From 2005-2007, I suffered from excruciating back and leg pain. My pain was so bad that I was unable to sit for nearly a year. The only time I would sit was to drive myself to work, and the pain during that drive was so intense that there were several times I had to crawl out of my car once I arrived.
An MRI revealed a herniated disc, so I began a series of medical interventions that included seeing two chiropractors (a second after the first failed to help), two different types of physical therapists with two different approaches, and an acupuncturist, and receiving three cortisone shots, to name just a few of my treatments. Although I occasionally experienced relief, it never lasted long, and my pain got worse. I reluctantly decided to undergo back surgery.
To help deal with my pain as I awaited surgery, I began exploring nontraditional approaches and came across a book by Dr. John Sarno called Healing Back Pain: The Mind-Body Connection. In the book, Sarno, a physician, outlined a radical approach to curing back pain that he had developed through observing his own chronic pain patients for decades. He theorized that pain such as mine was caused not by structural abnormalities or injuries but rather by oxygen deprivation and faulty neuropathways in the brain. Furthermore, Sarno argued that the brain can actually create physical pain as a means of protecting people from experiencing painful emotions such as anger, rage and guilt. He labeled this condition tension myositis syndrome (TMS).
Learning about my pain
This isn’t to suggest that chronic pain is not real or is “all in your head.” On the contrary, Sarno believed that TMS pain was real and could be excruciating. However, because chronic pain is often not caused by structural abnormalities, Sarno argued, it could not be cured by focusing solely on the body. In other words, surgery, manipulations, injections, stretches and so on cannot cure the pain because the pain originates in the mind, not the body. Even for me, a licensed mental health counselor, this theory sounded crazy at first. After all, I had an MRI that proved I had a bulging disk.
At the same time, there was also something that resonated with me about Sarno’s ideas. First, he described how people with TMS tended to have shifting pain that could manifest in different ways and move to other areas of the body. This could include experiencing migraines, heartburn and other digestive issues, knee and shoulder pain, and so on. These were all things I had suffered from since I was a child, but none was occurring now that I had back pain.
Second, Sarno outlined how people with TMS often experienced more severe pain under times of stress and how that pain could diminish during less stressful times. This was certainly true for me. At the time, I was working very hard to earn tenure as a professor at the University of Rochester, and my wife and I were raising two small children. It was among the most stressful times in my life. I also noticed that my pain would sometimes subside during less stressful times such as vacations.
Third, Sarno outlined a series of personality characteristics that are consistent with people who suffer from TMS. Not only do TMS patients tend to ignore their own emotional reactions, but they are incredibly hard on themselves (i.e., they are perfectionistic, highly driven, tend not to seek out help, etc.). These personality characteristics fit me perfectly. Furthermore, Sarno argued that an MRI would reveal structural abnormality in almost all patients over the age of 30 — but most people don’t experience any pain as a result. In other words, if Sarno was to be believed, my herniated disk wasn’t the cause of my pain; rather, it was my personality.
I decided that Sarno’s approach was worth a try, so I delayed back surgery, stopped physical therapy and seeing chiropractors, and began working on my emotions. I found a therapist who worked from a psychoanalytic approach designed to help clients uncover repressed emotions, and I began therapy. I also began engaging in psychoeducation, behavioral interventions and mindfulness (which I will describe in more detail later).
Miraculously, after just a few weeks of practicing this integrative mind-body intervention, I was free of pain. Not only was I able to avoid back surgery, but I was able to heal a number of other chronic health issues with which I had suffered for years. To this day, my back remains pain free, and I am able to engage in physical activity without any restrictions.
In 2017, I began advanced training and research in mind-body therapies, and later that year, I opened a private practice focused on helping clients who are in chronic pain. Since then, I have helped dozens of people overcome a variety of chronic pain conditions, including back, neck, shoulder, knee and hip pain; fibromyalgia; migraines; and chronic nerve pain. Like me, most of my clients suffered for years and were not able to find cures from mainstream medical approaches. Several of them were on disability from work or school but have now resumed normal life activities.
In this article, I provide an overview of the mind-body counseling approach I use with clients who are in chronic pain and provide suggestions to counselors interested in integrating this approach into their work.
Integrating a mind-body approach
When I began my own healing journey, few resources about this intervention existed beyond Sarno’s books. Thankfully, things have changed. The advent of social media has allowed the hundreds of people healed by Sarno to share their stories (many presented in the documentary All the Rage), and a growing body of research now supports the efficacy of Sarno’s ideas.
This increased awareness and popularity have led to numerous options for professional counselors to receive additional training in this modality. Although I highly recommend that counselors pursue this additional training through workshops and clinical supervision, many of the mind-body counseling interventions are consistent with skills that counselors already possess.
To begin, counselors must carefully screen clients to ensure they are appropriate for the intervention. Most importantly, clients must be screened by their physicians for serious medical conditions such as cancer, heart disease or broken bones that require medical attention and cannot be cured by mind-body counseling. Second, as with all counseling interventions, the mind-body approach is most helpful to those who believe in it, are familiar with the process, and are committed. While most clients arrive with some skepticism (like I did), those who are completely closed to the idea (e.g., clients who attend only to appease someone else) are not likely to be helped and can often become frustrated with the process. In addition to posting information about my approach on my website, I also conduct extensive phone consultations with prospective clients to explain the approach in detail and assess their potential fit.
Once clients are screened, several counseling interventions can be used in ways that effectively integrate Sarno’s strategies. These interventions include:
- Psychoeducation about the nature of chronic pain
- Behavioral techniques to build confidence and reduce fear
- Mindfulness to help clients become more comfortable with uncomfortable physical and emotional sensations
- Intensive short-term dynamic psychotherapy (ISTDP) to allow clients to become aware of and express painful emotions
- Social support from other mind-body clients
The first step in integrating this mind-body approach to healing chronic pain is to provide clients with psychoeducation regarding the relationship between their minds and their pain. In addition to Sarno’s books, a number of other recent books by mind-body experts such as Howard Schubiner, Allan Abbass, Nicole Sachs, David Clark, Steve Ozanich and spine surgeon David Hanscom review scientific evidence that supports and extends Sarno’s ideas about mind-body connections to many forms of chronic pain. These resources expose clients to research that shows:
1) Most people with healthy (i.e., pain-free) backs, knees, shoulders and hips show structural abnormalities that should cause pain, supporting the notion that human bodies naturally change with age in ways that look structurally problematic but do not cause pain.
2) There are relationships between childhood trauma and physical health, including many forms of chronic pain.
3) fMRI research has established links in neuropathways responsible for physical and emotional pain.
4) There are strong relationships between chronic pain and the inability to be aware of, experience and express painful emotions such as anger and guilt.
Familiarizing clients with research showing that their pain is not likely of a structural origin, which is contrary to what they have been told by other health care providers, and providing them a path for recovery can instill hope and reduce fear. This process alone can begin to reverse the fear-pain-fear cycle that can activate and reinforce pain neuropathways in the brain.
At the same time clients are learning about mind-body connections to chronic pain, counselors should also begin engaging them in behaviorist interventions designed to reduce fear and encourage reengagement in their normal activities. Well-meaning health care providers frequently instruct people with chronic pain to discontinue physical activities that they enjoy in order to allow their bodies to heal. This is great advice for injuries such as broken bones or sprained ligaments but extremely problematic for mind-body ailments. Several health care professionals told me to swim laps instead of playing basketball. After several weeks of swimming (which I hated), a chiropractor then told me that swimming was the worst thing I could do for my back because of all the twisting and bending involved. He instructed me to disengage from all activity. In reality, the less activity I engaged in, the more depressed and hopeless I felt, and the worse my pain became.
As clients become educated about mind-body connections to their pain, they are encouraged to gently reengage in physical activity without fear of harm the next day. Counselors can facilitate this process by encouraging clients to engage in daily affirmations to reduce their fears of physical activity. This could include declarative statements such as “I am strong, and my body is capable of engaging in this activity” or “There is nothing structurally wrong with me, so doing this can’t hurt me.”
Clients should also be instructed to chart their progress as they reengage in life activities. Often, clients can become discouraged and feel hopeless when minor setbacks occur. Logs that indicate their overall progress over time can help clients sustain optimism during these setbacks.
Counselors should also encourage clients with chronic pain to engage in somatic tracking. These clients often arrive at counseling having already devoted extensive time to seeking potential relationships between their pain levels and physical activities (e.g., exercise, household chores) or the foods they eat. This process can become incredibly frustrating because many of the activities or foods they once associated with their pain often are disproved over time. Counselors integrating this mind-body approach should instead encourage clients to document relationships between their physical pain and their emotional states.
A very common example is that people suffering from chronic pain can experience reductions in pain during less stressful times in their lives such as vacations. Traditional structural models of pain often seek to correlate these improvements to things such as nice weather, changing humidity levels or even the quality of the mattress at the hotel. However, counselors operating from a mind-body approach should encourage clients to document their emotional states when feeling free from pain. This same process is used when pain increases.
For example, pain that went away during vacation often returns or becomes even worse when the client returns home. It is tempting to attribute this increase in pain to uncomfortable travel conditions (e.g., car or airplane seats) or weather changes. However, clients should be encouraged instead to explore problematic interpersonal issues to which they may be returning at home. Sometimes these answers can be very clear; other times, the answers are hidden from view, especially when they involve traumatic events or emotions that clients feel guilty about having toward others. In these cases, ISTDP is central in uncovering hidden emotions related to pain flare-ups.
Counselors can also help clients consider, without judgment or fear, the secondary gain that their pain potentially provides them, particularly regarding what their pain gets them out of doing or feeling. Chronic pain often requires people to become confined to their homes and, therefore, to miss out on potentially stressful interpersonal encounters. These can include social events that they may be dreading, conflicts with colleagues or family members, or even having to provide care for children, partners or aging parents.
Understandably, clients are often resistant to exploring these possible relationships because it may feel like they are being blamed for their pain or accused of it all being in their heads. Counselors need to continually reassure their clients that mind-body pain is real and not “created” on purpose. In fact, it is often a result of people trying to subconsciously protect others from their feelings toward them.
Counselors should encourage clients to create logs of what they miss out on during severe pain flare-ups. This may reveal correlations between their pain and their hidden (but potentially powerful) feelings of fear, anger and guilt. Sometimes, the patterns that emerge, although difficult to recognize initially, can become too prevailing for clients to ignore. Once these patterns are identified, ISTDP can be particularly useful in assisting clients with unpacking and understanding the complex relationships between their pain and their hidden emotions toward others.
Mindfulness-based stress reduction, first introduced into Western medicine by Jon Kabat-Zinn, has been used for over 30 years to treat chronic pain. While research indicates that mindfulness shows only moderate effects in alleviating chronic physical pain, the approach has proved highly effective in improving psychological symptoms associated with chronic pain, such as depression and anxiety, and reducing physical limitations associated with the pain.
From my experience, mindfulness is also extremely useful in helping clients become more comfortable with uncomfortable emotions. This can greatly enhance the effectiveness of the behavioral approaches mentioned previously as well as emotional-focused therapies such as ISTDP.
A detailed description of mindfulness is beyond the scope of this article. Counselors interested in effectively implementing this mind-body approach should seek training in mindfulness and mindfulness-based therapy. However, even counselors without training in mindfulness can encourage their clients to participate in mindfulness workshops and to develop regular mindfulness practices outside of their counseling sessions.
While Sarno argued that many people could heal themselves through psychoeducation and behavioral approaches alone, he also realized that some people (like me) needed psychotherapy to assist them with recognizing, experiencing and expressing repressed painful emotions that might be causing pain. Specifically, Sarno advocated that people with chronic pain engage in ISTDP, which is an attachment-based, emotion-focused somatic therapy developed by psychiatrist Habib Davanloo.
Through extensive research over several decades, Davanloo identified a series of core defenses some people have developed, often since childhood, to block uncomfortable feelings and repress traumatic experiences. While these defenses can often be adaptive when people are children, Davanloo found that they create tremendous emotional and physical suffering later in life.
Chronic pain, from an ISTDP perspective, is an unconscious attempt to protect (or distract) people from experiencing uncomfortable emotions and harmful impulses toward others, particularly loved ones, as well as the guilt they carry for harboring these negative feelings and impulses. Counselors conducting ISTDP therapy help clients notice strategies (or defenses) that they have developed to prevent themselves from becoming close to others and experiencing emotions toward them. Counselors also integrate experiential techniques that help clients become aware of, experience and express these painful, repressed emotions toward others and to recognize and even act out potentially threatening impulses associated with these painful feelings.
This process of skillfully pressuring and challenging client defenses can result in what Davanloo referred to as an “unlocking” of repressed emotions, where defenses are loosened and waves of painful feelings are experienced consciously. When partially or fully experienced in therapy, an unlocking can result in dramatic improvements in both physical and psychological well-being.
ISTDP is a complex and powerful approach to therapy that requires years of supervised training to implement. Even after completing extensive reading on ISTDP, attending numerous conferences and workshops, and participating for several years in a core training group and individual supervision with an expert ISTDP practitioner, I still feel like a novice. Even so, leading mind-body physicians such as Sarno and Schubiner have suggested that all health care professionals, including those without formal training in ISTDP, should integrate aspects of this approach into their mind-body practice. Specifically, they advocate for people in chronic pain to journal about their feelings toward others and to engage in meditations designed to help them connect their emotions to their bodies.
More information about ISTDP, including how to integrate elements of the approach into health care practice, can be found in Abbass and Schubiner’s book Hidden From View: A Clinician’s Guide to Psychophysiologic Disorders.
When I began this process as a client 15 years ago, I remember feeling very alone in my journey. The few attempts I made to discuss these ideas with health care providers, or even friends and family members, were usually met with skeptical or condescending looks and remarks. Now, having counseled many others, I have learned the power of social support in the success of this process. A consistent comment I hear from clients in my pain groups is how integral the support they receive from their fellow group members is to their success.
Engaging in pain groups may not be possible for everyone, but a number of online communities are available through Facebook and other social media platforms that can provide opportunities for clients with chronic pain to connect with others like them. There are also several podcasts, including The Mind and Fitness Podcast, hosted by former chronic pain sufferers who share their own and others’ success stories overcoming various forms of chronic pain through the mind-body process. These stories usually detail their struggles with chronic pain; their frustrations with health care professionals who performed costly and unnecessary tests and medical procedures; their mind-body healing journeys, including how they overcame setbacks; and their quality of life since becoming free of chronic pain.
Such connections provide clients not only with role models, but with continual support from others. This can enhance the effectiveness of the intervention, especially during times of struggle. There is even an app called Curable that is specifically designed to provide people in chronic pain with resources, activities and social support in ways consistent with Sarno’s approach.
Summary and conclusions
The integrative mind-body approach outlined in this article is a powerful and underutilized approach to helping clients heal from chronic pain. The approach is particularly well suited to clients who have been cleared of serious health conditions and who have exhausted traditional medical interventions with no relief.
While many of the intervention strategies align well with traditional counseling approaches, counselors who are interested in specializing in this work should engage in professional development by attending mind-body trainings and workshops and participating in an ISTDP core training group. Among the ISTDP master clinicians who offer core training are Allan Abbass, Patricia Coughlin, Marvin Skorman and Jon Frederickson. Counselors may also consider enrolling in the University of Rochester’s advanced certificate program in mind-body healing and wellness (see tinyurl.com/Mind-BodyCert). It is the first program of its kind to provide advanced-level training in this type of mind-body intervention.
Douglas Guiffrida is professor, counseling program director, and director of the mind-body healing and wellness program at the Warner Graduate School of Education and Human Development at the University of Rochester. He is a licensed mental health counselor and a national certified counselor. To learn about his private practice or to contact him, visit DouglasGuiffrida.com.
Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.
Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.