Marsha was a 36 year-old businesswoman with two young children. She was referred to me by another patient and came to see me from the east coast. She had a spontaneous onset of back pain about eight years ago. Everything possible had been tried, but she continued to spiral downward with increasing pain.

In 2005, she had an MRI scan done that showed some mild degeneration of the discs in her lower back. These were normal for her age. A surgeon recommended she undergo two artificial discs at L3-4 and L4-5. They did not help her pain; in fact, she got worse. The discs buckled, and a year later they were removed at another hospital on the west coast. During this operation, they went back in through her abdomen to remove these artificial discs. In this situation, the major blood vessels are scarred down and attached to the discs. It is a very difficult procedure, and during the operation, her major vein, the vena cava, was torn. Her ureter (tube from the kidneys to the bladder) was also torn. Both were repaired, but she was left with residual swelling of her feet due to the partial disruption of the vena cava. A year later, she had L5-S1 fused for ongoing low back pain.

When she saw me, she still had ongoing low back pain, thoracic pain, and neck pain. Two other spine surgeons had recommended that she undergo a two-level fusion in her neck. The MRI of her neck was normal for her age, showing just some mild degeneration.

She desperately wanted to go back to work. Her husband was threatening to leave her. She was on drugs to wean her off narcotics but was having a difficult time. She was extremely motivated to get better, but she was also completely trapped by her pain and lacked a plan to solve her pain problem.

None of her surgeries were helpful or necessary. Yet the spine world was offering her only more surgery. I do not know the end of this story. I spent a couple of extra hours with her explaining the DOCC protocol to her in detail. She seemed to be fully engaged, and I do think that in over 12-24 months, she could have become pain-free and functional.

It is upsetting to me that she has the three-level fusion in her lower back and residual swelling in her feet. If she had been able to engage in the structured rehab before any surgery, her potential would have allowed her to completely come back to normal. Now, she will have some permanent structural limitations.

I am writing this about two years after our visit.  I never heard another word from her.  There is a high probability that she went on to another operation.  The mindset that “surgery is the only solution” becomes its own irrational circuit.  I have found out that the longer I try to talk someone like this out of surgery, the less productive it becomes for both of us.  Often, the patient becomes extremely agitated and sometimes will progress rapidly into a rage. You cannot solve irrational anxieties by rational means.

I am a spine surgeon who is paid extremely well to do surgery, but I’m trying my best to talk you out of surgery. If that isn’t even the slightest bit persuasive, you need to look very closely at your decision-making process. Right now, trying to break through this barrier is my biggest challenge.

BF

Fibromyalgia

We Enjoy Treating Mind Body Syndrome – Including Chronic Pain

A frequent conversation I have with my patients in clinic goes like this:

“Think about someone that you strongly dislike. You don’t have to say his or her name, but get a clear picture of that person in your mind.” I give them a few seconds and then they usually nod that they have it. “You are being judgmental, correct?” They again will nod ‘yes’. If they are already acquainted with the DOCC Project, I’ll say, “Now, you have decided after some self-reflection that being judgmental is taking away from the quality of your life, and you don’t want to be that way anymore. So now you have decided not to be judgmental when you meet or think about this person. And yet, you’re being judgmental—what happened? Often, he or she doesn’t know. Much of the time, the patient has fallen into a trap. The pitfall is this: if you continue to be judgmental, you will continue to suffer, but if you try to simply will yourself to be positive or pretend to like this person, your suffering will be even worse. Taking up the attitude of “not being judgmental” really reinforces your judgmental neurological pathways. When I point this out, the patient always immediately sees the problem.

So what do you do?

WRITE THE ACTUAL JUDGMENTAL THOUGHTS DOWN! The more graphically you can write them down, the more effective the exercise. You cannot get rid of those circuits, but detaching from them means that they are no longer running the show. Now when you interact with the person, you don’t have to like him/her. In fact, you may continue to dislike him/her. You don’t have to label this person as “liked” or “disliked.” However, you can at least now deal with the issue at hand. Also, the possibility now exists of developing a meaningful relationship with that person. With labels in place, there are no possibilities. You don’t like being labeled a “chronic pain patient.” Why should other people you come in contact with enjoy your labels on them? Finally, your interaction with others is a direct reflection of your interaction with yourself. No one is harder on you than you.

Bottom line: Let it ALL go.

BF

Programming

I am a strong supporter of psychology, psychiatry, and any mental health profession that can provide insight into how to live a full and productive life. However, I want you to think differently about mental health for a moment. Consider it not in terms of talk therapy but in terms of “neurological programming.” If you look carefully at your life, you’ll see that many of your attitudes and behaviors are a direct result of adopting or rebelling against your family’s patterns. We have all been “programmed” by our families, but it’s also possible to “reprogram” ourselves.

One day, I happened to hit a nerve with a patient regarding his family patterns. Jim needed a back operation for a pinched nerve that was causing pain in his right leg. Moody and uncooperative, he hadn’t followed up on anything we’d discussed in his appointments. I couldn’t get him to engage in any of the stress management tools.

Finally I gave up. “Look,” I said. “I am going to cancel your surgery. I cannot engage with you if you don’t want to participate in learning the tools I’m trying to give you to get better. It’s just the way I work.”  I had a sense that Jim’s resistance to stress management stemmed from his background experiences, so I also added, “We are all programmed by our past. For example, if you were raised in a family that was active in the Ku Klux Klan, what do you think your belief system would be?” His fiancée suddenly burst out laughing hysterically. It didn’t seem that funny to me, particularly since I was frustrated with his unwillingness to engage.

I thought I’d picked a completely random example, but Jim looked me in the eye and said, “My father and grandfather were Grand Knights in the Klan.”

I cancelled the surgery, but my example of family programming apparently hit home, as Jim finally began to engage in the DOCC Project. The surgery was done three months later and was successful in relieving his leg pain. He has made a great deal of progress with stress management skills because he shifted his thinking and came at the process from a different place. Jim’s struggle to learn a better way to deal with stress borders on heroic. I hear from him every few months and he continues to evolve. His skills have created a better life for him, his wife, and their three small children. It is a high stakes game.

Once the reprogramming foundation is established, my patients work hard to apply the principles to their lives. The only patients I’ve seen that do not experience significant benefit from reprogramming exercises are the ones who did not fully engage on a long-term basis. With full engagement, success in eliminating your pain is probable, not just possible.

More to This Story

After I performed Jim’s surgery, he did pretty well for a while and then began to slide back into his old pattern of pain. We had had the conversation that the surgery would address his leg pain but would have no effect on his back pain. In spite of his ongoing back pain, he kept trying to become more functional. His leg pain had not completely disappeared.

His living circumstances were difficult. He was living with family in cramped quarters.  Although workers’ comp had paid for some counseling, it was limited. He and his fiancé readily admitted that they fought all the time and were becoming increasingly worn out by the ongoing battles. As they had no other resources, I would see them back about once a month and do the best I could to help them out. As Jim had been raised in the KKK environment, that was his baseline. He did not view his life as being filled with anger.  However, his reactions said otherwise. Both he and his fiancé were incredibly determined to make things work, but it was clear to me that they did not have the tools to pull it off. I was incredibly frustrated because their situation was potentially very solvable with the right support and counseling. I saw them both about a year ago and it seemed that things were beginning to take a turn for the better.  This is the letter I received last week.

The Letter

Hello Dr. Hanscom!

Hence the email address, this is ____,  _____’s wife.

(Little redheaded lady, with the two kids and husband who you performed surgery on.)

I believe in your book, ____ was used as an example, under the name Jim.

I wanted to give you an update on how he’s doing.

For several years, ____ struggled with emotional ups and downs, a lot of chronic pain, and how to deal with it all. We ended up getting married. For a long time to follow, I nearly regretted that decision. With both of us working, or able to go to school, needless to say money was tight. With two kids, ____’s pot addiction, etc, it was too much.

We had an unusual fight about a year and a half ago. He had been taking some kind of pills that were supposed to help his moods, according to the doctor he was seeing at the time. Needless to say, the pills in fact had a very negative effect on him. By the time the argument was over, Eric spent the night in prison. At that point, I was ready to walk. This was enough, the last straw.

The night passed, I picked him up, and explained it was over. We had done it all. Seeked professional help, taken the pills, read the books. I saw no end. There wasn’t anything left. This was who he was, and I couldn’t do it anymore. My boys were not going to grow up in this sad, depressing, unstable environment.

He begged, and said he realized something in jail that night. He said he needed God. As a “devout” atheist, he decided he had no options, and as a last resort, maybe God would be somewhere to look. The next Sunday, we were in church.

Since then, our life has changed more than it ever has. We don’t argue. We get along, and better than that, are in love again. We both have stopped smoking pot. For ____, this was a big step. He was using it for both mental “well being”, and pain control.

I have started working again. Found a great job. Flew to Denver in January to be trained. It’s been amazing. One of the highlights, ____ is working on developing his own business. He has decided to be a gunsmith. For the first time in years, he is doing something to better himself. He’s been taking small steps, one at a time, and I believe he will make it. It’s the first time in a long time I’ve seen him with drive, and with passion. As long as he’s happy, I will be there to support him.

Plus much more.

God has touched our lives, and helped turn it around 180 degrees. He’s got a lot of love to give, and I’m thankful to see Him sharing that with my family.

I know as a Doctor, you may think that’s crazy. I still wanted to share.  I wanted to take a moment to say thank you, for investing the time with ____ that you have. It’s very appreciated. We needed you. He needed someone to tell him he was worth it. I know he still thinks about that, often. Thank you sooo much.

Please keep in touch, I would love to hear from you once and a while.

Best regards,

My Final Thoughts

I want to make something very clear at this juncture. The DOCC Project entails five stages of five steps in each stage. The final stage is “Living a Full Rich Life.”  Another name I have used for this stage is “The Spiritual Journey.”  It can take many different forms, religious or otherwise. I have seen many patients benefit greatly from their church community as part of their healing process. I think that being in a group of people jointly acknowledging a power greater than themselves is incredibly helpful.

However, this is a much different experience than having a rigid religious belief system that is intolerant of others. I have uniformly seen my patients in this mindset fail, or more frequently not engage in any open dialogue about the possibilities for healing.  Rigid belief systems, religious or otherwise, are a thinly disguised form of control and anger. Remember that your judgment of others is a mirror of your own self-judgment and vice versa. Judgment is a problem. Period.

I personally am not involved in a religious organization. I did learn through my Hoffman experience how critical it is to acknowledge a higher power outside of ourselves. Only then are you truly able to give something back.

BF

Almost every patient of mine who is in chronic pain is also experiencing a lot of other adversity in the rest of his or her life.  The stories I hear each day are mind-boggling.  They include abuse, murder, family suicides, extreme financial struggles, homelessness…the list goes on.  The anger I hear expressed is more than legitimate, but my point is always that the energy you are expending on your anger is the energy you need to solve your dilemma.  The more legitimate your anger, the harder it is to let it go, but it will destroy you if you don’t, so you need to let it go.  Chronic pain of course is a very legitimate cause for anger.  It will be intensified and driven by your anxiety. Don’t let this anger consume you.

It is critical that you figure this one out quickly: separate your position in life from your happiness.  When your peace of mind is independent of your external circumstances, then you are free.  Period.  End of story.  Here is one of my personal learning experiences:

I started my Seattle practice in 1986.  I thought I had it made and had all the tools needed to help people out with spine surgery.  I quickly found out that it wasn’t that easy.  I was working long hours.  Most patients did well after surgery but many did not and were upset with me.  There are always complications associated with spine surgery and some of them were severe.  They also took a personal toll.

I remember sitting at my desk late one night in 1988 ruminating about my problems.  I had a patient with a massive wound infection; another 300-pound post-op patient was belligerent and fighting with the hospital security guard; I was having a hard time financially meeting the office overhead; a malpractice suit had been placed on my desk earlier in the day.  I remember thinking,  “I can do this, I’m really tough.”  About six months later, I started to have anxiety.  In 1990, I began to experience panic attacks.  I was also just getting tired, feeling fatigued all of the time.

I made a decision to quit being a spine surgeon.  Nothing about my lifestyle seemed to make any sense.  I did not understand the anxiety, as I had not experienced that much of it before. I didn’t know why it was occurring with such intensity.  Somehow in the midst of all of this, I instinctively knew that if I bailed out of spine surgery, I was not going to solve the anxiety problem.  I decided that I was going to commit to remaining a spine surgeon, and if I ever decided to change careers, it would be on my terms and not from a fear of anxiety.  In retrospect, it was the correct choice but a close call in that I almost did not make it through.  However, I was correct that the anxiety was a separate issue, one that was going to follow me regardless of what I did.  It wasn’t until 2003 that I finally found the correct approach and was able to escape the pit of anxiety and frustration.

I wrote a website post, “The Eye of the Storm”.  The gist of it is that the center of a hurricane is very still and quiet.   The winds represent racing thoughts and/or life circumstances.  Most of us are programmed to think that if we had the perfect set of circumstances, we would be happier, or if we could control our thoughts, we would be more at peace. This just isn’t true. You have to learn to be happy regardless of your circumstances.

You cannot control a hurricane, yet people spend a huge amount of energy trying to control their thoughts or circumstances to obtain peace of mind.  It cannot and does not work.  What are the odds that you will have every variable in your life so perfect that you will be at peace?  When you try to control your thoughts, they just spin faster.  The goal of the neurological reprogramming tools is to pull you into the center of the storm and stay there.  Then you’ll have the mental clarity and emotional energy to solve and deal with situations as they arise.  It does not matter if the problem is in your career, friendships, family, accomplishments, body image, or project work.  Your peace of mind will be independent of all of them.  But you cannot do it through positive thinking or “mind over matter.”  You must use reprogramming strategies.

Going a step further, you will eventually be able to view each adversity as an opportunity to practice what you have learned.  Your energy levels will go through the roof and you’ll be able to create whatever life you like on your own terms.  You cannot run from anxiety.  It will follow you everywhere.  You need to tackle it head on. The sooner you do so, the sooner you will be free.

• Your situation in life will never be perfect
• Happiness and peace of mind don’t come from a perfect life
• You need only face life’s problems and the anxiety they bring

BF

It is an almost universally held belief among surgeons and patients that a specific structural lesion is usually the source of pain. If that lesion can be identified and repaired, the pain will abate. This seems plausible. A diagnostic test ought to be able to identify the source of intense pain and point to a solution. This simply isn’t the case.

During my first five years of practice, it was my assumption that if a patient had experienced low back pain for six months, then it was my role to simply find the anatomic source of pain and surgically solve it. I was diligent in this regard. The test I relied on most heavily was the discogram. The discogram is a test where dye is injected into several discs in your lower back; if the patient’s usual pain was produced at a low injection pressure, it was considered a positive response. The only patients I did not fuse were those who did not have a positive response or had more than two levels that were positive. I performed dozens of low back fusions and felt frustrated when I could not find a way to surgically solve my patients’ low back pain.

I have a physiatrist friend, Jim Robinson, who is a strong supporter and contributor to the DOCC Project. From 1986 to 1992, we both served on the Washington State Worker’s Compensation clinical advisory board and helped set standards for various orthopedic and neurosurgical procedures. Our discussions were based on this assumption that there always is an identifiable “pain generator.” It is just a matter of figuring out what test is the best one to discern it. We did not think in terms of structural versus non-structural sources of pain. We knew about the role of psychosocial stress but did not fully appreciate how large a role it played.

I define a structural lesion as one that is distinctly identifiable on a test, which correlates the patient’s pain symptoms with the lesion. An example would be a ruptured disc pinching a nerve that causes pain down the leg. A ruptured disc between the fourth and fifth lumbar vertebrae will cause pain down the side of the leg. This is the pathway of the fifth lumbar nerve root. A ruptured disc between the fifth lumbar and first sacral vertebra will cause pain down the back of the leg, which is the pattern for the first sacral nerve. If in either of these two examples the pain was going down the front of the leg, it would not be considered the cause of the pain because that is the path of the fourth lumbar nerve root and it does not match.

Many of you experience pain whose source is not identifiable on any test modern medicine has to offer. We cannot cut into your physical body and eliminate your pain, but your pain is still real. When there is no structural source of your back pain, we cannot treat your back, so me must treat your pain. This idea is at the heart of the DOCC Project.

BF

There Must be an Identifiable Source for the Pain

The intent of this section is to give you a feel that pain is a perception that can be affected by several categories of variables.  Our western medical culture has focused on the ideas that there is always a “pain generator” that can be identified and fixed.

You are Not a Machine

It is similar to thinking of terms of taking your car to a shop for a repair.  Usually once the part is replaced or the necessary adjustment is made, your car is almost as good as new.  However your body is not a machine and there is little resemblance of your body to a mechanical device:

• Automobiles are DEAD and do not react to a pain signal.

They do not have:

• Pain fibers
• A nervous system that interprets pain signals
• Hormones
• Emotions
• Memories

There is NOTHING in the mechanical world that remotely resembles pain.  In fact, every attempt that has been made to reproduce pain in the mechanical world has failed miserably. Yet it is understandable for patients to become focused on finding the physical source of their pain.

Multiple Variables Affect Your Perception of Pain

Your pain problem is solvable once you understand the various aspects of pain and then address ALL of them.  There is not one magic bullet in this web site.  However, if you fully engage with the tools described here, there will be no question of ‘whether’ you will improve, but only a question of ‘when’.

• Your pain may not be physical, but it is REAL
• Pain is complicated–it is entangled in an intricate web
• With full engagement of this program your chronic pain is a solvable problem

BF

I don’t remember much about learning how to ride a bicycle.  I remember something about training wheels and taking a few nasty falls after they came off.  I do know that my father wasn’t there to help me or witness it.  He was a small town family doctor who routinely worked over a hundred hours a week.

I think that I must be traumatized by not having my father around when I accomplished this rite of passage.  In fact, the longer I sit here thinking about it, the more upset I think I am getting.  What do you think I should do?

One option would be to talk to someone about this childhood trauma. Do I have an unconscious stress response when I even just see a bicycle?  Maybe that is why I never took up serious cycling.  I don’t know if I should talk to a psychologist about this experience or to a trainer to unlearn how to ride a bike.  The latter would be more effective.  I wonder how long it would take me to unlearn this skill?  I am sure I would have a better life.

Unfortunately, you can’t unlearn how to ride a bicycle. The problem is you can’t eliminate the neurological pathways associated with the experience.  In fact, you can’t eliminate any of the past experiences from your brain.  Most of your lifetime is sitting there and any part of it can be triggered by a word, comment, or image.  The linked event to it also cannot be broken.

Not only can your pain pathways not be eliminated, but all of the experiences that are proximate to your pain pathways are bound tightly to them.  The continued assault of pain only makes the pathway more intractable.

What are you going to do? Reprogram your pain pathways.

BF

I wrote a letter to the “Roundtable” in reponse to a story about a patient who had undergone a straighfowrd simple knee surgery with a terrible result. (I’ve talked about this patient before in “The Snarled Stumper,”)He was in terrible pain, worse than before surgery.  This is Anne’s input regarding my letter. (Anne is a patient of mine who has experienced remarkable success with the DOCC Project; she has done this on her own through this web site and through occasional phone calls and emails with me to clarify some of the concepts–I’ll tell her full story in the near future.)

First, here is what I said:

“Dr. ____, I agree with your concept of “disengagement” and “stuck”. The term I have used for a while is “entrenched”. What I have learned the hard way is that the common denominator is anger. The more I have tried to convince a given entrenched patient to not become angry the worse it gets. I am in the middle of a disaster right now that has dramatically reinforced my perception. I had submitted a paper to the roundtable a few months ago, “Ability and Motivation.” If the patient is angry their motivation is destruction, including self-destruction. Their ability to deal with the situation is limited, as they cannot see it clearly. I have learned that I have to let go but still keep the door open.”

This is Anne’s response:

“I couldn’t agree more.  If I had been introduced to this program before my first surgery (instead of fourth and fifth), I may have been saved a lot of pain and 9 years of my life.  I am floored by the fact that anger and lack of forgiveness can make you physically incapacitated.  I never understood that until the last several weeks.  I honestly was angry with you for suggesting that I was angry.  Go figure.  Keep up the good work.”

Me again:

“I am changing the term from “entrenched” to “noncompliant”. I have historically felt that noncompliant was a derogatory term. I now understand the depth of frustrations these patients experience. Any human that is experiencing this degree of anger is not going to be rational and responsive. I am continually challenged on how to break through this barrier.”

Anne again:

“Noncompliant is a derogatory term, but maybe that is what it takes to shake people up enough to get a response.  Until you got a little harsh with me and told me to engage I didn’t hear a word you said.  The thing that kept me listening was that I respect you and thought what can it hurt, I’ll try it his way and it won’t work and he will see that he missed something.  Boy was I wrong.”

Just some thoughts!

Also, I’m currently reading The Hoffman Process. All I can say is, “WOW!”

BF

Dear Dr. Hanscom:

You may not receive these kinds of letters from nurse case managers very often.

I thought I would advise you of the above captioned patient that you performed a redo L5-S1 microdiscectomy about a year ago.   Ron got quite discouraged when he did not improve.  He was almost done with your book, “Back in Control” when he got off the couch, got motivated, moved forward, and we saw a dramatic change in his attitude. He worked through his pain, eventually stopped all medications, completed PT, and work conditioning programs. He was recently declared fixed and stable and was released to his job of injury as a sorter. (One of the hardest jobs around, believe me!)  He is back on the job and doing very well!!

Please thank your assistant for all of her help.

Thank you for all you have done for Ron.

Sincerely,

_____________, RN, BSN,  Medical Case Manager

Ron’s Story:

Ron was only in his early twenties when he ruptured his lowest disc, L5-S1, while on the job a couple of years earlier.  A prior surgical attempt to remove the disc had not given him lasting relief.  When I first saw him, he was experiencing ongoing severe sciatica down the back of his leg.  His repeat MRI scan showed a large ruptured disc.  It had probably re-ruptured relatively soon after his first surgery.

I am very clear about the goals of surgery and what I can and cannot accomplish with a given operation.  He had a significant amount of lower back pain (LBP) in addition to his sciatica.  There is not an operation that I feel relieves LBP, and I explained to him that I would only address his leg pain.  I also explained to him that once you have had ongoing pain for more than four to six months that the brain lays down pain pathways, which are permanent.  Although it was necessary to re-do his operation, my observation has been that the sciatica still will often persist.  The pain is usually better, but often it is still severe enough to really destroy the quality of your life.  The back pain and residual sciatica are treated by the tools on this website.

After my operation, which was a redo of removing the disc at L5-S1, he did not do that well.  He did have the ongoing back and leg pain as I had anticipated. I had explained the DOCC Project to him, but he had not really engaged.  Finally, about three months after the surgery, I was extremely clear with him about where he was headed.  Living the rest of your life in chronic pain when you are in your early 20’s is not an inviting prospect.

I did not post this story right away.  In the interim, I began to think about my historical view in dealing with patients that are on Worker’s Comp.  I was taught and believed that it was my role as a physician to “set boundaries.”  It was in the patient’s best interests for me to be tough and just “shut the door.”  Injured workers are focused on gaming the system and remaining off of work.  It is often repeated in seminars that injured workers have “secondary gain” issues and that if the benefits were decreased or cut off that would be the best motivator to get people back on the job.

I realize that a small percent of people are gaming the system.  It is that way in every life circumstance.  However my strong belief is that given the opportunity, people want to thrive.  Surviving on a fixed income when you are only in your 30’s or 40’s is not living a full life.

Years ago I would have told him to “buck up and just get back to work.  That would be the best thing for you to do to help your life and pain.” I would have just closed his case.

When you have been physically and emotionally beat up by the pain and the system, you have lost the ability and motivation to become productive.  Once you have the tools to reconnect with, you really are where you want to go, and there is no stopping you.

It took about six weeks for Ron to fully engage, but he did it.  This whole project is about showing you the tools to heal yourself.  My role is to be a coach and cheerleader.  Watching patients like Ron start smiling again as they make strides in becoming pain free is one of the most rewarding aspects of my practice.  I am grateful that I have been able to help show him the way.

BF