Today the medical sphere may offer us good examples of how the existing diversification of approaches and methods towards the treatment of people is related to the fundamental shifts in our perception of the old problem of finding the connection between the human body and the mind. In fact, on one hand medicine as such is on the most fundamental level an inherently conservative filed of knowledge and practice because what is at stake for a doctor is often the very human life, the value of which overthrows any possible dubious methods of treatment that may lead to the lack of positive results, or even to negative ones.
On the other hand, as we are constantly learning new things about such an intricate structure as the human body is, it becomes clear that phenomena that had been thought understandable in reality have a much more complicated nature, which requires elaboration of existing scientific approaches, or even demands refusal from some of the traditional medical postulates.
To grasp challenges that arise from such shifts in our understanding of mind-body connection we may consider perhaps too extreme examples – numerous schools of the so-called New Age medicine which under the pretence of the break-through knowledge all too often advance simply untenable and absurd claims based on mere speculations (Reisser, Reisser, and Weldon, 1988, pp. 147-52), and the overly sceptical defenders of the traditional Western medicine who may tend to be too inflexible in their admission of the validity of alternative approaches to medical treatment of people.
More specifically, the matter of the influence of human psychological processes on what has traditionally been considered purely physiological disorders is one of the most inflaming causes of disagreements between the mentioned approaches. This tension that in one form or another is ongoing between representatives of different medical camps to a large degree defines the modern discourse of approaches to the medical treatment (Miller, 2003, pp. 185-187).
In this regard, it would be interesting to closely investigate the existing literature that represents the current state of affairs in the perception of the connection between the mind and the body. As a suitable object of our analysis may serve the book written by Doctor of Medicine John E. Sarno, a Professor of Clinical Rehabilitation Medicine at the New York University School of Medicine, and attending physician at the Howard A. Rusk Institute of Rehabilitation Medicine at the New York University Medical Center.
His best-selling work “The Mindbody Prescription: Healing the Body, Healing the Pain” belongs to the list of the most popular books that highlight academic and practical achievements in the field of psychosomatic medicine, a school of medicine which is based on the principle of unity of the mind and the body, and which aims to examine the mechanisms of the interdependency between emotions and bodily functions and to promote psychological methods of medical care (Levenson, 2004, pp. 3-66).
The combination of the academic approaches of the author to the support of his material and the popularity of the book among lay people to whom it is largely addressed suggests that on the example of this work we may judge the level of penetration of what could unanimously be perceived alternative medicine not long time ago into the modern medical discourse. With all this in mind, let us examine the volume of John E. Sarno in the context of its connection as of a textbook of applied psychosomatic medicine with the modern medical paradigms.
For this purpose, we will briefly outline the history of psychosomatic medicine, then will try to link it with the book of Sarno, and in the main body of the paper will provide the book report with relevant comments on the book`s contents. Background on psychosomatic medicine The origins of the psychosomatic medicine can be found in the teachings of early Western philosophers and physicians who acknowledged that emotions played an important role for the human health (Cacioppo, 1989, p. 589).
Still, the Western medicine has traditionally been more inclined towards the study of the significance of bodily functions (Loudon, 1997, p. 238). However, by the middle of the nineteenth century the level of attention to the involvement of emotions in diseases development grew as the observational evidence was accumulating that had suggested that some disorders were not always accompanied by organic affections (U. S. National Library of Medicine, 2005).
For example, only since the seventeenth and the eighteenth centuries such a neurosis as hysteria began to be linked with emotional factors and the nervous system in general. Even Sigmund Freud participated in the study of symptoms of hysteria, and one of his conclusions was that they are based on memories linked to mental traumas which under certain conditions may intrude in the processes of somatic innervation. In this way, a possible mechanism for the interaction between mind and body was offered that was reminiscent of mechanisms that Sarno would be describing in his book.
The German psychoanalysts Georg Groddeck even went as far as claiming that psychological mechanisms engendering hysteria can be applied to all somatic diseases which from this point of view are the bodily manifestations of unconscious psychological processes. In the 1930s psychoanalyst Franz Alexander attempted to find a compromise between the Freudian theory, such views as those of Groddeck, and existing knowledge of physiology.
He was against excessively psychological interpretations that ignored the automatic mechanisms in the body that to a large degree directed emotional expressions. The theoretical basis developed by Alexander contributed in the United States to the invigorated extensive research of psychosomatic mechanisms, and psychosomatic medicine as a separate field of study was formed in 1939 when the medical journal dedicated to this branch of medicine was published.
After that time, psychosomatic medicine was only gaining momentum. For example, World War II spurred the interest to it due to numerous manifestations of psychosomatic symptoms in soldiers. Eventually, by the 1950s interest to psychosomatic medicine and its scientific background grew so much that its concepts entered the popular culture as media started to publish numerous articles and thus popularized psychosomatic theories (U.
S. National Library of Medicine, 2005). Now, fast forward to today, and we can witness that many of the postulates of psychosomatic medicine are already among the undisputed popular opinions of many people, and for instance the maxim that in order to stay healthy a person should avoid excessive stresses and disturbing emotional states is among the most frequently heard ones in both media sources and in our everyday interaction.
However, after the surge of academic interest to it half a century ago, psychosomatic medicine, in contrast to its successful penetration into the public perception, somewhat lost momentum within scientific circles in the second half of the twentieth century (Kennedy, 2004, p. 400). So, it is in such circumstances that the book of John E. Sarno “The Mindbody Prescription: Healing the Body, Healing the Pain” saw the light of the day. The book of John E. Sarno in the larger social and historical context
“The Mindbody Prescription: Healing the Body, Healing the Pain” builds upon themes from Sarno’s previous book “Healing Back Pain: The Mind-Body Connection” that advanced the idea that the cause of back pain, headache, slipped discs, and other chronic forms of pain is actually rooted in our psychology (Sarno, 1991). In “The Mindbody Prescription” Sarno adds new knowledge about the psychology of emotionally stimulated physical manifestations, and elucidates how such emotions as anger, anxiety, guilt, and other negative mental states can cause mental stimulation of negative physical symptoms.
Thus, in both of those books the author touches upon very urgent topics for the modern American society in which an increasing number of people are plagued by back, neck, or limb pain. In fact, this is a serious economic problem as well, as industries in which large percentage of people are working at computers bear significant health insurance burden due to a variety of similar disorders causing pain, like fibromyalgia or repetitive stress injury (Sarno, 2005). More generally, pain as such in its different forms is a crippling problem for many individuals in both their professional and private lives (Margoles, 1998, pp.
9-32). So, “The Mindbody Prescription” addresses precisely this disturbing epidemic as it analyses clinical data to find the main cause of the pain disorders, and elaborates methods to treat those disorders. Importantly, in doing so the author tries to fill the gap existing in the traditional methods of chronic pain treatment that are apparently unable to stop this pain epidemic. From the very beginning of the main body of the volume it becomes clear for a reader that the author adopts a holistic approach to his subject.
More specifically, Sarno opens the first chapter of the book with construction of various typical and stressful scenarios that in one form or another take place in lives of many of us and contribute to chronic physical pain that people experience. What is untypical, though, is that Sarno from the very beginning of the book begins to draw our attention to what could be considered as a minor element of those scenarios, but what in reality, according to the author, underlies the different manifestation of the pain disorders.
This significant element is the factor of unconscious anger or outright rage that Sarno envisions as inevitably accompanying all of the scenarios that he delves in, like our troubles with private life, or within family, or career-related frustration, and many other different “or” that Sarno repeats in succession to bring home to us his case of unconscious mechanisms that generate anger in so many people.
Now, this initial attention to the emotional side of our life is in a good agreement with our above observations about the widely acknowledged role that our mind plays in our health, and the author as if resumes that the existence of the definite connection between our emotional experiences and our bodily health is factual. But, judging from the way he begins his work, what we can expect from Sarno is the elaboration on the exact mechanisms that keep the mind-body connection running, especially as the author immediately claims that the disorders that he is about to discuss “. . .
are neither illnesses nor diseases, but rather symptomatic states induced by the brain to serve a psychological purpose” (Sarno, 1998, p. 3). After all, while general public does not always bother to verify its views, practitioners of classical pathophysiology would surely expect solid support of any claim related to the emotional aspects of diseases and illnesses and to the connection between pain problems and stress. At the same time, having chosen the non-technical style of presentation Sarno procured the easiness of reading for common people whose pain-related problems are the actual target of the book.
The structure and the contents of the book “The Mindbody Prescription” consists of three parts preceded by an extended preface and an introduction that deals with a historical perspective of the book`s theme. The preface and the introduction of the book summarize theories and experience of Sarno with treatment of back pain and other types of musculoskeletal disturbances. Naturally, already in the opening parts of the work the emotional foundation of the pain is emphasized.
In the end of the book we can find a thorough appendix, which provides supportive citations for conclusions of Sarno, and a bibliography which refers to articles that cover physical and psychoanalytic issues related to chronic pain and its treatment. In the first part of the book Sarno reflects upon concepts underlying mind-body medicine, and exemplifies influences that physical stress and such psychological states as feeling of guilt, anxiety, depression, or personality disorders have on the range of symptoms manifested in patients.
Sarno categorizes the range of painful symptoms that may arise due to psychological processes as belonging to what he terms Tension Myositis Syndrome (TMS), which is a painful condition that develops in the back, shoulders, neck, or buttocks, and may equally arise in other parts of the body, and which throughout the whole book would be the main object of study for the author.
But before shifting to investigation of concrete instances of TMS-related maladies, in order to justify his principal claim that chronic pain symptoms are in reality a kind of a defense mechanism used by our brain to distract our attention from our unconscious emotions of anger, Sarno copiously refers to the prominent figures whom we have discussed – Sigmund Freud, Franz Alexander, and some other defenders of the theory of psychoanalysis like Stanley Coen and Heinz Kohut.
I believe that this approach is beneficial as it helps readers appreciate the historical inheritance that underlies basic conceptions of the psychosomatic medicine, and thus provides a firmer footing for beliefs held by many people who have had successful experiences with psychosomatic approaches to treatment of illnesses. Aside from the references to important figures in the history of psychosomatic medicine, the first part of the book also elaborates a distinct and well-structured explanation of the concepts constituting the basic principles of mind-body interaction.
In the process of such explanation the author mentions such fields of study and such medical and psychological notions as neurophysiology of psychogenic disturbances, problems of psychosomatic origin, and reactions of conversion (which is one of the types of interaction between the mind and the body when unconscious elements of human psyche intrude into somatic processes) (Sarno, 1998, pp. 173-174).
Sarno also mentions the findings of Candace Pert, a neuroscientist who found opiate receptors in the human brain, and who greatly contributed to the growth of our knowledge of links between biochemical processes in the brain and physiological phenomena. In this way, Sarno anchors the theme of his book in the history of psychosomatic medicine, and, even though he is mentioning some radical concepts that may be critically perceived by adherents of traditional pathophysiology, the style of Sarongs presentation is lucid and definitely absorbing.
All in all, the first part of the book serves as a bridge between the general discussion of the psychological mechanisms of emotional influence on physical disorders and more detailed investigation of psychoneurophysiology that underlies psychogenic processes. In the second part of the book Sarno closely examines his clinical experience with emotionally caused physical disorders, and is primarily concerned with various manifestations of TMS and with the possibility to extend his theory of the mechanisms of TMS emergence to other diseases and illnesses.
In fact, many of the clinical problems that he examines have already been known to have a connection to stress, which either produces them, or aggravates their effects. However, what makes the work of Sarno special is his approach to explanation of these disease states from the point of view of unconscious working of repressed anger and rage. To prove his case, Sarno has combined physical medicine with psychoanalytic theory in order to give what he believes is a proper account for TMS, which, according to his practice, is the main cause of musculoskeletal and back pain.
For Sarno, the origin of painful manifestations of TMS lies in repressed emotions. And the pain in various parts of body as such is theorized by the author as being caused by a diminution of blood flow to the corresponding tissues. This process of blood flow reduction is mediated via the autonomic system as a stressful reaction of brain to repressed emotions. We may chart the TMS pathophysiology in the following way: The formation of unconscious repressed emotions (anger/rage); ? Abnormal patterns of autonomic system`s activity; ? Decrease of the level of local blood circulation; ?
Development of mild oxygen deprivation; ? The resulting pain in muscles and other possible symptoms (for example pain in tendons, tingling, numbness, weakness). Having established such a mechanism of the emergence of pain, Sarno surmises that this approach from the TMS formation theory can as well be applied not only for the fixed number of cases of muscle and back pain, but to a wider range of physical disturbances. In this light, Sarno earlier pointed out that in a 1975 survey it had been found that “88 per cent of patients with TMS had histories of up to five common mindbody disorders” (Sarno, 1998, p.
29). And, indeed, Sarno manages to extend his theory of the emergence of pain disorders to migraine, to such various conditions as carpal tunnel syndrome, fibromyalgia, colitis, peptic ulcer, post-polio syndrome, infections, skin disorders, and even to more unusual instances like the chronic pain that accompanies Lyme disease, which is caused by bacteria transmitted through ticks. The author also mentions disorders in which emotions might be involved, among which are atherosclerosis, hypertension, one of the most common heart problems termed mitral valve prolapse, and even cancer.
Of course, with such a broad scope of concern at hand Sarno has to offer an adequate methodology for unambiguous diagnosing of emotionally induced pain. For this purpose, his requirement is that the TMS diagnosis can be ascribed to a patient only if traditional physical exam failed to uncover existing abnormalities. However, according to the author, even in the presence of an abnormality TMS still can be working in a patient and exasperate the pain to the higher level than the found abnormality itself would be capable of.
In the third part of the book Sarno discusses approaches that may effectively treat TMS and related physical disturbances. From what we have observed before it should already become clear that Sarno essentially assigns to the pain the function of a defense reaction that aims to divert our consciousness from the need to face repressed anger or other unbearable forms of emotional strain. On ground of this, as the only possible way of treatment of the real cause of TMS symptoms Sarno postulates the examination of the physical origins of repressed negative emotions as the way for the deliverance from pain.
Generally speaking, a person has to find ways to single out those harmful emotions and roots of the unconscious anger that are undermining his or her psychological well-being. And what also makes the theory of Sarno special is that, according to him, the mere acknowledgement of certain emotional concerns, and not of any bodily abnormalities, as the ground of the deteriorated physical state is in many cases already a sufficient condition for healing.
One may not even have to remove the psychological problem itself in order to procure a visible clinical improvement. This contrasts with some of the New Age schools of psychotherapy that also associate unconscious repressed emotions with various maladies, but which require that before the healing can take place such unconscious `problem spots` must be dissolved, like is proposed, for instance, by the so-called primal therapy, a school of psychotherapy elaborated by psychologist Arthur Janov (Janov, 1999).
For Sarno, the identification of a problem is the main task for people suffering from emotionally induced physical disorders, and such identification can normally be implemented by means of an insightful self-examination, perhaps with the help of such techniques as meditation or self-affirmation (a method of compensation for the lowered self-esteem in one area by consideration of one`s proficiency in other areas (Sarno, 1998, p.
22; Nezu and Nezu, 2004, pp. 182-188). In this regard, from the point of view of Sarno it is also very important that a patient should have no doubts about the correctness of the TMS diagnosis, and that he or she fully realizes the exclusively psychosomatic origin of pain.
To bolster this indispensable perception in patients, after the mentioned thorough physical examination needed for the elimination of possibility of the presence of real physical problems, Sarno accentuates the need to educate people and to assure them that the influence of repressed emotions is a sufficient condition for the reduction of the flow of blood to the affected areas of the body which leads to the pain and other troublesome symptoms, which nevertheless should not be viewed by people as those inflicting permanent damage to the body.
Even if some structural abnormalities related to ordinary changes due to physical activity or aging are found, the patient should have a clear understanding of their nature. Basically, what is demanded from a patient is in no way the denial of the presence of the pain but rather the acceptance of its genuine origin. To help maintain such an attitude to chronic pain, Sarno recommends to patients who know that they have no physiological abnormalities to suspend physical therapy and to return to normal physical activity.
In addition to that, patients should on the daily basis remind themselves the following points: I only have a mild oxygen deprivation and not structural abnormalities; my condition stems from repressed negative emotions and is not physically harmful; TMS exists to divert my attention from emotions; there is nothing to be afraid of for me; the physical pain is not dangerous; I will not allow pain to trouble and intimidated me; I will change the object of my concern from pain to emotional experiences; it is my conscious part that will have control, and not my subconscious mind; I have to think about psychological aspects of my life, and not so much about physical. When such a set of attitudes towards the role of one`s unconscious emotional experiences and towards one`s own body is obtained, Sarno believes that the brain that aims to contain the repressed emotions will no longer be able to fool us by drawing our attention to body. To illustrate how psychological relief may have a radical influence on the chronic pain, the author offers examples of some practical cases. In one of such cases a patient knew about the most probable origin of her back pain but still did not have an improvement, and even had increased level of pain.
According to Sarno, the worsening of the pain was brought about by the last efforts of the brain to keep hidden emotions unconscious, but when the feelings finally burst into the patient`s consciousness the pain, as if miraculously, went away. Sarno documents the account of this patient: “. . . in an instant, I started to cry. . . Out of control tears, anger, rage, desperate tears. And I heard myself saying things like, Please take care of me, I don’t ever want to have to come out from under the covers, I’m so afraid, please take care of me, don’t hurt me, I want to cut my wrists, please let me die, I have to run away, I feel sick-and on and on, I couldn’t stop . . . And as I cried, and as I voiced these feelings, it was, literally, as if there was a channel, a pipeline, from my back and out through my eyes.
I felt the pain almost pour out as I cried . . . I knew . . . that what I was feeling at that moment was what I felt as a child, when no one would or could take care of me . . . the feelings were there and they poured over me and out of me” (Sarno, 1998, p. 13). However, as in order to get rid of pain we have to use our insight to understand its foundation, one may wonder that if the real cause of the pain is the repressed anger, how helpful psychotherapy may be in the healing of TMS symptoms? The author says: “The therapists to whom I refer patients are trained to help them explore the unconscious and become aware of feelings that are buried there . . .
When we become aware of these feelings . . . the physical symptoms . . . go away” (Sarno, 1998, p. 161). Still, according to Sarno, the need for psychotherapy should not arise too often. The author reports numerous cases when people did away with pain simply after having read the book and having followed suggestions contained there. In fact, Sarno claims that the percentage of those who report the improvement of their condition is as high as 90-95 percent, and that many of his patients had been living with physical disorders and pain for a large part of their lives and could not be treated by the traditional medical approaches. General critical observations
Even though the belief that emotions and stressful circumstances are related to physical conditions of people is today generally accepted, the extent to which Sarno emphasizes the role of psychological factors will nevertheless surely seem too extreme for many clinicians. Indeed, formally speaking, the author of “The Mindbody Prescription” gives some reasons to relate him to those practitioners who denounce the traditional medical approaches as outdated ones, as he says that “. . . poor medical advice . . . keep[s] your attention riveted on your body, which is your brain’s intention” (Sarno, 1998, p. 147), or that “Modern medical science studies the details of maladies but rejects unconscious emotional processes as the cause… ” (Sarno, 1998, p. 117).
On the other hand, the effort of the author to extend the validity of his TMS theory to a range of disorders which in combination are shared by significant fractions of Western societies` populations may also seem to be too ambitious and at the same time not sufficiently verified according to strict scientific standards (Wilson, 1991). In this light, while Sarno rightfully remarks that “. . . proper management [of TMS and related disorders] would alleviate much suffering and reduce the enormous cost of medical care that now burdens modern society” (Sarno, 1998, p. 126), he perhaps should also pay more attention to the fact that the majority of physicians still have doubts about the ability of psychological processes to cause chronic pain in the first place, and are more ready to agree that emotions may only aggravate physiological problems, but still in most cases should not be considered as their primary causes.
In his turn, Sarno disputes that such processes as osteoarthritic changes and herniated vertebral discs are always the immediate sources of the pain and suggests that very often they may just be coincidentally present close to affected areas that due to emotional causes are deprived of oxygen. Such views further distantiate him from the conventional approaches to treatment of these disturbances. Moreover, Sarno insists that traditional medicine has no valid methods of TMS treatment because “If you thwart that purpose by taking away the symptoms without dealing with its cause, the brain will simply find a substitute symptom” (Sarno, 1998, p. 39). In any case, despite the unconventional elements of his methods of treatment, Sarno has numerous adherents who attest to the practical applicability and effectiveness of the theory of connection between psychological processes and manifestations of TMS.
Therefore, I believe that even if Sarno is not able to provide a completely reliable from the academic point of view account of the mind-body connection, he may be practically exploring the mechanisms of the human body that the fundamental science is only beginning to test experimentally (Brush, 2005, p. 259). For example, consider the recent finding related to the famous placebo effect in which it was again confirmed that such a purely psychological factor as our expectations has not only psychological but as well physical effects on health. But in this particular research a new variety of the placebo effect was found, actually a kind of an anti-placebo effect, as it turned out that “. . .
once Alzheimer’s disease robs someone of the ability to expect that a proven painkiller will help them, it doesn’t work nearly as well. . . ” (Neergaard, 2005). This fact testifies to the power of our psychology to intervene in the what might seem as purely physiological realm of our bodily functioning, and the data is being gathered to prove that at least such a psychological factor as the placebo effect “. . . actually is physical, and that expecting benefit can trigger the same neurological pathways of healing as real medication does” (Neergaard, 2005). Now, this conclusion is in a perfect agreement with the principles underlying the theory of TMS origin advanced by Sarno.
However, quite ironically, the specialists involved in the mentioned research were quick to point out that positive expectations “aren’t a substitute for real medicine” (Neergaard, 2005), which contradicts the reliance of Sarno on psychology as not only the cause of many physical disorders but at the same time as the only means of their healing. But I suppose that if Sarno produces an impression of being too confident in the self-sufficiency of his conclusions it could only mean that due to his extensive observational experience he may just be a little bit ahead of the vanguard of the mainstream medical science. And, after all, if we want to find what unites Sarno with the conservative part of the medical establishment it is his traditional recommendation for his patients to resume full activities of daily life, including physical exercises. Critical observations about Sarno`s view of migraine as an equivalent of TMS
While Sarno devotes a large portion of his book to back pain, among other painful physical disturbances related to mechanisms that lead to TMS he mentions migraine, which is a very common condition that causes headaches, and physiological mechanisms of which are currently quite poorly understood (Cochran, 2004, p. 156). Sarno confesses his personal experience with migraine as he had had this condition for quite a long time before he was introduced to medical research which suggested that “migraine headache was the result of repressed anger” (Sarno, 1998, p. 111). As he was already amassing evidence in support of the significant influence of psychological factors on many widespread medical problems, he was inclined to test that idea.
After trying to find out what anger that he could be repressing was causing his migraine, Sarno allegedly got rid of migraine headaches for the rest of his life. However, he himself acknowledged that some symptoms of migraine still continue to happen to him, which brings us to a question whether the method of the author of the book can be applied without reserve to all the types of chronic pains that seem to have no accompanying physical abnormalities. Indeed, it may be that our lack of understanding of the causes of migraine simply leaves us ignorant of possible physiological mechanisms that underlie it, and even though approaches borrowed from TMS treatment may often be effective for removal of painful symptoms, purely psychological vision of the migraine origins may hide from us its genuine cause.
Besides, it may be somewhat alarming that the definition of migraine that Sarno advances is different from the one offered for example by the National Migraine Association. Sarno says that migraine is supposed to arise from “. . . sudden constriction of a single blood vessel within the substance of the brain” (Sarno, 1999, p. 111), while on the website of the National Migraine Association it is stated that: “Migraine is disease, a headache is only a symptom. Migraine pain is caused by vasodilation in the cranial blood vessels (expansion of the blood vessels), while headache pain is caused by vasoconstriction (narrowing of the blood vessels). During a migraine, inflammation of the tissue surrounding the brain, i. e.
, neurogenic inflammation, exacerbates the pain” (Coleman and Burchfield, 2006). Therefore, at least in the case of migraines it seems warranted to say that physiological mechanisms may be working to produce migraine independently from psychological processes, and that without knowing the exact causes and possible consequences of migraine-related tissue inflammation it is perhaps risky to adopt a strategy of assuring oneself that the pain is not physically harmful. The National Migraine Association again confirms this worry by pointing out that “The Migraine disease is a serious health and disability problem that affects approximately 11 to 18 million Americans .