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7 Articles in Volume 1, Issue #5
Accidentally Speaking
Breaking Down the Barriers of Pain: Part 5
Cancer Pain: Successful Management of Patients’ Fears
Emergency Medicine: Emergency Department Protocols
Magnets & Medicine
The Neural Plasticity Model of Fibromyalgia Theory, Assessment, and Treatment: Part 3
Thinking About Pain

Thinking About Pain

Psychologically based pain management can provide relief for pain patients.

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.

Third Leg: Attention

Of course by focusing on pain with an attitude of surrender and relaxing into it, this exercise not only utilizes relaxation, it incorporates the other legs of the pain experience table — attention and interpretation. The third pain-supporting leg is attention. Pain has an informational function, letting the body know something is wrong and that action is needed to stop the damage or to deal with the injury. Unfortunately, when pain has become chronic, its constant thrust into one’s attention ceases to provide useful information, only annoyance. As strong as pain can be, there can be no experience of pain without conscious awareness. For those in intense pain, the unconsciousness of deep sleep can be craved merely as an escape from unrelenting pain.

It isn’t possible to pay attention to many things at once, and sometimes, even pain gets squeezed out of one’s awareness. What is called the conscious mind does not hold very much at one time. It holds only those few things to which one pays attention at any given moment. Interestingly, whatever is attended to, becomes one’s experience of that moment. Most people with chronic pain know that deep absorption in something else will push pain from their experience at least temporarily.

With limited attention, learning to control focus can be a powerful means to alter pain. There are powerful attentional training skills that cultivate enough control over awareness to reduce or eliminate the experience of pain. Meditation is a technique that develops control over attention and can be extremely useful in controlling pain, however, it requires considerable practice. Other very useful techniques that use attentional control are hypnosis and guided imagery. These both involve becoming absorbed into images that allow us to create an experience without pain. The images can also be useful in redefining ones relationship with pain and thereby making it more tolerable.

The anger Tony felt in reaction to his pain made him difficult with which to live. His wife was at her wits end and his son had become afraid of him. Hypnosis was used to give Tony another route to deep relaxation and to provide images to reframe his pain experience and filter his anger. As a prison guard he knew the importance of not being tense and irritable in the face of difficult prisoners. Images were created to view his pain like the outbursts of unhappy prisoners in his body. He was able to see himself in a role he already knew — that of guard, working both to keep the noisy “prisoners” calm and protecting the outside world from their disturbing effects.

Fourth Leg: Interpretation

The final leg of the pain table is the way pain is interpreted. This includes the thoughts, emotions, and attitudes people have in reaction to pain. Sometimes this is called the suffering leg. There is a big difference between pain and suffering. Pain is actually only a sensation. Suffering is all the interpretation that we give to the pain — the judgments, expectation, attributions, and emotions that can habitually accompany the sensation. Thoughts like, “This is killing me,” “I can’t stand it,” “This is destroying my life (day, moment),” or “Why is this happening to me?” are judgments that increase the suffering component of pain and tend to increase the intensity that is perceived.

Nevertheless, patients all have the potential to develop some control over their minds and over their experiences of pain.

The suffering component of pain is a big factor in other common emotional problems that come with chronic pain, like depression and anxiety. It is easy to imagine how these thoughts can lead one to feeling helpless and hopeless, two feelings that readily turn into depression. Continued fear of the many things that might add to already unbearable discomfort can grow into an ongoing anxiety.

Treatment in this area involves becoming more aware of how thoughts impact experiences of pain, and learning how to change one’s interpretation to reduce suffering. There is an old saying, “Pain is inevitable, suffering is optional.” Of course working with a psychotherapist is one way to work on this. It is often necessary to give patients an objective voice into their experiences to even become aware that what they are thinking isn’t the only possible reality. When done properly, psychotherapy can be an exciting path of self-discovery. There are other such paths. A form of meditation called mindfulness is a wonderful way to becoming an objective observer of one’s own mind. Mindfulness takes some instruction and considerable practice, but, fortunately, is becoming increasingly available across the United States.

As Tony developed an increasing sense of control over his pain and anger, his mood improved. His struggle with pain continues and, at times, he feels overwhelmed by it. However, he feels he has the ability and tools to win the battles. His periods of depression are briefer and less extreme. He has asked his family to help him with his anger by pointing out his sarcasm to give him more feedback. His anger episodes are less frequent and his relationships with his wife and son are much more positive.

Conclusion

Three of the four legs of the pain table are clearly territories of the mind. Muscle tension, attentional focus, and interpretation are all amenable to psychologically based strategies. By learning to reduce the impact of these three factors supporting the pain experience, the patient can take control of pain with reduced medication or by eliminating the medication all together. One must recognize that mind-based pain control techniques are skills to be developed and require some practice to gain therapeutic effect. Patients vary in which exercises are best for them. Some do better with exercises that focus on the pain and others prefer focusing away from the pain. Not all patients will have the patience or motivation to devote the necessary time and effort to master any of the techniques. Nevertheless, patients all have the potential to develop some control over their minds and over their experiences of pain.

Last updated on: January 4, 2012
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