[Content warning: discussion of chronic pain and related conditions, and the debate over whether some of them may be psychological in origin. None of this is medical advice or a recommendation to start or stop any form of therapy. Low confidence in my conclusions here.]

I.

Some of the most interesting lectures in medical training are the ones that start with “Okay, you’re all going to think I’m a quack, but…”

This was how Dr. Howard Schubiner started the lecture he gave at the hospital where I work. Dr. Schubiner isn’t an obvious quack – he’s a professor of medicine at the local university, directs a clinic at a reputable hospital nearby, and is on the editorial boards of a bunch of medical journals. And although his lecture raised what we will generously call a few red flags, there was also just enough interesting stuff there that I couldn’t resist buying his book Unlearn Your Pain to learn more.

Dr. Schubiner’s specialty is psychosomatic complaints – bodily symptoms that don’t come from any obvious disease and seem to reflect psychological stress. Everyone agrees that this category exists. Most doctors have stories about conversion disorder – usually patients who become “paralyzed” in previously healthy limbs after some life crisis. One of my medical school professors had a pretty good diagnostic test for this – feign a punch at the patient’s face, really quickly, without warning her. If she instinctively uses her “paralyzed” limb to block it, it’s conversion disorder. The same sort of thing works for pseudoseizures – apparent seizures not associated with objective seizure EEG activity. There’s a legend about a neurologist telling a medical student that a certain patient’s fit was a pseudoseizure, and the patient interrupting his seizure to protest “No it isn’t!”.

Most people who have worked with conversion or pseudoseizure patients don’t doubt their inherent honesty. These patients aren’t faking, per se. Such a person genuinely can’t move their limb, can’t just decide not to have seizures. Often they’re very distressed at what’s happening to them (although sometimes they really aren’t). Psychologists like to say that it’s subconscious – whatever that means. Just like somebody crippled by panic attacks, the symptoms are real and involuntary, but they’re also psychologically produced.

The existence of this category isn’t controversial, but its size definitely is. Some people propose a long list of conditions – fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome, chronic Lyme disease, tension headaches, interstitial cystitis, et cetera – that they think of as mostly or entirely psychosomatic. On the other hand, patients’ rights groups get very upset at claims that their conditions are “all in their head”, accuse doctors of thinking that they’re lazy or making up their symptoms, and pass around stories with titles like RE: RE: RE: FWD: RE: THE MEDICAL PROFESSION about some guy whose doctor dismissed him as making up his symptoms but who was later diagnosed with zebra-itis and cured with an experimental gene therapy treatment.

Dr. Schubiner is a psychosomatic complaint maximalist. He thinks that just about anything that can’t be traced to a well-understood physiological cause is probably psychosomatic – in his language, Mind-Body Syndrome or MBS. He quotes a fascinating theory by Edward Shorter that this all dates back to the invention of the tendon hammer, ie that little thing doctors hit your knee with:

An important advance in medicine was the discovery of deep tendon reflexes. The simple test of striking a tendon with a reflex hammer can quickly distinguish pathological from psychological paralysis. Amazingly, once doctors could do this test, the number of people with this type of conversion disorder decreased substantially, and now the condition is rare. When doctors and the general public come to view a medical condition as psychologically induced, it is less likely to occur..the subconscious mind is unlikely to produce symptoms that will be easily seen as psychological. But since humans continue to experience great stresses and strong emotions, paralysis has been replaced by chronic back pain, fibromyalgia, fatigue, irritable bowel syndrome, and many other symptoms.

When Schubiner talks about fibromyalgia and fatigue, he’s not so far outside (one edge of) respectable medical opinion. But he goes further and lists migraine headaches, heartburn, carpal tunnel syndrome, tinnitis, postural orthostatic tachycardia, repetitive stress injury, and reflex sympathetic dystrophy as likely Mind-Body Syndrome as well. And most explosively, he says the condition explains almost all pain.

Schubiner admits there is such a thing as anatomically-caused non-psychological pain. It tends to be associated with very obvious injuries like dropping an anvil on your foot, and it tends to go away after a couple of weeks at most. Anything more mysterious and chronic – facial pain, TMJ pain, joint pain, abdominal pain, neck pain, shoulder pain, tendonitis, and especially back pain – is probably Mind-Body Syndrome. After a medical workup has failed to reveal obvious cancer or infection, these are almost certainly psychosomatic and continuing to treat them as potentially medical just makes them worse:

When patients with Mind-Body Syndrome are labeled as having degenerative disc disease on the basis of an MRI….symptoms can be exacerbated and patients harmed by medical diagnoses. This occurs because the diagnosis creates fear and the belief that there is something seriously wrong with one’s body. These emotions activate the anterior cingulate cortex, which creates even more pain by ramping up the learned nerve pathways of MBS.

If this were true, it would be really important. Surveys suggest that between 40 million and 100 million Americans have chronic pain; the former study finds 67% of them say their pain is “constantly present” and 50% say it is sometimes “unbearable and excruciating”. The financial cost is between $60 billion and $600 billion per year. I’m not sure what to think about all these estimates that differ by orders of magnitude, but the point is that there’s a “chronic pain epidemic” and it’s really bad. The mainstay of treatment for chronic pain is opioids, and by non-coincidence there’s also an opioid addiction epidemic and an opioid-related death epidemic. To some degree the government can use regulation to trade off pain burden against opiate deaths, but no point at that curve is very palatable and we desperately need some kind of real solution.

Schubiner says he has it. It’s time to admit that all of this pain that’s getting all epidemicky is almost entirely psychosomatic. It might start with a real injury, but after that injury heals the brain “remembers” the relevant pain pathways and exploits them as a way to express psychological stress. He presents some fascinating and delightful evidence for this.

A guy named Harold Schraeder studied prevelance of chronic whiplash in Lithuania, of all things. He found the prevalence was zero. In most Western nations, a certain subset of people who get in car accidents suffer chronic disabling neck pain, presumably related to having their neck get suddenly jerked by the force of the impact. But Schrader found that this never happened in Lithuania, even though they had a lot of accidents and their cars were no safer than ours. Simotas and Shen found that there was zero whiplash in demolition derby drivers, even though they got into crashes all the time and it was basically their job description. Further studies found that accident victims with more neck injury were no more likely to develop whiplash than victims with less neck injury. Perhaps, they argue, chronic whiplash isn’t a bodily injury at all, but a culture-bound syndrome in which people who expect whiplash to exist use its symptom profile as a way of expressing their psychological tension.

Then there’s back pain, one of the most common and disabling types of chronic pain – Medicare back-pain related costs have grown about 3-4x in a decade. Standard medical workup for back pain usually involves getting an x-ray or MRI, finding some problem with the discs in the spine, and treating with painkillers, steroids, or surgery. Schubiner is not convinced. He notes studies that find that radiographic findings of disc degeneration or herniation do not accurately predict future back pain. Yes, most back pain sufferers will have problems visible on MRI, but most perfectly healthy people pulled off the street will also have problems visible on MRI – for example, this study finds that half of all 21-year-olds in Finland have a degenerated disc, and a quarter have a bulging disc. The book quotes an NEJM article as saying that “neither baseline MRIs nor followup MRIs are useful predictors of low back pain”. However, studies (1, 2) find that a patient’s job satisfaction does predict their future back pain. Books and studies called things like Time To Back Off?, Back In Control and Watch Your Back point out that many surgeries and injections for back pain work no better than placebos in controlled experiments, with a review article in the Journal of the American Board of Family Medicine concluding that “prescribing yet more imaging, opioids, injections, and operations is not likely to improve outcomes for patients with chronic back pain” On the other hand, Schofferman et al found that childhood trauma correlates heavily with success of back pain treatment: 95% of patients with a happy childhood got better after back surgery, but only 15% of patients with multiple childhood traumas did.

Based on these studies and others like them, Schubiner concludes that chronic back pain is psychological rather than physiological. He thinks there may have been some original minor injury, of the sort that most people would get over in a couple of weeks. This causes the nerves to “sensitize” – ie the brain is primed to think about and remember this form of pain. Then, when people recall their subconscious tension over childhood trauma and the stresses of life, they express it as back pain through the sensitive nerve pathways.

Extend this model to headaches, irritable bowel, chronic fatigue, and everything else, and you have Dr. Schubiner’s theory of pain.

II.

If all of this pain has a psychological cause, then it should have a psychological solution. But psychological solutions to chronic pain are no more effective than physical ones. For example, Cochrane Review finds that cognitive behavioral therapy for chronic back pain has a moderate short-term effect which fades quickly. There was a similar effect for neck pain which Cochrane found “could not be considered clinically meaningful” and which also faded quickly.

Dr. Schubiner says this is because cognitive behavioral therapy is inappropriate for this condition. It’s caused not by negative thoughts and dysfunctional behaviors, but by unresolved childhood traumas. He recommends a therapy designed to help resolve such traumas called Intensive Short Term Dynamic Psychotherapy.

Freudian therapy (“psychoanalysis”) usually takes several years to get anywhere, and may take ten years or longer to complete. Around the 1960s, some psychiatrists got tired of waiting and invented a high-speed version called “psychodynamic therapy”. Schubiner’s version, which derives from the word of a guy named Dr. Davanloo in Montreal, promises results in as little as four weeks. It involves a lot of stuff, including some kind of silly-sounding things like writing affirmations, finding your acupuncture points, and putting your body in very masculine “power poses” and raising your fists and shouting “I AM GOING TO OVERCOME MY PAIN!”. Dr. Schubiner demonstrated this last in front of us and he did indeed look very masculine and determined; if I were chronic back pain, I would definitely put him on my list of people to avoid.

But the heart of the therapy is a technique for returning to traumatic childhood moments. You try to figure out what your traumatic childhood moments were – for example, maybe your father got drunk and beat you up. So you go back to the incident, either as a solo visualization or in a conversation with a partner. It goes something like this:

Doctor: Tell me what’s happening Patient: I’m in my childhood home. My father approaches me, beer bottle in hand, looking really angry. Doctor: How do you feel? Patient: Really scared. Doctor: But also? Patient: Angry. Doctor: Good! You have every right to! Tell your father that! Patient: Father, I’m really scared and angry! Doctor: Now what does your father do? Patient: He doesn’t care. Doctor: And what would you like to do now? Patient: Beat up my father. Doctor: Then go back into that experience and beat up your father. Patient: AAAARGH! I HATE YOU SO MUCH, FATHER! YOU RUINED MY CHILDHOOD! GRAAAAAAAAAH! DIE! DIE! DIE! DIE! DIE! Doctor: How do you feel now? Patient: My chronic back pain is gone!

There are enough variations on this to make it a four week course, but in Schubiner’s examples (which he takes from real clinical practice), even something as simple as this can be enough to make chronic pain go away near-instantly. He has about a dozen anecdotes from his own practice where this happens. Then the rest of the course is just solidifying that gain and making sure it doesn’t come back.

I talked to a professor of psychoanalysis I work with about this. She says that Davanloo is well within the psychoanalytic mainstream. She says that she herself is not a big fan of his work, because she thinks it’s important to spend those several years unpeeling a patient’s defenses instead of just smashing them with a sledgehammer. But she says chronic pain patients may have unusually strong defenses and that maybe the sledgehammer approach is the right one. So overall she cautiously approves.

On the other hand, my more cynical readers might note that “well within the psychoanalytic mainstream” isn’t exactly equivalent to “definitely not a quack”. Schubiner is aware of this and has tried to get some evidence for his method. Along with a case series, he has published a study on the psychological treatment for fibromyalgia, in which 45% of the intervention group experienced significant pain relief compared to 0% of the controls. He also tested the full version of his therapy in a preliminary trial in which “two-thirds of the patients improved at least 30% in pain”.

So, should we believe him?

III.

I tried to verify some of the claims in this book and discovered things were much more ambiguous than it let on.

The idea of whiplash as psychosocial is still controversial in the literature. It’s true that some studies in Lithuania and Greece show almost no whiplash. But some critics say that these studies lacked enough power to find a difference in whiplash rates among countries even if such a difference existed. There were also extremely weird fluctuations in the data – for example, the same team in the same city doing two studies a few years apart found neck injury rates of 15% versus 47%. Here’s a long and acrimonious debate in a medical journal about this. But interestingly, even the pro-psychosocial side doesn’t seem to want to say there’s no biological component. And such a claim would be difficult to sustain given studies that show significant effects of things like head position during an accident on future whiplash rates. You can find a good summary of some of the points on each side here. Here’s another review by Dr. Arthur Croft, Ph.D., D.C., M.Sc., M.P.H., F.A.C.O., and Emmy award nominee (really) – who says, brutally:

Ferrari, et al., have recently promoted the so-called biopsychosocial model in the context of whiplash, making numerous excursions into the literature in support of it. The lynchpin of their theory relies on two studies conducted in Lithuania which purportedly followed the natural history of late (i.e., chronic) whiplash in a population of persons exposed to rear-impact motor vehicle crashes – the putative injury mechanism for acute whiplash injury. Unfortunately, “fatal” errors in study design in both cases prevented meaningful interpretation of their results, not the least of which was that only a small portion of their cohort actually had an acute whiplash – the necessary precursor for late whiplash. Our post hoc power calculation revealed that their cohort was inadequate to support any of their conclusions. Unfortunately, many authors – since these flaws were pointed out – have failed to be dissuaded from citing this literature in support of the biopsychosocial theory, particularly those authors from the camp of the nonbelievers. These Lithuanian papers, it should also be noted, stand alone as outliers to more than 50 other published reports of outcome over the past 45 or so years, and arrive at some rather improbable conclusions that almost immediately beg some questions. In the first paper, the results suggested that persons exposed to whiplash mechanisms would have about the same long-term neck pain as age-matched uninjured persons in the population. In the second study, acute whiplash trauma exposure seemed to actually have a protective effect, somehow immunizing these people against future neck pain. Again, these findings would be particularly interesting if the studies had the added virtue of being valid on a statistical and methodological basis.

To these I would add that even if a US-Lithuania whiplash rate difference existed, it wouldn’t necessarily have to be psychological. Some people bring up Americans having bigger cars; other people bring up differences between American and European car seat headrest design, and still others bring up differences in US and Lithuanian diets and lifestyles which might affect pain and healing.

The book’s treatment of back pain also raises some concerns. It is definitely true that the relationship between back pain and radiographic findings is way lower than anybody wants to admit, and that MRI isn’t very useful for diagnosis. That having been said, the relationship is not zero. For example, in this study, patients with the highest level of radiographic degeneration were 4.5x more likely to be in the highest back pain category compared to patients with the lowest level of radiographic degeneration. The correlation is not one, but neither is it zero. Some people with lots of back pain will have no radiographic findings, and some people with lots of radiographic findings will have no back pain, and the relationship is weak enough that using MRIs for diagnosis is heavily discouraged, but in general the two have a positive and significant relationship. See for example here, here, and here. I don’t know to what degree this affects the book’s thesis, but it seemed important to point out.

Nor is there any more clarity about the relationship of back pain to job (dis-) satisfaction. I was able to find three meta-analyses on it. One of these, Linton, said that:

The available literature indicated a clear link between psychological variables and neck and back pain. The prospective studies indicated that psychological variables were related to the onset of pain, and to acute, subacute, and chronic pain. Stress, distress, or anxiety as well as mood and emotions, cognitive functioning, and pain behavior all were found to be significant factors. Personality factors produced mixed results. Although the level of evidence was low, abuse also was found to be a potentially significant factor.

But Hartvingsen et al concluded:

According to recent epidemiological literature we found moderate evidence for no positive association between perception of work, organisational aspects of work, and social support at work and LBP. We found insufficient evidence for an association between stress at work and LBP. Regarding consequences of LBP, there was insufficient evidence for an association between perception of work in relation to consequences of LBP. There was strong evidence for no association between organisational aspects of work and moderate evidence for no association between social support at work and stress at work and consequences of LBP. There were major methodological problems in the majority of studies included in this review and the diversity in methods was considerable. Therefore associations reported may be spurious and should be interpreted with caution.

Finally, Hoogendoorn, Poppel and Bongers, who sound like a band for very young children, are very ambivalent. They do find some effects, but they all give off an air of desperation, eg “Low job control was found to have a statistically significant positive effect on short and long absences due to back pain, except in men in lower grade jobs and women in higher grade jobs, in whom the effect was reversed”. They are very open about this, and conclude:

“Evidence was found for the effect of some of the psychosocial work characteristics, but there is no psychosocial work characteristic for which evidence was found in all reviews…the conclusions drawn in the various reviews appear to be rather heterogenous”.

And, very significantly for our purposes:

“Having evaluated the strength of the evidence for both physical and psychosocial factors as risk factors for back pain, using the same methods, the question arises of whether the findings indicated a difference in the evidence for physical and psychosocial factors. Strong or moderate evidence has been found for heavy physical work, lifting, bending, and twisting, and whole body vibration at work. Unlike the results for psychosocial factors, these results were rather insensitive to slight changes in the assessment of the findings and the methodologic quality of the studies and in agreement with the results of previous reviews on physical load. This indicates that the body of evidence supporting the role of these physical load factors as risk factors for back pain is somewhat more consistent than that for the psychosocial factors)

The consensus in pain medicine is that pain depends on both psychological and physical factors working together. Schubiner is trying to shift that consensus to say pain is almost entirely psychological and based mainly on childhood trauma. But the studies, while not ruling out a psychological cause, are very emphatic that physical causes definitely matter. And even the papers supporting psychological causes say that, among all such causes, there is unusually little evidence for childhood abuse as a factor.

But the part that bothered me most was the use of Schofferman’s study showing that childhood trauma predicted back surgery success rate (I should note that he doesn’t cite this explicitly in the book, but he implicitly works off it, and he discussed it explicitly during the lecture). This was a surprising study that cried out for replication – and which was in fact re-tested in 2002 on a larger sample by Nickel, Egle, and Hardt. They were unable to replicate the findings. Chronic back pain patients, surgery-failing and otherwise, were no more likely to have childhood trauma than anybody else. This bothered me because Schubiner played up Schofferman’s 1991 study that supported his hypothesis without even mentioning this one. People have a right to present their case the way they want, but when someone clearly ignores better and more recent evidence, it makes me a little more skeptical of everything they say.

IV.

What about the psychiatric part of Unlearn Your Pain‘s program?

The psychodynamic therapy literature is even more of a mess than the back pain literature. I’ve been there before and don’t want to go back. You can read Jonathan Shedler and Jared DeFife in support and James Coyne and Michael Anestis in opposition. I find myself more sympathetic to the “doesn’t work very well” camp, but the field is muddy enough, and my biases against it strong enough, that I place little confidence in that judgment.

So let me try to cut through all of this with my favorite weapon for these kinds of things: behavioral genetics. Of the five behavioral genetics studies on back pain I could find, four (1, 2, 3, 4) found no shared environmental effect on back pain, with only one dissenter. This is in common with a large literature finding little shared environmental effect on a host of psychological problems including depression, anxiety, and bipolar disorder – and indeed, it would be very strange if chronic pain were more related to childhood experiences than those were.

Psychiatry tried really hard to give the “childhood trauma causes everything” thesis a go for fifty-something years. Sure enough, psychiatrists found loads of childhood trauma, because, much as pretty much everybody will have something weird with the discs in their backs that can be detected on MRI, pretty much everybody will have something weird with their childhood that can be detected with psychotherapy. Using the kabbalistic method, you can always find suspicious coincidences linking their childhood trauma with their current pain. Schubiner writes – as far as I can tell, 100% seriously – that:

When someone develops a pain in the buttocks, there may be someone in their lives who is ‘a pain in the butt’.” Someone who develops difficulty swallowing may be reacting to a situation in life that is ‘hard to swallow’. I evaluated a woman with pain in the bottom of her feet. While waiting in line one day, she realized there was a situation in her life that she ‘just couldn’t stand anymore’

I want you to appreciate how much willpower I’m showing here. There is form of psychiatry based around corny puns, and yet instead of emailing these people my resume immediately I’m trying to maintain a cautious skepticism.

And when I do, I just can’t believe it. The early psychoanalysts weren’t doing science, they were taking Sofer’s Law and running with it. Eventually we realized that talking about childhood traumas wasn’t predictive, wasn’t especially curative as per rigorous studies, and we moved on.

There’s a lot of controversy around this decision, but I think behavioral genetics has made the childhood-trauma side increasingly untenable. Assuming twin studies aren’t entirely fatally flawed – something thousands of people have looked for and nobody has found – childhood shared environment, which presumably includes things like abusive parents, just doesn’t affect adult outcomes very much. I can’t see a way to reconcile that with psychoanalytic theories and I don’t think we should keep trying.

I don’t deny that there are a lot of suspicious coincidences. But I think if we look harder, we can find that those suspicious coincidences all have more reasonable explanations. Like, yes, people with a lot of psychological problems tend to have a lot of back pain. But again, when you do twin studies:

On initial analysis considering the participants as individuals, rather than twins — and therefore not accounting for genetic and familial factors — the odds of having back pain were about 1.6 higher for those with symptoms of depression and anxiety. On further analysis of monozygotic twins — who are genetically identical — the association between symptoms of depression and low back pain disappeared. This suggested that the strong association found in non-identical twins resulted from the “confounding” effects of common genetic factors influencing both conditions. For example, genes affecting levels of neurotransmitters such as serotonin and norepinephrine might affect the risk of both conditions. Previous studies have shown a “consistent relationship” between back pain and depression — a combination that may complicate diagnosis and treatment. However, the nature of the association remains unclear. The new study is the first to examine the relationship between depression and low back pain using twin data to control for genetic and familial factors.

When you control for genetics, WHICH YOU SHOULD ALWAYS DO AND I AM SO SERIOUS ABOUT THIS, this explains the entire psychological problem/back pain link. Combined with the previous twin studies showing no effect of childhood environment, this is a very strong challenge that theories claiming a psychogenic origin of back pain based in life events will have trouble surviving.

V.

So in the end, what do we make of chronic pain?

Many, many, many people report using the techniques in Unlearn Your Pain (or the closely related techniques of Dr. John Sarno) and having good success. I don’t think this is entirely coincidence or bias. But I’m also not willing to entirely buy into this repressed childhood trauma theory.

There are definitely some types of pain which are not related to bodily injury. My best evidence for this, which Dr. Schubiner talks about too, is the people who have pain which is anatomically implausible or “migrating”. By “anatomically implausible” I mean pain that cuts willy-nilly across the body’s neural regions; pain in the distribution of the ulnar nerve may be an ulnar nerve problem, but if it has half the distribution of the ulnar nerve plus half the distribution of the median nerve, while leaving the other half of both distributions pain-free, it’s a little harder to figure out what could be causing it (especially if it’s on both sides equally!) By “migrating”, I mean that somebody has right hand pain, the doctor gives them some kind of treatment, that goes away, the next day they have right foot pain, another treatment, it goes away again, and the next day they have diarrhea. While there are very rare processes that can do something like that, when it goes on long enough that’s good evidence that the pain isn’t anatomical.

But I think the way in which pain isn’t anatomical is more complicated than the simple model that Unlearn Your Pain uses. Instead of the brain “using” pain to express repressed emotions, maybe gating and modulating pain sensations is just really hard.

Let me give an example [trigger warning for inducing mild bodily discomfort]. Right now, you’re suddenly aware of the feeling of your tongue in your mouth. And right now, the top of your head is suddenly really itchy. Also, right now something is wrong with your saliva and you’re swallowing consciously, but it feels awkward and you’re worried something might be wrong with your throat.

This isn’t because I have magic powers inflicting these things on you, it’s because you’re constantly receiving all sorts of sensations and your brain effectively gates and modulates them. You’ve always got micro-itches and micro-pains going on everywhere – no part of your body is one hundred percent optimal and even if it were there are still variations in neural noise – but your brain usually correctly decides these aren’t worth your time. It’s only when something forces you to focus on them – whether worry about a back injury, or an annoying blogger – that they make it through.

All psychiatric disorders are heavily comorbid. People with one or more of depression, anxiety, OCD, anorexia, autism, gender dysphoria, PTSD, et cetera are many times more likely to have all of the others, and it doesn’t just seem to be in a boring “OCD is depressing and makes me anxious” sort of way. All of this seems to relate to a general factor of neural messed-up-ness. It wouldn’t be surprising if this correlated with some kind of messed-up-ness in the neural systems that are supposed to process and gate pain.

Remember also that stress can cause relapses of many very biological and serious diseases like ulcerative colitis, multiple sclerosis, or epilepsy. Also, inflammation seems to be a shared and complicated factor between various bodily illnesses, stress, and depression. So for stress to cause a “relapse” of chronic pain, all we’d need is for it to put extra pressure – whether through inflammation or some other method – on an already slightly messed-up pain-gating system in the brain. And then there’s muscular tension, which I inexcusably forgot to mention until now but which is also a relevant system by which stress affects chronic pain.

We know that pain is very sensitive to the placebo effect – I’m generally a placebo effect skeptic, but even arch-skeptics Hróbjartsson and Gøtzsche agree that pain is one of the few places where the placebo effect really dominates. This is why we so often see faith healers and saints and miracle water from Lourdes treating pain so effectively – at least briefly. It’s why homeopathic treatment for pain shows such an amazingly good effect size.

And, I will say cynically, it’s why so many people have reported (genuine) success from Unlearn Your Pain and related programs. It’s why Schubiner writes:

I believe that each and every person with Mind Body Syndrome can get better because it is possible to overcome MBS by using this program. Those people who are unable to accept that their symptoms are due to MBS, or who do not develop positive expectations of relief, or who are unable to believe that they can make changes in their health and in their lives are the people who are less likely to improve.

Part of me wants to say that we have a word for medical treatments that only work if you believe that they will, and it rhymes with “gazebo”.

Another part worries this is unfair. If the placebo effect comes from the brain’s ability to gate pain, then saying “You’re not really affecting the brain’s ability to gate pain, it’s just the placebo effect” stops making sense. It’s not that it doesn’t work and is just placebo – it’s that it does work, via placebo.

There’s something to be said for glorifying in the placebo effect, laying it on as hard as possible, putting on the fanciest robe and wizard hat you can find and saying “I CAST YOU OUT BY THE POWER OF PLACEBO, GO FORTH AND SIN NO MORE!” I think in some ways there can be better and worse placebo therapies just as there can be better and worse real therapies, placebo therapies that activate the placebo effect only a little and don’t help much, and placebo therapies that activate the placebo effect really strongly and use it to work miracles. Maybe we should give more status to the best placebo therapies, to view them as highly perfected works of the placebomantic arts in the same way that powerful medications are triumphs of psychopharmacology. I think psychodynamic therapy and everything descended from it would have a high place in that pantheon.

In that sense, I think Unlearn Your Pain might be a useful book. I think that even if I accept what I consider the consensus theory of chronic pain – genuine (if small) lingering injuries (or nerve sensitization from such) interacting with a poorly-wired pain gating system in the brain which is highly susceptible to placebo effects – Unlearn Your Pain remains a useful book, as the distilled wisdom of many years of work trying to activate those effects as strongly as possible.

Another possibility is that the active ingredient isn’t the intensive psychotherapy, it’s the belief that the pain is caused by Mind-Body Syndrome. It seems just possible that this belief could break the cognitive loops that seem so relevant in all of these processes.

So I guess I’m in a weird spot in terms of what I think of Unlearn Your Pain.

I think it’s definitely right that a lot of pain has psychosomatic components. I think it probably helps treat psychosomatic pain, maybe really effectively, and partly for the reasons that it thinks it does.

But I’m not convinced by its more sweeping claims that physical injuries play little-to-no role in chronic pain. Along with Schubiner’s talk of nerve sensitization, one can imagine a scenario in which alternatively apparently-healed physical injuries may leave very small irritations on local nerves, and that the degree of irritation a nerve is able to bear without giving you chronic pain is related to your general neural-non-messed-upness and stress level. In such a scenario psychological factors might play a role in gating the pain, or in tensing or releasing muscles around the pain, but would not entirely explain it.

I’m also not convinced by its claims that childhood trauma has any interesting relationship with pain, nor that trauma-related therapy has a unique non-placebo ability to deal with such pain. I think that childhood trauma is overemphasized throughout psychiatry and that this theory of pain represents a step in the wrong direction. If trauma-related therapy works, it works by a nonspecific process of making people feel like they’re doing something useful and taking their attribution for their pain off of bodily processes.

Niels Bohr used to hang a horseshoe above the door to his office, saying “I’m not superstitious, but I hear this works whether you believe in it or not.” Part of me is tempted to recommend Unlearn Your Pain to my patients on the same principle. And if any readers of this blog have chronic pain and want to try to the month-long self-help therapy course in this book, I would be very interested in hearing back from you (please tell me before you start, so that there aren’t response biases). If the $25 price of this book is the difference between someone in that category trying vs. not trying it, I’m happy to send you the book if you agree to get back to me with your results. Contact me at slatestarcodex@gmail.com if you’re interested in this.