Category Archives: Chronic pain

Pain and Communication

The problem of pain

Pain and communicationCommunication has a large role in pain from the perspective of telling someone that you are suffering but also in the treatment of pain. At the BASRaT Symposium last week I outlined some of the key features that I will summarise here.

Before discussing communication I highlighted what is the one of the most significant and costly problems on the planet: pain. There are vast costs to society and individuals as the numbers of people suffering chronic pain are enormous. The British Pain Society recently called it the ‘silent epidemic’.

It is thought that 20% of the population suffer on-going pain, including 1 in 5 children. Whilst we can say that the former is a significant number necessitating action, the latter absolutely needs to change. We must understand why this is the case. What is it about modern living and culture that is creating a generation of pain and anxiety? There are some obvious candidates: pressure to achieve at all costs, a lack of self-esteem, narcissism encouraged by popular culture, and obsession with social media at the expense of developing connections and communication skills (including addiction to devices).

One of the main reasons for the scale of the pain problem is the misunderstanding of pain through society. The biomedical model still predominates when there is the search for a structure or pathology to explain the pain and extent of the pain. The preferable biopsychosocial model takes into consideration the important psychological and social dimensions, but often the ‘bio’ receives most attention. Modern understanding of pain would suggest that actually, a better framing would be a sociopsychobiological model because whilst understanding the pathophysiology and molecular aspects of pain is important for scientists and clinicians, the person in pain just needs to know what to do when they are in pain. They need a process to follow with an understanding as to why this is important. Neuroscience education has a place in the treatment of pain, but not a primary one.

Pain is a subjective experience emerging in the person, influenced by a range of social, cultural, contextual and environmental factors, past experiences and beliefs, in the face of a perceived threat. Pain is about protection and survival.

Pain & communication

With the size of the problem in mind alongside the understanding that pain is poorly related to injury and tissue health or pathology, we looked at some important aspects of communication.

One of the communication streams that is often forgotten is the inner dialogue. This is the story that you tell yourself about you and life; that little voice that is so familiar and if not trained can be so disruptive. This is the inner dialogue that can cause such suffering when we berate ourselves for not being good enough. This is relevant for the person with chronic pain as self-criticism is a common feature when in fact kindness and self-compassion is a key driver in getting better. Equally, the clinician’s inner dialogue will affect his or her approach and decision making. Think of a scenario when you are tired, you were late for work, you stubbed your toe on the bed and then you are faced with your first patient who has not improved. You need clarity of thought to approach this situation, not a mind cluttered with annoyance and frustration.

What are you telling yourself? What are you convincing yourself? How are you choosing to think?

How we communicate pain to the person has an impact on their understanding, which is paramount in validating their story to date, and in helping them engage with the programme. Firstly we must listen deeply so that we can know the person as much as the condition ~ the two are not separate. Listening deeply is a skill allied with active listening when you are fully present, in contact via body position, your eyes and expressions (verbal and non-verbal), and allowing them the space and time to tell their story. This narrative holds many clues so our full attention is required, jotting down key points and phrases. In sum, there are different communication dynamics co-existing: the inner dialogue of the person, that os the clinician and the (outer) communication between the two.

Compassion and empathy

Cultivating compassion and empathy as a clinician is an extremely worthwhile exercise. Those who have chosen the caring professions have already demonstrated these characteristics by the very nature of the choice ~ we care and want to help others to live their lives. It is interesting and reflective to consider the question: why do I care?

Not only is this important for the clinician, but also for the patient to learn such skills, especially if they are hard on themselves. It is very easy to pick up on this when they speak to you. The problem with being a self-critic without control is that it is very threatening and hence is provoking the self-protect systems that exist to make sure we survive. These systems have a significant role in pain and hence we are aiming to do the very opposite: active the care-giving systems and effect parasympathetic actions. In a sense our job is to help the person realise that they are safe, how they can safely build up their meaningful activities and adapt in a way that means they are living meaningfully.

What are compassion and empathy?

  • Empathy ~ the capacity to share the feelings of others
  • Compassion ~ feelings of warmth, concern and care for the other…with a strong motivation to improve the other’s wellbeing (Singer & Klimecki)

These will be familiar to clinicians and therapists, but what may not be so familiar is the fact that we can train and practice simple skills to improve our capacity.

It will not be a surprise to many that our brains change when we practice and learn, and this is no different for compassion. Neuroscientists have been looking at these mechanisms for some years now, gathering data on these brain changes and how they manifest in the person. Aside from the science, developing a compassionate society has obvious benefits for all:

Love and compassion are necessities, not luxuries. Without them, humanity cannot survive ~ Dalai Lama

These are skills that should be practiced from an early age with purpose, in homes, schools and workplaces. And just to be clear, compassion is not characterised by weakness or femininity as can be said; not at all. Compassion takes courage and is for all.

Simple practices

There are a range of practices that clinicians and therapists can use for both themselves and their patients. Remember that there is an interaction between the care-giver and receiver, both benefitting from a kind action on a chemical level. Fostering and nurturing every opportunity means that we set the scene: the welcome, the greeting, the opening question or comment, the engagement, the demonstration of care, the calm environment, and much more. Being aware of the present moment and crafting each unique session is a skill to be fostered.

It is beyond the scope to describe the following in detail, but as an indicator, these practices are easily started, often a challenge to continue, but immensely worthwhile for the individual and society:

  • mindfulness
  • lovingkindness meditation
  • the practice of gratitude
  • cultivating an ability to control the wandering mind
  • purposefully generating positive emotions

It is worth remembering that as a clinician, you are the treatment as much as any approach you apply. There is no separation. Developing your capacities hence will have a significant impact on your clients and patients as you increasingly set the scene and communicate in such a way that the person feels trust towards you, a sense of being cared for and a belief that they can get better.

Here is a great video from one of the foremost researchers in the field of compassion, Richard Davidson

For further information on the Pain & Wellbeing Coach Programme or clinician/therapist 1:1 Pain Coach Mentoring contact us below or call 07518 445493

24Oct/16
Women in pain

Women in pain

Women in painRecently I gave a talk to a group of female health professionals at the Inspiring Women in Medicine meeting entitled ‘Women in pain’. I spoke about the significant societal problem of women suffering persistent pain, which is one of the issues that comes under the banner of women’s health. Society needs women to be healthy and hence the problem of women in pain must be addressed. Fundamentally at present, society does not understand pain sufficiently to address this enormous public health matter effectively, which is where I believe we must begin: understanding pain.

If society understood pain….

  • individuals would know what to do and think in order to orientate themselves towards getting better
  • it would not be feared; instead the focus would be on overcoming pain
  • healthcare would deliver the right messages early on so that the right actions are informed by correct beliefs about pain
  • the right treatment appraoches would be employed from the outset
  • there would not be the same level of suffering — the figures say: 100 milliion Americans suffer persistent pain; 20% of the population; 1:5 children

Chronic pain is a huge global health burden that costs both individuals and society enormously in terms of finances and suffering. Of course, this pervades out into family and social networks and hence those around the individual can also be suffering through their on-going provision of care. Pain is a strain on society, literally. If it were understood, this can change.

Women in painWomen are reported to suffer more pain and visit their doctor more often about pain than men. Females are more likely to suffer functional pain syndromes. There are still many people, including healthcare professionals, who do not know what functional pain syndromes are or have insight into the basic biology that emerges as a range of painful problems that are very common. They include irritable bowel syndrome (IBS), migraine and headache, back pain, fibromyalgia, pelvic pain (e.g. vulvodynia, painful bladder syndrome, dysmennorhoea) and temporomadibular dysfunction. Other regular features include anxiety, depression, a history of early life events (and later in life when a challenging situation brings about pain and suffering), perfectionism, a person who is very hard on themselves and hypermobility.

This being the case, one would expect that research into how females experience pain and why they feel more pain would be stacking up. Unfortunately this is not the case with most research done in males and male rats. Clearly that has to change alongside the overall attitudes to women in pain.

Women in painRecently the press ran with stories about how women in pain receive different care and approaches to men. Women waited longer for treatment, were less likely to receive opiates for pain (opiates are effective for acute pain — there are big issues with the use of opiates for chronic pain) and were deemed to be more emotional and hence somehow their pain was different in the sense of how it should be treated. Of course this is wrong on every level. Each person has a unique pain experience that is flavoured by a perception of threat within a certain context and enviornment, based on prior experience and beliefs of that person. Therefore, each person needs to be addressed as such and treated according to this principle, man or woman.

There arWomen in paine some ideas as to why men and women should experience pain differently. The most obvious is that of gender biology based primarily around hormones and the menstrual cycle. In particular there maybe an important time at the onset of menarche when sensitisation could emerge in some individuals, thereby priming them for future events such as injuries, viruses and illnesses when the systems that protect us (immune, nervous, sensorimotor, autonomic, endocrine — they work together as opposed to being in isolation) are active in the face of a perceived threat and increasingly vigorously. What the person lives are the symptoms of thee systems working including fever, pain, altered perceptions of the world, altered thinking and emotions. It can sound like these are all separate ‘reactions’ when in fact they are part of an on-going cyclical process: we think, perceive and act as a unified lived experience.

Another observation relates to empathy and how women maybe more empathetic for the purposes of caring for their children. A truly empathetic person is a caring person yet they must be careful and skilled so as not to embody their own versions of observed others’ suffering. As an example, it is not uncommon for me to feel a pain in the same place that a patient is describing their pain to me. Understanding the mechanism, I can rationalise the feeling and it will pass as I actvely change my perception — this is likely the same mechanism that underpins the change from being in pain to not being in pain in all people. I know that others I have spoken to also have this experience, which one could argue is deeply helpful as a healthcare practitioner as we seek to understand the causes of the other person’s suffering.

A described emotion that often appears within conversations about pain, particularly women in pain, is that of guilt. The reasons for expressing guilt are based around the conflict between work, home, partner and children — trying to please all but rarely pleasing or looking after oneself. Being kind to self is important in the sense that being hard on oneself can be the cause of great suffering. This is common and will almost certainly be taking the woman closer to her biological protect line, the point at which threat is perceived and enacted as a pain experience. Learning how to foster the existing compassion towards oneself then, is a typical part of a comprehensive programme for getting better. With many whom I see displaying and admitting perfectionist traits, it is not a surprise that harsh inner dialogue results in repeated negative emotions. Strung together frequently, this forms the basis for chronic stress, which in turn is the means for a pro-inflammatory state, which emerges as aches and pains, troubled tummies, headaches, mood changes, sleep issues, fertility problems and more. The reason is simply that in the pro-inflammatory state, the body is in survive mode that is great when there is a real threat. However, most of the time there is no threat, it is just something we are thinking about that triggers the same response via a prediction taht one exists.

Now, there is nothing wrong in experiencing negative emotions. We need them as much as the others. It is really about the apporpiateness of the emotions: when we feel them, how long we feel them for, how often etc etc. If we consistently think that something bad will happen or ruminate on things that have happened rather than seeing things for what they really are in this moment, then this basic survival biology will keep going. This is where mindful practice is so beneficial, cultivating awareness of existing habits that allows for a reappraisal, a space to see things for what they are and gain insight into the causes of your own suffering and others, from which you can choose a new and healthy way onward. Clearly there is much more to say about mindfulness and its benefits, in particular in the face of mcuh exciting data from studies across the world.

Whilst this blog scratches the surface, it hopefully provides some food for thought. This is a significant public health issue that we can tackle by understanding pain and applying simple and sensible compassion-driven care, which will make a huge difference. Coaching the individual woman to coach herself in a direction that is toward her desired outcome is out role as we empower individuals and allow them to realise their sense of agency in getting better. There are simple measures such as movement, exercise and mindfulness that work in synergy to create a meaningful life to be engaging and enjoyed so that when challenges arrive, they are overcome and used as learning experiences. Science, compassion and sense are at the heart of the Pain Coach approach, one that we can all adopt to change for the better. Ourselves and our patients.

RS

The Pain Coach 1:1 Mentoring programme is for busy clinicians who wish to develop their working knowledge and to be effective in coaching people suffering chronic pain to lead meaningful and fulfilled lives. Contact us on the form below or call Jo for further information t. 07518 445493

 

 

 

23Oct/16

Is mindfulness for everyone?

MindfulnessWalk into a bookshop and you cannot help but notice the ever-increasing number of books about mindfulness filling the shelves, which begs the question, is mindfulness for everyone?

In my opinion, mindfulness is a practice that everyone could choose to incorporate into their lives, however, not everyone will wish to make that choice. It is also the case that the route to mindful practice can be different for different people. For example, sitting or lying and being mindful or meditating can be result in greater suffering in some circumstances and hence that person needs something else at that time. An individual suffering PTSD for instance, could discover that mindful practice leads to a greater state of stress and anxiety. There are several possible reasons for this, including whether they have been instructed in the right way about what mindfulness really is and how we go about the practice. With so many people offering mindfulness at the moment, it can be difficult to know who best to listen to or follow.

Starting any new practice is a challenge and requires dedication and perseverance. In so doing, one learns and realises that each moment there is an opportunity to get better at what you are doing. As Ajahn Brahm says, ‘there’s no such thing as a bad meditation’ — we can always take something from the practice, and the fact that you have practiced has created a learning opportunity. Sometimes the practice results in a great feeling of serenity as the inner dialogue quietens, and sometimes the voice chunters away. Good? Bad? It is what you think it is!

Mindfulness is simply about being aware of your thoughts, feelings and sensations as they pass by, which they always do. The realisation of impermanence is an important one as moments continuously flow. Noticing what you are thinking and feeling without judgement means that you begin to see things for what they are and the causes of your, and other’s suffering. This insight is invaluable for our health. One is tempted to say emotional health but this would suggest some kind of separation between body and mind. There can be no separation between body and mind as we are a whole person living experiences that are unified of cognition, perception and action. The practices of mindfulness provide a way of ‘doing’ this, although really when being mindful, we are not actually doing anything other than being aware, using our attention. To add compassion to this means that you have the intention to be kind to others and yourself with all the accompanying health benefits from positive social interactions and kindness to self.

Mindfulness is a practice with several straightforward methods (below), which is why it is accessible to all. However, actual practicing is the challenge as we have so many existing habits of thought. Our minds do wander and are filled with chaotic thoughts that inform feelings, emotions, actions and perceptions, yet all of these dimensions inform each other. This complexity defines the challenge and how one day we can quieten down the inner chat and another day it seems to make no difference. Remembering that it is not the thought or series of thoughts that is the issue, instead it is recognising that this is the content of the mind, which is not me per se. I am not the contents of my mind, and being able to realise that is hugely empowering.

Two common practices are mindful breathing and mindful walking, both if which are accessible at any moment to most. Paying attention to what arises in this moment is at the essence of the practice that develops one’s ability to focus, choose what to attend to, to reappraise a thought pattern, see things for what they are, realise that anger or another emotion is present yet you can remain focused on your intention. Keeping a focus on your intention is a great skill demonstrated at a time when an argument ensues. Instead of emotional reactions with hurtful words, maintaining a course for the intention that is usually a kind action towards another, you listen deeply and understand the other party, allowing for effective communication towards a resolution. Be able to see the reasons for the other person’s actions provides great opportunity for transforming the situation. This would be a good example of using mindfulness and compassion, the two differing.

Returning to the primary question, I believe that mindful practices can be integrated practically into people’s day to day living if the person makes the choice to do so. Potentially, this is the case for anyone. However, each person needs good instruction and guidance, in essence to become their own coach to transform their inner dialogue to one of kindness and compassion toward self and others. Mindfulness creates the awareness within which this can happen through attention training (mindfulness is about attention whereas compassion is my motivation or intention ~ there’s a difference). Some will need other ways into the regular practice by using breathing and movement, some will need different explanations to be guided and supported, but the the aim is always to develop ways to reduce suffering.

RS

Mindfulness practice is a part of the Pain Coach Programme for overcoming pain | contact us by email: [email protected] or call us 07518 445493

28Aug/16
Pain and communication

Simple skills

simple skillsThere are a number of simple skills that can be practiced to become a better clinician. In essence, when we are fully present and engaged, we are communicating this to the patient thereby creating a nourishing environment. This environment sets the scene for new understanding and new habits, beginning the transformation of the suffering person.

We are not separate from the environment in which we reside and hence we, the clinicians, have a role in how the environment supports the person getting better. Arranging the treatment space is important then, enabling the patient to feel welcome, heard, comfortable and free to express themselves. This expression is the story to which the clinician must listen deeply as all the information is contained within the narrative. Allowing the person to speak in their own language with occasional prompts and guidance is the basis of the onward journey towards their vision of a desired outcome.

For the clinician to practice mindfulness is a simple way of maintaining presence and engagement with the patient. This simply means that you are listening deeply and using insight to see the causes of suffering that are revealed as the person speaks freely. Add to this compassionate speech and the communication facilitates the way forward. Communication is part of the treatment as the clinician helps the patient understand their pain and suffering — what has happened so far, what is happening now, what is influencing their pain, what they can do, what the clinician will do and how they will go about it.

Practicing mindfulness is a simple skill. As a starter, the clinician can take 4-5 breaths between patients, paying attention to the rise and fall of their chest. On the out-breath you can consciously let go of unhelpful and distracting thoughts. As soon as your mind drifts into the past or future, you are no longer present and your engagement dissolves. During the session, recognising this happening and bringing your attention back to your breath is a way of re-engaging once more.

Taking a break midway through the day to move, breath and nourish is an important refresh and renew point. A period of deep relaxation for 10-20 minutes gives us energy to be present once more and focus on the patient: their words, their gestures, their messages. We must develop our abilities to gain insight into the causes of the patient’s suffering so that we can guide and treat, enabling them to get better and ease their pain and suffering. In fact, by gaining insight ourselves, we can then help the patient to develop their insight into the causes of their own suffering and create new healthy habits around their thinking, choices and actions to actively infer new experiences.

Practical point: start by taking 4-5 breaths between patients, and at the start of the day express gratitude for the opportunity to help people get better.

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Pain Coach 1:1 Mentoring Programme — develop yourself and your insights to coach people overcome their pain | t. 07518 445493

27Aug/16
If pain

If pain

If painIf pain was understood, there would be less suffering.

If pain was understood, the right messages would be given from a young age, sculpting behaviours based on what needs to be done.

If pain was understood, there would be no fear about it.

If pain was understood, we would focus on what we can do to feel better.

If pain was understood, it would be known that listening deeply is the first step to help someone transform their pain.

If pain was understood, it would be known that understanding pain changes pain.

If pain was understood, there would be an enormous amount of money available for a better society.

If pain was understood, it would sit in the realm of public health and not medicine.

If pain was understood, there would not be the reliance on medication.

If pain was understood, what would the world be like?

— this is the mission of UP | understand pain; to globally change the understanding of pain, because put simply, the world would be a better place if pain were understood.

www.understandpain.com

23Aug/16

Inequalities in pain relief

A brief article in yesterday’s Guardian highlighted one of the inequalities in pain relief. The author, Grace Rahman, focused on the question why black patients are given less pain relief in the light of recent research. With pain being the most common cause of Emergency Room visits, there is plenty of data to analyse. This is likely to be the same in the UK, pain being the primary vehicle that takes people to seek help. As a significant aside, it astounds me that pain is so low on the public health agenda in terms of funding for research as well as overall recognition.

Depression and chronic pain take the first two positions in global health burdens — they cost us the most. Yet where are the campaigns? Where is the TV coverage? They do not exists despite the fact that pain is a universal experience, except in an unlucky few with a rare genetic disorder, which is normal and necessary for survival but so deeply troubling when it persists. Therein lies a major issue contributing to the question penned by the journalist: why are black patients given less pain relief?

Previously, young babies may not have been given pain relief and older people may still not receive adequate pain relief, especially those who are cognitively impaired. The aggression seen in someone suffering dementia may well be due to pain that a simple analgesic would relieve. The misunderstanding of pain underpins all of these contexts, resulting in poor treatment that is based on the wrong thinking. The lack of pain education is incredible when you consider it in this light.

A study quoted by the author highlighted the knowledge gaps of white medical students who rated pain levels to be lower in black people when looking at case studies. Why would this be the case? It was thought to be due to ‘entrenched ideas’ about how people differ biologically and about how they behave in relation to using medication.

Each person is unique with their own personal experiences and narratives of their life to date. This makes an individual’s pain unique, and at any given moment our lived experience that could include pain, is also unique. I have never had this moment before and never will again. So even in the individual, the pain is never the same. We are always changing as we build up prior experiences with every passing moment in time. Understanding this is important and also delivers hope, because when combined with a working knowledge of pain and what we can do to actively steer a desired course within realistic parameters, we actualise change.

Therefore, as clinicians and as a society we must appreciate that each person’s experience of pain is unique and just as they person says it is — listening deeply is vital to gain an understanding with the required compassion. Just spending those moments with the person, allowing them the time and space to describe their experience allows a calming. We must certainly appreciate culture, gender and beliefs as we impart the truth behind someone’s pain, giving them knowledge and skills to overcome their pain and what fuels the sensations. This is the same for every person — whatever the colour of your skin, age or sex. Deep listening, compassionate speech and a focus on what action to take in this moment.

Much suffering comes from how we think about our pain, which is why we feel better when we understand pain and the fear dissolves. When the fear and worry decrease, so the pain eases and we can focus on what we need to do to get better. Fear, worry and depression are based on the contents of our thinking from the past or the future, neither of which exist except in our embodied minds. The only real moment is this one, now. Practicing being present and seeing what is actually in front of you by using the breath for example, allows the person to let go and concentrate on this moment. This is the foundation for moving onward in a chosen direction.

Medication is part of overcoming pain. It can be useful when used wisely within a plan that includes how and when the drugs will be reduced. Of course this is individualised to the person, their condition and their needs. Many people choose not to use pain relief, and certainly the opiate based drugs. Everyone wants relief and this should be a primary aim of any treatment programme, however, the person needs to understand how they themselves via their own thinking, perceptions and actions can change their pain. This is the main bulk of the work for that person as they need to be able to coach themselves at any given moment, each day. The strategies and exercises become healthy habits formed through practice that interweaves into the day. Continuing with normal activities in tolerable chunks maintains a sense of living a life and I often say to people that they can only get only get back to living by getting back to living — doing the things you want to and starting doing the things you have not been doing, bit by bit; thinking ‘can’ instead of ‘cannot’. It is just that you need some ways and means to do so as you build up tolerance by following a programme. A simple analogy is all the background work that an athlete would do in order to perform their sport. The programme is the background work.

Bearing this in mind, there is only one way and this is to consider and treat the unique person as much as the condition. In doing so we learn about their suffering and guide them forwards with treatment that gives the person working knowledge of their pain and skills so that they can coach or mentor themselves forward by thinking and acting in such a way as to take them forwards.

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Pain Coach Programme for persistent and chronic pain | t. 07518 445493

 

18Aug/16
Mindfulness

Trauma

TraumaAll injuries have a degree of trauma, but some more than others. The moment of injury is just that, a moment. Part of the experience is an urge to do something in a way of protecting the self both in thought (what shall I do here?) and action taken. The thoughts and actions, unified into a lived experience of action-perception, are based on prior knowledge and situations as we try to make some sense of what is happening now. As humans, we have a tendency to flavour the present moment with thoughts of the past or future, neither existing beyond the thought itself. The problem lies in the fact that the thought is embodied, resulting to a greater or lesser degree from the current body state, which we then fully experience with sensations in the body, feelings and emotions; embodied. For example, purposefully thinking about a prior happy occasion usually fills you with the same feelings of joy and pleasure as if you were there again. The same is true for thoughts of an unhappy situation in the past. However, this body state is continually updating and hence we are in a position to steer our change in a desired direction by thinking-acting in a way that aligns with our values and vision of how we want to be. We purposely put ourselves into situations to get better.

Understanding the state of the individual before the trauma and at the time of the trauma provides important insight into the subsequent unfolding of events. A person experiencing persistent pain continues to suffer despite the tissues (body) healing, which they do to the best of the body’s ability, because the systems designed to protect us continue to be vigilant to potential dangers. These potential dangers soon become normal day to day situations, now regarded as posing a threat to the individual’s survival, hence the pain to motivate defensive thoughts and behaviours. The longer these habits persist, the more suffering. But, this is not set in stone and indeed the practice of new, healthy habits steers a new course. We are designed to change and we can decide on the direction, using new habits to get there. Not always a smooth route, it is the one that takes you towards a meaningful life as you overcome the challenges with new understanding of pain and the best course of action. Maintaining this course also relies upon recognising distractions (unhelpful thoughts that affect mood and motivation — old habits) and re-orientating to the desired route.

Healing is not simply about the muscles, bones and other tissues repairing. It is about the person resuming their sense of self — ‘I feel like me’. This is a process of understanding, adapting, gaining insight into the causes of suffering, the practice of new habits and gradually engaging once more in normal activities including socialising. I think about this as getting back to living, by getting back to living instead of waiting for pain to subside before re-engaging. The re-engaging itself has a role in getting better and pain easing. This comprehensive approach, or whole-person approach, is key to success.

A pure focus on tissues means that the person living the experience is neither acknowledge nor addressed. There is the pain, the injury (the two are not well related) and the person’s appraisal of both, which if not validated and considered, means that a huge source of suffering is neglected. This does not mean in-depth psychological assessment, instead recognising that there is an individual with a story that needs guidance towards getting better. We are more than an injured leg or back. Insightful and compassionate clinicians will work in an egoless way as they focus on the person getting better by helping them to understand how they create the conditions for their health — environment, surrounding and influential people, their programme. We often use the phrase ‘I want to go back to how I was’, but of course this is impossible as we cannot go back in time. What we can do is adapt and focus on getting fit and healthy, and in so doing the body, the self, predicts less and less need to protect and hence the pain changes as we get better.

On first seeing a person who has experienced a trauma and on-going suffering from their persistent pain, we must consider prior health, pain experiences and beliefs about how we overcome problems. It is common to have had or to have other sensitivities, sometimes for many years, which exemplify a pre-existing state (or pain vulnerability) that has been primed by painful episodes over the years. This means that a new injury or situation deemed in need of protection will arouse a more vigorous and potentially prolonged set of protective responses, vigilant and fear-based behaviours. Knowing this from the outset means that the new issue can be addressed fully. Examples of common prior conditions include irritable bowel syndrome, migraines, jaw problems, persistent aches and pains (e.g. back pain), pelvic pain or period pain. These sensitivities can have arisen as part of an overall protect state following early traumas in life that have triggered the protect state, which has continued to emerge in many circumstances including normal ones. We learn to avoid and look out for trouble and can see it in the face of day to day activities, resulting in persisting pain and anxiety. However, with change occurring every new moment, we are able to transform this suffering by seeing things for what they are as opposed to being lost in thoughts about the past or future that arouse unpleasant sensations and emotions (in the body — we are embodied).

In discussing emotions and thoughts, this does not mean that we only focus on these dimensions. As stated earlier, we must focus on the person and their unified experience that is constructed by their brain, mind, person, body etc. On shifting a thought purposefully, inferring something different, we immediately feel differently about that situation. ‘How are you choosing to think about this?’, you could ask yourself. ‘Is there another way I can look at this?’. Recall the experience of where you feel emotions. It can only be in the body as thoughts are embodied. They are not ‘out there somewhere’, they are here, in me. My body state determines my thinking as much as my thinking determines my body state. Sit up for a while and notice how your thinking and feeling changes. You can gain insight into how someone is feeling by observing their posturing and manner. Imagine going into a business meeting to find the person you are about to discuss a deal with, sprawled across his chair with his feet up on the table. He has not said anything yet you gain insight into his approach, character and manner. Will you do business with him? Further, force a smile by gripping a pencil longways between your teeth, look in the mirror and notice how your feelings and emotional state change.

We are complex, predicting what needs to be experienced in any given context based on what we know. There are a huge number of variables that we cannot account for as we are only aware of a very thin slice of what is going on in any given moment — what we are conscious of, making many assumptions from prior learning. In terms of persistent pain, the intensity, the impacting nature of the experience usually far outweighs any signs of ‘damage’ or injury. Often there is evidence of natural degeneration that slowly evolves, quietly informing body systems which predict the meaning of the information, eventually reaching a point of conscious protection when it hurts. This is a slow burner with a point in time when pain is noted. 

In trauma, there is an obvious incident, which is embossed upon the person at that moment in time. The reverberating effects from there on depend upon that person: what they have experienced before, how their body systems predict the causes of the sensory barrage, urges manifesting as behaviours and actions taken, thoughts about the situation (meaning, attribution of causes etc.), emotions that emerge and the onward unfolding of these experiences unified as the story. Naturally the time frames vary according to the conscious awareness of the person, wherein a head injury would impact on memory of the event. In an emergency situation, clearly there are priorities for the medical team to protect the person and maximise the chances of survival and sets the scene for recovery and healing.

From the earliest possible time point, the right messages about what has happened and what needs to be addressed should be purported. The person needs to understand their pain and problems so that they can focus on the right action to get better. This is day to day, moment to moment as the advice and education are taken, internalised and become second nature as new healthy habits are practiced. The notion of the Pain Coach emerged from this thinking, blended with a strengths-based approach. Strengths-based coaching focuses upon developing a person’s existing strengths and managing their weaknesses. On the basis that we are seeking to focus and perform to the best of our ability, the strengths coaching method offers an effective modus operandi stretching across recovery from injury to sports and business performance. Strengths are many, and can include perseverance, attention to detail and compassion. People often realise that they use these strengths in other areas of their life but not in relation to getting well again.

Experiencing trauma in life presents the person with a challenge in many different ways. It also presents a challenge to those around them including family and friends as we are not in isolation to others or the environment in which we reside. There may be a region of the body that has been injured or affected, however, it is always the person who has to deal with the situation and recover. This is a key point that can often be missed, particularly when the injury is complex and multiple parties are involved in the treatment planning. Whilst we discuss the incident, the injuries, the symptoms and the impact upon that person’s life, they are living that life and only they know what that experience is like. This is the reason why deep listening is so important from the outset. It is the person who heals and recovers. It is the person who gets better, and hence it is the person we must know and treat as much, if not more, than the condition because each of us will experience our life events in our own unique way.

The Pain Coach Programme to overcome persistent and complex pain | t. 07518 445493 

15Aug/16
Pain and communication

Get the most out of your exercises

get the most out of your exercisesIt is highly likely that when you visit a physiotherapist you will be given exercises and hence here is a brief guide to how you can get the most out of your exercises. The training is important, setting the scene for a desired change, but in order to be successful, we need to think about how we will be doing the exercises. In the Pain Coach Programme, we look at this in the necessary detail so that the individual can achieve the best outcome. Usually the exercises themselves are very straightforward, with the most complicated piece of equipment being the person, followed by a mirror. That’s it. We need to set the scene, focus, attend to what is happening now, practice, put in maximum effort, perform and learn. Sounds easy!

1. Create the right environment

Where do you do your exercises? How does that environment affect you? Are you doing some of the exercises at home, at work or outside. Notice where you can concentrate with ease and where makes you feel good about what you are doing. We are not separate from the environment in which we find ourselves and hence it can work for us well in creating the conditions to get better. It should be light, spaceous enough to move freely and as calming as possoble without stimuli that trigger survive responses. This includes phones, computers etc that can grab your attention and make you think about something else.

2. Take a moment to be present

To truly concentrate you must be present and aware of what you are feeling, thinking and doing. From there you are able to learn by gathering insights into what you are doing versus what you want to do, making corrections to movements for example. Mindful presence means you are present and aware, rather than being lost in thoughts about the past or the future that are embodied. In other words, our thinking is affected by our body state and vice versa as there is no separation. As an experiment recall a happy time: where you were, who you were with and what you were doing. This is a thought, but how do you feel in your body? So, how to be present? Simply take a breath and notice the in-breath and then notice your out-breath. We can only breathe now so gently concentrating on the breath is a simple way of being both mindful and present. Anytime you notice your attention drifting away, kindly bring it back by noticing your breath.

3. Connecting it all together

We must be fully aware of our mind and our body as a unified experience. How can you learn about your body and how it moves if you are thinking about a meeting yesterday or dinner tonight? You can bring your attention to your breath, saying to yourself ‘I am breathing in’ as you breathe in and ‘I am breathing out’ as I breathe out. Notice how you become aware of this moment, which is the creation of the right conditions for recovery and for learning. You can then expand your attention out to your whole body, thereby connecting it all together in a nourishing way. This only takes a few moments, but without the right attention, the exercise will have a limited effect as you will not realise what you have done.

4. Write a learning diary

‘What we focus upon we have more of’, is a useful way of being. When we notice our positive emotions, which can be subtle, and purposefully attend to them, our thinking broadens. There has been a good amount of research looking at this effect. Keeping a diary is a way of documenting the way we feel and what we have achieved so that when we look back and read what we wrote, we have an accurate view of what was happening at that time. Our memory of what happens is poor, but we do convince ourselves that certain things happened or we felt a particular way. Whether or not it happened like that becomes irrelevant as it is the memory we think we remember that counts. On this basis, writing down each day something that we have learned from our practices of training is a useful insight that motivates further learning as we focus on our achievements and strengths. This is encouraged by positive psychologists as well as featuring in mindfulness practices and strengths based coaching, and for good reason — focus on your strengths and manage your weaknesses, but you have to know what they are first!

5. Accepting where you are now as a stepping stone towards a desired outcome

To accept that I am here in this moment allows you to focus on what needs to be done right now that is in alignment with your desired outcome. Being really great at all the things that you need to do now will naturally allow you to move to the next step as you continue to transform. We are changing all the time and hence need to ensure that our change is in a desired direction. For this we need a vision of where we are going; a vision of a successful outcome that we visit often to ask the question to ourselves: ‘is this taking me towards my desired outcome or am I being distracted by thoughts of the past or future?’. Acceptance does not mean giving up, instead just saying ‘here I am right now’ and ‘this is what I need to think and do to keep myslf going in the right direction’.

The Pain Coach Programme to overcome chronic pain and injury | t. 07518 445493

09Aug/16
sea

Refresh and renew

seaRefresh and renew is one of the most important strategies that I teach individuals who have been suffering persistent pain. Within the refresh and renew there are a range of techniques that can be used dependent upon place, time and context, all of which are important ingredients making a whole. We are in no way separate from where we are, what we are thinking, what we are doing and what we are feeling. These are merely the conscious elements and of course there are the vast subconscious elements including our biology in the dark.

Being in pain is exhausting, usually added to by feelings of anxiety and concern. There can often be a cycle of pain and sleep disruption, one begetting the other as time moves on. It seems more and more probable that sleep is fundamental for our health, which is why creating the conditions for a consistent daily rhythm of activity and rest is vital. Most people know what it is like to ‘survive’ after a bad night’s sleep, but imagine the effect when this is on-going.

Refresh and renew is needed throughout the day by everyone. Every 90 minutes we may feel an urge to do something: move, take a few breaths (4-5 is good), have a healthy snack or a glass of water. This is certainly the case when one’s health is below par as we need to create the conditions for our biology in the dark to switch into health mode rather than survive mode. The person suffering persistent pain spends much of their time in survive mode as they are both consciously and subconsciously protecting themselves from perceived threats. Consider the person with back pain who walks into a room to survey for the closet chair, whether it is likely to be comfortable or if they will be able to have a conversation because their pain maybe too distracting. The thought processes, predictions, anticipations and expectations that are embodied, will prime the coming experiences. The good news is that creating new habits can change this routine for the better, beginning with being aware that this is what you are doing.

All the extra monitoring and thinking is tiring as you use your resources, along with imprecise and guarded movements that require more energy than normal. Too much muscle activity for example, has a huge energy consequence, which is why refresh and renew is so important through the day. Setting reminders and alarms can be effective in the beginning, but as the new habits take hold and the internal messages become second nature, you increasingly make the choices that orientate you to getting better; your desired outcome.

Pain Coach Programme to overcome persistent pain | t. 07518 445493

05Aug/16
New thinking in dystonia

Facial pain

Facial painYesterday I spent the day in Leicester and Northampton seeing several people suffering facial pain with a colleague who has been working in the field. All pains are unique to the person, however, I feel that there are some particular features of facial pain, which are similar to those of facial dystonia. Identifying these shared characteristics has guided treatment and training techniques that aim to improve sensorimotor function as part of adapting and restoring a sense of self.

The loss of the sense of self is a significant part of suffering in my view. People describe how the pain or dystonia impacts upon their lived experiences and their choices, narrowing both. This means that they are not doing what they wish to and hence do not feel themselves as they feel they should. A shift has occurred, part of which is constructed via the ‘physical’ sense of the body. Of course we have a unified experience of ‘me’ including the sense of the body, a sense of a past, a projected future and the inner dialogue that strings it together.

We literally face the world with our face and hence anything that affects our perception of how we are doing this will impact on how I feel, think, the actions I take and perceptions I perceive. There is a spectrum: a red spot through to jaw dystonia — something visible to others that makes us second guess what they may or may not be thinking. Quite easily this can mean we avoid going out or seeing people. The isolation that ensues then gathers momentum, affecting us on many levels including genetically.

In cases of facial pain there may be no clear and consistent visible signs such as the involuntary movements of facial dystonia, however there are often habitual posture and facial expressions — tension, attempts to relax by opening the mouth, rubbing, speech impediments. When we are in pain, our body sense can be different, the perception of the environment can be different, the way we plan changes and our emotional state is one of protection, as is that of our underlying biology. Whilst this is vital for survival when there is an actual threat (an injury or pathology), in most cases of persistent facial pain and other pains, there is no significant injury. The pain is a habitual response to perceived threats that increase in number with time via learned responses and expectations. Things that would not normally pose as a threat now do, including the way we think about ourselves and the world. With a sensory system detecting changes internally and externally, in survive mode we can be jumpy and very responsive.

Facing the world with a painful face is challenging. Understanding pain is the first step to steering change in a desirable direction — how do you want to be? When the person understands that pain can and does change, and that they are the drivers of that change, then new habits can be formed — new habits of thought and action that are practiced over and over to create the right conditions. Likewise in dystonia, the practice of new habits to change the way in which the sensorimotor system is working but integrated with training that addresses the influences upon this system — e.g./ the environment, thinking, emotion. Learning to recognise and let go of unhelpful and distracting inner dialogue, focusing on what you can do, noticing positive emotions and how you evoke them, re-training sensorimotor function, gradually doing more normal and desired activities are all part of a comprehensive programme based upon the neuroscience of pain and using your strengths to be successful.