Mindfulness in the management of pain - Dana Jack

Editor's Notes

1. Metaphor of the lotus. Out of the muck and mud, the pain, sorrow and loss, beauty can grow. So yes, a number of studies of demonstrated that mindfulness meditation is a highly effective way of relating to our pain I prefer to say mindfulness in how we relate to pain, rather than to how we ‘manage’ it. The word ‘manage’ follows the metaphors dominant in our society, like we can ‘be on top of things,’ or somehow control things when, in fact, it’s how we RELATE and REACT to what life hands out, including our pain, that affects our experience of it. So in this talk, I’ll first discuss mindfulness, what it is, then give some research findings related to effectiveness of mindfulness in changing people’s experience of pain, offer a few ways of engaging with pain through mindfulness, and leave time for questions. Want to spend a few minutes describing how I came to this, and what I’ve observed in teaching mindfulness at Fairhaven College of Interdisciplinary Studies for 8 years, and also what I’ve learned from being part of the amazing Mind and Life Institute since 2003. First,
2. Everyone has heard of it. I’m sure many of you practice mindfulness. It’s the Act of openly and actively observing our moment to moment experience with kindness. As we do this, we will begin to understand our bodies and minds better and not be so reactive in our daily life to thoughts, emotions, and physical sensations. We will have more space, inner freedom or choice in our life. Mindfulness is not about feeling a particular state, or having a kind of experience. With mindfulness, we develop a quality of attention that can be present no matter what is happening. This will help us to have more peace, ease, and balance in our lives. We start with awareness of our breathing, and open our awareness more and more to all our experiences, including sounds, bodily sensations, emotions, thoughts, and mental states. Hundreds of published intervention trials have shown that mindfulness meditation can relieve anxiety, stress, depression, exhaustion, attention, and other psychological and physical distress. Jon Kabat-Zinn – Just now, close your eyes and feel the sensations in your body, with no preference, no judgments. Focusing your awareness on your breath, just staying with one full inbreath as it comes in, one full outbreath as it goes out. Just returning to the breath when the mind wanders. Abandon all ideas of getting somewhere or having anything happen. Just keep bringing the mind gently, kindly, back to focus attention to the breath – again and again.
3. Physical pain is the response of the body and the nervous system to a huge range of stimuli that are perceived as noxious, damaging, or dangerous. There are really three dimensions to pain: the physical or sensory component; the emotional, or affective component, how we feel about the sensation; and the cognitive component, the meaning we attribute to our pain. Let's say you've got a pain in your back. You can't lift your children; getting in and out of the car is difficult; you can't sit in meditation. Maybe you can't even work. That's the physical component. But you're having to give up a lot, and you're going to have feelings about that—anger, probably—and you're susceptible to depression. That's the emotional response. And then you have thoughts about the pain—questions about what caused it, negative stories about what's going to happen. Those expectations, projections, and fears compound the stress of the pain, eroding the quality of your life. Medicine much better with acute pain than chronic pain. More on cognitive and emotional pain: . Primary pain arises from illness, injury or or damage to the body or nervous system. ‘raw info’ sent by the body to the brain. Secondary pain is the mind’s reaction to primary pain but is often far more intense and long lasting. It’s controlled by ‘amplifiers’ in the brain that govern the overall intensity of suffering. Example of leg cramps – the fears, catastrophizing, makes the body tense up even more, amplifies the pain. Importantly, social and emotional conditions can affect powerfully, just like physical ones since psychological pain draws on many of the same neural networks as physical pain. 3. As analyzes the pain, sifts through memories when you’ve suffered similarly in the past. Searches for clues that will lead to a solution. Can get enmeshed in thoughts about your suffering – can get consumed by future anxieties, stresses and worries as well as physical pain. Can happen in an instant before you’re consciously aware of it. Secondary pain is real; is the minds reaction to primary pain.
4. Instead of focusing on how badly we want the pain to stop, we pay attention to our pain with curiosity and without judgment. The last thing we want to do is pay more attention to our pain. But that’s the premise behind mindfulness, a highly effective practice for chronic pain (among other concerns)….This approach is very different from what our brains naturally do when we experience the physiological sensation of pain “What we want to do as best as we can is to engage with the pain just as it is.” It’s not about achieving a certain goal – like minimizing pain – but learning to relate to your pain differently. JKZ - “From the perspective of mindfulness, nothing needs fixing. Nothing needs to be forced to stop, or change, or go away.” You change your relationship to the pain by opening up to it and paying attention to it. You "put our the welcome mar.' Not because you're masochistic, but because the pain is there. So you need to understand the nature of the experience and the possibilities for, as the doctors might put it, learning to live with it," or, as the Buddhists might put it, "liberation from the suffering." If you distinguish between pain and suffering, change is possible. As the saying goes, "Pain is inevitable; suffering is optional." There have been studies looking at how the mind processes acute pain at the sensory level. Subjects are randomized between two groups, then given the cold pressor test, where a tourniquet is placed around your bicep, then you stick your arm into ice water. There's no more blood flow, so your arm gets very painful very fast. They measure how long you can keep your arm in the water as a function of whether you are given an attentional strategy, such as paying attention to the sensations and really moving into them and being with them as nonjudgmentally as you can—a mindfulness strategy, in other words—or a distraction strategy, where you just try to think about other things and tune out the pain. What they found was that in the early minutes of having your arm in the ice water, distraction works better than mindfulness: You're less aware of the discomfort because you're telling yourself a story, or remembering something, or having a fantasy. But after the arm is in the cold water for a while, mindfulness becomes much more powerful than distraction for tolerating the pain. While distraction alone, once it breaks down and doesn’t work, you’ve got nothing. First and second dart – learning to recognize the thoughts as just thoughts. I can’t stand it, there is no hope for me, my life is a mess. These are thoughts: none of these are the pain itself, but magnify the pain. Reactions of mind, wanting things to be different from how they are. See the sensations as sensations – with curiosity.
5. Founding Director of Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School. He is also the founding director of its renowned Stress Reduction Clinic. His research between 1979 and 2002 focused on mind/body interactions for healing; on various clinical applications of mindfulness meditation training for people with chronic pain and/or stress-related disorders; on the effects of mindfulness-based stress reduction (MBSR) on the brain and how it processes emotions, particularly under stress, and on the immune system; and on the use and effects of Mindfulness-Based Stress Reduction (MBSR) and mindfulness meditation with women with breast cancer and men with prostate cancer; on patients undergoing bone marrow transplant; with prison inmates and staff; in multicultural settings; and on stress in various corporate settings and work environments. Essential elements: Body Scan Meditation, a supine meditation, Gentle Yoga, practiced with mindful awareness of the body; Sitting Meditation mindfulness of breath, body, feelings, thoughts, emotions, and choiceless awareness; Walking Meditation e) “Informal” Mindfulness Meditation Practices (mindfulness in everyday life): Awareness of pleasant and unpleasant events, Awareness of breathing, Deliberate awareness of routine activities and events such as: eating, driving, weather,
6. BODY SCAN: The Body Scan is a variation on a traditional Burmese practice- called sweeping;. Goenka teaches in his ten-day Vipassana retreats. The traditional method involves tuning in to sensation in a narrow horizontal band that is slowly brought down through the entire body as if you were giving yourself a CAT scan. It is done Iying down starting at the toes and moving up through different regions of the body.This practice is a way of getting out of the head and developing intimacy with the body. The challenge is, can you feel the toes of your left foot without wiggling them. You tune in to the toes, then gradually move your attention to the bottom of the foot and the heel, and feel the contact with the floor. Then you move to the ankle and slowly up the leg to the pelvis. Then you go to the toes of the right foot and move up the right leg. Very slowly you move up the torso, through the lower back and abdomen, then the upper back and chest, and the shoulders. Then you go to the fingers on both hands and move up the arms to the shoulders. Then you move through the neck and throat, the face and the back of the head, and then right on up through the top of the head.And all the while, you’re in contact with the breath. I tend to have people feel the breath moving in and out of the body region they're attending to, so that there's a sort of dual awareness. As you move up the body, you're learning how to focus on a particular region, then let go of it and move on. It's like cultivating concentration and mindfulness simultaneously, because there is a continual flow. You're not staying with one object of attention. The body scan is a meditation practice, not a relaxation exercise. Relaxation is done with a goal in mind. Meditation is about nonstriving and emptiness. If you get into thinking, ''I'm doing this meditation to rake away my pain," you're coming at it with the wrong motivation. Meditation doesn't "work" or not "work"; it's about being with things as they are. Basically, you're intentionally bearing witness to the pain rather than distancing yourself from it; we're not teaching mindfulness as a dualistic practice. Nevertheless, there's a sense that there's the pain, and there's the observing of the pain. It's important to understand that as an intermediate step toward ultimate liberation. It means that I can rest in awareness, then ask myself, "Is the awareness in pain in this moment?" And the answer invariably is, "As I look at it right now, the awareness of the pain is not in pain.'' When you realize you can rest in this awareness, the pain may be just as intense, but you're now cultivating equanimity and clear comprehension. You're seeing the pain as it is, as sensation. There is a knowing that it is nor pleasant. But the interpretation that the pain is killing me, or ruining my life, and all the emotions and stories that go with that, are seen for what they are. In that seeing, they often go into abeyance.
7. BODY SCAN Body Scan - bringing awareness to each body part and instead of immediately reacting to your pain, the body scan teaches your brain the experience that it can actually be with what’s there.
8. When pain arises, the brain reacts automatically, with thoughts, such as “I hate this, what am I going to do? You can calm your mind and ground your breath. When pain is intense, breathing in slowly and saying to yourself “In,” and breathing out slowly and saying “Out.” Describe RAIN: recognize, accept, investigate, non-identify.
9. investigators trained young adults to engage in compassion meditation, an ancient Buddhist technique to increase caring feelings for people who are suffering. In the meditation, participants envisioned a time when someone has suffered and then practiced wishing that his or her suffering was relieved. They repeated phrases to help them focus on compassion such as, "May you be free from suffering. May you have joy and ease." Participants practiced with different categories of people, first starting with a loved one, someone whom they easily felt compassion for like a friend or family member. Then, they practiced compassion for themselves and, then, a stranger. Finally, they practiced compassion for someone they actively had conflict with called the "difficult person," such as a troublesome coworker or roommate. Compassion training was compared to a control group that learned cognitive reappraisal, a technique where people learn to reframe their thoughts to feel less negative. Both groups listened to guided audio instructions over the Internet for 30 minutes per day for two weeks. "We wanted to investigate whether people could begin to change their emotional habits in a relatively short period of time," says Weng. The study measured changes in brain responses using functional magnetic resonance imaging (fMRI) before and after training. In the MRI scanner, participants viewed images depicting human suffering, such as a crying child or a burn victim, and generated feelings of compassion towards the people using their practiced skills. The control group was exposed to the same images, and asked to recast them in a more positive light as in reappraisal. The researchers measured how much brain activity had changed from the beginning to the end of the training, and found that the people who were the most altruistic after compassion training were the ones who showed the most brain changes when viewing human suffering. People seem to become more sensitive to other people's suffering, but this is challenging emotionally. They learn to regulate their emotions so that they approach people's suffering with caring and wanting to help rather than turning away The fact that alterations in brain function were observed after just a total of seven hours of training is remarkable,
10. Talk about JKZ again.
11. First, MBSR highly effective for a range of things, incl pain. Describe the study: Showed that meditation engages multiple brain mechanisms that alter the construction of the subjectively available pain experience”. 18 healthy medical students from Wake Forest Med school attended four 20-minute training sessions on mindfulness meditation, technique adapted from Tibetan Buddhist form of meditation called Samatha. Focus on breath and let go of thoughts as they arise, and also of distractions. To gauge the effect, administered a distracting bit of pain: a small thermal stimulator heated to 120 degrees was applied to the back of each volunteer’s right calf. Subjects reported the intensity and unpleasantness of the pain. If pain were music, intensity would be volume. Unpleasantness would have more of an emotional component, like how much you like or dislike a song. After meditation training, participants reported a 40% decrease in pain intensity and a 57% reduction in pain unpleasantness. Not just perception of pain changed; so did brain activity. Meditation was shown to reduce activity in key pain-processing regions of the brain. The citation refers to a more recent article that presents a detailed review and summary of what brain functions are affected by meditation to reduce felt pain.
12. In those who have had 3 or more episodes of depression. Pain is physical and mental.
13. Community resources: Mindfulness Northwest (Tim Burnett), teaches MBSR in group setting. An important resource: http://www.mindfulnessnorthwest.com/ A range of other groups in the community that have regularly scheduled meditation sittings. See http://karenfitzgerald.com/bdh/ and http://www.gosit.org/Selections.asp?vReg=NW