Thinking About Pain | January 4, 2012 | Roderick A. Borrie, PhD
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
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, Morris 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 patient and treatment of pain-related emotional problems, the psychologist can help change the patient’s perception of pain and even bring significant relief.
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.
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
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.
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
with long-term pain, the continued bracing seems to increase the pain and cause it to spread to adjoining areas.
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.
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.
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.
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.
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
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
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),”
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.”
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.
“Some practice” is never quantified, but I doubt just a weekend workshop could have a lasting effect.
Mental powers can require months and years to develop sufficiently to control pain. However, mental control is one of the very few techniques we have total control over, and this makes it very appealing.
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.