PDF Summary:The Mindbody Prescription, by John Sarno

Do you struggle with ongoing pain that doesn’t seem to respond to treatment? In The Mindbody Prescription, physician and professor of rehabilitation medicine John Sarno explains that the Western world is experiencing an epidemic of disorders characterized by chronic pain with no clear cause. Doctors diagnose and treat these pain disorders as physical problems, but often, their treatments don’t provide any relief. Sarno explains that this is because the problem isn’t physical, it’s emotional—and the key to solving your pain is resolving your emotional tensions.

In this guide, we’ll explain the development and principles of Sarno’s theory and discuss what kind of person is most likely to develop these types of disorders. We’ll also explain the different physical ways in which emotional tension manifests, as well as Sarno’s treatment method. We’ll supplement Sarno’s ideas with scientific and social context as well as tips from other experts on dealing with chronic pain.

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Additionally, Berne describes some positive traits of the child, while Sarno focuses mainly on the negatives. According to Berne, the child is the source of our creativity, spontaneity, and intuition. He also suggests that the child is the most valuable aspect of one’s personality.

Berne also suggests a more social factor in the role of the ego states. He explains that when someone treats us as a child—for example, when we’re scolded by someone else for something “bad” we’ve done—it activates the child ego state, which then causes us to behave in a childlike way. So while Sarno’s focus is on how the parent and child interact within our psyches, Berne emphasizes how external social interactions bring out these different states.

The Conscious and the Unconscious

Also important here is the distinction between the conscious and the unconscious, another of Freud’s concepts. The conscious is the part of our mind that we’re aware of: It’s logical, rational, mature, controlled, moral, and confident. The unconscious is the part of our mind that we’re unaware of: It’s irrational, childish, uncontrolled, lacks morals, and has low self-esteem.

The emotions we’re conscious of are our perceived emotions. However, many of our emotions are unconscious, or repressed. These are the emotions that come from the child—and more specifically, from the conflict between the parent and the child. We’re not aware of them, but they heavily influence our lives, behavior, and—according to Sarno—our physical state. In particular, he explains that our perceived (conscious) emotions may increase pain we’re already feeling, but only repressed emotions can cause pain.

The Unconscious: The Source of All of Our Problems?

Other writers suggest a similarly impactful role of repressed emotions. In Existential Kink, Carolyn Elliott argues that our repressed emotions are so powerful that they’re responsible for creating all the negative behaviors and patterns in our lives. Even though we outwardly desire positive things—like success, independence, and connection—our unconscious desires both positive and negative things—such as failure, dependence, and loneliness. As with the child-like emotions, we repress these desires, but they continue to manifest in our behavior.

According to Elliott, this is why someone might be stuck in a negative pattern like only getting into relationships with controlling partners. Their conscious desires freedom, but their unconscious desires dependence and containment, so the unconscious drives that person to behave in ways that attract controlling partners and repel healthy partners. In the same way, no one consciously wants to experience physical pain, but our repressed emotions must make themselves known in some way—so the unconscious creates pain.

Which Emotions Do We Repress?

We’ve now explained that the repression of certain emotions is what leads to chronic pain and TMS, but we still need to understand which emotions are repressed by the brain rather than perceived. The emotions we repress tend to be considered negative ones, often associated with the undesirable tendencies of the child. These include shame, sadness, and especially anger. Sarno explains that we repress these emotions because we’re uncomfortable with them, so on a psychological level, we can’t stand to process or acknowledge them.

We’re often particularly uncomfortable with emotions that aren’t considered socially acceptable. For example, a person who’s recently lost a loved one may feel angry at that loved one for dying. This is a natural emotional reaction characteristic of the irrational child, but expressing this emotion outwardly would be considered wrong. Thus, that person represses that anger because it’s intolerable to them.

(Shortform note: Sarno explains which emotions we repress and why, but he doesn’t address how we learn to repress them. Experts suggest that it has to do with our home environment: We learn how to deal with our emotions from our families. In particular, research suggests that there are three major ways we learn how to deal with our emotions from our parents: 1) how our parents react to our emotions, 2) how our parents discuss emotions, and 3) how our parents express their own emotions. When parents teach us that we can and should control our emotions (for example, by telling us to stop feeling a certain way or by hiding their own emotions), we learn to “control” our undesirable emotions by repressing them.)

Why Do Repressed Emotions Cause Physical Pain?

This brings us to the physical manifestations of repressed emotions: Because these emotions are intolerable to the conscious mind, the mind goes to great lengths to avoid acknowledging them. It distracts itself from them by forcing the person to focus on what’s going on in their body instead of what’s going on in their head, leading to physical symptoms like pain.

The mind chooses physical symptoms because, unlike emotional distress, physical conditions are socially acceptable. As diagnoses for a physical condition increase, doctors treat it as more “real,” which validates it as a socially acceptable condition. This is why chronic pain diagnoses change over time according to what’s popular (despite the root cause being emotional distress).

(Shortform note: The social stigma against emotional distress is widespread: Research suggests that a majority of Americans have negative attitudes toward mental illness. This can lead to stereotyping of mentally ill people as well as prejudice and discrimination against them. For example, only a small minority of states have legislation requiring schools to excuse student absences for mental health reasons. People with mental illnesses often internalize this social stigma, which can cause them to hold negative views about themselves and their emotions. These views make it even harder to deal with negative emotions, causing a destructive cycle.)

In the past, TMS has commonly manifested as gastric ulcers, but the rate of ulcers declined over the past few decades. According to Sarno, this is because people began to realize they were caused by stress, which delegitimized them in the public eye. To continue functioning as a socially acceptable distraction from emotional issues, our unconscious minds had to replace ulcers with other physical symptoms, which is when the epidemic of neck, back, leg, and shoulder pain arose.

(Shortform note: Some research suggests that the development of ulcers may be more physiological than Sarno implies. Stress can cause ulcers, but the gut is linked to the brain in a way that muscles aren’t: Not only does the brain send emotional signals to the gut, but the gut also sends emotional signals to the brain through the vagus nerve. Additionally, stress can affect the bacteria in the gut—potentially causing an increase in the growth of certain bacteria that can cause ulcers. This means such ulcers are physiologically (rather than psychologically) induced. These differences suggest that TMS and ulcers may not be as equivalent as Sarno argues.)

How Do Emotions Cause Physical Pain?

We know now that emotional tension causes the brain to send signals to the autonomic nervous system to reduce blood flow, which leads to oxygen deprivation and thus pain. However, we don’t yet understand how emotions produce these signals. The field of mindbody disorders is a new one, and little research has been done on it so far. It’s also closely tied into the overall functioning of the brain, which we also know very little about; we don’t know, in a medical or scientific sense, how the brain can think, or process stimuli, or generate novel ideas. However, this lack of knowledge isn’t a valid basis to discredit TMS theory, Sarno asserts.

(Shortform note: Research into the mindbody connection has made great strides in the decades since Sarno published his book. Recent studies have identified neural connections between brain regions that control cognitive processes like thinking and planning, and regions that control involuntary bodily functions like heart rate and blood pressure. Ongoing research in this area may someday shed light on the neurological process that turns emotions into physical pain.)

Personality Traits: Who Is Predisposed to TMS?

Psychoanalytic theory helps explain why the mind represses some emotions and why the body translates those emotions into physical pain. However, everyone has repressed emotions, but not everyone suffers from TMS. According to Sarno, some personality traits are especially associated with TMS. These tend to relate to feelings of inadequacy and the need for approval from others. They include perfectionism, self-criticism, low self-esteem, conscientiousness, ambitiousness, and the desire to be a good person and to please others (which leads to guilt when these desires aren’t met).

These traits are characterized by pressure on oneself, explains Sarno, and this pressure enrages the child part of the mind because the child wants to be free of responsibilities and expectations. Because rage is the primary emotion these traits engender, and because these traits are practically universal in people suffering from TMS, Sarno concludes that rage is the primary repressed emotion that causes TMS.

The Role of Rage, and Character Traits That Make It Easier to Cope With Pain

Some experts suggest that anger is the primary emotion associated with narcissism (and as mentioned earlier, the child is strongly characterized by narcissism). This supports Sarno’s identification of the narcissistic child as a source of rage. They go on to explain that this rage likely stems from the narcissist’s (or child’s) perception that others’ behavior (such as the impositions of the parent) threatens their sense of entitlement or disrespects their authority.

So, for example, when the parent demands perfection from the child, the child feels disrespected and becomes enraged, and the conscious mind represses this rage, leading to pain. A helpful tool, then, may be to exercise greater self-compassion and avoid judging or punishing yourself (and your mind’s child) for your imperfections.

Some experts also suggest that there are certain personality traits you can cultivate to help you better cope with chronic pain. In particular, research indicates that training yourself to have a zest for life—a feeling of liveliness and energy for your own life and the lives of others—improves “self-efficacy.” Self-efficacy refers to a sense of being able to handle the challenges of life, and it’s shown to improve daily functioning despite pain. It also correlates with lower rates of depression and anxiety. Activities like journaling and monitoring your thoughts and behaviors can help you cultivate zest and self-efficacy, which may counteract some of the traits Sarno identifies as predisposing one to TMS.

Pressure Comes From Stress—Both Positive and Negative

Sarno explains that pressure results from both positive and negative events in our lives— not all the events that cause rage are bad, and some are even socially desirable. Sarno cites a list of many of the most common stressors: The two most stressful events on the list were the death of a spouse and divorce, while marriage was the seventh most stressful and reconciling with a spouse was the ninth most stressful.

The list also included: negative stressors like serving jail time, mortgage foreclosures, and difficulties at work; positive stressors like personal achievement, vacations, and Christmas; and stressors that may range from negative to positive like changes in the frequency of spousal arguments, beginning or ending school, and changes in recreational or social activities.

(Shortform note: It may seem strange that positive stressors could result in repressed rage, since they’re usually accompanied by positive emotions. However, experts assert that any kind of stress leads to similar physical effects, such as increased breathing rate and increased levels of blood glucose. This suggests that since the physical impacts are similar, both negative and positive stressors can also lead to repressed rage.)

What Does TMS Look Like?

So far we’ve explained that pressure results in undesirable emotions like rage, that the unconscious mind represses these emotions, and that the brain distracts the conscious mind from these emotions by creating physical symptoms. These symptoms tend to include pain in the neck, shoulders, back, or legs. However, TMS can manifest in many different ways, all of which appear to be different conditions but which arise from the same source.

The symptoms of TMS can include nerve pain, joint pain, muscle weakness, inflammation, temporomandibular joint dysfunction, tendonitis, and chronic fatigue, all of which tend to be diagnosed as their own discrete disorders. Sarno also explains that TMS can manifest itself as seemingly unrelated but ultimately equivalent conditions such as tinnitus, dizziness, anxiety and depression, gastrointestinal disorders, circulatory and cardiac disorders, skin disorders, and genitourinary disorders (related to the genitals and urinary tract). Many of these symptoms can occur as a result of non-TMS conditions, but in those cases, treating the underlying condition should resolve the pain. Pain that has resisted multiple treatments is a strong indicator of TMS.

(Shortform note: Many of these symptoms and conditions are often lumped together under the diagnosis of “Medically Unexplained Symptoms,” particularly those that aren’t considered conditions in and of themselves (such as tinnitus). Critics of the Medically Unexplained Symptoms diagnosis argue that all symptoms can be medically explained, and that labeling them as “unexplainable” is dangerous because it can destroy patients’ hopes of having their symptoms effectively treated—and research shows that hope provides vital healing benefits. The TMS diagnosis could offer patients a less pessimistic outlook on their symptoms, especially since a key feature of Sarno’s theory is that TMS is very treatable.)

Diversity of Symptoms Leads to Ineffective Treatments

This variety of symptoms and diagnoses means we’re frequently treating TMS symptoms with ineffective and invasive methods. Patients often undergo surgery, such as joint replacements, spinal fusions, and herniated disc surgery. Other treatments include medication, chiropractic, and different types of physical therapy. The treatment may be effective in temporarily treating the pain, but because the root cause hasn’t been addressed, the pain often recurs or is replaced by another manifestation of TMS.

(Shortform note: Research suggests that the frequency of ineffective treatments like those listed in this section is extremely high, as are the associated risks. In the US, about half a million lumbar spine surgeries are performed each year, but experts estimate that more than half of such surgeries are unnecessary. Additionally, 20% to 40% of back surgeries fail to treat back pain. These surgeries are often expensive and can result in dangerous complications. The other treatments Sarno describes can also be expensive, and pain medication can come with side effects ranging from headaches to breathing problems and seizures. As we’ll see in the next section, TMS treatment isn’t likely to come with such risks.)

How to Treat TMS

According to Sarno’s theory, chronic unexplained pain is a harmless physical manifestation of repressed emotions. Therefore, physical treatments won’t cure TMS. Instead, Sarno explains that the most effective treatment for TMS starts with knowledge: You have to understand mindbody disorders and where the pain is actually coming from in order to treat it. This is why, according to Sarno, many people can cure their pain simply by reading his books or attending his lectures. However, Sarno emphasizes heavily that patients should only take on this diagnosis and treatment after doctors have effectively ruled out the chances of a serious illness.

(Shortform note: Testimonials from people who’ve found success with Sarno’s method support his statement that knowledge is the key to treatment. Prominent media figures like Howard Stern and Larry David have praised Sarno’s method, and there’s a website called thankyoudrsarno.org featuring over 100 success stories and thank you notes to the late doctor.)

Once the patient understands the source of their pain and how the mindbody relationship works, treatment consists of three steps:

Step 1: Reject the diagnosis of a structural abnormality. If you think of yourself as someone who just has a “bad back,” or believe that you’ll have to get used to your pain and deal with it indefinitely, you won’t get better. You have to accept that your condition is harmless. This will get your attention off of your body, which defeats the brain’s tactic of distracting you from your unconscious emotions by forcing you to focus on your physical state.

Step 2: Recognize that your emotions induce the pain. You have to understand that the source of your pain is not physical, but rather that it arises from your suppressed emotions as a way to distract your conscious mind.

Step 3: Accept the nature of the mindbody relationship. Don’t make yourself feel lesser or broken for the symptoms you’re experiencing or the emotions you’re repressing. Everyone has an inner child that’s irrational and emotional. What you’re experiencing is perfectly normal and affects everyone to some degree.

(Shortform note: These steps comprise important features of resilience, a collection of traits such as optimism (believing you’ll get better and that you don’t have a “bad back”), a sense of control (understanding that you can control your pain by changing how you deal with emotions), and social support (understanding that everyone experiences mindbody symptoms and that you’re not alone). Resilience is shown to have a positive correlation with strong immune function and anti-inflammatory responses, indicating that resilience plays an important role in healing. As Sarno’s method suggests, resilience is not an inborn trait but can be cultivated through activities like the three steps described above.)

Concrete Strategies

Since it can be challenging to “just change” your mindset around your pain, Sarno provides four more concrete strategies to try.

1) Overcome Your Brain’s Distractive Tactics

When you experience pain, deliberately focus your attention on your emotions. This can be difficult because pain is such an effective distractor, and because your mind is so resistant to acknowledging or processing your repressed emotions. However, you have to fight against your brain’s natural tendencies and redirect your attention to the source of the problem. When pain arises, ask yourself: “What rage or other difficult emotion am I unconsciously experiencing right now?” In dealing with his pain from migraines, Sarno found that this question alone could provide some immediate relief from pain.

(Shortform note: It might feel unnatural to disregard your physical pain. Pain, after all, is an adaptive response that developed to help us survive. However, this applies to acute pain, an immediate feeling of pain that occurs in response to a potentially harmful stimulus. Sarno’s method deals with chronic pain, which, according to experts, has no survival value. As you employ Sarno’s strategies, it’s important to distinguish between chronic pain—which is a distraction from your emotions—and acute pain—which is a necessary survival mechanism that you shouldn’t ignore.)

2) Make a List of the Sources of Your Repressed Emotions

Create a list of all the pressures you feel in your life, because these form a large portion of your rage. Also, consider what aspects of your childhood may have instilled some residual anger in you. Write out all the things that worry you or stress you out, then identify which ones are within your control and which ones aren’t. For those that are within your control, take some action to resolve them. For those that aren’t, accept them as reality, but refuse to let them cause you further pain.

(Shortform note: If you need additional help coping with and accepting the sources of your anger, consider a treatment like rational emotive therapy. This method focuses on helping you deal with emotions in a healthy way through strategies like improving social skills and conflict resolution skills, reframing troubling events, humor, and meditation. The treatment has a particular emphasis on acceptance, which could make it especially well-suited to people who struggle with accepting the stressors beyond their control.)

3) Communicate With Your Brain

Talk directly to your brain. Tell it that you know what it’s trying to do and you know it’s just a harmless distraction. You might even shout if it feels better to do so. You can also explicitly order your brain to increase its circulation to the affected muscles. Sarno notes that research supports the idea that you can communicate directly with your brain in this way.

(Shortform note: While talking to or shouting at your brain may help you confront its distractive tactics, it’s important to avoid slipping into negative self-talk. The way you talk to yourself can have a direct impact on your self-esteem, mental health, sense of control, and (as Sarno says) your pain levels. So, treat yourself with compassion as you communicate with your brain to tell it to stop distracting you or increase your blood flow.)

4) Make Time to Reflect

Set aside time each day to reflect on your pain and its purpose. Curing your TMS pain requires a conscious effort that you have to make time for, especially if you’re a particularly busy person (and people with the personality traits that tend to accompany TMS are often very busy people).

(Shortform note: Research shows that people tend to prioritize tasks with close deadlines over more important tasks with less immediate deadlines. Even though caring for your body is extremely important, Sarno’s method may be difficult to implement because it doesn’t have a clear deadline. To help you prioritize it, consider adding a designated time slot to your schedule every day to work on your TMS, and try to eliminate other tasks you don’t need to do in order to free up more time in your day.)

What You Don’t Need to Do

Sarno also notes that there are some things you don’t need to do to treat your pain.

Don’t Try to Change Your Personality

While the personality traits listed earlier in the guide tend to correlate with TMS, you can’t and shouldn’t change who you are. Curing your pain is a matter of accepting these aspects of yourself, not altering them.

(Shortform note: While the general understanding at the time of Sarno’s book was that personality couldn’t be changed, more recent research has shown that it is possible to alter personality traits. It’s not easy, though, and usually requires a lot of time and effort. Unless your personality traits are causing other problems in your life, your energy may be better spent accepting your traits than changing them, as Sarno suggests.)

Don’t Try to Eliminate Stress From Your Life

Pressure leads to pain, and stress leads to pressure. Eliminating stress from your life is impossible, so make it your goal to change how you process and express stress. This way, you can keep it from causing rage to accumulate in your unconscious mind.

(Shortform note: In addition to Sarno’s tips, other experts offer plenty of advice on how to keep stress from ruling your life. Strong social support is particularly important—research shows that support from others reduces your body’s stress response to difficult situations. Other people can also help comfort you when you are feeling stressed. Reducing stress where it’s possible can also help. If your job is stressing you out, consider a job change or asking others for help. If you find yourself in a state of unusually high stress, try taking a break by postponing tasks you don’t have to do right now, and engage in self-care and non-stressful activities.)

Don’t Try to Change Your Lifestyle

Drastic lifestyle changes are often impossible or unsustainable, and usually, the goal in pain treatment is to return to the activities you enjoy.

Once your pain has gotten better, eliminate the fear you have of exercise, recreation, or the other things you’ve been told by doctors to avoid. Fear of injury keeps your attention focused on your body, but because your pain is emotionally induced, you don’t need to worry about hurting yourself. However, Sarno suggests waiting a few weeks after you’ve accepted the TMS diagnosis before you resume your physical activities. While exercising won’t cause damage, if your pain is still at a high level, you’ll likely have trouble keeping your mind off of it while you’re doing these activities. Therefore, it’s better to give your brain time to rewire itself and wait for the stress-associated pain to abate.

(Shortform note: Research supports Sarno’s suggestion that chronic pain rewires the brain. In a process called central sensitization, the brain continues to perceive pain in the absence of a painful stimulus. This is because the brain has adapted to react to potentially painful stimuli, so eventually even something like a gentle touch can feel agonizing. Gradually returning to normal activities can reteach the brain to respond normally to stimuli. However, because this process takes time, doing too much too quickly can increase pain, suggesting that it’s important to take your time.)