What is the best muscle relaxer?
So, you sprained your lower back shooting hoops, a stressful work week spurred on a series of tension headaches, arthritis has you waking up with stiffness and neck pain. Now what? Tense, aching muscles can be frustrating, distracting, and throw a wrench into your schedule. When muscle pain hits, it can have you looking for fast-acting relief so you can get on with life. Whether you experience back pain, muscle spasms, arthritis, or injury-related chronic pain, muscle relaxers offer fast pain relief, allowing your body to function as usual. Consider this guide your roadmap to the top muscle relaxers on the market.
What is the best muscle relaxer?
It’s difficult to declare one muscle relaxant better than all others because each type has its own advantages and uses. In general, pain relief treatments fall into one of three categories: over-the-counter (OTC), prescription, and natural. Determining the best muscle relaxer depends entirely on your specific condition and pain level. When in doubt, consult your healthcare provider.
Over-the-counter remedies: OTC pain relievers are often the first line of defense against pain, inflammation, and tension. They can work wonders for milder conditions like neck and lower back pain. Typically, your doctor might start you out on an OTC medication, and if that doesn’t provide the relief you need, he or she may write a prescription for something higher-grade.
Prescription drugs: For more chronic pain and conditions where OTC medications just won’t cut it, your doctor may prescribe something stronger. Because of their more serious side effects, prescription muscle relaxers are designed for short-term use, after which your doctor will transition to other drugs or treatments.
Natural remedies: For minor soreness and stress-related symptoms, the only treatment you need might be drawn straight from nature. Before rushing off to the doctor for an examination and potential prescription, you might be able to administer an effective plant-based therapy right from home.
What is the best over-the-counter (OTC) medicine for muscle pain?
These are the medications that you can find while perusing the aisles at your local pharmacy or convenience store. Most of them are household names, and it’s not uncommon to keep them on hand, stashed in a medicine cabinet, just in case. Even though OTC medications are easy to obtain, they’ll do the job for many aches and pains, and doctors often recommend them prior to prescribing stronger treatment options.
“OTC NSAIDs, like ibuprofen and naproxen, are a good first-line agent to decrease inflammation surrounding an injury,” recommends Joanna Lewis, Pharm.D., creator of The Pharmacist’s Guide. They might not have the same potency of high-grade muscle relaxants, but they’re still effective and have very few side effects. If you roll your ankle at the gym or wake up with back pain, try one of these before asking your doctor for a prescription.
(ibuprofen): This is a staple of parents, doctors, and athletes alike. Ibuprofen is one of the most widely used nonsteroidal anti-inflammatory drugs (NSAIDs) available. As such, Advil doesn’t just remedy pain, but also inflammation as well. It’s highly versatile. Use it to treat low back pain, osteoarthritis, menstrual cramps, fever, headaches, migraines, sprains, and other minor injuries. Low doses are available over the counter, but a doctor can prescribe higher doses as well. (ibuprofen): Don’t be fooled by the different brand name. Motrin IB and Advil are the same drug. Therefore, they shouldn’t be taken together, as it could increase the risk of overdose. (naproxen): Another medicine cabinet staple, naproxen is similar to ibuprofen in many ways. It’s also an NSAID, so it works by reducing inflammation. It’s useful in treating muscle pain, headaches, migraines, osteoarthritis, fever, cramps, and minor injuries. The main difference between naproxen and ibuprofen is their dosing. You can take naproxen every eight to 12 hours and ibuprofen every four to six, so Aleve is slightly longer-lasting. : One more NSAID for you. Aspirin treats many of the same conditions, relieving pain and reducing inflammation. However, daily doses of aspirin have been proven effective at reducing the risk of blood clots, strokes, and heart attacks in some people. Ask your doctor before using for clot prevention. If you’re a candidate, you will likely take a “baby” aspirin, or 81 mg, coated tablet daily. Common brand names include Bayer or Ecotrin. (acetaminophen): Unlike NSAIDs, acetaminophen focuses solely on treating pain—not inflammation. It’s used for muscle aches, headaches, migraines, back and neck pain, fevers, etc. However, if swelling and inflammation is the underlying cause of your pain, acetaminophen will not be nearly as effective as NSAIDs like those listed above. Acetaminophen’s wide range of uses and relatively few side effects make it the most popular OTC pain reliever worldwide.
What are the best prescription muscle relaxers?
There are certain times when over-the-counter medications simply aren’t enough. If you’ve been taking acetaminophen or ibuprofen consistently but are still dealing with back pain, spasms, or other issues, it might be time for something more robust. In cases like these, doctors may look to prescription muscle relaxants as a more effective, albeit temporary, answer.
“A pulled back muscle or neck pain may require a doctor’s visit or other diagnostic tests to get to the heart of the issue,” Dr. Lewis says. “There are several good prescription medications like methocarbamol, cyclobenzaprine, and metaxalone.”
Recent studies have shown that skeletal muscle relaxants (SMRs), or antispasmodics, outperform anti-inflammatory drugs (NSAIDs), like ibuprofen and acetaminophen, in relieving severe pain associated with conditions like acute back pain. On the flip side, they also have potentially more serious side effects and shouldn’t be used for long-term pain management. Even so, these prescription drugs are effective and reliable options for short-term pain relief:
- Flexeril or Amrix (cyclobenzaprine): Cyclobenzaprine is a popular and relatively inexpensive generic muscle relaxant often used short-term to treat muscle spasms and pain related to sprains, strains, etc. A typical dose is 5 to 10 mg at bedtime for two to three weeks, although your doctor might approve up to 30 mg daily (taken as one 5 or 10 mg tablet every eight hours) if your case is more severe. Side effects include drowsiness, dry mouth, dizziness, and fatigue. (methocarbamol): Commonly used to treat severe muscle spasms, back pain, and occasionally tetanus spasms, methocarbamol is administered orally in up to 1500 mg doses or intravenously in 10 ml of 1000 mg. This dosing is usually higher in the first 48 to 72 hours, then decreased. Patients may experience drowsiness, dizziness, blurred vision and—in intravenous doses—reactions at the injection site. However, it’s generally less of a sedative than most other muscle relaxants. (metaxalone): While it’s slightly more expensive than other SMRs, like methocarbamol, the upside of metaxalone is that it delivers the same effectiveness with a relatively low rate of side effects. In three to four 800 mg doses per day, it acts on your central nervous system (brain and spinal cord) and may cause drowsiness, dizziness, irritability, and nausea, but metaxalone doesn’t sedate as heavily as the alternatives. (carisoprodol):Similar to Robaxin, Soma is generally used to treat pain associated with acute musculoskeletal conditions. Carisoprodol acts on the central nervous system to intercept neurotransmitters relayed between the nerves and brain. It’s administered in 250-350 mg doses three times per day (and at bedtime) for up to three weeks. Common side effects include drowsiness, dizziness, and headaches. It has also been associated with addiction, so it should be used with caution. (diazepam): Most often, you’ll hear about Valium as a treatment for anxiety disorders and alcohol withdrawal symptoms, but it can also be an effective medication for muscle spasms. Diazepam is a benzodiazepine (like Xanax) that decreases the sensitivity of certain brain receptors. Dosage varies depending on the condition, but for skeletal muscle spasms, it’s typically 2-10 mg, three or four times per day. Because it slows down brain activity, Valium frequently causes fatigue and muscle weakness so, like other muscle relaxants, you shouldn’t combine it with alcohol or other drugs. (baclofen): Unlike the muscle relaxants above it on this list, baclofen is primarily used to treat spasticity (continuous muscle tightness or stiffness) caused by multiple sclerosis or spinal cord injury. It is given as an oral tablet, or can be injected into the spinal theca. Most often, baclofen is prescribed on a schedule that increases the dosage gradually every three days. It can cause sleepiness, dizziness, nausea, hypotension (low blood pressure), headache, convulsions, and hypotonia (weak muscle tone), so even though it’s effective for spasticity treatment, it might not be the best option for pain relief. (chlorzoxazone): This is yet another SMR that acts on the central nervous system to treat the pain and spasms associated with muscle and bone conditions. It’s fairly well-tolerated despite occasional drowsiness, dizziness, lightheadedness, and malaise. In rare cases, it can cause gastrointestinal bleeding, so doctors will often opt for other medications. Typical dosage is 250 to 750 mg three or four times daily. (dantrolene): Similar to baclofen, dantrolene is primarily used to treat spasticity. It’s effective for spasms associated with spinal cord injury, stroke, cerebral palsy, or multiple sclerosis, and is also sometimes used for malignant hyperthermia. Common side effects include diarrhea, drowsiness, dizziness, fatigue, and muscle weakness. The starting dosage is 25 mg daily and it can be increased slowly if needed, up to 100 mg three times daily. In rare cases of overuse or long-term use, it has been attributed to liver damage.
- Norflex (orphenadrine): In addition to treating injury-related pain and spasms, orphenadrine is also effective in relieving the trembling from Parkinson’s disease. Some patients may experience dry mouth along with heart palpitations, blurred vision, weakness, nausea, headache, dizziness, constipation, and drowsiness, but usually only with increased dosages. However, this muscle relaxant can sometimes cause anaphylaxis, a type of severe allergic reaction. So, for basic muscle pain, doctors often go with one of the other options on this list. Standard dosing is 100 mg, twice per day. (tizanidine): Tizanidine is primarily used to treat stiffness and spasms associated with multiple sclerosis and cerebral palsy, similar to baclofen. Both show effectiveness, although tizanidine sometimes shows fewer side effects, which can include dry mouth, tiredness, weakness, dizziness. It’s administered in 2 or 4 mg doses.
What is the best natural muscle relaxer?
Let’s say your pain is lifestyle-related. Maybe a new workout routine put you through the wringer, or slouching over your laptop has started to take its toll on your back and neck. Minor soreness or aches happen all the time for any number of reasons, and they might not be severe or chronic enough to warrant muscle relaxers or other pain relievers. The good news is that there are plenty of natural remedies and dietary solutions to mild body pain. Even better is that you can find most of these treatments in food and supplements.
Dr. Lewis considers certain natural remedies ideal for stress management or to supplement other treatments. “Lavender oil and chamomile are great ingredients for relaxation when taking a bath or getting ready for bed,” she says. “They aren’t usually a first-line treatment but are great in conjunction with other things to manage tension from stress.”
CBD oil (cannabidiol) has been a popular but widely-debated natural supplement. Extracted from the hemp plant, it doesn’t cause a “high,” but it can be effective in treating epilepsy, anxiety, and general pain, among other ailments. Many swear by it for a broad scope of conditions, but research is currently ongoing as to what else it can do.
Additionally, the Food and Drug Administration (FDA) has only approved one CBD product, Epidiolex, which may be prescribed to treat two rare forms of epilepsy. “Many [CBD products] are not regulated, [so] the effectiveness between products is not consistent,” Dr. Lewis explains.
Or, you may have heard of arnica gel, made from an herb native to central Europe. It’s commonly used to treat injury-related pain and swelling and arthritis. Like CBD, there isn’t extensive research on it yet, but arnica has shown promise as a natural pain remedy.
Going the natural route? These natural muscle relaxants can promote pain-free living and holistic health:
|Natural Remedy||Administration Route||Common Treatments|
|Chamomile tea||Oral||Anxiety, inflammation, insomnia|
|CBD oil||Oral, topical||Epilepsy, anxiety, chronic pain|
|Arnica gel||Topical||Osteoarthritis, muscle aches/soreness|
|Cayenne pepper||Oral, topical||Stomach pain, joint pain, heart conditions, cramps|
|Lavender oil||Topical||Anxiety, insomnia, general pain relief|
|Magnesium||Oral||Muscle cramps, indigestion, constipation|
|Lemongrass||Oral, topical||Stomach ache, digestive tract spasms, rheumatoid arthritis|
|Turmeric||Oral||Osteoarthritis, indigestion, abdominal pain|
|Massage, physical therapy||Topical||Muscle pain, soreness, stress, anxiety|
While this list isn’t exhaustive, it presents you with plenty of options, no matter what has you hurting. As always, consult your healthcare provider for professional medical advice before taking a new medication. Even natural treatments can cause serious drug-drug interactions.
The ABCs of CBD: Separating fact from fiction
CBD. Cannabidiol. No matter what you call it, you may have heard health claims about this little-known part of the marijuana plant, which comes from the plant's flowers. Some say it treats muscle aches, anxiety, sleeping troubles, chronic pain, and more.
But what does the science say?
We spoke to NIH expert Susan Weiss, Ph.D., to learn more and find out why consumers should be careful. Dr. Weiss is the director of the division of extramural research at the National Institute on Drug Abuse (NIDA).
What is CBD?
CBD (or cannabidiol) comes from the cannabis (or marijuana) plant.
The chemical compound THC [tetrahydrocannabinol] is the part of the cannabis plant that most people are familiar with because that is the part that makes people “high.” Most effects of marijuana that people think of are caused by THC.
Most recreational marijuana has very little CBD in it. CBD products are available through dispensaries, health food and convenience stores, and the internet. It's a widely used product that's not regulated—and is not legal to sell for its largely unproven health benefits.
How does CBD work?
Nobody really knows what is responsible for the mental and physical health benefits that have been attributed to it. CBD affects the body's serotonin system, which controls our moods. It also affects several other signaling pathways, but we really don't understand its mechanisms of action yet.
How much do we know about CBD as a potential treatment?
There are over 50 conditions that CBD is claimed to treat.
We do know that CBD can help control serious seizure disorders in some children (e.g., Dravet and Lennox-Gastaut syndromes) that don't respond well to other treatments. Epidiolex is an FDA [Food and Drug Administration] approved medication containing CBD that can be used for this purpose.
There's also data to suggest the potential of CBD as a treatment for schizophrenia and for substance use disorders. But these potential uses are in extremely early stages of development.
Are there side effects?
We don't know of any severe side effects at this time. But there were mild side effects reported in the epilepsy studies, mostly gastrointestinal issues like diarrhea. There were also some reported drug-to-drug interactions. That's why, for safety reasons, it's important that CBD or any cannabis product go through the FDA review process.
Are there any specific CBD studies that you are focused on?
We are interested in CBD as a potential treatment of substance use disorders.
There is some research looking at it for opioid, tobacco, and alcohol use disorders. If CBD can help prevent relapse in those areas, that would be really interesting. We're also interested in it for pain management. Trying to find less addictive medications for pain would help a lot of people.
What else would you like people to know?
We are concerned about the health claims being exaggerated or incorrect. The FDA issued warning letters to several companies because of untested health claims. And the CBD products themselves didn't always contain the amount of CBD that they were reported to have—some actually had THC in them.
Another concern is that people are using CBD to treat ailments for which we have FDA-approved medications. Thus, they may be missing out on better treatments. And when they're using CBD or other cannabis products for conditions we don't know very much about, that's worrisome.
A counselor’s journey to healing from chronic pain
From 2005-2007, I suffered from excruciating back and leg pain. My pain was so bad that I was unable to sit for nearly a year. The only time I would sit was to drive myself to work, and the pain during that drive was so intense that there were several times I had to crawl out of my car once I arrived.
An MRI revealed a herniated disc, so I began a series of medical interventions that included seeing two chiropractors (a second after the first failed to help), two different types of physical therapists with two different approaches, and an acupuncturist, and receiving three cortisone shots, to name just a few of my treatments. Although I occasionally experienced relief, it never lasted long, and my pain got worse. I reluctantly decided to undergo back surgery.
To help deal with my pain as I awaited surgery, I began exploring nontraditional approaches and came across a book by Dr. John Sarno called Healing Back Pain: The Mind-Body Connection. In the book, Sarno, a physician, outlined a radical approach to curing back pain that he had developed through observing his own chronic pain patients for decades. He theorized that pain such as mine was caused not by structural abnormalities or injuries but rather by oxygen deprivation and faulty neuropathways in the brain. Furthermore, Sarno argued that the brain can actually create physical pain as a means of protecting people from experiencing painful emotions such as anger, rage and guilt. He labeled this condition tension myositis syndrome (TMS).
Learning about my pain
This isn’t to suggest that chronic pain is not real or is “all in your head.” On the contrary, Sarno believed that TMS pain was real and could be excruciating. However, because chronic pain is often not caused by structural abnormalities, Sarno argued, it could not be cured by focusing solely on the body. In other words, surgery, manipulations, injections, stretches and so on cannot cure the pain because the pain originates in the mind, not the body. Even for me, a licensed mental health counselor, this theory sounded crazy at first. After all, I had an MRI that proved I had a bulging disk.
At the same time, there was also something that resonated with me about Sarno’s ideas. First, he described how people with TMS tended to have shifting pain that could manifest in different ways and move to other areas of the body. This could include experiencing migraines, heartburn and other digestive issues, knee and shoulder pain, and so on. These were all things I had suffered from since I was a child, but none was occurring now that I had back pain.
Second, Sarno outlined how people with TMS often experienced more severe pain under times of stress and how that pain could diminish during less stressful times. This was certainly true for me. At the time, I was working very hard to earn tenure as a professor at the University of Rochester, and my wife and I were raising two small children. It was among the most stressful times in my life. I also noticed that my pain would sometimes subside during less stressful times such as vacations.
Third, Sarno outlined a series of personality characteristics that are consistent with people who suffer from TMS. Not only do TMS patients tend to ignore their own emotional reactions, but they are incredibly hard on themselves (i.e., they are perfectionistic, highly driven, tend not to seek out help, etc.). These personality characteristics fit me perfectly. Furthermore, Sarno argued that an MRI would reveal structural abnormality in almost all patients over the age of 30 — but most people don’t experience any pain as a result. In other words, if Sarno was to be believed, my herniated disk wasn’t the cause of my pain; rather, it was my personality.
I decided that Sarno’s approach was worth a try, so I delayed back surgery, stopped physical therapy and seeing chiropractors, and began working on my emotions. I found a therapist who worked from a psychoanalytic approach designed to help clients uncover repressed emotions, and I began therapy. I also began engaging in psychoeducation, behavioral interventions and mindfulness (which I will describe in more detail later).
Miraculously, after just a few weeks of practicing this integrative mind-body intervention, I was free of pain. Not only was I able to avoid back surgery, but I was able to heal a number of other chronic health issues with which I had suffered for years. To this day, my back remains pain free, and I am able to engage in physical activity without any restrictions.
In 2017, I began advanced training and research in mind-body therapies, and later that year, I opened a private practice focused on helping clients who are in chronic pain. Since then, I have helped dozens of people overcome a variety of chronic pain conditions, including back, neck, shoulder, knee and hip pain; fibromyalgia; migraines; and chronic nerve pain. Like me, most of my clients suffered for years and were not able to find cures from mainstream medical approaches. Several of them were on disability from work or school but have now resumed normal life activities.
In this article, I provide an overview of the mind-body counseling approach I use with clients who are in chronic pain and provide suggestions to counselors interested in integrating this approach into their work.
Integrating a mind-body approach
When I began my own healing journey, few resources about this intervention existed beyond Sarno’s books. Thankfully, things have changed. The advent of social media has allowed the hundreds of people healed by Sarno to share their stories (many presented in the documentary All the Rage), and a growing body of research now supports the efficacy of Sarno’s ideas.
This increased awareness and popularity have led to numerous options for professional counselors to receive additional training in this modality. Although I highly recommend that counselors pursue this additional training through workshops and clinical supervision, many of the mind-body counseling interventions are consistent with skills that counselors already possess.
To begin, counselors must carefully screen clients to ensure they are appropriate for the intervention. Most importantly, clients must be screened by their physicians for serious medical conditions such as cancer, heart disease or broken bones that require medical attention and cannot be cured by mind-body counseling. Second, as with all counseling interventions, the mind-body approach is most helpful to those who believe in it, are familiar with the process, and are committed. While most clients arrive with some skepticism (like I did), those who are completely closed to the idea (e.g., clients who attend only to appease someone else) are not likely to be helped and can often become frustrated with the process. In addition to posting information about my approach on my website, I also conduct extensive phone consultations with prospective clients to explain the approach in detail and assess their potential fit.
Once clients are screened, several counseling interventions can be used in ways that effectively integrate Sarno’s strategies. These interventions include:
- Psychoeducation about the nature of chronic pain
- Behavioral techniques to build confidence and reduce fear
- Mindfulness to help clients become more comfortable with uncomfortable physical and emotional sensations
- Intensive short-term dynamic psychotherapy (ISTDP) to allow clients to become aware of and express painful emotions
- Social support from other mind-body clients
The first step in integrating this mind-body approach to healing chronic pain is to provide clients with psychoeducation regarding the relationship between their minds and their pain. In addition to Sarno’s books, a number of other recent books by mind-body experts such as Howard Schubiner, Allan Abbass, Nicole Sachs, David Clark, Steve Ozanich and spine surgeon David Hanscom review scientific evidence that supports and extends Sarno’s ideas about mind-body connections to many forms of chronic pain. These resources expose clients to research that shows:
1) Most people with healthy (i.e., pain-free) backs, knees, shoulders and hips show structural abnormalities that should cause pain, supporting the notion that human bodies naturally change with age in ways that look structurally problematic but do not cause pain.
2) There are relationships between childhood trauma and physical health, including many forms of chronic pain.
3) fMRI research has established links in neuropathways responsible for physical and emotional pain.
4) There are strong relationships between chronic pain and the inability to be aware of, experience and express painful emotions such as anger and guilt.
Familiarizing clients with research showing that their pain is not likely of a structural origin, which is contrary to what they have been told by other health care providers, and providing them a path for recovery can instill hope and reduce fear. This process alone can begin to reverse the fear-pain-fear cycle that can activate and reinforce pain neuropathways in the brain.
At the same time clients are learning about mind-body connections to chronic pain, counselors should also begin engaging them in behaviorist interventions designed to reduce fear and encourage reengagement in their normal activities. Well-meaning health care providers frequently instruct people with chronic pain to discontinue physical activities that they enjoy in order to allow their bodies to heal. This is great advice for injuries such as broken bones or sprained ligaments but extremely problematic for mind-body ailments. Several health care professionals told me to swim laps instead of playing basketball. After several weeks of swimming (which I hated), a chiropractor then told me that swimming was the worst thing I could do for my back because of all the twisting and bending involved. He instructed me to disengage from all activity. In reality, the less activity I engaged in, the more depressed and hopeless I felt, and the worse my pain became.
As clients become educated about mind-body connections to their pain, they are encouraged to gently reengage in physical activity without fear of harm the next day. Counselors can facilitate this process by encouraging clients to engage in daily affirmations to reduce their fears of physical activity. This could include declarative statements such as “I am strong, and my body is capable of engaging in this activity” or “There is nothing structurally wrong with me, so doing this can’t hurt me.”
Clients should also be instructed to chart their progress as they reengage in life activities. Often, clients can become discouraged and feel hopeless when minor setbacks occur. Logs that indicate their overall progress over time can help clients sustain optimism during these setbacks.
Counselors should also encourage clients with chronic pain to engage in somatic tracking. These clients often arrive at counseling having already devoted extensive time to seeking potential relationships between their pain levels and physical activities (e.g., exercise, household chores) or the foods they eat. This process can become incredibly frustrating because many of the activities or foods they once associated with their pain often are disproved over time. Counselors integrating this mind-body approach should instead encourage clients to document relationships between their physical pain and their emotional states.
A very common example is that people suffering from chronic pain can experience reductions in pain during less stressful times in their lives such as vacations. Traditional structural models of pain often seek to correlate these improvements to things such as nice weather, changing humidity levels or even the quality of the mattress at the hotel. However, counselors operating from a mind-body approach should encourage clients to document their emotional states when feeling free from pain. This same process is used when pain increases.
For example, pain that went away during vacation often returns or becomes even worse when the client returns home. It is tempting to attribute this increase in pain to uncomfortable travel conditions (e.g., car or airplane seats) or weather changes. However, clients should be encouraged instead to explore problematic interpersonal issues to which they may be returning at home. Sometimes these answers can be very clear; other times, the answers are hidden from view, especially when they involve traumatic events or emotions that clients feel guilty about having toward others. In these cases, ISTDP is central in uncovering hidden emotions related to pain flare-ups.
Counselors can also help clients consider, without judgment or fear, the secondary gain that their pain potentially provides them, particularly regarding what their pain gets them out of doing or feeling. Chronic pain often requires people to become confined to their homes and, therefore, to miss out on potentially stressful interpersonal encounters. These can include social events that they may be dreading, conflicts with colleagues or family members, or even having to provide care for children, partners or aging parents.
Understandably, clients are often resistant to exploring these possible relationships because it may feel like they are being blamed for their pain or accused of it all being in their heads. Counselors need to continually reassure their clients that mind-body pain is real and not “created” on purpose. In fact, it is often a result of people trying to subconsciously protect others from their feelings toward them.
Counselors should encourage clients to create logs of what they miss out on during severe pain flare-ups. This may reveal correlations between their pain and their hidden (but potentially powerful) feelings of fear, anger and guilt. Sometimes, the patterns that emerge, although difficult to recognize initially, can become too prevailing for clients to ignore. Once these patterns are identified, ISTDP can be particularly useful in assisting clients with unpacking and understanding the complex relationships between their pain and their hidden emotions toward others.
Mindfulness-based stress reduction, first introduced into Western medicine by Jon Kabat-Zinn, has been used for over 30 years to treat chronic pain. While research indicates that mindfulness shows only moderate effects in alleviating chronic physical pain, the approach has proved highly effective in improving psychological symptoms associated with chronic pain, such as depression and anxiety, and reducing physical limitations associated with the pain.
From my experience, mindfulness is also extremely useful in helping clients become more comfortable with uncomfortable emotions. This can greatly enhance the effectiveness of the behavioral approaches mentioned previously as well as emotional-focused therapies such as ISTDP.
A detailed description of mindfulness is beyond the scope of this article. Counselors interested in effectively implementing this mind-body approach should seek training in mindfulness and mindfulness-based therapy. However, even counselors without training in mindfulness can encourage their clients to participate in mindfulness workshops and to develop regular mindfulness practices outside of their counseling sessions.
While Sarno argued that many people could heal themselves through psychoeducation and behavioral approaches alone, he also realized that some people (like me) needed psychotherapy to assist them with recognizing, experiencing and expressing repressed painful emotions that might be causing pain. Specifically, Sarno advocated that people with chronic pain engage in ISTDP, which is an attachment-based, emotion-focused somatic therapy developed by psychiatrist Habib Davanloo.
Through extensive research over several decades, Davanloo identified a series of core defenses some people have developed, often since childhood, to block uncomfortable feelings and repress traumatic experiences. While these defenses can often be adaptive when people are children, Davanloo found that they create tremendous emotional and physical suffering later in life.
Chronic pain, from an ISTDP perspective, is an unconscious attempt to protect (or distract) people from experiencing uncomfortable emotions and harmful impulses toward others, particularly loved ones, as well as the guilt they carry for harboring these negative feelings and impulses. Counselors conducting ISTDP therapy help clients notice strategies (or defenses) that they have developed to prevent themselves from becoming close to others and experiencing emotions toward them. Counselors also integrate experiential techniques that help clients become aware of, experience and express these painful, repressed emotions toward others and to recognize and even act out potentially threatening impulses associated with these painful feelings.
This process of skillfully pressuring and challenging client defenses can result in what Davanloo referred to as an “unlocking” of repressed emotions, where defenses are loosened and waves of painful feelings are experienced consciously. When partially or fully experienced in therapy, an unlocking can result in dramatic improvements in both physical and psychological well-being.
ISTDP is a complex and powerful approach to therapy that requires years of supervised training to implement. Even after completing extensive reading on ISTDP, attending numerous conferences and workshops, and participating for several years in a core training group and individual supervision with an expert ISTDP practitioner, I still feel like a novice. Even so, leading mind-body physicians such as Sarno and Schubiner have suggested that all health care professionals, including those without formal training in ISTDP, should integrate aspects of this approach into their mind-body practice. Specifically, they advocate for people in chronic pain to journal about their feelings toward others and to engage in meditations designed to help them connect their emotions to their bodies.
More information about ISTDP, including how to integrate elements of the approach into health care practice, can be found in Abbass and Schubiner’s book Hidden From View: A Clinician’s Guide to Psychophysiologic Disorders.
When I began this process as a client 15 years ago, I remember feeling very alone in my journey. The few attempts I made to discuss these ideas with health care providers, or even friends and family members, were usually met with skeptical or condescending looks and remarks. Now, having counseled many others, I have learned the power of social support in the success of this process. A consistent comment I hear from clients in my pain groups is how integral the support they receive from their fellow group members is to their success.
Engaging in pain groups may not be possible for everyone, but a number of online communities are available through Facebook and other social media platforms that can provide opportunities for clients with chronic pain to connect with others like them. There are also several podcasts, including The Mind and Fitness Podcast, hosted by former chronic pain sufferers who share their own and others’ success stories overcoming various forms of chronic pain through the mind-body process. These stories usually detail their struggles with chronic pain; their frustrations with health care professionals who performed costly and unnecessary tests and medical procedures; their mind-body healing journeys, including how they overcame setbacks; and their quality of life since becoming free of chronic pain.
Such connections provide clients not only with role models, but with continual support from others. This can enhance the effectiveness of the intervention, especially during times of struggle. There is even an app called Curable that is specifically designed to provide people in chronic pain with resources, activities and social support in ways consistent with Sarno’s approach.
Summary and conclusions
The integrative mind-body approach outlined in this article is a powerful and underutilized approach to helping clients heal from chronic pain. The approach is particularly well suited to clients who have been cleared of serious health conditions and who have exhausted traditional medical interventions with no relief.
While many of the intervention strategies align well with traditional counseling approaches, counselors who are interested in specializing in this work should engage in professional development by attending mind-body trainings and workshops and participating in an ISTDP core training group. Among the ISTDP master clinicians who offer core training are Allan Abbass, Patricia Coughlin, Marvin Skorman and Jon Frederickson. Counselors may also consider enrolling in the University of Rochester’s advanced certificate program in mind-body healing and wellness (see tinyurl.com/Mind-BodyCert ). It is the first program of its kind to provide advanced-level training in this type of mind-body intervention.
Douglas Guiffrida is professor, counseling program director, and director of the mind-body healing and wellness program at the Warner Graduate School of Education and Human Development at the University of Rochester. He is a licensed mental health counselor and a national certified counselor. To learn about his private practice or to contact him, visit DouglasGuiffrida.com.
Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.