Profits over quality

The business of medicine, like any other business, is focused on making a profit. There are computer programs that monitor physicians’ contribution to the profit margin. The most revenue comes from performing procedures, many of which have been documented to be ineffective. (1) The downside risks include unnecessary costs, significant risks and patients are often worse off than before the intervention. (2) It has also been documented that only about 10% of spine surgeons are addressing the known risk factors for poor surgical outcomes. (3) Dr. Ian Harris, who is an orthopedic spine surgeon from Australia, has done extensive research on the utilization of ineffective procedures. He wrote a book, Surgery: The Ultimate Placebo, where he extensively documents the data behind many procedures that have been proven to be of no benefit and it hasn’t stopped physicians from using them – at all. (4)

What works

Effective treatments are often not covered or don’t have a way of generating revenue. For example, expressive writing has be shown to been helpful in multiple medical conditions in over 1,000 research papers. (4) Yet, I had never heard of it until I accidentally ran across it in 2003. It costs nothing, has minimal risk and is rarely presented as a treatment option. It has proven to decrease symptoms of asthma, depression, rheumatoid arthritis, improve student’s athletic and academic performance and diminish many other symptoms. I had dinner with the original author of the technique, James Pennebaker, who is a psychologist from Austin, TX. The methods may differ, but it has only been reinforced as an effective tool. There is a lot of debate of why it works, but not about whether it works.

Mindfulness-based stress reduction has also been demonstrated to decrease pain in many papers and is usually not covered by insurance. I watched several excellent pain programs in the Puget Sound shut down because they could not afford to keep them open. Listening is a proven healing modality in addition to being a basic requirement to understand a given patient’s whole situation. Dr. Francis Peabody, a famous Boston physician, was concerned about the intrusion of technology into the patient-physician relationship. One of his more notable quotes was, “The secret of care is caring for the patient.” He wrote this in 1927. (5)

The business of medicine

Currently, mainstream medicine is pretending to deliver medical care. At the same time, people still trust their physicians. My observation is that it isn’t the individual physicians that are the issue. The corporatization of medicine is backing us into a tight corner. Not only are we not given the time to talk to our patients, many are often penalized heavily for not being “productive enough.”

One problem that is not often acknowledged is that of inducing a depression from repeatedly dashing people’s hopes. This was powerfully demonstrated by Harry Harlow. (6)

Harry Harlow

Harry Harlow was an internationally renowned psychologist who pioneered research in human maternal-infant bonding using primates.  During the first half of the 20^th century, it was felt that mothers should touch their children as little as possible.  The leading mental health professionals aggressively discouraged mother-child interaction in research papers, lectures, books, and the media.  Interestingly, or tragically enough, their recommendations were based on rodent research.  Dr. Harlow was the leading force in changing the tide of opinion using various species of monkeys. His story is well-presented in an entertaining book, Love at Goon Park by Deborah Blum. (6)

In the 1960s, he turned his attention, also based on primate research, to some of the smaller details of human interaction.  One model he worked on for a while was that of inducing depression.  He used various isolation methods and ways of simulating parental neglect or even abuse. He was able to consistently produce monkeys that were seriously disturbed, but he wasn’t able to cause depression.  At the time, he was experiencing his own severe depression associated with his wife’s diagnosis of terminal cancer.

He finally found a consistent methodology by devising an apparatus that resembled an upside-down pyramid. The sides were steep, but still allowed the monkey to climb to the top to peek outside. The top was covered with mesh. For the first couple of days, the monkeys would repeatedly climb up to look out and quickly slide back down. Within a couple of days they would give up, sit in the middle of the device, and not move. They became almost unresponsive, and when they returned to their families, they would not revert back to normal social behavior. It didn’t matter what problems the monkey had prior to the experiment. The abnormal monkeys became worse and normal monkeys suffered the same fate. Even the “best” monkeys from stimulating and interactive families would succumb. The researchers called the apparatus, “The Pit of Despair”. It was felt by the research team that this “learned helplessness” was from a combination of feeling the loss of a good life reinforced by occasional glimpses of the outside world and feeling trapped. Within a half a week, every monkey spiraled down.

Physical therapy, chiropractic adjustments, injections, acupuncture, vocational retraining, medications, traction, inversion tables, and finally surgery. How many times can your expectations be dashed before you lose hope?

1. Jonas, JB, et al. Are invasive procedure effective for chronic pain? A systematic review. Pain Medicine (2019); 20: 1281-1293.
2. Perkins, FM, and Henrik Kehlet. Chronic pain as an outcome of surgery. Anesthesiolgy (2000); 93: 1123-1133.
3. Young AK, et al. “Assessment of presurgical psychological screening in patients undergoing spine surgery.” Journal Spinal Disorders Tech (2014); 27: 76-79.
4. Harris, Ian. Surgery, The Ultimate Placebo. New South Publishing, Sydney, Australia, 2016.
5. Peabody, FW. The Care of the Patient. NEJM (1927); 88:877-882.
6. Blum, Deborah. Love at Goon Park. Perseus Publishing, New York, NY, 2002.

The post “The Pit of Despair” first appeared on Back in Control.

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Begin writing now

I ask my patients to begin the expressive writing quickly before they read my book. From the beginning it creates some level of a shift and seems to open the door to change. Many people resist this simple exercise. That includes me. I am not sure why so many people resist this foundational step, since there is no risk or cost. Over 2200 research papers have demonstrated its effectiveness. But I hear and endless number of reasons why he or she can’t write. One of them is, “My hands hurt or are unsteady.” “I don’t have the time.” “My life is unusually stressful.” There is another alternative – the verbal route.

The mirror

Dr. Wegner, author of the famous “White Bears” article (1) on suppressing thoughts pointed out that the verbal route of expressing thoughts is also effective. I recall in the midst of my misery that one exercise that helped create a shift was one suggested by David Burns in his book, Feeling Good. He said to stand in front of a mirror and talk to that person using the self-critical voices in your head. You would never talk to another person in that manner. Of course, you can speak with freedom and there is nothing to destroy. I have to say that it was disconcerting I and I quickly realized how toxic these thoughts were. So I suggest to my patients that they can express themselves verbally in private with or without a mirror.

One research paper (2) looked at switching the self-talk voice from the first to the third person. Of course, most of our self-talk is negative, which is an unfortunate part of the human experience. They were able to document on functional MRI (fMRI) scans, which document area of brain activity that this process calmed down the region of the amygdala (considered the danger signal area) without engaging the higher thinking areas of the brain. In other words, it cut through the need for using your cognitive function to do battle with anxiety.

Using words

I want to share an email I received from one of my colleagues.

While expressive writing is great, I find that at home, I rarely can find a solid uninterrupted 20-30 minutes to dedicate to it, with professional obligations, my wife, and daily life/planning/activities/chores. I’ve tried doing it at work, but distractions and tasks are ever-present.

So, what I have been doing is during my drive home (which can be up to 45 minutes or more), or during my 15-20-minute walk to the gym, I simply visualize writing, or narrate to myself what I would write. It flows even faster than writing, and once I get going, the words flow, the images flurry, and I get it all out in the open. Then, if in the car, my personal favorite is to laugh at how ridiculous it sounds or, if particularly angry, swear it all away. When at the gym, with every repetition I imagine squashing it.

I do this about 4 times a week and all the negatives of the day, personal challenges, or doubts about the future turn from massive, insurmountable problems to very solvable obstacles; it’s incredibly energizing.

I have found that even with the writing exercises, it wasn’t the act of writing, but the act of ripping it up and throwing it away that felt so liberating. If it was a great week and my writing was all positive, I’d read it a few times and be proud, and throw it away. It is that physical act of squashing, tearing, destroying negativity that is what makes all the difference.

A few months ago I read a book called The Charisma Myth, and one part was about managing stress with public speaking. The technique the author described was closing your eyes, identifying all doubts, negative thinking, worry, stress, and visualizing all this negative energy being expelled to either a benevolent god, the universe, or something that the individual personally identifies with. When I had to have some difficult conversations and meetings over the last few months, before every meeting I closed my eyes, identified my stress, nervousness, doubts, etc. and visualized myself breathing out these thoughts to a collective universal being, where I identified that billions before me and billions after me have had these same exact feelings, and I could expel it to a pre-existing unity. I walked into the meeting calm, cool, and collected, and though it was tough, I was able to think clearly, not shy away from making my case, and stand my ground confidently.

I think this illustrates that feelings, especially negative ones, like anxiety, stress, uncertainty, self-doubt, pain, etc. are all intangible ideas.  The act of making it tangible, whether it be through the written word, a visualized entity, or an audible sound (like when I dictate to myself) makes it something tangible and something people are comfortable dealing with. Squashing that tangible thing, whether by tearing it up, pounding it away in the weight room, swearing it away in my car, or breathing it out to a universal entity, are all physical, tangible methods of dealing with a now tangible foe that was before just an illusory concept. And that’s what makes these tools so powerful.

Neuroplasticity

The concepts of rewiring your brain (neuroplasticity) are based on awareness, separation and reprogramming. The writing creates an awareness of what is racing around in your brain and now there is a space between you and your thoughts. The verbal route also creates a separation, and you are now able to re-direct your attention to whatever you choose. The data is convincing.

Here is a link to a detailed overview I created to explain the details of expressive writing. You don’t have to write for 15-20 minutes day. As little as a minute can change the nature of your day. I also feel it is important to write at least several times a week indefinitely. It is a way of “maintaining” your brain.

We asked Dr. Pennebaker, the originator of the research, why he thought it was so effective. It was his impression that it was a simple way to release secrets, not solve or get rid of them. Everyone has some parts of themselves they are not particularly proud of. It is just the way human consciousness works. It is not a solution for your mental or physical pain in isolation, but it is a necessary starting point. I have seen few, if any, people deeply heal without this exercise.

References

1. Wegener DM, et al. “Paradoxical effects of thought suppression.” Journal of Personality and Social Psychology (1987); 53: 5-13.
2. Moser, JS et al. Third-person self-talk facilitates emotion regulation without engaging cognitive control: Converging evidence from ERP and fMRI. Scientific Reports (2016); 7: 4519 | DOI:10.1038/s41598-017-04047-3

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A story of healing

This is a letter that was submitted to the “Stories of Hope” section of my website.

I had back pain which became sciatica- it got worse and worse and I could only walk 50 yards. I read Isobel Whitcomb’s piece in Slate, where she discussed doing a Dr Hanscom workshop- I thought ok, let’s give it a try and within about 5 minutes my pain had gone from a 7 or 8 to a 2 or 3. 4 months later, I’ve got no pain at all- I’m running 2 or 3 times a week. My boss thinks I should advertise myself as a healer and throw chicken bones at people’s pain before giving them a “special pen” to write down all the pain. I am incredibly grateful to Dr Hanscom- he has changed my life.

Breaking down the healing journey

Expressive writing is the foundational tool of healing all chronic pain – mental or physical. It is rarely the definitive solution, although the shifts can happen quickly and be profound. The originator of the approach is Dr. James Pennebaker, who is an academic social psychologist in Austin, TX. He published the first paper in 1986 and over 2000 papers since then have documented its effectiveness.

The response from this person’s boss response is typical. It seems unlikely that such a simple approach can have such profound effects. But the data is deep and the benefits are consistent. Expressive writing was what began my journey out of pain after suffering from 17 different mental and physical symptoms for over 15 years. I discovered it accidentally and I did not understand what had happened until many years later. All my symptoms are gone and have not returned for almost 20 years. I layered on many other tools and eventually a healing sequence has evolved that has helped many people. However, expressive writing is always the one necessary starting point.

Interestingly for me, is that if I slack off on my expressive writing for two or three weeks, some of my symptoms will return. The most common one is burning in my feet, ringing in my ears, and skin rashes will come and go. Even 30 seconds of writing makes a significant difference. I now view the exercise as part of my regular mental hygiene.

Dr. Pennebaker has summarised the research in his book, Opening Up by Writing It Down, 3rd edition. Just a few of the effects include:

• Faster wound healing
• Decreased anxiety, anger, and depression
• Lower viral load in HIV
• Improved symptoms of asthma, rheumatoid arthritis, and other autoimmune disorders
• Better athletic and academic performance

Why does this approach work?

We asked this question to Dr. Pennebaker and he is quite open in that none of us really know. His feeling is that it is a process that allows people to give substance to “secrets” that every human being has in some form. Just by the nature of consciousness we all have thoughts we are not particularly happy about or even ashamed of. Also, most of us have taken actions or been in situations we regret. Of course, we don’t want to share them with anyone, but we don’t have to. Just putting them down on paper gives them substance and separation. He pointed out to our study group that keeping secrets requires a lot of mental energy. Since 20-25% of our entire body’s fuel consumption goes towards running our brains, you’ll eventually wear out. And with time these secret circuits become much stronger. You cannot do battle with them. You can only separate from them and is the reason that expressive writing is a necessary step to begin the healing journey.

The core of the healing journey

There are two separate but linked skill sets to the healing journey. Both are equally as important. One is learning to process your survival circuits that humans call anxiety and anger. The other is moving your conscious brain into the life you want. But you can’t move forward while being enmeshed with your past. The expressive writing is the beginning exercise to break you loose. I have not seen anyone really heal without using a version of this tool. The main “risk” is that your life will change, but you get to choose the direction.

References

1. Pennebaker, JW and JM Smyth. Opening Up by Writing It Down: How Expressive Writing Improves Health and Eases Emotional Pain Third Edition. The Guilford Press, New York, NY, 2016.

The post No More Back Pain – A Story of Healing first appeared on Back in Control.

The post No More Back Pain – A Story of Healing appeared first on Back in Control.

I am somewhat beside myself regarding several aspects of her story.

• Mainstream medicine is overlooking the basic physiology that we all learned in high school. When you feel threatened, your body goes into flight or fight and you experience physical symptoms. When this state is sustained, your body will break down, and you’ll develop serious illnesses. (1)
• The medical profession took away her hope. It has been documented in the neuroimmunology literature that hope/optimism directly lowers inflammatory markers. Taking it away does the opposite.(2)
• You may consider her story unusual or a “miracle.’ What is a miracle is life and the body’s capacity to heal. What if broken bones couldn’t mend as strong as they were before? What about cuts and deep wounds? What if your body couldn’t fight off infection? What kills patients in cancer treatment is often infection because strong drugs that kill cancer cells often compromise the immune system.
• Every day, I take a moment to consider how my heart can beat 60-80 times a minute with the only rest being between beats. It doesn’t make any rational sense.
• But what I find especially upsetting is the story of her early family life, of which variations occur on over 35% of American families.(3) How can this continue to be? We know better and it all keeps happening. The effects of an abusive childhood have been documented to last the rest of your life.

Here is her story of hope and what keeps me moving forward.

I am an unwanted child who was abused by her family. I do not remember ever being healthy. At 13, I started getting migraines.

5 years ago, at age 52, I broke my ankle and had horrible pain after surgery. Even though the most prominent pain doctor in our country diagnosed me with CRPS (chronic regional pain syndrome), physical therapists and the physiatrist didn’t believe it. I tried my luck at another great centre for PT, but it was the same. After each session I could not live for days because the pain was so bad even though I was on opiates.

I reluctantly decided I would re-learn to walk by myself. I had to go excruciatingly slowly, but in a few months I was able to walk with almost no pain. I got off opiates without a problem. Getting in touch with anger that I repressed all my life was extremely beneficial. Even though both my surgeon and the pain doctor were mad at me for giving up on PT, they each wrote that the PT was “a bit too harsh” after they saw me walk again.

Everything was going quite well until I got herpes zoster. When I recovered I was very keen to go walking. I pushed myself to walk for the next few years, but each step I took was painful. In the midst of it, I convinced the surgeon to remove the hardware, which did not help. In the last few months I finally gave up on walking longer distances even though I love to walk.

I have been writing JournalSpeak/expressive writing for 2+ years. It has been a great way to get the anger and other repressed feelings out. In the first 4 months, I got rid of my lifelong insomnia, and my chronic depression was way less. I was able to slowly lower the dose of antidepressants. I am able get rid of my migraines with writing the anger out, and I also need to validate my feelings. While writing down my feelingsI discovered I was scapegoated and gaslit by my family. I see others and myself in a completely new way, and do not feel so helpless anymore.

I was incredibly lucky to discover Dr. Hanscom on the Trauma Superconference. No matter how much anger I got out in writing, I could not get any relief from ankle/hip/back pain. I was eager to try his advice: no listening to the news, no criticising, no talking about pain, and using another virtual desktop on my computer without pain being discussed. He also gave me “permission” to focus on happier things like planning for things I would love to do and am able to do instead of trying to make sense of the past.

I realize that I have pushed myself too hard all my life. I can walk the same distance, but if I push myself, every single step is painful. If I say to myself, “I am going out and will walk as much as I can,” I can walk the same 1.5 km with little to no pain at all. If the pain returns, my nervous system is calm enough now that I can believe myself when I say, “I am safe. My ankles/hip/back are OK” – and the pain goes away!

The fact that the pain doctor said in an interview only a couple of years ago that nothing much can be done for chronic pain, incredibly saddens me. Two of Dr. Sarno’s books(4) were translated to our language years ago. A psychologist that works with people with chronic pain has a 3+ years waiting  list for her groups. She recently said in a lecture for rheumatoid patients that they need to talk about their pain. Even though one patient insisted that people ignore or do not believe her, the psychologist insisted they continue to talk about pain. I know firsthand this does not work. A couple of years ago I joined an online support group for chronic pain, and just reading about pain made my pain so much worse that I had to leave.

I am so incredibly grateful to Dr. Hanscom for saving my life. All the advice and information he shares, allows us to help ourselves even if we live on another continent.

This is not about me

I would like to emphasize that the healing journey is based on deeply-documented interventions. The DOC (Direct Your Own Care) Journey is simply a framework that presents them in organized and accessible manner. There are a growing number of practitioners that understand the human need to feel heard, validated, and safe. Each of them has their own style of educating their patients, implementing effective treatments, and helping patients access their own capacity to heal. Some of the main principles are that chronic disease is complicated, multiple aspects of it must be simultaneously addressed, and the patient must take responsibility for his or her own care.

One interesting aspect to her story is that belonging to a pain support group carries a poor prognosis in that most them are focused on discussing the pain, medical care, and how badly they have been treated.(5) Although they may be correct, these discussions place your brain on the problems and not moving into the two-part solution – letting go and moving forward.

Some other effective interventions include:

• PRT – Pain Reprocessing Therapy(6)
• EAET – Emotional Awareness and Expression Training(7)
• ISTDP – Intermediate Short-Term Dynamic Psychotherapy(8)
• ACT – Acceptance and Commitment Therapy(9)
• Mindfulness-base Stress reduction(10)

She found way out on her OWN 

Again, each of these must be framed in an overall treatment approach. As much (most) of it is self-directed, not a lot of resources are required. When needed, they can be plugged into the bigger picture. I liken it to doing a jigsaw puzzle that is not that difficult. They key is persistence.

Note, that although the framework provided by Back in Control helped her move forward in a powerful way, she had already done a lot of work. I have never seen or corresponded with her. She truly pulled herself out of the hole and entered into a new life! For many who heal, this is the way it often happens.

References

1. Holmes TH, Rahe RH. The Social Readjustment Rating Scale.J Psychosom Res (1967); 11:213–8. doi:1016/0022-3999(67)90010-4
2. Dantzer R, et al. Resilience and Immunity. Brain Behav Immun (2018);74:28-42. Doi.10.1016.j.bbi2018.08.010
3. Felitti VJ, Anda Rf, Nordenberg D, et al. The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine (1998); 14:245-258.
4. Sarno J. The Mind Body Prescription. Warner Books, New York, NY, 1998.
5. Friedberg F, et al. Do Support groups help people with chronic fatigue syndrome and fibromyalgia? A comparison of active and inactive members. J Rheumatol ((2005); 32:2416-20.
6. Asher YK, et al. Effect of pain reprocessing therapy vs. placebo and usual care for patients with chronic back pain. JAMA Psychiatry (2021).doi:10.1001/jamapsychiatry.2021.2669
7. LumleyMA, Cohen JL, Stout RL, Neely LC, Sander LM, Burger AJ. An emotional exposure-based treatment of traumatic stress for people with chronic pain: preliminary results for fibromyalgia syndrome. Psychotherapy (Chic) 2008;45:165–72.
8. Abbass Allan, et al. Intensive short-term dynamic psychotherapy to reduce rates of emergency department return visits for patients with medically unexplained symptoms: preliminary evidence from a pre-post intervention study. CJEM (2009); 11:529-34.
9. McCracken LM and Vowles KE. Acceptance and commitment therapy and mindfulness for chronic pain: Model, process, and progress. Am Psychol (2014); 69:178–87.14. Hann KEJ,
10. Cherkin DC, et al. Effect of mindfulness-based stress reduction vs. cognitive behavioural therapy or usual care on back pain and functional limitations in adults with chronic low back pain. JAMA (2016); 315:1240-1249. doi:10.1001/jama.2016.2323

The post “My Way Out” (of “The Abyss”) – One Patient’s Story first appeared on Back in Control.

The post “My Way Out” (of “The Abyss”) – One Patient’s Story appeared first on Back in Control.

Health care professionals want to provide healing. When we don’t have the tools to help you, all parties become incredibly frustrated. Additionally, the most basic healing modality is feeling safe with your provider because it creates a shift in your physiology to one of safety or “rest and digest. This is where healing occurs, and we are limited by the business of medicine that won’t let us spend time with our patients. How can we know you? What is your life like? Are you feeling stressed? How can we methodically understand your care up to this point, and make thoughtful decisions about what to do next? What has been done to optimize your chances of a good outcome of surgery?

Modern medicine is evolving in a dangerous direction with regards to your care. The major factor in deciding to offer a procedure or treatment is often whether it’s covered by insurance and how well it is reimbursed. The effectiveness of the intervention is a lesser consideration. In fact, we are sometimes encouraged to perform surgeries that have been documented to be ineffective. Additionally, there is little accountability for the outcomes unless there is severe negligence.

Profits over quality

The business of medicine, like any other business, is focused on making a profit. There are computer programs that monitor physicians’ contribution to the profit margin. The most revenue comes from performing procedures, many of which have been documented to be ineffective.¹ The downside risks include unnecessary costs, significant risks and patients are often worse off than before the intervention.² It has also been documented that only about 10% of spine surgeons are addressing the known risk factors for poor surgical outcomes.³

Dr. Ian Harris, who is an orthopedic spine surgeon from Australia, has done extensive research on the utilization of ineffective procedures. He wrote a book, Surgery: The Ultimate Placebo, where he extensively documents the data behind many procedures for pain that have been proven to be of no benefit and it hasn’t stopped their use.⁴

We want to provide relief, it is what we are trained to do, but we are not aware of the alternatives. It is like trying to hit a major league baseball pitch with a golf club. I would have no insights either unless I hadn’t suffered with chronic pain for over 15 years.

What works?

There are many ways to cause your body to change from threat physiology to safety. A term for this is, “dynamic healing.” Input (your stresses) are processed in a manner that has less impact on your nervous system, the nervous system can be calmed down, and there are ways to directly stimulate the powerful anti-inflammatory effects of the vagus nerve.

Effective treatments are often not covered or don’t generate enough revenue. For example, expressive writing has be shown to been helpful in multiple medical conditions in over 1,000 research papers.(5) Yet, I had never heard of it until I accidentally ran across it in 2003. It costs nothing, has minimal risk, and is rarely presented as a treatment option. It has proven to decrease symptoms of asthma, depression, and rheumatoid arthritis, improve student’s athletic and academic performance, speed up wound healing, and diminish many other symptoms. I had dinner with one of the pioneers of the technique, James Pennebaker, who is a psychologist from Austin, TX. The methods may differ, but it has only been reinforced as an effective tool. There is a lot of debate of why it works, but not about whether it works.

Mindfulness-based stress reduction has also been demonstrated to decrease pain in many papers and is usually not covered by insurance. I watched several excellent pain programs in the Puget Sound shut down because they could not afford to keep them open.

Listening is a proven healing modality in addition to being a basic requirement to understand a given patient’s whole situation. Dr. Francis Peabody, a famous Boston physician, was concerned about the intrusion of technology into the patient-physician relationship. One of his more notable quotes was, “The secret of care is caring for the patient.” He wrote this in 1927 when he was concerned about the intrusion of technology into the patient doctor relationship.(6)

What about the patient?

A person suffering from chronic pain is trapped beyond words. My term for it is, “The Abyss.” These are just a few of the ways.

• You have told that there is nothing wrong and you have to live with your pain the best you can. The reality is that there is a physiological explanation for all of it.
• There does not seem to be way out. Most people lose hope. The solutions are there but not being offered. The patients who break out of it feel the healing process is “disturbingly simple.”
• You are labeled by almost everyone, including the medical profession. They include, drug seeker, malingerer, lazy, not motivated, making things up, not tough enough, and the list is endless.

When you are trapped by pain, your frustration and anger is deep and powerful. This scenario creates a more intense flight or fight response, the blood supply to your brain shifts from the thinking center to the survival midbrain, and your behaviors are not rational.

Another problem that is not often acknowledged is that of inducing a depression from repeatedly dashing people’s hopes. This was powerfully demonstrated by Harry Harlow.⁶

Inducing depression–“The Pit of Despair”

Harry Harlow was an internationally renowned psychologist who pioneered research in human maternal-infant bonding using primates. During the first half of the 20^thcentury, it was felt that mothers should touch their children as little as possible. Leading mental health professionals aggressively discouraged mother-child interaction in research papers, lectures, books, and the media. Interestingly, or tragically enough, their recommendations were based on rodent research.  Dr. Harlow was the leading force in changing the tide of opinion using various species of monkeys. His story is well-presented in an entertaining book, Love at Goon Park by Deborah Blum. (

In the 1960s, he turned his attention, also based on primate research, to some of the smaller details of human interaction.  He wanted to understand how to induce depression. He used isolation methods and ways of simulating parental neglect or even abuse. He was able to create seriously disturbed monkeys, but not depressed ones.

He finally found a consistent methodology by devising an apparatus that resembled an upside-down pyramid. The sides were steep, but still allowed the monkey to climb to the top to peek outside the mesh-covered top. For the first couple of days, the monkeys would repeatedly climb up to look out and quickly slide back down. Within a couple of days, they would give up, sit in the middle of the device, and not move. They became almost unresponsive, and when they returned to their families, they wouldn’t revert back to normal social behavior. It didn’t matter what problems the monkey had prior to the experiment. The abnormal monkeys became worse and normal monkeys suffered the same fate. Even the “best” monkeys from stimulating and interactive families would succumb. The researchers were upset and called the apparatus, “The Pit of Despair”. It was felt that this “learned helplessness” was from a combination of feeling the loss of a good life reinforced by occasional glimpses of the outside world and feeling trapped. Within a half a week, every monkey spiraled down.

Tulsa

The surgeon was doing what he was trained to do with the best of intentions. I would feel badly during the first eight years of my career if I could not find a way to relieve my patients’ pain with surgery. The patient was trapped at a level that is indescribable and surgery is often viewed as the definitive answer. It also requires enduring more pain and a lot of anxiety about the whole process. So, the level of disappointment is even higher when it fails.

The literature also shows that pain is often worsened when surgery is performed in the presence of untreated chronic pain.² I was also not aware of that data until after I had quit my surgical practice. For him to act out the way he did is unacceptable but understandable. BTW, suicide is problematic in patients suffering from relentless pain. I was also at that point towards the end.

Recap

Physical therapy, chiropractic adjustments, injections, acupuncture, vocational retraining, medications, traction, inversion tables, and finally surgery. How many times can your expectations be dashed before you lose hope? You cannot blame a person for actions taken in this state of mind.

All the parties were victims of the business of medicine and I put the blame squarely on its shoulders. There are many variables, but the energy is all directed the same direction–money.

The business of medicine has trapped both the providers and patients and with computerized medical records, it is getting steadily worse. There are real solutions, but both the medical profession and patients are going to have to demand it.

References

1. Jonas, JB, et al. Are invasive procedures effective for chronic pain? A systematic review. Pain Medicine (2019); 20: 1281-1293.
2. Perkins, FM, and Henrik Kehlet. Chronic pain as an outcome of surgery. Anesthesiology (2000); 93: 1123-1133.
3. Young AK, et al. Assessment of presurgical psychological screening in patients undergoing spine surgery. Journal Spinal Disorders Tech (2014); 27: 76-79.
4. Harris, Ian. Surgery, The Ultimate Placebo. New South Publishing, Sydney, Australia, 2016.
5. Pennebaker JW and JM Smyth. Opening up by Writing it Down. 3^rd edition. Guilford Press, New York, NY, 2016.
6. Peabody, FW. The Care of the Patient. NEJM (1927); 88:877-882.
7. Blum, Deborah. Love at Goon Park. Perseus Publishing, New York, NY, 2002.

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• There is deep basic science research that has revealed the nature of chronic pain and this understanding will allow you to discover your version of a solution. The essence of the problem is sustained exposure to threat and the core of the solution lies in finding safety.
• Create safety by learning skills to:
  • Stimulate neuroplasticity – create and shift to new neurological circuits in your brain.
  • Learn to regulate your body’s neurochemical response to threats (stresses).
• As you learn about chronic pain, it is helpful to simply get started using some of these core tools to “jump start” the healing process.
  • Expressive writing
  • Active meditation
  • Restful sleep
  • No discussing your pain or medical care with others – especially your family

Many years ago, I would spend hours explaining chronic pain to my patients in the office but it was too complicated and it wore me out. That is when I decided to write, Back in Control. Patients would have a better understanding but there was no action. The website, www.backincontrol.com was the action plan and evolved into a self-directed process that allowed hundreds of people to break free from their chronic pain. The DOC Journey is the next rendition of the program. But the healing process begins when you begin to use methods that stimulate your brain to change. During the last few years of my practice I would ask patients to simply begin to learn and use the basic tools as quickly as possible and the rest of the concepts would fall into place. This is the first lesson of The DOC Journey.

 The nature of chronic pain (mental and physical) – sustained threat vs. safety

The essence of chronic illness, including chronic pain, is your body’s reaction to sustained stress because it responds with profound elevations of stress hormones, metabolic activity (rate of fuel consumption), and inflammatory markers (destroys invaders and your own tissues). The result is many different disruptive mental and physical symptoms.

The solution lies in learning the tools to create sense of safety, which normalizes your body’s survival fight or flight reaction. Successfully implementing these strategies causes a shift your mood, pain, and other physical symptoms. I am suggesting to dive in and begin using some of these basic foundational strategies right away. Why wait?

Creating Safety

Neuroplasticity is a term that describes your brain’s capacity to change its structure. You can form new connections, grow cells, increase the insulation around the nerves (myelin), and shift from unpleasant to pleasant circuits. Your brain physically changes in shape and structure based on programming.

As you learn strategies to regulate your body’s responses to stress, you have regained control, which creates safety. There are many ways to accomplish this and with repetition the process becomes automatic. It is like an athlete or musician attaining a high-level of skill. It cannot be done by just reading a book.

Let’s begin with these core strategies – Now

• Begin expressive writing. It is the one mandatory step to start. People can improve without doing it, but I have rarely seen people go pain free without engaging in this exercise. It has been documented in over a thousand research papers to be effective in creating significant shifts in multiple organ systems. (1)
• Practice active meditation. This involves placing your attention on a physical sensation for five to ten seconds as often as you can remember. You are switching to neutral or pleasant sensory input which causes less of a reaction in your nervous system. It requires minimal time and effort.
• Adequate sleep is critical. Lack of sleep has been shown to cause chronic pain. (2) With a multi-pronged approach, restful sleep can usually be achieved within 4-6 weeks. Medications may be needed for a few months.
• Never discuss your pain or medical situation with anyone except your medical providers. The solution for chronic pain lies in rewiring your brain around your memorized pain circuits. Your nervous will develop and evolve wherever you place your attention.

Why should this program work?

An important early step is to acknowledge and embrace your skepticism. Why should this DOC Journey work? You have been bounced around, promised relief time and time again, undergone failed interventions, and your pain is worse than ever. There is not any reason to think that this is going to work. I agree. In fact, primate research has shown that you can induce a major depression by repeatedly dashing hope. (3)

Every treatment offered in this program has been well-documented by decades of deep medical research; implement what is already known. I have watched well over 1500 patients break free from chronic pain and not only regain their life but thrive at a level they had never experienced at any point in their lives. It happened by them learning and using this DOC Journey sequence that evolved from my experience coming out of severe chronic pain and discovering what was effective with my patients.

What is not helpful is “believing” in the DOC Journey or David Hanscom, using positive thinking, or affirmations. It is about connecting with your current reality, which is unpleasant enough for you to sign up for this Journey. You are rightfully angry, frustrated, and trapped. It is the starting point. Feeling and knowing where you are at allows you to learn the strategies that allow you change direction. One successful patient commented what you need is a, “suspension of disbelief.”

Anything is possible

The DOC Journey begins with acknowledging doubt, learning awareness, and allowing hope to re-enter. Research has shown that hope and optimism are anti-inflammatory. (4) There is a lot of hope in hearing about other’s successes. I am increasingly convinced you can stimulate your brain to rewire around almost any pain regardless of the source.

I got another reminder when a patient who I never personally treated resolved his pain largely through The DOC Journey approach. He is now in his late 60’s and had experienced severe pain for over 22 years. He lost his marriage and business, ended up addicted to high-dose narcotics and attempted suicide. During this period, he underwent 28 surgeries. He has not only been free from pain for over five years, but he is enthusiastic that he has not felt this good since he was 30 years old. Historically, I would never have thought that this was possible in light of the severity of his trauma.

Please acknowledge your disbelief, embrace it, start with using these basic tools, and you’ll learn as you go. Helping patients emerge from The Abyss of chronic pain has been the most rewarding phase of my career. I am continually inspired by the resiliency of the human spirit and I am honored to be a part of your journey.

Recap of Lesson one – “Let’s Start Now”

Healing your pain requires repetition of tools that simulate your brain to change (neuroplasticity) and calm down your body’s survival response. The sooner you can engage with these strategies, the quicker you can begin to heal. That is why you might as well begin to use them ASAP. You will learn more about the nature of chronic pain and the principles behind solving it in a logical stepwise sequence throughout the rest of the course.

The next lesson will expand on the concept of threat vs safety and then more detailed explanations of these basic tools will be presented as you progress through leg one.

References:

1. Pennebaker JW and JM Smyth. Opening Up by Writing It Down. The Guilford Press, New York, NY, 2016.
2. Agmon M and G Armon. Increased insomnia symptoms predict pain among employed adults. PLoS One (2014);9:e103591. doi:10.1371/journal.pone.0103591
3. Blum D. Love at Goon Park. Perseus Books, New York, NY, 2002.
4. Dantzer R, et al. Resilience and immunity. Brain Behav Immun (2018);74:28-42. doi:10.1016/j.bbi.2018.08.010

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Hi Dr. Hanscom,

My name is Tom and I am 67 years old.

I’ve had 28 surgeries including six spinal operations, three heart attacks, one stroke, an attempted suicide, opioid addiction and 20+ years of debilitating chronic pain. My body is a mass of scar tissue that requires extensive stretching every morning. I’ve done my time in the deep, dark Abyss and yet, I have overcome each of these experiences. I’m a survivor, not a victim.

Driving home from work one night, I was rear-ended by a young teenage driver, which exacerbated an already bulging disc in my back. This one, minor accident began a chain of events that would change my life into one of endless misery, pain, and despair.

I tried every therapy I could find from surgeries, injections, chiropractors, acupuncture, drug therapies, hypnosis, biofeedback, counseling from eight different psychologists and psychiatrists, and even a healer that worked with tuning forks. No one could figure out why I was in constant, debilitating pain. Nothing worked. The only common treatment I received was a prescription for narcotic painkillers.

Into The Abyss

My whole life deteriorated as I was overcome with debilitating, chronic pain. It wouldn’t go away and I talked about it obsessively. I was too ill to attend my son’s baseball games and my wife and I weren’t able to have any quality time together. Friends and family didn’t want to talk to me anymore because I was such a “downer.” I became self-isolated. I was obsessed and all I could focus on was my pain, suffering, and how I was victimized.

Things got worse. I had a stroke when I was 47 years old.

I woke up, got out of bed, and fell on my face. My left leg would not respond to commands and my thinking was clouded and unclear. For a few hours, I was temporarily blind. I also lost my short-term memory. I went from reading a book a week to not being able to comprehend two sentences in a newspaper article. By now, I was deep into the Abyss. I had lost everything, including my business and marriage. I spent my days wallowing in chronic pain and self-pity.

My neurologist kept assuring me that my brain could reprogram and I might regain my balance, the use of my leg, my reading comprehension, and some of my memory. I had my doubts, but I had nothing to lose by believing him. Over a period of eighteen months, I regained full control of my left leg. Most importantly, after a few years, I reprogrammed my brain so that I could function almost as well as I did pre-stroke.

Connection

In all of this crisis and personal implosion there was a glimmer of light. I reconnected with my high school sweetheart, Patty. We had broken up when we were 21 and had gone our separate ways. She found me on Facebook and we reconnected 10 years ago. We’ve been inseparable, ever since. Patty and I are a team. She is my soul mate to whom I owe my life. Patty was the one who called the medics when I attempted suicide. And it was Patty who never gave up on me, although I gave her plenty of reasons to.

I attempted suicide not because I wanted to die, but because I couldn’t stand the physical pain of living any more. When my suicide attempt failed, I was faced with the reality that I’d quit trying to get better. I started to listen when people said my life still had some meaning and that I meant something to others and those in my family. I decided that any life, even one full of pain and suffering, was worth living. I told myself I would never give up again.

“I’m done with this”

I made the decision to quit narcotics and find a solution for my chronic pain. I didn’t think there was a cure, but rather a better approach to cope with it. I started calling clinics and caregivers across the country looking for relief. I discovered your project and that of another doctor, the late Dr. Peter Przekop in Palm Springs, with whom I spent a month.

Under Dr. Przekop’s care, I learned how to meditate, and through that practice, I experienced a profound recovery while in an altered state of consciousness. However, I was still feeling pain and prior to reading your book, was convinced that I’d never be pain-free.

The tipping point occurred when I started reading the “Stories of Hope.” When I first picked up Back in Control, I was focused on other people’s stories of hope, pain, and suffering. I perused these types of stories because I wanted to confirm that my pain and suffering was worse than everybody else’s. However, as I read their stories of pain, suffering, and recovery I started to realize that the solution was within me. It was up to me to resolve myself. I started to ask, “What can I do for myself that the doctors couldn’t?”

Taking charge

Through The DOC Journey I finally figured out that I was going to heal myself. I was done waiting to see what “they” were going to do to help me, how were “they” going to fix my pain. Drugs, injections, surgeries, and therapy were not going to cure me – I was.

In the long run, my stroke was actually a blessing rather than a curse. I had first-hand success with neuroplasticity and knew that the process worked. While I had doubts about the power and influence anger was having on my chronic pain, I knew that I could reprogram my brain.

Expressive writing forced me to accept that regardless of my chronic pain and suffering, I was still accountable for my words and actions. I wrote about my wounds, demons, and downfalls. I wrote about all of the people who had caused me anger and earned my scorn. Expressive writing helps me manage my anger and frustrations as I “shred and shed them” each morning.

I learned to forgive and move on, which helped to cleanse me of the anger I had built up inside of myself. I forgave my dad, the teenager that crashed into me, and the neurosurgeon that erred. I came to understand that the anger inside me was preventing me from moving on with my life.

Choosing not to remain a victim

To this day I have resolved to deal with my anger head-on, without delay. Anger is inevitable, but allowing it to poison your life by hanging on to it is a choice. I have elected to take responsibility and control of my “pain circumstances.”

It was absolutely critical to my recovery that I learned to control and manage my anger, learn forgiveness, and be compassionate towards those I resented. Once I learned to forgive and forget, I become unstuck and was able to move on.

Physically, I haven’t felt this good since before I was hurt 30 years ago.

From reading Back in Control, I have learned to use the principles of active mediation, expressive writing, anger management, daily walks, yoga and swimming as daily endeavors. I got a second chance to live my life, to repair the relationships I’d damaged, and become a survivor – not a victim.

I did not elect to be in pain, but rather I elected to not be in pain.

Best, Tom

He is The DOC Journey

His story gives me a lot of hope. I always chose to give every patient that walked through into clinic my full attention and to work with them. However, down deep I would not have had much hope for improvement for him with this amount of trauma. I certainly would not have expected this kind of a turnaround. If you look at his story, he engaged with every concept presented in the DOC process. It is not a self-help program but rather a framework to break the parts of your pain into smaller components, and people find their own way out.

He and I have now met and connected and he is looking forward to giving back, which is also an important aspect of healing.

I could write a book about all the aspects of escaping pain that are illustrated by his experience (I guess I already did). I just want to highlight two of them. The greatest obstacle to solving pain is your unwillingness to engage in any part of a healing journey. The DOC process is just one possibility. One my successful patients made a comment that he had to, “Suspend disbelief” to embark on his journey.

The second point is that the tipping point of deep healing is always processing anger through forgiveness. This is not a philosophical issue. It a matter of deciding to take full responsibility for every aspect of your life. Anger is the last ditch effort to regain control to survive and your stress hormones are through the roof. The mental and physical toll of living with anger at your core is horrific. One of the clearest parts of his story is him deciding that he was done living like he was and he decided simply to take his life back regardless of where it took him.

His story is remarkable, but not unique.

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Mark Owens’ Story

This is a video that we shot of Mark Owens, who wrote the Forward of my book. I’d like to give you some additional background to his story, both from his and my perspective. He is a PhD scientist who has spent his life addressing environmental issues. At age 29, driving a battered 3rd-hand Land Rover, he and his wife found their way into some of the most remote reaches of the Kalahari Desert of Botswana, and later, the Luangwa Valley of Zambia. There they conducted wildlife research on lions, elephants, hyenas and migrating antelope, and established model programs to protect these animals from commercial poachers while raising the living standards of indigenous people. After 23 years, he accomplished his vision, and his work still continues on through the structure he put into place and the local people he trained to carry it on. His story is reflected in his books, Cry of the Kalahari, The Eye of The Elephant, and Secrets of the Savanna .

Back in Idaho after more than two decades, he purchased and restored a large piece of land and its wetland in Idaho as a wildlife preserve for wolves, grizzlies and other wildlife. He also reversed much of the environmental damage done by indiscriminate ranching and logging practices. His commitment to making the world a better place is remarkable.

The horse accident, as he related in the Forward of my book, occurred while searching for grizzles on his ranch in the Cabinet Mountains of Montana, and his injuries were severe. A fractured spine represents severe trauma, but it isn’t nearly as painful as a crushed chest wall. After the surgery, he developed severe chronic pain for over nine years. Why?

My perspective 

Here are some points that I want to add to his remarkable story of healing.

Although this was a major injury, the usual post-operative course for a fractured spine is moderate to severe pain for a couple of weeks and then it usually resolves in about six weeks. From a surgeon’s perspective, he was the “ideal surgical candidate.” He was extremely motivated to get better, which is true for almost everyone in pain. However, there were a few details that were missed, and no one asked him the right questions.

First, he was under a large amount of stress. He left Africa after corrupt government officials and poachers had plotted his assassination for the third time.  And in Idaho, hunters and ranchers resented his conservation efforts on behalf of predators that they perceived as a threat to their domestic stock. Under less stress, it’s unlikely he would have developed such severe chronic pain. He’s really tough. Few people on this planet would have attempted what he accomplished in Africa.

Second, after he developed chronic pain from the first operation, a second one was performed to address degeneration at the lumbar 2-3 level just below his prior thoracic surgery. The surgeons performed a fusion with a known success rate of less than 30% for disc degeration. It has been well-documented that disc degeneration is not considered a source of pain.

Additionally, it has also been demonstrated that performing surgery in the presence of ongoing chronic pain of any kind, can induce pain at the new surgical site or worsen the pain at the surgical region. (1) His pain become dramatically worse.

Third, several surgeons had recommended surgically breaking his spine in two, re-aligning it and fusing him from his neck to his pelvis. One surgeon referred to the procedure as the “Blue Plate Special.” If a one-level fusion had made him worse, what do you think a 12-hour procedure with a high complication rate would have done to him? From my perspective, the decision not to recommend surgery was easy. His spine showed disc degeneration that was normal for his age. There was nothing to operate on.

Fourth, although he was not without some hope, he was quite skeptical and he didn’t really believe me that his pain was solvable, with or without surgery. The DOC project is not about believing in it or not. It is simply a framework that allows the patient to more clearly and readily sort out his or her scenario, and find a solution. The principles are universal and hold true regardless of how you feel about them. The key is to engage and move forward.

Fifth, his healing was dramatic, which many of my patients find discouraging because they don’t have an immediate response. Most people don’t, and I have observed that the process generally begins to create change over three to four months. Maybe one out of twenty people experience such a rapid response. The key is persistence.

Sixth, there are over 1000 research papers that document the effectiveness of expressive writing. (2) There is no debate that it improves mood, performance and lessens over 30 possible physical symptoms. The issue is how and why it works. Conversely, there is little evidence that a spine fusion is a solution for back pain. The success rate is less than 30% at two-year follow up and has never been compared to carefully structured non-operative care, such as the DOC program. (3) Unfortunately, insurances don’t cover most of the treatments that have been demonstrated to work.

Finally, his life wasn’t perfectly pain free after the initial healing. Unpleasant circumstances will cause your body to be full of stress chemicals, which increases the speed of nerve conduction and increases pain. (4) We worked through several major flare-ups together and eventually he acquired the skills to pull out of these flares on his own.

We have become close friends and we now support each other. Not only is he doing well over four years later, he’s thriving. The cost of healing was negligible for him and society. The risk was zero. I feel privileged that I was able to give back what I learned through my own ordeal with chronic pain. Watching people connect with their own healing capacity continues to be a remarkable experience.

Forward to Back in Control

1. Perkins FM and Henrik Kehlet. Chronic Pain as an. Outcome of Surgery. Anesthesiology (2000); 93:1123-33.
2. Smyth JM and James Pennebaker. Exploring the boundary conditions of expressive writing: In search of the right recipe. Br Jrn of Health Psychology (2008); 13:1-7.
3. Carragee EJ, et al, A gold standard evaluation of the “Discogenic Pain” diagnosis as determined by provocative discography. Spine (2006); 18:2115-2123.
4. Chen X, et al. “Stress enhances muscle nociceptor activity in the rat.” Neuroscience (2011); 185: 166–173.

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“Now I will read the whole book. Recommend 100%”

–An Amazon reader

Breaking my fall

The above quote is an Amazon review of the second edition of my book, Back in Control. Feedback like this from readers bolsters my belief in the expressive writing exercise and how critical it is to the DOC (Direct your Own Care) process.

I completely understand what the reader went through: After over fifteen years of trying everything I could get my hands on to relieve my pain—“desperate” does not begin to describe my frantic search for a solution—I had lost all hope. Then, in 2002, I inadvertently discovered expressive writing and put it to the test. Within two weeks I noticed a shift in my mood, and within six months I had pulled myself out of the deadly tailspin of chronic pain.

But the expressive writing exercise seems so simple, I fear that, when I recommend it to patients, many of them feel that I don’t believe they are really in pain nor do I understand the depth of their suffering. Yet, in addition to my experience and that of many other chronic pain sufferers, over 300 research papers document its effectiveness; while essentially no papers validate the benefit of a spine fusion for low back pain. Compared to spine surgery, how much risk is there in writing down your thoughts and then discarding the pages? What can you lose by trying it out?

I have consistently observed that expressive writing is the first step toward healing, and little of substance happens until a patient engages the process. When I walk into an exam room, I can tell within thirty seconds if my patient has started to write. If not, I offer more details of its importance. I tell my patients that reading my book is helpful, but it will not make a difference in their mood or in their level of pain. I ask them to return a few weeks after they begin writing.

“This is ridiculous!”

One patient, a professor, came to me with lower back nerves that were so tightly pinched, they were causing leg pain. He refused to do the writing. I told him I thought he would benefit from a simple operation, called a laminotomy, to relieve the pressure. However, I said he would need to find another surgeon, since he was not willing to employ even the simplest tools to contribute to his recovery. A few weeks later, he returned. Laughing, he said, “This is ridiculous! I began the writing and within a week my pain was gone!” He began to employ the rest of the DOC strategies. Three years later, he is still pain free. He may need surgery someday; but now, it would make no sense. Why perform surgery on someone who is feeling fine?

Mental pain = physical pain

I have a theory to explain why expressive writing works so well to alleviate chronic pain, and it comes from my review of the latest neuroscience research, for the second edition of my book. The studies find that the nervous system processes thoughts the same way that it responds to physical sensations such as taste, smell, and pain. All these stimuli—whether they are thoughts, feelings, or physical sensations—are interpreted as sensory input, they travel the same neural pathways, and the body responds with essentially the same chemical reactions. So, from a purely neurological standpoint, emotional pain and physical pain are equivalent stimuli. In fact, I’m now convinced that anxiety is actually the pain. If that sounds crazy, consider this: Most of my patients, when I ask them if they would rather relieve their physical pain or the mental anguish that goes along with it, say they wish to be free of the anxiety. That is the intolerable part.  That certainly was my experience. Am I operating on your pain or anxiety?

Compared to other living creatures, we humans have the unique problem of harboring unpleasant thoughts that are difficult or even impossible to escape from. Each person struggles with anxiety over the course of his or her lifetime, either addressing it or masking it, with varying decrees of success. All the writing does is free you from these repetitive circuits, so that you can redirect your attention and focus on other things. That’s it. It is neither a solution nor a “fixing” exercise. It’s more of a “disassociation” exercise.

The neuroscience research has shown that chronic pain is driven by the emotional regions of the brain. Since writing taps into and releases strong emotions such as anger, blame and anxiety there is “space” for other more positive connections. (1)

Just start the expressive writing

So I ask my patients to begin their expressive writing even before they read my book or dive into my website, and to destroy their written pages immediately after they finish them. There are two good reasons for not saving your pages: First, knowing that no one else will see them, you can write with complete freedom. You do not want to censor any thoughts or feelings, no matter how harsh or otherwise unacceptable they may seem to you. (Research shows that suppressing thoughts can damage the memory center of your brain.) (2) Second, as I mentioned in the last section, the writing is meant only to create distance from your thoughts. For our purposes, analyzing your thoughts and feelings is counter-productive. It focuses your attention on those negative thoughts, which further reinforces the pain-inducing neural pathways. Trying to “fix” yourself is like placing your hand into a hornet’s nest. A pain colleague has succinctly pointed out that holding on to your written words from the expressive writing exercise means you are holding on to your pain.

Certainly many other forms of creative writing are meant to be saved and refined. But expressive writing is only an exercise, to be performed once or twice a day, and its output is to be discarded. If you can’t write, you could record your thoughts audibly, although saying them out loud engages a different set of brain circuits. David Burns, in his book Feeling Good, suggests standing in front of a mirror and verbalizing the self-critical thoughts in your head. Notice how hard on yourself you are. Would you ever talk to another human being that way?

Make it a routine

Consider expressive writing as something you do automatically every day, like brushing your teeth. You’ll find that it’s such a powerful tool that it is habit forming. I’ve made it part of my daily routine, although I confess that sometimes I neglect it. During these periods, within a couple of weeks, symptoms of neurophysiologic disorder (NPD) predictably return. My sleep quality drops, I am more reactive, my scalp itches, my feet burn, and rashes reappear on my wrists. My wife will ask me, “Honey, have you been doing your writing?”

Resistance to Expressive Writing

It is remarkable how resistant so many people are to this simple but profound exercise. There is no cost or risk. It can be done anywhere and it only takes a few minutes. How much time do you spend on your smartphone? Why on earth wouldn’t you do this? I have so many more thoughts on this subject, which I will discuss at a later date; but for now, I have only one question for you: How much do you really want to give up your pain?

1. Hashmi J, et al. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain (2013); 136; 2751–2768.
2. Hulbert J, et al. Inducing amnesia thought systemic suppression. Nature Communications (2016); 7:11003.

The post More on Expressive Writing first appeared on Back in Control.

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The first book was based on my personal experience and observing the successes with my patients. A great deal of new neuroscience research has since been published, which both supports my treatment approach and explains the reason for its success. Reading the neuroscience literature has deepened my understanding of how the process works. On a personal note, I also developed severe arthritis in both of my knees. About six months into my ordeal I realized that I had developed chronic pain. I re-engaged with these tools and have experienced a marked improvement in my symptoms.

Here are some of the concepts that I have learned through the literature and observation:

• Emotional pain and physical pain are processed in the brain in a similar manner and are equivalent entities. (1) They both cause the secretion of adrenaline and cortisol. When you feel anxiety you are simply feeling the this hormonal surge. Therefore, anxiety is a chemical reaction to sensory input and is not primarily a psychological issue. The Neurophysiologic Basis of Chronic Pain Most patients, given a choice of getting rid of their physical pain versus mental pain would rather get rid of their emotional pain. Fortunately, as anxiety drops, adrenaline and cortisol levels decrease and the physical pain will diminish. Stress chemicals increase nerve conduction and pain by 30 – 40%. (2) Anxiety, anger and adrenaline

• In the first edition, I was emphatic that surgery for a structural problem should be performed more quickly since people in chronic pain don’t tolerate additional pain. My experience and the literature do not support that idea. If you operate in the presence of a fired up nervous system, the pain will frequently worsen and often dramatically. I now have all of my elective spine surgery patients engage in the tools outlined in Back in Control for at least 8 to 12 weeks. Surgical outcomes have been more consistent with less pain after surgery and a faster rehab. I also am no longer seeing some of the dramatic failures from a well-done surgery like I saw in the past. The name for this preoperative rehab process is “prehab”. Video: Get it Right the First Time

• What has been the most surprising turn of events is that during the prehab process I have witnessed dozens of patients become pain free that have severe pathology with matching symptoms. I had scheduled each of them for surgery and they cancelled it because their pain dramatically decreased. They did not want or need surgery. I now realize that you can calm down and reprogram your nervous system any way that you want with consistent practice of these tools. It has been rewarding seeing patients become free of pain without the cost or risk of surgery. Avoiding surgery by raising the pain threshold

• I have changed the name of the DOCC (Defined Organized Comprehensive Care) project to the DOC (Direct your Own Care). My book is not a formula. It is a framework that breaks down chronic pain into its component parts and my patients find their own personal solutions. I have watched hundreds of patients become pain free with this largely self-directed process. If someone does not want to engage in these concepts, whether or not they use my book, they cannot and will not get better. The one factor that predicts a good outcome is being truly open to learning and using your personalized version of the tools. DOC-A framework of care

• Research shows that the writing and ripping up exercise does not have to express just negative thoughts. Writing down any thoughts and feelings, either positive or negative is effective. Expressive writing is still the foundation of the DOC project. (3) Write and don’t stop

• These concepts apply to pain from any source in any part of the body. Interestingly, as the process depends on decreasing adrenaline, pain in multiple body areas will disappear about the same time.

John

I had a middle-aged patient who had suffered a significant fracture of the middle part of his back. His spine was bent forward almost 45 degrees. However, since it was just at one level he was able to compensate and was still balanced with his head centered over his pelvis. I would have quickly recommended surgery for it for ten years ago. Then I found out he had been suffering from severe anxiety since he was ten years-old and sleeping poorly. I put him through the prehab process, which included expressive writing, active meditation, normalizing his sleep and getting him more physically active.

He was initially unhappy with me delaying surgery, which would have corrected the deformity. However, the medical literature is clear that surgical outcomes are compromised without the above-mentioned issues being treated. He came back a few times asking for the surgery but was not really engaging in the project. I finally said, “Look, you are welcome to find another surgeon, but I am not going to put you through surgery until these problems are least partially solved.”

He came in a few weeks later with a huge smile on his face. His pain was gone and his anxiety was beginning to decrease. He was sleeping much better and his whole personality was transformed. I will admit that I thought he was going to get his surgery done elsewhere. I am still endlessly surprised and fascinated when my patients come out of their pain pathways, although we witness it every week.

New format

The new edition is organized around following format:

• Section One – The Evolution of Chronic Pain
• Sections Two – The Principles Behind the Solution
• Section Three – The Roadmap Out of Chronic Pain
• Section Four – Continuing Your Journey

I am excited about the new edition. I have learned how to clearly present these concepts, since I have a better grasp of these principles. I am seeing a higher percent of people engaging and improving. This edition reflects that experience as well as the recent advances in neuroscience that support it. I am looking forward to seeing how this whole process unfolds and this new edition is the next step in my journey.

Am I operating on your pain or anxiety?

1. Eisenberger N. “The neural bases of social pain: Evidence for shared representations with physical pain.” Psychosom Med (2012); 74: 126-135.

2. Chen X, et al. “Stress enhances muscle nociceptor activity in the rat.” Neuroscience (2011); 185: 166-173.

3. Smyth JM and James Pennebaker. “Exploring the boundary conditions of expressive writing: In search of the right recipe.” British Journal of Health Psychology (2008); 13: 1-7.

The post Back in Control – Second Edition first appeared on Back in Control.

The post Back in Control – Second Edition appeared first on Back in Control.