The Tao of Chronic Pain
Flower Veil Jellyfish by Jenny Brown
Suffering is Optional. Here’s how to find the teacher inside.
By the time Jolene came to see me at the pain clinic at Stanford, she was no longer able to do much of anything. She had been rear-ended by a truck while stopped at a traffic light, and was sure the neck and back pain would subside after a few weeks and she would return to work. But it didn’t go that way. Her pain progressed and she was ultimately forced to leave her high-powered career. Then, for about a year, she forced herself to maintain her role as family caregiver and homemaker. But in the past few months her body decided that even this plan was no longer viable: She wasn’t able to brute-force herself through things anymore. Doing fewer and fewer tasks around the home and spending more time recovering from pain put her in an existential crisis: If she didn’t have a career and wasn’t a good mother and wife, who was she?
“I feel like I’m letting my family down,” she said, tears streaming down her face. “I’m not there for my kids, I’m missing important events, and I feel guilty because I’ve become the burden.”
Of course the stress was terrible and it was feeding back into her pain—making it worse. Her doctor gave her high doses of opioids to dial down the pain, but the meds made her mentally foggy. Even with such powerful painkillers, she was anxious a lot, fearing the next spike of pain. Her husband was concerned about the medication, and so was she. She didn’t want to take pills, but she couldn’t live with the pain.
Jolene represents a kind of nightmare scenario that I see all too often at the pain clinic. My job as a psychologist is not to cure such pain—some pain doesn’t go away. Instead, like the famous proverb attributed to Buddha—pain is inevitable, suffering is optional—my job is to reduce suffering. In my practice I explore what might be called the Tao of pain—the way of mastering pain—that is deeply rooted in Eastern philosophy and spirituality. Often, my work involves teaching people to surrender to the present moment and all that it encompasses—with nonjudgment—allowing patients to begin to embody acceptance of what is rather than to fight futilely against themselves.
Many of my patients need to learn that to resist is to feed the very thing they are resisting. They will never “conquer their pain.” With the acceptance of pain in this moment, they are freed to begin focusing on the actions that will provide comfort and self-care, and therefore reduce their suffering—sometimes dramatically. The training can prevent an overreliance on medical interventions and the health problems related to medications. Such understanding and practices can also help prevent pain from spiraling out of control in the first place.
What Is Pain?
Pain is a catchall term for an uncomfortable if not noxious experience. Examples of emotional pain are crushing sadness, depression, and grief. Examples of painful physical experiences include torturous stabbing or burning pain. There is so much overlap and shared neurobiology between physical and emotional pain that rendering distinctions between the two can be trivial. I became a pain psychologist in part because I learned that lesson the hard way. (See the box “The Making of a Pain Psychologist.”)
Though exceptions apply, humans are largely bio-behaviorally hardwired to escape pain, regardless of its form. In other words, pain is a warning meant to promote survival. In part, physical pain works through triggering emotional responses—fear, anxiety, and anger—all of which motivate action to escape from the source of pain and potentially from physical harm. A child who is painfully attacked by a cat will quickly learn to escape the cat, and to fear and perhaps to hate cats. Humans are hardwired to behave in ways that foster escape, avoidance of pain, and safety.
Like the famous proverb attributed to Buddha— pain is inevitable, suffering is optional—my job is to reduce suffering.
Persistent or chronic pain is different because it no longer has survival value. Chronic pain is internally generated, and as such there is no external threat or potential harm to run away from. However, the body and the nervous system do not understand this distinction. To the body and the nervous system, pain is pain. Stress responses and neurobiological processes to facilitate escape are set in motion, despite the fact that one cannot escape a migraine or back pain in the same way that one can remove a hand from a hot stove. The common pain-related emotions—fear, anxiety, and anger—fuel more pain, despair, and suffering.
A critical part of the solution is simple but far from easy, because it runs counter to our hardwired biology: It is to be in the midst of pain—with nonreactivity and nonjudgment, and with compassion for self and others.
Pain as a Teacher
Nobody wishes to have chronic pain. Like many major diseases and health problems, chronic pain can alter the trajectory of one’s life course and perceived destiny. Chronic pain can greatly limit engagement in activities, relationships, and one’s roles and responsibilities to the point that it threatens one’s identity. Feelings of injustice may set in. Anger directed at oneself and one’s body may arise as people feel their body has failed them. Feelings of betrayal or abandonment may also arise and be directed toward one’s body, others, or even God. While such feelings are understandable and can be hard to avoid, they make the problem worse.
Less appreciated—but much more helpful to reduce suffering—is chronic pain’s role as a teacher and an opportunity for personal and spiritual growth. Living with pain limits one’s energetic resources, thereby forcing a reflection on one’s real priorities, life goals, self-concept, and identity. Chronic pain can force individuals to begin giving to themselves—filling their own cup first—so that they may offer others a drink, too. To function maximally and continue to be of service to others, self-care must become a priority.
The cultivation of self-compassion, learning to honor oneself, and making authentic choices that align with one’s deepest desires is holy work. Pain can provide the opportunity to set appropriate limits with others and with oneself; in doing so, right relationships may emerge, and imbalances may be corrected. In this way, pain can be the teacher that shapes behavior toward honoring oneself. In doing so, wisdom is cultivated
In working with Jolene, multiple family stressors came to light. She was doing far too much for the family, mainly out of guilt, and entirely at the expense of herself and her pain. Through our work together Jolene acquired skills to manage her stress, pain, and fear about disappointing others and herself. She learned about the importance of self-care, and set out to do the difficult work to begin saying no to others in her life, in order to save herself.
At first, she was met with some resistance from her husband and daughters, all of whom were used to her doing things for them. In the past, she would have retreated into old, unhelpful patterns of doing for everyone else, thereby fueling her cycles of pain. After working together, she found she was able to challenge some of her old thinking and adopt a longer-range view. “I began to see that setting day-to-day limits with my family was actually an investment in us being able to do more together tomorrow. And, I am more present with them because I’m not suffering like I was.”
As she began doing less for others and focusing more on her daily yoga, walks, relaxation skills, and activity-pacing, her anxiety, stress, and pain improved. She started sleeping better and so felt less tired and painful the next day. She began cutting down on her opioid medication because she was having fewer pain flares. Over time, she found she had more energy and was enjoying things more. “I feel stable and less fragile,” she said. “I still have pain, but I’m no longer at the mercy of pain.” She began journaling, discovered an authentic desire to cultivate creativity, and committed time each day to this endeavor. Out of difficult circumstances, through chronic pain management Jolene acquired wisdom about self-compassion, self-care, authentic choices, and empowered living.
The Making of a Pain Psychologist
In my childhood and adolescence I lived with chronic pain, but because it was never addressed medically I somehow never considered it so. When I was 19 the person I was closest to was killed and I was thrown into immense emotional suffering—and my chronic pain became intolerable. One night, fearful of the intensity of my pain, I left my college apartment and took a taxi to the hospital. I hoped that someone could tell me what was wrong and how to fix it, but the tests revealed nothing. The ER doctor sent me home with a bottle of Vicodin. Though I didn’t know it at the time, Vicodin was not a good answer to my problem. Taking such meds is fraught with complications for navigating grief.
After about six months, I decided on my own to stop taking the meds, and I was left with the next big problem: how to deal with my pain. I never considered going to see a pain psychologist, though that would have been an excellent treatment pathway for me. I had to figure out my pain on my own, and while my victories were hard won they came with the invaluable gifts of understanding and wisdom.
After completing my doctoral degree in clinical psychology at CU Boulder, I went to the Tucson Veterans Affairs for my clinical internship. Veterans have a lot of chronic pain, depression, post-traumatic stress disorder, and substance use disorders. I loved working with veterans and chose to pursue advance training at the Johns Hopkins School of Medicine, doing a postdoctoral fellowship that involved researching and treating complex medical problems such as amputation, spinal cord injury, and catastrophic burn. Everyone had some degree of pain. I found I was comfortable being with the suffering of others and enjoyed helping lead people to relief.
I don’t claim to understand every person’s experience of pain; pain is personal and unique to the individual. But I do have a keen awareness of the larger lived experience of ongoing pain in the context of the medical system, and what’s needed to best empower patients to control their own symptoms and relief. Twenty-five years later, this issue of patient empowerment for pain self-management is vitally important. The solution is not just about educating patients: We need to educate physicians, psychologists, health care clinicians, and even the broader culture. By doing so, we can mitigate risks, treat pain better, and help people get on to doing the important work of their lives.
Getting to Empowered Relief
Step 1. Seek Pain education
The International Association for the Study of Pain defines pain as a negative sensory and emotional experience. In other words, psychology is built into the definition of pain, though it is rarely treated as such. What that means in practice is that psychological factors will undermine the effectiveness of opioids or surgery. To reduce your need for medication, you need to treat the full definition of your pain with a comprehensive assessment, pain education, an integrative treatment approach, and a focus on opioid-sparing strategies. Ultimately, treatment should emphasize self-management.
Step 2. Calm your nervous system daily
Pain puts your nervous system on high alert. By using techniques to calm your nervous system each day you can begin to train your nervous system—brain and spinal cord—away from pain and toward comfort and relief. The goal is to engage the parasympathetic nervous system. By doing so, heart rate, respiratory rate, blood pressure, muscle tension, and mental stress are reduced. Blood vessels dilate, increasing blood flow to the extremities.
Functional magnetic resonance imaging studies show that when calming strategies are used, pain processing in the brain is reduced. Effective calming techniques include diaphragmatic breathing, progressive muscle relaxation, gentle yoga, and mindful meditation. Exercise has also been shown to boost the healing and calming relaxation response.
Step 3. Find freedom with pain psychology treatment
Focusing on pain by catastrophiz-ing, ruminating, or feeling helpless all grow the pain experience in the nervous system. Fortunately, these impacts on the brain are reversible with treatments like pain-CBT.
Cognitive Behavioral Therapy for Pain (pain-CBT) is the gold standard psychological treatment for pain because it has been studied the longest and has the best evidence to support it. Pain-CBT typically includes eight weekly two-hour sessions delivered by a psychologist or skilled mental health professional to individuals or groups. Pain-CBT includes content on pain education; the connection between mood and pain; the connection between thoughts and emotions and pain; activity pacing within the context of pain; addressing maladaptive pain beliefs, such as hurt = harm; reducing pain behaviors; setting appropriate activity goals, and gradually increasing activity.
Acceptance and Commitment Therapy (ACT), sometimes called contextual CBT, is a variant of CBT that emphasizes diffusion of distressing thoughts and nonreactivity within the context of encouraging goal-directed behavior toward life pursuits that are most meaningful and central to one’s values. In pain-CBT individuals learn that psychological approaches are unlikely to render them pain-free; after all, the underlying medical conditions remain. Through conscious modulation of thoughts, emotions, and daily choices, general self-regulation is enhanced, and control over suffering from pain is gained.
Mindfulness-Based Stress Reduction (MBSR) teaches nonreactivity and nonjudgment to pain and other stimuli, with an awareness and acceptance of the present moment—and has been found to be as effective as Pain-CBT for chronic back pain. The nine-week course is often not covered by insurance and costs about $350.
Compassion Cultivation Training is a nine-week course developed by the Stanford Center for Compassion and Altruism Research and Education (CCARE). The first two classes involve basic instruction in mindfulness meditation. Week 3 involves meditation centered on cultivating feelings of compassion for someone with whom one has or had a close relationship. Weeks 4 and 5 are devoted to cultivating self-compassion, week 6 to compassion for strangers, and week 7 to compassion for difficult people through the recognition of a common humanity. Week 8 involves a “Tonglen” meditation practice, in which participants imagine taking in suffering (either in general or from a specific person) on the in-breath and releasing it on the out-breath. Week 9 includes suggestions for continued integration of compassion practices into one’s daily life. Research we conducted revealed that participants reported significantly reduced pain intensity and anger.
- Breathe2Relax: A free meditation app from the Department of Defense. t2health.dcoe.mil/mediakit/breath2relax-mobile-application
- Headspace: A widely acclaimed guided meditation app available from iTunes. Headspace.com
- “Enhanced Pain Management”: a binaural audio CD and MP3 audiofile; 20-minute relaxation includes diaphragmatic breathing, progressive muscle relaxation, and autogenic training ($6). bullpub.com/catalog/Enhanced-Pain-Management-Binaural-Relaxation-CD
- Less Pain, Fewer Pills: Avoid the dangers of prescription opioids and gain control over chronic pain ©2014 by Beth Darnall PhD. (Includes Enhanced Pain Management Relaxation MP3 audiofile/CD)
- The Opioid-Free Pain Relief Kit ©2016 by Beth Darnall PhD
- The American Chronic Pain Association. theacpa.org
- Pain Toolkit of more than 50 different videos related to self-management of chronic pain. Paintoolkit.org
- “Understanding pain and what to do about it in less than five minutes.” youtube.com/watch?v=RWMKucuejIs