Dr Lizzie Croton
GP and SIRPA practitioner
Introducing – the SIRPA Programme
Who are we?
SIRPA (Stress Illness Recovery Practitioners Association) is a revolutionary approach to chronic pain. It was founded in 2010 by Chartered Physiotherapist Georgie Oldfield in Huddersfield, UK. The aim of this blog is to give you an overview of the SIRPA programme and how it works. I’ll also be explaining a little of how I became involved with the association and how the programme fits in with the Western medical approach.
Chronic pain is now a leading cause of disability affecting 7.8 million people in the UK.(1) The term “chronic” essentially means that that the pain has persisted for more than 3 months or has persisted after healing is complete (2). Typically patients experiencing chronic pain are cared for by their GPs or in multidisciplinary pain clinics. Usually they will be given medication to suppress the symptoms together with various “talking based” therapies aimed at helping patients cope better with their symptoms. Physiotherapy aimed at improving functioning through physical interventions is commonly used
This approach works for some patients but in my experience as a GP, there are a fair number who are not helped by this approach. For these individuals, we need a different paradigm.
The origins of Stress Illness – Dr John E Sarno MD
Dr Sarno MD was Professor of Rehabilitation Medicine at the New York University School of Medicine. Back in the 1970’s, he became curious about why the conventional approaches for chronic pain were not more successful. He noticed that 88% of his patients with pain were also experiencing symptoms that were commonly held to be caused or exacerbated by stress. These included medical conditions such as heartburn, migraines, IBS and tension headaches. These conditions were “emotionally induced” in that strong emotions in the body were triggering physical symptoms. The concept of an emotion triggering a physical symptom in the body is not an unusual one – think of, for example, the physiology of a erection during sex or blushing when we are embarrassed.
Dr Sarno hypothesised that chronic pain had the same underlying cause and over the years developed his own unique programme of recovery from chronic pain. His results were exceptional for many conditions that had previously been deemed incurable. He coined the term Tension Myositis Syndrome which later became Tension Myoneural Syndrome (TMS) to encompass the involvement of nerves in the process. SIRPA founder, Georgie Oldfield travelled to the US to meet him in 2007 and was inspired to create SIRPA here in the UK. This work continues to develop at a hugely exciting pace and there is now a network of SIRPA practitioners working throughout the UK and Ireland.
The SIRPA Philosophy
SIRPA offers a revolutionary alternative to the traditional medical chronic pain management approach. Traditionally Western medicine splits the body and the mind into two and maintains that they are different systems that have little connection between them. This has resulted in different specialities of medicine having different responsibilities for different parts of the body.
Traditionally problems that could be treated using medication or surgery were the responsibility of physicians and surgeons. Problems involving the emotions or psychological problems were the domains of psychiatrists and psychologists. We now recognise that the mind-body split is not an accurate representation of how the body works. The whole body works together as an integrated whole and in fact emotions are felt in the body as sensations rather than in the mind. The huge vagus nerve in humans runs from the body into the brain and carries nerve impulses in both directions between these two sites. It simply doesn’t make sense to split the body and mind into two!
The SIRPA approach maintains that chronic pain and indeed many other medical conditions such as migraine and IBS are driven by strong unconscious emotions arising from the body-mind. These very often have their origins in past traumas that we have experienced earlier in our lives. We many not consciously remember these events or even regard them as significant. Stressful events experienced in childhood may seem insignificant when viewed through an adult’s eyes but to a child an event such as an operation or a parental illness can be interpreted as a very real threat to life.
We tend to find that many TMS symptoms are experienced by people with certain personality characteristics. These people tend to be highly conscientious, good people who want to be liked and seen as good and reliable. They may be highly successful, with perfectionist traits but struggling with medically unexplained back pain or neck pain. These personality characteristics are highly sought after in society but can lead to huge reservoirs of unexpressed anger and fear. These may be people who feel that they run around after everyone else but have little time for themselves. They may fear expressions their emotions (or may not even know what they feel) but are struggling with physical bodily symptoms.
An essential part of the SIRPA philosophy is that anything suspicious of a disease process needs to have been ruled out before beginning the SIRPA programme. For example if a person was experiencing severe headaches it would be appropriate for them to have a full medical assessment so that we can be confident that the symptoms are not being caused by a physical problem in the brain such as a tumour. This may involve scans such as an MRI, blood tests and a neurological review by a specialist. It’s important to emphasise that the symptoms experienced by people with TMS are REAL. They are not made up or imaginary or “all in your head”. This is something that thankfully the medical profession are becoming more aware of and it is our hope that this will continue to improve as awareness of this work grows.
Dr Howard Schubiner MD is a internal medicine and paediatrics specialist in Southfield, Michigan. He is a recognised expert in Mind-Body medicine and has worked extensively with Dr Sarno and Georgie Oldfield in this field. He has produced a very informative video explaining the difference between the pain and symptoms of TMS and the pain of symptoms which are caused by disease processes. This is available on YouTube with the link to the video given below (3). Typically pain (or any symptom) can be caused by actual tissue damage e.g. a broken leg will cause pain. Doctors are generally very good at finding the cause of this type of pain through medical tests or surgery.
There is another cause of pain which is caused by “nerve pathways” being activated (the mechanism of TMS/stress illness). These are collections of nerves between the body and brain which fire in repeated patterns to certain triggers Here the organs and tissues where the pain is perceived to be originating from may be completely normal. There are “pain” nerve pathways and “no pain” pathways. “Pain” pathways are activated by fear and stress and other triggers. “No pain” pathways are activated by confidence, knowledge of what is happening and a sense of personal power. This is why a knowledge of stress illness and a belief that they can recover are so powerful in an individual’s recovery. Recovery from TMS/stress illness involves helping the individual turn off these “pain” pathways so that their symptoms disappear. This is achieved through a combination of knowledge, behavioural work and emotional work and is the basis of the SIRPA programme. Dr Schubiner explains this beautifully in the video and I highly recommend that you watch it to gain a greater understanding of this concept.
What can I expect from my session with a SIRPA practitioner?
Initially we will chat with you over the phone or face to face in an introductory session. This will be to find out more about you and what you hope to achieve through our work together. We also need to check if the programme is suitable for you at this moment in time. It may be that you have physical symptoms that have not been discussed with your Doctor and if this is case we would require that you do this before starting the programme. If you have a diagnosed mental health condition we would also ask that you discuss the suitability of the SIRPA programme with your doctor or psychiatrist. We would also recommend that you read Georgie Oldfield’s book “Chronic Pain: Your Key to Recovery” which is available on Kindle and in paperback (4).
This book not a prerequisite for starting the programme but we have found that it gives an excellent overview of the concepts of stress illness. For many people with TMS symptoms, this book is an “epiphany moment” when they can actually “see” themselves in the case studies and the descriptions of typical TMS symptoms. This is an important part of the recovery process.
Once we have concluded that the programme is suitable, you will be sent an assessment questionnaire to complete which is a detailed history of your symptoms and also your personal history from childhood. This can be an emotional but very freeing process. All information in the questionnaire will be kept strictly confidential and will be used for the basis for our work together. Once we have the completed questionnaire, we will then schedule our face to face meetings where will go through the personal history together looking for any patterns of symptoms and their relationship to any life stresses. Then based on the information from the history, together we will work together to help you resolve and integrate these stresses from your life. This may involve a number of techniques such as unsent letter writing, expressive writing and mindfulness work as well as other techniques that have been shown to help in the recovery from stress related symptoms.
Typically we will work together until you feel that you have gained enough knowledge and empowerment to more forward with your life. This will usually result in the reduction or (most commonly) the elimination of your symptoms and a greater confidence in your ability to live life. There is no average number of sessions and everyone is different and so the programme is as individual as you are. There is also a SIRPA online programme which can be worked through from home and details can be found on the SIRPA website link detailed below (5).
SIRPA practitioners gain their qualification though a quality assured training course followed by a rigorous case study based assessment where they are required to demonstrate that they have the necessary skills to guide a client through the recovery process. They then have to show that they are up to date in the field through participation in continuing professional development (CPD). SIRPA also operates a system of clinical supervision run by Georgie Oldfield and the organisation has the support and endorsement of experts in the Mind-Body field such as Dr Schubiner and Dr Dave Clarke MD who is Assistant Professor of Gastroenterology at Oregon Health and Science University. This system of certification and support ensures that SIRPA practitioners have the necessary skills and expertise to support and guide you in your recovery journey.
(These are real cases published with the permission of the individuals concerned – names have been changed to protect their confidentially)
S (34 year old female)
Anxiety and migraines
“I was experiencing really severe migraines with anxiety that were affecting my ability to complete my university work. All my medical tests and scans had been normal. I was really struggling and had no idea how to help myself. I turned to the SIRPA programme out of desperation. After I started the program, I realised that I had a number of TMS personality traits. I was a perfectionist and a people pleaser. I had very little time for myself and was constantly bowing to the demands of my father back in my home country. I was actually very angry towards him but didn’t feel I could express it. Once I worked through this anger and set boundaries with him and took time out to relax, my symptoms reduced dramatically. I felt much calmer and today if I get a migraine (it’s rare!) I take it as an instruction from my body that I need to relax. I am so much happier – thank you!”
D (47 year old male)
Back and neck pain
“This programme has changed my life. I had severe back and neck pain which the doctors couldn’t find a cause for. I was taking strong medication and was very limited in my ability to look after my kids and socialise with my friends. I discovered the SIRPA programme and was at the stage where I would try anything. I wasn’t at all in touch with my emotions – typical man I suppose! I realised through my work that I was very angry about several things that had happened in my life. My work redundancy and a family argument were the two main culprits. Expressive writing really helped me get in touch with my emotions. The most amazing thing was that my back and neck pain has almost completely gone. I’m really grateful for this programme.”
My story Dr Lizzie Croton
I’ve been a GP since 2008. I see a number of patients with chronic pain and also other TMS related conditions. I was used to treating these patients with medication but deep down I was deeply dissatisfied that many did not recover or feel any better. Many suffered from the side effects of these drugs and seemed to get worse. Some improved and I was deeply curious as to why this was the case. Similarly many people would have X-rays for various conditions and incidental findings such as arthritis would be found. Many of these patients had no pain whereas some people with mild arthritis on X-ray would have severe pain. Why was this so? It seemed deeply inconsistent. Now Dr Schubiner’s “nerve pathway” explanation helps us to understand why this is happening.
I was chatting through my frustrations with a fellow doctor one day and she recommended Dr Sarno’s book “The Divided Mind – The Epidemic of Mindbody Disorders”(6). She said that it had helped her to understand what was likely to be happening with some of her patients. I ordered it that day and must have read the whole book cover to cover in under a day. It made so much sense and I wanted to find out if anyone was doing this type of work in the UK. I subsequently contacted Dr Sopher in the US who is another specialist in Mind-Body medicine who has worked with Dr Sarno. He put me in touch with Georgie Oldfield and SIRPA. I have found my SIRPA work a fascinating and rewarding aspect of my medical work and I’m really excited to be part of the ongoing development of this field in the UK.
1. Donaldson L. Annual report of the Chief Medical Officer for 2008. London Department of Health 2009. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/AnnualReports/DH_096206
2. Merskey H, Bogduk N, editors. Classification of chronic pain. 2nd Rev ed. Seattle: IASP Press; 1994 (Rev 2011-2). www.iasp-pain.org/PublicationsNews/Content.aspx?ItemNumber=1673&navItemNumber=677