In this episode, we talk to Dr. Howard Schubiner about Pain Reprocessing Therapy and Emotional Awareness and Expression Therapy, chronic pain treatments that focus around curing pain rather than managing pain.
“But if you step back and you’re the parent, what do you want to teach that kid? You want to teach the kid that it’s ok to fall. So, when the kid falls, you smile and say ‘Oops! That was fun, you’re ok buddy! Let’s do it again!’ Right? And that’s what you’re doing to your brain. Because your brain is looking to you; your brain is giving you pain and you’re either freaking out or you’re going ‘Oops that’s silly! I’m ok!”
– Dr. Howard Schubiner, Internist and Pediatrician, Director of the Mind Body Medicine Center at Ascension Providence Hospital in Southfield, Michigan
Dr. Jen Barna discusses recent breakthroughs in curing chronic pain with esteemed guest, Dr. Howard Schubiner. Dr. Schubiner and colleagues developed Pain Reprocessing Therapy and Emotional Awareness and Expression Therapy, chronic pain treatments that focus around curing pain rather than managing pain. Dr. Howard Schubiner offers listeners his key insights as to what he has learned is the best way to confront pain that may be stopping you or your patients from living freely. In today’s episode, Dr. Schubiner discusses neuroplasticity and the effective process in which you can ultimately retrain your brain to move away from pain, rather than continue to be stuck in a negative feedback loop. As physicians, it is often your job to find the source of you or your patients’ pain. Being able to offer solutions to patients in chronic pain can be life-changing for patients and can be very fulfilling to clinicians. Dr. Barna and Dr. Schubiner also discuss the effectiveness of cognitive-behavioral based therapy and other practices that have proven to help manage pain, to cope with pain, but not to cure it. The paradigm shift that is now occurring is to recognize that research has demonstrated with randomized, controlled trials that chronic pain, even pain that has lasted for decades, can be alleviated in a short amount of time with lasting results using Pain Reprocessing Therapy and Emotional Awareness and Expression Therapy.
Links to Podcast episodes mentioned:
-Episode 172: Healthcare Burnout & PTSD with Dr. James Zender
Documentary:
This Might Hurt– https://www.thismighthurtfilm.com/
“This Might Hurt is a documentary that offers solutions to reduce and unlearn chronic pain. The film follows three chronic pain patients who have spent years searching for answers. Desperate for relief, they enter a new medical program — run by Dr. Howard Schubiner — that focuses on uncovering hidden causes of pain, and retraining their brains to switch the pain off.”
Books:
Unlearn Your Pain: A 28-day Process to Reprogram Your Brain by Howard Schubiner, MD with Michael Betzold
Unlearn Your Anxiety and Depression by Howard Schubiner, MD
Hidden From View by Allan Abbass, MD and Howard Schubiner, MD
Websites:
- Unlearn Your Pain – https://unlearnyourpain.com/
- The Psychophysiological Disorders Association- https://ppdassociation.org/
- The Tension Myositis Syndrome Wiki: The PPD/TMS Peer Network- https://www.tmswiki.org/w/index.php?page=The_Tension_Myositis_Syndrome_Wiki
- The Pain Reprocessing Therapy Center- https://www.painreprocessingtherapy.com/
Videos:
“What is Pain?”- Animated Series by Dr. Howard Schubiner
English: https://www.youtube.com/playlist?list=PLsJVYZbo6uWrKc57MDUL1vGciEGnPYrV9
Spanish: https://www.youtube.com/playlist?list=PLsJVYZbo6uWoBAVQxNhQhz618T_HHwfDX
Online Programs & Apps:
Other Recommended Authors:
- Dr. David Clarke
- Alan Gordon, LCSW
- David Hanscom, MD
- Georgie Oldfield, Pain Specialist
- David Schechter, MD
Dr. Howard Schubiner is an internist and the director of the Mind Body Medicine Center at Ascension Providence Hospital in Southfield, Michigan. He is a Clinical Professor at the Michigan State University College of Human Medicine and has authored more than 100 publications in scientific journals and books. He lectures regionally, nationally, and internationally. Dr. Schubiner has consulted for the American Medical Association, the National Institute on Drug Abuse, and the National Institute on Mental Health. Dr. Schubiner is the author of three books: Unlearn Your Pain, Unlearn Your Anxiety and Depression, and Hidden From View, written with Dr. Allan Abbass.
Dr. Schubiner has collaborated extensively with colleagues such as Mark Lumley, Tor Wager, Yoni Ashar and Alan Gordon to develop two novel psychological treatments for chronic pain: Emotion Awareness and Expression Therapy (EAET) and Pain Reprocessing Therapy (PRT), which have been shown to be highly effective in randomized, controlled trials. EAET is now listed as a treatment option in the U.S. Department of Health and Human Services Pain Management Best Practices Inter-agency Task Force Report.
Dr. Schubiner is part of the team that conducted the Boulder back pain study, along with Tor Wager, Yoni Ashar, Alan Gordon, Christie Uipi and Mark Lumley. This study demonstrated that 75% of the people with chronic back pain treated with a novel therapy called Pain Reprocessing Therapy recovered fully. The study also documented the changes in the brain that occurred with this treatment using function MRI scans.
The documentary This Might Hurt, follows Dr. Schubiner and several of his patients through treatment that focuses on uncovering hidden causes of pain, and retraining their brains to switch the pain off.
“The film had its world premiere at Austin Film Festival and is now in the midst of a two-year community screenings campaign. If you’re interested in hosting a virtual live screening, we encourage you to reach out to us at [email protected]. 100% of the proceeds for This Might Hurt go towards creating affordable community screenings for diverse audiences around the globe.” -https://www.thismighthurtfilm.com/
Dr. Schubiner lives in the Detroit area with his wife of thirty-eight years and has two adult children.
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Enjoy the full transcript here
Dr. Schubiner: But if you step back and you’re the parent, what do you want to teach that kid? You want to teach the kid, “It’s okay to fall.” When the kid falls, you smile and say, “Oops, that was fun. You’re okay, buddy. Let’s do it again.” That’s what you’re doing to your brain because your brain is looking to you. Brain is giving you pain and you’re either freaking out or you’re going, “Oops, that’s silly. I’m okay.”
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Jen: Thank you for joining us here today on DocWorking: The Whole Physician Podcast. I want to take a moment and let you know that we’ve been working around the clock at DocWorking to bring you CME credits, so that now, you can let your continuing education budget help you to prioritize your own wellness and get on the path to living your best life. Everything we do at DocWorking is specifically designed with you in mind. We hope you’ll head over to docworking.com today and take our two-minute quiz to find out where you are right now on the balance to burnout continuum. Take our burnout quiz and this simple step alone can put you in the right direction toward living your best life.
Welcome to DocWorking: The Whole Physician Podcast, where we bring you incredible guests doing groundbreaking work and we talk about topics that can make your life even better, starting today. I’m thrilled to bring you a phenomenal guest, whom I greatly admire, who is an internationally recognized thought leader and at the leading edge of his field, Dr. Howard Schubiner, an internist and pediatrician, director of the Mind-Body Medicine Center at Ascension Providence Hospital in Southfield, Michigan, Professor at Wayne State University School of Medicine and Michigan State College of Human Medicine, author of three books, Unlearn Your Pain, Unlearn Your Anxiety and Depression, and Hidden from View, which he coauthored with Dr. Allan Abbass, author of more than hundred publications, as well as the doctor featured in the documentary This Might Hurt.
Dr. Howard Schubiner has collaborated extensively with colleagues to develop two novel psychological treatments for chronic pain, emotional awareness and expression therapy, and pain reprocessing therapy, both of which have been shown to be highly effective in randomized controlled trials. It’s an honor and a privilege to speak with you Dr. Schubiner about the paradigm shift that’s happening in the field of chronic pain treatment and to bring awareness to our audience of this exciting change, because it affects us both personally, and it affects so many of our patients regardless of our specialty. Dr. Howard Schubiner, welcome to DocWorking: The Whole Physician Podcast.
Dr. Schubiner: Thank you. It’s a pleasure to be here. I’m glad to be here. I think the paradigm needs to shift quickly [chuckles] because there’re so many people suffering, aren’t there?
Jen: Oh, my goodness, yes. It’s millions of people. It’s another epidemic on top of the pandemic and it’s a chronic one that we’ve experienced for such a long time in this country, and it affects so many of our patients and so many of us as professionals.
Dr. Schubiner: Yeah, for sure. If you take back pain, neck pain, headaches, anxiety, and depression, and then other musculoskeletal pain, that comprises the vast majority of the disability, not the death, not the mortality, but the morbidity in the world.
Jen: With the types of pain treatments that you have been involved in creating and testing in large, randomized controlled trials, can you tell us a little bit about pain and what we’ve learned in the past? It’s been longer, but it’s really in the past 10 years where people are recognizing that pain originates in the brain.
Dr. Schubiner: Yeah, it’s really shocking. It’s shocking to understand. What I say to all my patients is, “You can’t understand pain unless you understand how the brain works.” I was just talking to a physician the other day, who’s a spine surgeon, and he was telling me about some of his own pains that he had. He had headaches when he started medical school, he had neck pain when he started his residency, he had shoulder pain when he started his fellowship, and they couldn’t find anything wrong with him. He said to me, “Dr. Schubiner, I wouldn’t have believed that these pains that I had were due to my brain if I hadn’t experienced it myself, I was not taught that in medical school, it never made any sense to me, it’s a complete paradigm shift.”
I think we have to understand not to underestimate the power of the brain to create and generate what we feel. When you touch a hot stove, it’s not your finger causing pain. Just that [laughs] is a revolutionary concept because our brain works by predictive processing, which means that it generates our experience. Our brain generates what we see. We don’t see with our eyes, we see with our visual cortex. We don’t hear with our ears, we hear with our auditory cortex. Those parts of the brain have to be trained and well, the impulses have to be processed within nanoseconds, so that we can function in the world and what we feel is produced by our brain. It turns out that we have this danger alarm mechanism in the brain and it’s always there. We’re constantly on guard at the subconscious level for a bird flying, or a car coming toward us, or anything like that. This danger alarm mechanism has inputs from our body, but it also has inputs from our memory and what we’re thinking about all the time.
If somebody gets an injury, they may get pain, but they may not. There’s millions of stories. Back to Henry Beecher, back in World War II, where all these military people were injured and had no pain at all, two thirds of them in his study. Then we have thousands of cases of people who have pain with no injury. That’s the part that messes doctors up because we try so hard to find a cause for the pain. That’s our job. You don’t want to miss anything. I feel that intensely with every patient I see. I don’t want to miss anything structural.
But on the other hand, most people with headaches don’t have a structural problem. That’s why they’re called primary headaches, migraine, tension headaches that slip along the route, and there’s no disease there. People with irritable bowel syndrome, they don’t have a disease in their bowel, people with fibromyalgia, they don’t have a disease in their muscles, and people with most pelvic pain syndromes, vulvodynia, interstitial cystitis, so called pelvic floor dysfunction. There is no structural disease there that we can find. When it comes to back pain and neck pain, that’s where we really get messed up, because everyone has an abnormal MRI – as a radiologist, [laughs] you know that.
Jen: Oh, my goodness, yes.
Dr. Schubiner: The level of degenerative disc disease in the population rises to 90% in 60-year-olds, 80% in 50-year-olds, 40% in 40-year-olds who are healthy, who have no pain at all. The other day a friend of mine came up. He’s got pain all up and down his back from his lower cervical, all the way down to the lumbar. Paraspinal pain when he stands, when he walks, and his MRI shows foraminal narrowing at L5 S1. He sees a neurosurgeon and he says, “Yeah, we can fix that.” Well, if you have disease due to foraminal narrowing, you’d have pain in your leg. He doesn’t have any leg pain. The guy says, “Yeah, we’ll fix it.” My friend says, “Yes, sign me up. I want surgery.” How’s that going to help his pain that goes all up and down his back? I don’t know. [laughs]
Jen: It’s such an important question. Often treated in a way that ultimately leads to worse pain for patients. Maybe there’s some pain that isn’t explainable by the MRI, but then the surgeon decides that they’ll try to treat it anyway because the pain is so severe and the patient is in such distress.
Dr. Schubiner: Exactly. It’s so frustrating for the patient. I just feel for everybody because the doctors are frustrated. They have chronic pain patients who are wanting and needy, they get into arguments about what pain medicine they should be given. We did a study just recently with 220 people with chronic neck and back pain to determine, using the criteria that I developed, to help understand– I’m not the only one, but, a lot of people have developed, to understand how to diagnose, how to assess what I would call a neurocircuit condition or a nociplastic pain as opposed to structural pain.
For example, when the pain is moving from one part of the back to the other, when the pain goes away when you’re on vacation, when it hurts when you sit in certain chairs but not other chairs, when it’s triggered by sound or triggered by stress, we have all these criteria, right? And so you can rule out a structural problem by the MRI not showing a tumor, an infection, a fractured et cetera. severe neurologic compromise, a big disc that’s causing footdrop, et cetera. You don’t have any of that. You do have the normal findings on MRI – degenerative disc disease, bulging disc, but everybody has those, I do. I know. The neck has horrible arthritis, it has horrible bulging discs if you look at the MRI. Anyway, so, you can rule out a structural problem, you can rule in a neurocircuit or neuroplastic problem, which is brain generated. We found that 88% of the people, of the 220, had nonstructural pain. 88%, that’s a huge number.
Jen: Absolutely. And with the patients who have structural problems such as arthritis or such as a single extruded disc, for example, where you can see that there is an impingement on a nerve, but the pain is out of proportion for example to what you would expect, in addition to what you would expect or maybe there’s pain in other locations as well. Perhaps it’s mirrored in the other limb, for example. I would love to talk specifically about these types of therapy and how they apply to these types of situations. What you’ve seen, for example, in some of the more recent studies such as the Boulder Back Pain Study, which if you’re a listener, is not a study about getting back pain after lifting boulders.
[laughter]
Jen: I’d love to hear about some of the groundbreaking results that you’ve been involved in with Alan Gordon and others.
Dr. Schubiner: Yeah, I’d love to talk about that. The process that we’re using basically is to explain to people that their pain is real, that they’re not crazy, that they’re not malingering, that they’re not faking it. Psychogenic pain or neurocircuit, neuroplastic pain occurs because the brain is turning on pain. It doesn’t mean that the person is crazy or that they want it. It means that they’ve been under stress, they’ve been under emotional situations, and their brain is responding to this danger signal, to emotional danger in the same way that the brain would respond to physical danger and injury. fMRI studies show that the brain responds in the same way to emotional stress as it does to physical stress.
When you’re talking to a lot of physicians, a lot of medical professionals, a lot of them have had back pain. What if we thought a little bit about when the back pain started? Did we actually injure ourselves or was it a time when we were feeling trapped in our job or something was going wrong in our family life, finances, or whatever? That’s an amazing way to think of this. We explain how the brain works, we do this assessment to rule out structural problems, and then we institute two forms of therapy. One is PRT, pain reprocessing therapy that you’re asking about with the boulder study. The other was emotional awareness and expression therapy that we use in a randomized controlled fibromyalgia study.
The pain reprocessing therapy model relies on the diagnosis of a neuroplastic problem, and lowering the fear, and the worry about it. It is very, very simple, but it’s incredibly powerful because if there’s nothing actually structurally wrong, what’s happening is these neurocircuits in the brain keep firing, firing, and firing, and creating this real and severe pain. But there’s a feedback loop. What happens when you’re in pain, you start fearing it, worrying about it, focusing on it, getting frustrated by it, fixating on it, trying to figure it out. All those things send feedback loops to the brain, which makes it worse. When you stop doing it, and you start realizing that you’re not actually damaged, and you start living your life, and you start doing things little by little, and when the pain comes, you just smile at it, and you just keep going, and you tell yourself you’re okay, it sounds so silly. It’s so simple.
But in these randomized controlled trials, 75% of the people who got this treatment for chronic back pain of 10 years’ duration, were pain free in one month. There’s never been a back pain study that had these remarkable results. I personally evaluated all the participants for the medical assessment and 95% of the ones that I saw, 43 out of the 45, did not have a structural problem. They got better.
Jen: With that study you did as you’ve mentioned functional MRI prior to the treatment and after the treatment, can you tell us about the results of that?
Dr. Schubiner: This study was done with Tor Wager, who’s the incredible fMRI neuroscientist, who was at Boulder, Colorado, then he’s at Dartmouth now. One of his grad students, Yoni Ashar, who’s a PhD psychology and PhD in neuroscience, and yes, we found some changes. The changes were similar in the fMRIs of the brain to other studies which showed when people got out of pain. When people get out of pain, their brain changes. It had mainly to do with the anterior insula. The pain is in the brain, the pain is real, the pain is reversible, that’s the message, and the treatment is fairly simple. The hard part is getting people to buy into it because when you say, “Oh, your pain is in your brain,” what do people hear? The pain is in my head. You’re saying I’m crazy. That is so difficult because there’s so much stigma against pain being psychological. It’s not psychological, it’s real. It’s neurocircuit. This is real as any pain because all pain originates in the brain, but not everybody can hear that and not all doctors really can grasp that frankly because as physicians, we’re steeped in this model, there must be something wrong in the body when there’s pain.
Jen: When I first was exposed to Sarno’s work about the concept of pain originating in the brain that was exactly my reaction to it, was that saying that you’re imagining it, and that’s not at all what you’re saying. Actually, what you’re saying is that pain is the brain’s way of interpreting whether something is critical that you need to get away from or fix. When you’re in a chronic situation of pain, your brain is still interpreting this as an emergency and giving you that signal that you need to do something differently. But often in these cases or most, the vast majority of the time, when there’s no structural problem that is going to harm you, your brain just has that feedback loop on to constantly be reinterpreting or misinterpreting the signal as a warning that it needs to warn you that there’s something that you need to change.
Dr. Schubiner: Yes, that’s exactly right. I was at a conference a couple of years ago, when a guy stood up and he said, “In my culture, pain is viewed as a gift from God.” What do you think of that? I was so taken aback. But when I thought about it, it is. Well, first of all, if you think God created us, God created us or we evolved to have this kind of brain. This brain that has a smoke alarm in it, [chuckles] that gets activated when you’re in physical danger like if you get a cut, but it also activates in the same way if you’re in an emotionally difficult situation. So, it’s a gift because it’s a message. But it’s up to us to interpret the message. That’s where doctoring comes in.
Good doctoring can really help to explain this to people and help people figure out that they’re not as damaged, and crippled, and as broken as they think they are and that there’s hope for recovery. It helps us as physicians to be able to know what to do with this large swathe of people, who have chronic symptoms which includes chronic fatigue, and anxiety, and depression, and insomnia. And medications are great when they work, but we’re spending incredible amounts of money on invasive and sometimes risky procedures. We could do better.
Jen: Even with such severe pain syndromes as complex regional pain syndrome.
Dr. Schubiner: Yeah. You look, you can see somebody’s foot, it might be swollen, purple, red, and yet there’s no damage to it. This is an autonomic nervous system dysfunction but what controls the autonomic nervous system? Your brain. You’ve mentioned Dr. Sarno. There’s a movie about Dr. Sarno, who I learned this from back in almost 20 years ago now called All the Rage. In that movie, there’s a woman who had CRPS and she shows a picture of her foot – big, swollen, and deformed horrible looking foot. The doctors kept telling her, “Don’t walk on it, don’t walk on it. Get all these treatments.” It turned out, she was in a very stressful situation in her life when it started and she said, “I’m going to walk” and she just started walking and she got better. She took control of her mind, [chuckles] her emotions, and her body, and she got better. There’s another movie also called This Might Hurt made by two young filmmakers, Kent Bassett and Marion Cunningham that follows me working with some of my patients, which is pretty amazing. [laughs]
Jen: When you do this therapy with patients would you say that part of the therapy is teaching people to calm their mind and to retrain their brains to interpret safety in a context that we previously were misinterpreting as danger?
Dr. Schubiner: Absolutely. When a kid falls off a bike, they look to you to see if they should cry or not. So it’s a natural tendency to freak out, “The kid fell.” But if you step back and you’re the parent, what do you want to teach that kid? You want to teach the kid, “It’s okay to fall.” When the kid falls, you smile and say, “Oops, that was fun. You’re okay, buddy. Let’s do it again.” That’s what you’re doing to your brain because your brain is looking to you, brain is giving you pain and you’re either freaking out or you’re going, “Oops, that’s silly. I’m okay.” A huge difference. When a kid has a temper tantrum, if you freak out and worry about, if you know they don’t have something in their eye, the best thing to do is you just need to ignore them, right? But it’s hard to do because you’re the parent, and you love them, and you want them to be happy. But you have to step back, say, “Hey, I’ll just wait.” And that’s what you have to do when you’re having pain or these other symptoms. If you can’t sleep, the harder you try to fix your sleeping problem, the worse it’s going to get. The harder you try to fall asleep, the worse it’s going to get, so you have to step back and say, “Yeah, I’ll fall asleep. If I don’t fall asleep tonight I’ll fall asleep tomorrow night.” It’s so simple.
The other thing is you have to do it, and this sounds silly coming from an internist, but you have to do it with love. [chuckles] It’s like, “We love our kids. So, we let them cry now. We love our kids, so we don’t freak out when they fall.” When the kid is lying in bed fearful of a monster in the closet, we don’t get mad at them because we know they’re afraid. That’s what the brain is. The brain is basically operating under fear. With the kid, we open the closet door and say, “Look, there’s no monster.” With our brain, we say, “Hey, there’s no damage. My back’s not broken. My stomach’s okay.” Then we soothe and we calm, and we engage in our life, and most people are going to get better.
I tell patients, “If you’re ready for the treatment, you’re going to have to realize it’s going to be way too simple, it’s going to be way too silly, and we’re going to laugh and have fun.” This doctor, who I was telling about, the spine surgeon friend of mine, he’s having all these symptoms. Then when he realized that it was not his body and it was his brain, he just started living his life and then it just went away.
Jen: There’s another story that you tell about a woman who actually was experiencing terrible pain and when she understood this type of treatment, she wrote a letter to her brain.
Dr. Schubiner: There’re all sorts of techniques. What we’ve been talking about now is what we’re calling PRT or pain reprocessing therapy, which is, it’s changing your relationship to the pain. If you’re having trouble walking more than two blocks, you start walking five steps without fear and then you do 10 steps and then 20. That’s a behavioral approach. But it’s based on the idea that you’re going to get better, you can get better, there’s nothing wrong with that. But some people need a little bit more because some people have these problems. It is well known. Higher rates of migraine headaches, fibromyalgia, interstitial cystitis, irritable bowel, pelvic pain syndromes, back pain syndromes is much higher in people with childhood trauma. The adverse childhood experience studies have shown it very clearly. Some people have not only their pain, but they have tremendous anxiety, and fear, and histories of trauma. For those folks, we’ve designed other models that have to do with dealing with the emotions and dealing with the trauma.
Jen: For someone who may be listening to this, who is familiar with cognitive-based therapy and other therapies that have been used prior to this to help people to deal with pain, whereas this helps people to treat pain and make it go away, can you explain what the differences are in the results between those two?
Dr. Schubiner: I’m really glad you asked that. We think of it as a curing model versus a coping model. Cognitive behavioral therapy works. It’s been studied in thousands of studies for all sorts of things. It works but it doesn’t work that much. The average decrease for pain, CBT for pain, the average decrease in pain is about one half of one point on a 10-point Likert pain scale. It’s no better than acceptance and commitment therapy or mindfulness-based therapies. These therapies are designed to help people cope better with the pain because they’re not designed to evaluate this cause of the pain and say is it neuroplastic versus structural. They’re designed to take pain and help you cope with it better, which is what they do, but they don’t do it that much. And so, our model is distinctly different because of the assessment, because of the diagnosis, because of the understanding and the brain science, and because of the treatment designed to eliminate the pain not to cope with it. It’s really important, because the techniques we use sound, they’re so simple, like, anybody could do them, but it’s based on the underlying assumption is different.
Jen: And does someone need to have formal treatment or is this something that you’ve seen people have very good results just on their own? I know you have the book, Unlearn Your Pain, what feedback have you gotten with people who are using that, or the app, the Curable app?
Dr. Schubiner: Yeah, there’s a burgeoning growth of treatment for this in this arena. The Curable app is one of the first ones. It’s really, really good. It’s something you do on your own. Some people when they read about it, they look at the Curable app, or they read my book, or one of Dr. Sarno’s books. There’s a bunch of other books. David Hanscom has got a great book. A lot of people can read the book and say, “Oh, that’s me. I can see it. That’s obvious.” Then they just start to do the exercises and they get better. Other people are like, “Are you sure, it’s me? I’m not sure it’s me. I really need to know if it’s me.” [chuckles] And so, then they need to seek care, and then they’re emailing me, and they’re trying to find doctors who can make sure that they’re not structurally damaged.
That’s where physicians can come in. Because any good physician can evaluate somebody and say, “Yeah, diagnosis is fibromyalgia.” That’s not a structural disease. It’s real. It’s not a structural disease. irritable bowel, migraine headaches, tension headaches. And with the back pain, we can do the same. Some people need counseling. They need somebody to coach them and help them lower their danger signal, and help them stop fearing the pain so much because they get so wrapped up in it. You can tell those folks. Any doctor can just see somebody who’s so on edge about their pain. And so, they’re going to need help more, some of them are going to need help. Then some people like I say need emotional processing type work on top of that.
Jen: One thing that I see among physicians is certain character traits are common like perfectionism, and being very harsh on oneself, and that seems to be shared between the two groups. There’s a bit of a Venn diagram overlap.
Dr. Schubiner: [laughs]
Jen: I wonder when you talk about people who have traumatic events that happened during childhood, what about that versus someone who is just a sensitive person, who is very hard on themselves, but maybe in a positive way, so, it has pros and cons?
Dr. Schubiner: Yeah, that’s a great question. I have neurocircuit or neuroplastic pain. When I started my internship, I had diarrhea for six months. Why? Because I was scared shitless about killing somebody. I’m a young doctor. My sensitivity, or my perfectionism, or my people pleasing, and my worry about making a mistake was high enough to cause my brain to cause me to have diarrhea as a message that something’s wrong. It went away in about six or eight months as I got used to being a doctor. But when I was in my 30s and 40s, and I was starting a career as a faculty member, you’re teaching, “Oh, there’s research, oh, there’s clinical practice, oh, there’s administration, oh, community service, oh, you’re a dad, you have young kids? Oh, what about your wife.” [argh] There’s so much going on, and I started to get neck pain, and I was just trying to please everybody.
I was trying to be the best that I could possibly be, and I’d wake up with this horrible neck thing, and then my MRI would show bulging disc and arthritis, and then I get PT, and then it’ll get better, and then it’ll get worse again, and get better, and get worse again. Now, I don’t have any neck pain. I still have all those MRI findings, but I’m more at peace with myself. It’s the external pressures that get put on us and it’s the internal pressures that we put on ourselves on top of it, and that can be a recipe for the brain’s alarm system to go like, “Hello, [laughs] something’s gone wrong,” because their brain just can tap you on the shoulder and say, “Doctor, heal thyself.” [laughs] The brain just gives you a headache or stomachache.
Jen: You mentioned mindfulness therapy and I know that’s different from mindfulness tying into the treatments that you recommend. What’s the difference between mindfulness therapy and using mindfulness to help you to calm your brain?
Dr. Schubiner: That is a great question. I have been teaching mindfulness since 1999. Everyone should learn it, children should learn it, doctors should learn it, teach to our patients. It’s a great way to have skills to navigate life. If it’s so great, how come the research using mindfulness for chronic pain has not shown that to be very effective? The effects are small and they wane over time, which is different than our study where the effects were large and they didn’t wane over time. We have one year follow up in that Boulder Back Pain Study with no decrement in pain. So, why is that? The reason is that mindfulness is a way to accept what is, and separate from it, and let it go. That works great with thoughts. Because if you have a thought, okay, well, you know the thought’s coming from your brain. It’s just the thoughts. You can notice the thought, accept the thought, let the thought go say, “next”, notice the next thought, and you can learn to deal with thoughts, which everyone has because they’re just thoughts.
But when you’re using mindfulness for pain, if you assume the pain is due to a structural problem, you’re not going to just let it go. You’re going to notice it and try to separate from it. But there’s a ceiling effect. When you recategorize the pain into a thought, so to speak, another is a brain generated phenomenon, a sensation, and now you do mindfulness with it. Once you know you’re not damaged, now it can be incredibly effective. So, it’s the same technique. We use mindfulness in our treatments, but we use it in by first re-categorizing the symptom from a structural one to a neuroplastic one, and that makes all the difference in the world.
Jen: Wow, thank you so much, Dr. Howard Schubiner for this conversation, which I think is going to be life changing for some of our listeners. Dr. Schubiner, if listeners would like to find out more, can you please give us some examples of resources and we’ll also list those in the show notes?
Dr. Schubiner: Yeah, thank you very much. We have a nonprofit professional organization called The Psychophysiologic Disorders Association.
Jen: We interviewed Dr. David Clarke, actually [crosstalk] months ago.
Dr. Schubiner: Yeah, David Clarke, Dave is amazing and wonderful, smart guy. He’s the President and it’s ppdassociation.org. There’s a peer-run group called tmswiki.org, which is run by people who’ve been in pain, and suffered with it, and have recovered, and want to help others. There’s a ton of resources there. There’s the PRT Institute website, painreprocessingtherapy.com, I think it is, and they’ve got a list of practitioners as does these other sites, they have lists of practitioners and resources. My website is unlearnyourpain.com and there’s a lot other resources there and videos. In particular, I’ve created a set of six animated videos, short five-minute, six-minute videos explaining pain, explaining how to diagnose and treat neuroplastic pain in animation form that patients, they really like it, and they can really understand it, and it hopefully can make sense to them. Because it’s hard to explain and doctors really don’t have the time. So, that’s one resource that I use all the time is these animated videos that are, you can link on my website.
Then, there’s a ton of books. Some of my books, but also books by Alan Gordon, David Clarke, David Hanscom, Georgie Oldfield, David Schechter. There’s a lot of resources out there. Then there’s the apps. There’s freedomfromchronicpain.com online program, Curable app online program, Lin.Health online program, The DOC Journey, another good online program.
Jen: Tremendous. Well, thank you so much. Dr. Howard Schubiner, thank you. I think this is going to make a big difference for our listeners and in the lives of their patients. So, thank you for taking the time to be with me here on DocWorking: The Whole Physician Podcast.
Dr. Schubiner: It’s my pleasure. Thank you, Jen.
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