Mindfulness for Pain
MindLetter post written by Dr Kitty Wheater.
Hello from a quiet, green June morning. The MindLetter this week comes a little late, or a little early, depending on how you look at it: it's a bumper edition on Mindfulness for Pain, following on from my workshop last week.
Pain, particularly chronic pain, is something we see a lot in the Chaplaincy. My workshop materials were recorded, and will be made available as a toolkit on the Mindfulness website shortly. Meanwhile, feel free to pass on this MindLetter to those you think would find it useful; it too will make its way to the MindLetter webpage soon. I hope it helps.
Mindfulness for Pain
About ten years ago, I met Vidyamala Burch at a mindfulness conference. Vidyamala is a softly-spoken New Zealander who founded Breathworks, a mindfulness-based programme for living well with pain and illness, over twenty years ago in the north of England. She lives with chronic pain, and is also in a wheelchair, after two spinal injuries in car accidents as a young woman.
I learned two lessons about chronic pain that day. The first was from watching Vidyamala manage her own pain. Every twenty minutes, a timer would go off, and Vidyamala would stand up for a short time, because this helped alleviate her pain. Sometimes, if in mid-conversation, she might wait a moment or two before she shifted; but when she stood up and sat down, she did so calmly, without anxiety, and without apology. Her experience had taught her what she needed to know; she trusted that knowledge, and trusted herself.
The second lesson was contained in a short practice that she guided. ‘Notice where in the body feels pleasant,’ she counselled. ‘It could be something very small. The sensations at the backs of the knees, or the contact between the eyelids.’ I had never turned to my own body in this way and deliberately looked for small, ordinary places of ease and comfort. Indeed, when I teach this practice, students and staff often say that it had never occurred to them to look, either.
Because here is the thing about pain: it is evolutionarily designed to loom bigger and bolder than anything else in your perception, whatever else the latter might contain. Our minds are primed to hook onto whatever has a flavour of the unpleasant or difficult, and nothing is more unpleasant or difficult than pain. When we hook on, the field of awareness narrows, so that pain fills it up entirely. In the moment, it feels as if nothing else exists. Chronic pain, when we experience pain constantly over a long period of time, can slowly but surely come to write the story of our lives. This is particularly the case if it is traumatic in origin. Perception and mind reorient around pain – what caused it, how bad it is, what to do about it, and whether it will ever go away.
Because evolution has primed every attentive neuron in the nervous system to zero in upon pain, our reaction to pain follows predictable lines. This is the good news: messy, frightening, depressing, and frustrating though pain is, we can start to see clearly how our experience of it plays out through the nervous system reactions of fight, flight, and freeze.
Fight, flight, and freeze: how the nervous system reacts to pain
We fight pain through fixation. Internally, this will take the form of rumination: worrying and planning. You may notice recurring fixated thoughts: ‘I don’t want this,’ ‘why is this happening’, ‘how can I make this stop,’ and ‘what does this mean’. Externally, you may find yourself running from one potential ‘cure’ to the next; you may spend hours on the internet, researching pain, reading about pain, trouble-shooting pain, bouncing the problem off anyone who might listen, trying one hot bath or miracle stretch or massage ball after the other.
The ‘fight’ reaction is very understandable from an evolutionary point of view, because we experience pain as a threat – particularly so because it is right inside us. If there were a lion or a bear attached to your arm or leg or head, you would need to fight it, and to do so very quickly. This is why the ‘fight’ reaction is so powerful, and so involuntary. If you experience pain in particularly vulnerable parts of the body, such as the belly, throat, face, or genitals, this will be all the more so. Your nervous system is doing exactly what it is designed to do: sounding the alarm, with persistence and dedication.
This is entirely appropriate with acute pain; we need to figure out what to do, and fast. But with chronic pain, it comes with costs. The major cost of the fight response is that it triggers mind-body feedback loops around pain that often amplify it. When we worry and panic about a place in the body, the nervous system directs all attentional and energetic resources to that place. Physical tension and bracing mount up around the pain, adding layers of dense tissue, thereby preventing the natural diffusion of pain, and incurring further discomfort. The more we panic, the more pain we experience; it may increase, radiate through the body, or both. In increasing desperation, we will almost certainly jump next into flight mode.
We flee pain through avoidance and denial. We avoid anything that we fear will trigger the pain: movement, stillness, particular situations. Again, with acute pain this can be perfectly appropriate – but over time it can become a pattern. We may even avoid things that are supposed to ‘help’, such as physio or exercise, because engaging in it can activate pain, and remind us that it is still there. We often engage in numbing, whether through the obvious candidates – pills, alcohol – or the sneakier, dopamine-fuelled ones: work, food, sex, video games, Facebook. A healthy dose of good TV, or a delicious meal, can be a huge morale booster when pain flares up – but watch for psychological fixation, as this indicates that you may be in flight mode. In denial, which is slightly different from avoidance, we tend to ‘push through’ pain, forcing ourselves through exercise, work, or other commitments.
Fleeing, like fighting, makes perfect nervous system sense. If we can flee, why wouldn’t we? But the problem with chronic pain is that it is in us, not outside us. When we pause to rest from our flight, the pain is often still there. Moreover, because we have tuned out from the direct experience of pain, we may have pushed ourselves past our current physical limits, incurring pain flare-ups. These are themselves frightening and disorientating, and may send us right back into fight mode. Many of us oscillate between the two interminably, but endless cycles of fight and flight may actually tip us into the nastiest of the nervous system reactions to pain: freeze.
We freeze through dissociation and despair. In pain the body feels like a profoundly unsafe place to be, and so we leave it. In this state, you will find that you are actually less aware of the direct physical experience of pain, but you are highly vulnerable to its emotional load. Here, you may notice despairing thoughts like ‘my life will always be like this’, ‘I can’t do this any more,’ and ‘this is my fault’. This is the nervous system in shutdown; it is most common with traumatic pain, caused by sudden-onset illness, accident, or injury, and is also a natural response to the cumulative trauma of cycling through fight and flight with any form of chronic pain.
The main cost of freeze mode is that mental health suffers, spiralling from fear and anxiety through to hopelessness, depression, and self-blame. But critically there is another, less obvious cost: because our physical experience of pain has been hijacked by its story, we may no longer notice moments or places in the body that we are not in pain. Here, the mind-body takeover of pain is complete. It’s a horrible place to be. The good news? It’s not the end of the road.
Mindfulness for pain
The fight, flight, and freeze reactions to pain are all based on something very simple: the nervous system’s perception of pain as a threat, on equal footing with bear, lion or tiger. But chronic pain is not a predator. It is a messenger, the body’s way of speaking. ‘Something’s happening here,’ it’s saying; ‘I think you need to know.’ In the face of strong evolutionary impulses to shut down, run away from, or block out those messages, mindfulness for pain means practising a gentle, deliberate, and curious listening. When we listen, and stay curious about what we find, this is when we can begin to respond to pain in ways that work with it as nervous system information, rather than as source of threat.
Here are my ‘three Rs’ for working with pain: Resource, Recognise, and Respond.
In a state of pain takeover, the first step is to begin to broaden perception so that other places in bodily experience – those of neutrality, even pleasance – can become resources and oases of safety for the attention. In pain, the body can become a place that we no longer go; tuning into places of respite and comfort in the body helps us begin to befriend it. We need this, ultimately, to process pain through embodied experience, rather than conceptual overlay.
You can try my 9 minute Resourcing for Pain practice, here. In this practice, you’ll begin to tune into places in the body that offer grounding, steadiness, and support for the attention. The soles of the feet, and sit-bones on the chair, are often helpful. Allow your awareness to begin to settle and pool in these places; if focus is drawn away to pain, or thoughts, simply acknowledge where it’s gone, and gently bring it back.
Then, begin to notice where there might be other places in the body that feel pleasant or neutral. This doesn’t have to be very big; just a slight sense of comfort, ease, or warmth. It could be as simple as the contact between the eyelids, or the weight of the hands in the lap. Spend a couple of minutes here, tuning in, and exploring.
For a longer, more in-depth exploration, try this 25 minute Mindfulness of What’s Pleasant practice.
The physical experience of pain is embedded in perception and memory. This means that when we are fighting, fleeing, or freezing, we are not actually reacting to that single experience of pain just as it is: we are experiencing every instance of pain we have ever had. This is especially difficult with chronic pain, where experiences of pain sediment into each other over a long period of time. ‘Recognising’ pain, by contrast, means noticing what is present in the moment right now, just as it is.
For this part of the practice, once you have resourced the awareness, check in with your experience in the present moment. What sensations do you notice? What thoughts, and what emotions?
If there is pain, see if you can notice with curiosity where it is in the body, and what are its qualities. Is it tingling, aching, or stabbing? Notice the thoughts that come up with it. They could be thoughts of not liking or fixing; notice if there are avoidant thoughts, where the mind jumps immediately to something distracting. Finally, notice what emotions come up with the sensations, and name them internally: there may be frustration, irritation, or fear.
This three-part structure for Recognising pain – sensations, thoughts, and emotions – is revealing. It can show us what kind of pain reaction we are having, whether fight, flight, or freeze. And it can help us see exactly what our pain is like in the present moment. Often, when I teach this practice, people will notice that the direct physical sensations of pain are not as bad as the fears or judgements that the mind brings to it; sometimes what we will notice is that actually, in this moment, we are not in pain at all.
If pain levels are very high, we might stay with ‘recognising’ for just a few moments, before returning to resourcing. You can also cycle between recognising and resourcing to help you explore what’s present bit by bit, grounded by a safe place in the body.
After resourcing and recognising, we move to Responding. Holding the direct physical sensations of pain gently in awareness, you might quietly voice the question: ‘what does this need right now?’
Drop it into the mind almost like dropping a pebble into a pond, and notice what comes back. Often, because this inquiry is grounded in present-moment experience, the needed response is something very small and simple: a particular gentle movement, hot drink, or comforting stretch. This may be quite different from the kind of reaction that comes out of the default fight, flight or freeze.
On a day when pain is intense, and there is a lot of reactivity, you might do the Resourcing practice followed by this 9-minute Recognising and Responding, a few times during the day. With practice, you can also take yourself through the three Rs. This can take just a few minutes, and help offer comfort and clarity in the midst of pain.
Physical pain is among the most challenging experiences we have, because it is both potent and confusingly non-linear. As we begin to down-regulate, pain can even increase temporarily. This is because the numbing and bracing effects of the fight response are beginning to dissolve, meaning that pain that has been ‘backed-up’ comes through. This is very normal, but often prompts panic, trapping us in further cycles of bracing and discomfort. Gently resourcing ourselves in the midst of pain, befriending it, and allowing it to move through, are wise responses that come with practice and experience. To take this exploration further, this 28 minute practice offers a spacious awareness of pain and discomfort; if you have chronic pain, you might try it a few times a week for a couple of weeks, and see what you notice.
With time, clear and gentle practices, and good support, we can discover something that might have surprised our fighting, fleeing, and freezing self: that it is possible to live with pain; and that it is possible even, like Vidyamala, to live very well.
Wishing you nourishment and grounding, this week, whatever aches and pains you carry.