TMS Recovery Program

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This recovery program was contributed by Alan Gordon, LCSW, Director of the Pain Psychology Center. Alan and his team of therapists utilize this program's approach and other techniques to help alleviate chronic pain for patients. Sessions are held both in-person for the Los Angeles area or worldwide via Skype.

Preface

This two-part recovery program was created to help those of you who are having difficulty reducing or eliminating your physical symptoms. This is a different kind of recovery program in two respects:

First of all, as opposed to providing structured daily activities, it aims to generally provide you with a deeper understanding of why you have your pain, how it’s being perpetuated, and what steps you can take to eliminate or significantly reduce it.

Secondly, I’ve always believed that it’s easier to learn a concept when you don’t just learn the theory but you see it in practice. So the majority of Part II will be demonstrated by stringing together segments from different mini-sessions in a way to cohesively elaborate on the theory. (In other words, in addition to telling you, it will show you what to do.)

This recovery program may help provide insight into certain unconscious processes, but isn’t meant to take the place of therapy. Being your own therapist is a lot like cutting your own hair: it’s possible, but it’s easier if someone else is doing it; after all, they can see things that you can’t.

I’ve found that almost everyone has the capacity to either eliminate or significantly reduce their symptoms; it’s just a matter of finding the right tools and learning how to use them. I hope that this recovery program might help you to find the tools that you need.

Introduction

If you aren't yet familiar with the TMS approach, the following article provides a quick introduction. However, if you already know the basic concepts, you can skip to the next section.

Miracles of Mindbody Medicine

Part I

Accepting the Diagnosis

It all starts with acceptance. Accepting the TMS diagnosis (believing that the pain is psychologically caused as opposed to structurally or physically caused) is a very important component of recovery. But as many of you have probably found, that’s easier said than done. Even after reading the books, seeing yourself on every page, and even possibly getting confirmation from a physician, some of you may still be struggling to fully accept (both intellectually and on a gut level) that your pain is generated psychologically.

The following clip is a talk I gave at the 2012 TMS conference. It addresses why it can be so hard to fully accept the TMS diagnosis and what you can do to overcome these barriers. As you watch, see if any of the concepts mentioned apply to you. (Do you have any conditioned responses? What counter-evidence can you compile? Have you had any “exceptions”? Etc.)

(The talk was geared toward psychologists, so feel free to disregard any terms you’re unfamiliar with. Also, don’t be confused by the term PPD, it’s just a fancy way of saying TMS.)


Accessible version of this video

See if you can identify your conditioned responses. Do you have pain when you sit? Stand? Type? Walk? Run? Swim? Read a book? Drive your car? Shampoo your hair? Go to the dentist?

The majority of TMS sufferers have at least one physical position or activity that’s linked with their pain. And it’s these conditioned responses that makes acceptance so difficult.

Below is Patricia’s evidence sheet, as discussed in the video above:

Evidence Sheet

Sat for 2 hours watching NCAA basketball tournament with no pain.
Had a therapy session where pain went from 4 out of 10 to 1 out of 10 while sitting the whole time.
Pain gets worse when husband stresses me out.
Was diagnosed with PPD by respected physician.

Spend some time compiling your own evidence sheet. Have physicians told you that there’s nothing wrong with you? Have there been inconsistencies with your pain? Do you possess the personality traits that are common with TMS? Did a stressful event precede the onset of your symptoms?

These all belong on your evidence sheet. You can add more evidence as you discover it.

Look at this evidence sheet often. Repeat these pieces of evidence to yourself throughout the day (especially when your mind starts injecting doubt).

Accepting the diagnosis is generally an ongoing process, so don’t feel like you have to achieve 100% acceptance before moving on. It’s true, acceptance can lead to a reduction of symptoms, but even truer is that a reduction of symptoms can lead to acceptance.

Reframe the Meaning of the Pain

One of the ways that you may be able to reduce your symptoms is by changing the way you think about the pain. Many TMS sufferers think about their pain all the time; mostly from a perspective of fear: “I’m not in pain right now, when’s it going to come?” “I’ve had it for so long now, is it ever going to go away?” “Nothing else has worked so far, will this recovery program be any different?”

This very common type of thinking can actually perpetuate the pain. The following article, Breaking the Pain Cycle, explains the concept of reinforcement, how you may be reinforcing your symptoms without realizing it, and what steps you can take to break this cycle.

To emphasize, your TMS symptoms themselves aren’t serving as a distraction from painful unconscious emotions, it’s the fear and preoccupation around the pain that is serving as this distraction. That’s the purpose of the pain in most cases, to generate fear. It’s for this reason that runners often get leg pain and screenwriters often get wrist pain (and not the other way around.) It’s for this reason that pain often manifests in a place where you know you’re structurally vulnerable. And it’s for this reason that some TMSers can eliminate their symptoms simply by reading one of Dr. Sarno’s books (as it can neutralize the fear associated with the pain).

Consequently, every one of those pain-themed fear thoughts is actually serving to reinforce the pain. (Perhaps you may have just had the thought, “Oh man, I’m never going to be able to overcome those thoughts. I’m doomed.” That’s another one right there. See how prevalent they are?)

Familiarize yourself with these thoughts. Spend some time watching how frequently your mind goes in that direction. Shining a light on this type of thinking brings it to conscious awareness, and it is the first step to diminishing the power of these thoughts.

In Part II, I talk more specifically about how this type of fear-thinking develops, and how to best respond when it rears its head.

Working Toward Outcome Independence

The way you respond when your symptoms arise can have a direct impact on how bad they get and how long they last.

Often TMS sufferers go through constant cycles of hope and disappointment. When the pain is either gone or minimal, there’s a desperate hope that it won’t come back, and a crushing disappointment when it does.

To eliminate your symptoms, this pattern needs to change; your objective needs to change. In the short term, the goal isn’t to prevent the pain from coming on, but to change the way you respond when it does. This is difficult but possible, even in cases of severe symptoms.

This article on outcome independence further expands on this point.

Outcome independence is an important component of recovery, but is generally only effective once you're confident in the TMS diagnosis. If you still believe that your symptoms are due to structural causes, it's difficult to be authentically indifferent toward your symptoms.

For an example of outcome independence, listen to the following clip. Christie has had hand/wrist pain every time she's typed or texted for the last two years. We did a brief outcome independence exercise, her typing while I was talking, and by the end of it her pain had disappeared.

Listen to Alan's session with Christie

Of course, the next day her pain was back. Rome wasn't built in a day. But over the next few weeks she was able to use these techniques to get rid of her pain for good.

Hopefully some of the previous steps can help you alter the way you respond to your pain, and work toward a feeling of empowerment.

To discuss this program, click here.

Part II

Part II focuses on what’s going on underneath the surface. Often the abusive or neglectful way that we treat ourselves, consciously and unconsciously, can lead to the development of symptoms.

The underlying message of Part II can be summed up in four words: be nice to yourself.

Of course you’ve probably heard this many times, and it’s about as useful as telling you to grow six inches or change your eye color. What I aim to outline is how you may be treating yourself cruelly, show you what it looks like, and teach you what you can do to change that.

Generate Self Compassion

Before getting into it, I’d like you listen to a segment of a session I had with Brandon during one of the TMS webinars. Brandon beats himself up, pressures himself, and scares himself. But what’s most alarming is that he doesn’t seem to care. If you’re not invested in how you’re being treated, it’s a lot harder to change that behavior.

Pay particular attention to the stance that Brandon takes toward himself, and to the shift in his attitude over the span of eleven minutes:

Listen to Alan's session with Brandon

Around the 9 minute mark, Brandon starts to care that he treats himself poorly. It matters to him. Essentially, he begins to generate self-compassion. This is so important, because you need to care about the fact that you’re suffering before you can really work toward changing it.

The following technique can be helpful in generating self-compassion: Exercise in Generating Self Compassion

Recognize Destructive Behaviors

In many cases, people aren’t even aware that they’re treating themselves in an abusive or neglectful way.

Look at Brandon. When I ask him about ways he may be treating himself poorly, he responds, “I don’t drink, I don’t smoke, I don’t do drugs,” oblivious to the fact that that what he’s doing to himself psychologically could be just as damaging.

In these cases, recognizing and identifying the destructive behaviors is essential.

Let’s start off with abuse. There are three primary ways that people psychologically abuse themselves.

The first is criticism. People beat themselves up all the time. Some of the more general messages might be, "You're worthless" or "What's wrong with you?" More specific (and more subtle) examples might be, “How could you have screwed up that presentation?” or “You’re not talking enough, you’re so boring.”

These messages are toxic. Would you talk to someone you care about this way? Why would you treat yourself worse than a loved one?

Click here to listen to an example of self-criticism

Another way people abuse themselves is by putting pressure on themselves: “You’re not working hard enough,” “You’re not making enough money,” “You need to lose more weight.”

When you put pressure on yourself, it carries the underlying message of, “You have to do this or else…” You may not be saying these words, but that’s how our primitive minds interpret this pressure.

It’s like having a drill sergeant in your head.

A lot of clients I’ve worked with feel like the pressure is their friend. “If I didn’t put pressure on myself, I wouldn’t get anything done. I’d just lay around all day in my sweat pants eating bon bons. The pressure helps me accomplish things.”

In reality, the opposite is often true. Pressure can be a motivation killer. Remember how much more enjoyable it was reading a book for fun than when it was assigned for homework? Discipline can exist without pressure. You can be free to work on things with a sense of joy, instead of a sense of a heaviness. Some clients have told me that when they stop putting so much pressure on themselves, they actually become more productive.

Click here to listen to an example of pressure

Finally, one of the most common ways people abuse themselves is with fear. “What if I don't get better?” “What if the pain is structurally caused?” “What if I never get married?” “What if no one likes my cooking?”

This is like having the boogeyman in your head. And our primitive minds can’t tell the difference between a physical threat (“There’s a tiger behind that bush”) and a psychological threat (“What if I fail my midterm?”) So these fear thoughts throw us into a state of fight-or-flight.

Click here to listen to an example of fear

Abusing yourself in these ways can have consequences. Just as a child might rebel if treated abusively or neglectfully, the body can rebel as well in the form of pain, anxiety, or depression.

The following exercise might help you better identify some of these destructive thoughts: Exercise in Recognizing Destructive Behaviors

To discuss this program, click here.

Identify Source of Abuse

Where do these abusive habits come from? Often the way we treat ourselves is based on messages we get when we’re younger.

Maybe your mom made you feel bad about yourself.
Maybe your dad got excited when you got good grades and was bummed out when you didn’t.
Maybe your grandmother ignored you as a form of punishment.
Maybe your dad had epilepsy and unintentionally terrified you each time he had a seizure.
Maybe you had an older brother who got all the attention.
Maybe your mom was depressed and you were preoccupied with making her feel better.
Maybe your dad was irrationally anxious and you never felt completely safe.
Maybe you were one of eleven kids and you made yourself invisible because you saw how overwhelmed your parents were.
Or maybe your home life was relatively trauma-free, but you were bullied in 7th grade, went to an ultracompetitive high school, or your college girlfriend cheated on you.

There’re many different reasons why you could have come to develop this inner bully. Sometimes it can help to understand why. Sometimes it doesn’t matter.

A word about the inner bully. It’s you, but it isn’t you. A lot of clients that I work with have a difficult time getting angry at the part of their mind that abuses them, because they feel they are getting angry at themselves. Brain imaging research and studies on split brain patients have shown that many of our thoughts and feelings come from a place of our mind that is out of our conscious control. Like dreams. Consequently I’ve found it best to think of the inner bully, this destructive side of our minds, as coming from someone else, not the “I” that you identify with.

There’s often an irony in learning about the way you abuse yourself.

When I point out to clients that they seem to beat themselves up a lot, they often respond, “You’re right. What the hell’s wrong with me?”

When I point out their tendency to pressure themselves and the impact it has, it’s, “I need to change this immediately!”

And with those that terrify themselves, “I don’t think I’m ever going to be able to stop this!”

It goes to show that the mind is so clever, even awareness of these tendencies aren’t enough to change them.

Later on in the program, I’ll address how to alter these abusive behaviors, but for the time being I’d like to focus on learning to recognize them.

Mindfulness

One of the best ways to learn to recognize your thought patterns is by utilizing the technique of mindfulness. It’s a great way to discover the messages you subtly give yourself, and for you perfectionists out there, could eventually lead to spiritual enlightenment. But let’s take it one step at a time.

Click here for a mindfulness exercise

If you want to learn more about mindfulness, I recommend the book, “Fully Present” by Susan Smalley and Diana Winston.

Address Repression

Part of treating yourself nicely is learning not to neglect yourself. I'm not talking about ratty t-shirts or chipped nail polish, I'm talking about emotional neglect.

Often, people have feelings come up that are difficult to tolerate, and unconsciously send them away. This is known as repression. To avoid these uncomfortable feelings, our minds employ defense mechanisms like pain or anxiety.

Sadness

The following is a 7 minute segment of a session with Ginger. Ginger didn't get her emotions validated when she was young, and subsequently developed a number of defense mechanisms to keep feelings of sadness from reaching the surface.

Listen to Alan's session with Ginger

Sadness is one of the most common emotions that people repress. Ginger’s unconscious mind is working hard to keep her from her sadness. I ask her what she is feeling and she tells me what she is thinking. I ask her about her sadness and she starts telling me why she is sad. These are defense mechanisms in action. And we can see why her defenses are so entrenched. She (her emotional brain, not her logical brain) has the belief that once the floodgates opened, she will never be able to shut them.

Assuming it’s an emotion you tend to repress, increasing your capacity to tolerate sadness is important, but there’s more to it than that.

Linking the sadness to the way that you’re being treated (by your own destructive side) can really give it meaning. It’s a healthy form of grieving for the suffering you’ve undergone. Additionally it’s a wonderful way to further generate self-compassion.

The following session with Kelly exemplifies this concept.

Listen to Alan's session with Kelly

Anger

Anger or rage is another emotion that people tend to repress. Many people think they don’t repress rage (or “If anything, I express it too much”). If you beat yourself up a hundred times per day or scare yourself all the time, and don’t feel any rage toward this inner bully, you likely repress rage.

If you get angry very easily at family members, neighbors, bad drivers, inanimate objects, Kobe Bryant, Barack Obama, or Fox News, this is displaced rage.

As I discuss in the following session, rage is more than just anger. Human beings have the capacity for deep, primitive, even murderous rage. Have you ever seen a one-year-old get angry when you take their toy away? They’ll hit, kick, they’d kill you if they could. Often aspects of our upbringing, or just living in a culture that looks down on rage can lead to repression of this emotion.

I want to emphasize that it isn’t necessary to express this rage in order to heal. You don’t have to beat up your boss, you just have to connect to the feeling that your boss brings up within you. Expressing it is an option (though I’d recommend that you do this assertively, not aggressively; and maybe not to your boss), but it isn’t necessary.

The following session is intense. Just a warning. Dustin has a tendency to repress his rage, and gets in touch with it in a very meaningful way. The specific approach that I used during this session is called Intensive Short Term Dynamic Psychotherapy (ISTDP). It’s geared toward aggressively confronting defense mechanisms and targeting repressed emotions.

Listen to Alan's session with Dustin

You can see the barriers, both conscious and unconscious, that Dustin had in place to keep from feeling this rage, and the calmness that came over him once he did. Often when you get in touch with such powerful feelings, guilt or love can come up as a result, and it’s important to process those as well.

As I mentioned during the session, the primitive part of our brain doesn’t know the difference between fantasy and reality. This is why when you’re watching the movie Die Hard, your heart is beating 180 beats per minute. Your primitive brain doesn’t know that you’re not the one trying to take down Hans Gruber and his gang of terrorists.

Allowing yourself to imagine unleashing this rage, as Dustin did, can bring a feeling of relief.

This is most effectively done with the guidance of a therapist who has experience in this area.

To discuss this program, click here.

Identify Source of Repression

There are different reasons we learn to repress emotions.

You may repress sadness or anger because these emotions weren’t validated when you were young. Perhaps you were even shamed for expressing them.

Maybe your parents got so sad or so angry, that it was terrifying and you unconsciously decided you never want to be like them.

Perhaps it simply wasn’t modeled by your parents and your four-year-old brain interpreted this as meaning that it must not be okay.

Maybe you didn’t want to overwhelm your parents with your emotions if you felt they couldn’t handle them.

Or maybe you don’t know why, which is okay too.

Feel Your Feelings

One of the biggest barriers that people face in attempting to feel their feelings is that they often go through the wrong channel.

Perhaps a symptom is coming on, and you ask yourself, “Okay, what am I feeling now?” And you try to figure it out logically.

“Let’s see, I had to work late yesterday which I wasn’t happy about. And my boss didn’t even thank me, and I know that my parents never paid me much attention so I’m particularly sensitive to feeling ignored. So my needs weren’t acknowledged and I was made to feel invisible…I must be angry!”

This is an interesting thought process, but doesn’t do much to help you. We develop symptoms because we’re not feeling our feelings, not because we don’t know what our feelings are.

Using logic to try and get to your feelings is like going to a Chinese restaurant and ordering in Spanish. You’re using the wrong language.

Recent research has shown that emotions first manifest as physical sensations. One of the things you may have noticed from the past three clips is that I would ask, “What does this emotion feel like in your body?” This is the language of emotions.

Sadness can feel like a heaviness in your stomach or chest and perhaps a softness around the eyes. Anger can feel like a hot, powerful feeling in the stomach that’s rising up through the chest and head. (These are simply examples as there isn’t a right way to feel feelings. Everyone is different.)

When someone tells me they’re sad or angry or happy or guilty, I’ll often ask, “How do you know?” Bringing your attention to the sensations in your body is a great way to practice connecting with your emotions.

Stand Up to the Inner Bully

When you’ve developed the self-compassion to care about how you’re treated, and you have the capacity to feel anger, it’s a lot easier to stand up to the mom, dad, older brother, or high school bully in your head.

When you hear this internal bully criticizing, pressuring, or terrifying you, let yourself feel the justified anger that such mistreatment warrants.

“How dare you!” “Get the hell out of here!” Or imagine yourself punching the bully in the face.

Choose your own words or imagined actions. They don’t matter as much as the feeling behind them. You’re being bullied, terrified, pushed around. Imagine if you had a child in kindergarten who was being bullied on the playground by a second grader. The rage would come naturally, you wouldn’t have to force it or fake it. When you truly care about yourself, you can respond to this internal abuse in the same way.

Let’s link this back to your symptoms. As I mentioned in Part I, the purpose of the pain in most cases is to scare you. Your inner bully is using this pain as ammunition to abuse you.

So how are you going to react? Will you cower? Pile on even more? Fall at the mercy of the fear? Or will you stand up for yourself?

As I mentioned earlier, it’s not about preventing the pain from coming on, but changing the way you respond when it does.

The following clip is from a TMS supervision teleconference I did last year. In it I discuss a TMS symptom that arose in me just moments before, the way I responded, and the subsequent result. It’s a great example of the inner bully attempting to use pain as a vessel for fear.

Click here to listen

When you first change the way you respond to the onset of pain, don’t expect it to go away as quickly as it did in my example. It takes time, patience, and repetition, but once you overcome the fear of the symptom, you can often eliminate the pain pretty quickly when it comes up.

If you stand up to this inner bully with a desired outcome in mind (e.g. getting rid of your pain), it’s inauthentic and just a subtle form of pressure. If you generate anger because you’re genuinely upset that you’re being treated cruelly, that’s when you’re on the right track.

Here’s an exercise that may help you explore and express feelings of anger toward this inner bully: Inner Bully Exercise

Provide Comfort

There’s more to it than standing up for yourself. When your hypothetical kindergartner is getting bullied, you don’t just head down to the school to protect him, you comfort him too. He needs to know that he’s safe.

Many of us were never truly soothed growing up or comforted when we were scared. Subsequently we grew up feeling on a primitive level that the world isn’t safe. Learning to comfort yourself, not with logic or rationale, but on an emotional level can help teach this primitive part of you that you’re safe.

Listen to Alan's session with Mandi

The pain scares you. When you feel this fear, try and soothe yourself. Give yourself the comfort that you may not have received when you were young, or that you may have received but are now withholding from yourself.

I’m often asked, “How do I know when to respond to the fear with anger and when to respond with comfort?”

It’s a funny question. When you see your child getting pushed around by an older kid, you don’t have to ask, “Should I comfort him or should I stand up to the bully?” You just know. Because you feel it.

Try not to look at it as a formula. You care about yourself. When you feel yourself getting abused, sometimes you want to be soothed, sometimes you feel anger toward the abuser. See what works for you. Follow your gut. And whatever you do, don’t constantly question whether you’re responding in the right way. That’s just more fear (see how sneaky it is?)

The following technique is a great way to disarm your fight-or-flight response, and provide an underlying sense of safety: To Fear or Not to Fear

Prioritize Yourself

Just as you can use anger as a tool to stand up for yourself when you’re being abused, you can likewise use it as tool when you’re being neglected.

People often prioritize external things over their internal sense of comfort. You feel anxiety when you’re running late, you feel judged when you’re at a party, you’re stressed out when you’re studying for a midterm.

The standard question you can ask is, “What’s more important, x or me feeling comfortable right now?” Unless x is your physical safety, your family’s welfare, or the Lakers making the finals, it should pretty much always be the latter.

“What’s more important, getting to my appointment on time or feeling comfortable for the next 20 minutes?”

“What’s more important, what this random person thinks of me, or feeling content in this moment?”

“What’s more important, being perfectly prepared for this midterm, or feeling free of anxiety?”

Of course, the implication isn't that you should avoid all the responsibilities that cause your stress, but that you do what you can to meet these responsibilities while simultaneously prioritizing yourself.

For example, you still need to study for your test, but you can prioritize being in a calm state while doing so.

Our inner child doesn’t like it when we deprioritize ourselves. It sends the message that our needs don’t matter.

When you recognize that you’re neglecting yourself, you can use anger as a tool to take the power back. Just as you felt rage toward the inner bully, you can feel rage toward the inner neglector.

The following session with John exemplifies this concept.

Listen to Alan's session with John (clip #1)

Attend to Your Internal State

Often we neglect ourselves on a physiological level too.

Many times throughout the day you’ll have a rise in anxiety, and more often than not, you power through it without even realizing it.

Your internal state is like an infant. When you hear your baby crying, you attend to him. And when you attend to him, it calms him.

It is the same with your internal state. A slight rise in internal anxiety is like your body letting you know, “I need to be attended to.” When you attend to it, it calms down. When you don’t, much like a baby, its cries will get louder.

A low level of anxiety might escalate to a moderate level of anxiety, which can turn into a slight headache, and then back pain.

But if you attend to it early, you can bring it back down and prevent your symptoms from escalating. This is a learned skill.

Listen to the previous caller, John, at an earlier stage of the session.

Listen to Alan's session John (clip #2)

As you can see, John focuses so heavily on the words of his story, he’s oblivious to the increase in his physical anxiety.

I can’t overstate the importance of attending to your internal state. Throughout the day when you pressure yourself or scare yourself, it doesn’t just have an impact on your mind, it affects your body as well; like little fight-or-flight jabs.

Checking in throughout the day, recognizing increases in anxiety, and calming your system down can go a long way toward reducing your symptoms and improving self-care.

To discuss this program, click here.

Take a Loving Stance

When you hear the term “unconditional love” you might think of Tom Hanks and Meg Ryan on top of the Empire State Building (or Robert Pattinson and Kristen Stewart in the forest, if you were born after 1985), but you probably don’t think of your relationship with yourself.

Unconditional love is just what it sounds like: love, untainted by conditions such as accomplishments, achievements, or physical features.

If you weren’t given this as child, if you came to believe that you were unworthy or undeserving in some way, you may not look at yourself through a lens of unconditional love.

When you truly have love for yourself, everything we’ve talked about: standing up to the inner bully, soothing yourself, and validating your emotions, comes naturally. Treating yourself nicely isn’t work when you have self-love.

Self-love is a learnable skill. It may take patience, discipline, and repetition, but it is wholly attainable.

In the following session with Layne, notice how she struggles to look at herself through loving eyes, and how the messages she was given when she was young have shaped her self-perception.

Listen to Alan's session with Layne

Conclusion

The goal of this recovery program is to help you identify some of the areas that you might need to address psychologically, and provide you with some tools to that end.

The development of self-compassion, self-love, an internal protector, the ability to self-soothe, and the capacity to attend to your emotions is an ongoing process. Be patient with yourself in this venture. Your symptoms have the potential to scare you, knock you down, render you hopeless. Stay the course though, you can beat this thing. Trust me, I’ve been there.