Unlearn Your Pain: Harnessing the Power of Neuroplasticity – A Conversation With Howard Schubiner

Welcome to the Mad in America podcast. My name is Brooke Siem, and I am the author of the award-winning memoir on antidepressant withdrawal, May Cause Side Effects. Today, I’m excited to have Dr. Howard Schubiner on the show. Dr. Schubiner is an internist and a clinical professor at the Michigan State University College of Human Medicine and has authored more than 100 publications in scientific journals. He lectures internationally and is the author of three books, including his most recent book, Unlearn Your Pain: The Science of Recovering from Chronic Pain, Fatigue, Anxiety, and Depression.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Brooke Siem: Howard, welcome to the show.

Howard Schubiner: I’m so happy to be here, Brooke. It’s going to be fun to talk about this stuff. I’ve spent the last 23 years challenging a lot of medical orthodoxies.

Siem: When I picked up your book and started reading the foreword, I saw your references to Dr. Sarno, who wrote about back pain. His book, Mind Over Back Pain, was the answer to my back pain problems. I had an injury, and I knew there was no longer any actual injury there, but I was still having debilitating pain. His book started to be one of the early seeds that upended my relationship with medicine and my body, and I’ve always had such respect for his work. Then, right in your foreword is the mention that you were a bit of a protégé of Dr. Sarno.

Schubiner: He’s the one who started me on this path. I had a whole career prior to meeting him, 18 years as a medical school faculty, became a full professor and did a lot of research. But then I was in a mid-career, and I read one of his books, and I thought, wow, this is amazing. I called him up and went to work with him. This led to the last 23 years of being immersed in this book and voraciously reading about the science of neuroplasticity, predictive processing and how the brain works. Then expanding this work into doing high-level randomized controlled trials, showing that this work is superior to the standard therapies for chronic pain.

Siem: I’m going to read just one sentence that, to me, stood out as to what everything boils down to. This is in the context of really any sort of pain, emotional pain, psychic pain, spiritual pain, back pain. You said, “The brain creates real symptoms automatically, and these danger signals come from a subconscious part of the brain that is trying to protect us.” Can you explain a little bit more about what you mean by that and how this ties into your life’s work?

Schubiner: Mental health therapists generally are not taught that our brain creates what we experience. This is called predictive processing. If you look at the high-level neuroscience from some of the great modern neuroscientists, we don’t see with our eyes, our brain creates what we see. This is amazing. We can see in our sleep when we dream. We don’t hear with our ears; our auditory cortex creates what we hear.

When you touch a hot stove, it’s not your finger causing pain; that’s actually the brain because you can have an injury and have no pain, and you can have pain in the absence of injury. Our brain is trying to protect us and alert us to danger if there’s danger at any moment. We walk down the street, and everyone we see is friend or foe, friend or foe, our brain is constantly there to protect us.

High-level research studies of the brain show that emotional pain leads to the same reactions in the brain as does physical pain. This is how we’re wired.

When people say that emotional pain can cause physical pain, that is completely true, and emotional pain obviously can cause anxiety or depression or chronic fatigue or a whole variety of symptoms, and those are real. They’re not imagined, they’re not fake, they’re not all in people’s heads.

The thesis of this book is that everyone needs to figure out what they have. If you have back pain, is it because there’s damage in your back, or is it because you’ve been hurt or betrayed or abandoned, or things have happened to you that have caused your brain to go into danger mode and cause pain or any other symptom that the brain might produce? I think that really encapsulates it, and most doctors are totally unaware of that.

Siem: I think one of the things that’s so difficult when it comes to psychological distress is that we can’t measure it and it’s so subjective. What is distressing to me may not be distressing to you and vice versa. What’s so interesting about your work is that there are ways to see it play out in the physical body. Could you give us a little background on how this thesis could play out, let’s say with back pain, and then how we can take that understanding and apply it to the world of psychology and mental health?

Schubiner: Let me tell you a story about a woman who had a back and pelvic pain problem. She’s a physician, and the day she graduated from medical school is the day her pain started. It turned out that a few months earlier, both her parents had suddenly passed away, and she just soldiered on and tried to do the best she could. But on graduation day, she got this pain, and it persisted, and it kept going and going and going. She went to doctors, and they couldn’t find anything major wrong with her back. She had some mild degenerative changes, but everybody has these degenerative changes without pain.

She had endometriosis also, and so she was offered surgery for endometriosis. Well, a lot of women need surgery for endometriosis, but as a doctor, she started looking up the literature. She found that a fair number of women actually have endometriosis without pain, so how was she to know? She was talking to her friend, and her friend said, there’s this mind-body work that Dr. Sarno was doing for years and wrote about; he’s helped a lot of people, and there are modern people who are now carrying on this tradition.

Her friend asked why did it start on your graduation day? Maybe there’s a clue there. She goes to see a mind-body therapist. The therapist explains that the brain can cause pain, and it can cause pain in relation to stress, trauma and emotional stuff, right? They also recognized that this woman was kind of criticized when she was young. She was trained not to stand up for herself, not to be assertive, not to take care of herself, to be people-pleasing, to always say yes, to put everybody else first and not be her authentic self. They recognized that.

One day, a week later, she was having lunch with a friend, and afterwards, her pain shot up really high. She’s got all this pelvic pain, all this back pain, and she goes, what happened? What did I eat? Then she realized her friend had asked her to do something, and she said yes, because she always says yes. She really wanted to say no in her heart. With fear trembling, she picked up her phone, she called her friend, and she said, you know, I can’t do that. I’m sorry. She felt a little pride, and she felt a little exhilaration, and the pain disappeared on the spot and went away completely. Not forever, but it went away in that moment, and that was her moment to know she didn’t need surgery. She needed to be more authentic in her life, that this pain was real, it’s not all in her head, she’s not crazy, it’s not her fault, it’s real pain, because the brain produces real pain.

Then she went on to change how she related to herself and others, and she started being authentic with someone really important in her life, her husband, who she had never really spoken about her needs. Their relationship improved, and her pain completely went away over the next few months. That’s an example, I think, of how this can play out in people’s lives.

Siem: How do we take that concept and apply it to psychiatric distress? Anybody who’s experienced this knows it feels so out of your control. It’s so interesting to me, because I remember my mom, when I was going through depression, and I was very wrapped up in the conventional narrative, she just would say to me, “You can choose not to be depressed”, and I would hit the roof. That made me so angry that she would say that because it felt so out of my control.

Then I got off the drugs, went through withdrawal, and it’s been 10 years now. Oh, boy, do I understand what she means by saying you can choose not to do this. But it’s so hard to embody that, and there’s so little support. So how do we apply this to psychology and mental health?

Schubiner: This work is so moving because people are suffering and they’re being told that there’s something physically and structurally wrong with them. They’re being told that they have something physically wrong with their brain when they’re depressed because they’re told they have low serotonin levels, and there’s no evidence for that. It’s not scientifically valid. They’re being told that antidepressants are the only way to treat anxiety and depression because of this idea that it’s a neurotransmitter problem.

Antidepressants have a very high efficacy rate in randomized controlled trials. But the placebo effect is just as high. It’s actually a placebo effect if someone gets better from an antidepressant, which means they may be able to harness the power in their brain because of neuroplasticity to change the neural circuits in their brain to recover.

What happened with me is that I started working with pain when I met Dr. Sarno. A woman came in, she had back pain and it was really severe. We started working with her on her pain. Then, after a couple of weeks, her pain dramatically went down, but at the same time her pain went down, she got so anxious. Her anxiety just went through the roof. I could see in that moment how the brain can create either pain or anxiety. It can turn one on and turn the other off. This is how neural circuits work. It can turn on fatigue or it can turn on depression. In 23 years of doing this work, I’ve seen all those kinds of things, and I’ve seen how they can turn on and off. I’ve seen how they’re related to people’s lives, what happened to them and how these neural circuits can be reinforced so it seems like they’re out of people’s control. This is the subconscious brain doing this.

They’re not voluntarily doing that. They can’t just click a switch and turn it off, but neural circuits are changeable. That’s the work that we’ve done in terms of the types of therapies we’ve developed to help people. The beauty of this work is that we found that these treatments, one we call pain reprocessing therapy and one we call emotional awareness and expression therapy, have been effective for pain, anxiety, for PTSD, for depression, for trauma, for chronic fatigue syndromes and things like that.

In fact, in one of our Emotional Awareness and Expression Therapy trials done by Brandon Yarns, our colleague from UCLA, in veterans with musculoskeletal pain for more than 20 years, the people who did the best in this study were the ones who had coexisting anxiety, depression, and PTSD. That is amazing because the general consensus would be that those people would be the hardest to treat because they have pain plus anxiety, depression, and PTSD, but they’re the ones who benefited the most from this treatment.

Siem: Tell us a little bit about nocebo and placebo in the context of your specific work. I think it really helps us expand and understand why these types of treatments can be quite effective.

Schubiner: One of the things I write in the book is never underestimate the power of the brain. When we think about placebo effects, the antidepressant trials are really an incredible way of understanding that. But the point is the placebo effect is real. It’s changing neural circuits in the brain when you have a placebo effect. Surgery can have a powerful placebo effect. A lot of people can get better from surgery for back pain, but how do we know it’s not a placebo effect? When you take an antidepressant pill, it turns out that the vast majority of the effect is due to the placebo effect, it’s not due to the actual medication. It’s due to the person believing that the medication will help, and that belief can change neural circuits in the brain to reduce the actual symptoms of depression. That’s the power of the brain to do that, and the power of believing that something will work.

In pain, white pills work better than pink pills or red pills. If you give someone a pain pill and you tell them this pill costs $2.50 and this other pill costs $0.10 in a randomized fashion, the more expensive pill works better. Their pain goes down more than that of the people who got the cheap pill. But in the study, actually, both pills were placebo pills.

Now, the nocebo effect is the opposite. The COVID vaccine was tested in 40,000 people in randomized controlled fashion against a placebo. People who got a COVID vaccine, 25% of them developed a headache. People who got the placebo, 20%, developed a headache. Getting a headache after a placebo injection is a nocebo effect.

One of the most famous stories is of a guy who was depressed and suicidal, really devastating. He was in a research trial, and he had a bottle of pills for the study, and he took the whole bottle of pills. He got to the hospital, he collapsed on the floor, and he said, “Help me, I took the whole bottle”. His blood pressure was low, his pulse was weak and thready, and he was barely awake.

They admitted him to the hospital, they gave him IV fluids to raise his blood pressure, and they looked at his bottle of pills; it just had a phone number. It didn’t say what it was. They called the number in the research trial and found out he was in the placebo arm of the study. He overdosed on a placebo; he didn’t overdose on an antidepressant. They told him that, and he recovered fairly quickly. The power of his brain to produce this as a nocebo effect is really profound.

This is predictive processing; our brain creates what we expect it to create. That’s why symptoms are what we would call neuroplastic, brain-generated symptoms. We’ve done a big research study showing that the vast majority of people with back pain have neuroplastic pain, abdominal pelvic pain, irritable bowel, fibromyalgia, anxiety, depression, or chronic fatigue, and don’t have structural damage to account for it. We would call that neuroplastic, which means it’s changeable.

What happens in the brain is that it gets stuck in an auto loop pattern. Every time you wake up in the morning, the brain says, time for depression, time for anxiety. Every time you hear a car backfiring, and you’ve been in a war zone, your brain goes to, well, that’s gunfire, so it creates these powerful symptoms. The brain is predicting what it does, and neurons that fire together wire together. We can change the neural circuits in the brain by giving the brain a different experience in relation to these triggers of time of day, or being around certain people, or whatever it is that triggers them. These things are changeable, and that’s the beauty and the power of this work.

Siem: What would be the very first steps for somebody? What you’re saying is there’s a little bit of space there. How do you grab onto that little bit of space and start working with it, especially when people are starting this journey? How do you start making inroads when you can’t believe that there’s any hope, and that belief is inherent to having a placebo “work” how do you start?

Schubiner: First, I would say, everybody needs medical testing to make sure they don’t have a serious medical problem. If you have an anxiety disorder, we want to make sure you don’t have hyperthyroidism. With depression, we want to make sure you don’t have a very low testosterone level, if you’re a man, for example.

Then people can look at the literature and look at what’s really happening, because there are so many myths out there with anxiety and depression in the psychiatric world where they’re telling people it’s their neurotransmitters, it’s their genetics, it’s their inflammation. All these things that are making them believe that they’re structurally damaged. If you believe you’re structurally damaged, it’s going to be a lot harder to get better.

We want to be skeptical of people telling us that we’re incurable. When someone has depression, and they recover, and then they get depression again, well, why would you get depression again? Well, your brain, if you’re in a stressful situation and your brain turns on depression, there’s a warning signal. That’s its job. But in the psychiatric community, they say ”Oh you have treatment-resistant depression, you have relapsing depression, you’re going to be treated for the rest of your life”. Well, I would say that’s not true, but it gives a message, and that message becomes a powerful nocebo effect.

When you have that moment first thing in the morning where you feel like, oh, hey, I feel fine, there’s that moment. That’s the truth. That’s the evidence. You can feel fine, even if it’s only for 10 seconds, because your brain can turn things on and turn things off. Also looking for the evidence of how things vary by time of day. I’m better in the morning, but worse in the afternoon. Well, why is that? A structural damage problem doesn’t change like that.

Neural circuits in the brain can go up and down, turn on and off. Why is it so much worse with certain triggers, the weather, cold or heat or light or sound or computer screens? Often those are clues. We’re really looking for the evidence that people can find in their own life that can help them see that this is possible.

Siem: Another thing that strikes me about this work that I really like is that so much of my efforts are in the world of antidepressant withdrawal. It becomes a job in and of itself to start going through these processes and to try and isolate triggers that people have. We become very reactive when we’re trying to get off a psych drug, and we can sort of incept ourselves very easily. We can end up in a situation, or we can put ourselves in a situation that we know is going to induce a withdrawal wave.

Sometimes people get cranky with me when I talk about this because they get defensive and think that what I’m saying is that withdrawal symptoms are fully controllable and that if someone’s experiencing a symptom, they chose to do it. There’s so much nuance to this, and many things are true at once. There are aspects of withdrawal that are out of your control and are a matter of time, waiting and learning how to dance with that symptom. There are other things that we do to ourselves. I’ve watched it happen to a lot of other people. It’s just that we don’t realize how powerful we are.

My point is that it can become quite the checklist to try and go through all this. People get exhausted from just the act of trying to figure out, well, is this the blueberries or is it the raspberries? Which one is causing the problem?

What I really loved about my experience with Dr. Sarno’s work in my back pain, and I’m wondering your thoughts on how it could apply here, is that once I sort of understood why this was happening, I could sort of let go of all the details and just focus on the path forward with the treatment because it really didn’t matter if the blueberries or the raspberries were involved in the problem. The whole point was that I learned to reframe and shift my whole mindset. Then the raspberries and blueberries wouldn’t be a problem anymore. It didn’t matter which one it was. Does that make sense?

Schubiner: I think that’s a real key for people is to be exploring oneself. That’s kind of what I was talking about by saying, look deeply at how things happen for you and look at these inconsistencies. One of the things that we do is we try to help people see that sometimes it’s clearly true that there’s a physiologic effect, say a withdrawal symptom that’s clearly real. It can also be true that sometimes some of the symptoms that seem like withdrawal could be coming from the brain generating them out of fear of the withdrawal. This is extremely common.

One of the things that I’ve done is to set up what’s called an “N of 1” trial. It’s a research study you do just for yourself. If you find that there are certain symptoms that occur when you lower a dose from 20 milligrams to 19.8 or 19.5 milligrams, a very low reduction, how could you know if those symptoms are due to the physiologic effect or due to the brain causing a nocebo effect? It’s really hard to know, but you can figure it out by doing an “N of 1” trial where you have a partner who blinds you to which dose you’re taking on any given day, and then you randomize it. You don’t know if you’re taking the 20 milligrams or the 19.8. Then you write down how you felt each day for a week or two weeks or whatever, however long you want to do it.

When you don’t know which one it is, you tend to eliminate the nocebo effect. Then, if you find that every day on the 20, you feel better than every day on the 19.5, then you know this is a physiologic effect. But if you find that it’s random, where some days you feel more symptoms on the 20 milligrams and fewer symptoms on the 19.5, and it’s variable like that, then you know you can be a little bit more confident in lowering your dose because you can begin to use the power of your belief that you can do this. If you have some amount of symptoms when you’re lowering from a little bit, just by a little bit, you can tolerate those and know that it will pass.

Then you can really begin to make progress as opposed to feeling completely stuck. I don’t know if that makes sense, but I’ve seen that work. It’s one way of gathering more evidence.

Siem: I think that one of the things that tends to happen in withdrawal for folks is that you get such an intensity of emotion that starts to happen as you become less numb. It’s very difficult to tell what’s just my life or what is maybe, for women, where I am in my hormonal cycle. You forget that you didn’t sleep well last night, like there are a lot of things that are adding to the complication on an already delicate system. I see a lot of people just getting very scared about dropping the dose than they are about the actual symptoms happening. I’ve often wondered how to handle that. One of the things that’s come to me has been sort of a, well, can somebody else actually be in charge of when we drop? I know in the world of weightlifting, sometimes you can lift a lot more if somebody else loads the plates, and you don’t know how heavy it is.

Schubiner: Yes, exactly. It’s kind of like I said before: don’t underestimate the power of the brain to heal and recover and to use our power. Dr. Sarno really talked about this a lot. A lot of times, part of the problem is not believing that this will work for you, not believing that you can do this. Belief in yourself and belief that this process will work for you, if you commit to the process, is very powerful.

Siem: It’s also difficult because I think people go on these drugs for usually very good reasons, but a lot of the subconscious messaging in that, especially for children and teens who are medicated, is that you are not powerful enough on your own to handle this. Here’s a pill, right? Even if nobody has said those words to you, it’s a subconscious inception every single day, and then when you get off these drugs, you have no skills. You have not spent your life believing that you are capable of handling your life.

On top of that, you are by definition stepping into more pain and struggle because that’s life. Now you’re doing it without the aid of the numbing effect of these drugs. You are paradoxically getting off these drugs to feel more and to feel more alive, but feeling more alive comes with feeling a lot more pain. Then you don’t know if you’re recovering or what. There’s quite the push-pull there.

Schubiner: We want to give people tools so that they have the belief that they can handle life’s stresses and that they can deal with their symptoms. That’s where these treatments come in. We want to give them tools to deal with the emotions and emotional situations that are so often underlying these issues.

Siem: Can you walk us through these primary treatments that you use?

Schubiner: The first one we call pain reprocessing therapy, but it applies equally to non-pain symptoms. It’s based on this simple idea that neurons that fire together wire together. If someone has anxiety related to a trigger, such as grocery shopping, going outside, sunlight, family events, or driving, for example, what we want to do is help them see that the trigger is because of learned neural circuits that have gotten reinforced over time. Every time you go into the trigger, subconsciously your brain is expecting to produce the anxieties, and then it does. It keeps doing it because that’s what it did before. If we can give somebody a new experience to help their brain learn that they could approach, let’s say driving, with less subconscious fear with more empowerment, with more beliefs that they can do it, with a lighter affect, etc., all these ways of making the brain feel safe.

One of the simple ways of doing that is to ask people to imagine just being in a room with a therapist or by themselves and imagine driving, what happens? Imagine you’re getting into the car and starting to drive. What happens? Well, you start to feel anxious, but it’s a low-level exposure to that stimulus. Then they can see, oh yeah, it’s pretty obvious the brain is doing that, I’m not in the car. It’s okay. Well, thank you, brain. You’re protecting me. You’re worried about me. It’s there for a reason. It thinks that driving is dangerous, but maybe we can correct that. We can use tools of mindfulness and calming, and the affirmations and self-talk to our brain to say, okay, I got anxious by imagining driving. Let me calm down and see what happens. Let me do it again. Imagine driving again and calming down. Imagine driving with a smile. Imagine driving with affirmations. Affirmations have been shown to change the brain in a variety of studies. Imagine driving while taking your fear and setting it next to you. Your fear is there, but it’s okay.

There’s a variety of these techniques. We’re training the brain to approach driving or whatever the trigger is with more equanimity, with more empowerment. Then we start to gradually ramp that up. It’s a typical behavior response situation where you can just get in the car and sit in the car and then feel good about that. Then drive up and down your drive or whatever. It’s gradually changing neural circuits in the brain. That’s kind of the essence of pain reprocessing therapy, knowing that the symptoms are brain-generated, that they are reversible and that you can learn to tolerate them and change your brain in response to them.

Siem: Then the other one, EAET?

Schubiner: It’s Emotional Awareness and Expression Therapy. There are a lot of trauma treatments out there, and I’m not saying ours is the only one. I’m not saying ours is the best, but I am saying that ours has been shown in randomized controlled trials to be more effective than cognitive behavioral therapy. It’s very rare. There are no other studies that show that one psychological treatment is superior to the other, but we’ve actually shown that in relation to pain. We’re proud of that. We’re excited about that.

Mark Lumley and I are the ones who developed this model. What it involves is helping people to see that emotions are not dangerous, that emotions are our friend, that emotions are there for a reason.

People who grow up with a rageaholic father, people who grow up with situations where they’ve been hurt or traumatized or abused, are often very fearful of anger. That anger comes up, and their brain suppresses it because it’s dangerous. I don’t want to be like that. I don’t want to be like my father. The anger could be violence. People who grew up in families where there was emotion that was not seen, heard, tolerated, it may be hard for them to feel sadness because the sadness is seen as dangerous by their brain. A lot of times, people grow up with guilt. There’s sadness, guilt and anger. These are all normal emotions that we help people activate in safe and healthy ways.

To relive your trauma is cruel, right? We don’t want people to relive their trauma. That’s a horrible thing to do to somebody. But how do you know what your trauma is? It’s your memory of it. Memories are changeable. This is science. Memories are always changing, in fact. We will help people take their current self, go back to their younger self to change it, to give their younger self love and care and compassion, to help their younger self get angry at somebody who hurt them or abused them or neglected them, to yell and scream at them or kick them or push them or do whatever the anger wants to do to get it all out in their imagination in a safe and healthy way to change the neural circuits.

So many people who have been hurt in their lives have a hard time being compassionate to themselves. This work is about compassion. This model is to help people deal with powerful emotions in traumatic situations in safe and healthy ways that are effective. Oftentimes, that’s the key to helping people recover from these neuroplastic conditions.

Siem: It’s very interesting for me to hear you say this, and I feel like there’s inevitably going to be a few folks who decide to go try this on their own. What I’m hearing is that the most important part about this, in order to just ensure that you’re not running over yourself with trauma, is that there are two things. One, you mentally play out the situation in the way you wanted it to happen, or in a protective way. But then, most importantly, is that you go to the parenting, to the self-soothing, you comfort the new version that you created in your head. I think, and gently come out of what could be a pretty intense experience, I imagine.

Schubiner: It’s very deep work. It’s very powerful, and it’s very beautiful because we’re helping people become their own self, their true self. Everyone needs agency, belief that they can change their world and have power over themselves and some parts of their world. Everyone needs connection, connecting to ourselves on a deep level, and then using that to be able to connect to others. Everyone needs self-compassion. So those are the three elements of EAET that we hold foremost in our minds.

Siem: Well, thank you so much for introducing us to this work. Can you let me know where the audience can find you? Are there any closing notes you’d like to leave with them?

Schubiner: Thanks so much, Brooke. I really appreciate being here. The work you guys do is amazing. It’s so important to bash some of the myths that are out there in the world, particularly in the psychiatry world, to help people deal with the after effects of medication and get themselves to a place where they are good with themselves. And so I just really appreciate that.

I think the work that I do is just really connected. I think it fits really well with it. Many people who are in the psychiatric community, so to speak, also have pain, right? If you’re a therapist, you’re seeing people for anxiety and depression. Roughly 50% of the people you see will also have a pain condition like tension headaches, migraine headaches, fibromyalgia, irritable bowel, back pain, pelvic pain, etc. These all really are intertwined.

We have a nonprofit called the Association for the Treatment of Neuroplastic Symptoms, which is at Symptomatic.me. My website is unlearnyourpain.com. On both of those sites, there’s a lot of free resources, there’s lists of practitioners who do this work. I think the parting thing that I would say is that there’s hope, because the vast majority of people who are in these worlds of chronic pain, anxiety, depression, and chronic fatigue syndromes have neuroplastic symptoms that are potentially reversible. I think getting stuck in the idea that everything is structural and everything is incurable is a horrible place to be. And for the vast majority of people, there is hope. That’s what drives me.

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