IFS and Chronic Pain

Listening to Inner Parts that Hold the Hurt

By Howard Schubiner, Richard Schwartz, Ronald Siegel

January/February 2021

https://www.psychotherapynetworker.org/magazine/article/2523/ifs-and-ch…  

Susan is a dance teacher in her mid-30s who performs regularly. For years now, she’s lived in constant fear that her back will go out. She’s haunted by chronic low-level backaches, which flare up without warning every few months, turning into days-long bouts of excruciating pain.

Two years ago, on the day of a big recital, she could barely get out of bed. Her right side was spasming, and even tying her shoes was a challenge. She managed to muddle through the final dress rehearsals and the show itself while tanked up on benzodiazepines and pain medications. But as soon as she got home, she crawled into bed and stayed there for two weeks.

In the aftermath of that dreadful episode, Susan’s general practitioner prescribed more meds and referred her to an orthopedist, who suspected bulging disks with scoliosis. Convinced that her back was vulnerable and needed protecting, she started sleeping with pillows under her knees, carrying a special cushion in her car, and not lifting heavy objects. She went so far as to give up jogging and bike riding. She stared compulsively strengthening her core in an attempt to compensate, and warming up for hours before performances—much longer than any of the other dancers.

No matter how stringently she cared for it, however, her back never felt fully healed. She eventually went in for an MRI, and the results showed that the wear and tear on her discs was typical of people her age, most of whom experienced no back pain at all because of it.

Though others might’ve been comforted to learn this, Susan was upset. Why was she so riddled with pain when others weren’t? She started to feel desperate. Who, she thought with some dread, would believe her pain and help treat it now?

Seeing Pain Clearly

When in physical pain, we understandably think that there’s a structural cause for our suffering. But to the surprise of doctors and patients alike, research suggests this often isn’t the case. It turns out that most chronic pain, and an astonishing variety of other medical maladies, have little to do with damaged tissues or untreated infections. They’re maintained by complex mind–body interactions, in which our brain’s natural proclivity to avoid pain traps us.

We’ve begun to learn, for example, that histories of childhood sexual or physical abuse are significant risk factors for chronic back pain, and that job dissatisfaction is a much stronger predictor of it than having a job that requires heavy lifting, lots of sitting, or other physical strains. We’ve seen placebos turn out to be effective treatments for countless pain syndromes and related disorders; and for some maladies, such as irritable bowel syndrome, they can work even when people know that they’re taking a placebo.

When we’re anxious, states of chronic fight-or-flight arousal can disturb the normal function of our organs. We see this when anxiety causes our stomachs to produce too much acid and gives us heartburn, or our intestines to dysregulate and bring on irritable bowel syndrome, or our muscles to seize and result in chronic back pain. Sometimes, even when our physical systems are functioning normally, our brains actually produce or amplify pain and other troubling sensations either out of fear or to fulfill psychological needs.

Effective treatment of chronic pain involves understanding the roles that psychological factors play and finding ways to address them. One particularly useful way to do this is through Internal Family Systems therapy (IFS), a psychotherapy that’s rooted in a clear understanding of the interplay of psychology and the body. IFS is based on the observation that each of us comprise many psychological “parts,” seen as valuable members of an inner family, which exist to help us thrive and to protect us from pain.

Trauma and attachment injuries, however, force many of our parts into serving functions that can be problematic. One such group of parts, called exiles, are young and vulnerable, and carry early emotional injuries (what IFS calls burdens), such as a sense of worthlessness, terror, or emotional hurt. Before the trauma, they were the lively, creative “inner children,” but after they began to carry the burdens of trauma, we locked them away to keep them from overwhelming us with their raw emotions and vulnerability.

Once we develop exiles, the world feels more dangerous, and we feel more fragile being in it. As a result, another group of parts tries to protect our exiles from getting triggered. To do that, these protector parts take on roles like the harsh internal critic, the overachieving perfectionist, or the frightened avoider. In IFS terminology, these protectors function as managers, dictating our day-to-day activities to make sure our exiles don’t get emotionally injured.

During times of increased stress, when these managers can’t adequately manage our emotional pain, another set of protectors, termed firefighters, jump into action at an even higher level of defense. Firefighters are emergency responders, and their activities include acute depression and suicidal thoughts, cutting, binging, alcohol or drug use, and panic attacks. Both protector-managers and firefighters may use physical pain to protect our exiles.

Susan eventually found her way to an IFS therapist, who helped her understand that her fears and resulting avoidance of normal movement were playing a role in her ongoing struggle with pain. Therapy focused on exploring the parts of her that were driving this behavior.

In one session, Susan zeroed in on what she called her pusher part, which she physically located in her forehead. When she listened to it closely, she learned that it was young, feisty, and determined to conquer her back problem, no matter what. She said she relied on this pusher because it had helped her succeed in school and was responsible for her success as a dancer, teacher, and businessperson. It was diligent and obsessive, and once it identified a goal, it pursued it at the expense of all competing needs. This part was going to fix her back pain at any cost.

After compassionately validating this part’s desperation and asking it to step aside for a moment, Susan noted a very vulnerable exile that her pusher part was working to protect. This part was even younger—an innocent little girl, who’d fallen, hurt herself, and felt helpless and alone. It was hard for Susan to stay with this part, who longed for a mommy or daddy to hold and comfort her. It’s not that Susan’s parents weren’t caring, just that they’d communicated to her from as far back as she could remember that people shouldn’t wallow in their misery. She realized that this made it feel unsafe to be in pain, so she’d panic whenever she started to feel any. Beneath her panic, she realized this part was frozen in time.

This discovery led Susan to notice another part that also didn’t get much attention in her daily life: a nurturing part, which was pretty good at holding her own daughter when she was in distress. This maternal part could be with her daughter’s pain without immediately needing to fix it. She recognized that while she could provide that kind of nonjudging compassion to her daughter, her pusher part wouldn’t let her do that for herself.

Connecting with these different parts, Susan began to find it easier to risk giving up her vigilant, fearful approach to her back pain. She began to see that when she could relax into resuming normal activities, her fear around her back diminished, and this shift made it less likely that she’d have another episode.

She also realized that her back going out before the recital was related to her fears of things going wrong that day: fears of experiencing her vulnerable, tender part, who sometimes just wanted mommy or daddy to hold her. She discovered that the more she could connect with this young part, the more her capacity for wise and compassionate awareness and action (called Self in IFS) could care for it, thereby making the prospect of another back episode less terrifying.

Eventually Susan gave up her back props, began sleeping normally in her bed, and went back to riding her bike and jogging. She now understands that she may have another back spasm, but she feels better equipped to deal with it. Her vigilant, diligent pusher part can relax more, and she has confidence that she can self-nurture when she needs to. In fact, she’s come to view recurrences of back pain as an alarm or a barometer of a vulnerable part being activated by challenging situations.

How Do We Know if Pain Is Psychological?

Before treating chronic pain psychologically, tumors, infections, inflammatory conditions, and other physiological conditions need to be ruled out. That said, most patients with chronic pain don’t actually have dangerous medical disorders. Rather, they’ve probably received other kinds of worrisome diagnoses, like tension or migraine headaches, trigeminal neuralgia, fibromyalgia, small fiber neuropathy, irritable bowel syndrome, interstitial cystitis, pelvic floor dysfunction, pudendal or occipital neuralgia, bulging or herniated disks, or functional dyspepsia. More holistic practitioners might’ve offered alternate diagnoses such as adrenal fatigue, chronic Lyme disease, leaky gut syndrome, toxic heavy metal accumulation, or candida overgrowth.

It’s useful to inform patients that most of these terms merely describe the condition: they don’t reveal its cause. Helping clients understand that they don’t have something dangerous, incurable, or necessarily disabling is an important first step in treatment. This relaxes their protector parts and helps them trust that returning to normal activities is safe and even wise.

The next step is to look for clues that will help them see that their mind might be playing a role in their distress, such as pain that comes and goes, shifts location, or gets triggered by innocuous activities or stimuli, such as lights, sounds, weather changes, and foods. Pain that’s widespread or spreads over time in a pattern that isn’t typical for known diseases—like a whole arm or leg, or one side of the body—is also likely to be psychologically induced.

If clients have had other mind–body disorders, such as anxiety, depression, eating disorders, chronic fatigue, and other pain-related syndromes, the probability that their pain is psychophysiological increases. Finally, if there’s a history of adverse childhood events or a client can trace the onset of symptoms to significant life stressors, it’s even likelier that the mind is playing a major role.

Frightening medical diagnoses often lead to depression and frustration, further activating an already overactive fight-freeze-flight system.

Desperate Parts Chasing Futile Treatments

Many patients with chronic pain have devoted their lives to finding cures. They may have begun with conventional medical evaluation and treatment, which itself can make things worse. When their condition is diagnosed as being due to structural problems, they may wind up enduring unnecessary procedures while painful symptoms spread and worsen. Frightening diagnoses often lead to depression and frustration, further activating an already overactive fight-freeze-flight system.

Many have spent a great deal of money and time seeking additional tests and alternative treatments. Some of these may have shown promise for a while, since the hope of relief helps reduce the fear that so often plays a role, but when they fail to provide truly lasting relief, patients sink back into despair.