[MUSIC PLAYING]
SPEAKER: We are very pleased
to welcome Howard Schubiner
at our talks at Google Seattle.
Howard is a doctor.
He's an internist at
Providence Hospital in Michigan
and also a professor at
Wayne State University
College of Medicine--
HOWARD SCHUBINER:
Michigan State.
SPEAKER: Michigan
State, oh, yeah.
HOWARD SCHUBINER: We switched.
SPEAKER: Oh, OK--
Michigan State University.
He has published two books
now, "Unlearn Your Pain"
and "Unlearn Your
Anxiety and Depression."
And he's coming out
with a third book soon.
And Yeah, please welcome
Howard Schubiner.
HOWARD SCHUBINER: Thank you.
Thank you.
That's kind.
Thank you.
I'm going to tell you a story.
It's a uniquely American story.
And to borrow a
phrase from a TV show
that I've never
seen but heard of,
it's an American horror story.
This is a guy, 41
years old, who I saw
for low back pain, seven years.
It started-- he was 34.
So he was running.
He had no injury.
But he started having
pain in his back
while he was running one day.
It was kind of a dull ache.
It kind of came and
went, not a big deal.
But it just gradually
got worse over time.
Eventually, it became constant,
mainly on the lower-left side
of his spine in the lumber area.
But sometimes it would be kind
of more on the right side.
Sometimes it would
shoot down to his butt.
He started having
trouble sleeping,
because he was in pain.
There was no
neurological impairment,
meaning reflexes are normal.
Strength is normal in his legs.
Sensation is normal.
No evidence of any nerve damage.
That was good.
EMG is a test to test
for nerve damage.
That was normal.
So he had an MRI.
That's going to tell us
what's wrong with him, right?
Maybe.
He had degenerative
disk disease.
And he had a moderate
disk bulge at L4-5.
So he started to get
treatment, physical therapy,
another course of
physical therapy--
not helping-- pain
management specialist,
injections in the spine--
not helping-- Botox injections,
piriformis injections--
is in the butt--
more injections, a TENS unit.
Let's try to distract your
brain from pain by giving you
this electrical stimulation.
He got Duloxetine.
That's an anti-depressant.
He got gabapentin.
That's a nerve pill,
kind of like Lyrica.
Someone gave him opiates.
Is that a good idea?
Well, but he wasn't
getting better.
So he said, well,
I'll go another route.
Let's try acupuncture.
I'll take yoga.
Two years later,
nothing's working.
So he goes to the surgeon.
The Surgeon says, oh, we can fix
that disk, L4-5 bulging disk,
no problem.
He gets a fusion
L4-5, doesn't help.
Years go by.
Another year after
that, another doctor
says, well, your
SI joint, the joint
that's connecting the
sacrum and the pelvis--
SI joint is kind of like a
joint connecting your ribs
to your sternum.
It's not much of a joint.
But there's some
arthritis there.
We can fuse that.
He had that surgery--
not better.
When he was 42, he
started having neck pain.
Now we got a whole other
thing to worry about.
The MRI of his neck, facet
degeneration, disc space
narrowing, a small disk bulge.
That doesn't sound good.
He goes to see the neurosurgeon.
He says, well, you're
not a candidate
for surgery in your neck,
but epidural injections.
He decided he already tried
that in his lower back.
He didn't want to do that.
And his pain just continued.
So he has lower back pain.
He's got neck pain.
And then within
the last year, he
started having some stomach
sensations, this fluttering
sensation in his stomach.
So now he goes to a
pain psychologist.
And they give him
relaxation exercises.
He basically doesn't have a
lot of hope of getting better
at this point.
That's the horror
part of the story.
So we have a problem
in this country.
More people are
affected by chronic pain
now than the combined
total of diabetes,
heart disease, and cancer.
Millions of people are suffering
a lot of back pain, headache
pain, stomach pain, pelvic
pain, widespread pain
that we call fibromyalgia.
Certain professions get
repetitive strain injury.
They get neck strain.
They may have trouble
with squinting,
because they're looking
at screens all the time.
Does that sound familiar?
And we're going to
talk a little bit more
about that in a minute.
And the treatment is often
completely ineffective.
Pain management seems
like a good idea.
But do you want
to really manage?
Do we want to manage our pain?
That's not what
most people want.
How many randomized
control trials show
that back surgery is
better than either exercise
or conservative therapy?
How many studies have
shown that surgery
is better than any
non-surgical intervention?
Zero, not a single
study to show that.
How about back injections?
A large number of studies, meta
analysis of these studies--
and when you compare
back injections
versus placebo injections, the
result, not much difference.
How about opiates for pain?
It's a national disaster.
So let's work on the brain,
psychological therapies
for pain.
The main psychological
therapies for pain,
cognitive behavioral therapy,
mindfulness therapy, acceptance
and commitment therapy.
None have been shown to be
any better than the other.
And none have been shown to
be better than relaxation
therapy, which is what he got.
The effects are small, and
people continue to suffer.
So what are the things
that weren't taught
in medical school, and
are still not being
taught in medical school?
I'm working with
three medical schools
trying to get more of
this into the curriculum.
Well, the power of the mind
and the control that our brain
actually has over
our experiences.
A conversion disorder
is when someone
has a sudden onset
of inability to speak
or paralysis of the arm or leg.
And what happens is is
that the arm is paralyzed,
and that you say,
well, try to move it.
And they can't.
It's completely paralyzed.
But in a conversion
disorder, there's
no medical cause
for this problem.
It's psychologically-induced
paralysis.
I saw a teenager one time
who had a lot of problems
leading up to this.
And at one point, his
arm just became dead.
He had a huge medical work-up.
And he started getting better.
But he would wake
up in the morning,
his arm would be fine, eating
breakfast, drive to school.
Gets in the parking lot of
his high school, arm dead.
3:30 in the afternoon,
the bell rings,
gets out of school,
arm fine again.
Unbelievable, the power of
the brain to induce that.
Can symptoms be contagious?
Can you catch
something from somebody
called social contagion?
One of the main
symptoms that's been
found have social contagion
is repetitive strain injury.
In the 1980s in Australia,
there was an epidemic of RSI.
People were typing, and
it got worse and worse.
And more and more people got it.
And at one point, the government
had to step in and say,
no more disability for RSI.
And it started going down.
How much is typing?
We had RSI since computers.
So we're typing.
We're going like this.
Have you ever typed on
a manual typewriter?
You know what that's like?
Crunch.
That's a lot more strenuous.
And we didn't have RSI when
people were doing that.
I know a guy who
went to grad school.
And as he was going
to grad school,
he was kind of tense, a
lot of things going on.
And he had this thought.
I hope I don't get RSI.
I hope I don't get RSI.
I hope I don't get RSI.
Guess what happened?
He got RSI.
And then his hand's hurting.
And his wrists are hurting.
And it goes from one arm,
goes to the other arm.
And he becomes kind
of incapacitated.
And he eventually found the
work that I'm telling you about.
He's fine now.
But for example, I
had a woman who had--
and you'd think
it was structural.
Everyone thinks that
all pain is structural.
And I had this woman who
had pain with typing.
Monday, Tuesday, it got
worse as her week went on.
By Friday, it was excruciating.
So that sounds
pretty structural.
Because the more she's
typing, the more it hurts.
And I asked her, does
it hurt any other time?
And she said, yeah,
Sunday evening.
Are you typing on Sunday?
No.
What's going on?
Her brain is anticipating it.
And that was the moment.
That's the "House" moment.
I go back to the '70s-- the
"Colombo" moment, the "Sherlock
Holmes" moment, where you go,
OK, now we know what this is.
And she's fine now.
How many of you have
regular hallucinations?
Is that common?
Not really.
Yeah, join the group.
We think of hallucinations
as being crazy.
But how many of you have
had the experience where
you felt the vibration of
your cell phone in your pocket
when it wasn't vibrating?
There we go.
That's a hallucination.
One study showed 90%
of college students
had that hallucination.
The brain commonly creates
a whole range of experiences
that I'm going to
talk to you about.
And do you know where you
hold stress in your body?
Do you know, when
you're stressed,
where you feel it in your body?
Do you have any sense of that?
Most people do.
But we think of that as a
different category than what
this guy I was
telling you about has,
because his problem is severe.
So our brains construct
our experience.
Vision is constructed.
Have you ever tried to find
an icon on your cell phone
when it was in a
slightly different place,
or when you're not expecting
the color, or whatever it is?
You don't know
exactly where it is.
And you're looking at
it, but you can't see it.
We see with our visual cortex.
And about 10% of the fibers
that go to our visual cortex
come from our eyes,
from the retina.
90% come from within our brain.
I'm sure you've seen
this picture before.
What do you see?
It's interesting how what we see
is actually a neural pathway,
kind of what we expect to see.
Can you switch it?
Do you know what I'm
talk-- does everyone see?
There's a younger
woman, an older woman.
And can you switch it?
Can you just try to look at one?
Or sometimes you get
stuck in one mode.
Oftentimes, we get
stuck in one mode.
And we have to say, what
mode are you stuck in?
If you're stuck, which
one, the older or younger?
See, the chin of the
older woman is down here.
And the nose of the
younger woman is up here.
And her ear is there.
And so, as soon as you see
it, then your brain can shift.
When people are an
eyewitness to a crime,
who do they pick
out of the lineup?
They pick out the
person that their brain
tells them is most likely to
have committed the crime based
on their understanding
of crime and criminals.
And that's been shown.
So now we talk about pain.
This looks painful.
A friend of mine inadvertently
shot a nail in his hand.
He had zero pain.
Pain only occurs if the brain
activates a danger alarm
mechanism--
no danger alarm
mechanism, no pain.
Kids skin their knee and cry.
Other times, they skin
their knee and don't cry.
Or they cry when they see
a concerned parent running.
Our brain has to activate pain
in order to experience pain.
The body doesn't send
pain signals to the brain.
It sends signals.
And our brain has to interpret
if that signal is actually
a danger or not.
Our brain controls pain.
All pain is in the brain.
This guy was written up in
"The British Medical Journal,"
jumped off a
scaffolding onto a nail.
Nail impaled itself
through his boot.
Rushed him to the
hospital, a lot of pain.
They hurriedly
took his boot off.
What did they find?
The nail was
positioned precisely
between his toes,
no injury at all.
His brain had activated
pain as a warning mechanism.
But it was completely
mistaken about the risk.
I met a doctor a few years
ago who told me this story.
He was in the Vietnam
War as a young man.
His company got
ambushed one day.
He took shrapnel
wound to his leg.
He had a lot of pain,
got medevaced out.
Comes home stateside,
his injuries heal.
What happens to injuries?
All injuries heal.
His brain turned off the
danger alarm mechanism.
And now he's fine.
20 years later roughly, he's
walking down the street.
He gets startled by the sound
of a helicopter coming up
from behind.
And he gets the same pain in
his leg after all those years.
How do we snap our fingers?
How do we ride a bike?
How do we do silly
things like that?
These things happen because
our brain forms connections.
Millions of brain cells
connect themselves
into neural circuits or a neural
pathway for a specific purpose.
That's how we live our lives.
And his brain learned
pain from the injury,
remembered it all those
years as a neural pathway,
and then activated
it later in life
upon the mental association
of the helicopter.
We now know that, when someone
gets an emotional injury,
the parts of the brain
that are activated
are identical to
those that happen when
someone gets a physical injury.
This is the mechanism
by which emotional pain
can cause physical pain.
And children who grow up feeling
unsafe for whatever reason,
parental abuse, or neglect,
or all sorts of things
that can happen to children.
The feeling of growing
up unsafe sensitizes
that danger and alarm
mechanism in the brain
that then can be
activated later in life
by another life stressful
event or by a physical injury,
such as a car accident.
And so this whole
variety of pain syndromes
that are the commonest
pain syndromes
we have are all associated
with childhood adversity.
And when you scan the brain
of people who have back pain,
what happens is--
these are people who had back
pain that was persistent,
chronic.
And the somatosensory areas of
the brain go down to normal.
But the emotional laden
areas of the brain go up.
In chronic pain, it's not
particularly a physical problem
for most people,
which is shocking.
And so there's this
whole range of syndromes
that all hang together.
The chance that a
tension or migraine
headache is due to a
structural problem in the brain
is 2% or 3%.
The vast majority of people
with tension migraine headaches,
fibromyalgia, irritable bowel,
most pelvic pain syndromes
do not have structural
problems in their body.
And studies show that
approximately 85%
of people with neck
or back pain do not
have a clearly identifiable
structural cause
for that pain--
85%.
And that's shocking.
So what happens is, is that
you may have somebody who is--
let's say their father was--
I'll exaggerate a little.
My father-- I'm
talking about me now--
was kind of critical,
and could be
judgmental, a little bit harsh.
And you have a
sensitive young boy
growing up in that environment.
It certainly wasn't abusive.
But the danger pathway becomes
a little bit sensitized.
And then you get to internship.
So first day of my internship,
I'm a terrified young doctor.
I start getting diarrhea.
It lasts for six months.
Something about being a doctor
simply scared the crap out
of me.
And so the danger mechanism,
then, is producing a symptom.
Then I decide, oh,
here's a good idea.
I'll have kids.
I'll try to get
promoted in my job.
I'll start doing research.
I'll start working on national
committees, great idea.
All of these things
are great ideas.
But they cause stress.
And then my neck starts to hurt.
And I wake up in the morning,
and I go to work like this.
You ever see anybody
go to work like this?
It's pretty common.
And what do they all say?
I slept on it wrong.
That's what I said for years.
And my MRI shows these
bulging disks, and arthritis,
and all this stuff.
And I still have these
bulging disks in my neck.
But I don't have any pain now.
And then what if I
get in a little car
accident, fender bender?
And then I begin to
get other things,
or something else
happens in your life.
And then it can just
spiral from there.
Because what happens is that
the experience of having pain
further activates the danger
alarm mechanism, which
activates more pain.
So it's a vicious cycle of
pain, leading to fear of pain,
leading to more pain.
And that describes why many
people with chronic pain
get worse over time.
And their pain tends to spread,
like from their lower back
to their middle back, or to
their neck, or to their belly,
like the guy that I
was telling you about.
And so what I explain to
people is injuries send signals
to the brain.
And the brain has to decide.
When I say the brain,
these are processes
that are happening
completely outside
of our conscious awareness.
That's why American horror
stories is apt analogy.
Because people move
into this house.
It's haunted.
And everything is
out of control.
Things are happening to them.
And people stuck in this
spiral, like the patient
I was telling you
about, feel like things
are happening to them
that are completely
outside of their control.
And it's their brain
that is doing it
at a subconscious level.
And emotional injury can
activate the danger signal
in exactly the same
way as physical injury.
And then pain becomes
learned as a neural pathway.
So when I evaluate
patients with pain--
and I should
mention other things
that are connected to this.
So people with fatigue,
insomnia, anxiety, depression
are common ones.
But if we're talking about
pain, my job, number one,
is this a structural problem,
like, you fell on your wrist,
it's broken, you need a cast?
Or is it a neural
pathway problem?
Because pain is a message
that our brain is giving us.
It's our job to encode it.
I saw a woman a few years ago
who had pain in her butt right
here.
And I said, well,
when did it start?
She said, well, right about
the time my husband retired.
And if you think about it--
you guys aren't
thinking about it.
Are you thinking about it?
That's a very different message.
So my first job is to rule
out a structural disorder.
The guy that we're
talking about,
he had had everything
done to him
that could be done structurally.
Nothing had helped.
He had a bulging disk.
They already fixed it.
They fixed things that
weren't even broken.
And so he had no
evidence of nerve damage.
There was no evidence that
he had a structural problem.
So now my second
job is to say, well,
if we can rule out a
structural problem,
maybe we can rule
in a neural pathway
or a brain-induced problem.
Well, this is a very
important slide.
It's a meta analysis,
3,300 people,
a bunch of studies
lumped together.
If you take completely
healthy, pain-free 30-year-olds
and you give them MRIs, 50% of
them have disc degeneration.
40% have bulging disks
completely pain-free.
If you take 50-year-olds,
those numbers are 80% and 60%.
And if you get to be the
ripe old age like me,
we're talking
about 90% of people
have degenerative disk, DDD,
Degenerative Disk Disease
like it's a disease.
The vast majority of
adults have abnormal MRIs
that are not the cause of pain.
And doctors know
this information.
It's not a secret.
They just don't know what to do
with it, how to interpret it,
how to apply it, in general.
And so what were the messages
that this patient that I
was telling you about was
getting from his doctors?
The messages were,
you're damaged.
There is a problem here.
It might be genetic.
We don't know.
We tried to fix
it, but we couldn't
fix it, which leads to no hope.
No hope leads to more pain,
because of the vicious cycle.
So what are the clues?
So we're looking at, do
people have a variety
of symptoms over time?
It was headaches, and
then it was stomach pain,
and then it was back pain,
or neck pain, or insomnia.
Do people have adverse
childhood events
that maybe has primed
that danger alarm
mechanism in their brain?
And do people have
this tendency to want
to please, to be
perfectionistic,
to care what other people
think about them, to be overly
conscientious and responsible--
kind of like you
guys, kind of like me.
And that's good.
Those are the best
people in the world.
But when we put more
pressure on ourselves,
we have more tendency to
activate this fear and danger
mechanism, the danger
alarm mechanism.
And then we're looking
at, what was going on
in your life or their
life at the time
that symptom A started, at the
time that symptom B started,
et cetera?
And then we're looking
at a distribution pattern
from a medical point of view.
Someone has pain.
It starts in the left top
of the head, the left side.
It goes all the way down to the
left torso, all the way down
the left leg.
There is no disease
that does that.
There's no disease that has
pain from in the morning,
and then it goes away by
2:00 in the afternoon,
and then it's gone
the rest of the day.
There's no disease
that does that.
And so we have to understand
that we can evaluate people
and rule in brain-induced pain.
So what happens with an injury?
You get an injury.
It hurts.
And then it gets better
over two days, or five days,
or a couple of weeks.
Fractures take
six weeks to heal.
But what we see--
and you can diagnose people
in your family and friends
very easily by saying, oh, I
got an injury, it never healed.
Well, how likely is that?
Probably not.
If the pain is continuing
and worsening over time
after a fairly mild injury,
that's not the normal pattern.
That's not
structurally-induced pain.
The pain shifts from one
area of the body to another.
Fibromyalgia is
classic for that.
The pain is in the arms.
And then the next
day, it's in the legs.
It can shift on a dime.
Because neural pathways
can turn on and turn off,
which is the beauty
of what I do.
Because people can get better.
Symptoms spread, as I mentioned,
often bilateral lateral.
The brain often says, well,
I hurt my right wrist.
And now my left
wrist is hurting.
That's a red flag for me.
Social contagion, we
talked about that.
There is a study from Germany.
The Berlin Wall came
down in 1989, I believe.
In 1991, they started studying
back pain in East Germany
and West Germany,
these two populations.
And the West German
back pain was up here.
And the East German
back pain was down here.
And over time, the
East German back pain
just rose to the level
of West German back pain
as those cultures mixed.
And the conclusion of the
article was that back pain
is a contagious disorder--
interesting.
Not all cultures have
the amount of back pain
that we have in this culture.
A friend of mine was
a doctor in Iraq.
And when he came here, he
said, why does everyone
have back pain here?
People don't come to the
doctor for back pain in Iraq.
I know.
Maybe they have other
problems, but they
did come to the doctor
for their other problems.
They just didn't
come for back pain.
So that's the kind
of work that I do.
So back to this guy, our friend.
He's an engineer.
He's from Detroit--
so everyone's
an engineer-- but not a computer
engineer, auto engineer.
Of course, a lot
of auto engineers
actually are computer
engineers now.
His wife works part-time.
He's got two kids.
He didn't have a particularly
adverse childhood.
But he was sensitive.
He noticed he had
stomach pains before he
had to do school presentations.
The onset of his headaches
and the buttock pain
coincided with his first
position in his new job.
The marriage was rocky at times.
But about eight years
ago, when the back pain
started, which
spread to neck pain,
his company was sold,
increase in workload,
concern about keeping his job.
There was the recession, puts
a lot of pressure on himself.
He started going to work,
7:00 AM, and then 6:00 AM,
and then 5:00 AM.
And he started getting
pain, because his brain
was sending him a message.
So here's the kicker for him.
He goes on vacation,
pain goes away.
That's solid evidence.
He spent a week camping
on a hard ground
and his back was fine.
And that tells me everything
that I need to know.
The other thing he
noticed is is that he
didn't notice that his
back pain was worse
in stressful situations.
But he did notice that
his stomach discomfort
was related to stressful
situations at work or at home.
And he also noticed,
when his stomach hurt,
his back didn't hurt.
And that's another
more positive evidence
for neural pathway pain.
I want to shift
gears for a second.
This is a study we
published last week.
It's an NIH-funded trial.
It was directed by an
extraordinary colleague
that I have, Mark Lumley
at Wayne State University.
And we randomized 230
people with fibromyalgia,
who have severe and chronic
pain but no tissue damage
in the body, to three groups.
And this was a three-arm study.
The first group, the first arm
got education for fibromyalgia
as a control group.
The second arm got the
standard pain psychology,
cognitive behavioral
therapy done
by our excellent colleagues
at the University of Michigan,
specifically designed
for fibromyalgia.
And the third arm was an
arm that Mark and I devised.
And we based it on the work
of one of our colleagues,
Dr. Allan Abbass,
And in this group,
we talked to people
about the connection
between emotions and pain.
And we asked them to
do the difficult work
of looking at, recognizing,
experiencing, and expressing,
and processing emotions
that they may have avoided
in their lives such as anger,
guilt, sadness, and compassion.
And we didn't know
if people were really
going to engage in this
kind of thing anyway.
Because it's not the standard.
In cognitive behavior
therapy, the idea
is to help you cope
better with the pain.
We're talking about getting
to an underlying mechanism.
What we found was striking.
At a six-month follow-up
after the treatment,
the people in the emotional
expression and awareness group
had significantly higher rates
of dramatic, more than 50%,
pain reduction compared
to the other two groups.
And I don't know how much you
know about medical statistics.
But the number needed
to treat was 7.
So if you go to your doctor
and your cholesterol is high--
and you've never
had a heart attack.
Your cholesterol is high,
and your doctor says,
here, I want to
take this medication
to lower your cholesterol.
What's the chance that that
medication will actually
help you?
In that situation, the number
needed to treat is 100.
That means 1 out of 100 would
be likely to not get the heart
attack.
So we do that every day.
This is a number
needed to treat of 7.
It's a very powerful effect, in
terms of medical interventions.
And we also found that
changes in widespread pain
index, the emotional
awareness and expression arm
was better than the CBT arm.
And in terms of the percentage
of people who actually still
met the criteria
for the disorder
at the end of the
study, was much less
in the emotional expression arm.
This is the first large-scale
study to our knowledge
to show that one psychological
intervention for pain
is actually superior to
any other psychological
intervention.
So what have we learned?
Well, a lot of people with
pain have issues in their lives
from childhood and onward.
Pain is connected to emotions.
And this kind of therapy does
better than the standard.
And this, we think,
is a landmark study
in a lot of ways.
And this study doesn't even
include the whole range
of therapy that I'm going
to talk to you about that we
give for this guy.
This is another study,
just an outcome study
we published from data from
my work and my program.
And in these people with
roughly half with back pain,
half of with fibromyalgia , the
average duration of pain was
nine years.
The average duration of pain
in this sample was nine years.
And these people, when they
go to pain management clinics,
usually don't get much in the
way of actual pain reduction.
But in our sample, 2/3
of them had at least 30%
pain reduction.
And over half had more
than 50% pain reduction.
So it's a different paradigm.
The paradigm that all pain
is due to injury in the body
and is simply
reflected in the brain
is not working for people
with brain-induced symptoms.
We need a different paradigm.
And if you're aware of
the history of science,
paradigms don't shift easily.
It can take decades
for a paradigm,
for an idea that
initially seems completely
counter-intuitive to
go to totally obvious.
Plate tectonics, the idea
that the continents were
all together and
one thing, you can
see-- if you look
at the map, you
can see how they fit together
like a puzzle, right?
It took 50 years for
scientists to agree that that's
what had happened, 50 years.
And it's obvious.
You can see it.
So the symptoms of
this disorder are real.
But they're not damaging.
The brain has been sensitized.
And the brain has the
power to produce even very
severe symptoms.
And most people have,
at least to some degree.
It's a very common phenomenon.
We believe that the majority
of people with chronic pain
have this phenomenon and
are being treated by an old.
paradigm.
Yet skepticism
continues to abound.
What do we do?
The interventions are
straightforward and
inexpensive.
The most important
one is understanding
that this is what's going on.
Because people who get
it, who understand, like,
oh, my goodness,
I'm not damaged,
I'm not broken,
I can get better,
that allows them to do the work
of detaching from the symptoms.
Whereas people who are under the
belief that they were actually
damaged, it's very
hard to do that.
And so the idea is that people
need to really understand.
And that's why I spend so
much time examining people,
and listening to their
story, and looking
for those details that are
going to make or break the case,
so to speak.
So this is a woman
who I never met.
She says, 21 months
post-op, third back surgery,
3-level fusion--
doesn't sound good--
21 months trying every therapy
to get out of enormous,
unrelenting back pain, on
top of 22 years of chronic,
limiting back pain, no success.
My doctor sent me a
link to your website.
That's my website-- six days.
I considered the possibility
that this could apply to me.
I came back.
I read it again.
I said, oh, my god, that's me!
I see it.
It's obvious-- paradigm shift.
And what happened to her pain?
It just went down.
Most people don't have
that kind of response.
But when you have the response
that you actually get it,
and you see the paradigm shift,
and you see what's going on,
then you have the opportunity
to get completely better.
And she had a dramatic effect
just from understanding
and learning about this model.
And then she said,
well, I started walking.
Before I could barely
walk around the building.
But I kept telling myself--
what did she tell herself?
I can walk.
I can walk.
I'm OK.
I'm not damaged.
And she starts walking.
And she says, well, forgive
me for being effusive.
But going from crippled,
to fearful, bewildered,
discouraged, bordering on
despair to regaining my life,
this is kind of a minor miracle.
So once people get the idea
and understand what's going on,
then they can begin to reduce
the danger alarm mechanism.
They can begin to worry
less about the pain,
stop anticipating it,
stop monitoring it,
stop allowing the
pain to dominate their
every thought and
every action, begin
to reengage in physical and
social activities despite pain,
knowing that they
actually can, knowing
that they're not
damaged, knowing
that they can get better.
And I'm going to talk about
mindfulness in a minute.
So this is a woman.
She said, I had a
huge success today.
I was determined
to go for a walk,
but my back was killing me.
So I said to my brain, I'm
going for a walk today.
You can either make this easy
or you can make this difficult.
But we're going.
It's kind of like those
old gangster movies
they say you're, going to talk.
You can either make
it easy or difficult,
but you're going to talk.
And she's saying
to her brain, look,
this is how it's going to be.
We have the ability to
change our neural pathways.
Because the brain
neural-plastic.
As we think differently,
as we act differently,
we can sooth the brain
and calm that danger alarm
mechanism, which is
kind of like calming
a child who's really upset.
And if you keep
doing it, and you
keep working at it, what happens
is most people get better.
And then there's
emotion-focused techniques.
And I don't have time to
talk too much about that.
But one of the simplest
things that anybody can do
is get out a piece of
paper and start writing.
You can write a letter
to anybody you want,
dead or alive.
And you can shred it.
So you can say
anything you want.
And it's a very healing process.
This is a woman who wrote to me.
This is a woman in Germany
who was working this program.
And she said, well, I did my
first writing exercise, tears
streaming down my face.
I was finished, my whole
body was screaming with pain,
no, you can't stand facing that
So she had activated emotions.
And her pain went
from here to here.
And then she did
something brilliant.
She wrote a letter to her brain
saying, yes, I can face it.
I'm capable of doing this.
It's OK.
I am allowing myself
to feel emotions.
We're afraid of emotions, often.
And we avoid them at all costs.
And then her pain
just dissipated
as she did this work.
It's amazing.
And this kind of
thing, it's really hard
to understand unless it's
actually happened to you.
When it's happened to you,
you go, oh, my god, that's
unbelievable.
But in the abstract,
it's like, yeah,
that's probably true
for other people.
But my pain's real.
And so mindfulness
is everywhere.
I've been a teacher of
mindfulness for 17 years now.
And I'm passionate about it.
I think everyone should
learn mindfulness.
But the data on mindfulness
for chronic pain
shows it has small effects.
It's not particularly effective.
And the reason is
the same reason
that cognitive behavioral
therapy suffers.
Because we're not looking
at the underlying cause.
So we're using mindfulness to
cope better with chronic pain,
as opposed to understanding
that mindfulness can actually
be the key to relieving
it, to resolving it,
once you know that it's
actually a product of the mind.
If the pain is a product of the
mind, then mindfulness works.
Because now you're noticing
it with detachment.
Now you're noticing that
you're tolerating it.
You're accepting it.
And it doesn't bother you.
You don't care as much anymore.
And that turns off the
danger alarm mechanism.
Is a very powerful intervention.
And then lastly,
sometimes people
need to make changes
in their life.
They need to do something.
If there's a difficult
marriage, or a job, or neighbor
situation, or
something, sometimes you
have to take action and deal
with it as best as possible.
So what about our friend?
Well, initially, it
was kind of hard.
It's like, people have been
telling me for eight years
how damaged I am,
how bad my back is.
And it takes time to
go over the evidence,
and explain, and apply
it, and personalize it,
and to care, and to show
that you actually care,
and that you're doing
everything that you can.
And when he sees
that, he's much more
likely to trust you
and believe you.
And so we started
doing that work.
And he had his ups and downs.
Initially, his pain
got worse as he
started to do this work,
because he's shaking things up
and this danger alarm-- like
the woman with the writing.
But he persisted
in the conviction
that he wasn't damaged,
that he could get better.
And about four months later,
he was basically pain-free.
He was fine after eight
years, back pain, neck pain,
and stomach pain all caused by
the same underlying mechanism.
And these would
recur at odd times.
Every now and then,
all of the sudden,
he would get an ache, or
a twinge, or whatever.
And what's going on?
His brain just going, like,
oh, I remember that, zing.
And then you get the pain.
But he knows what it is now.
He doesn't immediately go to
fear, or frustration, or worry.
He says, oh, that's
my brain, no big deal.
Goes on, it goes away.
Or when he has a
stressful life event,
the pain comes as a message.
We need pain.
Pain is very important.
And so it serves as a
protective mechanism.
Children who grow up without
the ability to feel pain
often die at an early age.
So we need pain.
And in his case, he's
got a great barometer.
Whenever his stomach
is bothering him,
he's going, like, oh,
maybe I should check out
what's going on in my life.
Because something
is bothering me.
And that's a gift.
So research now
confirms that all pain
is a protective mechanism
by neural pathways.
It can be triggered
by structural disorder
or by simply the neural
pathways in the brain.
And a significant proportion
of pain that we have
is brain-induced.
MRI findings are often
not correlated with pain.
And we can make this distinction
between structural pain
versus nonstructural
pain. or sometimes
it's a combination of the two--
because the treatments
are radically different.
And reversal of
this syndrome can
occur when you combine
an understanding of it,
when you combine the
cognitive, behavioral,
and the emotional interventions,
the results can be dramatic.
So as I said, paradigms
don't shift easily.
As Sherlock Holmes
said, there's nothing
more deceptive than
an obvious fact.
You just hearing what
you heard today--
and maybe you knew
all this stuff.
But you will run into people
with this syndrome frequently.
It's that common.
And it's easy to
recognize when you just
know what you're looking for.
And how are most
people going to react
if you happen to mention it?
Disbelief and outright
rejection, that's happens.
But the more people who
understand pain the way
you do now, the more likely
the paradigm will shift.
This website, the TMS Wiki is a
nonprofit website clearinghouse
for information on this.
The next URL is for a
three-minute, animated video
made by my colleague,
John Gordon.
And there's a bunch of
books that all explain this.
And what happens,
a lot of times,
is people initially
reject the idea.
But then they hear
about it from somebody.
And then somebody else
happens to mention.
And somebody else
happens to mention.
Eventually, they take a look.
And eventually, they
look at themselves.
And it's hard to
do, to self-reflect.
But the bottom line is
that the rain of pain
lies mainly in the brain.
So thank you for
letting me be here.
And I'll be happy
to answer questions.
Yeah?
AUDIENCE: How can we
help our children not
follow these patterns
in the first place?
HOWARD SCHUBINER: Yeah, they've
got to find their own way.
Well, I mean, children
mirror what their parents do.
And if the parent has always
got a bad back, that's
going to set up
in the kid's mind,
like, oh, yeah, when
I have a problem,
my back was started hurting.
So we have to be
careful about that.
We have to be careful about
giving a pill for everything.
There's a woman in
Maryland who came up
with obecalp, which is
placebo spelled backward,
to give to kids when they had
a tummy aches to give them
a pill.
It's a placebo.
Like, why would you do that?
I have a friend who was
on vacation with his son.
And the parents were divorced.
And they were doing this hike.
And the kid's stomach
started hurting.
And they're going,
like, what did
you eat, through every physical
thing that you can think of.
And finally, he says,
OK, I got to ask.
I've got to say, is there
something bothering you, buddy?
No, no, everything's fine.
OK.
Is there something
bothering you, buddy?
No, no, everything's fine.
Is something on your mind?
He goes, I miss my mom.
And so just the idea
of understanding
that-- and he goes,
yeah, I miss her, too.
But you'll be seeing her soon.
And we'll write her a letter.
And we'll save FaceTime
her tonight or whatever.
And then he's running
around, and he's fine.
And so the more we
understand, the more
we can bring our kids
up to understand.
Other questions?
Yeah?
AUDIENCE: Is there
other methods that you
found that we can use to,
like, reframe the way the
we interpret structural pain?
HOWARD SCHUBINER:
Are you saying that,
can we use the mind to help
structurally-induced pain?
Is that the question?
AUDIENCE: Yeah, that's correct.
HOWARD SCHUBINER: Yeah, well,
you can use the same things.
I mean, the brain--
you know, the guy with
the needle in his hand.
The brain can, actually,
reduce structural pain.
And so studies
show, for example,
when someone gets a
pain that's intentional,
it hurts a lot more
than if it's accidental.
And there's something else
I was going to tell you.
We know that you can
tolerate a severe pain if you
think it's for a short time.
But it's almost intolerable
to tolerate a minor pain
if you think it's forever.
And so framing how we view the
pain as, how damaging is it,
and how much can we
do, and how much do we
want to focus on living
our life, as opposed
to letting the pain dominate it?
So at least what we can do with
structure of pain is, at least,
hopefully, prevent
it from falling
into the vicious cycle of
it getting worse and worse
over time because of increased
fear, monitoring, anticipation,
and worrying about it.
Yeah?
Yeah?
AUDIENCE: The example you
gave of the [INAUDIBLE] pain
from the shrapnel.
HOWARD SCHUBINER: Yeah,
yeah, the Vietnam veteran.
AUDIENCE: You said
it sort of came back
in a very small period of time.
HOWARD SCHUBINER: Yeah.
AUDIENCE: How does he solve
that, and puts that kind of--
HOWARD SCHUBINER:
It came and went.
His brain just turned
it on for that moment
by that association,
so that, for him, it
wasn't an ongoing pain.
It was just a short-lived.
It just is a great
illustration of how
the brain learns pain, remembers
pain, and then can activate it.
A lot of pain is triggered.
It becomes a
conditioned response.
So I say, I know I have
a problem with my back
because every time I turn here.
But the way the brain works is a
model called predictive coding.
So if the brain thinks
something is going to happen,
it will create it.
So we used to think
that, when you stand up,
that as you stood up, there's
a sensor in the carotid artery
that would send signals
to the brain to say,
oh, you're standing up.
Brain, send more blood to
the brain so we don't faint.
It turns out, when you
think about standing up,
the brain activates
that mechanism.
So the brain is predicting ahead
of time what it needs to do.
And so every time you bend over,
your brain is predicting pain.
And it will do it.
So people with typing, the brain
is predicting pain with typing.
Brain is predicting pain
when they're sitting.
And these are conditioned
responses, Pavlovian responses,
actually, that we can
work to eradicate.
I had a lot of back pain.
And every time I
bent over, it hurt.
And when I figured
out that it wasn't
my back, every time I bent
over, I just said to myself,
I'm fine.
I'm OK.
This won't hurt.
And you do that enough
times, and your brain finally
gets the message.
And it turns off that
conditioned response.
It's fascinating.
Yeah?
AUDIENCE: Is there any concern
that this kind of treatment
will impair people from feeling
necessary or useful pain?
HOWARD SCHUBINER:
You can't stop pain.
I mean, people get
pain all the time.
The main thing is that people
always ask, who say, well,
how do I know if
it's real or not?
How do I know?
And we say, use common sense.
If you fell, you hurt yourself.
And when I get pain and
I don't know what it is,
I go to the doctor
and try to make sure.
But with common sense, if
it's not getting better,
or you just kind of investigate
it, then you can tell.
But pain is not going
away any time soon.
That mechanism is pretty
well wired, so to speak.
So I have a couple more
things I can tell you,
a couple of more little
stories, if you don't mind.
And then we can wind up.
We'll be on time.
We'll be even early.
So I flew here
yesterday from Detroit.
I get up early in the
morning, get in my car,
drive to the airport,
get on the plane.
Everything's fine.
I'm on the plane.
I'm walking up and down.
I get my bag, get in the
car, get to the hotel.
Everything's fine.
I get out of the car at my
hotel, and I start walking.
And all of the sudden,
I have this sharp pain
in the bottom of my big
toe and my right foot.
It's like a needle
is sticking in it.
This is a sharp pain.
And every time I
step down, it hurts.
And I'm like, what the heck?
What could possibly be wrong
from all day it was fine,
and all of the sudden, I've
got this needle-like pain?
So my mind-body-doctor brain is
going, like, OK, what's wrong?
You don't like the hotel?
Or you're giving
a talk tomorrow,
maybe you're nervous about that.
What's going on?
And then my medical
doctor side says, god,
it feels like you got
something in your foot.
And then by my human side
says, dang, this hurts.
So I go up.
And I get into the hotel.
I'm at the registration.
I check in.
And I'm standing there.
And then I put a little
pressure on my toe.
And it's fine.
And I push harder on it.
And it's fine like
it's gone away.
And then you're like,
OK, that was my brain.
Because if it was
something there,
it wouldn't just
go away like that.
So I get my key.
I got up in my room.
I'm walking.
Now it starts hurting
again, every step.
And by the time I got to my
room, I'm working on my heel,
because I don't want to put
any pressure my big toe.
And so I get inside the room.
And I perform a diagnostic test.
What was the test?
Look.
So I pull off my shoe.
And this is what I
found, a shard of glass
sticking in my sock.
How the heck did
it not bother me
all day until I just got there?
But as we say,
you've got to look.
You've got to rule out
structural causes first.
I was giving a lecture.
I was thinking about
this the other day.
I gave a lecture a couple of
years ago in London, actually.
And at the end, this guy got up.
And he said, in my culture, pain
is viewed as a gift from God.
What do you think about that?
And I go, well, yeah, it is.
However we were formed, we
have this ability to have pain.
And it's a barometer
of our structural body.
And it's a barometer of our
brain and all the experiences
that we bring to this moment.
And when pain occurs--
or other symptoms
that I mentioned--
when pain occurs,
something is going on.
And it's our job to encode it.
It's our job to learn from it.
And it's a complete gift.
And people who've been
through-- like this guy.
He's going to be so
much better in his life.
Because now, he
understands himself better.
He understands,
what triggers him?
What are some of the
issues in his life?
He can take action
and do the work
to deal more effectively
with what life brings.
And sometimes people need to
make big changes in their life.
But there's an experience that
is not that well known, which
is post-traumatic growth.
Not all trauma leads to
post-traumatic stress disorder.
Trauma can lead to
post-traumatic growth
if we know how to use it, if
we know how to interpret it,
if we have the tools to
help us grow as people.
And I think that's kind
of what life is all about.
So with that, I'll leave you.
And thanks a lot.
