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The Psychology of Back Pain

by Sheldon Litt, Ph.D.(more info)

listed in back pain, originally published in issue 56 - September 2000

On the front page of today's leading Swedish daily newspaper, the respected broadsheet DAGENS NYHETER (The Daily News), is featured a major article on back pain. The gist of this long article, in large headline print, is that in 19 out of 20 cases of back pain, no physical cause can be established. An eminent orthopaedic surgeon from Gothenburg has directed a comprehensive study (Back Pain/Neck Pain) which included the cooperation of many foreign experts, over a period of more than four years. This research effort has just been published in a volume of over 800 pages, and concludes that the most effective treatment for back and neck pain is cognitive behaviour therapy. According to their conclusion, psychosocial factors play the major role in both acute and chronic cases of back pain as well as neck pain. And results show that stress and anxiety are the main underlying factors here.

Back problems are now the major cause of sick leave in Sweden for people between the ages of 20 and 60; and this is true for both men and women. The rate for Sweden is about three times higher than for England and Holland, according to this survey.

In all, more than eight of ten Swedes will suffer from back problems at some time during their life, while neck pains will afflict about one half the population at some time or another. These problems now cost Swedish society more than $4,000,000,000 each year!

Despite these high numbers, only in five per cent of the cases studied is it possible to find some definite physical cause of the problem. In all other cases, the remaining 95%, no evidence can be found to suggest what the cause might be, and why there is any pain.

Naturally, here the obvious psychological factors play a role.

As Dr Alf Nachemsson, the director of this study says, those patients who receive larger payments through the health insurance system tend to file more claims for sick leave due to back pain than their less fortunate fellow citizens who only receive small funds when absent from work due to back pain.

I'm no expert on back pain, having only on one or two occasions fallen victim to this malady, but luckily both times I was able to avoid the traditional health care system and received immediate help from friends who practise alternative forms of treatment – the Alexander Method was most helpful to me, and at other times I have had beneficial results from the Feldenkrais approach.

However, most patients end up in the traditional health care system where, according to this new research, the process of diagnosis and treatment often only adds to the patient's unease and anxiety. This is primarily due to the fact that the practitioners treat the patient as 'sick', and relegate him to a more passive role than is helpful. Added to this is the social stigma of being on sick leave and receiving state benefits from the medical care system.

Most of the experts agree that the worst thing for the patient to do is to spend all day in bed with a bad back. This only leads to additional problems, such as weakness of muscle functioning and general stiffness in the joints. The best procedure is to be as active as one can tolerate. In addition, according to Dr Nachemsson, it may be necessary to examine the conditions at work, to determine if the physical movements required of the patient may be leading to painful patterns. Moreover, in addition to checking on the ergonomic structures, it may be necessary to investigate psychological stress factors stemming from the patient's occupation.

The conclusion of this study that psychotherapy sessions are the best form of treatment for back problems perhaps stems from this notion that job stress seems to be the underlying cause of the difficulties. The authors suggest that if the patient is able to lessen his work-related conflicts then his physical difficulties will also diminish.

This result, of course, assumes that there is no other cause for the back pain. It may be well be the case, however, that the diagnostic techniques available for this research were simply inadequate to discover the true nature of the symptoms. Who can say that in the future, with better methods of diagnosis that some other cause, perhaps a virus or who knows what, will be discovered to trigger off back pain in those 95% of cases for which no discernible cause has yet been found.

But for now, in any event, it may be necessary to look closer at the psychological factors in back and neck pain when no clear physical clues are seen.

(Reading this report brought to mind an anecdotal incident from many years ago. One of my colleagues in New York, let's call him Jim Roberts, had a visit from his father whom he had not seen for more than 20 years. His estranged father was an alcoholic who had abandoned the family, so Roberts was somewhat apprehensive about this sudden visit. His father arrived and asked his son for a drink. Roberts politely offered a glass of whiskey, but his Dad insisted on having some ice. As Roberts reached up into the freezer to collect some ice cubes, he wrenched his back and recoiled in pain. For some weeks afterwards, he was writhing in terrible agony. Perhaps in this case, it was a bit of aggression and resentment at his father which may have contributed to this mishap.

I'm not saying here that all back pain may be traced to such an event, but only offer this as something to think about.)


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About Sheldon Litt, Ph.D.

Dr Sheldon Litt is an American psychologist who trains professionals in modern methods of psychotherapy. He has taught at many universities in northern Europe. He was trained by Fritz Perls at the New York Institute for Gestalt Therapy.S. Litt, Inedalsgatan 25, S-11233 Stockholm, Sweden. Tel: +468 651 2489 Email:


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