Pros: Sarno has built his career around an important and interesting idea, about the importance of the mind in health. This is a valuable baby that should not be thrown out with the bathwater.
Cons: The “bathwater” is that Sarno has also taken his idea too far, attributing far too much power to the mind. His most recent books promise near miracles and have lost touch with reality.
All of Sarno’s books are variations on a strong common theme: that healing of all kinds can be affected by informed, rational confidence in the power of the mind to affect our tissues, particularly our muscle tissue. In my opinion, this is both true and important, but also easy to get carried away with — and, hoo boy, Sarno really does get carried away.
Sarno’s earliest book, Mind Over Back Pain was, first published in 1984 (two Berkley editions followed in 1986 and 1999). Then Healing Back Pain was first published in 1991, presumably as a replacement for Mind Over Back Pain, and then The Mindbody Prescription, in which Sarno expands his thesis — over-reaching, in fact — to explain how other common health problems are created and mediated by the mind.
Either Sarno’s Mind Over Back Pain or the more recent Healing Back Pain are worthwhile reading for many people — not just those with low back pain, but also many others patients with chronic body pain. They are also good reading for many health care professionals — Sarno is an articulate writer, with many insights that have general significance to health care.
And many that don’t!
Original published 1984: Mind Over Back Pain: A radically new approach to the diagnosis and treatment of back pain
Sarno goes too far
Sarno is articulate and has some important ideas, yes — but he’s also gotten into the business of selling miracle cures. The more recent the book, the less he sounds like a doctor and the more he reads like a mind-body medicine guru trying to convince you that you can heal anything if you can just master the right mental attitude.
Yuck. I don’t care for that. I don’t like it any better than I like the opposite extreme: denying the importance of the mind in medicine is just as foolish as exaggerating it.
History has shown us that it is all too easy to sell books by promising that the “power of the mind” can do whatever you want to believe it can do. Sarno has jumped on that old bandwagon. And so, unfortunately, it is not possible for a serious thinker to take Sarno at his word straight through his books. It is necessary to take the good, and filter out the exaggerated, the grandiose, the empty promises.
MPS vs. TMS
Another major problem with Sarno is that he stubbornly insists on reinventing wheels. His most important observations are duplications of much more well-established set of ideas. It’s not necessary verboten to repackage old ideas, but this is pretty glaring.
First, back in 1984, Sarno attributed back pain to a phenomenon he called “tension myositis syndrome.” At roughly the same time, myofascial pain syndrome was already much more thoroughly defined and studied by the famous physician Dr. Janet Travell, who worked for President Kennedy, and her research partner Dr. David Simons. Drs. Travell and Simons spent their careers studying MPS, and 1991 they published the first edition of their seminal textbook, Myofascial Pain and Dysfunction: The Trigger Point Manual. Although far from perfect (see Trigger Points on Trial) these books were and still are (in new editions) much more medically and scientifically influential, with broader clinical implications.
What is MPS, then? “Too many sore spots,” basically. What most people think of as “muscle knots” are just common, unexplained sensitive spots in soft tissue, mostly muscle, associated with stiffness and aching and a bewildering array of otherwise mysterious aches and pains, especially low back pain. When you have too many of these so-called “trigger points” — too severe, and for too long — it might get described as “myofascial pain syndrome” or perhaps “fibromyalgia,” both of which are just terms for a clinical pattern of chronic widespread pain with too many trigger points.
Even as flawed and limited a model as MPS is, it still makes TMS look simplistic and rather pointless. TMS was always a shallow idea, and it should have been aborted soon after it was conceived. Unfortunately, decades later, Sarno was still banging the TMS drum. More recent editions of his books still show no sign of awareness that MPS is a much more dominant and mature concept.
And he acts like the “discoverer” of the psychology of pain
TMS was a glaring case of wheel-reinvention, but there’s also his more sweeping lack of originality when it comes to attributing physical symptoms to psychological forces.
Again, nothing wrong with attempting to popularize and re-frame old ideas, but Sarno obnoxiously writes like his big idea was new. It comes off like arrogant colonization, “discovering” something that already existed: the intrepid explorer Sarno arrives on the shores of the Land of Psychology, already quite populated and civilized, and claims it for himself! He doesn’t give credit where due, as if he’s the first person to discover somatization, or that processing trauma can be helpful for pain. Plenty of psychiatrists and psychologists had already been onto that for decades, and helping people with that way. The psychology of pain existed before Sarno, and he doesn’t seem to know it.
A book for the people
Although much more widely known than TMS, the word about MPS has not exactly spread as far as it could. Some doctors and most manual therapists do know about MPS, but many others remain disconcertingly oblivious even to the phenomenon (let alone its hypothetical explanations and controversies).
It’s good that Sarno took the idea to the public under any name. As important as their work is, Travell and Simons never wrote for ordinary people — their textbook is seminal, but impossible to read without some medical education, and expensive. It is for the bookshelves of professionals only. Sarno’s modest paperbacks, on the other hand, weigh less than a pound and cost less than a meal.
Not only is Sarno’s book suitable for any reader with back pain, he explores some of the more human and philosophical implications of MPS/TMS, something that had never really been done before, and he proposes some valuable self-treatment strategies.
Before I read Sarno, I was still trying to gently beat trigger points into submission with physical manipulations, one the methods taught by Travell/Simons, and popularized by many others. Sarno’s thinking persuaded me to enrich that approach with a strong emphasis on education and reassurance. Happily this is much more consistent with what I understand about pain science today.
And Sarno isn’t a voice in the wilderness on this score. Consider this passage, in which author Marni Jackson paraphrases Dr. Nikolai Bogduk’s well-respected opinion:
Although [Nikolai] Bogduk has a reputation for having all the answers and being a bit of a ‘needle jockey’ who travels everywhere with his little vial of painkilling bivucaine, his presentation in Vienna surprised his colleagues. Instead of talking up the latest surgical intervention, he spoke about addressing the patients’ fears and anxieties, and ‘getting inside their heads.’ He emphasized that what was most important was to first eliminate ‘red-flag conditions’ that might be (but probably weren’t) causing the back pain, and then to reassure the patient that the back would most probably get better and not worse. He still believed in judicious painkilling, but what was more important in treating back pain, he had found, was communication and reassurance. Preventing acute [back] pain from turning into chronic pain was often a matter of ‘treating the patient nice and convincing him that there is nothing so horribly wrong.’
~ Pain, by Marni Jackson, p. 120–1
Sarno was saying the same thing about twenty years sooner, and he deserves credit for an early illumination of something profound about human nature: that just like blind faith can cause some healing via the placebo effect, informed confidence can also have startling effects.
Some more quibbles
Consistent with his possibly stubborn clinging to TMS, Sarno seems to write like he has a monopoly on this wisdom — which he certainly does not! — and this attitude has an unfortunate consequence, namely that he is dismissive of some other useful ideas, or just ignorant of them. Any half-decent massage therapist could have told him most of what he laboured to figure out for himself, and much more besides, and it seems strange that he is so unaware of this.
Also, I believe that Sarno plays too fast and loose with some of his facts, conspicuously ignoring some evidence which undermines his position, and sometimes making too much of evidence that supports it. And many of his citations are of dubious quality.
A long time ago, I borrowed one of Sarno’s citations without examining it closely enough. Eventually one of my own readers pointed out that it was a terrible source. I easily replaced it with a much more credible one. This kind of thing is pretty irritating: expert writers have a responsibility not to get sloppy just because they are writing for a less critical audience.
Although Sarno writes imperfectly about TMS instead of MPS, the labels don’t really matter to the people in pain, and the imperfections are overshadowed by the importance of some of his ideas, particularly in the two low back pain books: I recommend them to anyone with low back pain or chronic muscle pain, just with the caution that you need to think critically.
About Paul Ingraham
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
Appendix A: A better low back pain book
Sarno was my starting point. In the earliest days of my massage therapy practice, when I first read Mind Over Back Pain, I could see the importance of his ideas, but also their limitations. As much as I valued the book, and admired some of Dr. Sarno’s best ideas, I also thought, “I can do better than this.”
So I set out to write my own book about low back pain, inspired by Dr. Sarno to do better but also determined to offer more: above all, not to make low back pain seem like an “all in your head” problem (as Sarno tends to do). After years of regular revising and updating, today my low back pain tutorial is, I hope, not just better but much better than anything Sarno has ever written.
There are several reasons why I think it is better than Sarno’s book:
- I make a much more airtight case than Sarno does that backs are not fragile — much more research, much better sources.
- More thorough explanation of MPS, the likely cause of most back pain.
- Although Sarno has impressive expertise and clinical experience, he does not have the extensive hands-on experience that I have as a massage therapist.
- A much broader range of science-based and specific self-treatment recommendations.
- Instant gratification! It’s available digitally: you can have it right here, right now.
Appendix B: Excerpts from Mind Over Back Pain (plus some commentary)
Most doctors are uncomfortable with medical conditions that have a psychological basis.
~ p. 12
Sarno is the only expert I know of who is willing to say that spondylolisthesis and stenosis are rarely primary causes of low back pain even when they are obviously present, and he has only his clinical experience to support the claim. However, his experience is significant, particularly in light of all the other evidence that structural deformities do not cause low back pain. It’s not a great leap! With regards to spondylolisthesis, Sarno writes: “I have had a number of patients with this abnormality and have found in each case that the patient also had TMS [same as MPS — PI]. In every case the pain was eliminated by proper treatment for TMS, suggesting that spondylolisthesis was not the cause” (p25). This is followed by a “dramatic case history.” With regards to stenosis, “ … it has been my experience this ‘abnormality’ is rarely responsible for leg or back pain” (p27). For my part, for now I accept that these two conditions may cause pain, but not inevitably — and I eagerly await the day when research is done to investigate Sarno’s claim.
In 1978 I surveyed a group of a hundred TMS [same as MPS — PI] patients with regard to how their pain started .... Sixty percent reported that when the pain began it was not associated with a physical incident ... However, all of those patients tried to recall something physical that had happened, sometimes going back twenty or thirty years, because they thought there had to be such an incident, since everything they had heard about back pain related it to an injury and a structural problem. It was clear from their histories that there could be no possible relationship between those remote physical incidents and the onset of pain.
~ p. 27–8
Indeed, any deviation in the x-ray appearance of the spine from what is considered ‘normal’ will be blamed for back pain because of the deeply held conviction that the spine is the source of such pain. It is a conviction often without any scientific support.
~ p. 27
It is interesting to speculate how the world got along without back surgery for so long. I suspect that even though the family physicians of seventy-five years ago were unaware of the existence of TMS [same as MPS — Paul], they tended not to take back pain or ‘sciatica’ very seriously. Mustard plasters were widely used and probably brought about relaxation of muscle spasm through the heat generated by the plaster. Sometimes folk medicine is more sensible than ‘modern’ medicine. In any case, I suspect that the low-key, nonthreatening approach to back problems characterized by an earlier time helped to prevent the kind of long-term, disastrous courses that exist today.
~ p. 31
… surgery is a powerful placebo, perhaps the ultimate placebo. The effectiveness of a placebo is directly proportional to the impression it makes on the patient’s subconscious mind.
~ p. 35
I did a survey of a large group of patients with TMS [same as MPS — PI] and found that 88 percent had a history of one or more of these conditions [psychophysiological disorders such as heartburn, ulcer, gastritis, hiatus hernia, colitis, spastic colon, migraine, hives, eczema, hay fever, asthma]; 28% had experienced four or more during their lives ...
~ p. 58
To summarize, most neck, shoulder and back pain is due to TMS [same as MPS — PI], a harmless physical disorder of the muscles and nerves that is most immediately due to reduced blood circulation to these tissues. This circulatory abnormality results from constriction of the small blood vessels that feed the involved tissues ....
~ p. 66
A knowledgeable physical therapist can slowly build up patients’ confidence by reassuring them that there is no structural problem and reminding them of the physiologic reason for the pain ...
~ p. 92
It is my impression that ‘pain-killing’ drugs improve the patient’s mood rather than take away the pain.
~ p. 97
… our diagnosis and treatment of of tension myositis syndrome [same or similar to myofascial pain syndrome — Paul] represent yet another instance of what is possible when the power of the mind is mobilized for healing the body. It’s not magic; it is as scientific as the appropriate use of antibiotics, for science encompasses everything that is true in nature.
We must learn to recognize nature’s truths even though we don’t understand them, for some of those truths may still be beyond the ability of the human mind to comprehend. What we need is a compound prescription of humility, imagination, devotion to the truth and, above all, confidence in the eternal wisdom of nature.
~ p. 109
There is probably no other medical condition which is treated in so many different ways and by such a variety of practitioners as back pain. Though the conclusion may be uncomfortable, the medical community must bear the responsibility for this, for is has been distressingly narrow in its approach to the problem. It has been trapped by a diagnostic bias of ancient vintage and, most uncharacteristically, has uncritically accepted an unproven concept, that structural abnormalities are the cause of back pain.
~ p. 112
- “A Skeptical Look at the Theories of Dr. John Sarno,” Todd Hargrove, BetterMovement.org. Superb and clearly written account of some of the main problems with Sarno’s work.
- “Book Review, Unlearn Your Pain [Schubiner],” Scott Alexander, Slatestarcodex.com.
A methodical and skeptical but funny and diplomatic review of Dr. Howard Schubiner’s ideas about “mind-body syndrome” … which is basically a Sarno clone. It’s the best review of Sarno-like ideas I’ve read! I’m sure there are differences, but nothing of much importance.