The Mindbody Prescription - Healing the Body, Healing the Pain

My personal notes on the book “The Mindbody Prescription: Healing the Body, Healing the Pain” (Sarno, John E.).

The Mindbody Prescription

• Conflicts rage constantly in the unconscious, born of the various elements that represent the mosaic of the human psyche. These conflicts result in the development of emotions that cannot be tolerated and, therefore, must be repressed. Because these undesirable feelings appear to strive for recognition, the mind must do something to prevent them from coming to consciousness. Hence, the mindbody symptom.
• The psychological reality is that while we all tend to make the best of things consciously, life’s pressures produce internal reactions in the unconscious, of which we are totally unaware.
• No matter how we react to life’s pressures consciously, another world of reactions exists in the unconscious. Because we are not aware of those unconscious feelings and cannot, therefore, control them, and because they are so threatening and frightening, the brain will automatically induce physical symptoms to prevent the dangerous feelings from becoming overt, and thus becoming conscious.
• I believe that rage in the unconscious has three potential sources:
  1. That which may have been generated in infancy and childhood and never dissipated
  2. That which results from self-imposed pressure, as in driven, perfectionist or goodist people
  3. That which is a reaction to the real pressures of everyday life
• TMS teaches us that only feelings that the mind perceives as dangerous, and therefore represses, induce physical reactions.
• Inhibited or consciously suppressed anger contributes to the reservoir of rage in the unconscious
• While anger that is known to a person plays a role in the genesis of TMS when it is suppressed, it is not nearly as important as anger that is generated in the unconscious as a result of:
  1. Internal conflict
  2. Stresses and strains of daily life
  3. The residue of anger from infancy and childhood
• The intensity of the anger, to the point of rage, determines the necessity for physical symptoms as a diversion. The threat of rage to explode into consciousness must be of sufficient magnitude to warrant the production of TMS or one of its equivalents.

Avoidance: Symptom as a Distraction

• Stanley Coen, a Columbia psychoanalyst and author, suggested that the purpose of the pain was to distract attention from frightening, threatening emotions and to prevent their expression.
• Symptoms are not physical substitutes for bad feelings, like anxiety. Nor are they self-punishment for bad thoughts or guilt. They are players in a strategy designed to keep our attention focused on the body so as to prevent dangerous feelings from escaping into consciousness or to avoid confrontation with feelings that are unbearable.
• Because the unconscious is often illogical and irrational, it may react automatically in the face of disturbing feelings. Most people, if given the choice between coming to terms with difficult feelings or experiencing intense physical pain, would choose to deal with the feelings. That’s logical. But the way the human emotional system is now organized dictates how it will react; at the unconscious level it is often illogical.
• In Beyond the Pleasure Principle, Freud wrote, “The unconscious itself has no other endeavor than to break through the pressure weighing down on it and force its way either to consciousness or to a discharge through some real action.”
• When patients become aware of the presence of rage or unbearable feelings, these feelings can cease their struggle to become conscious. Removing that threat eliminates the need for physical distraction, and the pain stops.
• We must seek to know the reasons for the rage to fully understand the process.
• Experiences in infancy and childhood make the earliest contribution to the pool of anger.
• Unconscious resentments may occur in perfectly normal settings. One need not postulate “bad”, “cruel” or “inadequate” parents. Deeply repressed feelings of inadequacy foster the development of personality traits that are almost universal in people with TMS. They tend to be perfectionistic, compulsive, highly conscientious and ambitious; they are driven, self-critical and generally successful. Parallel with these traits, and sometimes more prominent, is the compulsion to please, to be a good person, to be helpful and nonconfrontational. In short, people with TMS have a strong need to seek approval, whether it is love, admiration or respect.

LOW SELF-ESTEEM

• Deeply repressed feelings of inadequacy and self-doubt appear to be our common lot. Earlier societies may have done a better job of rearing their offspring by being more nurturing, less controlling, having a simpler set of rules by which to live and providing good role models and rites of passage.

PERFECTIONISM

• The drive to be perfect must surely derive from a deep need to demonstrate to ourselves and to the world that we are truly worth something. Virtually every patient I have seen in the course of my experience with pain syndromes has been to a greater or lesser degree perfectionistic.
• Why does the drive to be perfect lead to rage? The pressure superimposed by the mind-parent on the residual child is enraging. Ben Sorotzkin, a practicing psychologist, suggests that perfectionists unconsciously set up standards for themselves they cannot possibly meet; their inevitable failure to live up to them results in unconscious shame and rage.

GOODISM

• Perfectionism is the predominant personality characteristic in many of my patients. In others, however, a closely related compulsion - the need to be good - is primary. These people are driven to be helpful, often to the extent of sacrificing their own needs. They have a desire to ingratiate, to want everyone to like them.

HOSTILITY AND AGGRESSION

• TMS theory would identify hostility and aggression as overt manifestations of something far more dangerous - repressed rage and suppressed anger. Physical symptoms, anxiety, depression or hostility are, in effect, equivalents of each other. They all reflect powerful processes going on in the unconscious.

GUILT

• Guilt is another reaction spawned by the psychic parent, another self-imposed pressure that contributes to the critical mass of rage. One can feel guilty about many things, including past transgressions and inadequacies. Because the self cannot tolerate discomfort of any kind, and guilt is yet another attack on our sense of worth, all contribute to the rage Self-criticism is apparently as enraging as criticism from others.

DEPENDENCY

• One of the residuals of childhood is the desire to be taken care of. Because we do not view this desire as appropriate adult behavior, it is deeply repressed; we are unconsciously dependent. This may lead to unconscious anger because the dependency needs are never satisfied and, paradoxically, we may be unconsciously angry at the person or persons upon whom we are dependent.

The World Around Us

• Pressure is enraging to the self, whether it is pressure from within at the dictates of the parent or from the realities of our daily lives. Being conscientious and concerned makes matters worse, aggravating the pressure of being a competent worker, a good spouse and parent, a loving child to an elderly, dependent parent.
• Even happy events like landing a good job, getting married or having a baby can result in inner turmoil, pressure and anger.
• Both positive and negative stress generate unconscious anger, whether or not one is consciously angry. Accumulated anger is rage, and frightening, unconscious rage leads to the development of physical symptoms.

Six Basic Needs

• To fulfill our basic needs we put ourselves under pressure, which is enraging to the self. Or we become frustrated and angry because some of the needs are not adequately met. These basic needs are:
  1. To be perfect (to excel, achieve, succeed; high expectations and standards; self-critical and very sensitive to criticism)
  2. To be liked (approved of, loved, admired, respected; a compulsion to please, be a “nice guy,” or be a mother or father to the world)
  3. To be taken care of (a desire that never goes away unconsciously no matter how old or independent we are)
  4. To be soothed (so we seek gratification through food, drink, smoking, sex, entertainment, play)
  5. To be physically invincible (strong, unrestricted, sexy)
  6. To be immortal (we are unconsciously enraged by the inevitability of death)

The Rage/Soothe Ratio

• I believe a kind of rage/soothe ratio may play a role in determining when physical symptoms will occur. Patients frequently ask, “Why did the pain start now?” Invariably I reply, “Because your rage has reached a critical level; because it now threatens to erupt into consciousness.”

Anxiety and Depression as Equivalents

• The idea that the physical conditions just listed are psychologically induced is controversial. Even more controversial is my conclusion that both anxiety and depression are equivalents of TMS, signifying that they, too, may serve to distract us from underlying, threatening emotions. The psyche is eclectic in its choice of distractors.

Obsessive-Compulsive Disorder as an Equivalent

• OCD is an anxiety equivalent, which is a TMS equivalent. Hence, the decision to include OCD as a TMS equivalent is logical. Its capacity to absorb the patient’s attention parallels that of the pain of TMS. Not infrequently, patients with TMS are obsessed with their pain symptoms, indicating the intensity of the unconscious need for a distraction.

Treatment

• Mindbody symptoms exist to serve a purpose. If you thwart that purpose by taking away the symptom without dealing with its cause, the brain will simply find a substitute symptom or disorder.
• One of the most important clinical features of TMS is the tendency for sufferers to develop a specific pattern of pain, including what time of day or night they will have pain, what activities or postures will bring it on, what things they can and cannot do. These are programmed reactions.
• We very quickly and unconsciously associate these activities, postures and times of the day and night with the onset of pain.
• We must somehow thwart the brain’s strategy.
• To accomplish that I encourage patients to:
  • Repudiate the structural diagnosis, the “physical” reason for the pain (TMS is a different kind of physical process)
  • Acknowledge the psychological basis for the pain
  • Accept the psychological explanation and all of its ramifications as normal for healthy people in our society
• Repudiate the Structural Diagnosis
  • The pain will not stop unless you are able to say, “I have a normal back; I now know that the pain is due to a basically harmless condition, initiated by the brain to serve a psychological purpose, and that the structural abnormalities that have been found on X ray, CT scan or MRI are normal changes associated with activity and aging.”
  • This initial realization is essential to thwart the brain’s strategy, which is to keep your attention firmly fixed on your body and unaware of the threatening feelings in your unconscious. As I explained in Part I of this book, the mind fears that the unconscious rage will break out into the consciousness
• The Principle of Simultaneity
  • TMS symptoms often begin in association with a known structural abnormality
• Acknowledge the Psychological Basis for the Pain
  • The brain tries desperately to divert our attention from rage in the unconscious.
  • This is an automatic reaction of the mind, not based on logic or reason. So we must bring reason to the process. This is the heart of the very important concept - that we can influence unconscious, automatic reactions by the application of conscious thought processes.
• Accept the Psychological
  • We must say to ourselves, “It’s all right to be the way we are: illogical, unconsciously enraged, like a child having a temper tantrum. That’s part of being human and it is universal.”
• Think Psychological
  • I tell my patients that they must consciously think about repressed rage and the reasons for it whenever they are aware of the pain. This is in contradiction to what the brain is trying to do. This effort is a counterattack, an attempt to undo the brain’s strategy. It is essential to focus on unpleasant, threatening thoughts and feelings to deny the pain its purpose - to divert your attention from those feelings.
• Talk to Your Brain
  • It sounds silly, but it’s very effective. The conscious mind addresses the unconscious, the more forcefully the better.
  • You tell your mind that you know what it’s doing, that you know the physical pain is harmless and is a distraction from the repressed rage, and that you no longer intend to be diverted and intimidated. You might even tell it to increase the blood flow to the involved tissues.
• Make a Written List
  • List all the pressures in your life, since they all contribute to your inner rage. There are self-imposed pressures, typical of the conscientious perfectionist or the goodist, and the pressures of everyday life, including “happy” things like marriage and children, since they, too, represent great pressure. You should also list anger left over from childhood.
  • By identifying and dealing with sources of pressure consciously, you reduce their potential negative effect in the unconscious.
• A Daily Reflection or Meditation Period
  • This part of the treatment is essential for very busy people who don’t have a moment to think of anything but their work during the day. The treatment for TMS and its equivalents is to think your way out of it. This is best done in quiet and solitude, so a time must be found each day when you can sit and think about what it takes to get better.
• Physical Activity and the Fear Factor
  • The path to resumption of full physical activity, without fear, may be slow and uneven. Don’t worry if you begin to exercise too soon and experience some pain. You cannot hurt yourself; TMS is a benign process. Continuing pain with activity means the brain is still in the process of changing its programming. You must bide your time, try and try again, and stay secure in the knowledge that you will prevail in the end. This has proven to be the case for thousands of patients.
• In most cases the cessation of pain takes only a few weeks, although banishing the fear may take a lot longer.

How the Strategy Works

• Why does repudiating the physical and acknowledging and accepting the psychological make the pain stop? Remember that the purpose of the pain is to divert attention from what’s going on emotionally and to keep you focused on the body. In essence it is a contest for conscious attention.
• Reflection is a therapeutic tool. For most patients it will banish the pain and usually prevent its return. For most people just thinking about the rage in this fashion is as good as experiencing it.
• Knowledge Is the Cure: For some people simply shifting attention from the physical to the psychological will do the trick. Others need more information on how the strategy works, and still others require psychotherapy. But in every case knowledge is essential to the “cure,” for by making people aware of what is going on both physically and psychologically we frustrate the brain’s strategy.
• By changing the focus of attention from the body to the psyche we render the pain useless, take away its purpose and reveal what it was trying to hide. In a small number of cases the person must actually experience the emotion, like rage or profound sadness, before the pain will cease.
• Goodism is just as potent an instigator of unconscious rage as perfectionism, as is the anger that goes back to childhood experiences, which is very important for some people with TMS.
• Because TMS originates in the unconscious, the new ideas must penetrate and be accepted there for the pain to cease.
• First, that TMS and its many equivalents are essentially harmless, though the severity of symptoms may make that hard to believe at times. Mindbody physical symptoms are universal in Western society; they do not imply mental or emotional illness or abnormality. We are much stronger than we know, and have the capacity to influence what is going on in our bodies. But we must learn how. Where the group of mindbody conditions described in this book is concerned, knowledge of the process, and most particularly knowledge of its emotional sources, is essential and almost invariably results in a “cure.”
• Our greatest enemies are fear and misinformation. In the realm of the emotions, we have two minds and must not make the mistake of judging the unconscious mind by the accepted rules of logic and rationality that are characteristic of the conscious mind.