An Interview with Internist Howard Schubiner

Howard Schubiner, MD is an internist and both the founder and director of the Mind Body Medicine Center at Ascension Providence Hospital in Southfield, Michigan. Dr. Schubiner is a clinical professor at the Michigan State University College of Human Medicine and is an expert in the mind-body connection, as it relates to one’s health.

Nicole Izquierdo:  Thanks for joining us today for this installment of the Seattle Psychiatrists Interview Series. I'm Nicole Izquierdo, a research intern at Seattle Anxiety Specialists, and I'd like to welcome with us Dr. Howard Schubiner. Is that how you pronounce it? Is that correct?

Howard Schubiner:  It is.

Nicole Izquierdo:  Okay. So Dr. Schubiner is an internist and both a founder and director of the Mind Body Medicine Center at Ascension Providence Hospital in Southfield, Michigan. He is a clinical professor at the Michigan State University College of Human Medicine and is a fellow in the American College of Physicians and the American Academy of Pediatrics. He has authored more than 100 publications in scientific journals and books, and lectures regionally, nationally, and internationally. So before we get started with the official questions, would you like to share a little bit more about yourself with our listeners, and what made you interested in becoming a physician?

Howard Schubiner:  Well, that's a great question. First of all, it was a long time ago. It just seemed like a good idea at the time, I guess. I wanted to do something that would be useful and meaningful. I wanted to work in a community. And I was in university at the time, and I don't know, I just thought I would see what it was like. I took a few science classes and I found them to be not too difficult, and it just kind of led from there. I started volunteering at a free clinic and learned more about healthcare and medicine and some of the problems in medicine, frankly. Even way back then in the 1970s, it was becoming very clear that the biotechnical approach to medical problems had tremendous potential and tremendous value, but it also left things lacking. And it turned out, as my career has meandered and wandered over the years, that I've come to a place now where my main work has to do with the failings of biotechnological medicine and the promise of more simple and more patient-centered approaches.

Nicole Izquierdo:  Thank you. Thank you for sharing that. So you specialize in the mind-body connection as it relates to one's health. Do you mind defining what that is to our listeners?

Howard Schubiner:  Sure. Everyone knows the brain and the body are connected. The mind and the body are connected. When you get embarrassed, your face turns red. When you have to give a speech, your stomach may flip into knots. Everyone knows that. But it turns out it goes much, much deeper. It goes deeper in the sense that we have learned, in the last couple decades or so, that our brains actually create all of what we experience. Which is really a revolutionary concept. And it's called predictive coding or predictive processing. And so when you touch a hot stove, it's not your finger causing pain. It's actually the brain. The nerve signals go up to the spinal cord into the brain, but the brain makes a decision. It sounds weird, but the brain makes a decision whether to turn on pain or not. And we know that, because a lot of times, people have injuries without any pain. And we also know that the brain can activate pain or anxiety or fatigue or depression or insomnia when it's under stress. It's like a warning signal.

And so pain is a protection. We need pain. The reason we have pain is that it warns us that there's something wrong, usually wrong physically in the body. But our brain can turn on pain, the same pain, exact same pain, when we feel trapped or emotionally in danger, and that pain is real. And so it's really important for people to understand that pain and anxiety and depression are actually generated in the brain, and they're generated in the brain as a warning signal, as an alarm, like a smoke alarm.

And so it's up to us to figure out what the message is, why that's happening. If you have pain in your back and it's a kidney stone, then that's the message. You need to deal with the kidney stone. But if you have pain in your neck because you're in a job that's untenable and harsh or you're in a relationship where you get betrayed, then that's the message. But the pain can be exactly the same. The anxiety can be exactly the same. So once you understand that the brain creates what we experience, now you have an inroads for understanding how we work, what makes us tick, and how to deal with it.

Nicole Izquierdo:  So would you say that those instances where it's more like a psychological stressor causing let's say neck pain or a headache or back pain, would that be, what's the term, psychophysiological disorder, or is that something else?

Howard Schubiner:  No, that's exactly right.

Nicole Izquierdo:  Okay.

Howard Schubiner:  In the old days, they used the term psychosomatic. They still use that term in Europe, but we don't use it here because it seems mean. But the fact is, since our brain controls what we experience, it's not mean. The fact is that we are psychological beings, we are emotional beings, we are social beings. And so the fact that we can get... If I have pain and I know it's from my brain as opposed to from my body, I'm happy. It shouldn't be stigmatizing, because the symptom is real. It's not imaginary. I tell people, anyone who says the pain or the anxiety or the depression or the fatigue or the insomnia is all in your head, it doesn't understand how things work. It's real. It's not your fault. It's not because you're crazy. It's not because you're weak. It's not because you're deficient. It's not because you want it. It's because your brain is sounding an alarm. There's something important that's going on in your body or in your life, and so it's up to us to figure that out.

Nicole Izquierdo:  Yeah. That's nice that the terminology is changing to capture that change of... Because it is invalidating, telling someone, "No, it's fake. It's not as bad as a 'real' injury or 'real' pain." And "real" in quotation. Are there any specific examples of these disorders? Like diagnostic names, diagnostic criteria?

Howard Schubiner:  Well, yeah. We have developed a lot of diagnostic criteria for these disorders. And, well, first of all, people who develop these mind-body conditions or what I sometimes call neurocircuit conditions are more likely to have stressful childhoods, more likely to have histories of trauma, more likely to feel like they have been criticized or feel they are not good enough or put other people first and not stand up for themselves. They're more likely to be in difficult situations currently in their life.

And the symptoms that they have are more likely to turn on and off, to shift or move. And we see, what's interesting is we see, because as we understand the brain creating these conditions, we frequently see that some people may have headaches for a while, and then the headaches go away, and then they get back pain, and then the back pain goes away, and then they get anxiety, and then the anxiety goes away, and they get fatigue, and then the fatigue goes away and they get irritable bowel, and the irritable bowel goes away and they get depression. And these can shift and move, sometimes within days or hours or weeks or months. And you can see the pattern where you can see that someone's been under stress and their brain has created a variety of different warning signals. And so we're looking very carefully at people's stories and listening to them. And, as you said, validating them, caring for them, being compassionate toward them, and helping to understand them and understand that their symptoms may be reversible, as opposed to being incurable.

Nicole Izquierdo:  How would you recommend that sometimes to get to that point, once you check everything else off the list that is let's say a kidney stone, for the back pain. How would you recommend going about it so that patients that do struggle with this aren't also struggling with the toll of going through a bunch of tests or the cost associated with those tests?

Howard Schubiner:  Yeah. That's a great question. We always recommend getting testing. If you have anxiety, you need to have your thyroid checked to make sure that you're not hyperthyroid. If you have anxiety, you need to have your heart checked to make sure you're not having a tachyarrhythmia or something like that. If you have depression, you need to have your thyroid checked, you need to have your hormones checked. These are obvious. If you have back pain, you need to get your back checked.

But we don't want to over-interpret things and we don't want to make people think that just because their symptoms are chronic that means that they're incurable. There has been a lot of research showing that, for example, in neck and back pain, that most people have abnormal MRIs. The MRIs are going to be abnormal. They're going to have degenerative disc disease, spinal stenosis, things like this. But those things are common in people who have no pain at all. So you shouldn't be saying, "Oh, that's the cause of your pain, because you have these mild abnormalities that everybody else has."

Similarly, with anxiety and depression, I feel strongly that we shouldn't be telling people that... And I know this is controversial and some people in your groups may disagree with me, but when we tell people that the problem is inflammation of the brain or it's genetic problem, what we're telling them is that it's not fixable. What we're telling them is that they're doomed and that they'll just have to cope with it. And that's the same thing doctors tell people with back pain when they see an abnormal MRI. And so we're trying to break out of that rigid biotechnical model to embrace this mind-body model or this predictive processing model, because it's much more optimistic and much more hopeful about making changes and getting better.

Nicole Izquierdo:  So one of your books is titled Unlearn Your Pain, and we actually have several clients that come to us seeking relief for chronic health issues, many of which included chronic pain. So without giving the entirety of the book away, can you explain how this could be possible?

Howard Schubiner:  Sure. Well, it starts with what we've been talking about. It starts with understanding predictive processing. It starts with understand how the brain works. And then it's an assessment, so it's making an assessment to make sure that there's nothing actually structurally wrong. And most people with chronic pain do not have a structural condition. Most people with headaches, fibromyalgia, irritable bowel, chronic abdominal pain, chronic pelvic pain, chronic neck and back pain, do not have a structural problem in their body, and I would assert the same is true for people with chronic fatigue, insomnia, anxiety, and depression. So the first part is that assessment. And then after that, there's three types of things that we help people to work with. One is we call pain reprocessing therapy. The second, we call emotional awareness and expression therapy. And the third is making changes in someone's life and dealing with their current issues in their life.

Pain reprocessing therapy can also be used for anxiety and depression, and what it is, it's a process of changing your relationship to the sensations you have in your body. Instead of fearing them and focusing on them and trying to figure them out and trying to fight them, it's actually being with them and tolerating them and knowing that they're not serious, that they can't hurt you, that you're going to be okay, and it's practicing graded exposure to gradually do more and more and tolerate the sensations of these uncomfortable, unpleasant physical sensations, and by changing your relationship to them, you're calming that danger alarm mechanism in the brain, which will then turn down the symptoms. That's the first step, the first treatment.

The second treatment is emotional awareness and expression therapy, which I developed with my colleague, Mark Lumley, and that involves dealing with the emotional issues that people have been through. Dealing with the emotions of anger and fear and grief and sadness and guilt, and moving through those to compassion for one's self. And it's a process instead of trying to just moderate the emotions to actually feel them, identify them, feel them, and express them in safe and healthy ways.

And then the third step is what do you have to do in your life? Sometimes, people need to make a change in their life. You need to set boundaries or make changes in their relationships in order to free their danger signal from continuing to create the pain or the fatigue or the anxiety or whatever.

Nicole Izquierdo:  Thank you for sharing that. Would you say that there is an evolutionary reason for something like the brain turning on those pain signals when there is no physical or structural issue?

Howard Schubiner:  Yeah. It's speculative, of course. We can't really go back in time and understand. But the way I think of it is that pain is a protector. Anxiety, depression, fatigue, they're protectors. Our brain is turning them on as a message to protect us from something, to alert us to something. When we get a broken ankle, our brain turns on pain in order to tell us to stop walking on that ankle, get rest, get help. So way back in hundreds of thousands of years ago, Neanderthals lived on the earth and homo sapiens did. Neanderthals were bigger, smarter, faster, they had bigger brains, they were better hunters. Why didn't they survive? Homo sapiens survived because they worked in clans. They got together in groups and they communicated and they hunted together and they looked out for each other. And that's, we think, why we, so to speak, survived.

And so if you were back in those days and you got bit by a tiger, obviously, your brain, you want pain. You break an ankle, you want pain. But why would you want pain or other symptoms in an emotional situation? Well, if you survive because of your clan, if you get kicked out of the clan, you might die. That's a life-threatening thing, to get kicked out. Why would you get kicked out? Because of shame, because of guilt, because you did something wrong, but you beat up somebody or you betrayed somebody. And then the group would enforce the rule by shaming you or yelling at you or criticizing you, or whatever. And then you would be in danger of ostracism, which could mean death. So from my point of view, it makes sense that our brain would turn on a very strong reaction not only to a physical injury but also to an emotional injury. And I think that's why that occurred, but it's a bit of speculation, of course.

Nicole Izquierdo:  So you were featured in a new documentary titled This Might Hurt, which follows three chronic pain sufferers and offers solutions to such suffering. So your paradigm for diagnosis and treatment was found to be effective in several randomized trials, and it was actually listed as a best practice by the HHS's taskforce to combat the opioid epidemic. Can you speak a little bit more about this film and what has led to the ongoing opioid epidemic in the US?

Howard Schubiner:  Sure. The film is This Might Hurt. It was directed and produced by Kent Bassett and Marianne Cunningham, two young people. Kent himself had chronic pain and cured himself by changing his mind, changing how he related to it, changing his understanding of it, without any medical intervention. He had very severe chronic pain that it was incapacitating for quite a while. So he wanted to make this movie, and the movie kind of shows the real-life issues that people with pain have. One of the women in the movie was bedridden for eight years with chronic abdominal pain. And after going through this program, she got up, she got out of bed, she could work. She went back and got a job. I mean, it's amazing what can happen when you have this different way of looking at it, as I was describing, this whole different way of looking at it and different way of treating it.

Because the main paradigm for treating chronic symptoms in our medical world, chronic pain, is that you're going to have to cope with it. We'll give you medications, injections, physical therapy, acupuncture, meditation, all these things to help you cope with it better, but they're not offering, actually, to make it better. And the research shows that the coping method doesn't work all that well with chronic pain. And similarly, I would argue, with anxiety and depression and chronic fatigue, we're finding that the coping model of doing a little bit of this and a little bit of that doesn't... It has kind of a ceiling effect. You're saying, "Well, you can get better, but you can't get all the way better." And so you're stuck in this danger signal in your brain. And so we're trying to think of these things in a different way, which I think is actually scientifically valid. It's not pie in the sky or just rose-colored glasses. It's actually based on the neuroscience of how the brain works.

And so the opioid epidemic was a response, but it was a kind of neurobiotechnical response. You have pain. There must be something wrong in your body. We have to treat the pain. We'll have to give you medication because there's nothing else we can do. And so over time, more and more people got more and more medications. Of course, the drug companies were complicit in this, in trying to tell doctors that these medications weren't addicting or weren't as addicting as people were concerned. And in addition to that, our society has basically been falling apart in a lot of ways. And so that clearly weighs on people's minds and makes people much more likely to turn to pain relievers, because their lives are so difficult.

Nicole Izquierdo:  Thank you. So our practice specializes in treating anxiety and anxiety-related disorders, and so we were particularly interested to see you have another book titled Unlearn Your Anxiety and Depression. Do you mind elaborating on how this might be possible, and whether this is something that someone can do by themselves, or whether it has to be under the care of a mental healthcare provider like a therapist or a psychiatrist?

Howard Schubiner:  Yeah. Good question. When I started working in the field of pain, and so I saw a lot of people with pain and I learned a lot. I've been doing this for almost 20 years now. So I just learned a lot about pain, and what I saw over time was that frequently, the people who had chronic pain also had anxiety or depression. If you're in a counseling center and you're seeing people with anxiety and depression, about 50% of your patients are going to have a chronic painful condition. So there's a tremendous overlap in these conditions, number one. Number two, there's tremendous interchangeability of these conditions, as I mentioned before, where you see people where symptoms will kind of come and go, and anxiety may be replaced with pain and pain may be replaced with fatigue and fatigue may be replaced with insomnia and then depression. And so when you see that in people, you can see, well, gee, the brain may be turning on one set of symptoms and then may be turning on another set of symptoms.

And what I've found over the years is that if you apply the similar diagnostic assessment tool mechanism to people with anxiety and depression as I did with people with chronic pain. Again, really not a structural problem, and looking for the clues that suggest that it is a neural circuit problem, number one. And then number two, using the changing your relationship to the symptoms. For example, if someone has anxiety... What I'm doing is not rocket science, not super complicated, but it's very optimistic, and it's saying that you can change.

And so if someone is having anxiety in a certain situation, in elevators or in work meetings or in family situations, the first step would be to have them imagine that situation in their mind. And when you imagine that situation in your mind, what happens in your body? What response do you get? And so if you're imagining being in a work meeting and your stomach starts to flip into knots and you feel a little bit trembly, then that's your brain turning that on. You're not actually in the situation. You're just imagining it. And that's a low-level exposure. And then we help people to smile at that, to calm their brain, to soothe the brain, to treat the brain like a scared child lying in bed, fearful of a monster in the closet, and to give themselves love and compassion and caring, give their brain love and compassion and caring. Recognizing their brain is not the enemy, it's just afraid. It's just afraid of the situation.

And then we use these techniques to help calm those symptoms, calm the stomach, calm the trembling. And then go back and imagine the situation again, and then calm the sensations. And then imagine the situation again. And you keep doing that, and then it's just like the old classic way of treating a phobia of snakes. Desensitization. And then you gradually get people to go into those situations with this calmness, with these techniques. And the techniques are not all that brilliant. They're just the normal calming techniques. But it's knowing that you can do it. It's knowing you're going to be okay. Knowing it's just your brain that's afraid. And that's the key that can really help people to propel themselves to changing their symptoms. And then, of course, certain people may also need to deal with some of the traumas in their life, some of the emotional situations. And that's what we talked about with the emotional awareness and expression therapy part of it, as well.

Nicole Izquierdo:  So you would say it's ideal for this to happen under the care of a practitioner, developing the exposure hierarchy? Or even having someone there when you're experiencing those stressful situations to make sure they're not in danger?

Howard Schubiner:  Yeah. I mean, some people clearly need help and need a therapist. But there's not enough therapists in the world to deal with all the people who have chronic pain and have chronic anxiety and depression. There's nowhere near enough therapists in the world. So my view is that a lot of people can do this on their own. A lot of people can learn these techniques. And that's why I've written these books into a self-help guided recovery program that people can use. And I get emails all the time from people who are using these on their own.

And so it's really a question of what level of worry and concern and what level help people need, and what level of underlying trauma people have, what the severity of their situation is. So I think it's kind of a mixture. When I work with people, I work with them individually, but then I give them lots of homework, and I say, "Here's how you can start to practice this on your own. Here's how you can do this on your own." Because ultimately, we want people to be in charge of their own health, as much as possible.

Nicole Izquierdo:  Thank you. Yeah, I see something similar with that and what we're trying to do with our website with interviews and writing articles. Because some people can't afford to start treatment or continue treatment forever, so.

Howard Schubiner:  Absolutely.

Nicole Izquierdo: Nice that that was your goal with those books. I appreciate that. So we're approaching our final question. As a doctor specializing in the mind-body connection, do you have any other words of advice or parting words for our listeners?

Howard Schubiner:  No. I really think that the most important thing is compassion. So many people who have been brought up in difficult situations have learned that it's much easier for them to be compassionate to others than to be compassionate to themselves. We see this all the time. And if they can begin to do that, if they can begin to look out for themselves, stand up for themselves, speak up for themselves. If they can recognize that they are, it sounds silly, but, worthy and deserving and worthy of being loved, just as everyone else is, that is just such an important step for people to take. And there's ways to do that, and there's books written about self-compassion, for example, that people can follow and learn to take care of themselves. Because what's happening is that their brain is reacting out of fear and worry, and some of the fear and worry they're actually putting on themselves because they're feeling inadequate. And so, to me, it really starts with compassion.

Nicole Izquierdo:  Thank you. So to wrap things up, we just wanted to let our listeners know that Dr. Schubiner has a series of animations on YouTube that are very insightful, so we will be linking those on our website. And I just wanted to say thank you so much for joining us and sharing your knowledge, Dr. Schubiner. We really appreciate you taking the time to speak with us, and we wish you the best.

Howard Schubiner:  Thank you. It's a pleasure. Thank you for doing what you're doing. I appreciate it.

Nicole Izquierdo:  Thanks.

Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.

Editor: Jennifer (Ghahari) Smith, Ph.D.