Saturday, February 24, 2018

Chronic Pain: Psychogenic Roots and Psychological Treatment

Emotional State

By Edwin K. Yager, PhD

Chronic pain may serve a purpose without the sufferer having conscious awareness of that purpose. Pain may subconsciously satisfy many needs that appear irrational to the conscious mind, such as getting attention from others, self-punishment, and distraction from unpleasant thoughts.

According to Hansen and Streltzer (1), addressing emotional issues is very important in the evaluation and treatment of pain. Treating the physical pain alone can leave these issues unresolved and possibly exacerbate them through reinforcement. Psychological issues are particularly prominent in chronic pain. My own experience suggests that if a patient suffers from psychogenic pain, psychotherapy in some form is indicated, and the preferred treatment is psychodynamic. Even if the pain is not psychogenic, the resolution of pain-reinforcing, negative emotional factors can be a major component of pain relief. Pain is often considered an exclusively biological process; however, current theories of pain based on physiology are not adequate to explain such phenomena as phantom limb pain (2) or the elimination of pain by hypnotic suggestion (3), or the fact that surgical severing of nerves does not necessarily relieve pain (4). Pain may continue to be experienced long after an injury without evident physical cause. Moreover, pain may be felt at an elevated level of intensity that is inconsistent with the apparent severity of the stimulus.

Perception of Pain
As I understand it, pain exists only as it is perceived. Human perception of pain varies over time and with circumstance and is modulated by emotion and sometimes by factors that seem unrelated to the stimulus. Persistent pain may continue without conscious awareness of its actual cause, with only the effect—the pain—perceived consciously. When pain persists unnecessarily, it may be because the patient has been conditioned to perceive it. Subconsciously, if the patient has learned to expect pain to continue, or assumes the pain has value in some way, that learned influence may persist, causing continued pain in opposition to conscious desire, will, and logic.
In the case of acute pain, relief may be effectively achieved by altering the patient’s perception through hypnotic suggestion, especially when the cause of the pain is evident. However, in the case of chronic pain, subconscious influence is involved, and for sustained relief, the subconscious influence must be uncovered and resolved by one means or another.

Pain can be created and maintained physically or mentally. In the case of physical injury or disease, the purpose of the pain is clear; it provides motivation to do whatever is necessary to relieve the pain. Acute pain is adequately explained by current pain theory unless it reaches chronicity. In that case, where the initial stimulus is not recurring and no physical cause is evident, the sustaining stimulus may derive from conditioning integrated during life experience, and thus be psychogenic.

As an illustration, in a time of trauma and under the influence of adrenaline, a person might learn to associate pain with knowing he is alive. A remark to that effect, made by a medical attendant in a traumatic situation, might result in a victim unknowingly internalizing the concept, tantamount to the integration of a hypnotic suggestion. That integrated influence might have the consequence of causing any pain in present life as a means of “knowing I’m alive.” The blatant irrationality of that learned response is not recognized subconsciously, where the continuing pain is being instigated; only the initial association matters there. The theory of subliminal therapy assumes that development of some part of the subconscious domain was arrested at the time of the initial experience leaving that domain ignorant of present life, and that re-conditioning essentially consists of educating that part about present life.

Chronic Pain as a Consequence of Psychological Trauma or Subconscious Need
Pain may also occur in reaction to various psychological stimuli, such as guilt or regret for bad judgment that led to a poor outcome. In such cases, pain seemingly becomes the subconscious infliction of self-punishment. For example, fear may cause muscle contractions, contributing to low back pain or other chronic pain. Consciously unrecognized benefits of pain, learned at a subconscious level, may support the chronicity of pain, as when pain has become a means of getting attention that is not otherwise available.

Patients have uncovered numerous subconscious causes of psychogenic pain during successful treatment with subliminal therapy. In each case, the reason for the pain was rational at the time of the impelling experience, but the initial stimulus could no longer be considered rational in current life. Regardless of the initial cause of the pain or the patient’s subconscious purpose for continuing the pain over time, the reason for the pain that was learned in the initial, sensitizing situation always had legitimacy in that situation. Recognition of that legitimacy, coupled with reframing of that information at the subconscious level, successfully resolved the pain in these cases.

Psychological Treatment of Chronic Pain
Treating chronic pain psychologically requires a means to go beyond the patient’s limited conscious understanding of its cause; the subconscious influence must be identified and resolved. During treatment, insight regarding the cause or purpose may surface, and yet insight alone is not sufficient. Experience from subliminal therapy and other forms of psychotherapy indicates that insight must be evaluated in the light of current knowledge and reframed in that context. Moreover, for prolonged relief to be achieved, the underlying cause must be resolved within the subconscious domain of the patient’s mind.

Although episodes of chronic pain may appear to correlate with consciously identifiable, non-physical factors such as, “It’s worse when I am stressed/when I go to bed /wake up/sit down/when my husband is in the room,” this correlation may not be consistent. Chronic pain may also occur at other times and for unidentified reasons, and until all subconscious reasons have been identified and resolved, resolution of the pain will likely not be possible.
Regardless of the treatment to be employed, both ethical and pragmatic necessity requires clinicians to consider and ensure correction of physical causes of pain. Nevertheless, in some instances there are clear initial indications that the presenting pain is psychogenic, and psychological treatment might be the only treatment necessary. Such indications include the pain being episodic or cyclical and/or substantial variation in intensity over time.

Hypnotic trance can uncover subconscious reasons for the presence of unnecessary pain through the utilization of age-regression techniques or ideo-motor inquiry (3,5). In addition, ego-state therapy demonstrates effectiveness (6), and free association in trance may also be effective to some degree (7) in uncovering subconscious reasons for pain. These and other protocols have in common the engagement and involvement of conscious knowledge, opinions, and beliefs as the process of therapy unfolds. In contrast, when using subliminal therapy the clinician communicates with an extra-conscious domain of the patient’s mind, avoiding interaction with consciousness to the extent possible.

Once the uncovered causes of the patient’s pain are identified, reframing them at the subconscious level results in their resolution. Considering an event in light of more mature understanding than was initially available can change the effect of the event by changing the patient’s understanding of the event. For example, a childhood memory of being terrified in a dark place—with consequent phobia of the dark—can be understood by the adult as being a normal situation at that time, and not true in present time, thereby eliminating the phobia. However, for permanence of benefit, the reframed understanding must be integrated into the subconscious domain, not just recognized consciously. This step is most effectively accomplished by using subliminal therapy.

Treating Chronic Pain with Subliminal Therapy
The use of subliminal therapy is indicated when pain is the consequence of experiences that have continuing negative influence that has been stored in the patient’s mind below conscious awareness. It is based on the premise that values, beliefs, responses, behaviors, and reactions to stimuli all develop as a consequence of conditioning from life experiences. Chronic pain can represent such a conditioned response. I have had great success in treating chronic pain following the discovery and development of subliminal therapy.

The underlying assumptions of subliminal therapy are: 1) Individuals are conditioned by their experiences in life without conscious recognition that conditioning is taking place; 2) Such conditioning can result in both physical and mental disorders; and 3) All individuals have higher level abilities at an extra-conscious level that exceed conscious abilities (8).

Thus, if chronic pain is a conditioned response, reconditioning must also be possible. This is the intent and focus of the protocol of subliminal therapy. Effectiveness has been high, and the intervention is time-efficient as well, with treatment usually completed in three to five hours.

The Protocol of Subliminal Therapy
Following initial instructions, the patient is guided to subjective awareness of his or her extra-conscious level of mental functioning and rational communication is established between that domain and the clinician. Spoken communications from the clinician are perceived directly by the extra-conscious domain, while communications from that domain are consciously perceived by the patient and verbally relayed to the clinician; this is the patient’s only conscious role during treatment. Resolution of the problem takes place within the patient’s extra-conscious domain as the clinician poses a logical sequence of questions and requests. The clinician guides the process of subliminal therapy without the patient being consciously involved in the details of the work, even though consciously aware of the process. This therapy bypasses the limitations and rationalizations of consciousness by engaging this “higher level” of the patient’s mental ability, a feature unique to subliminal therapy.

By engaging extra-conscious abilities, subliminal therapy enables the patient to identify and resolve the actual subconscious cause of the pain—as opposed to his or her pre-conceived beliefs about the cause. As subliminal therapy is employed, the subconscious domain is reconditioned as a result of being re-educated about previously held, dysfunctional subconscious beliefs and values. False understandings and convictions are revealed and corrected by being exposed to the patient’s current, more mature knowledge and judgment.

Subliminal therapy involves a logical progression of questions and requests, each predicated on previous responses, using the same protocol for a variety of conditions (8). Patients readily embrace the rationale and theory of subliminal therapy. It makes sense to them and offers new hope for desired change. Many chronic conditions, including chronic pain, have been resolved within three to five sessions, leaving both the patient, and sometimes the clinician, pleasantly surprised.

A Case-Series Report
I have been collecting data during the past six years to determine the effectiveness of subliminal therapy in treating a variety of psychogenic problems, including chronic pain. The concept of chronic pain suggested here is psychological; it attempts to explain subjective experience, rather than relying on textbook physiology. The clinical results of a series of 29 cases support psychogenesis as the etiology of many cases of chronic pain and the use of subliminal therapy as an effective, psychological treatment.

Twenty-nine patients with chronic pain were treated using subliminal therapy as the sole psychological treatment, adjunctive to usual medical care. These patients represent a small portion of the patients presenting with various conditions in my private psychology practice. The results of chronic pain treatment with subliminal therapy are shown in this figure, below:

Treatment of Chronic Pain by Subliminal Therapy

The results are derived from a patient-completed questionnaire, Yager Subjective Effects Inventory (YSEI) (9), completed before and after therapy, and, where possible, at follow-up. This inventory measures 15 dimensions in which pain is negatively impacting the patient’s life. The overall success rate of subliminal therapy in these patients was 66% with an average treatment time of 2.9 hours.

While the concept of classical conditioning is not new, considering it as a possible cause of chronic pain may be new to many. Chronic pain may be psychogenic in its initial cause, its maintenance, or both. Thus, treatment of chronic pain by psychological intervention, preferably employing psychodynamic techniques that bypass conscious interference, is indicated. To date, evidence supporting the effectiveness of subliminal therapy in treating chronic pain is limited; the number of subjects treated in the reported series is small and lacks controlled conditions. Yet, the magnitude of its effectiveness series is quite high, justifying controlled investigation that is planned under the auspices of the Subliminal Therapy Institute, Inc., a not-for-profit, 501(c)(3) California Corporation.

Edwin K. Yager, PhD, is a psychologist in private practice in San Diego, California, a Clinical Professor in the Department of Psychiatry, University of California San Diego, School of Medicine and President of the Subliminal Therapy Institute, Inc., a non-profit California corporation established to research the efficacy of Subliminal Therapy. He is certified as a Consultant in Hypnosis by the American Society of Clinical Hypnosis and is a Past-President, Fellow and current Board Member of the San Diego Society of Clinical Hypnosis. He offers training in hypnosis and Subliminal Therapy in the UCSD School of Medicine and under the auspices of the San Diego Psychological Association.

1.    Hansen GR, Streltzer L. The psychology of pain. Emerg Med Clin N Am. 2005;23(2):339-348.
2.    Jensen TS, Rasmussen P. Phantom pain and related phenomena after amputation. In: Wall PD, Melzack R. Eds. Textbook of Pain. 2nd ed. Edinburgh: Livingstone Churchill; 1989:508-521.
3.    Yager EK. Foundations of Clinical Hypnosis: From Theory to Practice. Bethel, CT: Crown House Publishing; 2009.
4.    Rainville P, Bao QV, Chretien P. Pain-related emotions modulate experimental pain perception and autonomic responses. Pain. 2005;118(3):306-318.
5.    Ewin DM, Elmer B. Ideomotor Signals for Rapid Hypnoanalysis: A How-to Manual. Springfield, IL: Charles P Thomas Pub; 2006..
6.    Watkins HH, Watkins JG. Ego States: Theory and Therapy. New York, NY: W.W. Norton & Company; 1997.
7.    Patterson JR, Jensen MP. Hypnosis and clinical pain. Psychol Bull. 2003;129(4):495-521.
8.    Yager EK. Subliminal Therapy: Using the Mind to Heal. Bethel, CT: Crown House Publishing; 2011.
9.    Yager EK. Yager Subjective Effects Inventory (YSEI). San Diego CA: Subliminal Therapy Institute, Inc; 2007.

Edwin K. Yager, PhD, is a psychologist in private practice in San Diego, California, a Clinical Professor in the Department of Psychiatry, University of California San Diego, School of Medicine and President of the Subliminal Therapy Institute, Inc., a non-profit California corporation established to research the efficacy of Subliminal Therapy. He is certified as a Consultant in Hypnosis by the American Society of Clinical Hypnosis and is a Past-President, Fellow and current Board Member of the San Diego Society of Clinical Hypnosis. He offers training in hypnosis and Subliminal Therapy in the UCSD School of Medicine and under the auspices of the San Diego Psychological Association.

Originally published in The Pain Practitioner, Winter 2014.

One response

  1. December 28, 2015 at 1:21 pm

    Nice article. I am in total agreement with pain as a perceptual experience. But pain perception incorporates about 16 brain areas including TANs (coalesces cognition, emotion, and memory with primary output to the motor system) in addition to the physical expected neurological areas, of which the insula is quite critical. (I would refer the readers to Chapters 70 and 71 in the AAPMed textbook: Comprehensive Treatment of Chronic Pain by Medical, Interventional, and Integrative Approaches.) I have likened pain perception to a holographic experience, with all the physical inputs, cognitive, emotional, and memory inputs acting like laser beams. Any treatment, of which subliminal therapy is one, that can reduce the intensity of, or eliminate, any of those lasers will weaken and/or wipe out the hologram. One good example is the use of Functional Medicine, which by eliminating a “leaky gut” and changing nutrition to do it, can eliminate migraine headaches and the need for headache medications. So I thank Dr. Yager for sharing his approach, which can add one more tool to the treatment tool box.

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