Here is the essence of the problem with RUTs and the human condition. The sequence begins with your unconscious brain that is constantly on alert for danger and is much more powerful than our late-evolving language-based consciousness. Humans use language to give meaning to everything, especially to sensations generated from inside of your body (interoception). Danger, real or perceived creates threat physiology that generates various levels and kinds of discomfort, and we have created many words that describe how badly we feel. These unpleasant thoughts evolve into concepts. They originate from the brain and also are sensory input back into it that we react to with threat physiology. We are on a spinning wheel without brakes and our brains are on fire.

New Africa/AdobeStock

The conscious versus unconscious brain mismatch

So, we generate positive thoughts to counteract unpleasant ones. We work hard to develop enough self-esteem to feel better about ourselves. But the powerful unconscious brain can generate an infinite number of troubling thoughts with minimal extra energy expended whereas the conscious brain can only create a limited number of “good” thoughts that requires effort and expenditure of energy. It is a gross mismatch, your survival brain overwhelms your efforts to feel better about yourself, you experience cognitive fatigue, and you are worn down.

The root cause driving the creation of RUTs is your fired up inflamed brain. Once the thoughts are released, how can you put them back into the box? You cannot. It is like trying to kill a swarm of mosquitos with a fly swatter. What’s effective is calming down threat physiology (anxiety and anger), the RUTs are diminished, which lessens the threat load even more. This is a bidirectional process. The medical/ psychology world has primarily focused on the RUTs without addressing the physiological root cause. Over the last decade, that is changing, and many practitioners are using methods to calm people down as the primary focus. Why not drain the swamp?

Consider a hornet’s nest where the inhabitants are minding their own business. They are working together constructing a home, gathering food, watching out for danger, and reproducing. Then someone or animal comes along and starts poking at the hive. Appropriately, they sense danger and use the weapons at their disposal to fight off the threat. Swarms of hornets attack the predator with the intention to inflict pain and they do. What is the best answer? Is it trying to battle the hornets once they are in the battle mode, or would it be easier to quit prodding the nest? It is impossible to do battle with your innumerable RUTs. Why not calm down your inflamed brain? Your RUTs will quiet down. Then you have the ”space” to move into brain circuits where you can nurture joy, move away from pain circuits, and where the definitive healing happens.

schankz/AdobeStock

Dissolution of your ego

The final step of allowing your ego (self-esteem) to dissolve can’t happen until you are able to tolerate the painful thoughts arising from your unconscious brain. Emotional pain is processed in similar regions of the brain as physical pain. The reason we spend so much time and energy on our self-esteem is because RUTs make us feel so badly about ourselves and we don’t like to hurt. Once you have no more need to “defend” your identity built largely from cognitive distortions, you can live your life in freedom.

There is another layer to the devastating effects of RUTs. “Good” self-esteem is a cognitive distortion of labeling. It doesn’t matter whether your label is “better than” or “less than”, it is still a distortion and where does it end? Then think of how many aspects of your identity are determined by “stories” consisting of cognitive distortions. A major one is “should or should not” thinking, which is at the core of how we are programmed from birth. It manifests in perfectionism and self-critical voices. These voices become stronger with time and become embedded in our brains as concretely as physical objects. At some tipping point, we spend the rest of our lives processing our worlds though our life lens and it is continually reinforced. Many people develop mental rigidity as part of this process, and it is a trait that is at the center of almost any mental health problem. Defending and becoming attached to your own sense of self is the antithesis of awareness which is essential for successful human interactions.

RUTs are one of the expressions of threat physiology. Addressing this root cause allows definitive solutions. Humans must learn to navigate cognitive consciousness in ways other than a survival mindset. Understanding the nature of the problem opens up possibilities to thrive. It is the next step in our evolution of our species with dire consequences if we don’t.

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It is only about me

The problem is that our primitive brains are wired to ensure our survival, at all costs. At the same time, the reason we as a species survived at all is that we learned to cooperate with each other. Unfortunately, our highly evolved consciousness, which allowed us to dominate earth’s food chain, is no match for our unconscious survival instincts. So our conscious efforts to control our instinctive patterns of behavior usually are doomed to failure. The neurophysiological basis of chronic pain

Your “story”

Since our survival behaviors are often not exactly virtuous, we do many things to “dis-identify” from them. The common strategy is to concoct a story of who we are, called self-image, largely based on external feedback. Another expression for this activity is building self-esteem. We aspire to high self-esteem by avoiding negative thoughts about ourselves and reinforcing positive ones. Trying not to be judgemental

Now, part of this practice yields positive results. Our brains will develop in areas where we place attention; and consistently choosing a positive outlook is healthy. The problem arises from suppressing the unconscious tendency to be on the alert for danger, which has serious consequences. Your personal brain scanner You are now focusing energy doing battle with powerful unconscious neurological circuits. You cannot win. You are inadvertently reinforcing them and wearing yourself down. There is also evidence that such suppression damages the memory centers of the brain; and in addition, may facilitate a disposition to drug addiction. Ever wonder why it is so hard to hold on to our positive thoughts and feelings? It is because our brains are always busy looking for the negative, for the worst case scenario—for our survival. The myth of self-esteem

Body image disorders

It’s incredible to me how many supermodels have body image disorders. It might have to do with the fact that so much of their “identity” is based on physical appearance. Of all the features we like and appreciate about our bodies, what do our minds tend to fixate on? On that one feature or idiosyncrasy we dislike. Since we cannot easily change it, we are trapped. It is my guess that great majority of us has some degree of body image disorder.

The same holds true of any trait we value for our identity: Intelligence, athletic skill, artistic or musical talent, toughness, net worth—the list is endless. The more important the attribute, the greater the potential for progressive anxiety.

I had lunch with a young body builder, one of the strongest people I have ever known. Hard as I tried, I could not avoid staring at his biceps, which were so large that they sagged almost parallel to the ground when he leaned his elbows on the table. He proceeded to share with me he how bad he felt about his body because he felt so “small”. It drove him to work out almost two hours a day. It hit me how strongly our images of ourselves could affect us. Many of them do not reflect reality and detract from our capacity to enjoy our lives.

One of my patients was an absolutely stunning woman with an eating disorder. When I asked her, “How would you feel if I obtained 10,000 signatures attesting to how attractive you are,” guess what she said: “They don’t really know me.”

Connecting

So what is the answer? Let it go. You are never going to win the battle with your unconscious brain. It is impossible. But you can learn to calm down your nervous system and to create new pathways that circumvent negative circuits. The general term is somatic work, and there are many avenues to get there. The focus is on clearing out the noise in your head to connect with yourself and your own capacity to heal.

Who are you allowing to define you?

“The World’s Ugliest Woman”

This video showcases a woman with a congenital disfiguring disability, who describes her struggle and resolution with self-image. She is truly inspirational. I am not sure I could have created a full and meaningful life if I had to deal with her condition. What is disturbing about her story is that someone posted her picture on the Internet with the label “The World’s Ugliest Woman.” Even more upsetting is that, of the thousands of comments, she did not find one that was supportive. What is uplifting is that, despite all the attacks from mean people, she still managed to transcend their shallow values. School or prison – What’s the difference? -Bullying

The Way to Love

I read the late Anthony DeMello’s book, The Way to Love weekly, to keep his ideas fresh in my consciousness. He presents the most compelling picture of the “attachment” trap, and provides a brilliant solution. As you become aware of your attachment to defining ourselves by external things, you have the power to dissolve it – if you want. The result is a life of freedom that is almost unimaginable.

Let go. Learn to be accepting of uncomfortable feelings. It is a learned skill using effective tools. Increase your awareness and let your ego diminish, along with your pain.

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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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Objectives

• Most of us are under the impression that you must first solve your chronic pain before you can move forward and enjoy your life.
• It is actually the opposite scenario. You have to fully engage in life in order to move away from your pain.
• Fully engaging in today, with or without the pain, is your only option. To change your brain, you have to direct your attention to where you want to go and keep doing it.
• You also must use tools to lessen the impact of mental and physical pain. These are critical in that you can’t move forward without letting go.
• To have a good life, you have to live a good life; It requires practice.

“Life is like riding a bicycle. To keep your balance, you must keep moving forward.”

Albert Einstein

The goal of The DOC Journey is not to rid yourself of your pain. In fact, there is no goal because there is no beginning or end to it. The only “goal” is to live your life fully today with the deck of cards you have been dealt – with or without your pain. You must keep moving forward to move through and past your pain.

Understandably, everyone wants to be free of pain. But that isn’t life. The brain treats emotional and physical pain in a similar manner and the body’s physiological response is the same. So, even you were to be rid of your physical symptoms the quality of your life would not change as much as you might think. The emotional circuits will keep firing in response to day-to-day stresses.

Historically, I felt if I surgically relieved a specific symptom caused an identifiable structural problem, the degree of relief would be so compelling that it would propel him or her out of chronic pain and back into a full life. I could not have been more wrong. Unrelenting anxiety, which essentially is the pain, was intolerable and it didn’t improve with surgery. I was shocked as normally the pain should have been easily relieved with the operation. What was also disturbing was that even if the pain resolved with surgery, another body part would frequently light up.

I now understand that research has documented that if you have surgery in the presence of untreated chronic pain, you can induce pain at the new site between 40-60% percent of the time. Five to ten percent of the time it will be a permanent problem.¹ Of course, you can worsen the original pain.

Moving on

So, if you can’t fix yourself and there is no “goal”, what can you do? The patients who were successful in regaining their lives just moved on – with or without their pain. Paradoxically, there was a much higher chance they would leave it behind. Your incredibly adaptable brain develops wherever you place your attention. One metaphor is that of diverting a river into a different channel. There is initially a small amount of water flowing in the new direction, but eventually the volume of water will create its own channel. There are many ways to re-direct. Some include:

• Not discussing your pain – ever with anyone.
• Mindfulness – active meditation
• Meditation
• Visualization
• Engaging with family and friends in a meaningful way.
• Awareness – simply watching where your attention is focused allows you to re-direct it.
• Play

Visualization

 A friend of mine, who may have been the first DOC success in 2006 sent me this email that suggested a different take on visualization. My take on the following quote is that people age because their dreams are crushed by anxiety. You will note that this quote has been used several times in The DOC Journey.

Hi David,

Great quote from your latest post:

“It is not true that people stop pursuing dreams because they grow old. They grow old because they stop pursuing dreams.”

Gabriel Garcia Marquez

To your quote about anxiety crushing dreams and the ability of dreamers therein, I’d add that pushing through the anxiety and daring to dream, regardless of how you feel, creates an inverse effect of calming the anxiety, because sometimes, just having something to believe in, as simple as that, takes us out of our anxiety momentarily enough to see clearly, and thus move forward to a better place.

It works for me as a visualization tool to break the “anxiety cycle” as I call it. And if someone doubts this protocol, they only need to buy a lottery ticket. For the cost of $1, you walk out of that store and start visualizing what you’ll do with the money, and in that very moment, you’re not anxious. Instead, you find yourself, calming, your breathing slows, as you really indulge, if for only a few moments, how you’d be with all that extra cash on hand. It’s an amazing, albeit temporary salve, a balm to the anxious heart. And here’s the trick: We can recall that feeling over and over again and build on it, finding new ways to create the lives we want, just by using this tool of positive visualization. As our mind uses this, our thinking becomes stronger and we can begin to avert the waves of anxiety and in the spaces between, create constructive, positive events, in which to build the life of our dreams. Ironic that what starts with a fantasy – a one-dollar lotto ticket – can actually become reality, with positive visualization techniques tasked toward constructive events in real life context. And hey, we can use every tool we can find along the way, as I see it! Even for a buck!

Play

Play circuits are also permanent and are present to a greater of lesser degree in everyone. Re-connecting with them, with or without your pain, is a powerful way out of pain. These circuits do get buried under the weight of life stresses, but you can create a shift back onto them with specific tools and repetition. This does not mean obsessively engaging in play to distract yourself. Rather, it is a mindset of wonderment and curiosity. Your body chemistry will shift to safety hormones and an anti-inflammatory state, your brain will be less sensitized, nerve conduction improves, and your pain can dramatically decrease or resolve.

It is not logical to think that if your pain was gone that you could enjoy your life. There are too many ways to experience pain. You have to first learn to enjoy life regardless of its challenges, understanding there are days that you will enjoy it more than others. A positive outlook, which has been shown to lower inflammation, with a sense of play will move you moving forward.²

An old song returns

One example I often used in clinic is that any time you do not spend time practicing a skill, you will eventually lose it. My wife played guitar in her 20’s and became proficient in a picking style of performing. Two years ago, she began to take lessons from an extraordinary Bay Area guitar teacher. About six months into her lessons, parts of some old songs began to return in her head. One day she sat down and played a complete piece that she had not thought about for decades. The memory was still there. Pain, anxiety and anger circuits will atrophy, if you turn your attention elsewhere. But they will never completely disappear since these are also necessary survival emotions.

Recap

Nurturing the part of your brain that enjoys life is a learned skill. That is why it is so critical what you choose to program it with. If your default state of mind is that of being agitated and upset, that is what will evolve. As you trigger the same response in those close to you, then there is no end to this universal ping pong game. Conversely, if you choose gratitude and joy, the same phenomenon will lift you upward.

There is a lot to be angry about and also much to enjoy. What is your choice? How and when are you going to move forward?

Two Wolves

Questions and considerations

1. Life is challenging in many ways for all of us. It never stops and solving problems tends to be the default program of our brain. Consider how much of your life is spent solving or thinking about problems compared to purposefully enjoying yourself.
2. It would be great not to have pain, but how long would you survive without its protection. People born without pain sensors don’t live past 10 – 15 years of age.
3. When pain becomes chronic, it is permanent and memorized and does not serve a protective function. The more you try to get rid of it, the stronger it will become.
4. It is by separating from it, moving on, connecting with enjoyable circuits, and leaving it behind that allows your brain to heal.

 References

1. Perkins FM and H Kehlet. Chronic pain as an outcome of surgery. Anesthesiology (2000); 93:123-33.
2. Dantzer R, et al. Resilience and immunity. Brain Behav Immun (2018); 74:28-42. doi: 10.1016/j.bbi.2018.08.010

Listen to the Back in Control Radio podcast Moving Forward with Your Pain.

The post Moving Forward with Your Pain first appeared on Back in Control.

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