Hi Dr Hanscom,

I have been meaning to check in with you for a while now and let you know that the DOC program seems to have worked for me. My lower back & leg pain has disappeared and I’m a firm believer in the process, especially the concept that anxiety is the driver of tension and pain in many cases. I picked up the book, Forgive for Good at your recommendation back in the winter and found it to be excellent. I’ve also been doing mindfulness training and it’s been extremely helpful.  If you aren’t familiar with the book, The  The Mindful Way through Depression, I’d definitely recommend checking it out.

I hope you are doing well and enjoying the summer now that it’s finally arrived.

Best, Jean

My Perspective

This patient is the daughter of an esteemed colleague of mine. She had burned out of practicing law and had embarked on a pre-med pathway at the age of 38. She had experienced low back pain for over two years. There was also significant pain, numbness, and tingling throughout her right leg. She had a normal MRI of her thoracic and lumbar spine. Electrical testing of her leg did not show any specific problems with the nerves. As I knew her father so well, I was especially anxious not to miss anything that might be serious. I could not find a structural cause for her symptoms.

I first saw her about 18 months ago, and on our last visit six months ago, she was just a little better. I tried not to be too discouraged but, I was not sure she was going to improve.

What is remarkable about her recovery is that it was truly self-directed. She did not see me in follow-up nor did she see another physician. I had recommended a mental health professional, as I thought she might be depressed. But she wouldn’t engage in that conversation. She did use the Feeling Good book and was diligent writing in David Burn’s three-column format. She also pursued obtaining a good night’s sleep, utilized the re-programming tools such as active meditation, and worked out regularly in the gym. Two years later she is re-pursuing her medical school dream.

This story is not an exception. With full engagement with a structured program the results are consistent.

The post Depression Masking as Pain first appeared on Back in Control.

The post Depression Masking as Pain appeared first on Back in Control.

• Many of us become upset about the state of the world, which is definitely worrisome and disturbing. However, you have no control, your nervous system is fired up, and there is not an endpoint.
• We all have plenty of problems that we have to deal with without adding on ones that are irrelevant to our day-to-day life.
• Other tools that lower your stress response will be less effective if you continue to remain agitated about scenarios outside your sphere of influence.
• Learning to let go and focus on what you can change will free up energy and creativity to live a more enjoyable life. As you move towards this life, your pain circuits will atrophy from disuse.
• Creating and shifting onto more pleasurable neurological circuits allows you to heal. This process is at the core of The DOC Journey.
• “Choose your battles.” There are plenty of choices.

We know that the most stressful situations are those that are beyond our control, and it is also stressful trying to avoid stress. It is much more productive to learn to skillfully process it in a manner that has less of an impact on your nervous system and makeup of your body’s physiology. However, there are stresses that we unnecessarily create for ourselves. One common way is to not recognize our “errors in thinking” called “cognitive distortions. The other is mentally getting and remaining upset about situations that we have absolutely no control over. But think about it. We have enough to legitimate worries already. Why do we do this?

Anger is a powerful force and intended to keep you safe. It is a basic reaction and necessary to stay alive. Every living creature exhibits some version of it. Humans are different only in they uniquely possess language and a consciousness. We have to navigate a whole different level of mental threats that are not present in the animal kingdom. They are deadly in that neuroscience has demonstrated the unpleasant thoughts and emotions are processed by your body in a similar manner as physical threats, but you cannot escape from them. So, there is a baseline level of threat that is present for every human being that can become disruptive for many people – maybe most of us.

The essence of humanity – vulnerability

We don’t want to give up our anger because we’ll feel vulnerable, and there are few, if any rewards, in nature for being that way. You won’t survive. What is perverse about the human condition is that the best part of it is having enjoyable relationships with others, which requires awareness and vulnerability. But you cannot give up anger until you can allow yourself to tolerate uncertainty.

There are many ways of holding onto anger, with one of the more common ones being that of taking on the world’s suffering. You can remain angry indefinitely because there is little you can do about most of it. You can only make a difference in your own sphere of influence. Continuing to be upset about circumstances beyond your control, not only drains your energy, but if sustained, translates into unfavorable body chemistry with a much higher chance of developing a serious illness or disease.

Taking on the world’s suffering

There are plenty legitimate reasons to be upset or even enraged in this era of COVID, partisan politics, racism, homelessness, class inequities, elder and child abuse, human trafficking, terrorism, religious/ political persecution, and the list is endless. Which ones are you the most upset about? I have my top five.

Here is a letter from an old high school buddy of mine that reflects the problem. He is suffering from ongoing disabling back and leg pain.

“…… violence in nature is difficult for me, but human cruelty to others is incredibly upsetting. I have been this way since childhood. I am very sensitive, and I almost do not feel at home on this planet. I feel wired and tired at the same time.”

Meaning in the midst of suffering

I suggested that he read two books. One was Man’s Search for Meaning by Viktor Frankl.¹ He was an Austrian psychiatrist who survived the WWII concentration camps and found meaning and purpose in the midst of extreme suffering – even his own.  He made  a choice to thrive regardless of the incredible misery he was immersed in. Few people could accomplish what he did, but he did show us what was possible. There is always a choice regarding how we deal with our daily adversities and the cruelty of the world. Of note, many camp survivors understandably did not do well after the ordeal because of severe PTSD, while he went on to a brilliant career and was a prolific author.

The other book was The Swerve by Stephen Greenblatt² that tells the story of the discovery of an ancient Greek manuscript that contained the poem, The Nature of Things written by Lucretius. This finding was a factor in ushering humanity out of the dark ages. This book takes you into the lives of people living in the 1400’s – the Dark Ages. The extent of cruelty is indescribable and most of the population was controlled by fear and terror. We are fortunate to live in an era that has some level of freedom, although this is unfortunately still not true for many people. However, this reality was the norm for most people for thousands of years. Somehow, Lucretius, in the midst of the darkness of living in ancient times pointed out that all each person can and should do is to live a full, rich and meaningful life.

No one is asking you to be happy about the extreme suffering experienced by many at the hands of others. You don’t have to accept it. However, it is important to focus on whatever you can within your power to make the world a better place. Mentally taking on the totality of the misery of the world and remaining upset is common way of remaining in the victim role. Your life energy is diminished and the net result is that you are not able to be a source of light to those close to you.

Conserve your energy

A Heron

Heron stands in the blue estuary

Solitary, white, unmoving for hours

A fish! Quick avian darting

The prey captured

– 365 Tao³

This is a powerful metaphor for us in that we are responsible for only what is in front of us and within our control. Conserving your energy allows you to act decisively and quickly when it is required to do so. Remaining agitated drains you and is not helpful.

These books drove home that the history of the human race is largely extreme suffering, and we are the lucky to be alive in this modern era in spite of the ongoing challenges. I easily can get stuck on what is wrong and contribute to the world’s collective suffering, or I can step up, learn to enjoy my life, and be a conduit for happiness. This is a choice to be made multiple times every day.

Recap

The essence of healing is using tools and approaches to minimize your exposure to threat physiology. Your chemical state is partially determined by the nature of your input. If you are agitated for any perceived or legitimate reason, your body chemistry will be altered.

Choosing to remain angry about situations that are beyond your control is a sure way to remain upset. It creates a negative baseline perception of life, and makes it more difficult to find enjoyment, which is a physiological state of safety and is the essence of healing.

Letting go of situations that you have no control over frees up a tremendous amount of energy to live a more fulfilled and pleasurable life. You are then able to contribute to the well-being of those close to you. “Letting go” is a learned skill and requires a sequence of steps to acquire it.

This post presents a common way of being and remaining a victim. You may not yet see how this term even applies to you. But it is universal, and anger is an essential  of remaining alive. It is just that you want your anger to be situation specific, appropriate, and time limited. The first step in moving forward is always being aware of where you are.

Questions and considerations

1. The human existence has always been difficult, with one of the most disturbing aspects of it being how badly we treat each other. There is nothing you can do about this situation.
2. There is an endless list of wrongs and injustices to be upset about. Make a list of your top five. It is OK to be upset, but it is not helpful to remain in an agitated state about them. You are not helping you, your pain, or your family. It is a classic way of remaining in a victim role – indefinitely.
3. Remaining agitated, regardless of the reason, will drain your energy, and make it less likely that you will take action to contribute to helping others.
4. If your main contribution is creating a haven of safety and joy within your own home, that is more than enough.

References

1. Frankl V. Man’s Search for Meaning. Washington Square Press, 1959.
2. Greenblatt, Stephen. The Swerve: How the World Became Modern. W. Norton Co. New York, 2011.
3. Deng Ming Dao. 365 Tao: Daily Meditations. p. 14. HarperCollins, San Francisco, CA, 1992.

The post Don’t Take on the World’s Suffering first appeared on Back in Control.

The post Don’t Take on the World’s Suffering appeared first on Back in Control.

• Perfectionism is felt by many of us to be a virtue. It is reflected in terms of,
  “high standards,” “excellent quality,” and “strong work ethic.”
• It is actually a disguised version of anger directed at yourself. These ideas actually become translated our minds as, “not good enough,” “imposter syndrome,” and “why do I always do this?”
• Holding yourself up to impossible standards is a way of remaining in a victim role indefinitely.
• These “standards” also translate into judgments of others as you project your views of yourself onto them.
• The most disturbing aspect of this issue is that all of this arises from the unconscious brain, are hardwired circuits beginning from birth, you have no control over them, and are unresponsive to the conscious brain.
• They have to dealt with by reprogramming the unconscious brain.

Perfectionism may be the most common, almost universal disguise of anger. I had been raised with the idea that it was a virtue, and this perception was dramatically reinforced during my medical training. It was at the core of my burnout and journey into The Abyss of pain and I had no idea it was problem until well after I had crashed and burned.

Perfectionism fits into the anger cascade in the following manner.

• A given situation, person, or you, are less than your concept of ideal.
• You blame one of the above for being “less than perfect.”
• You are now a victim of “less than perfect”
• You will perpetually exist in some state of conscious or unconscious agitation.

David Burns in his book, Ten Days to Self Esteem,¹ points out that the gap between your concept of perfect and your reality is the degree of your unhappiness. Perfection does not exist in the human experience. Since perfection is unattainable, why do so many of us continue to embrace it? I will offer a couple of observations from the perspective of an extreme perfectionist.

Why do we keep holding on to “perfect?

First of all, we are programmed to “be all that we can be.” We are also taught that “pushing yourself” is the best way to accomplish this goal – except that pushing often evolves into punishing in the form of self-criticism without limits. Since this strategy often achieves impressive short and medium-term results, it seems like a reasonable pathway. It’s not. Using the medical profession as an example, the burnout rate amongst physicians is over 50% in every state in the US and has risen between 5-10% in the last five years. The burnout rate in neurosurgeons, in one study, demonstrated that it was over 65%.² The same driving energy that pushes you up the hill takes you down the other side. Striving for perfection becomes a deeply-established programmed pattern of thinking and behavior.

A second reason is that the victim role is so powerful that humans will do almost anything to create and hang onto it. Since perfect is unattainable, you are able to remain a victim of imperfection indefinitely. It is self-flagellation. The DOC Journey is about letting go, allowing yourself to repeatedly “fail,” and continuing to move on. Perfect does not allow for failure. BTW, much of your capacity to create a wonderful life is dependent on your ability to deal with adversity successfully and efficiently. Your body will spend less time being exposed to threat physiology. Also consider, “what is failure?”

Third, your self-critical voice is part of the powerful unconscious brain that is not subject to conscious interventions. There is a phenomenon called “the ironic effect” that sabotages your best intentions. When you try to focus on noble ideals and concepts, your brain focuses on ways that you might not attain them. In other words, the more you try to think about something positive, the less you will think about it. You’ll develop anxiety from the futility your efforts. We tend to take these voices personally and we should not. They are your brains automatic programmed patterns. We can “talk” to them as much as we want but there is no one there. It is tragic that we try to quiet these voices that are just repetitive circuits. The more of well-intentioned person you are, the louder they are.

Perfectionism is rampant

85% of people in chronic pain have not forgiven the person, employer, other driver, etc. who caused their pain. Interestingly, the person they are the most upset at is themselves.³ If your intention is to live a life filled with peace and joy, how can you accomplish it by holding onto resentment, especially if it is directed at yourself.

Starting a new life

I was talking to a friend of mine who had recently lost his wife. He was a high-level professional and trying to meet someone to start a new life. Invariably, his internal dialogue was “inadequate,” “boring conversationalist, narrow interests, unattractive, and the list went on. Then it came out that he placed these same labels on his dates. What he wasn’t aware of is that your mind projects onto other people and situations the way we feel about ourselves. The term for this behavior is projection. So, when you are in a judgmental mode and expressing it to others, you are revealing to the world the way you feel about yourself. This is particularly true when you are upset (in pain).

Hard on his family

I was talking to one my colleagues who had experienced a lot of success using the approaches in The DOC Journey with a marked decrease in his anxiety and stomach pains. He found the expressive writing and relaxation tools the most helpful. He had also read Dr. Luskin’s book, Forgive for Good.⁴

He had returned from vacation and stopped the expressive writing since he felt so good and relaxed. The day he walked back on the job his symptoms returned. It came out in further conversation that he is extremely hard on himself. He was an ex-baseball player who almost went pro. I asked him if he was critical of his kids. He admitted that he was. I pointed out that he was not going to be any easier on them that he was on himself and that in the big picture he was not being that nice to either. What he held up as “high standards” was really intense perfectionism. Was this really the world he wanted to create for himself and his family? It is antithesis of creating a haven of safety. Dr. Luskin is clear that forgiveness has to begin with forgiving and accepting yourself? We all sort of know this, but down deep we don’t pull it off very well.

Letting go

So what is the solution? These are not pathways that you can intellectually solve. They are mindless endless loops. Your body is also chemically reacting to these thoughts and creating n. Suppressing them makes the situation even worse. The key is to become aware of the depth and nature of your critical self-talk and create some “space” between you and these circuits. Writing down your thoughts down an awareness of them and also creates this needed space. Then you can use your conscious mind to redirect your attention to more pleasant choices. Just understanding the magnitude of the impact that perfectionism is having on the quality of your life also helps.

Finally, decide to be happy. You have to use repetition to reprogram the unconscious. This is different than positive thinking, which is a form of suppressing. It entails creating a positive vision. You cannot get to happy while remaining perpetually judgmental. Then choose to program your brain with positive alternatives and solutions. Paradoxically, you will possess an endless amount more energy to achieve your goals.

I hold a Q&A session a couple of times per week. Perhaps the most common topic that keeps coming up is “not feeling good enough” and self-criticism. I joke that we could call our roundtable, “The perfectionist’s club,” except it is not funny and actually is tragic. The accomplishments of this group are remarkable, yet there is a limited capacity to enjoy their successes. Perfectionism is what was the essence of my personal demise.

Recap

Creating a vision of excellence is much different than having “high standards.” You understand and accept where you are along with your resources. Then you create a plan to pursue your vision of what you want your life to look like. This involves filling your brain with positive solutions as well as accepting and processing  the inevitable failures. This is a different journey from wasting your energy flagellating yourself for your inadequacies and failures. If you are not willing to fail, then don’t attempt the journey. Paradoxically, you will have an endless amount of additional energy to achieve your goals. Happiness is only possible while pursuing a vision of excellence.

References

1. Burns, David. Ten Days to Self Esteem. Harper Collins, New York, NY, 1993.
2. Kurapati, Rajeev. Burnout in Healthcare. Sajjana Publishing, 2019.
3. Carson JW, et al. Conflict about expressing emotions and chronic low back pain: Associations with pain and anger. The Journal of Pain (2007); 8:405-411.
4. Luskin, Fred. Forgive for Good. Harper Collins, New York, NY, 2003.

The post The Ultimate Victim Role – Perfectionism first appeared on Back in Control.

The post The Ultimate Victim Role – Perfectionism appeared first on Back in Control.

An unfamiliar problem

A few years ago, I evaluated a retired businessman for pain down his right leg. It had begun about eight months earlier. The pain was moderate but frustrating. He had not experienced prior back problems and wasn’t used to being limited by pain. It was unclear what might have precipitated it. His wife accompanied him.

I mail an extensive twelve-page spine questionnaire to my new patients. It includes questions about sleep, stress, work, as well as medical and family issues. I noticed before I walked into the room that he had only filled out the part of the form dealing with his spine pain and medical problems, but he had skipped the questions that dealt with any personal issues. I looked at the MRI of his lower back before I walked into the room and noticed that there were some small bone spurs, but they were on the opposite side of his body from his pain. This meant that I did not have a structural explanation for his symptoms and surgery wasn’t an option.

I walked into the room and explained that I needed to have him fill out the rest of the intake questionnaire before I could finish in the evaluation. I walked in about five minutes later and he stated that he didn’t want to fill the personal profile section because he wasn’t a chronic pain patient. I took about ten minutes to explain that even if there was a structural problem that I could fix, I felt that surgery was only about a third of the solution, rehab and conditioning was a third, and that dealing with the central nervous system was at least a third of any solution. I also explained the phenomenon of phantom limb pain and that after six months of experiencing pain, memorized neurological circuits were a problem. It was my wish to give him the best chance at a good outcome with or without surgery. I hadn’t even gotten to the fact that I didn’t see anything I could operate on and that I needed to order more tests.

“But I’m not angry”

Well, to make a long difficult story short, he started to scream at me that he wasn’t angry and that all he needed was an operation to solve the problem and to get on with his life. He had a long vacation planned in three weeks. He turned to his wife and said, “Well Mrs. X, what do you think about what he’s saying?”  Her reply was, “I think you’d better listen to him.” I finally had to bring in my most experienced nurse to talk to him. She couldn’t calm him down and I offered to have him see one of my partners.

I have watched countless patients succeed and fail at surgery. If I perform surgery based on unclear pathology, it almost always fails. If I operate on patients who have refused to engage in at least part of the overall rehab program, the results are OK, but frequently not great. The patient will often become focused on the small amount of residual pain or pain in another area of their body and are often still unhappy. My patients who fully engage in the rehab program usually become essentially pain free. This includes both surgical and non-surgical patients. If there’s residual pain, it isn’t a major issue and they move on with their lives.

What should I do?

I wasn’t happy about any part of the interaction with this angry patient. I am continually challenged by my inability to break through to a given patient in a situation like this. Should I have waited to present my rehab concepts until the second visit after the diagnostic testing was done? Would it have been better if I requested that a new patient read about my rehab approach before they meet me? Should I just proceed with surgery knowing that the results are not what they could be? I understand the problem. My patients are in pain and they are looking to surgery to bail them out. When that option is taken off of the table, it would be surprising if they weren’t upset.

Ongoing pain is enough of a problem that it creates anger regardless of who you are. You are trapped by physical unpleasant sensations and it magnifies other life stresses.  Somewhere between three to six months into this process, while working through anger issues, the pain will often markedly abate. I don’t wait until that point to perform surgery if it’s required. I just need to have a working relationship with them. Know your surgeon – before surgery

The DOC project is an evolving process and I’m also a work in progress. Anger is the major obstacle to healing because it blocks learning and engagement. I remind myself every time I encounter this lack of connection to one’s emotions that I was in the same situation for decades. Now I work on becoming aware of the different forms the emotional disconnection takes. They are subtle and endless. Thinking I have “resolved” my anger issues is the biggest problem. My ongoing challenge is to continue on my own daily journey and see when and where I am blocked. In doing so, I will have a much better chance of figuring out some better approaches. Awareness is the cornerstone of relationships, life and healing. Becoming aware when you might be unaware is a critical part of it.

The post “But I’m Not Angry” first appeared on Back in Control.

The post “But I’m Not Angry” appeared first on Back in Control.

Thoughts

The central nervous system is the command center that translates all sensory input into chemistry and action. Any threat is met with varying degrees of a survival response. The problem of human consciousness is that this automatic unconscious reaction can be set off by just thoughts. So whether the threat is real or perceived the chemical response is the same. That is why thoughts are real because they immediately create physical responses but they are not your reality. The neurophysiological basis of pain

They become your reality if you do not recognize thoughts as simply thoughts because with repetition they become deeply imbedded in your nervous system. Your whole life will become run by your belief systems. You cannot see past them and instead of being connected to your environment and those around you, you are more attached to these stories. How else can you explain a significant percent of human behavior that is terrible? I do not need to provide examples. We intellectually know that many activities we engage in are simply wrong but that does not stop us. We rarely keep New Year’s resolutions. We regularly do things that we would never want our children to do? Do you think anyone addicted to a drug or behavior wants to be that way? No!! So why do we consistently act this way?

The unconscious brain

It is because the unconscious brain is about one million times more powerful than the conscious brain and the bodily reactions are strong. Any stress will be perceived as a threat with a corresponding physiological response. Since you cannot escape your thoughts you will become progressively buried by anxiety under this onslaught of consciousness. The progression of thoughts may be the basis for developing chronic pain. Attempting to control this massive reaction with a conscious response cannot work – and it doesn’t. It is like trying to stop a long freight train with car brakes. (1)

Consider what what your nervous pulls off second by second. Every muscular movement is balance by and opposite force. For example, when your biceps fire the triceps is also firing almost equally as hard to regulate the movement. When this sequence is out of balance you will experience spasticity. Blinking, balance, swallowing, speech, dilation of the pupils, heart rate, digestion, bladder function are examples of the complexity of this complex and elegant system. Avoiding actions that would cause pain is another example. When you are sitting in a chair your brain is telling you to keep shifting positions so your skin does not break down.

The mismatch

You cannot solve your mental or physical pain with will-power. You cannot win the battle with the unconscious brain. But once you are aware of this scenario, you can redirect your nervous system to form in a more enjoyable direction and it can happen quickly.

For example, I was working with a group that is focused on spreading compassion. It is a great concept and there is benefit in reminding people that it is important. But all of us already know this. I have long-observed, both in me and others, that when you become angry (ultimate survival response) most of the time compassion is simply buried. You may feel terrible later about your outburst but the odds are high that you will act the same way in a similar situation. It is also hard to see your effect on others because it is all about you.

The need to become aware

To solve this problem, you have to first become aware of and feel your automatic survival reaction to stress and substitute a more functional response. Without this awareness, you have little chance of creating a happy life. It is the basis of stimulating your brain to structurally change. You must first become aware, separates and then substitute a more rational response. It is one of the reasons than the exercise of expressive writing may be effective. You are aware of your thoughts and physically separated from them. In that physical and time space you are able to substitute a more functional and possibly more enjoyable response. With repetition your brain will physically change structure. It is well-documented that your brain will decrease in size while in chronic pain. Fortunately, it re-expands after the pain is gone. The descriptive term for this process is, “neuroplasticity.”

We need to figure out how to deal with this imbalance between the conscious and unconscious brain soon. We will do anything to avoid the deep feelings and physical sensations that are generated by thoughts. That is why so much of individual and societal behavior is irrational – and destructive. We want to avoid pain. Nothing else matters. I think our conscious brain has the capacity to figure this out – once we become aware of the problem.

1. Trincker, Dietrich. 1965 lecture at the University of Kiel. German physiologist.

The post Your Unconscious Brain first appeared on Back in Control.

The post Your Unconscious Brain appeared first on Back in Control.

Survival

Humans additionally have consciousness so just thoughts can produce the same neuro-chemical reaction. Secondary needs that become a problem include social interaction, self-esteem, companionship, validation, etc. It does not matter if the thoughts are based on reality. It was my friend, Dr. Fred Lusksin and author of Forgive for Good, (1)who pointed out that your body’s main focus, is to survive, not to have a good time. Therefore the default mode for your brain is negative. This characteristic causes many errors in thinking. As they are usually irrational, there is no solution and no end. The resultant relentless anxiety eventually becomes unbearable. It also worsens with age and repetition.

We assume that solving problems will diminish anxiety. It might be true for that specific situation. But what has become obvious to me is that my brain will quickly begin scanning everything around me for more danger. If there is nothing physical to be concerned about I will experience (create) endless irrational thoughts that are disruptive. In fact when things are quiet these thoughts often become even more intense.

What did I do Wrong?

One recurring example is when someone doesn’t return an email or phone call in a timely manner, I immediately assume that I said or did something that offended him or her. Or maybe he or she just doesn’t care for me anymore. My brain immediately begins spinning. Invariably, I find out that they were out of town or dealing with a difficult situation. The delay had nothing to do with me.

A few weeks ago I sent an email to a good friend of mine to have re-sent out to a group of colleagues. I became upset when it wasn’t posted. Instead of just re-sending the email or asking about what happened, I spent hours obsessing about what I could have done or said that upset him. It turns out that he hadn’t seen it. He happened to run across it while cleaning out his “in box” and really liked it. My hours spent being agitated were a complete waste of time.

There are endless problems created by your personal scanner, which is always on high alert.

The Problems

My patients often became so focused on the situation or person who wronged them that it consumed their life. One study showed holding on to anger around an injury significantly affected the level of pain and decreased emotional well-being. (2) I’ve had many intense conversations around this scenario. They’re convinced that when their lawsuit or claim is resolved they will be happier. That’s simply not true. First of all, most of the time these situations rarely resolve quickly. Your pain/ anger pathways are now deeply imbedded and solving the problem will not reverse those circuits. What if the problem is not solvable? Do you really want to remain miserable? Elephant’s noose

Second, your brain will immediately land on another problem. It always does. Just watch.

Third, one problem might get solved but is that your only one? Life constantly throws us unhittable curve balls. How many of your issues do you need to solve before you are content? What are the odds of every problem being solved to the point where you are now happy? It isn’t going to happen and if it could you would now worry when it was all going to fall apart. The Eye of the Storm

Fourth, if you cannot truly relax on a given day without worrying, when are you going to regenerate – especially if you are not sleeping well? It is critical to relax when you have the opportunity. When do you get to enjoy your life? Enjoy Your Day Today

Possible Solutions

Your personal brain scanner can’t be turned off. You’d die. So what’s the solution? I am not pretending to be an expert on this and these are just some of my observations of approaches that I have found helpful.

1. I think the one most important strategy is awareness. I am noticing how consistently my brain lands on negatives in spite of so many things I have to be grateful for. It helps me see the insanity of it.
2. I will never forget a simple comment made by the Dali Lama in his book, The Art of Happiness (3). He pointed out that we often compare ourselves to those who have more than us. Why not compare yourself to those who are less fortunate? I use this concept daily as I hear about the extreme suffering of so many people around the world. At the moment there are over 60 million refugees worldwide. I do not have much to complain about.
3. Reading history almost always wakes me right up regarding what I have to be thankful for. One example was a book, The Swerve by Stephen Greenblatt (4). He defines a “swerve” as a world event that changes the course of human history. The story is about the discovery of an Ancient Greek manuscript that was a big factor in ending the Dark Ages. Amongst many insights in this book, he describes the life of the people who lived in the Dark Ages. My worst day ever is infinitely better than their best day. I can write this post without worrying about the Inquisition priest walking through my door and hauling me off to an unthinkable fate. The book made a deep impression on me.
4. I re-committed to the expressive writing at a level that I haven’t done since I first began my journey out of The Abyss in 2002. It is still startling to me how effective this simple exercise is in disconnecting me from my racing thoughts and connecting me with my day. Write and Don’t Stop
5. The tool that helps me during my day is the active meditation. Instead of battling my thoughts I simply place my mind on a sensation for 5-10 seconds and I calm down. Engaging with these negative circuits give them more power. Active Meditation

Your brain is a scanner that cannot be turned off. Don’t think that solving a given problem is going to decrease your anxiety for any length of time. Your mind is going to find another target quickly.

1. Luskin, Fred. Forgive for Good. Harper Collins, New York, NY, 2002.
2. Carson, JW, et al. Forgiveness and chronic low back pain: A preliminary study examining the relationship of forgiveness to pain, anger, and psychological distress. Jrn of Pain (2005); 6:84-91.
3. Dali Lama, HH, and Howard Cutler. The Art of Happiness. Penguin Group, New York, NY, 1998.
4. Greenblatt, Stephen. The Swerve. Norton and Co., New York, NY, 2011.

The post Your Personal Brain Scanner first appeared on Back in Control.

The post Your Personal Brain Scanner appeared first on Back in Control.

Florence is an insane place to drive with people and motorcycles darting in front of your car every few seconds. It is part of the experience. From the moment we left the station he began to curse at everyone in his way. “They should be using the tunnel under the street. Get out of my way. Don’t you know cars to have use the road?” He did not stop his tirade until we reached our piazza. He clearly was more than burned out and had no interest in any conversation. The stress in his car was palpable.

I don’t know him or anything about his life. What I do know is that being chronically angry is a strong factor in creating burnout and depression. How could it not?

Physician Burnout

The burnout rate in every state survey shows that 50 – 55% of physicians are burned out. My spine fellow recently put an article on my desk showing that 65% of neurosurgeons are burned out. It’s both disturbing and predictable. There is a tremendous amount of stress in medicine and we are not trained how to process it. Additionally, the medical culture often engages in behavior similar to the cab driver in that we frequently become upset about things that we have no control over.

Dr. Fred Luskin, in his book, Forgive for Good, describes this phenomenon as the “unenforceable rules.” When you’re frustrated about any situation or relationship that you have no control over you are wasting your time and destroying your quality of life. An example might be that you wish your spouse would watch less TV or treat you better. It is fine to wish it but when that wish becomes a demand in your mind it has now become an “unenforceable rule”. If you write down a list of upsetting situations or people, you might be surprised at how long it is and how unsolvable they – at least by you.

The Emergency Room

One classic example in the medical field is in the emergency room. I worked in the ER throughout my residency when I had a few gaps in my schedule. The vast majority of ER visits are not emergencies. Examples include sore throats, back pain, neck pain, a low-grade fever, stomachache, etc. All of which could wait to the next day to be seen in a doctor’s office. These patients frequently show up around two to three o’clock in the morning. It is about time when the on-call physician is trying to grab some sleep. Many ER doctors become upset about a patient showing up with a minor problem at that hour. It’s understandable and frustrating. However, he or she might  tee off on the patient, letting them know that they shouldn’t be coming to the ER with a non-emergent situation especially in the middle of the night.

First of all, the on-duty physician is expected to work a full shift and be available the whole time. Second, is educating that one patient going to stop the other thousands of those who will be following? Why spend one second being upset about a runny nose at two o’ clock in the morning? Why not just take care of it and move on? Talk about an unenforceable rule. It is fine to wish that patients were more aware of what constituted an emergency but when you become upset that all of them don’t, then you have turned this wish into a demand. Indeed the burnout rate in ER physicians is as high as any medical specialty.

What are your unenforceable rules?

What are some of your unenforceable rules? “My claims examiner is not responding to my needs. I wish my spouse would lose some weight. I hate bicyclists in my way to work. My boss isn’t that nice to me. I want to be free of pain now. My son needs to be more serious about school. I just want my life back.” Take a few minutes to write them down. It will be long list in that there are many things wrong with this world and life is imperfect for everyone.

With age and repetition, many of these legitimate wishes will turn into “demands”. Unfortunately, becoming upset about them not only drains you, but worsens the problem. For example, people suffering from chronic pain commonly become socially isolated. One reason is that anger is not attractive, which pushes others away. One wish, of course, is to have more friends and become frustrated when they don’t seem to want to spend as much time with you. There is also a tendency to complain others about your pain and situation, which becomes old quickly. Are you sabotaging your wish?

Remaining upset about situations you have no control over will drive you into the ground and bury you. The first step is to become aware of your own unenforceable rules and how they play out in your life. Develop your own tools to process these “wishes” and truly move on.

Listen to the Back in Control Radio podcast The Unenforceable Rules

Your book is bullshit

The post “The Unenforceable Rules” first appeared on Back in Control.

The post “The Unenforceable Rules” appeared first on Back in Control.

The angry meditator

I have talked to several highly-skilled meditation teachers and they agree with my observation is that is common to encounter an “angry meditator.” There is a dark side to meditation because it is often used to counteract and suppress anger and anxiety instead of feeling it. A skilled meditator does allow those emotions to encompass him or her and then let them go. But, it isn’t a good starting point for most people because initially, it is challenging to cut through the intense neurological anxiety and anger circuits.

Avoiding stress

What I have often observed in many friends, patients, and me is that while in a quiet environment life is good and deep states of relaxation are more easily achievable. But what about being engaged in the craziness of the rest of your life? Triggers are everywhere and the reactions are still strong. Some will sequester themselves within a meditative community. I respect everyone’s choice to live within his or her capacity to deal with stress. However, there are a couple of problems with this approach.

Living in a bubble

First, it is eventually stressful avoiding stress. The process is endless and your world shrinks.

Secondly, when you are subjected to a difficult situation you lack the resilience to deal with it head on. Without consistently learning and practicing effective tools, your coping skills may be overwhelmed. Your world continues to shrink. It is a bit of a catch-22 because someone who is wise enough to pursue a meditative path, is probably not going to end up being a spine surgeon.

Meditation as a form of positive thinking

The most damaging problem is that meditation can be used as a tool to suppress anger. It can be effective in the short term. It eventually becomes a complex method of positive thinking or a form of denial. One thing worse than suppressing anxiety is suppressing anger. Those circuits will really become fired up. So when the trigger is hit the resultant response is not pretty for anyone, particularly the person who thought life was so peaceful and full. A full life means being able to absorb the fullness of every part of it, no matter how difficult.

Chronic pain will often persist or return quickly. There are also at least another 30 physical symptoms that may also appear. This is the process I am referring to that occurs in the angry “meditator.” He or she is at peace but they are experiencing migraines or their ears are ringing.

“Enlightened”

A few years ago I put a label on myself as being “enlightened.” In my mind, since I knew so much about processing anger, I thought that I was above diving into that hole. What a disaster! What occurred was that my angry reactions did not happen as frequently, but the intensity of them overshadowed any benefit. Finally, I realized that I will always go into a victim role many times daily. By being committed to being more aware of it, I am more able to not take any action until my reactivity has passed.

The sequence

Life is challenging for everyone and you will consistently be triggered. The sequence of stimulating neuroplastic changes in your brain to dampen the powerful survival response is:

• Awareness
• Detachment
• Reprogramming

Awareness and detachment

The writing down of your negative thoughts and throwing them away is a tool I write about incessantly and it is the foundation of the DOC (Direct your Own Care) process. The writing exercise creates an awareness of the troublesome thoughts and there is a space between you and the paper that is connected with vision and feel. I have often described it as, “mechanical meditation.” You have now separated from them.

Meditation can eventually be brought into play as it accomplishes all three aspects of regrouping your brain – awareness, separation, and reprogramming. It is a powerful tool to maintain your healing and move forward.

Skilled meditators

Many people who have a strong meditative practice can accomplish the awareness and detachment steps just through meditation. They are connected to their body or environment by feel or visualization. They can “watch” the disruptive thoughts enter and leave and then reconnect with the world with awareness. Most of us do not have that skill – especially early on when you are at war with your pain.

Meditation can connect you with your anger or be a global form of positive thinking. Do you embrace or avoid stress? Are you uncomfortable with your anger when it is triggered? Does it sometimes seem out of proportion to the situation?

Meditation is incredibly useful. Just don’t let it be a tool that disconnects you from what is actually going on inside of you.

The post The Angry Meditator first appeared on Back in Control.

The post The Angry Meditator appeared first on Back in Control.

Anger

Nonetheless, there are obstacles to becoming pain free. The absolute biggest block that I encountered daily was anger. I honestly didn’t know how to help a patient get past it. He or she becomes irrational. When you are chronically angry, it is your baseline, and you cannot even recognize that you are angry. I personally had no clue that I had any anger issues until I was 50 years old. In fact, one of the first lines to my wife when I first met her was that I was a “good catch” because  I had dealt with all of my anger issues. I am glad that neither of us had any idea that I had not even opened the door to my frustrations, as we never would have made it.

Noncompliant

The problem with anger is that you cannot listen and accurately assess a given situation. The conversation I have with a patient who is noncompliant goes like this. “Doctor, you mean to tell me that there is nothing wrong with my back? I have been in pain for several years and I know that this pain is not in my head. You must be missing something.”

I reply, “The pain you are experiencing is not imaginary pain, nor is it psychological. We know that if we did a functional MRI of your brain right now, the part of your brain that corresponds to your area of pain would light up brightly. All that matters is what is happening in your brain. We also know that the brain can fire spontaneously without an indentifiable source of the pain. I don’t just believe you have pain–I know you are experiencing pain and are frustrated about being trapped.”

I also explain to them that degenerated discs are normal as you age and that there is no correlation between a degenerated disc and back pain. The surgical success of a fusion for LBP is less than 30% with a significant downside of a failed surgery. They then say, “I don’t want surgery. I just want to be fixed and get my life back.” When I reply that we have had very consistent results following the steps outlined in this book, they explode saying, “I don’t want to read a book or anything like this. Just do something to fix my back.” They will then start ranting and often even yelling that no one will help them. Occasionally they will walk out of the room.

Anger is an absolute block to moving on

This is a frequent scenario. I would estimate that at least 50% of my patients fall somewhere in this part of the spectrum. They are noncompliant actually not by choice. I realize that chronic pain causes anger, but It is this anger that is also a complete block to engagement in effective treatment. Anger is destructive and it is multi-directional. It is particlurlarly self-destructive. You also have a strong sense of “being right” when you are angry and an even stronger sense of everyone else “being wrong.” I honestly do not know what to do to break this mind set.  I have tried everything from being confrontive to being incredibly patient. Nothing has worked. In fact, I have found that the longer I spend trying to convince someone to engage, the angrier they become. Angry people become upset when trying to be convinced to give it up. They just cannot hear me.

Address Your Anger

If you are angry or living in one of the above disguises of anger, be careful. You are trapped. You are truly stuck, and no one can even throw you a lifeline. What you cannot see is the havoc you are wreaking on those around you and onto yourself. I do not know how best to quell the anger rooted in chronic pain. I am open to suggestions.

The post Anger-The Absolute Block first appeared on Back in Control.

The post Anger-The Absolute Block appeared first on Back in Control.

She had undergone a major low back surgery and came to me with unrelenting pain in her left leg. As I re-worked her up, I realized that there was still a lot of nerve compression left from the prior surgery. Fortunately, after re-doing her surgery, her pain disappeared, but she was not moving forward like I had anticipated. She was extraordinarily pleasant and had a “life of the party” personality. I could not figure out what might be holding her back. Our conversations began to center around anger and she really felt that she was not angry. However, every time I mentioned her prior surgeon’s name she would become quite agitated.  One day she brought in the following letter from the surgeon.

The Letter

Dear Ms. “_____,”

I must advise you that you are beginning to wear your welcome thin.

I am fully aware of the stress that having major surgery will put one under. I also realize that individuals that do not feel well are not always at their best in terms of interpersonal relationships. However, you have been substantially difficult to care for thus far since your surgery last week, have stayed in the hospital substantially longer than other patients your age with similar problems, and have complained very steadily about the inadequacy of pain medication despite doses that are far in excess of what I usually administer.

I attempted to explain all of this in a very lengthy conversation. I advised you that I know that your pain tolerance was low, and that you would therefore not likely be able to gain the degree of relief that one would typically associate with narcotic medication. Having said that, I increased your doses yet again.

It would seem self-evident that a person who has had such difficulty with pain management would therefore make certain that the first thing accomplished after discharge was obtaining the prescriptions that I wrote for you. Yet tonight at almost 9:00 pm, I received a call from the answering service stating that you had a problem filling your medications.

Any additional nonsensical or adolescent behavior will be greeted with discharge from my care. Make no mistake about it, I have fired patients before, and you are not immune. By copy of this letter, I am notifying worker’s comp that thus far I have had difficulty getting you to follow simple instructions. Please make a better effort to be as good a patient to me as I am trying to be physician to you.

Sincerely,

Dr. “X”

I get it. In addition to being frustrated about her employer being negligent in causing her injury, she then had a surgery that did not go as well as planned. Then her surgeon scolded her when she was seeking relief from the pain that should have been relieved with the surgery.

I am sympathetic to her plight. But life rarely is easy. Surgeries fail. You are not always treated the way you deserve. No matter how legitimate your anger, it will still take you down into the depths of the abyss. You still have to let it go – completely.

In Forgive for Good, Dr.  Fred Luskin out of Stanford, reported on his work with the parents of children who had been brutally murdered.  Until those parents could forgive the murderer, their quality of life was done.

I had another three visits with her.  Each conversation was remarkably pleasant.  However, she never acknowledged that she might be angry.  She was just “right.”  I don’t know the final outcome of her situation, as she never followed up with me.

BF

The post “I Understand Your Anger. Get Over It.” first appeared on Back in Control.

The post “I Understand Your Anger. Get Over It.” appeared first on Back in Control.