Behaviorism, Conditioning, and Breaking the Pain Cycle

Note:this post is for people who are curious about some of the science and history of science behind TMS. It's quite technical and "wonky." If your only interest is on healing, other threads on this forum may do a better job of getting better. Knowledge may be the penicillin of TMS, but the emphasis should be on the internal work and accepting the diagnosis rather than cramming your head full of facts. If, on the other hand, you are curious, read on! A deeper knowledge brightens our world, bringing stimulating ideas and even, in a slower way, helps us help ourselves and others.

Early on in his popular essay, Breaking the Pain Cycle, Alan Gordon writes, "PPD pain has an underlying purpose of preoccupation. The preoccupying behaviors serve to reinforce the pain, thus perpetuating the cycle. Unless you read behaviorism treatises in your spare time, this probably means nothing to you; but here’s the gist: the way to eliminate or significantly reduce your pain is to break this cycle of reinforcement" (emphasis mine)

Alan does a terrific job of helping you understand the implications of behaviorism for treating TMS without going terribly deeply into behaviorism. However, I thought that some of you might be interested in some of the science behind the argument, so I thought I'd start a thread about it. I'll start by telling you a little about both classical and operant conditioning and then share an email that I wrote to Alan and Dr. Schubiner when Alan first sent me his essay.

A key to understanding the roots of Alan's essay in behavioral psychology is the distinction between classical conditioning and operant conditioning.

Classical conditioning is sometimes called Pavlovian conditioning because it was discovered by a Russian scientist, Ivan Pavlov. Pavlov found that if he rang a bell every time before he fed dogs, the dogs would begin to salivate whenever they heard the bell. Basically, in their brains, the dogs had learned to associate the bell with food, so it had started preparing to eat even before it had seen the food.

The term "Operant Conditioning" comes from Harvard psychologist B. F. Skinner, who contrasted it with Pavlov's classic form of conditioning in that it uses rewards and punishments to teach animals to "operate" on their environment using various "behaviors." Whereas classical conditioning is just about teaching an animal (such as a human) to associate one thing (like a bell) with another (like food), operant conditioning teaches us (or an animal) to do something using rewards or punishments.

(I put the words "operate," "classic," and "behaviors" in quotes in the previous paragraph to emphasize their connection to the terms, "operant conditioning," "classical conditioning," and "behaviorism." Incidentally, when you read "conditioning" just think of "learning that comes from the 'conditions' that an animal such as a human is exposed to.")

We are very familiar with the idea of conditioning in the TMS community because it explains why, for example, I used to hurt when I type, or why many people with back pain hurt when they stand or sit in certain ways. I would argue that what we normally think of as conditioning in the TMS community is classical conditioning, whereas what Alan is referring to in his essay is operant conditioning. Since both of these ideas about conditioning are vital to discussion of TMS, they are clearly worth learning about, however, I'm going to turn to a pair of videos to explain things in greater depth.

The first video, done by a Harvard undergraduate, uses great archival footage to discuss Pavlov's and Skinner's contributions and to relate them to more recent developments in behaviorism. Along the way it introduces you to John B Watson. Together, Skinner and Watson can be thought of as the fathers of behaviorism, so that time is certainly not wasted. It focuses on Skinner's invention of an "operant conditioning chamber" that he used to conduct some of the foundational experiments in behaviorism.

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The second video, is done by a psychology instructor who does a really terrific job of making it easy to understand the concepts of classical conditioning and operant conditioning. If you stick with it, you will genuinely learn something.

Because he's assumed that his viewers have read a little bit about the subject, let me just remind you that classical conditioning is just about teaching an animal (such as a human) to associate one thing (like a bell) with another (like food), operant conditioning teaches us (or an animal) to do something using rewards or punishments.

Incidentally, don't skip the part where he talks about negative reinforcement. If I understand him correctly, negative reinforcement is actually what Alan refers to in his essay. In the case of TMS and breaking the pain cycle, the negative reinforcement is that when we obsess about our symptoms and are afraid of our symptoms, that behavior is negatively reinforced because we are distracted from intolerable emotions. Dr. Sarno explained that this is how our unconscious tries to protect us.

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If videos aren't your preferred mode of learning, the about.com psychology site introduces a wide variety of concepts. They do a good job of communicating the core scientific ideas without assuming that the reader is already an expert in the subject. I'll link to their "operant vs. classical conditioning" page, but there are many other relevant pages linked to from there that may be interesting and may help clarify these ideas:
http://psychology.about.com/od/behavioralpsychology/a/classical-vs-operant-conditioning.htm

Okay, so now that we have some idea of classical and operant conditioning, we can talk about how this relates to TMS. First, if you haven't done so, please read Alan's excellent essay. If you've already read it, it might even be worth taking another look to see how he uses the terms "reinforcement." Recall that in reinforcement is one of the key ideas in operant conditioning: anything that makes you do a behavior more frequently is "reinforcing" that behavior.

Anyway, one of the things that I like about Alan's essay is how it uses the idea of operant conditioning and reinforcement to explain the distraction strategy that our unconscious mind uses in TMS. When he first sent me the essay, here's the response I sent him:

Hi Alan,

As expected, I really liked it. You really are an excellent communicator. I almost feel like I should study your article just for tips on how to make complex subjects simple for my students (seriously).

I don't know if I mentioned it when we spoke last time, but the approach that you describe is very similar to how I often think of the unconscious. The behaviorist approach really makes sense to me, so when people talk about the unconscious, I often find myself reframing their ideas within a framework that I think of as similar to behaviorism (I don't have formal training beyond psych 101 and a tad of ABA, so please cut me some slack if I get my terminology wrong). For example, when I hear that our unconscious mind creates pain to distract us from intolerable thoughts, it often sounds like there is a demon living inside of our heads - a demon that can flip the switches to our autonomic nervous system in a way that our conscious mind can't and that can plan ahead enough to realize that if by flipping certain switches it can prevent emotional distress.

However, if I just flip the idea around a little bit and think that perhaps someone was dealing with a distressing emotion, which made them tense, which led a certain part of their brain to cause the physiological reaction that actually creates the pain. This pain distracts them from the distressing emotion and makes them happier. I don't know if it is proper to say that this "reinforces" the part of the brain that created the physiological reaction, but the basic idea is that it learns that the brain is less distressed when it creates the physiological reaction that creates the pain. So it, obediently and helpfully creates the physiological reaction in spades and the person is distracted from the truly distressing emotional pain to the more virtuous physical pain.

I like this approach because it's simple. Occam's razor and all. It's just a couple hundred million relatively dumb neurons that just happen to realize that the brain is happier when they tickle the switches of the ANS in a certain way, so they do it, much like the dumb animals that we evolved from. After all, if we had a nearly sentient, demon in our brains, consuming many calories, it's hard for me to see why evolution didn't give us conscious access to it so we would be smarter (I mean, I can see why there might be a barrier, it's just that it feels like a bit of a stretch).

So, in short, I really like your theory. I really like how explains core TMS theory in a way that is palatable to an audience that is heavily exposed to behaviorism and neuroscience. It's really exciting to see this overlap between traditional psychodynamic approaches and CBT-influenced approaches. I love that Eric and Fran are so open to CBT and that you and Howard are so excited by both CBT and ISTDP. It's encouraging. I wish that in economics we could find similar common ground between behavioral economists and decision theorists.

I'm CCing this to Howard, as I know he likes your article as well, and I'd love to hear his thoughts on my take on it.

Forest​

One of the many things that I like in Alan's essay is how it uses behaviorism/operant conditioning to give us an explanation for how unconscious portions of our brains could "decide" to give us physical pain. It is simple negative reinforcement. As Sarno, Sherman, and Anderson explain, our unconscious brains are faced with very scary emotions. This is the bad thing which is taken away in negative reinforcement. Being distracted from the scary emotions prevents us from being scared by them, removing the fear and reinforcing the pain. This is a way of seeing what Sarno means when he says that the goal of the pain is to protect us from our unacceptable emotions.

One of the main themes of penultimate paragraph of my my email is the idea of unifying our movement and how important that is. There are many different perspectives on TMS and emotions can run very high because of the very high stakes involved. Everyone has a different perspective because everyone heals a little differently and everyone has a slightly different background. I feel like I learn from everyone on this forum, and that is one of my favorite parts of working in this movement. One of the most important things about this community is that we can all have different perspectives but we can express them in a respectful manner, looking for commonalities instead of differences. I think that it is vitally important that we maintain this as we grow. If we don't, we could find that we spend more effort fighting each other than we do in spreading the word and helping people. That, of course, would be a tragic loss.

Anyway, I thought that Alan's response was excellent. He wrote,

Hi Forest,
I'm on board with your interpretation. The ISTDPers would say that there is a distressing emotion, which is intolerable to deal with, so the brain causes a defense mechanism to protect the conscious from that intolerable emotion, and in effect the defense mechanism is the lesser of two evils (or makes someone less miserable.)

From my experience, the true defense is not the pain itself, but the constant level of preoccupation that the pain brings along. This in my opinion is why often after reading Sarno, when people do stop caring about/fearing the pain, it tends to fade. Because the preoccupation about the pain is the true defense.

It really is operant conditioning in its purest form. In this case, the pain is the behavior and the preoccupying thoughts/fears are the reinforcing agent. It's like evolution. There's a mutation, and if it's beneficial, it gets passed on, if it isn't it fades.

I've seen many clients who have developed a pain, but it didn't stick, because their mind came up with something that wasn't sufficient to preoccupy them. It was a behavior that failed in its attempt because there wasn't sufficient reinforcement.

For example, I recently had a client with a history of TMS who developed pain in his pinky. He could care less if he has pain in his pinky. So he felt no fear over it, there was no preoccupation, and as a result the pain went away in a couple days.

This same client had previously developed pain in his knee. He plays beach volleyball often, and this was a functional impairment to his way of life. As a result he feared it and thought about it often, which served to reinforce the behavior, and it stuck.

So these are two cases of the mind putting forth a behavior with the intent of distracting him from painful unconsicous emotions. The knee pain was a successful behavior because it elicited reinforcement, the pinky pain was unsuccessful because it didn't elicit reinforcement.

Our minds are so smart that they usually come up with successful behavior. It is for this reason as Howard says that a runner is more likely to get knee pain and a screenwriter is more likely to get wrist pain.​

I responded as follows:

I'm curious about your idea that the true defense is not the pain itself but rather the constant level of preoccupation. It certainly accords with my experience. I find that the easiest way to make symptoms go away is to stop caring in them (I also had tingling in my left pinky as well, for example, but I ignore it and it goes away).

I'd like to push this explanation a little farther by offering two stories. I'm very curious, of the following two stories, which do you prefer? In both stories, Tim feels very guilty about being angry at his mother and this anger reinforces the brain's behavior of creating the TMS symptoms. However, the way that the TMS symptoms starts is different in the two cases.

1.) When Tim realizes that he's angry at his mother, he feels guilty and gets tense/activated. Tension leads to a variety of chemical cascades and reactions which change various elements of his biology and biochemistry. One of these happens to lead to a physiological change that brings on a symptom, which distracts him from his guilt about his rage toward his mothers. This makes him feel better, so a cycle of operant conditioning begins, where his brain learns to create the precise chemical cascades and reactions that lead to the physiological changes that bring on the symptom.

2.) Part of Tim's brain is afraid that he might realize that he's angry at his mother. This part of his brain really doesn't want this to happen because it feels that this would imply that Tim is a bad person, so it thinks about what it can do. Among the many things it knows, it is smart enough to know that if it creates a series of chemical cascades and reactions, that it will lead to a specific symptom, even though it may never have ever kicked off the series of reactions strongly enough to create the symptom before. Further, it realizes that this symptom will distract Tim from the intolerable thought. All of this is happening in a portion of Tim's brain that he can't consciously access. It is as if he has a second brain, and a very smart one at that. This second brain decides to kick off the series of reactions. This kicks off a cycle of operant conditioning, leading to more and more deeply entrenched symptoms.

The first of these two stories seems much more of a pure operant conditioning model. Rather than presuming what practically amounts to a sentient being within our minds (i.e. the demon I mentioned in my previous email), it uses something akin to natural selection. In this story, random things happen - like random mutations happening in our genetic code. When the intolerable thought is considered, a host of different reactions occur, and most of them aren't reinforced. However, some of the things have consequences that reinforce the biological reactions that cause them. Much like a mutation that increases evolutionary fitness, these reactions get stronger because they are reinforced by protecting Tim from the intolerable thought.

From the outside, natural selection looks a lot like there is an intelligent force guiding it. It is *as if* a very clever force were coming up with just the right mutations to speed evolution along. However, in fact, there is no intelligence at all; there is only randomness and a mechanism (natural selection) that picks out the mutations that happen to do well.
Similarly, with the first model, there is absolutely no "demon" within our minds. It is all randomness, along with a mechanism (operant conditioning) that picks out the behaviors that happen to distract us from odious thoughts. Despite this, it *looks* like there is a very smart mind guiding it all, reinforcing exactly those physiological "behaviors" that kick off the cycle of preoccupation.

I like this an awful lot because while I know that our brain acts as if it have spirits inside of them, the second story seems to presume a part of the brain which deliberately acts like such a spirit, which many may find hard to swallow. While it make a lot of sense to me that more primitive parts of our brains may be out of the reach of our consciousness but would still respond to operant conditioning (i.e. story 1), it's hard for me to see how we could have this second brain that can make such complicated plans (i.e. the part of story 2 before the operant conditioning). From an evolutionary perspective, it would simply require an awful lot of calorie to sustain while not really conveying much of a benefit (if any). On the other hand, older portions of the brain that responds to operant conditioning (i.e. the first story) seems much easier to swallow.

I'm very curious what the two of you think of those two models. Can we reject either of them? Does either of them ring true? When you think deeply about PPD, what sort of model do you use?

In terms of myself, while I think about these issues a lot, I see myself as more of an editor and an activist than a scientist, so I'm blessed in that I don't have to take a position. As long as people are getting better and freeing themselves from the nightmare that is PPD, I really don't care. I focus on helping people, and strengthening the discourse by encouraging diverse views. These issues, while potentially interesting, are quite technical and I'm genuinely agnostic about them, feeling that it will still be a while before we really know what is going on.

Forest
[All three emails were edited for privacy, clarity or to reflect updates in my beliefs.]​

To this day, when I think about how the unconscious brain works, I tend to think about conditioning of both sorts, both classical and operant. Recently, though, I've become very interested in brain physiology, so I also think about what is happening in various regions of the older parts of the brain. Nonetheless, when I think about Alan's essay, I often reflect on the ideas that we wrote about in this exchange.

I'll write a bit more about how the conditioning that Sarno writes about is classical conditioning and will link to it from here. But for now, I need to take a break!

 

Heya, Ellen, thanks for your very thoughtful post. I think of your post as bringing up two separate issues: whether operant conditioning makes sense when the pain doesn't feel like it is under your control and the sense of overwhelm at the different paradigms. I'll talk about the overwhelm first because the issue you bring up may influence how you want to approach the question of operant conditioning.

... unfortunately, I've got so many balls in the air right now that I'm going to break my reply into two separate posts. That means that the first post might be the one that you are less interested in, so I hope that that is okay...

Oh, goodness, you've asked a wonderful question. I'm drawn to the question as someone who loves science, but at the same time, I don't want to contribute to your feeling of overwhelm!

First, at the risk of telling you things you already know, I just want to be clear that you don't have to think about this thread in order to heal. The core of TMS healing is contained in Dr. Sarno's 12 reminders, and I generally recommend that people read The Mindbody Prescription or Healing Back Pain. After that, everything is optional. You have a clear intelligence and wisdom such that I'm sure that you will develop your own way of healing, and I encourage you to listen to the inner voice that tells you what that method of healing is. This thread is more for people motivated by curiosity rather that healing.

Personally, I suspect that the reason why reading or learning can be healing for people is that it helps soothe their emotional state. Many people read Dr. Sarno's books and it soothes their fear. I read RSI success stories that people had posted online and it soothed my fear. Other people read/listen to the TMS Recovery Program and it soothes their self criticism. Other people try IFS and find that that soothes their inner conflicts or external rage.

So many things that help people heal tend to make people happy and decrease their internal tension. If feeling like you have to read more and more is increasing your internal tension, just throw all of that stuff out! Ignore it completely. Learning is just an strategy for quieting the mind, so do what you feel heals your mind. If you do this, from what I've seen, the body will follow. We all have to figure out what works to soothe our own minds by simply listening to how we feel.

With that being said, my hunch is that you already know most of the above. I wonder if this is bothering you not so much because you have to learn it, but rather that it represents a doubt that you have. I'll assume that that is the case and do my best to answer your question while simultaneously encouraging you not to worry about it.

... but that will have to wait for my next post. I'll write more later