A Sarno-Hanson Synthesis

by moridinamael3 min read12th Jul 201815 comments

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Content note: Speculative, relies on assumptions that may not be true, but generally points at something that I believe to be a useful map, with potentially important implications if true, and am interested in feedback.

John Sarno is the professor and physician who discovered Tension Myositis Syndrome (TMS), which has previously been discussed in detail by Scott Alexander. Briefly, a TMS theory suggests that chronic pain, and a handful of other chronic ailments, may be psychosomatic, and that the specific mechanism of action is the brain's expression of unacceptable emotions through physiological channels. For example, an embarrassing and inwardly unacceptable narcissistic rage at the conditions of one's life may be expressed as back pain or headache.

Sarno's theory is more detailed and specific than this, but for that treatment I recommend reading the book. It is relatively unimportant to this discussion whether the precise details of this theory are correct, especially because it is obvious that some weak form of the theory is true. The conscious mind is the tip of a vast iceberg of cognition, and the parts of the iceberg under the surface are by necessity those parts that create pain, emotion, compulsions, and all the other mental phenomena that the conscious mind can't take credit for - which is most of them.

I can't help but interpret Sarno's hypothesis much more broadly than he himself does. In 2017, Courtney Dauwalter won the Moab 240, a 240 mile race, in 2 days and ~10 hours. She beat the second-place finisher by ten hours. If you read or listen to any interview with her, she discusses how her secret is just not stopping. She's fit, but she's probably not 17% more fit than the second-best ultramarathoner. She's just unusually good at ignoring the powerful parts of the brain that are in place to stop the body from hurting itself. It turns out the physical limitations of the body are well beyond what the brain implies they are. The learning from this is that the brain is so good at convincing us that we have these limitations, that almost everybody eventually succumbs to their brain's insistence that they're going to die or break down if they keep running, even though it's not true.

Robin Hanson needs no introduction, but just in case, he's the economics professor and polymath who recently published The Elephant in the Brain. The premise of this book is that human behavior can be described as mostly being in pursuit of social status, and that to some degree, the function of consciousness and the self-narrative is to confabulate credible explanations about how this is not what we're doing, so we can more reliably deceive others about our true, unconscious motives.

If you take a broad interpretation of both of these thinkers, the upshot is that statements like "the subconscious is very powerful" are actually laughably understating the situation. The subconscious - the parts of cognition that are not conscious - is doing pretty much everything. The conscious mind is a particular functionality that serves as part of the system but has no real authority over it. The ubiquitous discussions of akrasia and motivation problems on this site exemplify the fact that any model of psychology that involves the "self" exerting "willpower" is a Sisyphean exercise typically doomed to failure. It's just not a realistic model of how we work.

A synthesis of these two thinkers that might yield testable predictions goes as follows: Hanson says most of what we do is signaling. Sarno says most if not all chronic pain is psychosomatic. Well, what is the point of pain if not to signal acute distress? Especially chronic pain - there is no individually adaptive purpose for chronic pain. A solitary leopard with debilitating chronic pain would just be a dead leopard. Humans are different. Much of our social fabric consists of unconscious but high-bandwidth signaling behavior. Body language is the most obvious example; humans can generally both perform and react to body language very consistently without even being aware of it.

So let's take the hypothesis that chronic pain is a social signal. Sarno's theory specifies that chronic pain is, again, an expression of unconscious rage. If we provisionally treat the Freudian distinction of Id/Superego as a suggestive map, if not precisely true, then the Id feels strong childlike rages at having its impulses stymied, and the Superego suppresses those rages and prevents them from reaching consciousness. To stir in a bit of Hanson here, perhaps the Superego's role is to help curate the outward narrative that we are purely prosocial and selfless, while the Id's role is to motivate necessary selfish behavior through generating self-serving impulses. It seems plausible to me that the relative "strength" of the Superego in modern society is much greater than it was in ancestral times, and this may explain why chronic pain is an increasingly prevalent issue in modern times, but this is just a speculation.

If we take the implications of all this at face value, then we can contemplate potential signaling purposes for chronic pain. In other words, what is the unconscious saying? Possibilities that come to mind:

  • "I am legitimately overburdened and direly require more help than I'm getting."
  • "My contributions are not being appropriately appreciated or compensated, so I will stop spending energy on them by incapacitating the body."
  • "There are aspects of my environment that I find profoundly distressing, but I am unable to express this to my cohort overtly because of social restrictions, so instead I'll give myself a migraine and let the tribe figure out why that might have happened."

I've only recently started thinking in these terms, but it has been beneficial to try interpreting every physical sensation as some kind of Sarno-Hanson message from the unconscious. Do you sometimes feel a physical exhaustion and lethargy that mysteriously vanishes when the opportunity to do something more fun arises? Do you ever experience a sudden rise in tension and heart rate for a reason you can't quite pin down? Do you have immense trouble getting out of bed in the morning, but if you have something to look forward to that morning, you spring out of bed easily? Consider that this is exactly the kind of thing that a canny trickster unconscious would do to see its desires fulfilled.

What's amazing to me - and what I had to read Sarno's book to actually get - is that you don't even necessarily have to figure out what the unconscious is trying to tell you to get such physical symptoms to dissipate. You just have to look inward and investigate your emotions, with an attitude of "Ok, I'm listening, and I see what you're doing, but I don't understand why." For some reason, this seems to be enough that whatever unconscious module is causing the problem can feel heard.

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I just wanted to note that MCTB-style insight meditation also draws quite heavily on the idea that we identify with muscle tension and that sometimes it feels like we're using muscle tension to make ourselves do stuff, or that our inner conflicts can be present in opposing muscle tension. The specific technique that you mention doing sounds kind of similar to a cross between Goenka-style body scanning and Tara Brach's RAIN technique (Recognize, Allow, Investigate, Non-Identification).

I'd encourage both you and the other rationalists who're digging into methods for breaking your sense of self into interacting sub-agents to really consider reading MCTB before you start continually applying these sorts of techniques to dissolve all your problems. Scott does a good job of highlighting Daniel Ingram's cautions about how many easy meditation techniques can seem to solve all your problems up until they completely stop helping and you end up stuck in difficult mental states:

If this last part sounds ominous, it probably should. If the fourth stage looks like a manic episode, the next five or six stages all look like some flavor of deep clinical depression. Ingram discusses several spiritual traditions and finds that they all warn of an uncanny valley halfway along the spiritual path; he himself adopts St. John’s phrase “Dark Night Of The Soul”. Once you have meditated enough to reach the A&P Event, you’re stuck in the (very unpleasant) Dark Night Of The Soul until you can meditate your way out of it, which could take months or years.
Ingram’s theory is that many people have had spiritual experiences without deliberately pursuing a spiritual practice – whether this be from everyday life, or prayer, or drugs, or even things you do in dreams. Some of these people accidentally cross the A&P Event, reach the Dark Night Of The Soul, and – not even knowing that the way out is through meditation – get stuck there for years, having nothing but a vague spiritual yearning and sense that something’s not right. He says that this is his own origin story – he got stuck in the Dark Night after having an A&P Event in a dream at age 15, was low-grade depressed for most of his life, and only recovered once he studied enough Buddhism to realize what had happened to him and how he could meditate his way out:

There's really nothing special about the existing meditation techniques that leads to this. Any consistently-applied enough introspection technique can lead there, especially if you're objectifying things as just thoughts, as sub-agents, or as muscle tension. I strongly suspect that the mental effects mentioned above are due to megadoses of the neurotransmitters underlying the Predictive Processing model. So I'd try to consider either limiting your use of methods like this or to acknowledge that heavy use might end up leading you to "meditate your way out" and read some discussions of what that might be like.

I've read a couple of meditation books (TMI and a couple others, haven't finished MCTB yet) and am a novice meditator, and I will remark that I consciously stopped meditating a while back because ... the act of meditating was causing incredible physical tension and eventually pain. This was very frustrating obviously but I wasn't convinced that "meditating through it" would work and couldn't figure out any other way through.

In retrospect, in this provisional Sarno framework, it seems possible that the pain and unpleasantness of meditation was a subconscious reaction to really not wanting to meditate, subconsciously. Knowing myself, paying attention to something that I don't want to pay attention to breeds a high level of resentment, and meditation is the purified and crystallized form of that. I'll tentatively try meditating again and see if the tension returns, with this perspective.

Also, I do really need to read MCTB.

In retrospect, in this provisional Sarno framework, it seems possible that the pain and unpleasantness of meditation was a subconscious reaction to really not wanting to meditate, subconsciously. Knowing myself, paying attention to something that I don't want to pay attention to breeds a high level of resentment, and meditation is the purified and crystallized form of that. I'll tentatively try meditating again and see if the tension returns, with this perspective.

That makes sense to me -- both directing attention and looking at your sense of self often can feel like the ultimate Ugh Field. TMI does have some good guidance about building the skill of directed attention gently and consistently, but it's mostly in the early sections of the book and most people overlook it and tend towards exerting effort.

I haven't read it yet, but there's a new edition of MCTB that just came out with a lot of additional material. TMI is probably enough instructions to work from, but it doesn't provide as much meat around what you can expect to happen emotionally and phenomenologically.

Try throwing in some coherence therapy cues as well. It sounds like your stance is still that the subconscious is dumb in many ways. Be open to the idea that your conscious mind is the who is wrong with significant probability.

Could you point me to a good resource/overview on coherence therapy? I've looked into it before but never quite got a handle on it.

I actually agree completely that the subconscious is often in the right. I think that question of which subagent is actually right is somewhat orthogonal to the chronic pain phenomenon, but I would be interested to learn more. For example, you may actually be doing far more than your share of work in the community without garnering any recognition for it, creating a net drain on your resources, and you continue to do so because that's what a Good Person would do, so your subconscious tries to intervene in way that is fundamentally self-protective but quite messy in execution. In this case the analysis by the subconscious is "right" but the cure is worse than the disease.

A good example of the proposed mechanism at work can probably be seen in the variety of psychosomatic symptoms experienced and reported by soldiers who fought in the first world war (Often diagnosed as "shell shock", "male hysteria", or "war neurosis"). Symptoms included hysterical blindness, deafness, becoming mute, even paralyzed limbs without any apparent cause were a thing.

Also, the "thousand yard stare" seems to be explainable by a similar mechanism: The module producing conscious experience seemingly "detaches" itself from the body it inhabits in an attempt to distance itself from horrors, which seems to be very similar to depersonalization disorder, which can also be triggered by highly distressing experiences.

PTSD and its way more sinister cousin, C-PTSD are great examples how we are all subconsciousness. What you are describing are all different kinds of dissociation, a subconscious and often unhealthy ways brain copes with trauma, defined as the level of stress that overwhelms its natural ability to cope.

Related to the sleep example, because you didn't say exactly this, and it makes a stronger case:

I noticed some time ago that my misery when waking up was a negotiation tactic from when my parents would wake me up. They were nice enough to let me sleep a little longer if I looked sufficiently upset at being woken up. It became obvious recently that I was pattern-matching my alarm to a parent. How do I know this? Because I knew that if I started loudly singing a cheery tune with a smile on my face I'd automatically become less miserable, but I never did, because I didn't want to be less miserable, even though my parents weren't around anymore. I started doing it when I realized this, and it works pretty well!

(There was one more problem, of feeling like I'm manipulating myself, which seems at first to be at odds with building self-loyalty. I think this went away as I got more comfortable with the idea of sometimes "wanting to be manipulated" for my own success, of desiring less freedom (which would be sacrilege to my younger self). Reading about Kegan's model of adult development and experimenting with BDSM helped me get there somehow.)

One problem with applying this thesis (did I mention I wholeheartedly agree with it?) is that it's hard to refrain from inadvertently reinforcing such negotiation tactics when someone else looks miserable (like my parents did), ie ferberization is painful (not to mention patronizing when done to adults). I think it's possible to be honest about it with someone reasonable and smart enough to grasp the subtleties, and then, usually only after they're done having their episode, but there's no good solution to this AFAIK. Else we wouldn't have hard problems of income redistribution either - the problem of helping those who need it without inducing weakness/dependence.

BTW, Is there an economic term for this specific problem?

Ten years ago I had a whole miserable year of Repetitive Strain Injury (and other things too) and then had a miraculous one-day recovery after reading Sarno's book. But I didn't (and still don't) agree with the way Sarno (and you) describe what the mechanism is and what the emotions are doing, at least for my own experience and the couple other people I know personally who had similar RSI experiences.

I think it's possible to use muscles in a way that's painful: something like having the muscles be generally tense and their blood supply constricted. I think state-of-mind can cause muscles to operate in this painful blood-supply-constricted mode, and that one such state of mind is the feeling "These muscles here are super-injured and when I use them it's probably making things worse."

If you think about it, it's easy to think of lots of things could predispose people to get stuck in this particular vicious cycle, including personality type, general stress level, factual beliefs about the causes and consequences of chronic pain, and so on. But at the end, I think it's this pretty specific thing, not a catch-all generic mechanism of subconscious expression or whatever like you seem to be thinking.

I don't really have much confidence in any of my assertions in the OP, but I will point out some possible questions that might challenge the "narrow" view.

1. Can you always/sometimes/ever subjectively correlate individual, transient spikes of pain/discomfort to particular external stimuli, and if so, what if those stimuli turn out to be extremely variable, as in, not reducible to one specific thing like "factual beliefs about pain's source"?

2. How does your theory explain ulcers, which don't have any obvious relationship to muscular tension?

3. How does your theory explain the fact that I can make pain/discomfort dissipate in the span of 10 seconds by asking, specifically, "What are you trying to tell me, Mr. Subconscious?" but not by simply thinking, "Oh, this pain is probably psychosomatic in origin."?

To comment further on question #1: when I'm in a particularly sensitive physical state, i.e. when my chronic pain is flaring up, I can walk down a street and simply take observations. I feel a flare of pain, and ask myself what's happening in my immediate surroundings. Perhaps I just walked by a homeless person. I didn't feel anything particular about the homeless person, but perhaps that's because I am "suppressing" some kind of disgust/annoyance for the homeless person, an emotional reaction which would be unacceptable to my conscious mind. Such an explanation feels post hoc and tenuous, but if I keep this monitoring process up for half an hour or so, I can't help but collate a list of pain flareups associated with events which specifically seem like they could be the kind of thing that my Id hates but my Superego is stifling.

Again, this whole topic is weird and confusing to me, I place low confidence in any particular beliefs expressed here.

My view is that the "constrict blood vessels and tense muscles" action (or whatever it is) is less like moving your finger, and more like speeding up your heart rate: sorta consciously controllable but not by a simple and direct act of willful control. I personally was talking to my hands rather than talking to my subconscious, but whatever, either way, I see it as a handy trick to send out the right nerve signals. Again like how if you want to release adrenaline, you think of something scary, you don't think "Adrenal gland, Activate!" (Unless you've specifically practiced.)

I guess where I differ in emphasis from you is that I like to talk about how an important part of the action is really happening at the location of the pain, even if the cause is in the brain. I find that people talking about "psychosomatic" tend to be cutting physiology out of the loop altogether, though you didn't quite say that yourself. The other different emphasis is whether there's any sense whatsoever in which some part of the person wants the pain to happen because of some ulterior motive. I mean, that kind of story very much did not resonate with my experience. My RSI flare-ups were always pretty closely associated with using my hands. I guess I shouldn't over-generalize from my own experience. Shrug.

"Constricting blood vessels" seems like a broad enough mechanism to be potentially applicable to back spasms, RSI, IBS, ulcers, and all the other superficially different indications we've all heard of. But I don't know much about physiology or vasculature, and I don't put too much stock in that exact description. Could also be something about nerves I guess?

It is interesting also from the point of view of the AI alignment: should AI align with conscious mind, subconscious mind, or both?

I agree, it is very interesting! Until we understand the conscious/subconscious interaction better, I don't see how AI alignment can even be well defined.