From Dr. Anderson:

Bronwyn,

First, I want to clarify: I have the keenest respect for RCTs. I was trained as a rigorous experimental psychologist before I switched to clinical psychology and psychoanalysis. I advocate research on the clinical reports made by medical, mental health, allied health care professional professionals, and people who have found relief from “TMS” pain. That research has already begun, in a study of fibromyalgia using RCTs (Howard Schubiner, personal communication February 2010) submitted for publication in a peer-reviewed medical journal. An application for research support from NIH has been submitted to expand this research.

I hope that the current and succeeding generations of pain professionals and concerned lay people will promote RCTs to evaluate the methods we have found to be effective, case by case, in our clinical practices for 40 years. We all recognize that in order for TMS to be included in the DSM, there will need to be substantive documentation that it is a “syndrome.” Pushing toward that goal, along with the aim of educating the public about TMS, the TMS EDUCATIONAL WORKING GROUP, a non-profit corporation, has just been formed by a coalition of people who have been successfully treated for TMS and health care professionals experienced in treating TMS, many of whom will be contributing to LA Mindbody Conference in March 27-28, 2010.

I would now like to invite you, Bronwyn, to comment on a section of my original response to your response: I recommend reading about the theoretical and empirical foundation for my treatment technique in my chapter in Relational Perspectives on the Body (www.francessommeranderson.com). I provide a detailed case presentation of my treatment of a patient with TMS pain, illustrating how overwhelming emotions were related to her long history of back pain and how she was relieved of this pain as she worked with disavowed affects. I ground my “technique” in the publications of psychoanalyst researchers such as Henry Krystal (Michigan State University), his son John Krystal (Yale University), and Graeme Taylor (University of Toronto) and his colleagues in Canada. These clinician-researchers have focused on the role of emotions/affects in health and illness. In particular, their findings document the value of recognizing what we’re feeling, and developing the capacity to tolerate and regulate both positive and negative emotions.

Feelings/emotions/affects become problematic when we need to avoid experiencing them because they may be overwhelming. Intolerance and avoidance of emotions can be associated with physical as well as psychological illness, as documented by these and other researchers. Researchers are increasingly focusing on the significant role of emotions, e.g., in the neurobiology of fear (Joseph LeDoux) and the neurobiology of trauma, e.g., Bessel van der Kolk and his colleagues. How these dysregulated emotions are related to health and illness should concern all practitioners.

My treatment approach is also influenced by the field of contemporary neuroscience, which the author values as a model in explaining chronic pain syndromes. I want to emphasize that I am not at odds with the identification of a neurobiological substrate for pain and other disorders. I am in favor, however, of an integrative approach rather than one that values biology or psychology over the other: Unfortunately, valuing neurobiology over psychology is once again a manifestation of the dichotomous mind vs. body philosophy that still informs much of Western medicine. My point is made most convincingly by a number of current clinicians and researchers. Allan Schore’s (http://www.allanschore.com/) integration of data from the psychoanalytic theory of development, neurobiology of attachment, and the neuroscience of emotional regulation demonstrates the value of an integrative synthesis of knowledge from the domains of psychoanalysis, psychology, and neurobiology. Daniel J. Siegel (http://drdansiegel.com), a psychiatrist who has studied mindfulness meditation and neuroscience, uses the term “interpersonal neurobiology” to capture the complexity of the interpenetration of the psychological and the neurobiological realms of theorizing (The Mindful Brain). A psychologist, Wilma Bucci (http://www.referentialprocess.org/), is a cognitive science researcher (Chapter in Bodies in Treatment, FSA Editor; www.referentialprocess.org) who has developed a “multiple code theory,” arguing for a “congruence” between psychological and neurobiological models of emotional and cognitive processing. Candace Pert’s substantive research (http://www.candacepert.com/), offered for a general audience in Molecules of Emotion, demonstrates how “emotions” are stored in every area of the body, including in the molecules.

The Where the Client Is interview with Dr. Anderson that got things rolling:

As a psychologist, I am not qualified to make a medical diagnosis, even a psychosomatic diagnosis such as TMS. A physician distinguishes the TMS pain through an interview and examination initially, thereby linking mind and body with a diagnosis of TMS. Teamwork with that physician is a requisite. Let me elaborate by illustrating why the teamwork is necessary. When I’m treating a patient who has been given a TMS pain diagnosis by a physician, I obtain written consent to collaborate with the physician, explaining the “rehabilitation team” approach, learned at Rusk Institute, which I have used effectively with Dr. John E. Sarno for more than 30 years…[continued]

Thompson’s response to the interview is here.

[U]nfortunately there is not a lot of good evidence for Dr Sarno’s hypothesis, particularly the second part (that people need to ‘heal’ their repressed emotions).  Having said that, some of the mindfulness and acceptance material I’ve been reading suggests that, instead of repressing, controlling or focusing on negative emotions, we may find it more helpful and less distressing to experience these ‘lightly’ or nonjudgementally, and in doing so, release ourselves from their influence and choose to act according to our values…[continued]

Dr. Anderson’s response to Thompson (here in full; posted as a Word document on HealthSkills):

Thank you for your careful reading of my interview and for posting your commentary.  I respond in the spirit of dialogue that opens up the very important topic of integrating domains of knowledge about mental, emotional, and neurobiological processing.

First, I want to clarify that Dr. Sarno and the clinicans who work with him do not do “chronic pain management.” We aim for pain relief in treating a mindbody pain condition that Dr. Sarno has delineated in his peer-reviewed publications and in his books directed at a broader audience.  Dr. Sarno initiated his treatment approach 40 years ago, when he was trying to treat people for whom ALL approaches to pain relief and management had failed, e.g., surgery, hypnosis, CBT.  I was fortunate to join his pain service 30 years ago, while it was still in the pioneering phase.  Dr. Sarno discovered, in collaboration with the psychotherapists who were on his rehabilitation team, that his patients had difficulty acknowledging their emotions, or affects–I will use this term interchangeably with emotions going forward.  It was common that these people could not feel positive or negative emotions.

While Dr. Sarno did not collect data via randomized clinical trials to document that his approach to pain relief works, his clinical success can be indirectly assessed by noting the volume of sales of his books and the vast number of testimonials on the internet attesting to complete recovery from pain, such as http://www.tmswiki.wetpaint.com. In addition, physicians from around the country, indeed from around the world, have been inspired by Sarno’s theory and treatment approach and have begun offering their own elaborations of it, e.g, David D. Clarke (www.stressillness.com), David Schechter  (www.schechtermd.com), and Howard Schubiner (www.unlearnyourpain.com).  The impetus for the upcoming Los Angeles Mindbody Conference on stress-related pain (www.lamindbodyconference.org) has come from patients who have been successfully treated by this approach, as well as from physicians and mental health clinicians who have worked with Sarno.  My colleague, Eric Sherman, PsyD, and I have been inspired to publish a book of cases studies in 2010, Pathways to Pain Relief (www.pathwaystopainrelief.com), to illustrate how we treat people who have been diagnosed by Dr. Sarno with Tension Myoneural Syndrome (TMS).

Like the author of this post, all of us who have been influenced by Dr. Sarno’s theory and treatment have an interest in “emotional regulation and self regulatory systems,” although we may be using different terminology.  I recommend reading about the theoretical and empirical foundation for my treatment technique in my chapter in Relational Perspectives on the Body (www.francessommeranderson.com).  I provide a detailed case presentation of my treatment of a patient with TMS pain, illustrating how overwhelming emotions were related to her long history of back pain and how she was relieved of this pain as she worked with disavowed affects.  I ground my “technique” in the publications of psychoanalyst researchers such as Henry Krystal (Michigan State University), his son John Krystal (Yale University), and Graeme Taylor (University of Toronto) and his colleagues in Canada.  These clinician-researchers have focused on the role of emotions/affects in health and illness.  In particular, their findings document the value of recognizing what we’re feeling, and developing the capacity to tolerate and regulate both positive and negative emotions.  Feelings/emotions/affects become problematic when we need to avoid experiencing them because they may be overwhelming.  Intolerance and avoidance of emotions can be associated with physical as well as psychological illness, as documented by these and other researchers.  Researchers are increasingly focusing on the significant role of emotions, e.g., in the neurobiology of fear (Joseph LeDoux) and the neurobiology of trauma, e.g., Bessel van der Kolk and his colleagues.  How these dysregulated emotions are related to health and illness should concern all practitioners.

My treatment approach is also influenced by the field of contemporary neuroscience, which the author values as a model in explaining chronic pain syndromes.  I want to emphasize that I am not at odds with the identification of a neurobiological substrate for pain and other disorders. I am in favor, however, of an integrative approach rather than one that values biology or psychology over the other:  Unfortunately, valuing neurobiology over psychology is once again a manifestation of the dichotomous mind vs. body philosophy that still informs much of Western medicine.  My point is made most convincingly by a number of current clinicians and researchers.  Allan Schore’s (http://www.allanschore.com/) integration of data from the psychoanalytic theory of development, neurobiology of attachment, and the neuroscience of emotional regulation demonstrates the value of an integrative synthesis of knowledge from the domains of psychoanalysis, psychology, and neurobiology.  Daniel J. Siegel (http://drdansiegel.com), a psychiatrist who has studied mindfulness meditation and neuroscience, uses the term “interpersonal neurobiology” to capture the complexity of the interpenetration of the psychological and the neurobiological realms of theorizing (The Mindful Brain).  A psychologist, Wilma Bucci (http://www.referentialprocess.org/), is a cognitive science researcher (Chapter in Bodies in Treatment, FSA Editor; www.referentialprocess.org) who has developed a “multiple code theory,” arguing for a “congruence” between psychological and neurobiological models of emotional and cognitive processing.  Candace Pert’s substantive research (http://www.candacepert.com/), offered for a general audience in Molecules of Emotion, demonstrates how “emotions” are stored in every area of the body, including in the molecules.

Thompson responds with How to Judge a Treatment:

Pain, like many other conditions, is complicated by the fact that it’s invisible – we don’t have any objective measures of pain itself, and we have to rely on behaviours (including verbal self report and movements) to determine whether treatment has done any good.  Behaviours are strongly influenced by external factors such as other people’s responses, along with internal factors such as beliefs and expectations…[continued]

Thompson’s response to this post:

Thanks for posting this discussion in full. I’d like to just correct a couple of points – ‘tension myoneural syndrome’ is not a term used commonly in New Zealand (and it also doesn’t appear in the International Association for the Study of Pain Taxonomy and Classification of Chronic Pain). I also note that it’s not a term used in DSM iv, nor indeed in any of the formal classification systems used in health care.
Now I’m not saying having pain that is associated with increased anxiety/stress or low mood (or even ‘trauma’ associated with a diagnosis of something like PTSD) do not exist. That’s silly because they do. What is arguable is their aetiology, and their ongoing management.

The terms more commonly used to describe widespread body pain (or regional pains) is central sensitisation conditions, and can include such things as fibromyalgia and regional pain syndromes. These are recognised as influencing the sensitivity of the nervous system and increase the sympathetic nervous system responses to change.

I did laugh a bit at the suggestion that what I’m saying returns to the great ‘mind and body’ divide – because that’s usually what I’m accusing the medical professionals I sometimes work with of doing! In fact it’s very clear that the whole experience of having pain is a psychological one with underlying neurobiological systems underpinning it.

I don’t see this as mutually exclusive, simply that we have much to learn about the ways the psychological and social processes work. It certainly doesn’t take away from the influence of attitudes, beliefs, biases and learning – but it does mean that we may not be in the best place to describe how they influence us. I’m really excited about neurobiological processes, because they do start to give us some idea of how our fabulous brains (and nervous systems) go about influencing things that have until now been a mystery.

I am personally not comfortable with using approaches that need special assumptions, and that can’t be tested. That’s why my response was around the need to use an evidence base in the peer reviewed literature. And I can’t find outcome studies of Dr Sarno’s approach – which is, in the end, the best way to determine what works and what doesn’t, irrespective of the mechanisms involved.

regards
Bronnie

The conversation continues here.

Frances Sommer Anderson, PhD is a New York-based psychoanalyst and expert on treating chronic pain.  She talked to WTCI via email about what she does and how she does it.  Hear Dr. Anderson speak and learn more about treating chronic pain at the

What’s your background? What do you do now?

The body–disabled, disfigured, and in pain–has been the focus of my work as a clinical psychologist and psychoanalyst, beginning in 1974 with my clinical psychology internship at Rusk Institute-New York University Langone Medical Center. Learning to help children and adults cope with and surmount congenital, traumatic, and progressive loss of bodily functioning was a daunting challenge in the beginning: I had to confront my own vulnerability to the vicissitudes of life and the fear that we all have when we experience a loss of the capacity to function physically. I soon found this work compelling and was fortunate to become a member of the psychology staff for 12 more years.

In 1979, while still at Rusk Institute, I began working in John E. Sarno, MD’s pain program, under the supervision of Arlene Feinblatt, PhD, the psychologist who collaborated with him in developing treatment of the pain syndrome initially termed, “Tension Myositis Syndrome, (TMS)” which he now refers to as “Tension Myoneural Syndrome.” Treating people in chronic, severely debilitating pain, as a psychosomatic manifestation according to Dr. Sarno, was an exciting opportunity to learn about the mindbody connection, which had fascinated me since my first undergraduate psychology course. After I left Rusk Institute in 1987 for full-time private practice and psychoanalytic training, I continued to collaborate with Dr. Sarno in treating TMS. In 1998, I published “Psychic Elaboration of Musculoskeletal Pain: Ellen’s Story,” a detailed presentation about my work with one of his patients (Relational Perspectives on the Body, The Analytic Press, Lewis Aron & Frances Sommer Anderson, Editors). In this chapter, I illustrated how overwhelming emotions were related to the development of Ellen’s TMS pain and discussed how we worked with these emotions in the psychotherapy process, thereby relieving her pain.

While treating Dr. Sarno’s patients, I developed a TMS symptom-tension headaches. As I delved into the early childhood origins of my own TMS, I refined my skills at identifying sources of TMS and its equivalents. I wrote about my personal journey, “At a Loss for Words and Feelings,” in my edited book, Bodies in Treatment: The Unspoken Dimension (The Analytic Press/Taylor & Francis Group, 2007). I have learned that accessing and experiencing “hidden,” “forbidden,” “repressed/dissociated” emotions is the crucial entry point in recovering from TMS. My colleague, Eric Sherman, PsyD, and I are publishing a book of case studies (late 2010), Pathways to Pain Relief, in which we illustrate how we treat people diagnosed with TMS by Dr. Sarno.

How do you distinguish TMS pain from other pain?

As a psychologist, I am not qualified to make a medical diagnosis, even a psychosomatic diagnosis such as TMS. A physician distinguishes the TMS pain through an interview and examination initially, thereby linking mind and body with a diagnosis of TMS. Teamwork with that physician is a requisite. Let me elaborate by illustrating why the teamwork is necessary. When I’m treating a patient who has been given a TMS pain diagnosis by a physician, I obtain written consent to collaborate with the physician, explaining the “rehabilitation team” approach, learned at Rusk Institute, which I have used effectively with Dr. John E. Sarno for more than 30 years.

As the treatment evolves, I learn about the person’s pain pattern. If the pattern changes for the worse, e.g., the pain intensifies and/or moves to a different location, I refer them to the physician to report these changes. While I may surmise that the intensification and/or change in location are related to emotions that are being evoked and/or warded off as a result of the therapy process, the physician needs to make an assessment before we explore the hypothesized emotional “triggers” further.

When I am working with a patient who was not referred for TMS treatment, I am, nevertheless, attuned to the mindbody connection and alert to “signals” of discord that may come in the form of unpleasant/painful sensations or other medical conditions. I first recommend that the patient consult with their established physician for an evaluation. If there are “no significant findings” or the results sound ambiguous, I raise the possibility of TMS by discussing the mindbody connection and suggesting that they read material about TMS written by physicians [see Recommended Reading, below]. If they “recognize” themselves in what they read, I refer them to a physician qualified to make a TMS diagnosis.

How do you go about treating someone with TMS?

First, I will oversimplify by saying that the treatment is implied in the diagnosis: If hidden/repressed emotions create somatic pain as a distraction or avoidance mechanism to protect the psychological self from intolerable emotional pain, then treatment must aim to identify and help the patient experience and explore those emotions. Now this appears to be very easy for many people–the ones who become pain free after reading a book on TMS. I hear stories about these people from patients and have witnessed this kind of cure among friends and family members. These people didn’t need my help! How they are cured so quickly is a very interesting and important matter that I can’t address further here except to say that I’ve learned a good deal from treating a few of these people over the years after they’ve experienced a recurrence of pain that won’t go away.

The people I treat have usually tried very hard to eliminate the pain and are quite discouraged and critical of themselves because they haven’t been “successful” on their own. They often feel that they’ve “failed” the program, citing statistics in Dr. Sarno’s books about how few people need psychotherapy. As he has described, often TMS sufferers have internalized the value “Americans” place on being independent, self-sufficient, and invulnerable and have been rewarded professionally and financially for these traits. Many of the founders of our country were people in desperate straits who had to work hard to survive. Acknowledging vulnerability and fear could have been more perilous than toughing it out. Thus, it seems to be a part of our national “character.” Another large group of people with TMS have been rewarded for being nice, considerate, peace-makers, for pouring oil on troubled waters, indeed for making sure that there are no troubled waters.

These admirable qualities contribute to building a robust economy and to the smooth working of our social structure. When relied on at the expense of acknowledging one’s own feelings and needs, however, a consequence may be emotional and/or mindbody disorders such as TMS and its equivalents. The disavowal of dependency, vulnerability, and anger/rage contributes to overflowing emotional reservoirs of shame, fear, grief, longing, rage, and even love. The reservoir of rage that Dr. Sarno has brought to our attention, is problematic for many of us in our civilized western culture. Within the last few years, he has increased our awareness of the young child within who needed, and stills needs, unconditional love and acceptance. He has encouraged his patients to get to know that child through journaling and in therapy. In addition, quite a few of my patients have discovered the frustrated, insecure, adolescent who has also been unconsciously disavowed.

So, the treatment begins by exploring the context in which the symptom developed. Often, people do not have an awareness of the emotional impact of the physical/work/family/relationship environment in which they live because they have learned to survive and thrive by disavowing the emotions I described above. I ask for minute details, like a journalist, sometimes annoying with my “picky” questions about “who, what, when, where, and why.” We learn a lot from what they can and cannot answer. My aim is to help them identify “stressors” that can lead to the overflow of an emotional reservoir into a pain symptom. For example, a 36 year-old patient recently told me that, within the past year, his father had died suddenly, he had lost his job, and separated from his life partner. While these life events would cause many of us to have overwhelming feelings, he had scant appreciation of just how stressful these events had been. Thus his therapy began.

While identifying the life events preceding the onset of the pain, I am listening intently to how the person is speaking about the event. How is my patient reacting emotionally to what they are telling me. For example, are they laughing when telling me about what sounds like an enraging/embarrassing/shaming/humiliating situation? Do they seem sad when speaking about sad matters? Can I detect any emotion at all as they speak about a highly volatile interaction or a devastating loss? I often refer to this function of the therapist as the “emotion detector.” In the initial consultation I begin to bring the patient’s attention to this dimension of their participation, carefully probing to assess the extent of their awareness and how they react to my inquiring. We often identify this as an area where they will need to do work both inside and outside of the session.

For people who have great difficulty being aware of what they are feeling about what they are saying, I work intensively on this in each session. I recommend that they take a “feeling inventory” several times during the day and evening: Ask yourself, “What am I feeling about the events that happened during the past hour? How did I feel when my supervisee didn’t meet the deadline and casually brought the work into my office without acknowledging that it was late? How did I feel when our nanny called to say that she had an emergency and had to leave immediately, possibly indefinitely? How did I feel when our 16 year-old son showed up two hours past his curfew, undeniably drunk?” At the beginning of therapy, some people need to take this inventory once every hour.

As we are doing this “emotion detection” work inside and outside the sessions, we are also tracking pain levels as well as presence and absence of pain. This strategy is aimed at making links between emotions and pain symptoms. I offer a few examples to illustrate:

1) A patient had been pain-free all day but noticed that his pain started on the way to the session.  I asked what he was thinking and feeling along the way.  He realized that he had mixed feelings about being in the session.  As we examine these feelings, his pain lessens but is not completely alleviated.

2) A patient is pain-free in the session until she starts to describe an interaction with her husband the previous night.  In our discussion, we discover that she was furious with him and afraid of feeling her anger.  We spend some time helping her tolerate that feeling right there in the session.  As she becomes more comfortable with feeling angry, we talk about some constructive ways to express it to him.  Her pain gradually subsides.

3) A patient is in excruciating pain as he enters the session and has no idea what brought on the pain the day before. We begin our search for the emotional triggers and discover that he had been dreading an upcoming phone call to his mother in which he planned to confront her in a way he had never done.  As we discussed his strategy and what he was afraid would happen, his pain started to subside.

Recommended Reading

For patients and therapists:

John E. Sarno, MD

Healing Back Pain: The Mind-Body Connection

The Mindbody Prescription

The Divided Mind

Howard Schubiner, MD

Unlearn Your Pain

David Clark, MD

They Can’t Find Anything Wrong

David Schechter, MD

The Mindbody Workbook

For therapists:

Lewis Aron and Frances Sommer Anderson (Editors)

Relational Perspectives on the Body

Frances Sommer Anderson (Editor)

Bodies in Treatment:  The Unspoken Dimension

All titles are available at the WTCI-Amazon Bookstore.

For more about Frances Sommer Anderson and TMS, try FrancesSommerAnderson.com and the TMS Wiki.