Thinking About Pain
Treating pain from the vantage point of the mind is an important component of a team approach to pain management. Psychologically-based pain management can be achieved through active participation of the patient and an encouraging health care provider.
Tony, a corrections officer, fell on the job and herniated two lumbar disks. Initial treatments of physical therapy and medications left him still in constant pain with a recommendation for surgical intervention. He surveyed others who had received the prescribed back surgery and, detecting rather poor odds for relief, decided he would rather wait for a promising new disc replacement surgery to become available. Unfortunately, his continued pain and inability to work left him vacillating between depression and anger. His inability to control his anger was tearing his family apart and eventually led him to seek psychological help.
In The Culture of Pain, Morris1 states, “Pain exists only as we perceive it. Shut down the mind and pain too stops.” While shutting off the mind is rarely an option, changing the perception of pain is. As pain management is more widely accepted as an interdisciplinary realm, the role of the psychologist is expanding. Regularly called upon for psychological assessments of the pain patient2 and treatment of pain-related emotional problems, the psychologist can help change the patient’s perception of pain and even bring significant relief.
Tony entered treatment with a chip on his shoulder but more open-minded than some since the therapist came recommended by a fellow officer. Every movement seemed to bring additional pain and he wanted to fight back. He appeared angry at the world. Over several weeks he learned a series of techniques that gave him an increasing sense of control over his pain. At times he could make it disappear, at least temporarily, until the next time he moved. With this “mental first-aid” he was able to reduce the amount of medication upon which he relied. Still, his episodes of rage ate away at his family life.
Morris’ bold statement is based on the fact that pain is ultimately a subjective experience. There is no reliable measure of pain that does not involve asking the patient. A conscious mind is necessary for the experience of pain, therefore, the mind should be actively recruited into the treatment of pain. There are three areas where the mind’s powers can be tapped that have a direct effect on pain: controlling muscle tension, controlling attention, and controlling the interpretation of pain.
The Pain Table
Often patients need some persuasion to overcome their resistance to a psychological approach to pain treatment. Referral to a psychologist is tantamount to being told their pain is all in their head. I use the analogy of the experience of pain being like the top of a table supported by four legs, each one a contributing factor to their pain.
First Leg: Physical Cause
The first leg is the physical cause of the pain signal. This is likely to be the original source of the pain and may be the result of injury, inflammation, or disease. Most medical treatments of pain focus on this leg of the pain table.
Tony’s disc herniations were the source of almost constant pain in his lower back. Any motion that involved his back would send pain signals into his upper back as well as shooting pain down his right leg. A torn meniscus in his right knee caused pain with each step and was agonizing on stairs. He knew this required surgery, but put this procedure off because his back could not handle walking with crutches, even temporarily.
Second Leg: Muscle Tension
The second leg supporting the experience of pain is muscle tension. There is an intriguing interplay between pain and muscle tension. Almost instinctively, people react to pain by bracing themselves. Muscles tighten and immobilize the areas surrounding pain. In the short run, this tensing reaction contains the pain and prevents further pain aggravating motion. Unfortunately, with long-term pain, the continued bracing seems to increase the pain and cause it to spread to adjoining areas.
Treatment of this problem often includes medication, but there are many non-pharmacological ways to relax muscles — massage, stretching, physical therapy — as well as with powers of the mind. Mental relaxation techniques have been called the “aspirin of mind-body medicine” because of their wide-ranging physical and mental benefits. It isn’t hard to learn to let go of muscle tension and to slip into a more relaxed version of oneself. Techniques include diaphragmatic breathing, progressive muscle relaxation, autogenic training, meditation, and guided imagery. Biofeedback sometimes accompanies these as a way for patients to better monitor their own progress.
Once the skill of general relaxation has been learned, it is possible to direct it into muscles around the pain itself. This technique is not only the opposite of the automatic bracing reaction, it goes against a natural tendency to avoid pain. When in pain, the last thing one wants to do is dwell on it. For this exercise, the patient learns to focus his or her full attention on the pain while refraining from tensing around it. Temporary surrender to the sensations of pain is necessary to gain a clear impression of the pain and be able to apply mental relaxation techniques like breathing into it and feeling it become heavier.
A drawback of this approach is increased awareness of pain which often means more experience of pain. Shifting from avoiding pain to focusing on it directly brings it fully into awareness. In addition, as the patient is able to release tension around the pain, he or she frequently discovers the pain increasing in size and intensity. This is because the chronic tension enveloping the pain does help contain it. As patients become aware of the full extent of the pain by relaxing into it, they are getting a more complete impression of the sensations — sometimes for the first time. Many patients report that performing this exercise allows them to see the pain as it is. Some report that they can see where the true center of the pain is and it is not where they thought.
Tony was quick to learn a variety of relaxation techniques. Every day he practiced the recorded exercises he was given. This was his first taste of relief that didn’t come from medication and he was thrilled. We took him to the next step with the exercise of focusing fully on his pain and relaxing directly into it. At first he was astonished with the power he had to relieve his pain with his own mental power. His pleasure with his newly found skill gradually faded as he found that it was necessary to use it every time he aggravated the pain, which was just about every time he moved. This meant spending a lot of time on the couch focusing on pain and breathing into it. He realized that he would have been on the couch taking medication anyway, but remained frustrated. We began the process of teaching him to relax even in motion. These exercises are similar to Tai Chi where one stands and moves slowly, all the while focusing on balance and staying completely relaxed. Tony continues to work on these exercises.