, und er verstärkt diese Gedanken, indem er sie sich im Laufe seines Lebens immer wieder sagt. Bei TMS-Patienten tragen diese Gedanken dazu bei, dass Schmerzen oder chronische Krankheiten entstehen und ihre Symptome fortbestehen. Es gibt vier Arten von Selbstgesprächen, die jeder Mensch verwendet, und sie haben einen erheblichen Einfluss auf das Leben der Menschen.

Stufe 1 – Negative Akzeptanz

Diese Ebene hat kaum einen Nutzen für den Menschen. Sie besteht aus Gedanken, die der Mensch über sich selbst hat und die negativ sind. Die wichtigsten Wörter auf dieser Ebene sind „Ich kann nicht“ und „Wenn ich nur könnte“. Das Selbstgespräch der Stufe 1 konzentriert sich auf das, was die Menschen glauben, nicht tun zu können. In Bezug auf TMS umfasst diese Ebene Gedanken wie Ich kann nicht gesund werden, Ich kann nicht aktiv sein, wenn nur mein Rücken nicht schmerzen würde. Jedes Mal, wenn Menschen diese Sätze zu sich selbst oder zu anderen sagen, verstärken sie diese Gedankenmuster. Dieses Denken führt zu Zweifeln an der Heilung und hindert TMS-Patienten daran, ein Leben ohne Schmerzen zu führen. Um von TMS geheilt zu werden, muss man Selbstgespräche der Stufe 1 aus seinem Leben verbannen.

Ebene 2 – Ebene der Anerkennung und des Bedürfnisses nach Veränderung

Auf dieser Ebene erklären die Menschen, dass sie sich selbst oder andere verändern wollen, was gut zu sein scheint. Allerdings bieten die Gedanken auf dieser Ebene keine Lösung für das Problem und enden unbewusst mit einer Aussage der Ebene 1. Ein Beispiel dafür ist, wenn jemand sagt, ich muss mich wirklich besser organisieren. Diese Aussage scheint zwar gut zu sein, weil sie ein Ziel nennt, das erreicht werden muss, aber sie bietet keine Lösung an. Außerdem folgt auf diese Aussage der Gedanke „aber ich kann nicht“. Was hier wirklich gesagt wird, ist: Ich muss mich wirklich besser organisieren, aber ich kann es nicht. Dadurch werden negative Denkmuster verstärkt, die Menschen daran hindern, sich zu ändern. Diese Ebene des Selbstgesprächs besteht aus Worten wie „ich sollte“, „ich sollte“, „ich muss“. Bei TMS-Patienten sind dies in der Regel Gedanken wie „Ich muss aktiv sein“, „Ich sollte Dinge loslassen“ oder „Ich sollte Sport treiben“. Wenn Menschen diese Aussagen denken oder sagen, meinen sie eigentlich, dass ich aktiv sein muss, aber nicht kann, weil mein Rücken schmerzt, dass ich die Dinge loslassen sollte, aber nicht kann. Diese Gedanken verstärken Schmerz und chronische Krankheitsmuster, die TMS-Symptome hervorrufen. Um von TMS geheilt zu werden, müssen die Selbstgespräche der Ebenen 1 und 2 vollständig aus dem Leben der Betroffenen verschwinden.

Stufe 3 – Die Stufe der Entscheidung zur Veränderung

Die Selbstgespräche der Stufe 3 sind die erste Stufe der positiven Selbstgespräche, die dazu beitragen, Veränderungen herbeizuführen und TMS-Patienten zu heilen. Charakteristisch für diese Stufe sind Sätze wie „Ich habe nie“ oder „Ich will nicht mehr“. Diese Aussagen werden in der Gegenwartsform gemacht, können sich aber auf etwas beziehen, das die Person noch nicht erreicht hat. Ein Beispiel wäre: „Ich habe nie Rückenschmerzen“ oder „Ich werde nicht mehr durch Schmerzen behindert“. Auch wenn die Person, die dies sagt, noch Schmerzen hat, schaffen diese Gedanken neue Denkmuster, die helfen, den Schmerz zu beenden. Indem man routinemäßig sagt, dass man keine Schmerzen hat, wird das Unterbewusstsein einer Person langsam darauf programmiert, zu glauben, dass sie keine Schmerzen mehr hat. Wenn der Verstand auf diese Weise umprogrammiert wird, werden TMS-Patienten keine Schmerzen mehr empfinden, weil ihr Verstand darauf programmiert wurde, keine Schmerzen zu erzeugen.

Stufe 4 – Die Stufe des besseren Du

Von allen Ebenen des Selbstgesprächs ist die Ebene 4 die effektivste, um Veränderungen zu bewirken und chronische Schmerzen und Krankheiten zu beenden. Sie besteht aus Sätzen wie Ich bin. Das Selbstgespräch der Stufe 4 drückt aus, wie eine Person sein möchte, wie sie es bereits ist. Beispiele dafür sind: Ich bin schmerzfrei, ich kann ohne Schmerzen trainieren, ich habe die Kontrolle über meine Gedanken und Gefühle. Indem eine Person diese Aussagen immer und immer wieder macht, programmiert sie ihren Verstand so um, dass diese Situationen entstehen. Eine Person, die chronische Schmerzen hat, wird zu einer schmerzfreien Person. Diese Stufe ist das komplette Gegenteil von Selbstgesprächen der Stufe 1. Anstatt sich auf das zu konzentrieren, was man nicht tun kann, dreht diese Stufe die Sache um und sagt, dass man es tut. Sie erzeugt das gewünschte Verhalten, indem sie Ihren Geist mit positiven Gedankenmustern umprogrammiert.


Der einzige Weg, wie jemand seinen Verstand umprogrammieren kann, ist, keine Selbstgespräche der Ebenen 1 und 2 mehr zu verwenden. Diese Formen der negativen Verstärkung müssen für immer aus dem, was Menschen denken und sagen, entfernt werden. Es gibt verschiedene Techniken, die eingesetzt werden können, um positive Denkmuster für Selbstgespräche zu entwickeln. Viele TMS-Patienten haben Schwierigkeiten, sich einzureden, dass sie schmerzfrei sind, wenn sie tatsächlich Schmerzen haben. Das ist in Ordnung und normal. Wenn eine Person weiterhin positive Affirmationen sagt, selbst wenn sie nicht daran glaubt, programmiert sie damit ihr Unterbewusstsein um, was zu einer Heilung führen kann.

Stummes Selbstgespräch

Stille Selbstgespräche kommen ständig vor. Ein Teil davon ist den Menschen bewusst, ein großer Teil bleibt unbemerkt. Dazu gehören alle Gedanken über uns selbst, an die wir jederzeit denken können. Durch den Einsatz von Selbstgesprächen der Stufen 3 und 4 kann man die Art und Weise, wie man Ereignisse betrachtet und wie man darauf reagiert, anpassen. Das stille Selbstgespräch besteht darin, negative Gedankenmuster in positive umzuformulieren und sie im Stillen vor sich selbst auszusprechen. Wenn Sie aufwachen und Schmerzen haben, sagen Sie nicht: „Ich habe starke Schmerzen und kann nichts tun“, sondern: „Ich bin schmerzfrei und in Kontakt mit meinen Gefühlen. Ich kann alles erreichen und tun, was ich will. Es mag albern erscheinen, aber indem Sie positive Gedanken verstärken, programmieren Sie Ihr Gehirn so um, dass es keine Schmerzen mehr erzeugt.


Jeder Mensch macht jeden Tag Hunderte von Kommentaren und Aussagen über eine Vielzahl von Dingen. Was würde passieren, wenn eine Person sich bemühen würde, jede ihrer Äußerungen positiv zu gestalten? Die Wirkung positiver Selbstgespräche kann einen erheblichen Einfluss darauf haben, wie unser Unterbewusstsein denkt und handelt. Wenn Sie jemandem sagen, dass Sie Schmerzen haben und etwas nicht tun können, teilen Sie Ihrem Unterbewusstsein mit, dass Sie Schmerzen haben und etwas nicht tun können. Dies ist Selbstgespräch der Stufe 1 und sollte immer vermieden werden. Es ist wichtig, dass wir unsere Worte in positive Aussagen umformulieren.


Selbstgespräche sind eine interessante Technik, die einen großen Einfluss darauf haben kann, wie man sich fühlt. Die Technik besteht darin, mit sich selbst zu sprechen und beide Gesprächsenden festzuhalten. Auf diese Weise öffnen Sie mehr Ihrer Sinne und beteiligen mehr von Ihnen an der Neuprogrammierung Ihres Gehirns. Sie können dies überall tun, aber vielleicht möchten Sie es zunächst an einem privaten Ort wie einem Badezimmer tun. Wenn Sie einen Ort gefunden haben, beginnen Sie einfach ein lautes Gespräch mit sich selbst. Stellen Sie sich Fragen und beantworten Sie sie. Eine effektive Möglichkeit, dies zu üben, ist, es am Morgen zu tun. Wenn Sie aufwachen, sagen Sie sich selbstbewusst und laut, dass Sie sich heute großartig fühlen und Ihre Gefühle unter Kontrolle haben werden. Dann antworten Sie: Ja, ich fühle mich großartig, ich werde einen großartigen Tag haben und meine Gefühle unter Kontrolle haben. Setzen Sie dieses Gespräch zwei bis drei Minuten lang fort und machen Sie positive Aussagen über sich selbst und darüber, wie Sie sein wollen. Indem Sie die Worte laut aussprechen, zwingen Sie sich selbst dazu, klar und deutlich zu sagen, wie Sie sich fühlen wollen. Dies hat einen enormen Einfluss auf die Umprogrammierung Ihres Geistes.

Selbstgespräche schreiben

Bei dieser Technik schreiben Sie Ihre Selbstgespräche auf ein Blatt Papier oder eine Notizkarte. Es hilft dabei, die positiven Selbstgespräche zu verstärken und sich auf die positiven Aussagen zu konzentrieren, die Sie aufschreiben. Es ist einfach, aber es kann ein wenig Zeit in Anspruch nehmen. Entwickeln Sie einfach mehrere Selbstgespräche, auf die Sie sich konzentrieren möchten, und schreiben Sie sie auf ein Blatt Papier. Schreiben Sie jede Aussage dreimal und gehen Sie dann zur nächsten Aussage über. Achten Sie auch hier darauf, dass diese Aussagen im Präsens stehen und positiv sind. Ein paar Beispiele sind: Ich habe meine Gefühle unter Kontrolle, ich bin schmerzfrei, ich bin aktiv und kann mit Leichtigkeit trainieren. Indem Sie diese Aussagen aufschreiben, programmieren Sie Ihren Geist darauf, sie zu wahren Aussagen zu machen.


Dies ist eine wirksame Technik, um Ihren Geist neu zu programmieren. Sie besteht darin, eine Reihe positiver Selbstgespräche der Stufen 3 und 4 aufzunehmen und diese Sätze über den Tag verteilt auf einer CD abzuspielen. Wie die selbst geschriebenen Aussagen sollten auch diese Sätze positiv sein und in der Gegenwartsform stehen. Erstellen Sie eine Liste mit etwa zehn Sätzen, die beschreiben, wie Sie sein wollen. Wenn Sie die Sätze aufnehmen, lesen Sie einen Satz dreimal und gehen dann zum nächsten über. Wenn Sie die Liste vervollständigt haben, indem Sie jeden Satz dreimal gelesen haben, gehen Sie zurück und lesen Sie jeden Satz noch einmal, aber ersetzen Sie das Ich durch das Du. Statt des Satzes „Ich bin schmerzfrei“ heißt es jetzt „Du bist schmerzfrei“. Es hat sich gezeigt, dass positive Verstärkung von außen dabei helfen kann, ein Verhalten zu bestätigen. Viele Menschen haben auch festgestellt, dass es hilfreich ist, wenn die Sätze von einer anderen Person gesprochen werden. Bitten Sie einen vertrauenswürdigen Freund oder ein Familienmitglied, die Phrasen für Sie aufzunehmen. Wenn Sie sich nicht wohl dabei fühlen, Ihre eigenen Affirmationen aufzunehmen, können Sie allgemeine Affirmationen auf iTunes kaufen, die denselben Zweck erfüllen. Sie können die Aufnahme abspielen, wann immer Ihnen danach ist. Viele Menschen spielen ihre Aufnahme in einer Schleife ab, wenn sie sich zu Hause entspannen. Indem Sie die Aufnahme im Hintergrund laufen lassen, programmieren Sie Ihre Gedankenmuster um und sagen Ihrem Gehirn, dass es keine Schmerzen mehr erzeugen soll.

Situatives Selbstgespräch

Für diese Form des Selbstgesprächs ist kein Skript erforderlich. Situatives Selbstgespräch zielt darauf ab, Situationen und die Art und Weise, wie Menschen sie betrachten, anzupassen. Es soll den Menschen helfen, ihre Sichtweise auf bestimmte Situationen zu verschiedenen Zeiten in ihrem Leben zu überdenken. Im Gegensatz zu den anderen Methoden zielt das situative Selbstgespräch nicht darauf ab, langfristig umprogrammierte Denkmuster zu entwickeln, sondern versucht stattdessen, die Sichtweise der Menschen auf kurzfristige Ereignisse zu ändern. Wenn jemand zum Beispiel nicht gerne läuft, könnte er sich sagen: „Laufen wird heute Spaß machen. Ich kann das mit Leichtigkeit tun und es genießen. Hinterher denkt man vielleicht, dass es gar nicht so schlimm war. Die Idee hinter dem situativen Selbstgespräch ist es, die Sichtweise auf bestimmte Dinge kurzzeitig umzuprogrammieren, so dass man in der Lage ist, Aufgaben auf positive Art und Weise zu erledigen. Es besteht aus kurzen positiven Sätzen, die immer dann verwendet werden können, wenn sich eine Person in einer Situation befindet, die sie als unangenehm empfindet oder nicht mag. Sie kann erfolgreich dazu beitragen, dass Menschen positiv denken, was langfristig zu einer Umprogrammierung des Gehirns führen kann. Situatives Selbstgespräch kann auch nützlich sein, wenn eine Person auf einen Symptomauslöser trifft. Es ist wichtig, dass eine Person erkennt, was ihre Symptome auslöst, wenn sie beginnt, positive Affirmationen zu verwenden. Wenn eine Person auf einen Auslöser stößt, kann es hilfreich sein, eine situative Affirmation zu verwenden, um den Auslöser zu überwinden. Entwickeln Sie eine Affirmation, die besagt, dass Ihre früheren Auslöser Sie nicht mehr beeinflussen. Wenn man zum Beispiel weiß, dass Sitzen Schmerzen im unteren Rückenbereich auslöst, könnte man sich vor dem Sitzen sagen: „Sitzen ist harmlos. Ich weiß, dass es keine strukturellen Probleme verursachen kann. Ich habe keine Angst vor dem Sitzen und werde weiterhin so viel sitzen, wie ich will. Dies kann einen großen Einfluss auf die Begrenzung der Auswirkungen von situativen Auslösern haben.

Positive Phrasen kreieren

Auch wenn Sie wissen, was Sie an sich selbst ändern möchten, kann es schwierig sein, die richtigen Worte zu finden, um einen positiven Selbstgesprächssatz zu formulieren. Im Folgenden finden Sie Vorschläge, wie Sie Ihre Sätze organisieren und schreiben können.

Setzen Sie Selbstgespräche in die Gegenwart

Es mag seltsam erscheinen zu sagen, dass Sie keine Schmerzen haben, wenn Sie starke Schmerzen haben, aber Aussagen in der Gegenwart sind der beste Weg, um Ihre Gedanken neu zu programmieren. Wenn Ihre Selbstgespräche in der Zukunft stattfinden, z. B. „Ich werde nächste Woche schmerzfrei sein“ oder „Ich wünschte, ich wäre schmerzfrei“, sagen Sie Ihrem Verstand im Grunde, dass Sie jetzt nicht schmerzfrei sind, und verstärken Ihre negativen Gedankenmuster. Wenn Sie Ihre Selbstgespräche in der Gegenwart führen, sagen Sie Ihrem Gehirn, dass Sie tatsächlich schmerzfrei sind, und Ihr Gehirn wird sich darauf einstellen und aufhören, Schmerzen in Ihrem Körper zu erzeugen.

Seien Sie spezifisch

Um den größtmöglichen Erfolg zu erzielen, ist es wichtig, dass Sie Ihre Sätze sehr spezifisch formulieren. Konzentrieren Sie sich auf einen bestimmten Teil Ihres Körpers, der schmerzt, oder auf ein bestimmtes Problem, das Sie haben. Es ist wichtig, mehrere spezifische Sätze zu entwickeln, die darauf abzielen, ein chronisches Problem zu stoppen. Jemand mit Rückenschmerzen könnte die folgenden Selbstgespräche führen:

Ich bin schmerzfrei. Mein Rücken ist stark und gesund. Ich bin in der Lage, alles zu tun, was ich will.

Es ist mir wichtig, mich körperlich zu pflegen. Ich halte mich gerne fit und fühle mich gut.

Ich habe meine Gefühle unter Kontrolle. Ich bin stolz auf mich

Ich genieße das Leben und lebe es in vollen Zügen. Es gibt nichts, was mich daran hindert, mein Leben zu leben.

Mein Rücken hat keine strukturellen Schäden. Er ist stark und gesund.

Ich erlaube mir, mich zu entspannen, mich wohl zu fühlen und aktiv zu sein. Ich genieße es, zu jeder Zeit und unter allen Umständen gesund zu sein

Die Menschen sind gerne in meiner Nähe. Ich habe Selbstvertrauen und Selbstachtung. Ich mag mich selbst und das sieht man.

Dies sind nur einige Beispiele für mögliche Sätze, die verwendet werden könnten. Wichtig ist, dass sie sich auf ein bestimmtes Thema konzentrieren. Indem Sie spezifisch sind, programmieren Sie Ihr Gehirn auf einen bestimmten Aspekt Ihres Lebens, den Sie ändern möchten. Dies kann bei der Eindämmung von chronischen Schmerzen und Krankheiten große Wirkung zeigen.

Unerwünschte Nebeneffekte vermeiden

Wenn Sie ein Skript für positive Selbstgespräche entwickeln, müssen Sie sicherstellen, dass Sie Ihrem Unterbewusstsein sagen, dass Sie Ihre Ziele auf sichere und sinnvolle Weise erreichen werden. Schmerzfreiheit ist zwar ein lohnendes Ziel, aber es ist wichtig, dass die Menschen bei der Erreichung dieses Ziels nicht ihre allgemeine Gesundheit beeinträchtigen. Um sicherzustellen, dass man sein Ziel auf eine sichere Art und Weise anstrebt, muss man seinem Unterbewusstsein sagen, dass es in seinem Streben sicher sein soll. Es wird auch empfohlen, einen Arzt zu konsultieren, um ernsthafte Verletzungen oder Krankheiten auszuschließen, bevor man Affirmationen als Behandlungsmethode einsetzt.

Erstellen Sie leicht zu verwendende Phrasen

Wenn sich eine Person nicht an die von ihr erstellten Phrasen erinnern kann, wird sie sie nicht verwenden können. Es ist wichtig, dass man sich das Skript, das man entwickelt, merken und leicht abrufen kann.

Praktisch sein

Achten Sie bei der Festlegung Ihrer Ziele darauf, dass es sich um praktische Ziele handelt, die leicht erreicht werden können. Wenn Menschen sich unpraktische Ziele setzen und diese nicht erreichen, sind sie manchmal frustriert und setzen den Kreislauf der negativen Selbstgespräche fort. Wenn ein TMS-Betroffener wieder mit dem Laufen beginnen möchte, ist es vielleicht besser, sich das Ziel zu setzen, ein oder zwei Kilometer zu laufen, anstatt einen Marathon zu absolvieren. Nachdem eine Person ihr anfängliches Ziel erreicht hat, kann sie sich zu größeren Zielen hocharbeiten. Es ist jedoch sehr wichtig, dass Sie Ihre Ziele praktisch und erreichbar halten.

Ehrlich sein

Während des gesamten Prozesses ist es von entscheidender Bedeutung, dass eine Person wirklich ehrlich zu sich selbst ist, was ihre negativen Selbstgespräche angeht, und bei TMS-Patienten, was die Hauptursachen für ihre Schmerzen oder chronischen Krankheiten sind. Nur wenn man ganz ehrlich ist, kann man wirklich verstehen, welche Gedanken und Eigenschaften die Symptome verursachen. Die Affirmationen, die man verwendet, sollten diese Ehrlichkeit widerspiegeln und genau beschreiben, was man überwinden muss.

Untersuchen Sie Ihre Selbstgespräche

Um angemessene positive Selbstgespräche zu entwickeln, ist es wichtig zu erkennen, welche Selbstgespräche Sie gerade denken. Konzentrieren Sie sich in den nächsten zwei Tagen auf alle Selbstgespräche, die Sie mit sich selbst führen. Untersuchen Sie jeden Gedanken, den Sie über sich selbst haben, ganz gleich, ob er positiv, negativ oder neutral ist. Erkennen Sie, wie Sie auf Situationen und Ereignisse reagieren, und machen Sie sich klar, wann Sie positiv oder negativ reagieren. Was bewirkt Ihr Selbstgespräch? Gibt es Ihnen Selbstvertrauen und baut es Sie auf, oder macht es Sie unsicher und gibt Ihnen das Gefühl, nichts tun zu können? Es ist wichtig zu verstehen, wie sich Ihre Gedanken und alltäglichen Ereignisse darauf auswirken, wie Sie sich selbst sehen.

Selbstgespräche von anderen

Es kann hilfreich sein, zu verstehen, wie andere mit sich selbst reden. Beobachten Sie, was andere Menschen sagen und tun, und untersuchen Sie, wie das auf sie wirkt. Es ist sehr einfach zu verstehen, welche Auswirkungen negatives Selbstgespräch auf jemanden haben kann, wenn man andere Menschen beobachtet. Versuchen Sie auch zu verstehen, wer die Kontrolle über die Gefühle anderer hat. Wie werden die Gefühle anderer Menschen durch äußere Kräfte beeinflusst? Untersuchen Sie schließlich das soziale Gerede, das die Prioritäten auf soziale Normen und Erwartungen setzt. Ein gängiges Beispiel hierfür ist „mit den anderen mithalten“. Untersuchen Sie, wie sich soziale Normen und soziales Gerede darauf auswirken, wie Sie sich selbst sehen und wie Sie mit sich selbst reden.

Listen Sie Ihr früheres negatives Selbstgespräch auf

Um neue positive Denkmuster zu entwickeln, ist es wichtig, dass Sie Ihre alten negativen Denkmuster erkennen. Machen Sie eine Liste mit etwa zehn negativen Selbstgesprächen, die Sie sich in der Vergangenheit regelmäßig eingeredet haben. Denken Sie daran, dass es sich bei diesen negativen Denkmustern um Selbstgespräche der Stufen 1 und 2 handelt. Sie sollten aus Sätzen bestehen wie „Ich kann nicht“, „Nichts läuft so, wie ich will“ oder „Wenn ich nur könnte“. Diese Gedankenmuster setzen den Kreislauf von chronischen Schmerzen und Krankheit fort. Es ist wichtig zu untersuchen, worum es sich dabei handelt und wie sie sich auf bestimmte TMS-Symptome auswirken. Nachdem Sie Ihre bisherigen negativen Selbstgespräche aufgelistet haben, gehen Sie die Liste durch und ändern Sie jedes einzelne in ein positives Selbstgespräch der Stufe 3 oder 4. Anstatt zu sagen, ich kann nichts richtig machen, sagen Sie, ich kann alles machen, was ich mir vornehme. Statt „Ich kann heute nicht trainieren, weil mein Rücken schmerzt“, sagen Sie „Mein Rücken ist stark und gesund. Ich bin aktiv und treibe regelmäßig Sport. Indem Sie diese negativen Sätze in positive Sätze umwandeln, senden Sie Ihrem Gehirn die Botschaft, dass Sie sich nicht länger von diesen negativen Gedanken beherrschen lassen, sondern positive Gedanken entwickeln werden, die Ihnen ein schmerzfreies Leben ermöglichen.

Mit dem Gehirn reden (es anschreien)

Mit Ihrem Gehirn zu sprechen kann eine wirksame Strategie sein, um TMS zu vereiteln. Dies kann im Stillen oder laut geschehen (wenn Sie allein sind). Schließen Sie die Augen und versuchen Sie, sich Ihr Gehirn vorzustellen. Dann beginnen Sie einen einseitigen Dialog mit ihm. Sie können damit beginnen, Dinge zu sagen wie: „Mein Rücken/Beine/Arme sind normal“, „Ich weiß, dass du die Sauerstoffzufuhr zu meinem Blut einschränkst.“ „Bitte hör auf.“ Oder Sie können versuchen, energischer zu sein: „Hör auf, den Sauerstoff in meinem Blut abzuschneiden!“ „Ich muss heute meine Arme benutzen, um den Blutfluss zu erhöhen!“ Probieren Sie verschiedene Dinge aus, bis Sie herausfinden, was für Sie am besten funktioniert.

IFS and Chronic Pain

Listening to Inner Parts that Hold the Hurt

Richard Schwartz Ronald Siegel Howard Schubiner

Susan is a dance teacher in her mid-30s who performs regularly. For years now, she’s lived in constant fear that her back will go out. She’s haunted by chronic low-level backaches, which flare up without warning every few months, turning into days-long bouts of excruciating pain.

Two years ago, on the day of a big recital, she could barely get out of bed. Her right side was spasming, and even tying her shoes was a challenge. She managed to muddle through the final dress rehearsals and the show itself while tanked up on benzodiazepines and pain medications. But as soon as she got home, she crawled into bed and stayed there for two weeks.

In the aftermath of that dreadful episode, Susan’s general practitioner prescribed more meds and referred her to an orthopedist, who suspected bulging disks with scoliosis. Convinced that her back was vulnerable and needed protecting, she started sleeping with pillows under her knees, carrying a special cushion in her car, and not lifting heavy objects. She went so far as to give up jogging and bike riding. She stared compulsively strengthening her core in an attempt to compensate, and warming up for hours before performances—much longer than any of the other dancers.

No matter how stringently she cared for it, however, her back never felt fully healed. She eventually went in for an MRI, and the results showed that the wear and tear on her discs was typical of people her age, most of whom experienced no back pain at all because of it.

Though others might’ve been comforted to learn this, Susan was upset. Why was she so riddled with pain when others weren’t? She started to feel desperate. Who, she thought with some dread, would believe her pain and help treat it now?

Seeing Pain Clearly

When in physical pain, we understandably think that there’s a structural cause for our suffering. But to the surprise of doctors and patients alike, research suggests this often isn’t the case. It turns out that most chronic pain, and an astonishing variety of other medical maladies, have little to do with damaged tissues or untreated infections. They’re maintained by complex mind–body interactions, in which our brain’s natural proclivity to avoid pain traps us.

We’ve begun to learn, for example, that histories of childhood sexual or physical abuse are significant risk factors for chronic back pain, and that job dissatisfaction is a much stronger predictor of it than having a job that requires heavy lifting, lots of sitting, or other physical strains. We’ve seen placebos turn out to be effective treatments for countless pain syndromes and related disorders; and for some maladies, such as irritable bowel syndrome, they can work even when people know that they’re taking a placebo.

When we’re anxious, states of chronic fight-or-flight arousal can disturb the normal function of our organs. We see this when anxiety causes our stomachs to produce too much acid and gives us heartburn, or our intestines to dysregulate and bring on irritable bowel syndrome, or our muscles to seize and result in chronic back pain. Sometimes, even when our physical systems are functioning normally, our brains actually produce or amplify pain and other troubling sensations either out of fear or to fulfill psychological needs.

Effective treatment of chronic pain involves understanding the roles that psychological factors play and finding ways to address them. One particularly useful way to do this is through Internal Family Systems therapy (IFS), a psychotherapy that’s rooted in a clear understanding of the interplay of psychology and the body. IFS is based on the observation that each of us comprise many psychological “parts,” seen as valuable members of an inner family, which exist to help us thrive and to protect us from pain.

Trauma and attachment injuries, however, force many of our parts into serving functions that can be problematic. One such group of parts, called exiles, are young and vulnerable, and carry early emotional injuries (what IFS calls burdens), such as a sense of worthlessness, terror, or emotional hurt. Before the trauma, they were the lively, creative “inner children,” but after they began to carry the burdens of trauma, we locked them away to keep them from overwhelming us with their raw emotions and vulnerability.

Once we develop exiles, the world feels more dangerous, and we feel more fragile being in it. As a result, another group of parts tries to protect our exiles from getting triggered. To do that, these protector parts take on roles like the harsh internal critic, the overachieving perfectionist, or the frightened avoider. In IFS terminology, these protectors function as managers, dictating our day-to-day activities to make sure our exiles don’t get emotionally injured.

During times of increased stress, when these managers can’t adequately manage our emotional pain, another set of protectors, termed firefighters, jump into action at an even higher level of defense. Firefighters are emergency responders, and their activities include acute depression and suicidal thoughts, cutting, binging, alcohol or drug use, and panic attacks. Both protector-managers and firefighters may use physical pain to protect our exiles.

Susan eventually found her way to an IFS therapist, who helped her understand that her fears and resulting avoidance of normal movement were playing a role in her ongoing struggle with pain. Therapy focused on exploring the parts of her that were driving this behavior.

In one session, Susan zeroed in on what she called her pusher part, which she physically located in her forehead. When she listened to it closely, she learned that it was young, feisty, and determined to conquer her back problem, no matter what. She said she relied on this pusher because it had helped her succeed in school and was responsible for her success as a dancer, teacher, and businessperson. It was diligent and obsessive, and once it identified a goal, it pursued it at the expense of all competing needs. This part was going to fix her back pain at any cost.

After compassionately validating this part’s desperation and asking it to step aside for a moment, Susan noted a very vulnerable exile that her pusher part was working to protect. This part was even younger—an innocent little girl, who’d fallen, hurt herself, and felt helpless and alone. It was hard for Susan to stay with this part, who longed for a mommy or daddy to hold and comfort her. It’s not that Susan’s parents weren’t caring, just that they’d communicated to her from as far back as she could remember that people shouldn’t wallow in their misery. She realized that this made it feel unsafe to be in pain, so she’d panic whenever she started to feel any. Beneath her panic, she realized this part was frozen in time.

This discovery led Susan to notice another part that also didn’t get much attention in her daily life: a nurturing part, which was pretty good at holding her own daughter when she was in distress. This maternal part could be with her daughter’s pain without immediately needing to fix it. She recognized that while she could provide that kind of nonjudging compassion to her daughter, her pusher part wouldn’t let her do that for herself.

Connecting with these different parts, Susan began to find it easier to risk giving up her vigilant, fearful approach to her back pain. She began to see that when she could relax into resuming normal activities, her fear around her back diminished, and this shift made it less likely that she’d have another episode.

She also realized that her back going out before the recital was related to her fears of things going wrong that day: fears of experiencing her vulnerable, tender part, who sometimes just wanted mommy or daddy to hold her. She discovered that the more she could connect with this young part, the more her capacity for wise and compassionate awareness and action (called Self in IFS) could care for it, thereby making the prospect of another back episode less terrifying.

Eventually Susan gave up her back props, began sleeping normally in her bed, and went back to riding her bike and jogging. She now understands that she may have another back spasm, but she feels better equipped to deal with it. Her vigilant, diligent pusher part can relax more, and she has confidence that she can self-nurture when she needs to. In fact, she’s come to view recurrences of back pain as an alarm or a barometer of a vulnerable part being activated by challenging situations.

How Do We Know if Pain Is Psychological?

Before treating chronic pain psychologically, tumors, infections, inflammatory conditions, and other physiological conditions need to be ruled out. That said, most patients with chronic pain don’t actually have dangerous medical disorders. Rather, they’ve probably received other kinds of worrisome diagnoses, like tension or migraine headaches, trigeminal neuralgia, fibromyalgia, small fiber neuropathy, irritable bowel syndrome, interstitial cystitis, pelvic floor dysfunction, pudendal or occipital neuralgia, bulging or herniated disks, or functional dyspepsia. More holistic practitioners might’ve offered alternate diagnoses such as adrenal fatigue, chronic Lyme disease, leaky gut syndrome, toxic heavy metal accumulation, or candida overgrowth.

It’s useful to inform patients that most of these terms merely describe the condition: they don’t reveal its cause. Helping clients understand that they don’t have something dangerous, incurable, or necessarily disabling is an important first step in treatment. This relaxes their protector parts and helps them trust that returning to normal activities is safe and even wise.

The next step is to look for clues that will help them see that their mind might be playing a role in their distress, such as pain that comes and goes, shifts location, or gets triggered by innocuous activities or stimuli, such as lights, sounds, weather changes, and foods. Pain that’s widespread or spreads over time in a pattern that isn’t typical for known diseases—like a whole arm or leg, or one side of the body—is also likely to be psychologically induced.

If clients have had other mind–body disorders, such as anxiety, depression, eating disorders, chronic fatigue, and other pain-related syndromes, the probability that their pain is psychophysiological increases. Finally, if there’s a history of adverse childhood events or a client can trace the onset of symptoms to significant life stressors, it’s even likelier that the mind is playing a major role.

Frightening medical diagnoses often lead to depression and frustration, further activating an already overactive fight-freeze-flight system.

Desperate Parts Chasing Futile Treatments

Many patients with chronic pain have devoted their lives to finding cures. They may have begun with conventional medical evaluation and treatment, which itself can make things worse. When their condition is diagnosed as being due to structural problems, they may wind up enduring unnecessary procedures while painful symptoms spread and worsen. Frightening diagnoses often lead to depression and frustration, further activating an already overactive fight-freeze-flight system.

Many have spent a great deal of money and time seeking additional tests and alternative treatments. Some of these may have shown promise for a while, since the hope of relief helps reduce the fear that so often plays a role, but when they fail to provide truly lasting relief, patients sink back into despair.

Henry was a successful engineer in his mid-60s, who struggled with chronic back pain that had started after a football injury in his youth. His pain disabled him for decades, preventing him from lifting his children or enjoying sports. He eventually had the good fortune to encounter a rehabilitation team that convinced him his so-called MRI abnormalities were often found in the pain-free population, and subsequently helped him regain full physical functioning.

Soon after he’d gotten over his fear of back pain, however, his knee started to hurt. He tried to push through it, but that seemed to make things worse. He began to fear that after finally getting over his back disability, now he’d be disabled by his knee.

Henry began to see specialists, traveling hundreds of miles to consult with the best knee surgeons, rehabilitation doctors, and physical therapists. He sought out acupuncture, massage, braces, taping, and every conceivable stretching and strengthening exercise. None of his imaging showed damaged structures other than typical mild osteoarthritis, but this didn’t stop the various practitioners from offering interventions. Each of these would help for a bit, but then his pain would return. The pain even spread to the other knee—which really scared him.

Near the end of his rope, Henry decided to see if psychological forces might be contributing to his condition. When his therapist first met with him, she asked him to stop pursuing physical cures for six months to create an opportunity to explore his emotional landscape instead.

The first of Henry’s parts they encountered in their work together was desperate to find a cure. It was obsessive, determined, indefatigable. What did this part fear would happen if it didn’t continue to investigate every possibility? That at 66, he’d stop being able to enjoy a physically active life.

As is often the case, this obsessive, treatment-seeking part was protecting another, deeply wounded part—one that had suffered through many years of back-related disability. As he connected to his vulnerability, torrents of tears came. He remembered all the opportunities he’d missed because of back pain, all the moments of feeling like a failure as a father and a husband. This exiled part carried the deep humiliation of his wife having to carry the groceries and laundry for years, while his son resigned himself to having a dad who couldn’t even toss a baseball.

We worked to understand, hold, and comfort this deeply wounded part in therapy. As that part was acknowledged, Henry’s desperate treatment-seeking part could begin to relax. Of course, he wanted his knee pain to go away, but perhaps this wasn’t a binary situation. Perhaps he could tolerate some knee discomfort as he continued to lead an athletic life as an older man.

Changing Minds about What Pain Is

To get clients to believe that their mind might be powerful enough to produce their pain often requires some psychoeducation.

It’s useful to explain that so-called spinal abnormalities aren’t so abnormal after all. As Susan discovered, some 50 percent of 30-year-olds and 80 percent of 50-year-olds who have absolutely no back pain show evidence of “degenerative disc disease” on an MRI.

Spinal stenosis is common in older pain-free individuals, while scoliosis, leg-length discrepancies, mild osteoarthritis, and imbalance in muscle group activations can be found in people of all ages without chronic pain. These findings are often coincidental to chronic pain, rather than causative.

There’s also evidence that structural interventions, including surgery, often fix the structural issue, such as a bulging or herniated disk, without improving patients’ pain. But vigorous exercise is often helpful, too, which wouldn’t make sense if the body were really injured, as are a wide variety of alternative interventions that influence the mind, rather than the body. This all suggests the powerful effect of placebo and expectation, and that pain does not necessarily equal injury or disease. But it’s important to explain this to clients in a way that doesn’t invalidate their experience.

It can be helpful to share with clients the evolution of our scientific understanding of pain. For centuries, physicians assumed that, as Descartes had suggested in the 1600s, pain was like a rope pulling on a bell. Something happens to disturb tissues somewhere in the body, nerves transmit that information to the brain, and we experience pain.

During World War II, however, the Harvard anesthesiologist Henry Beecher noticed that soldiers with serious injuries who were being carried off the battlefield alert, awake, and not in shock, often refused morphine, whereas in civilian practice, patients with far less severe injuries were in agony. This led to the laboratory exploration of how psychological factors—like the difference between being relieved to be leaving the battlefield versus fearing going into surgery—could radically affect the experience of pain.

One classic experiment involved ice water. If you tell subjects that they’ll need to submerge their hand for 30 seconds and ask them after 20 seconds to rate their pain, they’ll typically report “not too bad.” Duplicate the experiment but tell subjects that they’ll need to submerge their hand for 10 minutes, and after 20 seconds they’ll tell you it really hurts and yank their hand out.

Placebo studies offer another useful perspective to help clients grasp the influence of the mind on pain. In the 1950s, for example, a woman struggling with pregnancy-related morning sickness was told there was a miracle drug to cure it, and after being given syrup of ipecac (which typically makes people vomit), felt her nausea resolve. More recently, patients who received small arthro­scopic incisions (the placebo group) got as much relief from knee pain as those who received standard arthroscopic surgery. In fact, placebos can be so powerful for subjective symptoms that drug manufacturers often struggle to demonstrate that active medications are more potent.

Body pain

Our brains alert us to emotional distress through the same pathways they use to tune us into physical injury—and both types of pain can feel equally intense.

Feelings Can Really Hurt

What’s often surprising to clients is how much emotional pain and physical pain are intertwined. In fact, our brains have evolved to alert us to emotional distress through the same pathways they use to tune us into physical injury, and both types of pain can feel equally intense. We’ve all felt the common physical effects of emotional upset: tension in our neck and shoulders, headache, nausea, or abdominal discomfort.

Our brains use a process known as predictive coding to decide which situations will activate the neural networks to create pain, and conditioned expectations play a central role. If little Frankie had a bad reaction to a needle poke for a blood draw, he’s likelier to start crying when he sees the needle for a vaccination—and he’s likely to experience increased pain at subsequent needle pokes as an adult. Similarly, if Tracy was the victim of emotional abuse in an early marriage and at the time experienced headaches and nausea as a result, she’s likelier to develop the same symptoms when in a new relationship that’s becoming serious. Pain is thus a subjective experience created by the brain, heavily influenced by beliefs, fears, and other psychological processes.

The concept of predictive coding helps explain how acute pain can become chronic. After you experience a trauma, parts of you continue to view new situations in your life through their distorted trauma-based lenses, interpreting subsequent events as dangerous, even if they’re unrelated to the initial events. They become frozen in the time of the trauma and consequently believe you’re still in constant danger.

Over time, these desperate parts alert us to what they believe to be dangerous emotional situations, not through obvious alarms, such as anxiety and insomnia, but through less obvious, physical ones, such as fatigue, urinary frequency, nausea, and numbness, tingling in the hands or feet, and pain. If trauma happens in conjunction with certain foods, weather conditions, or other external factors, such as light, sound, smell, or touch, young parts can form neural connections that trigger pain in response to those stimuli, which can lead to significant avoidance behavior and impairment.

Finally, the response an individual has toward pain plays a critical role in whether pain becomes chronic.

Common and completely understandable reactions to pain include fear of it, obsessive focus on it, becoming frustrated by it, wanting to fight it, dissociating from it, and trying to fix it. All these responses suggest to our brains that the pain is, in fact, dangerous, and, as a result, make it more trenchant.

Parts Expressing Unmet Needs Through Pain

Needs like rest, self-care, and intimacy are often overridden by parts that view performance, achievement, caretaking, or some other building block of self-esteem to be paramount. But the neglected needs don’t just go away: they press for expression, sometimes by generating chronic pain.

When that’s the case, recognizing these unmet needs is necessary for effective treatment. This was the case with most of the subjects in a study using IFS to treat rheumatoid arthritis.

A group of 37 chronic rheumatoid arthritis patients received nine months of group and individual IFS therapy. They were compared to a control group of 40 rheumatoid arthritis patients who received only an educational intervention. The results were impressive. The IFS treatment group showed significant improvement in overall pain and physical function, as measured by blinded physicians and blood tests, as well as in self-assessed joint pain, self-compassion, and depressive symptoms.

Unlike most other psychological approaches to working with pain by focusing on the stress believed to be causing it, the therapists in this study took the bold step of asking subjects to focus on the pain itself, become curious about it, and ask what it wanted them to know. The subjects, many of whom were Irish Catholic mothers from Boston, did this readily and were often shocked by what they learned.

Forty-nine-year-old Mary, for instance, had arthritis so severe that she was using a walker, and her hands and knees were chronically aching. She rarely let anyone know how much she was hurting, instead remaining the upbeat matriarch to whom everyone in the family turned for care. The idea of talking to her pain initially seemed absurd to her, but she said she was so desperate that she was willing to try anything. When, from a place of genuine curiosity, she asked the pain in her wrist what it wanted her to know, it said, “I hate you!”

Startled, she managed to remain curious and asked the pain why. “You do things for everyone else and never us,” it told her. In that and ensuing sessions, Mary learned that she wasn’t talking to the pain itself but to the parts of her that were using the arthritis to try to get her attention and punishing her because they were so frustrated with her incessant caretaking.

The therapist then had Mary focus on her caretaker part, which she initially insisted was just herself, and ask it why it never let up. It showed her images of the women in her family, all of whom had been caretakers themselves and most of whom had arthritis. Thus, caretaking was what is called a legacy burden in IFS. The part also showed scenes of her as a child waiting on her mother, who was so incapacitated by the arthritis that she’d been in a wheelchair through most of Mary’s childhood. Her father, an alcoholic who spent most of his time at work or at a local bar, would come home drunk and scare the family with angry ravings. The compulsive caretaking part was driven by that child part’s belief that she was worthless, aside from her ability to please and nurture everyone.

As Mary helped retrieve that child from those dreadful scenes and unburden those beliefs, she began listening more to the assertive parts that were using her pain. She embarked on making important, initially disruptive changes in her home, but with the support of her therapist, she persisted. By the end of the study, the pain in her wrists and knees was negligible—she no longer needed a walker—and stayed that way through the follow-up.

Some of Mary’s parts were trying to get her to face how imbalanced her life was. Not only was she in exploitative relationships, but her caretaker part had taken on so much responsibility that her body was in a state of constant stress and exhaustion. These pain-provoking parts were like inner rebels, who wanted to create a coup and make her prioritize the well-being of her neglected inner family over her external one.

In some other subjects in the study, these rebels had become like terrorists who were so angry at the oppressive caretaking that they were simply punishing or sabotaging the subjects, creating enough pain and disability that they’d no longer be able to care for everyone else in their life. For others, the pain-provoking parts used the arthritis to try to achieve two things the caretaker parts wouldn’t allow: to get people to nurture them without having to ask directly, and to set boundaries by giving people an excuse to say no because they wouldn’t otherwise. All these parts were expressing how much they hated and felt oppressed by the massive caretaking parts that dominated the subjects’ lives.

The therapists then helped subjects get acquainted with their extreme caretaking parts. As they did, they learned that these parts believed that their main value as human beings was wrapped up in that role. If they took care of everyone else, they were worthy of existing, but if they asked for anything for themselves, they were selfish. When subjects asked the caretaking parts where they got those ideas, not only did they remember times when they were given the message that caretaking is what women did, but they often began seeing themselves as children who’d been abused or neglected, and whose experiences had left them with the belief that they were worthless.

In this way, they found parts that were frozen in those dreadful scenes, carried the burden of worthlessness, and had been locked away inside so that the subject didn’t constantly feel a sense of shame. These locked-away inner children, known as exiles in IFS, can powerfully and unconsciously mold people’s lives.

For some clients, pain became a window into a fascinating inner world of parts. When parts trust us to listen to them, they no longer need to use pain to communicate with us.

Parts Distracting from Exiles

It’s not just caretaking women who exile inner parts amid pervasive patriarchy. Exiling can result from typical male socialization, in which men are left with emotional repertoires limited to anger or sexual interest—with sadness, fear, or vulnerability banished from conscious awareness. For some men, even feelings and behaviors typically construed as male are off limits. Whatever the disavowed emotion may be, when it threatens to surface, the body will react as though it’s in danger.

Take Jorge, for example, a bookkeeper in his mid-40s, who, by everyone’s account, was “a nice guy”—remarkably pleasant and helpful. He hadn’t always been this way, though. As a boy, he’d gotten into trouble a lot for fighting at school, and he’d often felt like a misfit.

His father, however, was highly critical and insisted on good behavior, so by the time he was a teenager, Jorge had begun to conduct himself in an exemplary manner. As an adult, he made a point of being on time, eating a healthy diet, exercising regularly, and keeping his apartment organized. His reports at work were so complete and accurate that his boss used them to train new employees.

Yet even though Jorge was healthy and exercised regularly, he’d been suffering from frequent headaches for a decade. He’d had several MRIs of both his brain and neck over the years, but all the tests had come back normal, with the only finding being that his neck muscles were chronically tense. Complicating matters more was the fact that when Jorge found himself in stressful situations, on top of the headaches he’d also have abdominal pain and loose stools.

In therapy, it soon became clear that Jorge’s emotional life was seriously restricted. While he felt lonely and was often anxious, he never got angry at anyone, and hardly ever felt excitement or joy.

Jorge had told many doctors the story of his headaches and had received numerous medication prescriptions and even trigger-point injections. But no doctor had asked how he was feeling emotionally or what events were occurring in his life when the pain first appeared. As it turns out, when Jorge was 35, he was deeply in love. He got up the courage to ask his love to marry him, but she turned him down, and they broke up.

In working with Jorge, his therapist found that this heartbreak wasn’t the only issue in play. Suspecting that his pain might be related to his difficulty connecting with anger, his therapist began doing some parts work with him, starting with a “good” part—one that always wanted to do the right thing. It didn’t take long to identify what might happen if that part wasn’t performing its duties. His angry part, though locked away, was quite threatening. If his “good” part didn’t keep it in check, who knew what might happen?

Jorge had lots of images of himself as a kid, getting into all sorts of trouble for yelling and fighting. After convincing the “good” part to step aside to allow him to interact with young Jorge more, this angry part quickly came alive. When asked to reflect on the time that his chronic pain had arisen, the conflict became apparent. Along with feeling hurt when his beloved had rejected him, Jorge’s’ angry part was very much activated by her refusal. But having long ago exiled that part, and feeling threatened by it, headaches ensued.

We can understand this process in a couple of ways. One is simply that the fear of the angry part emerging created some combination of tension in his neck muscles, changes in blood flow in his head, and activation or amplification of pain circuits. Another way to see it is that his “good” part generated the pain to distract attention from—and protect him from—his angry part. Of course, it’s possible that the cause of his pain was a combination of these mechanisms.

The important point is that by connecting with and accepting his different parts, Jorge was able to allow his angry feelings to arise and then to befriend them. He came to see that his anger made sense, given his father’s overly demanding attitude. More at home with his angry part, he even found a way to talk to his dad about his experience. Over time, this allowed him to relax and his pain to diminish.

What Pain Teaches

It’s difficult for us to ignore severe pain, which can overwhelm our senses and render all other priorities moot. This makes it an excellent tool for any part that wants to be heard or to control a person. Pain can keep us from getting close to emotional situations that evoke childhood events deemed too upsetting to face; or it can help us avoid emotions deemed dangerous, such as anger, fear, and sadness. It can arise when boundaries are challenged by unwanted sexual interests or by getting lovingly close to others. It can distract us from feelings that we fear might make us crumble or act in dangerous ways.

Pain can also bring us secondary gains, like avoiding situations likely to create emotional conflicts. It doesn’t usually begin for this reason—rather with a random injury or illness—but our parts, unbeknownst to us, often learn to use pain to accomplish all sorts of aims and keep us from feeling vulnerable, lacking, or overwhelmed.

When the pain is emanating from parts, fighting with them typically backfires. That’s why we encourage approaching all parts that are involved in the creation and persistence of pain with curiosity and compassion. Compassion helps us access underlying burdens and integrate previously split off or disavowed experiences.

We can use parts work to help patients develop a mindful, accepting awareness of painful sensations, appreciate pain for its importance in protecting and messaging, and reengage in life-affirming activities. Many patients gain significant relief from addressing the parts that contribute to avoiding normal activities and fighting pain sensations. Others need to translate the message that the pain may be trying to communicate. This usually leads to exploration of previously unrecognized longings, fears, injuries, and life imbalances. It often connects clients to childhood or later traumas that have never been fully integrated. While it’s not always necessary to integrate all of these to transform a chronic pain syndrome, recognizing them can help avoid recurrences.

In many cases, allowing these parts to speak transforms the pain and often resolves the disorder entirely. Many of our clients say some version of how they wouldn’t wish the pain on their worst enemy, but they’re glad for the psychological growth it prompted. For them, pain became a window into a fascinating inner world of parts they had no idea existed. These clients come to learn something invaluable—when parts trust us to listen to them, they no longer need to use pain to communicate with or punish us.



Richard Schwartz

Richard Schwartz, PhD, is co-author, with Michael Nichols, of Family Therapy: Concepts and Methods, the most widely used family therapy text in the United States. Dr. Schwartz developed Internal Family Systems in response to clients’ descriptions of experiencing various parts–many extreme–within themselves. He noticed that when these parts felt safe and had their concerns addressed, they were less disruptive and would accede to the wise leadership of what Dr. Schwartz came to call the “Self.” In developing IFS, he recognized that, as in systemic family theory, parts take on characteristic roles that help define the inner world of the clients. The coordinating Self, which embodies qualities of confidence, openness, and compassion, acts as a center around which the various parts constellate. Because IFS locates the source of healing within the client, the therapist is freed to focus on guiding the client’s access to his or her true Self and supporting the client in harnessing its wisdom. This approach makes IFS a non-pathologizing, hopeful framework within which to practice psychotherapy. It provides an alternative understanding of psychic functioning and healing that allows for innovative techniques in relieving clients symptoms and suffering.

Ronald Siegel

Ronald D. Siegel, PsyD, is an Assistant Clinical Professor of Psychology at Harvard Medical School, where he has taught for more than 25 years. He is a longtime student of mindfulness meditation and serves on the Board of Directors and faculty of the Institute for Meditation and Psychotherapy. He teaches internationally about mindfulness and psychotherapy and mind/body treatment, has worked for many years in community mental health with inner city children and families, and maintains a private clinical practice in Lincoln, Massachusetts. Dr. Siegel is co-author of the self-treatment guide Back Sense, which integrates Western and Eastern approaches for treating chronic back pain; co-editor of the critically acclaimed professional text, Mindfulness and Psychotherapy and author of the new step-by-step comprehensive guide for general audiences The Mindfulness Solution: Everyday Practices for Everyday Problems,

Howard Schubiner

Howard Schubiner, MD, is an internist at Providence Hospital and a professor at Michigan State University.  He’s the author of Unlearn Your Pain, Unlearn Your Anxiety and Depression, and coauthor of Hidden From View.

Chronic pain is mostly mental

I Have to Believe This Book Cured My Pain
—A science writer investigates the 30-year-old claims of an iconoclastic doctor who said
chronic pain was mostly mental.
By Juno DeMelo
New York Times, Nov. 10, 2021
Every time someone tells me their back’s been giving them trouble, I lower my voice
before launching into my spiel: “I swear I’m not woo-woo, but … ”
Let me rewind a bit. For more than a decade, I had a near-constant throbbing in my left
piriformis, a small muscle deep in the butt. I tried treating it with physical therapy,
ultrasound and Botox injections. At one point, I even considered surgery to cut the
muscle in half in order to decompress the sciatic nerve that runs underneath.
Then, in 2011, I picked up a library copy of the 1991 best seller “Healing Back Pain: The
Mind-Body Connection.” It claimed that, in order to distract the sufferer from repressed
anxiety, anger or feelings of inferiority, the brain creates pain in the neck, shoulders,
back and butt by decreasing blood flow to the muscles and nerves.
The book’s author, Dr. John Sarno, was a rehabilitation physician at New York
University and something of an evangelist, touting a methodology bolstered by
anecdotes from his practice and passionate testimonials from patients like Howard
Stern or Larry David, who described his recovery from back pain as “the closest thing
that I’ve ever had in my life to a religious experience.”
According to Dr. Sarno, nearly all chronic pain is caused by repressed emotions. By
undergoing psychotherapy or journaling about them, he said, you could drag them out
of your unconscious — and cure yourself without drugs, surgery or special exercises. I
chose journaling and began writing pages-long lists of everything I was angry, insecure
or worried about.
I appreciated the tidy logic of Dr. Sarno’s theory: emotional pain causes physical pain.
And I liked the reassurance it gave me that even though my pain didn’t stem from a
wonky gait or my sleeping position, it was real. I didn’t like that no one in the medical
community seemed to side with Dr. Sarno, or that he had no studies to back up his
But I couldn’t deny it worked for me. After exorcising a diary’s worth of negative feelings
over four months, I was — in spite of my incredulousness — cured.
I didn’t think much about Dr. Sarno after that until May of this year, when I found
myself back in physical therapy for a pain in my inner thigh. My physical therapist
assigned me a handful of exercises, and I did them every day. The whole time, I worried:
If physical therapy failed again, would I have to go back to exhaustively cataloging my
woes? Did Dr. Sarno’s claims even hold water?
Pain often starts in the brain.
“The idea is now mainstream that a substantial proportion of people can be helped by
rethinking the causes of their pain,” said Tor Wager, a neuroscience professor at
Dartmouth College and the director of its Cognitive and Affective Neuroscience Lab.
“But that’s different than the idea that your unresolved relationship with your mother is
manifesting as pain.”
Dr. Wager said most scientists now believe that pain isn’t always something that starts
in the body and is sensed by the brain; it can be a disease in and of itself.
Approximately 85 percent of back pain and 78 percent of headaches don’t have an
identifiable trigger, yet few scientists would say that all or even most chronic pain is
purely psychological. “There are also social and biological reasons for pain. In most
people, it’s some confluence of the three,” said Daniel Clauw, a professor of
anesthesiology, medicine and psychiatry at the University of Michigan and the director
of its Chronic Pain & Fatigue Research Center. “I’m sorry, there are a bunch of people
for whom Sarno’s method isn’t going to work.”
Today, a similar approach to Dr. Sarno’s method is emotional awareness and expression
theory, in which patients identify and express emotions they’ve been avoiding. It’s not
only been shown to significantly lower pain in people with fibromyalgia and chronic
musculoskeletal pain, it’s also considered a best practice for treating chronic pain (along
with massage and cognitive behavioral therapy) by the Department of Health and
Human Services.
Pain can take on a life of its own.
But how does the brain cause chronic pain in the first place? Dr. Sarno’s theory that our
brain uses pain to distract us from negative emotions by cutting off blood flow to the
muscles is not backed up by science, according to Dr. Wager.
Instead of blood flow, scientists now look to the nervous system to understand chronic
pain that isn’t caused by nerve or tissue damage. Basically, your brain circuitry
malfunctions, prolonging, amplifying and possibly even creating pain.
Dr. Wager said we don’t fully understand the mechanisms of this, but “we do know that
stressors can promote inflammation in the spinal cord and brain, which is linked to
greater pain sensations.” Early adversity, such as child abuse, economic hardship,
violence and neglect, has also been linked to chronic pain.
Complicating things further: Pain can beget more pain. For example, an injury may turn
up the volume on your pain response to future injuries. Stress may cause pain to persist
long after an injury has healed. And if your back twinges and you start imagining all the
ways it could get worse, that fear can magnify your pain, which may lead you to avoid
physical activity, which then makes the pain even worse. Experts call this the pain cycle.
Here, Dr. Sarno’s notion of the brain triggering pain was partially right. Research shows
that catastrophizing can turn acute pain into chronic pain and increase activity in brain
areas related to anticipation of and attention to pain. This is one of the reasons
clinicians are starting to treat pain disorders similarly to, say, anxiety disorders,
encouraging patients to exercise so they can overcome their fear of movement. Whereas
a socially anxious patient might take small steps toward talking with strangers, for
instance, a patient with back pain might start jogging or cycling.
You can find the off switch.
The bottom line, according to Dr. Howard Schubiner, a protégé of Dr. Sarno, is that “all
pain is real, and all pain is generated by the brain.” Today Dr. Schubiner is the director
of the Mind Body Medicine Program in Southfield, Mich., and a clinical professor at the
Michigan State University College of Human Medicine.
“Whether pain is triggered by stress or physical injury, the brain generates the
sensations,” he said. “And — this is a mind-blowing concept — it’s not just reflecting
what it feels, it’s deciding whether to turn pain on or off.”
So, by this rationale, all pain is in both the body and the brain. Which is why, when my
adductor stopped hurting in July after eight weeks of physical therapy, I didn’t expend
too much mental energy trying to figure out what had worked: the exercises themselves,
my physical therapist giving me the go-ahead to keep exercising, the once-a-week
opportunity to talk with her about my recent move and the other stressors potentially
contributing to my pain or (most likely) all of the above.
In the end, Dr. Sarno was right about exercise aiding, not hampering, recovery and
about the link between emotional and physical pain. But not all chronic pain is
psychological. Dr. Sarno’s Freudian treatment is far from the only one that works. And
few scientists would say that our brain uses pain to distract us from negative emotions
(and definitely not by cutting off blood flow to muscles).
I still think of Dr. Sarno as a savior, and I continue to recommend his books to friends
and family; some have read them — and had success — while others have politely
declined. Yes, Dr. Sarno almost certainly oversimplified and overemphasized the
psychological origins of pain. But he also helped me see that both the mind and the body
are responsible for our physical suffering. And that we’re not powerless to change it.

Dr. Sarno – TMS

John E. Sarno, MD, is a pivotal figure in the arena of pain management because of his hotly debated approach to the diagnosis and management of back pain.

Dr. Sarno, Professor of Clinical Rehabilitation Medicine at New York University School of Medicine, and Attending Physician at The Rusk Institute of Rehabilitation Medicine at New York University Medical Center, is the author of 3 books that postulate the theory that most back pain is triggered by psychological origins instead of by a physiological defect.

This phenomenon, which is known as tension myositis syndrome (TMS), may also be the culprit in other pain disorders.

Dr. Sarno sat down with Medscape’s Pippa Wysong to spotlight how he became interested in pain management and outline how he came to structure his precepts for freeing his patients from back pain.

Auszug aus dem Interview mit Medscape

An Expert Interview With Dr. John Sarno, Part I: Back Pain Is a State of Mind

June 07, 2004

Seite 1

Medscape: Can you describe some of the diagnostic features you use? What about the physiology?

Dr. Sarno: Let me tell you very briefly about the physiology. I’ve based my findings on clinical experience and the way patients reacted to conventional treatments, as well as through material from the clinical literature. What is actually causing the pain in these people is not the herniated disc, or some of those other structural things, but a condition of mild oxygen deprivation, which is brought about by the brain simply altering the blood flow to a particular area. This mild oxygen deprivation is what causes pain in muscle.

Take sciatica as an example. There are a number of spinal nerves going into the leg via the sciatic nerve and the brain would mildly oxygen-deprive them. That would then, of course, give you pain in the leg, and give patients feelings of numbness and tingling. It would also produce actual weakness. But doctors have assumed that these changes and symptoms in the leg were the result of some damage to nerves in the low back — as a result of herniated discs and things of that sort.

Medscape: What exactly does the oxygen deprivation do?

Dr. Sarno: It produces symptoms. Oxygen is a crucial substance for normal function. You can’t do without it for more than a few minutes or cells begin to die. When there is even a minimal reduction in the oxygen supply to a tissue, say a muscle, a nerve, or a tendon — those are the 3 tissues that we realized the brain might target in order to produce this disorder.

Medscape: Are you saying that this oxygen deprivation is the underlying cause for all back pain?

Dr. Sarno: The underlying thing in this diagnosis, yes. If it involves a tendon around the knee, for example, the patient will have a painful tendon there. Invariably a magnetic resonance imaging (MRI) study will be done and doctors may find a minor tear of the meniscus, the cartilage, in the knee and say, „That’s where the pain is coming from.“

Invariably there are alternative explanations. For example, shoulder pain is very common now. With MRI studies demonstrating abnormalities of the rotator cuff, immediately doctors and radiologists will say, „That’s causing the pain.“ So, for every area in which people have pain, one can find structural abnormalities of one kind or another.

Seite 3

Dr. Sarno : Now let me tell you something interesting. Having said this, it wouldn’t make any difference if there were a half a dozen other explanations for the pain, as long as it was clear in one’s mind that the brain was doing this. That the brain was producing symptoms — and this is the heart of the matter and this is what’s extremely important — we haven’t gotten into the psychology yet. But the brain was producing symptoms in order to protect the patient from psychological trauma, turmoil, something of that sort. And I came to that conclusion only after many, many years. I wasn’t ready to say that until I published my book, The Mindbody Prescription, in 1998.

Medscape: So we’re shifting from a physical cause to a psychological cause?

Dr. Sarno: What has been clear right from the beginning is that people were responding to stressful situations in their lives. Even more interesting, people were responding to the pressures and the stresses that they put on themselves. I came to realize that people who tend to be perfectionists — that is, hard-working, conscientious, ambitious, success-oriented, driven, and so on — that this type of personality was highly susceptible to TMS.

Later, I realized that there is another kind of self-induced pressure, and that is the need to be a good person. This is the need to please people, to want to be liked, to want to be approved of. This, too, like the pressure to excel or to be a perfectionist, is a pressure and seemed to play a big role in bringing on this disorder.

Medscape: How would you say this all plays a role?

Dr. Sarno: You might say, „What is wrong with trying to be perfect and trying to be nice and good?“ Nothing is wrong in terms of our conscious lives. However, in doing this work I had to become very knowledgeable about the unconscious mind. Sigmund Freud’s work is critical in this regard because he introduced us to the idea of the unconscious. I realized that these self-imposed pressures were causing some difficulty inside our minds. There’s a leftover child in all of us that doesn’t want to be put under pressure, and indeed it can get very, very angry. It began to look as though the primary factor psychologically here was a great deal of internal anger to the point of rage.

Medscape: So this is the crux of your theory, that it has to do with internalized pressure and rage?

Dr. Sarno: Self-imposed pressure is one of the sources. It’s difficult to understand because one has to think in terms of what’s going on in the unconscious mind. There are other kinds of pressures that are equally important, the ones that life puts upon us. Pressures from our jobs, our personal lives, our marriages, our children, and so on. It turns out that these pressures were equally disturbing to this leftover child inside of us.

Then a third category, which is also extremely important, are the angers that might be left over from childhood. These can extend all the way from outright abuse to what I call subtle abuse. Say, parents that expected too much of a child, or parents who didn’t provide enough emotional support.


An Expert Interview With Dr. John Sarno, Part II: Pain Management Prophet or Pariah?

June 14, 2004

Seite 1

Medscape: Just to clarify: You’re saying that a lot of these conditions are due to a translation of stresses, anger, rage in the brain to physical symptoms?

Dr. Sarno: No. It’s not a translation, the brain is doing this as a protection. Protecting you from the unconscious rage and other bad feelings you might have. The reason childhood things are a factor is because — and we’ve known this for over 100 years — the unconscious has no sense of time. In other words, things that happened to us when we were 8 or 10 years old, if they’re emotionally powerful, are still there at the age of 40, 50, 70, or 90.

Seite 2

Medscape: Perhaps we can move on to treatment?

Dr. Sarno: Of course. Now remember, it’s not an approach, it’s a diagnosis. If you want to know what I do about it therapeutically, and this is very interesting, I teach people what’s going on. Believe it or not, doing that will stop the pain in many cases. There is a small army of people out there who have gotten totally better just by reading one of my books. I mean totally better. I get letters all the time from people around the United States telling me how this happened and they can’t believe it; they’ve had the problem for years and read the book. The reason that they get better is because they accept the idea that what is causing their pain is that disorder. That’s crucial. That’s the point of my teaching my patients. Obviously my patients are those who have not gotten better just from reading one of the books, because virtually all have done that before they come to see me. It’s clear that they need something more.

But those who stay with the program will get better. I think most people recover simply by learning in greater detail what’s going on, by going into the specifics of the pressures in their lives that are most important and so on.

About 20% of the people who come to see me, who come into my program, cannot apparently get better until they’ve spent some time working with one of my psychologists. Psychotherapy is needed for about 20% of the patients.

Seite 3

Medscape: Let’s move on to treatment. What should patients with back pain do? What should their doctors do?

Dr. Sarno: The only thing you can say to people in general, if they’re interested, is to read the books. The 2 that I recommend are Healing Back Pain and The Mindbody Prescription. There is another book that has a corny title by one of my young colleagues from Vermont: To Be Or Not To Be…Pain-Free: The Mindbody Syndrome, by Marc Sopher, MD. If people read the book and they have the same experience that some people in the United States have had, pain will go away spontaneously.

Medscape: So, what do you recommend? Look at sources of stress, potential emotional upsets?

Dr. Sarno: First of all, personality is number one; remember that. Self-imposed pressure. Be aware of that — being „perfect,“ being „good.“ Secondly, think about all of the regular pressures in your life. And if you are aware that your childhood was not the greatest, that probably is a contributing factor, too. If people look at these things and if they’re open to the idea, they may do better.

Medscape: Do you recommend relaxation exercises?

Dr. Sarno: No, no, I do not. This is not a physical disorder and I recommend nothing physical.

Medscape: How should patients deal with the stresses?

Dr. Sarno: The only thing I can recommend, and I hate to do it because it sounds self-serving, is to read the books. That’s the only thing out there for them. The last one has the most information about the psychology — that’s The Mindbody Prescription. It tells you what we do and what we try to bring about.

Medscape: Does it walk people through different things they look at? Does it have step-by-step mental exercises?

Dr. Sarno: Exactly. In the last book there’s even an outline by a patient from upstate New York. This is one of the patients I never saw but who got better by reading one of the books. He sent me this little program that he designed for himself and I put it in the last book. Actually, I have improved on that and made my own program, but I have to admit that he gave me the stimulus to do it. At any rate, it’s there and it’s something that people can follow.


„Neue Autorität: Das Geheimnis starker Eltern“ 3

Buch: Haim Omer / Philip Streit
„Neue Autorität: Das Geheimnis starker Eltern“

Gewaltfreie Widerstandsform der Eltern
– Transparenz und Öffentlichkeit schaffen:
destruktives Verhalten sollte öffentlich gemacht werden
Warum sollen Eltern alleine bleiben und Dinge verschweigen?
Sprechen Sie z.B. mit den Lehrern in der Schule über das Verhalten Ihres Kindes, welche Beobachtungen wurden dort gemacht? Berichten Sie, wie Sie Ihr Kind zuhause erleben. Ihr Kind soll von diesem Austausch Kenntnis haben.
Sammeln Sie die Telefonnummern der Freunde (deren Eltern) Ihres Kindes, auch Einrichtungen und Orte, wo sich Ihr Kind gerne aufhält. Wenn Ihr Kind sich unerlaubt dort aufhält, können Sie anrufen und darauf hinweisen.
Gehen Sie dorthin, wo Sie glauben, dass sich Ihr Kind aufhält – nicht alleine! Betreten Sie die Lokalität und signalisieren Sie, dass Sie Ihr Kind gesehen haben. Brechen Sie keinen Streit vom Zaun! Wenn Ihr Kind „das Weite sucht“, dann laufen Sie nicht hinterher, sondern bleiben Sie und sprechen Sie mit den Freunden, sammeln Sie Telefonnummern.

„Neue Autorität: Das Geheimnis starker Eltern“ 2

Buch: Haim Omer / Philip Streit
„Neue Autorität: Das Geheimnis starkter Eltern“

– innere Präsenz: Mein Kind braucht mich, auch wenn es mir
eine gegenteilige Botschaft vermittelt.
Wenn ich präsent bin, traue ich meinem Kind
zu, Herausforderungen anzunehmen und
Lösungen zu finden.
Ich kann meinem Kind zumuten, dass es
meine Botschaften aushält.

– äußere Präsenz: „Ich bin da“ – Wir sind mit all unseren
Sinnen präsent und zeigen, dass wir unser
Kind lieben.
„Wir bleiben da“ – egal, wie lange die
Durststrecke auch sein mag.
„Wir sorgen für Klarheit“ – Regeln, Abläufe
werden festgelegt und eingehalten. Klare
Strukturen machen Eltern souverän und
„Wir leisten Widerstand gegen deine
Verhaltensweisen, die aggressiv oder
gefährlich erscheinen. Wir geben dich
jedoch nicht auf.“

Elterliche Präsenz entwickelt sich schrittweise.
– Sie entwickelt sich durch Hilfe und Beistand.
– Verzichten Sie auf Eskalation und Gewaltanwendung.
– Sie können die Gedanken Ihres Kindes nicht kontrollieren –
gewinnen Sie Kontrolle über Ihre eigenen Handlungen!
– Bleiben Sie bei Ihren Botschaften, zwingen Sie Ihr Kind
nicht, sich Ihrem Willen zu beugen!
„Ich trete innerlich einen Schritt zurück, um eine Eskalation
zu vermeiden, aber ich komme auf die Angelegenheit zurück.
Ich will mein Kind nicht besiegen, aber ich bleibe dran.“
– „Wir“ – Sie helfen Ihrem Kind gemeinsam als Eltern, sowohl
Vater, als auch Mutter.
– Führen Sie elterliche gewaltlose Widerstandsformen ein.
„Wir beziehen Stellung! Wir positionieren uns und lassen uns
nicht abschütteln.“

Elterlicher gewaltloser Widerstand:
– Ankündigung: Eltern beziehen Position – so kann es nicht
Eine Ankündigung sollte schriftliche, in Briefform verfasst
werden. Fügen Sie 3-4 Verhaltensweisen ein, die Ihnen
Sorgen bereiten. z. B: „Lieber Sohn, wir lieben dich und
sorgen uns um dich. Aber wir sind mit diesen
Verhaltensweisen von dir nicht einverstanden…Wir werden
dagegen Widerstand leisten! Wir können dich nicht zwingen,
da du dein Handeln kontrollierst, aber wir werden
dagegenhalten und uns notfalls Hilfe holen, wenn die
Situation es verlangt. In Liebe, Deine Eltern.“
Dieser Brief wird zu einem vereinbarten Termin übergeben.

– Sitzstreik: wählen Sie einen ruhigen Moment für Ihren Streik.
Im Zimmer des Kindes / Jugendlichen setzen Sie sich so in
das Zimmer, dass Ihr Kind diese nicht ohne Weiteres
verlassen kann – Türnähe? (vielleicht nehmen Sie eine
weitere Person mit, als Unterstützung). Eröffnen Sie den
Sitzstreik mit den Worten „wir sitzen hier, weil wir dein
Verhalten (benennen) nicht in Ordnung finden.
Wir warten auf deine Vorschläge,
wie wir dieses Problem lösen können“. Daraufhin schweigen
Sie. Sie gehen auf keine Frage ein! Hier ist Ihre Ausdauer
Sollte Ihr Kind mit einer Lösung kommen, dann bedanken
Sie sich für den Vorschlag. „Wir bedanken uns und werden
uns nun zurück ziehen, um zu überlegen, wie wir weiter
vorgehen. Wir werden deinen Ideen mit einbeziehen.“

Sollte Ihr Kind keine Lösung haben, so beenden Sie den
Sitzstreik nach einer halben Stunde mit den Worten: „Wir
haben von dir keinen Vorschlag gehört, wir gehen nun. Wir
bleiben dran und kommen noch einmal auf unser Anliegen
zu sprechen.“

Wenn Ihr Kind gehen will, lassen Sie Ihr Kind gehen, wenden
Sie keine Gewalt an! Bleiben Sie die geplante Zeit im
Zimmer – so signalisieren Sie Ihrem Kind, dass Sie
unabhängig von seiner Reaktion präsent bleiben.
Sie entscheiden, wann der Sitzstreik beginnt und, wann

„Neue Autorität: Das Geheimnis starker Eltern“ 1

Autor: Haim Omer / Philip Streit

– Struktur: klares Regelwerk, verbindliche Regeln,
Die Eltern führen die Struktur ein, sie ist kein Diskussionsgegenstand!

– Präsenz: „Ich bin hier und ich bleibe da.“
„Alles was mit meinem Kind passiert, ist mir
„Ich möchte am Leben meines Kindes Anteil
Eltern nehmen die Verantwortung für die Erziehung ihrer Kinder wahr, führen Auseinandersetzungen konstruktiv, muten ihren Kindern etwas zu, erkennen Notsignale von Kindern und Jugendlichen und schützen diese vor Gefahrensituationen.

– Selbstkontrolle und Deeskalation: Klare, knappe und
Ansagen sowie
Kritisieren, Ignorieren oder
Wir können das Verhalten unserer Kinder nicht kontrollieren, sondern nur unser eigenes Verhalten!
Verzögern Sie die eigene Reaktion, Schweigen ist ein effizientes Mittel zur Deeskalation und Selbstkontrolle. Atmen Sie einige Male ruhig ein und aus und treten Sie innerlich einen Schritt zurück. Signalisieren Sie: „Das akzeptiere ich nicht. Ich werde mir darüber Gedanken machen und komme wieder darauf zurück.“ („Schmiede das Feuer, wenn es kalt ist“).

– Unterstützung: bitten Sie andere um Unterstützung
(Großeltern, Freunde, Geschwister,
Gemeinde, Nachbarschaft, Institutionen…)


Klienteninformation gem. der Datenschutz-Grundverordnung (DS-GVO)

Sehr geehrte Klientin, sehr geehrter Klient,

der Schutz Ihrer personenbezogenen Daten ist mir wichtig. Nach der EU-Datenschutz-Grundverordnung (DSGVO) bin ich verpflichtet, Sie darüber zu informieren, zu welchem Zweck meine Praxis Daten erhebt, speichert oder weiterleitet. Der Information können Sie auch entnehmen, welche Rechte Sie in puncto Datenschutz haben.


Praxisname: IhrePsyche, Marzella Arlt (Mag.) Heilpraktikerin Psychotherapie

Adresse : Ferdinand-Stucker-Strasse 14, 51429 Bergisch Gladbach

Kontaktdaten :

Ein ständiger Vertreter und/oder Datenschutzbeauftragter ist in der Praxis nicht vorhanden.


Ihre personenbezogenen Daten werden zum Zwecke der heilkundlichen Versorgung sowie zur Abrechnung der Leistungen erhoben und im automatisierten Praxisverwaltungssystem und in den händischen Patientenakten gespeichert. Bei den Daten handelt es sich neben Ihren Kontaktdaten insbesondere um Gesundheitsdaten wie Anamnese, Medikation, Diagnosen, Therapievorschläge, Befunde usw. Auch andere Heilpraktiker/Ärzte, bei denen Sie sich in Behandlung befinden, können uns zu diesem Zweck Daten zur Verfügung stellen.


Ich übermittle Ihre personenbezogenen Daten nur dann an Dritte, wenn dies gesetzlich erlaubt ist oder Sie eingewilligt haben.

Empfänger Ihrer personenbezogenen Daten können vor allem andere Ärzte / Psychotherapeuten, Kassenärztliche Vereinigungen, Krankenkassen, der Medizinische Dienst der Krankenversicherung, Ärztekammern und privatärztliche Verrechnungsstellen sein.


Ich bewahre Ihre personenbezogenen Daten nur solange auf, wie dies für die Durchführung der Behandlung erforderlich ist.

Aufgrund rechtlicher Vorgaben bin ich dazu verpflichtet, diese Daten mindestens 10 Jahre nach Abschluss der Behandlung aufzubewahren.


Sie haben das Recht, über die Sie betreffenden personenbezogenen Daten Auskunft zu erhalten. Auch können Sie die Berichtigung unrichtiger Daten verlangen.

Darüber hinaus steht Ihnen unter bestimmten Voraussetzungen das Recht auf Löschung von Daten, das Recht auf Einschränkung der Datenverarbeitung sowie das Recht auf Datenübertragbarkeit zu.

Die Verarbeitung Ihrer Daten erfolgt auf Basis von gesetzlichen Regelungen. Nur in Ausnahmefällen benötige ich Ihr Einverständnis. In diesen Fällen haben Sie das Recht, die Einwilligung für die zukünftige Verarbeitung zu widerrufen.

Sie haben ferner das Recht, sich bei der zuständigen Aufsichtsbehörde für den Datenschutz zu beschweren, wenn Sie der Ansicht sind, dass die Verarbeitung Ihrer personenbezogenen Daten nicht rechtmäßig erfolgt.


Rechtsgrundlage für die Verarbeitung Ihrer Daten ist Artikel 9 Absatz 2 lit. h) DSGVO in Verbindung mit Paragraf 22 Absatz 1 Nr. 1 lit. b) Bundesdatenschutzgesetz.


Marzella Arlt (Mag.), Heilpraktikerin Psychotherapie