Objectives

• Providing yourself with cues of safety is essential to healing. However, your body instinctively gravitates towards being aware of threats.
• Even when life is good, your brain is constantly scanning your surroundings (including your consciousness) for danger. It is your “personal brain scanner.”
• As disruptive as anxiety is, it is your protector and gift of life. You are not going to get rid of it or transform it into a pleasant sensation.
• Efficiently dealing with it daily allows you to nurture joy and live the life you wish.

Abraham Maslow was a prominent psychiatrist who looked at the human condition in terms of the hierarchy of needs.¹ At the base of it were basic physiological needs such as food, air, clothes, water, heat , sleep, sexual intercourse, light, hygiene, shelter, urination, and excretion. Without these basics being met, it is unlikely we can or will pursue the higher levels of needs with the top being self-actualization.

What he didn’t mention was that “not being in pain – mental or physical” is not only a foundational need but it is a driving force for most human behavior. People will do almost anything not to feel anxious and vulnerable. It is bi-directional in that lack of the above-mentioned resources will clearly create anxiety and meeting those needs will help lower it. I again want to acknowledge the depth of suffering that occurs in this scenario, and it is almost impossible to pursue a healing journey under severe adversity.

Stress = threat

However, if these needs are being met, then stress (threat) is not the problem. It is the reaction to it that creates so much chaos within you. Avoiding stress doesn’t work and becomes its own stressor. Remember the most impactful stresses are the ones you cannot control. So, that is why learning how to lower your threat physiology through the different portals is so critical.

The metaphor of a bathroom is relevant because you cannot get rid of anxiety and survive. It is part of everyday life. It is important to develop a “working relationship” with it and let it do its work. So, it is a matter of processing life every day, dealing with the waste, and visiting this room as many times as you need to. If your stress reactions build up without an outlet, you will eventually become ill.²

As you learn to develop this relationship with these emotions as opposed to fighting them, you’ll become more skilled in processing them, and your reactions will become fewer and less intense. There are three aspects of lowering this neurochemical inflammatory reaction.

• Separate your identity from this response. It is what you possess, not who you are! It is also universal and there is no reason to take anxiety personally.
• You can directly lower these hormones and inflammatory markers with tools such as humming, breath work, nasal breathing, and calming sounds.
• By stimulating neuroplastic changes in your nervous system, your automatic reactions are less disruptive, and the real healing comes from the creation of new circuits that are pleasurable and creative. There are infinite possibilities and the metaphor of building your new home is a foundational framework.

Emotional flexibility

One solution to dealing with anxiety is control. It is what this sensation is intended to do – be so unpleasant so as to compel you to solve threats – and it works. You are alive and reading this lesson. However, since mental and physical threats are processed in a similar manner, and humans can’t escape their consciousness, we are all trapped by our thoughts to a greater or lesser degree.³ Most of us instinctively fight disruptive thoughts and feelings, but this only reinforces them.

The other strategy, which is actually fairly effective is mental and emotional rigidity. If you train your mind to focus and become immersed in any number of belief systems, your mind is occupied, and unpleasant thoughts are largely “pushed aside.” The beliefs can take any number of different forms such as religion, politics, strong opinions about morality and people who are different than you. What is problematic is that humans are programmed by their own lives and infinitely unique. None of us see anything exactly the same way – even solid objects. Rigid thinking works quite well for decreasing anxiety for the person, but not for those around him or her. You have lost awareness of the needs of others and pigeon-holed them into your way of thinking.

One definitive solution for anxiety is giving up the need for control. In other words, you must learn that anxiety protects you, and is the gift of life. It is also why you have to separate your personal identity from this reaction and develop a “working relationship” with it. It is never going to be a pleasant sensation, but as you become more “emotionally flexible” you’ll learn to tolerate, even become comfortable with it. It needs to be processed daily, all day long.

Emotional perfectionism is a problem. You monitor your progress, feel like you have” failed” if you dive back into being anxious or angry, and your self-critical voices start talking to you. You are now a victim of these thoughts (and you really are), and you are not going to outrun them. Even if you can for a while, they are relentless and will wear you down.

Recap

Anxiety is a physiological state. Glance though the lessons in Leg 3 of this course. It is challenging to deeply change your concepts of anxiety. Most of us are raised to feel that this is a psychological issue and if you are overwhelmed by it, you are not tough enough. “If you can’t take the heat, get out of the kitchen.”

Nothing could be further from the truth. Suppressed anxiety is a disaster, causes damage to the memory center of your brain,⁴ and disrupts every aspect of your life. You are so used to doing it (who taught you otherwise), you may have no idea that this is what you are doing. Being “tough” was at the core of my own descent into The Abyss.

The main focus of The DOC Journey is learning ways to methodically become aware of and process anxiety and anger so you can live a life that reflects who you really are. To have a good life, you have to live a good life. However, this also requires learning how to efficiently separate from and deal with your survival reactions. Being anxious or angry isn’t good or bad. It is life.

 Questions and Considerations

1. Emotional pain hurts. Why would we want to feel that pain? We don’t. However, learning to live with it is essential to healing.
2. Anger effectively covers up feeling vulnerable, which we instinctively dislike. No one EVER wants to give it up, and we can’t. It is another factor in becoming emotionally flexible.
3. It is difficult to understand the necessity of anxiety and anger and also be aware of its impact on you and your life. These emotions preclude awareness and the reason why specific skills are required to break through this catch-22.
4. De-personalize these sensations and develop skills to deal with them. You must let go to move forward.

References

1. Miles Vich. Maslow’s leadership legacy. Journal of Humanistic Psychology (2008); 48: 444–445.
2. Smyth J, et al. Stress and disease: A structural and functional analysis. Social and Personality Psychology Compass (2013); 7:217-227. doi:10.1111/spc.12020
3. Eisenberger NI, et al. An experimental study of shared sensitivity to physical pain and social rejection. Pain (2006); 126:132-138. doi:10.1016/j.pain.2006.06.024.
4. Hulbert JC, et al. Inducing amnesia through systemic suppression. Nature Communications (2015); 7:11003. doi: 10:1038/ncomms11003

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Hey David,

I was hoping I could ask you a surgery question. I know you do a lot of revisions.

There’s a guy who came to me in early 2014. He could not sit, lie down, walk or do anything to get relief from terrible pain. I referred him to a colleague who is a McKenzie certified therapist (emphasizing extension of the spine). He couldn’t help him. The guy just didn’t know how to get through the system and I think his physician handled his case, from what I can tell, poorly. He was about a month from his onset when he first came to see me and he hadn’t even had an MRI. Anyway he wound up having a two level fusion right out of the gate. Are You Kidding Me? Not a microdiscectomy; straight to fusion for an L4/5 paracentral herniation (this is a bulging disc and probably not the source of pain). A year later he’s worse off than he was before the surgery and that’s saying a lot. Video: Get it Right the First Time

His surgeon keeps turfing him back to physical therapy because he just doesn’t know what to do with him but we can’t help him.

Other than the fact that he’s still in such bad shape how do you know when a revision is appropriate? As we know, you can always find someone willing to operate. I was talking with a patient the other day who seemed really down and when I asked her she said her daughter was going to have another back surgery. Number eleven!!! “The Pit of Despair”

This guy is only 32 years old and he lives every day in terrible pain. We just don’t know what to tell him other than we can’t help him. It’s so scary. What I’m going through is a mild nuisance compared to what this guy faces every single day. And I made it to 55 before my “problems” began.

Hope you’re well. I began doing some Qigong everyday a week or so ago. I think it’s been good for my mind. Best regards, Mike

My reply

Hi Mike, The data shows that when you perform surgery in the presence of chronic pain that there is a significant chance that you can induce chronic pain at the new surgical site.(1) Of course you can also make the pain worse at the site of the pain. You already know my thoughts about spine fusions. They simply do not work for LBP. I see this scenario every week and is maybe the biggest driving force in pursuing the DOC project. He is a classic person who would respond to the tools in Back in Control, but often patients are so angry that they are not open to anything. I have learned to simply let go hopefully they are open in the future. If he would be willing to read the book AND begin the expressive writing I would be happy to talk to him. Otherwise, I have learned that my conversation is not productive. Physical therapy is helpful, but as you know, is best combined with treating the other factors that affect pain. I am personally re-engaging with the writing/ active meditation at a much higher level along with the gym and a better diet. My knees are finally turning the corner. It has been very humbling and enlightening experience. I am glad to hear you are moving forward. Let me know if I can be of some specific help. Best regards, David

Mike’s unsettling answer

I’ll give it a shot. I’ve thought about it in the past but I just don’t know if he’ll go for it. When I first met him I had all kinds of alarm bells going off, as did my colleague Henry, about how the whole process was unfolding for this guy. And we both told him so.  But he just did the passive patient thing and allowed himself to be carried by the currents of a very unplanned plan of care that he had no capable point person guiding him on.

But at this point what’s he got to lose? As I say about so many of the changes I’ve undergone in my approach to all this; “There are no atheists in a foxhole”.

This whole process has been such a, I don’t know what to call it – a revelation to me. After becoming a physical therapist I became aware there are a lot of people living in chronic, unsolved pain out there. But once you’ve walked a mile in their shoes the numbers of people out there living like this guy becomes staggering and frightening. Like most people I always felt so bad about the people who died young but never really considered people who lived with pain every day. I would have a fleeting thought of “glad that’s not me” and would dread them turning up on my schedule because they made me feel so helpless. My god – the self-centeredness of that mindset. These people made me feel helpless.

I’ve come to believe that in many ways the guy who dies of cancer at age 32 is better off than this guy who, at age 32, has to live the rest of his life in the kind of pain he faces every day. And everything that goes with it: the economic insecurity of trying to live on a monthly disability check, the loneliness of not being able to take part in a life like the other members of his cohort lead, the horrible boredom of being unable to work, have a career and to be so limited physically.

The way I’ve come to feel about it now often makes me think of your remark about how the “certain inalienable rights” to which we are all entitled fell one short in not including a right to live without pain.

Speaking of which I’m really glad to hear your knees are getting better. Mike

Basic human needs

First, not being in pain is a basic human need along with food, air, water, etc. When any of these needs are unmet the human body’s reaction will be intense. Maslow’s Omission

Abraham Maslow was a prominent psychologist who chose to look at the reasons why people thrived in life. He developed a well-known “hierarchy of needs” that he presented as stacked rows shaped in a pyramid. The bottom row includes: air, food, water, sex, excretion, and sleep. The top of the pyramid is, “self-actualization. It is difficult if not impossible to progress up the pyramid until lower needs are met. One need that he did not mention was, “not being in pain.” It is my feeling that it is one of the basic needs that belongs on the bottom row. Your reaction of feeling trapped and angry is completely justified when they are unmet. That is why becoming pain free requires multiple strategies. You cannot just will yourself out of it with positive thinking or mind over matter. Your Personal Brain Scanner

Secondly, I have also felt that chronic pain can be worse than having a terminal illness. I clearly recall the intensity of my feelings when I did not have any hope the pain might end or when that might be. Being in constant mental or physical pain is one of life’s most difficult stressors. It’s paradoxical that a beautifully designed system intended to protect you can also cause so much grief. The crushing aspect of chronic pain is that there appears to be no escape or an end in sight.

The feeling of being trapped was familiar to Viktor Frankel, a famous Jewish psychiatrist who survived WWII concentration camps. He wrote a classic book, Man’s Search for Meaning. It is striking that in spite of the extreme physical hardships Frankel endured, for him the most difficult part of the ordeal was not knowing if and when it was going to end—which is similar if not identical to what patients in chronic pain experience.”

Finally, it is now well-documented in many research studies that not working is bad for your mental and physical health – really bad. (2) The human body is designed for survival and does not perform well when not challenged. Additionally it has been demonstrated that working and having a sense of purpose actually slows down the aging process at the cellular level.

Phantom Brain Pain

If you are reading this post with complete disdain for all of these ideas please understand you are experiencing one of the symptoms of a stressed and over-adrenalized nervous system – obsessive thought patterns. I call it “phantom brain pain.” Similar to phantom limb pain these spinning circuits don’t stop and are unpleasant. It appears that Mike’s patient may be in this situation.

It is also well-documented that your brain physically shrinks in the presence of chronic pain and fortunately re-expands with successful treatment. (3) Adrenaline may be a factor in that it diminishes the blood flow to your brain. This phenomenon affects your perceptions and reasoning. Anxiety, Anger and Adrenaline

Between a decreased brain mass, diminished brain blood flow, obsessive thought patterns that seem like your reality, and anxiety you may not have the mental capacity to process new concepts.  You also may not really want to heal and/or you just want to be fixed. The only chance you have is to begin to engage in some basic tools to break up these irrational thought patterns. It is well documented that writing down your actual thoughts has an effect on doing this. I call it, “mechanical meditation.” Write Your Way Out of Pain

My plea to you is simply pick up a pen or pencil and start spewing out any of your thoughts on paper and immediately tear them up. It can and will break through these circuits. Just do it.

1. Perkins, FM and H Kehlet. Chronic pain as an outcome of surgery. Anesthesiology (2000); 93: 1123-1133.
2. Waddell, G and Kim Burton. Is Work Good for Your Health and Well-Being? The Stationary Office, Norwich, UK, 2006.
3. Seminowicz DA, et al. Effective treatment of chronic low back pain in humans reverses abnormal brain anatomy and function. The Journal of Neurosci­ence (2011); 31: 7540-7550.

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Abraham Maslow

Abraham Maslow (1908-1970) was a brilliant professor of psychology. He founded a branch of psychology known as “Humanistic Psychology,” which focuses more on psychological virtues or excellences rather than on psychological disorders. Maslow is best known for his conceptualization of “man’s hierarchy of needs.” This hierarchy is usually represented as a pyramid, which is depicted above. Maslow thought that meeting one’s basic needs in the lower part of the hierarchy was necessary before progressing to the needs at the top. He also recognized that getting to the very top of the pyramid, what he called self-actualizing–flourishing as a human being, was not commonly attained.

Basic Human Needs

The most basic needs are physiological:

• Air
• Food
• Water
• Sleep
• Sex

According to Maslow, it is impossible to progress up the pyramid if you cannot obtain air, food, water, sleep, and sex.

Where is Pain?

A thought struck me as I looked at his hierarchy: where is the need to be free from pain? I believe this need belongs on the bottom row. Any time a basic human need is not met, anxiety quickly results. If the basic need remains unmet, then the anxiety will progress to anger, disrupting your quality of life and compromising your ability to function. When you are in pain, your body will flood you with anxiety in an attempt to protect itself from harm. (I talk more about the relationship between pain and anxiety in “Your Hand Stuck Over the Stove.”)

Will you have the wherewithal to progress up the hierarchy of needs when you are consumed by pain? You won’t. I believe it is impossible to flourish as a human being without first absolving yourself of your pain. Maslow simply missed including this basic need in his paradigm.

A.H. Maslow, A Theory of Human Motivation, Psychological Review 50(4) (1943):370-96.

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