Tami Simon: You’re listening to Insights at the Edge. Today my guest is Dr. Ronald Siegel. Ronald Siegel is an assistant professor of psychology at Harvard Medical School, where he has taught for over 35 years. He teaches internationally about mind-body treatment and has authored many books including the book Back Sense: A Revolutionary Approach to Halting the Cycle of Chronic Back Pain. With Sounds True, Ron Siegel has created a new audio program called Healing Through Mindfulness: Effective Practices for Chronic Health Conditions.
In this episode of Insights at the Edge, we learned about Ron’s personal experience with debilitating back pain and a herniated disc, and how that led him to a deep appreciation of the psychophysiological components that are involved in chronic conditions, like back and neck pain, gastrointestinal disorders, insomnia, anxiety and panic disorders, and other stress-related conditions.
We also talked about how to talk effectively with people who are suffering from chronic conditions, and to speak to them without judgment and bring curiosity to what the emotional contributing factors might be, exploring what Ron calls the “fuel source” underneath chronic conditions. We also talked about a practice he teaches called “Separating the Two Arrows,” how to make friends with fear and anxiety and how the medical profession is currently changing rapidly in its embrace of the practice of mindfulness. Here’s my conversation with Dr. Ron Siegel.
Ron, I’m so happy to have this chance to talk with you on Insights at the Edge. Thank you for making the time for this.
Ron Siegel: Thank you so much for having me. I’m glad to be here with you.
TS: OK. Let’s dive in. This new audio series you’ve created with Sounds True is called Healing Through Mindfulness: Effective Practices for Chronic Health Conditions. And towards the beginning of this new series, you mentioned what I thought was a pretty startling statistic that depending on the criteria used, between 60 and 90 percent of all physician visits are for stress-related disorders. So this made me start thinking of all of my visits to the acupuncturist, etcetera, etcetera. And I thought, gosh, I wonder how much of my own presentation of illness is stress-related. I think quite a lot. Tell me a bit about the statistic and what you mean by stress-related disorders.
RS: Well, if we think about the different things that bring us to a doctor’s office, there are some things that are not particularly stress-related, like upper-respiratory tract infections and other kinds of infectious disease. But an awful lot of the things that make us uncomfortable, and particularly problems that become chronic, actually have a stress component to them. Certainly back pain, neck pain, and other chronic muscle pain often has a stress-related component to it. Gastrointestinal distress—whether upper-GI symptoms such as heartburn and sour stomach and the like, or lower-GI symptoms such as irritable bowel syndrome, constipation, diarrhea—often has stress-related components.
Headaches, various other pains like temporal mandibular joint disorders, where the jaw hurts a lot when we use it, things like tinnitus or ringing in the ears—this is more dentist visits than doctor’s visits—but all the effects of bruxism, grinding the teeth, and things like insomnia and eczema and other skin disorders, sexual dysfunctions of all types, and all the different anxiety disorders that people come in with, all have stress-related components.
Now, this doesn’t mean that these disorders are purely caused by psychological states. They’re not purely caused by being obsessionally anxious or worrying or being agitated in some way, but it does mean that these psychological factors do play a role in all of these, and sometimes they play a completely causative role. In other words, these disorders really do just arise because of stress, and other times stress exacerbates these disorders. Very often we see a pattern in which the disorder arises whether from stress or from some other life circumstance or medical problem or an injury or an infection or something.
Then what happens is we become distressed about the symptom. And the distress about the symptom starts to exacerbate the symptoms. So we can say the stress plays a role in an extraordinarily wide variety of things that go wrong in the body.
TS: Now Ron, just for our listeners to become more familiar with you and your work, as a practicing psychologist as well as a professor of psychology, how did this focus on the healing of stress-related disorders come into focus for you?
RS: Well, I got into it as a patient, actually. I’m just doing the math quickly. About 30 years ago, I spent four-and-a-half months flat on my back with a herniated disc diagnosis, and I was not a happy camper. Back in those days, the usual advice given by well-trained physicians was, “Well, what you want to do is take the pressure off of the disc in your back. So you want to spend as much time horizontal as possible and basically lying down. You want to avoid walking. You want to avoid standing. You want to avoid sitting and hopefully, over the course of months, perhaps the disc will heal. If not, you’re a candidate for surgery, but surgery has iffy outcomes.”
So it was in that state that I first encountered these disorders, thinking that I had a purely orthopedic problem. But there were little things that started to suggest that maybe it was more complicated than simply the herniated disc. One was, for example, that my wife, who’s a clinical psychologist herself, would point out, “Hey Ron, you seem to complain more of the pain whenever we have an argument.” And I thought, oh great, this is my penance for marrying a psychologist. She’s going to take this orthopedic disorder and now interpret it—even worse, interpret it in the context of our relationship. I thought, well, that’s nonsense.
But there was something to it. I did sort of notice the same pattern myself and I thought, “I wonder what that’s about.” And then there was a particularly moving experience where a fellow at work had been bugging me for months, “Hey, you really should talk to Linda about this.” And Linda was a psychiatric social worker who was very good at what she did, but I thought, “What’s she going to know that the”—I was in the Harvard Medical School system— “that all the Harvard orthopedists and neurosurgeons and staffs don’t know.”
But he kept insisting I talk to her and one day I did. And she said, “Oh hi, Ron. I heard you’re having a back problem.” I said, “Yes.” She said, “What are you doing?” I said, “I’m lying down. It’s all I ever do.” I was really quite a peach at the time. I was pretty depressed and pretty frustrated. And she said, “Why don’t you get up and buy groceries? Your wife will appreciate it.” And I thought, “What? I can’t even walk. I can’t even sit. How am I going to buy groceries? This is crazy.”
She went on to present this model that said these are often psychophysiological. These are often . . . People get caught in pain, fear, pain loops—and the pain may have nothing to do with the herniated disc diagnosis. And I thought, really? I thought, well, I’m just going to . . .” She was so compelling and it was about two weeks away from the meeting with the surgeon—because I was now four-and-a-half months into this and hadn’t really gotten better. I thought, well, I’ll take it to heart. I had discovered that at that point, I could walk about a city block and then I would get very strong sciatic pain shooting down my leg.
So I thought, alright. Linda has this argument. I’ll push it a little bit. I’m not going to buy groceries, that would be crazy, but I’ll try walking a little bit more. I walked the city block and sure enough, got the pain down my leg and I pushed and I walked about another city block, maybe even two more, and then to my utter surprise, I developed pain shooting down my other leg as well. And that was a new experience. And I thought, well, that was great advice. Now I’ve got pain going down two legs.
But actually it was because the radiology report, the imaging said that the disc had herniated laterally, which they normally do, to the side. So I was supposed to have pain down one leg, but I wasn’t supposed to have pain down the other leg. So the question came up, what could be causing this? And frankly, my first hypothesis was, “Now I’ve shattered my spine entirely and it’s all over.” But then I did have the thought that, could it just be that there’s another mechanism going on here? Could it just be that this is in some way stress-related and psychophysiological?
I decided as one last-ditch effort before basically signing up to go under the knife, I would treat this as though it were a stress-related disorder. And of course, if you’re having a stress-related disorder and the muscles of your back are killing you, well, you don’t lie around and wait for them to get better, you start using them. You start stretching, you start becoming more active, you start facing your fears. And I did that, and two weeks later I was better. I had canceled the appointment and I was fine. I still had some residual pain, but nothing like I had before.
What I didn’t mention is during this period I had . . . As a psychologist, I was so frustrated by being inactive and being disabled and being out of work that I constructed a flat platform bed in my clinic office and my private practice office, and I’d begun a really bizarre parody of the classical psychoanalytic scene. I was lying down, my patients were sitting up and wondering about my pathology and my prognosis. And that was horrible. And I dismantled the beds and I just decided I was going to live normally.
I really got better. And that’s what got me into getting more curious about these disorders. I started teaming up with physicians who, in this instance, saw chronic back pain as largely psychophysiological and stress-related. That’s how I got into it. That was 30-odd years ago and it’s been immensely rewarding because I’ve seen so many people walk away from these disorders once they start to appreciate that they are stress-related or psychophysiological—or at least have a stress-related component to them—rather than treat them purely as signs of structural damage or other forms of illness.
TS: I’ve heard some of this theory before about back pain and the strong psychophysiological component. And one of the things I’ve noticed over the past years is when people share with me about some back pain that doesn’t seem to be going away, I think to myself, I wonder what’s going on with her life. I wonder what their stressors are. And I don’t quite know how to talk to them about it without them turning around and giving me the finger, or somehow just being very upset that I’m now telling them that before they go into back surgery they should consider that there might be psychophysiological influences here. How do you talk to people about this—you talk to clients about it all the time—so they don’t get just super angry at you and feel like you’re judging them?
RS: It’s really important to start with understanding ourselves and communicating the difference between what get called “psychophysiological disorders” such as these and conversion disorders. And let me say a little bit about that. Conversion disorders are disorders in which the person is experiencing it as though their body is not functioning normally. But actually, the tissues and organs of the body are pretty much intact. So these actually were the building blocks of psychoanalysis—when Freud was unable to make it as a research neurologist and had to go into clinical practice.
In the late 1800s, the standard clinical practice for a neurologist was hysterical blindness, hysterical paralysis, glove anesthesia—all of these disorders in which the body seemed to be intact but the person was experiencing it as though their arms were paralyzed, as though they were blind and couldn’t see, as though they couldn’t feel anything in their hands. And in those early days of practice with this, Freud, casting around for something to do, ran across Mesmer, the founder of mesmerism, and Charcot, who were two folks doing basically variants on what we now call hypnosis, and discovering that when hypnotized, people would pop out of this and they could suddenly see again or suddenly be able to use their arms again.
This, while fairly common in Viennese society in the late 1800s, is pretty rare today, at least in American culture. So what we’re struggling with here, typically, are not conversion disorders but psychophysiological disorders. And psychophysiological disorders are problems in which some kind of psychological state, usually a variant on stress as we’ve been describing it, causes an alteration in the function of an organ system. In this case, if we’re talking about back pain, what it does is it causes the back muscles to tighten up.
It’s really important, when talking to people about this, to communicate the understanding that “I know the pain is completely real.” My pain was completely real when I was going through this. And it is highly likely that it’s being caused not by structural abnormalities in the spine, but it’s being caused by some kind of chronic muscle tension. And in fact, that chronic muscle tension is probably compressing nerves, in a way, because most of the nerves of the back and the nerves going down the leg pass through these fleshy clumps of muscle. And if those clumps of muscle are tightened up, that can create all sorts of symptoms that feel like they’re neurological because of course, it’s affecting the functioning of the nerves.
We know that when muscles cramp up, they can hurt enormously. If you’ve ever had a charley horse in your calf muscle when it’s in spasm—gosh, that is excruciating even though there’s no damage at all happening to the calf and there’s nothing wrong with the bones and the joints of the leg. You’ve just got a charley horse in your calf muscle. So it’s typically by talking to people about the way in which the pain is completely real, and the pain is due to something very real happening to an organ system.
In the case of chronic back pain, it’s the muscles tightening up. In the case of GI distress, you really are having diarrhea and constipation, that’s not imagined. Or you really do have redness and rawness in the stomach when you have gastritis. It’s just what’s causing this might be a stressed-out psychological state.
And once we can shift our understanding from thinking, “How do I fix the medical problem?” to “What might be causing this psychological state and how might this psychological state be affecting my organ system?”—then people typically don’t feel like I’m accusing them of being nuts or making it up or in any other way being anything other than a perfectly normal human being who, like most human beings, experiences stress in their life, and has fallen into a loop in which the stress in their life has disrupted an organ system. That disrupted organ system is causing more stress, and now it’s turned into a vicious cycle.
And most people, if it’s explained that way, are willing to consider that, particularly if they notice that there’s stress in their life and particularly if they notice that actually their symptoms fluctuate. They’re not just solid and steady, but they get better and worse. And indeed, when they’re getting worse, they get more upset, and being more upset seems to keep the symptom worse. Once we start seeing these patterns, it becomes much easier to consider, “Oh, this might be happening for me.”
TS: Now let’s say somebody says, “Look, I have a physiological problem. I have a herniated disc.” Or something like that. Even in cases like that though, Ron, it seems to me—you’re the co-author of the book Back Sense: A Revolutionary Approach to Healing the Cycle of Chronic Back Pain—that even when there could be an x-ray that shows “Yes, you have a herniated disc,” it doesn’t mean that taking just a medical approach will be the best approach.
RS: Well, that’s a great question because it certainly is a big stumbling block for almost everybody, particularly if you live in a first-world country where it’s not that hard to get an MRI. Because what happens is you get this finding that there’s some structural abnormality in the spine—but of course, very few people get MRIs if they don’t have any back pain. So the interesting question is, I wonder what the spines of people who don’t have back pain look like. And there have been hundreds of studies now showing that the so-called abnormalities of the spine that are usually pointed to as the cause of these problems are actually normative in people who’ve never had any kind of back pain.
For example, there is one classic—one of the early classic studies. They took 99 people who had never experienced back pain lasting for more than 48 hours in a row. And you have to dig a little bit to find subjects like this because about 80 percent of the population has had back pain that lasted for more than two days at some point. So you take these people and this 20 percent of the population who we could call having unusually healthy spines. And it turns out that about two-thirds of them have at least one bulging or herniated disc. Over one-third have two or more discs that are implicated. And you see 10, 12 percent of the population having things like spinal stenosis, spondylolisthesis, and the other disorders that are usually pointed to as the cause of the pain.
So the fact that people without pain have these so-called abnormalities—in fact, more than half of them have these so-called abnormalities—means these abnormalities are actually not abnormalities. This is simply normal variations in what the spine looks like, and as the author of that classic study put it, the findings are frequently coincidental. This doesn’t mean there are no cases in which the findings at the level of the spine are related to people’s pain, it’s just they’re frequently coincidental.
I’ve had a clinical experience of seeing so many people pop out of these disorders once they understand it differently and start relating to it differently that it’s been quite compelling personally. In other words, the research data lines up with this personal anecdotal experience. It’s very interesting working with doctors around this. Physicians who have had the personal experience of one of their organ systems malfunctioning because of stress and discovering that it was because of stress and, once they started treating it that way, finding it resolved. Physicians who have had that experience personally in their own body are quite open to understanding these mechanisms and working with patients to free themselves from these mechanisms. Physicians who haven’t noticed it personally—it’s hard to believe. And indeed, when your back is killing you, it is really hard to believe that this thing could be a psychophysiological vicious cycle. But once it clears up and once you get free of it, then suddenly—oh my—this becomes quite, quite compelling.
TS: So let’s say someone’s listening and they say, “OK, I’m at least willing to be open-minded. I’ve had chronic back pain. It comes and goes throughout my life or for a period of time.” Or they’re listening right now and they want to give your approach a try. They come to you, let’s say, and they say, “Look, I know that there’s some component here that’s in my head,” so to speak. How do you work with them? What do you suggest?
RS: Well first I would just say, I wouldn’t use the phrase “in my head,” because most people think of that phrase as meaning it’s imaginary in some way. And the pain is not in any way imaginary. So I would start by talking to them about understanding that it is not in any way imaginary, but rather that perhaps a certain psychological attitude and a certain stressed state of mind and body might be contributing to this. So we start with making sure they’ve had a good medical workup, because after all, chronic back pain can be due to kidney disease. Chronic back pain can be due to cancer of the spine.
These things are rare, but they occur and, much as I learned in my psychological training, it would be quite bad form to psychoanalyze a brain tumor. Similarly, it would be quite bad form to treat as a psychophysiological disorder something that has a treatable medical cause. But usually by the time people are coming to me, they’ve seen quite a few physicians, they’ve had a number of workups, these other treatable problems have not been found and they’re frustrated and they’re having a lot of difficulty with it.
One thing that you mentioned, it comes and goes. That itself is of some diagnostic importance. Most of these structural damage issues, if it really is caused by structural damage, don’t come and go, come and go, come and go—while psychophysiological disorders come and go all the time. A person can be stuck with it for a month, for a year, even for several years. They can have years when they don’t have these disorders. So the coming and going pattern is suggestive that we’re in the psychophysiological arena.
Then I talk to people about what their assumptions are. How did they come to believe that whatever they think is the cause is the cause? Because one of the important components of breaking free from this is, after having a medical evaluation to rule out these potentially treatable medical findings, the next thing is we have to work on reconceptualizing the problem on a kind of cognitive restructuring. If I believe that my back pain is due to a faulty disc in my back, then I’m going to view my back as a fragile structure. I’m going to feel like I have to be careful when I bend, when I walk, when I move.
I’ll probably restrict my activity. Most people who believe they have structural damage to the spine for example, they give up tennis, they give up golf. In fact, they give up most of the activities that used to bring them stress relief, that used to bring them joy, relaxation, and engagement in life. They often stop running. They often restrict their sexual activity. All these kinds of things. So it’s really important to spend some time understanding how psychophysiological disorders work—understanding the robust and enormous body of research we have showing that these structural findings are seen in otherwise perfectly healthy people who don’t have any back pain—to really start to believe that this really could be a misunderstanding.
I want to just mention, because this sort of shift in cognitive view is so important, that the studies suggesting that the structural findings are not causative aren’t just limited to finding in pain-free people that the same structural abnormalities exist. The other thing is there are millions of people who are suffering from chronic back pain, chronic neck pain, and the like who go to MRI after MRI, and no abnormalities in their spine are found at all. So we see that people can be in terrible pain and their spine looks good. This further helps suggest that maybe the structural findings are coincidental.
Then there are all the people who have surgery. And the surgical repair is successful, but the pain doesn’t go away. And nowadays surgeons six months later, a year later will do a repeat MRI and they’ll say, “Hey, the surgery went fine, the craftsmanship is fine. I don’t know why you’re still in pain.” Then yet another set of evidence comes from the old days before we had MRI and CAT scans and the like. They used to open people up to do surgery just because they had certain symptoms, and many times, about half the time, they would find nothing out of place at all when they opened up the spine. So they would just sew the person back up again.
And that surgery—what they called negative surgical exploration, where they found nothing—would cure about half the cases of chronic back pain. So you have people who would pop out of this from surgeries that found nothing wrong. So this whole cognitive restructuring process involves understanding all of the different strands of evidence that all point in the same direction: that for the vast majority of people, this is not about the structural findings in the spine. This is about something else.
TS: So I want to make sure I understand the new cognitive frame that you’re proposing. I understand that I’m not going to necessarily see the back pain—after I’ve been checked out by a doctor—as being a physiological problem only. How am I going to see it?
RS: Well, it depends on the physician you see because some folks, unfortunately, even to this day with the research that’s out there, some folks will still find one of these supposed abnormalities in the spine that are found in pain-free individuals and they’ll say, “This must be the cause.” And unfortunately they tend to scare patients. In fact, as I take medical and psychological histories of people as I have over the years, many, many people find that their disorder actually got worse when they got their MRI and they got the results and they read the radiology report. Their heart sank and their pain got worse; which is a further indication that psychological factors are playing a role.
But let’s say we get through a medical evaluation and the physician didn’t scare the patient in a way that’s unnecessary. And I’ve had a chance to have a conversation with the person or they’ve read my book or other people’s books about this and they’re beginning to get that, “OK, the structural abnormality isn’t at the heart of my problem.” Then it’s important to begin to understand what my colleagues and I call the chronic back pain cycle, which is the alternate explanation for what’s going on here.
That can start in different ways. Let’s say, to work with back pain, let’s say it starts with where I live or where you live, it’s late December and we start shoveling snow for the first time in many months and indeed, we use the back muscles in a way they’re not used to being used and they might cramp up or in other way become painful. If we’re so unfortunate as to live in a culture that has already an established epidemic of chronic back pain, we’re going to have some negative thoughts. We’re going to think, “Oh gosh, I hope I haven’t hurt my back by doing this.” And almost all of us know lots of people who have had their lives badly derailed by back pain.
So these negative thoughts can be frightening to us, and if we get frightened or anxious or irritated or even angry about our condition, all of those emotions have an effect on the musculature. If you and the people listening to us now would like to try this as an experiment, just pantomime for a minute what it’s like to be really frightened. Just show it in your bodies as though you’re hamming that up and notice what’s happening to your muscles. And then try pantomiming, just for a moment, being really angry or really frustrated and what that looks like in the body. What would you say? What did you notice?
TS: Well, in both cases there was a lot of tension.
RS: Right. Tense muscles hurt. Anyone who’s ever had their muscles in and around the neck tighten up knows that those hurt. Anyone who’s ever had the charley horse we were talking about before for knows those hurt. So what happens is, as we have the negative thoughts about the pain and we start to have these negative emotions, those cause more tension in the muscles. There have been wonderful studies showing that people with chronic back pain differentially tense up their back muscles more than other muscles when they feel stressed, so those muscles are where the tension goes.
That’s going to increase the sensation of back pain. The person’s going to think, “Oh no, it’s getting worse, not better.” Almost everybody at that point restricts their activity. They decide, “I must have injured myself. I better be careful not to injure myself worse. I’m going to stop doing my exercise routine. I’m going stop going to yoga. I’m going to stop playing golf, playing tennis,” whatever it might be. If you restrict the physical activity, over time what happens is you lose strength, you lose flexibility, you lose endurance—the muscles actually do become vulnerable to injury now.
Psychologically, if we’ve started to become disabled in this way and limited our life, we tend to attack. We tend to get angry, depressed, chronically anxious, chronically frustrated. And you could see how this would simply become a recursive loop or a vicious cycle that just keeps going and going and going. Now, sometimes the whole cycle starts really just from an emotional event. We’re stressed out at work. We’ve had a difficult interpersonal family event. We’ve had another medical problem that scared us. Something got us frightened. Something got us angry. Something got us to chronically tense our back muscles. That caused a sensation of back pain that caused the negative thoughts, which led to the negative emotions, to more tensing and the like.
It seems in aggregate that about 50 percent of the time, this loop gets started by doing something physical and about 50 percent the time the loop gets started simply from a stressful emotional event in our life. But once it gets started, it takes on a life of its own. And I’ve seen patients who are stuck in this for a week, a month, a year, a decade. I’ve had two patients—my longest running patients in terms of their disability—who were completely disabled for 40 years each by this. They had given up everything and they were living their lives really as seriously disabled people. Both of whom—once they started understanding what was going on and found ways to work with their fears and the other emotions around this—got free from the disorder and both went back to playing tennis. One in their 60s and one actually in her 70s went back to playing tennis.
TS: Wow. That’s remarkable.
RS: So two remarkable things: one is the cure can be quite dramatic. The other thing is you can get stuck in this for a very long time because the nature of a vicious cycle is it continues until something interrupts it.
TS: Help me understand, Ron, how mindfulness is a useful tool to interrupt the cycle.
RS: Well, that brings us to the next step of the process of breaking free. The first step being the medical evaluation to rule out serious things that need treatment. The second one being, “Let’s come to understand this disorder differently so that I might start behaving differently.” And the third phase is going to be, “Let me go back to resuming a normal life.” And that’s not so easy because most people who have chronic back pain, anyway, and many of these other psychophysiological disorders, have started to restrict their lives. They’ve restricted their diets in the case of GI distress. They may have restricted their movement in the case of back pain.
You need to inch people toward not being restricted anymore. And the first thing that happens when we start giving up our restrictions is we usually feel pretty frightened to face the activity that we’ve been avoiding—and that fear usually increases the intensity of the symptoms. So mindfulness practices, which are really about training the attention to be able to be in the present moment, to step out of the thought stream a bit and not believe in our thoughts so much, to be able to see thoughts as coming and going and to be able to simply be with pleasant or unpleasant sensations without clinging to the pleasant ones and fighting the unpleasant ones—this rather simple practice can help us to begin to accept and work with the discomfort that arises as we start to free ourselves from the disorder. Because almost everybody, on their way out, experiences more discomfort at first, rather than less discomfort, because they’re starting to use their bodies in ways that they haven’t. And that can bring on pain initially.
The other way that mindfulness practices are very, very helpful is they help us to develop what’s called metacognitive awareness, which is the ability to see thoughts as thoughts rather than as realities. One of the things we start to notice is how often a frightened thought comes into mind about the psychophysiological problem. So the person struggling with back pain, if they start to practice mindfulness, will notice, “Gosh, I have an anxious thought about my back every few seconds or at least every few minutes.” Or the person who is struggling with the GI distress will notice, “Gee, I have a thought about my diet and what I eat and what I should eat every few seconds or every few minutes.”
Simply observing how often one of these negative thoughts pops into the mind and then mindfully observing the effect of the thought on the body—actually noticing the muscle tension that happens, actually noticing the stomach tightening up in the moment following the thought— helps us to both tolerate the process, so we don’t have to be reactive against it and so that we can gently urge ourselves toward resuming a normal life, and it can help us to work with all of the emotions that come up in the process.
Mindfulness practice turns out to be extremely useful for working with anxiety, for working with anger, for working with frustration, irritation. Because instead of fighting these feelings and desperately trying to make them go away, which tends to just multiply our miseries, mindfulness practices teach us how to be with these feelings, allow them to come and go, gain some perspective on them, and ultimately allow them to settle on their own. And this is a somewhat detailed process by which mindfulness practices help us work with the emotions, but many, many clinical studies show that they are quite effective.
TS: Now Ron, you told us pretty remarkable stories of two people that you worked with for decades of pain, and then they’re out on the tennis court and you underscored how both of these things are remarkable. I’m curious to know about the people you’ve worked with who didn’t get better and what was happening for them? I mean, in what way were they stuck, do you think?
RS: The vast majority of people that I’ve worked with that didn’t get better had a really hard time shifting their conceptual understanding of this. It was just really hard for them to imagine that the mind could be powerful enough to be wreaking this much havoc on the body. Interestingly, people for whom it’s often hardest are health care professionals, because health care professionals tend to study the body as a machine a lot. The body is indeed a machine in some ways, but modern medicine has really shifted away from noticing the effects of mental states on organ systems.
Ancient medical systems—whether you look at the Indian systems, Chinese system, the Greek, the early Western medical systems—were all quite attuned to this notion that mental states play a huge role in health. But in modern medicine, when we got really good at things like fixing broken bones and having anti-microbial agents that could treat infectious disease, we started saying, “Oh no, this is where the power lies. It’s in surgery and it’s in medicines.” We started to take less seriously the role of the mind in these processes. It’s not just healthcare professionals who have gotten stuck, but anybody who is quite wedded to the notion that it has to be structural has a very hard time getting free of this.
I’ve found that anybody who was able to make the conceptual shift was able to work their way free of it. And the reason why you can’t get free if you can’t make the conceptual shift is if I believe that my—going back to back pain—that my back is damaged, then every time my pain level increases, I panic. I think I’ve injured myself. And if I’m always going to relate to or react to an increase in pain level with fear, and that fear is going to increase the symptom, then I’m going to get stuck in a loop again, I will never get free.
Much of my work involves helping people look for the exceptions. Was there even one day when the pain was less? Was there even one hour when things were different? Because if you believe that it’s entirely due to some structural event in the spine, and then suddenly for one day you’re a lot better, well then it’s like, hmm, did the disc pop back into place again and then pop out of place again? What’s the explanation for that? That starts to chip away at the explanation.
The other group of people who can have trouble getting out of this are people who have had pretty rough childhoods. There’s a lot of evidence that shows that childhood trauma or high scores on what’s called the ACE Scale, the Adverse Childhood Event Scale, which basically asks patients, “Did you grow up in a family with sexual or physical abuse? Were there drug-addicted caregivers? Was there violence or divorce or turmoil?” Those are the intense items—there are lesser items on the scale of difficulty in life. If you’ve had a lot of trauma in your life, it can be hard to trust that things might be OK, because the universe just doesn’t feel like a safe place. It hasn’t been a safe place and in your formative years it really wasn’t a safe place.
There’s a lot of arbitrariness that goes into moments in which our body starts to malfunction. When our body starts to kick up pain or some other symptom arises, we can either kind of arbitrarily go in the direction of, “It’s probably nothing. It’s probably going to be OK. I’m probably going to be fine.” Or our mind can go in the direction of, “Oh my God, it’s probably something serious. This might be the thing that derails my life entirely and makes me miserable for the rest of my life.” And when we’ve had rougher upbringings, we are more likely to default on the negative and it’s going to be harder to trust that maybe I’m OK even though I’m having this symptom. And we sort of have to trust that to be able to move forward in the face of the symptom and resume our normal activities.
Those are the two big obstacles, I think, to recovery. It’s either having a real difficulty making the conceptual shift because of being quite wedded to a biomechanical model, or having had emotional difficulties in life that make it hard to relax in a trusting way and feel that “Maybe I’m going to be OK here,” and to basically be loving toward oneself and accepting of the circumstance. And these are natural things. When people get stuck in it, it’s not that they’re bad people or anything. It’s usually pretty easy to understand why a given individual wasn’t able to make the shift.
TS: OK. I’m going to ask you a question that I asked before, but I’m going to ask it in a slightly different way, which is—I need some coaching here Ron—how do I talk to someone who says, “Oh my God, my back’s really been killing me, blah, blah, blah.” And I know there’s some psychological investigation they could engage in. They could practice mindfulness, they could take a different approach. But they’re just looking at it purely as “It’s because I picked up that snow shovel,” or whatever they did to injure themselves. How do I have a conversation with them without them being offended by me? Because I’ve not been successful with this in the past.
RS: Right. Well, one place to start is to just be very curious about their experience and to ask them, “What do you think is going on here? What do you think the problem is and how did you come to understand the problem as you do?” That will give you clues as to how to talk to the person. It’s hard. There isn’t one generic line that will be meaningful in understanding everybody. We kind of have to understand how each individual person came to believe what they came to believe and why they believe it—and then to validate your understanding of, well, it makes perfect sense that they might think what they think, or feel what they feel based on their experience.
But also look for ways in which might they have simply overlooked perhaps additional factors that might be contributing to this. When I’m talking with a new patient, I never go in with the assumption that this is 100 percent psychophysiological and “Once you work out a different attitude toward this experience, once you learn mindfulness practices, once you apply them to the psychophysiological disorder, you’re going to be symptom free”—because I don’t know if that’s the case. I simply go in with the assumption that maybe this accounts for some percentage of the distress. And even if it just accounts for some percentage of the distress, since there is no downside to it and no cost to it, why not investigate this? Why not see what you can do, see what part of your care you can take into your own hands here?
And most people, if they feel like I understand why they see their problem the way they do and that I’m not saying, “You’re wrong,” but simply introducing the possibility that these psychophysiological processes might be playing a role, most people will be interested in learning more about it. That’s all you need to begin the conversation. People are only really convinced once they’ve been fully functional, not restricted at all by whatever the issue was for many months. It takes a while to gain confidence that, “Hey, I discovered what it is and I’m really all right.”
I mean, I’ve been at it for 30 years now and I’m pretty convinced that I’m fine. For 30 years I’ve been fine since understanding this is a psychophysiological disorder. It doesn’t mean I don’t ever have episodes of back pain. Occasionally I do, but I just don’t take them that seriously anymore because I understand these processes. Most people aren’t going to be there right away, but most people will be open to the idea that maybe this is playing a role, particularly if you try to understand how they came to see their problem as they do.
TS: You teach a technique in the series—the audio series with Sounds True: Healing Through Mindfulness called “Separating the Two Arrows.” Can you talk a little bit—what are the two arrows when we’re suffering from physical pain of some kind?
RS: Yes. Many of our listeners probably know that that while mindfulness practices have developed in diverse cultures throughout the world and throughout history, they’ve been very refined. We have a large record of varieties of mindfulness practices that come from Buddhist traditions. And one of the Buddha’s sermons on this topic was called “The Story of the Two Arrows,” in which he said, and I’m going to paraphrase, “When touched with the feeling of pain, the uninstructed run-of-the-mill person sorrows, grieves, and laments, beats his or her breast, becomes distraught.”
And then the person is suffering from two … They’re suffering the pain of two arrows as though they were shot with an arrow and immediately thereafter shot with another one. And the first arrow is the moment-to-moment physical sensations of discomfort that happen with pain, whether that’s GI distress, whether that’s a headache, whether that’s TMJ pain, whether that’s back or neck pain. It is the moment-to-moment sensations in the body that are uncomfortable.
The second arrow is the sorrowing, grieving, and lamenting. It’s basically our protest against that. It’s the thought, “I never should have shoveled the snow. I was such an idiot. I’m really screwed now. I’m never going to get better.” It’s the thought that, “Now I’m never going to be able to take care of my kid. What if I can’t work? What if this gets worse?” It’s all of the psychological factors that immediately kick in if we are so unfortunate as to live in a culture that’s got an epidemic of whatever the symptom is we’re distressed about.
One of the things that you learn how to do with mindfulness practice is to simply feel the unpleasant pain sensations, notice the impulse to react against them, and relax that impulse to react against them. So we actually simply feel moment-to-moment discomfort, but begin to relax both the tensing, guarding, and bracing that we do. That’s the tensing up against it when we hate it, as well as all of the negative thought patterns that are associated with it. And what most people find when they get skilled in mindfulness practice is that this goes a long way toward reducing their distress.
In fact, one of the classic studies that was done on this was done with experimentally induced pain, in which they had people sitting in a functional MRI scanner, which is basically an MRI machine that takes video film. The feet are sticking out, so they would apply a heat laser to the feet to create physical pain. They did this with people who were experienced with mindfulness practice and people who were novices, who were not experienced. And they looked at the brain regions that were lighting up in both groups.
The inexperienced people had a lot of activity in prefrontal cortical areas—basically the areas that are activated when we’re thinking, judging and reacting to experience—and not so much activity in an area called the insula, which is an area that is activated when we’re involved in interoception—in noticing and just being with sensations in the body. The experienced meditators, on the other hand, had much less activation in this prefrontal areas—these areas are associated with thinking, judging, and evaluating the experience—but much more activation in the insula, the interoception, as though the experienced meditators were actually feeling the pain more vividly, but were thinking about it and fighting it less.
Interestingly, when they asked both groups to evaluate the pain, “How bad was it?” The classic way to do this is on something called the Visual Analog Pain Scale, which is basically a 10-centimeter-long line, and you either put it at zero or at 10—”How bad was the pain?” The inexperienced people who had less activation of the insula, so they were feeling it less vividly, rated the pain as very bad, as maybe an eight on the scale, while the experienced meditators, who were feeling it more vividly but were judging it less, rated it as more like a two on the scale. It simply wasn’t so disturbing to them.
Separating the Two Arrows is really learning how to be with discomfort and disengaging from our reactivity against discomfort, because it turns out that gives us the capacity to be much freer in the presence of discomfort—even if somebody’s difficulty was entirely due to, say, structural findings. I mean, there are people with cancer pain where, look, there’s a tumor, it’s pressing on a nerve. That’s mostly what’s going on here. They can practice Separating the Two Arrows, because what happens is, if you don’t have the big overlay of psychological distress and resistance on top at the moment-to-moment pain sensations, the moment-to-moment pain sensations are actually more bearable. So that’s what that practice is about.
TS: So let’s say somebody has a lot of judgment. They’re like, “Look, I have a lot of judgment about my situation, about how I’m handling my situation. How will mindfulness help me?”
RS: Well, one thing we do in mindfulness practice, as most of our listeners probably know, is we choose a sensory object. It might be the breath, it might be sounds, it might be some other sensation, and we bring the attention to that object. And every time the mind wanders off into some kind of chain of narrative thought, we just gently and lovingly bring it back to the sensory object. And that very simple practice begins to help us to not identify so much with our thoughts, to see thoughts as contents that arise and pass in the mind, kind of like clouds that pass through the sky. They come, they go, they come, they go. And when we can begin to relate to thoughts in this way, they simply don’t grab us in this way.
So it’s not that if I’ve got chronic back pain, I won’t occasionally have the thought of, “Uh-oh, what if that gets worse?” I’ll just also have the awareness, “Oh, there’s one of those catastrophic thoughts coming again. Oh, there’s one of my judgment thoughts coming again.” We start to see thoughts as thoughts, and when we develop that metacognitive awareness, it’s a game-changer. The reason why cognitive behavioral therapy has had such an effect on the field of psychology is because it basically teaches people—modern CBT therapists use mindfulness practice as part of teaching people—this metacognitive awareness.
In the old days they used to just try to get people to notice thoughts and label them. But in any event, what you’re doing is you’re getting this kind of perspective on thought. This perspective on thought helps us not to be so swayed by our thoughts. And you could see how this would interrupt the chronic pain cycle. If I can notice my fright and thoughts about my back coming and going, well then I’m not going to have such a wave of fear each time. I’m not going to have such a wave of anxiety or frustration every time one of these thoughts arises. Rather, I’ll see them coming and going and then I can also tolerate the pain sensations coming and going and will find myself much freer.
TS: Ron, before we end our conversation I want to make sure I understand what’s underneath, if you will, the negative thought patterns that are fueling something like muscle tension that then leads to this terrible back pain. Is it fear and anxiety that’s underneath it? Can you say there’s a kind of “fuel source” underneath this looping pattern of thinking?
RS: That’s a great question. I think fear almost always plays a significant role in this. And one of the reasons is that we’re kind of hardwired as human primates to be frightened. If you think of our ancestors out there on the African savanna, they could have made one of two types of errors. We could think of them as Type I errors and Type II errors, roughly correlating to Type I and Type II errors in modern research.
A Type I error would be to look at a beige shape behind some bushes and think, “Oh my God, it’s a lion,” when it’s really just a beige rock. A Type II error would be to think, “Oh, I think it’s probably a beige rock,” when it’s really a lion. Now, our ancestors could have made countless Type I errors and still live to pass on their DNA. But one Type II error and that would be the end of their genetic line. So we actually inherited brains that have this strong proclivity toward these Type I errors.
My friend and colleague, Rick Hanson, likes to say, “Our brain evolved to be like Velcro for bad experiences and Teflon for good ones.” And this negativity bias in the brain, which makes perfect sense for the survival of our ancestors, wreaks a lot of havoc on us now. When we have bad experiences in life, we tend to react to them with the thought of, “Oh my gosh, it’s going to get worse. What if it does get worse?” And indeed, this has some protective value if you go through your life imagining yourself being like one of our ancestors. If you think of our ancestors as if they didn’t have the negativity bias, they’d be sitting around holding hands, singing kumbaya, discussing dynamite sexual encounters and luscious pieces of fruit, and they’d be perfectly happy.
But again, without the negativity bias, they would be more likely to make these Type II errors and have their DNA line ended. If they were our ancestors, who inherited this negativity bias, they’d be going through life thinking, “Oh my God, could be a lion. Could be a snake. Looks like a poisonous plant. Oh no, not another cliff.” And that’s the mind that we inherited from them. So it’s perfectly natural that when we have pain, we start having a lot of negative assumptions about what the cause of the pain is, what its prognosis is, and the like.
And as I mentioned, if we’ve had a trauma history, if we didn’t have a lot of good things happening to us during our upbringing, it’s going to be much more likely that when we’re in an ambiguous situation we’re going to think, “There’s something terrible to this.” And it is that propensity and that proclivity that absolutely is the engine behind this. And it’s why we think this is so epidemic. It’s because all of us inherited this kind of a brain.
TS: OK Ron, I think I have a pretty good overall understanding, big broad brush stroke understanding. When someone comes to you with back pain, how you would begin to work with them? What if somebody came to you and their complaint was, “I’m just totally in touch with my anxiety. I think I might have an anxiety disorder. The type of fear you’re describing, yes, I know it’s programmed into us, but in my case it’s extreme. How can you help me?”
RS: Well, I think anxiety disorders also follow the same pattern of needing to understand how they work first, in order to get out of them. Most people intuitively and automatically try to make anxiety go away when they feel it. And this makes perfect sense. Anxiety is uncomfortable, it’s painful. Again, if we go back to our ancestors—if our ancestors liked the feeling of anxiety, well then they would regularly walk up to lions’ dens, and that wouldn’t be very good for their survival prospects.
About the only organisms we know that do that kind of thing are adolescent boys, and they do endanger themselves quite a bit doing that. So it’s perfectly natural that when we feel anxious, we try to get out of the anxiety-provoking situation. The problem with this is anxiety disorders also can very easily fall into a vicious cycle. We’ll take the classic case of somebody who goes into the supermarket and has an experience in which, for whatever reason, they start to feel anxious. Now, maybe it’s coming at random. I usually think it has more to do with some association.
I was five years old and something happened involving Cocoa Puffs and my older brother. It was painful at the time. It’s been blocked out of awareness because it was painful. Here I am in the supermarket noticing the Cocoa Puffs in my peripheral vision and it starts to bring up the old memory and I feel a little anxious or something like that. In any event, if I start to respond to that anxiety with a sense of, “Uh-oh, maybe I’m having a cardiac event. Uh-oh, maybe I’m having a nervous breakdown. Uh-oh, what if I have a panic attack?” Then I’m going to try to escape the anxiety. Most people will do something like go out into the parking lot to so-called “get some air.”
There is enough oxygen in the supermarket; it’s not that. They’re looking for a change of venue because it makes us feel a little bit better to be in a new environment. Then the anxiety abates, we feel a little bit more relaxed. They call that negative reinforcement in learning theory. Basically it’s the reinforcement that comes from removing an uncomfortable or noxious stimulus. And I feel better. Now, what’s going to happen the next time I go into the supermarket, whether or not I go up the cereal aisle? I’m going to have the thought, “I hope it doesn’t happen again. I hope I don’t get anxious again. That was horrible. I don’t want to have to go through that again.” And that thought will be enough to bring up some anxiety and get the thing going again.
So we start to see that it is very easy—by trying to avoid the experience of anxiety—to get locked into a situation in which we’re actually going to feel more and more anxiety. In fact, things like panic attacks simply don’t occur unless we are afraid of having a panic attack. It’s feeling the psychophysiological arousal: the heart beating quicker, the racing thoughts, and thinking, “Oh no, what’s happening? I’ve got to get this to stop.” It’s the thought of “I’ve got to get this to stop” that actually amplifies the whole process and turns it into a full-blown panic attack.
So when we’re working with anxiety disorders, we need to shift from “How do I get rid of the anxiety?” to “How do I increase my capacity to accept and be with anxiety”—understand that anxiety comes and goes and allow it to arise and pass freely. And mindfulness practices can be very helpful here as well, because with mindfulness practices we actually, instead of being caught in the catastrophic thinking that goes along with a moment of high anxiety, we let the thoughts come and go and we simply feel the bodily arousal of anxiety and we feel it getting more intense or less intense.
In fact, there are exercises we can do where we actually—and they’re included in the program that I recorded with Sounds True—there are exercise we can do that actually practice increasing our capacity to simply feel the anxious sensations. The remarkable thing that happens is, much as with the chronic back pain when we no longer think of it as dangerous and we’re no longer trying to avoid it, we engage more in a normal life. It tends to diminish as a problem. When it comes to anxiety disorders, the more comfortable we get with being with moments of anxiety arising and passing, the less they take over our lives and the less we get trapped in problems of anxiety disorders.
TS: Ron, is there a simple technique you could offer people right now?
RS: Well, the simplest thing to explore . . . I’ll name two of them. One of them is to simply try turning the attention to the sensations of anxiety in the body as they’re occurring right now, and just allow yourself to breathe with the anxiety. Not trying to stop it, not trying to make it go away, but just trying to accept it as though it were really OK to feel anxious in the body. And you may even notice the sensations of anxiety in the body are actually quite similar to the sensations of excitement: the heart beating more quickly, respiration being a little quicker, maybe some body tension. And excitement’s OK, so maybe anxiety is OK too.
We can simply practice sitting and breathing and allowing anxiety to be there, rather than trying to get rid of it. And something else people can try at any time is to allow ourselves to notice what other emotions are closely connected to the anxiety. Of all the different things we fear as human beings, one that we fear the most is feelings, emotions. For one of us, we don’t want to feel sad. For another of us, we don’t want to feel angry. For someone else, they don’t want to feel lonely. We all have our different . . . Somebody else doesn’t want to feel like a failure. We all have different emotions that we tend not to want to feel.
A lot of our anxiety has to do with the fear that we’re going to feel some emotion that’s going to be unpleasant. So along with simply noticing the sensations of anxiety, another technique we can do is to just sort of ask ourselves, “Is there some other feeling that I’m afraid of here? Is there some sadness lurking? Is there some anger lurking? Is there some sexual feeling lurking? Is there something else happening here?” And sometimes just a little introspection will help us open up into whatever that other feeling is.
And that too tends to transform the experience because basically if we’re . . . The stress physiologists say we’re responding to the tigers within—basically emotions that we’ve pushed out of awareness—with this system that was designed to deal with tigers out there: this fight, freeze, flight response system. And if, instead of fighting the emotions within, we can turn our attention to the emotions within, then oftentimes we find that it transforms the experience of anxiety. But it’s tricky because you have to go in with the attitude of, “I’m not trying to get rid of my anxiety. I’m trying to make friends with it and I’m trying to understand it better” rather than, “How do I make it go away?” When we go down the pathway of “How do we make it go away?” we almost always just amplify the problem. The same way when we go down the path where we’re trying to make our back pain go away by restricting our activities and the like, we make that worse as well.
TS: OK. Just one final question for you, Ron. Here, you teach at Harvard Medical School. How does the medical profession need to transform such that some of the ideas and approaches that you’re talking about here become more widely accepted? You’ve offered so much evidence and grounded support for taking the approach that you’re proposing in this series, that there are effective practices we can do working with mindfulness and other ways of having this metacognitive awareness about what’s happening. How does this become more part of the medical profession?
RS: I’d like to say that the truth is it is becoming more part of the medical profession. That’s the good news. I’m at the Harvard teaching hospital, called the Cambridge Health Alliance, and we have a Center for Mindfulness and Compassion, which is a thriving enterprise there. Just across the river at Brigham and Women’s Hospital, another one the Harvard teaching hospitals, there’s the Center for Placebo Studies, which is just interested in another aspect of mind-body interactions, which is how beliefs affect all of these different disorders, which is really a component in this way out.
Things have changed. They’re no longer sending people to bed. If you see a physician who is up on current research and you show up with chronic back pain, they’re going to tell you, “Well, stay active. That’s the one thing we know, stay active.” They want to keep you from falling into the loop. So I want to say first of all, they are changing. The ideas I’m putting here were once fringe, but they’re now much, much, much closer to mainstream. We’ve seen many, many mindfulness programs at major teaching hospitals throughout the country.
But the other factors that I think are needed are some of them—this is just my point of view and I know well-meaning people disagree about economics and politics—but we need to continue the movement away from paying medical providers to do interventions, to do procedures toward paying medical providers to help keep their patients healthy. Because there’s very little money to be made if you’re teaching people mindfulness practice or spending the time it takes to help them reconsider their circumstance and understand their problem differently.
If you think of what a physician is paid to do—an injection or a surgical procedure—it’s hundreds of times what people are paid to do the kind of work that I’m describing here. So the incentive or the incentivization of the system isn’t great. Even if I’m a very well-meaning doctor and I’m paid a tremendous amount of money to do a certain intervention and I’m hardly paid anything to sit and talk at length with my patient, it’s going to be hard to spend most of my career sitting and talking with patients and not doing the intervention.
So I do think we have to shift the overall incentive system this way so that people can do more of what the research suggests we should be doing. I’d really like to emphasize that the topics we’re discussing and the approaches that are outlined in the course are no longer fringe; they are no longer outliers. They are so supported by research that, especially if you go to major teaching centers where people are doing practice based on research finding, you find many, many more approaches that are in line with this.
TS: I’ve been speaking with Dr. Ron Siegel. He’s created with Sounds True a new audio series called Healing Through Mindfulness: Effective Practices for Chronic Health Conditions. He’s also the co-author of the book Back Sense: A Revolutionary Approach to Healing the Cycle of Chronic Back Pain, and also a co-author of the book Sitting Together: Essential Skills for Mindfulness-based Psychotherapy. Ron, thank you so much for this conversation and all your good work. I learned a lot. Thank you.
RS: Thank you so much for having me.
TS: SoundsTrue.com: waking up the world.
