One of the most elusive and difficult conditions to bear and treat is chronic pain. In this article I refer to three forms of chronic pain – physical, emotional/mental and existential/spiritual. These three forms are similar in quality, in that they torture and can lead to despair. They are however dissimilar in distractibility – as you move from the physical to the mental and finally the existential form, it gets easier to find ways of distracting yourself from the pain. In other words, physical chronic pain is the form that is most ‘in your face’, inescapable and hard to find distraction from. In an ironic twist of logic, of the three forms it is therefore also the most efficient teacher of awareness. As you read on, you will therefore see me focus on physical chronic pain.
Pain is radically subjective and therefore invisible to direct observation. Only its ripple effects become visible: a bad mood, unhappiness and possibly dysfunctionality; an inability to cope, facial distortions and lamentation as the expression of suffering. Depending on a person’s attitude towards their chronic pain it can become exhausting to be around them, because one feels so powerless to help. One then tends to withdraw, and the person in pain feels like a burden and also withdraws, which creates social isolation as a secondary problem. Often people with chronic pain are not understood or believed, and sometimes even seen as faking and malingering. In children with chronic pain conditions it can even go so far as to put honest and caring parents into situations, in which they are accused of child abuse and their children taken away by the Children’s Aid Society. Chronic pain is awful, because it is relentless and real, yet elusive, difficult to quantify and difficult to treat.
Pain in general can be seen to be experienced along the two dimensions of how treatment-resistant and chronic it is. The less amenable to treatment it is and the longer it lasts, the less subjectively bearable it is and the more mindfulness training becomes important. This means that without mindfulness chronic untreatable pain is sure to cause despair and disability.
Along this ‘bearability spectrum’ we can categorize pain as a way to help us organize our thinking around the issue of mindfulness. The easiest pain to bear is the short-term one we know to be due to an underlying condition that is transient and treatable, such as the pain of breaking a leg. I will call this category 1 pain. A bit more difficult but still bearable is the longer term pain we know to be due to an underlying condition that is treatable, such as certain back pains (category 2). It gets more difficult when the underlying condition cannot be treated and the only way to get rid of the pain is pain medication or operations (category 3), because these pain treatments tend to be only partially effective and have side effects which negatively impact the quality of life. The most difficult situation is the one where not only the underlying condition is not treatable, but the pain itself is also resistant to treatment (category 4). These cases may sometimes belong to a subsection, in which the pain appears to be untreatable because we know little if at all anything about the underlying condition, the underlying condition is not recognized and missed, or access to treatment is difficult or unavailable. In these cases new medical discoveries, increased social awareness of a disease’s prevalence and increased medical access to treatment can suddenly move the situation into a more bearable category 1, 2 or 3 pain. An example of this would be the Ehlos-Danlos Syndrome (EDS), which has inspired the work of the ILC foundation. However, just because more insight into the disease through research, more social awareness of its existence and more access to treatment has allowed some children to become pain-free more of the time and has significantly improved their lives, does not mean that they cease to struggle with the impact of this devastating illness and some side effects of treatment.
Pain has a complex physiology that spans a whole spectrum of bodily structures and hormones. Let this paragraph wash over you like a pleasantly warm wave of Caribbean ocean water and don’t focus on details. Involved in the production of pain are peripheral receptors everywhere in the body that create signals traveling along attached nerve fibers, which converge in the spinal cord and ascend through the brainstem, the limbic system and the cortex all the way to the most evolved of all brain parts, the master integrator of the whole organism called the ‘medial prefrontal cortex’ (MPC). At every level along the way multiple parallel interactions and feedback loops between different brain centres and the body participate in the processing of pain and the unleashing of biobehavioral responses that attempt to return the organism back to safety and health. Engaged are not only the neurons of the nervous system with its neurotransmitters (Serotonin, Oxytocin, Acetylcholine, Norepinephrine, Opiates, Dopamine, Histamine – just to name a few), but also the hormonal system from brain to body, including the hypothalamus, pituitary and adrenal glands. Among many other hormones they secret Cortisol that affects the whole body, including blood pressure, blood glucose, the immune system, the whole metabolic energy system and the muscular-skeletal system. The glia cells in the brain (outnumbering the neurons by 5-10 times!) as well as the Nitrous Oxide system in the body are also involved in complex ways we are only just beginning to understand.
With chronic pain the organism’s attempts to heal often fail and a vicious cycle ensues. The very ways the organism tries to ‘get rid’ of pain in fact only serve to boost defensive processes that increase tension and further worsen the pain. Pain causes fight, flight and freeze survival responses. The person tenses up as a consequence of the constant barrage of suffering that feels like torture. Distraction is part of such defensive survival responses and often seems to be an effective way of making the pain more bearable, but in the long run the exact opposite happens. The tensions created by avoidance behaviors make the pain only worse as they block the organism’s healing potential. As the person becomes increasingly mobilized in an attempt at avoiding increasing pain, the organism gets weakened and stiffened, which only increases the pain further. This is a vicious cycle largely driven by our inbred autopilot reactivity honed over many years of life. In other words, the vicious cycle of chronic pain is nourished by a restricted sense of self-awareness.
What you need to take away from this are just three fundamental principles:
1. Pain is NOT the sensations from receptors in the body or the nerve impulses traveling up the neurons all the way to the cortex. Let me first say it in scientific terms: Pain is an emergent state of embodied self-awareness across the entire neural networks, and it is a re-representation of all the earlier processes of information. In plain language this means that pain is a subjective experience or a state of awareness that arises from the totality of all those nerve impulses across the whole body, but is not those nerve impulses themselves. In other words, pain is not a concrete thing, but a subjective state of self-awareness.
2. The MPC (see above) gives us the ability to modify our states of self-awareness. In the case of mindfulness training, we modify our state of self-awareness from being defined and restricted by autopilot reactivity into the direction of greater presence, which includes more openness to the totality of our human experiences, more acceptance of what is whether we like it or not and more curiosity towards all the ways we construct our reality. Being mindful is thus an expanded state of self-awareness, which is incompatible with autopilot reactivity. It is now hugely interesting to know, but also quite logical, that the mindful state of self-awareness is largely incompatible with the restricted, pain-filled state of self-awareness, since suffering from chronic pain is mostly due to autopilot reactivity. By altering our state of self-awareness we can alter and even extinguish the experience of pain. This means that body receptors may feed the same input signals to the brain like before, but how we experience it all and emotionally relate to it can be so permanently changed that the experience of pain significantly decreases and sometimes even vanishes.
3. Because pain is a state of self-awareness, the issue of awareness is key. Awareness is what gives us the space and freedom of choice. This leads to a paradox: The only way out is the way through. In order to liberate ourselves from the suffering created by pain, the reflex of trying to get away and distract from the pain does not work. Instead, we have to learn to dive right back into the pain and the body, and attend to the full experience of it all in embodied self-awareness. You now probably wonder what ‘embodied self-awareness’ is?
Embodied self-awareness has to be distinguished from conceptual self-awareness (Alan Fogel, ‘Body Sense’). Most people live most of their lives trapped in conceptual self-awareness. This is a more precise way of saying that we live in our heads, caught up in the train of our thoughts we deeply believe in. You are likely quite familiar with the experience of ‘having a pain in your chest’ and being flooded with thoughts telling you that you …. probably have a heart attack / which may kill you / you are too young to die / what a pity / you won’t see your grandchildren / when did you last review your will? / you wanted to travel to Borneo before dying / had you only taken more time off 10 years ago when you were in good health / what a mess / you don’t want to leave your loved ones / how are they going to cope without you? / you were just in the middle of renovating your cottage and now what will happen? / is the doctor going to be able to save you? / maybe it is not a heart attack, but a lung cancer / if so, could be an early stage / you smoked until 15 years ago / etc. etc. etc. These thoughts completely envelop you and define your sense of self. They are concepts created in the cortex, which is why the resulting state of self-awareness is called ‘conceptual’. Without being grounded in embodied self-awareness conceptual self-awareness is extremely limiting and stress-inducing when it stands alone (as it does most of the time for most people). Needless to say, this thought world you are entrapped by causes huge stress, even though it seems to you that all you are doing is problem-solve in order to get out of this situation. You are actually not problem-solving that much at all, but mostly ruminating and getting in the way of real healing.
Embodied self-awareness is very different. You would experience the sensations in your chest in great detail: 3-dimensional size and shape of the sensations; their quality (knifing, burning, searing, throbbing, compressing, etc.); their intensity and the way they change from moment to moment; how far they reach and how they transition into other sensations in the shoulders, the abdomen, the neck etc.; you would differentiate these sensations from those that accompany emotions such as anxiety, sadness, regrets etc.; you would notice the barrage of thoughts and how they threaten to take over, yet you would let them unfold in the background and continue to stay rooted in your body. In embodied self-awareness you would allow the organism to be open to the full spectrum of energy and reality without undue interference, thus maximizing its own healing potential. Once seen by the doctor you would eventually find out that you just had a ….. panic attack, and that all your catastrophic thoughts, so well-disguised as rational problem-solving ones you so deeply believed in, were just that – thoughts, and not reality. In short, conceptual self-awareness is limiting and toxic when not embedded in embodied self-awareness, and embodied self-awareness is the royal road to mindful self-awareness.
The ILC foundation is rightly so involved in helping children with chronic pain by addressing all angles of pain management. This includes spear-heading research, providing access to treatment, raising awareness of the problem, developing a residential treatment program, and coordinating an encompassing approach to these children’s plight including medication, surgical interventions, familial support, parent involvement, psychological interventions and social accommodations. We could say this: One of these many treatment facets is mindfulness training, both for children and their parents, so that they can all learn to develop the all-important state of embodied self-awareness that is fundamental to mindfulness and so important for healing. We can however also say this: Underlying all problem-solving about and all treatment approaches to chronic pain and illness in general lies a fundamental choice between staying within the limits of what can be done, and opening the gates widely to how our state of being (self-awareness) can so immeasurably enrich and enhance what can be done. This is the choice between staying on autopilot or moving into mindfulness, which astonishingly is often also the choice between no or only slight pain improvement and painlessness.
Before I get to the core issue of mindfulness and pain in this article, let me preempt a frequent misunderstanding that occasionally comes my way. Just because I focus on mindfulness and the aspects of pain management related to it does not mean that I am against medications, operations or any other approaches that help people cope with pain. If competently used with discernment, they are all very worthwhile and part of an encompassing approach to pain. All I am doing here is focus on what I specialize in as people come to me for help with chronic pain. So let’s zero in on the core issue of mindfulness and chronic pain.
Some medical practitioners are sometimes so overwhelmed by their patients’ demand for relief and so desperate to offer something, that treatments are offered (often surgeries) which at best do not improve the situation, at worst make it significantly worse with each further intervention. When the underlying reason for the pain is untreatable, the focus becomes the pain itself, and patients often end up walking around with a whole pharmacy of medications that leaves them drugged, sluggish and too tired to function – often with limited results. So then comes the million-dollar question: What if nothing more can be done? What if what has been done so far helps, but you are still left with substantial impediments to a good quality of life because treatments have side effects or because they only partly work? What if pain medication does not work or you don’t tolerate it, operations only make things worse and are not an option, and your specialists and medical practitioners politely distance themselves and give up on you, because there is just nothing else they can offer? What if this is as good (or as bad) as it seems to ever get? What if (to put this question into a completely different context) you cannot change your circumstances, the way you cannot change the circumstance of (taxes and) your mortality?
When I sit with some of my patients referred to me by pain clinics and hear their tragic stories, I can sense the emotional relief I represent for the health practitioners who send these patients to me. It is as if they were saying to themselves and their patients: “There is nothing else I can offer you – just go and see Dr. T and he’ll do something with you.” So here we then sit together, these suffering human beings full of agony and despair, and I, receptacle of these patients’ projected last hope, bearing my own life’s suffering as we all do, as limited in my knowledge and my ability to offer relief as both my patients and colleagues, having nothing else to offer but my presence. But presence is so unknown to most people. For some patients coming to see me represents the last struggle to hope for something we ‘can do’, and when they realize that even with me there is ‘nothing we can do’, I can see their final disappointment on their faces, the last hope having just vanished, as if I had just given a dying dog the last kick that sends it over the edge, and they sink into resignation and giving up. Some patients are in this state already the moment they walk through the door into my office. Paradoxically, it is exactly in this final letting go, in this final surrender to impotence on both our parts, patient and healer, that something radically and completely new arises we call presence.
In fact, this is when we begin to explore the difference between resignation and surrender, impotence and getting out of one’s own way, ignorance and unknowing. Resignation, impotence and ignorance are states of defeat at the end of the line of what can be done. Surrender, getting out of one’s own way and unknowing are states of vulnerability at the core of the journey to Being. In this moment of transition from doing to being it begins to dawn to my patients that the way to healing is not the way of doing more, but the way ofbeing differently, and this journey towards greater Being involves exactly the opposite of doing, let alone doing more – it involves learning to undo and to embrace not knowing in order to make space for something completely new we call wisdom. What is astonishing is to discover over months and years of practice and training in this direction how chronic pain changes, morphs, decreases and eventually even disappears, when we have allowed ourselves to move through paths and regions of Being and Reality that were totally unexpected and unfathomable. If this sounds like voodoo to you, I have good news for you: We are nowadays in a position to scientifically show and explain why mindfulness and ‘dropping into Being’ has such powerfully healing effects on the human organism. Of course, science cannot explain everything, but many people only find access to the seemingly fuzzy world of Being and the goodies that arise from that when they feel reassured by the relative objectivity of scientific insight.
One last word – a word of grounding and realistic perspective: As amazing as the results of mindfulness training can be, as unfathomable as the outcome of practice always is, as hopeful as the journey reveals itself to be, and as profound as the effects of mindfulness are on the body and the mind, please beware: This journey does not follow our rampant contemporary cultural naiveté, our tendency to drama and reality shows, and a general human propensity to seek what is fun, fast and easy. If for a moment you allow me to put it in biological terms, the plasticity (ability to change itself and rewire) of our brain and body is not only real, but also slow as compared to our expectations of instant results. To avail ourselves of the power of brain plasticity we are required to engage in steady, committed, longterm practice, combined with a good dose of courage and patience. The formula for success in this area may not be one you relish to hear: Failure plus hard work = success. To put it simply, mindfulness practices are easy, but it is difficult to become the one who practices. This is why we have to work with a good teacher – your worst enemy is yourself.
One of my most dedicated meditation students who has moved within the span of 4-5 years from being ‘a disabled, walking pharmacy’ just about to consider a third back operation for disabling chronic back pain, to living a very different and much improved life style, put it to me this way in a recent email:
“Imagine that no meds now for over a year and recently I’ve been waking up occasionally with significantly reduced pain. Seems inexplicable but I know the correct response – equanimity, no attachment. A world away from when I was first referred to you. Apart from pain management I have a deeper insight to life and how we should live it. And for that I am very appreciative. And so the journey continues!”
He has many moments of painlessness, and when the pain arises, it is not debilitating. As he puts it, this journey is not just about the pain, but about the fact that by changing our state of self-awareness through mindfulness, the pain turns into our teacher of life’s unfathomable mysteries – and the gifts are immeasurable.
Copyright © 2013 by Dr. Stéphane Treyvaud. All rights reserved.