There is one thing that pain does and that is narrow down our choices. A sense of choice has a major role in the sense of ‘me’ and who I am. Losing choice impacts upon us significantly as we feel less and less like ourselves and who we are meant to be. This is a very common description of the impact factor that I hear when listening to people enduring states of chronic pain.
Talking to people with pain as we seek to gain insight into the causes of their suffering. This provides a way to offer support, guidance and a way forward. Of course we can only move forward, but sometimes it does not feel like that! Groundhog day.
Enabling one to see their choices then, becomes a valuable and important exercise. We have many, but sometimes we just need a little help to realise and then actualise. I believe that the greatest steps are taken when this happens as the person feels empowered to steer their ship once more.
We need to know where we are going of course, a direction created by clarifying what we want as opposed to what we do not want ~ “I don’t want pain” versus “I want to live well”. Focusing upon living well motivates actions and behaviours in line with this whereas thinking about getting rid of pain keeps our attention on pain. We will only be successful, and we can be, if we have the right approach, mindset and attitude that we may have to cultivate and practice. Most I see do need to work upon these skills of attention, resilience, self-belief and determination. That is the first choice.
We can choose our approach. We can choose to engage in healthy activities. We can choose to take every opportunity to live well. We can choose to create the conditions to feel better. We can choose to have meaningful interactions. We can choose to leave some thoughts alone if they make us feel bad. We can choose to move and gradually move more as we adapt. We can choose to learn about our pain and our responses to pain, and then change them if need be. There are many choices we can make.
Of course it sounds easy when written and the doing is different. It is an experience. However, it is perfectly do-able. We are designed to change and do so every moment that passes. We can harness our potential and opportunities with simple measures, practices and skills based on new knowledge. Achieving success is with everybody’s reach although sometimes we need some help and guidance. But we can do it. This is the ethos of UP. Let us make choices to live well, create joy and face challenges with a sense of ‘I can’.
The inner dialogue ~ what do you listen to and what do you tell yourself?
You are beautiful by La Melodie https://flic.kr/p/99ACEa
One of the things that makes us human is the inner dialogue or inner voice that is fairly continuously ‘speaking’ to us. Of course the voice is part of each and everyone of us and is not an outside agent. To some people it can appear to be coming from somewhere or someone else as in the case of psychiatric disorders. That must be frightening.
The inner dialogue is part of the workings of our mind. Our minds play a significant role in our actions and perceptions but it is not a one way street. The physicality of our existence can impact upon the way in which we think. The branch of philosophy named embodied cognition has much to say on this matter, addressing the notion that our thinking is embodied. A simple example is when thinking about hunger and food, we would typically feel that in our body, interpreting the sensations as being in need of food. A further example is the way we gesture with our hands to demonstrate a point, freeing up resources for further thinking. Consider how you feel when you think of a loved one or a difficult situation in the past — where do you experience it? Certainly not ‘in the head’.
There is a skill in choosing whether to listen to and act upon our inner dialogue or our thinking. It is true that we do not choose the workings of our mind, however we can learn about how it works, our habits of thought and realise how we embody these thoughts. In so doing, we have the opportunity and responsibility to become increasingly skilful in deciding whether to pay attention or to let go of thoughts and the inner dialogue. Being mindful is just that. We are aware of the thoughts, noticing their impermanence, recurrent nature, the way they create feelings in the body, but we are not engaging or becoming embroiled. There is a monumental difference between being in the film and watching the film. You are still experiencing the full richness of the feelings and emotions but with curiosity, with compassion and with an intent to only act with kindness, towards self and others.
Learning to be observant of the inner dialogue allows you to make choices. We have choices and often need to realise them. How am I choosing to feel or think about a particular situation? Even asking yourself that question gives you space to decide what you can do. Shifting the thinking to take another perspective can give a very different feel to the experience. Knowing that you can do this is very empowering, as you know that you can face challenges with skill and insight.
The story we tell ourselves can be so impacting upon our reality, lived experiences and ultimately our health and sense of well-being. If you persistently tell yourself that you are not good enough, have not tried hard enough or blame yourself for all sorts of things that may not actually be your fault, this will create a range of unpleasant feelings in the body as well as paint a bleak picture of life. Being hard on oneself causes our protect systems to switch into action. A range of common ailments manifest if these systems are ‘on’ too much without adequate refresh and renew time. Such problems include chronic aches and pains, sleep disturbance, gut issues, mood variance and exhaustion; very common presentations in my clinic. This need not be the case by learning some simple skills of well-being and day to day practices that stoke up our healthy systems. This is the bulk of the work we do to overcome pain and health problems — see here.
The inner dialogue and pain
The inner dialogue can tell us our story; the story of me. The self that I experience moment to moment, which is continually updating. Our implicit ability to change creates great hope as we can transform our suffering by gaining knowledge and insight into our existing habits. From this awareness we can choose to create new habits that are based upon our value system (what is important to you in life) and are by design all about sustainably living a meaningful life.
Many people with chronic pain have received messages that suggest pain must be managed or that they must just cope. This lowers expectations and hence our story and the inner dialogue is based on this belief. We can and must do better. Changing our story, and this is applicable to any story we tell ourselves, creates a new way onward. This begins with understanding pain. Countless people have told me how much better they feel on starting to understand their pain when we discuss their experiences at the first meeting. There is no magic here. We feel better when we have understanding of a problem and insight into how we can address the issues — feelings of agency, choice and empowerment feed and motivate us to take action; the right action. The Pain Coach Programme is all about the right action based on the right thinking. Understand your pain, write and see a new story and then live it. This is the story of your success, whether it be overcoming pain, setting up a business, writing an essay, doing an exam or playing a game of football. Use the story wisely, make it count and use every moment in a way that encourages and motivates more and more great action.
The Pain Coach Programme is a blend of strengths based coaching and pain sciences for your to achieve your success | t. 07518 445493
Complex Regional Pain Syndrome (CRPS) is a collection of signs and symptoms that define this particular condition. A syndrome according to the Oxford Dictionaries, is a ‘group of symptoms which consistently occur together, or a condition characterized by a set of associated symptoms’. Therefore, we can clump together any set of symptoms and give it a name, which is really what has happened over the years in medicine. The important point is that when we use the term, we should all know what we are talking about and know what we should look for to make a diagnosis. In other words, a set of guidelines.
The Budapest Criteria delivers guidelines for CRPS, which you can read about in this paper by Harden et al. (2013). The clinical criteria (see below) acknowledge the sensory, vasomotor, sudomotor/oedema and motor/trophic categories that really highlight the complexity of CRPS. Pain is often the primary concern, with people describing their incredible suffering in a range of graphic ways. However, it is not just the pain that causes suffering but the way in which the life of the person changes together with their sense of who they are and their sense of agency seemingly lost. One of the roles of the clinician is certainly to help restore that sense of who I am, a construct that is built from many of life’s ‘components’.
1. Continuing pain, which is disproportionate to any inciting event
2. Must report at least one symptom in three of the four following categories
Sensory: Reports of hyperalgesia and/or allodynia
Vasomotor: Reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry
Sudomotor/Edema: Reports of edema and/or sweating changes and/or sweating asymmetry
Motor/Trophic: Reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)
3. Must display at least one sign at time of evaluation in two or more of the following categories
Sensory: Evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or deep somatic pressure and/or joint movement)
Vasomotor: Evidence of temperature asymmetry and/or skin color changes and/or asymmetry
Sudomotor/Edema: Evidence of edema and/or sweating changes and/or sweating asymmetry
Motor/Trophic: Evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)
4. There is no other diagnosis that better explains the signs and symptoms
Importance of diagnosis
A diagnosis made in the same way, based on the same criteria means that clinicians, researchers and patients alike are all discussing the same condition. This may seem pedantic but in fact it is vital for creating a way forward. Clinicians mus know what they are treating, patients must know what they are being treated for and researchers must know what they are researching. Sounds obvious but let’s not take it for granted. So the Budapest Criteria has pointed all those with an interest in the same direction. Consequently we can focus on creating better and better treatments.
As with any painful condition, the start point must be understanding the pain itself. The following questions arise that we must be try to answer:
why am I in pain?
why this much pain?
why is it persisting?
what influences my pain?
what do I, the bearer of the pain, need to do to get better?
what will you do, the clinician or therapist, to help me get better?
how long will it take?
New thinking, new science, new models of pain over the past 10 years has advanced our knowledge enormously. Understanding how we change, how our body systems update, how we can make choices as individuals, and the practices we can use to change our pain experience to name but a few, create great hope as we tap into our amazing strengths and resources as human beings. Detailing the treatment approaches is for another series of blogs, but here the key point is that the first step in overcoming pain is to understand it. It is the misunderstanding of pain that causes erroneous thinking and action, which we can and must address across society — pain is a public health issue. Chronic pain is one of the largest global health burdens (Vos et al. 2012). It costs us the most alongside depression, and I believe that this need not be the case if and when we change how we think about pain, based on current and emerging knowledge.
“The first step to overcoming pain is to understand it”
This is the reason for UP | understand pain, which we started in 2015 with the aim of changing the way people think and then approach their pain, realising their potential and knowing what they can do. We are about to launch the new website that is packed with practical information for the globe to access online. Alongside this we have plans to create a social enterprise that will purport the same messages, coming from the great thinkers and clinicians who are shaping a new era in changing pain.
In April I will be running the London Marathon to raise awareness of the work of both UP and CRPS UK. You can support the work that both are doing to change pain by donating here
Engaged physiotherapy for pain and the modern world
Engaged physiotherapy is an approach embracing full awareness of oneself as a clinician, full awareness of the person you are working with, full awareness of the context and past, compassion (self and others), insight, and modern sciences (the facts ~ what we know). I have ‘borrowed’ the term from Thich Nhat Hanh who describes engaged Buddhism, which is the practical use of the philosophical principles such as mindfulness, mindful breathing and mindful walking.
Cultivating our awareness as clinicians and gaining insight into the causes of suffering affords us the opportunity to think clearly about the best action for the individual, in this case in pain. Together with an understanding an use of modern sciences, especially pain science, cognitive science and neuroscience (there is vast overlap of course), and philosophy, we can consider each person’s story and create a way onward that is grounded in understanding, compassion, belief and the right attitude to succeed.
There are simple practices that clinicians can use each day that develop and grow awareness and insight. Here are some examples:
Being present during a consultation using the breath
Deep and active listening
The creation of a calm and peaceful environment
The initial contact often sets the scene. We can think about how we present ourselves with posturing, gestures, language and the simple smile. I would suggest always going to the patient to greet them in the waiting area, and behaving very much like you are welcoming an old friend into your home.
Using the breath we remain present and aware of what is happening right now. What is passing through me (my mind)? Any bias? Preconception? Judgement? Being aware allows us to let these go so we can focus on active and deep listening. Practicing mindful breathing each day formally for 5-10 minutes helps us to develop this skill that we can use through the day, every day for professional and personal relations to benefit
One of the most valuable gifts we can give to another person is ourselves and our time. Being fully present to listen to the patient (or colleague or family member or friend) creates the conditions for a meaningful interaction. All involved parties benefit from meaningful interactions as we release certain healthy chemicals in these contexts. In deep listening we can hear and understand the suffering of the other, enabling the best and wisest course of action, which may simply be to continue to listen without interruption. Learning to be comfortable with silence is a valuable skill. Much can emerge from moments of silence. (Reading here)
Choosing our words carefully, considering their effects, is an important skill to develop. The words we utter have potent effects on others as they hear, process, imagine, think and react. Of course using kind, compassionate words can create the conditions for calm and insight, enabling the person to see a way forward. A focus on health and being well maintains the desired direction, hence the use of words that encourage this thinking and vision helps the person to orientate themselves towards a desired outcome.
We have the spoken word and we have the inner dialogue. Being skilful with both is important as we need to consider which thoughts we are fuelling, or which seeds we are watering by the way we think and what we say. An example would be the effects of engaging in idle gossip. In the long-term, gossip can create issues of trust and miscommunication that breeds suffering.
As a clinician, we should always be thinking about delivering the right messages based on truth, and that provide a compassionate way forward. Helping the patient develop their skills of self-compassion is frequently needed in cases of chronic pain. Understanding that self-compassion is one of the skills of well being helps individuals to practice and benefit from the nurturing of the care-giving systems in the body that play such a big part in our health and happiness.
Creating a calm environment
We are very responsive to the environment. Consider how you would feel working in an office with no windows and in the basement of a block compared to an office with a view over a park or a river.
Clinicians need to think about how the patient might think and feel coming into the clinic. We seek to create a peaceful space for people to experience feelings of calm and gain insight into how they can be, how they can transform their state of being and how they can use these practices in their day to day lives.
The simple practices are just some of the ways we can use our knowledge and skills to create the conditions for people to get better. We no longer have to think about managing or coping, instead use engaged physiotherapy and approaches to give people the belief, understanding and skills to coach themselves, fostering independence and a sense of agency, restoring choice and meaningful living.
These practices are part of the Pain Coach Programme, which is a focus upon getting better and achieving success in overcoming pain. The programme for patients is a comprehensive way forward addressing a pain problem by focusing on getting healthy and well, and the programme for clinicians is to develop their skills and knowledge to coach patients. If you would like further information, please email us: [email protected] or call 07518 445493.
Creating peace is vital for suffering individuals and for society
Creating peace should be the aim of all society but of course peace must reside in each individual for this to happen. One of the greatest proponents of peace is Thich Nhat Hanh, a Vietnemese monk who works tirelessly to bring engaged Buddhism to the world. This means simply teaching simple practices that can be used by everyone, not in a religious sense, but instead as a way of creating peace through compassion and insight. Mindfulness is the main vehicle, and to be mindful is to be fully present, to be aware, to have insight, to have clarity, to experience emotions and thoughts in this moment, to be judgmental, and to be accepting.
Mindfulness is a simple practice ~ anytime, anywhere
Mindfulness is a practice that can be used through each day in different ways to gain these healthy benefits. Some describe a practice like this as a skill of well-being, or the skill of being well. These skills form a major part of the Pain Coach Programme, which is a comprehensive approach not only to overcome pain and chronic health issues but to create the best health to live a meaningful life within our ever-changing circumstances. It is much like learning to sail a boat when the sea is sometimes calm and the sea is sometimes ferocious. The wandering mind is an unhappy mind, read the title of a well-publicised piece of research. Whilst we also know that to permit mind wandering can be useful for ideas and creativity, having control over when this starts and finishes maybe important. Certainly being able to attend to what you are doing in this moment is a valuable health skill afforded by mindfulness practice.
Those who have practiced mindfulness will know that creating peace is one of the emerging experiences. We cannot quieten our mind directly, but the mind can calm within the context of being mindful. Thoughts just come, and we cannot stop them much like King Canute could not stop the sea. Yet we learn how to become insightful and skilful as these thoughts pop in, seeing them as just thoughts and opinions that are often very different from reality and truth. Being observant and curious about our thoughts, or the story that we tell ourselves, gives us space to choose how to respond. How can you respond? You can decide to re-focus your attention on what is happening now by using your breath, you can let the thought go (they pass by anyway), you can purposely generate a positive feeling, you can engage in a meaningful interaction or you can perform an act of generosity. All of these you can do in a way that is informed with self-compassion, being kind to yourself, a key skil of well-being.
Individually we are responsible for creating peace within ourselves. It is an error to think that somehow peace or happiness comes from somewhere or someone else. Mindfulness teaches us that we can come back to ourselves at anytime in order to feel at home and secure. That sense of safety, warmth, comfort and peace we can generate ourselves with increasing effect by practicing the skills of being well and cultivating our awareness and insight. In doing this, we are regularly promoting our own health by activating the care-giving systems in our bodies. These play a vital role in day to day physiological functioning: nourishing body systems, diverting resources to healing, repair, refreshing and renewing, digesting food and building energy levels that we need to live and feel well. This is in contrast to the protect and service systems that are designed to work in short bursts. It is when the protect mode is operating consistently that we can develop a wide range of common ailments: IBS, migraine, pelvic pain, wide spread aches and pains, chronic pain, fibromyalgia, and fertility issues to name a few. Choosing to lead a hectic life full of habits that promote survival without adequate deep relaxation only results in health issues. However, we can always make the choice to make a change in a new direction.
We are changing every moment, you just need to choose your direction in line with your vision of the well-you and groove new habits
There are many issues with modern society and its impact upon the health of all, however we also have a great deal of knowledge we can use to make an impact. There are many simple practices that we can use each day to improve our world. This all begins with a shift in thinking beyond oneself towards a mindset of how we can best give and serve our world and the people in the world. We are interconnected in many ways and collectively we can be responsible for social developments that benefit all. We are seeing this increasingly with social enterprises emerging in different sectors. This work is vital for all of us.
Creating peace within ourselves with a simple practice each day is the basis for a collective peace within society. On an individual basis, the creation of peace within is the same as creating the conditions for health as the parasympathetic nervous system predominates. There is so much to be gained from practices that can be learned by all ages (children, teenagers, adults and seniors) in different environments (nurseries, schools, workplaces, homes and healthcare facilities). Low cost, easily implemented and science-based there are a number of initiatives across the world that we can build upon and develop. However, it starts with the individual.
Pain Coach Programme to overcome chronic pain by using the skills of being well to lead a meaningful life | t. 07518 445493 or contact us using the form below.
Anyone who has tried to describe their pain knows how incredibly difficult it is to find words that truly represent what they feel. The same could be said for many lived experiences, the ‘what it is like to……’ that we attempt to transmit to another person. But of course the other person cannot actually know or feel what you feel. We only know what it is like to be ‘me’.
Acknowledging this issue, when we ask people to describe their pain, they are permitted to use any words from their own vocabulary and any comparison or metaphor that emerges from their thinking because this is as close as they will get. Whilst they are telling us what they feel, as well as words that attempt to describe the raw feel of pain, others will demonstrate the degree of suffering and emotional distress that are the additional factors, or second arrow in Buddhism terms. We experience a raw feel, which would be the first arrow, and then the thoughts and emotions that have their own ‘feel’ and typically are the source of the greatest suffering, which are the second arrows.
The raw feel of pain is the raw feel of pain. The add ons are all the thoughts and feelings associated with the pain that are the cause of great suffering.
Active or deep listening allows us to really hear what the person is saying to us. This is sitting in a state of calm and non-judgement, allowing the person to express themselves in their own unique way. Silence maybe part of this ‘exchange’ that the clinician can become increasingly comfortable residing in, with the knowledge that from silence can emerge important dialogue. Only through deep listening can we hear the words of the other that emerge within a particular context that must also be recognised ~ i.e. the difference in the way someone behaves in different situations such as the clinic when they may be anxious. We must get as close as we can to hear what the individual is saying: have I truly heard what they have said?
We can enhance the flow of communication with our posture and the way we move within the dialogue. A simple movement towards the person shows engagement whilst eye contact can be used judiciously. It is worth considering that for some people eye contact can be challenging or threatening, hence awareness and being present are important.
Our way of being, when filled with compassion and empathy, creates the opportunity for the person to speak and tell their story that is full of all the information that we need as clinicians to gain insight into their suffering and the causes of their suffering.
Pain Coach Programme for chronic pain | skills of well being to live a meaningful life | t. 07518 445493
Pain and Communication
The problem of pain
Communication 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.
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:
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
Trusting hands — Our hands have many roles, from manipulating tools to communication to soothing another person. We hold a pen and write, we gesticulate, we put our hand on someone’s shoulder. It is the last action that I am interested in here, as we employ touch to make someone feel better by both letting them know we care and changing the sensory activity of the body. There is one aspect of this that is important, and that is meaning. The meaning or intention behind my action and the meaning construed by the recipient. They can be at odds, so setting the scene and making a judgement is important. Certainly in the therapeutic setting, clinicians must judge the right time and the right approach for hands on therapy, especially in chronic pain. Trusting hands is one way to describe them.
In some cases, even light touch can be very painful. Sometimes the pain of hands on treatment can be deemed to be good — ‘that’s a good pain, keep going’ they may say! If the body systems and the person are in protect state, they may well guard the area by tensing up or gesturing to keep people away. They are in fact predicting and expecting that the touch will hurt and therefore put up a defence. There are also people who do not like being touched for a range of reasons beyond whether they think it will hurt or not. This is of course a consideration for the therapist who wants to use their hands.
The notion of trusting hands emerges from a compassionate approach to treating pain. Always beginning with deep and active listening to gain insight into the causes of suffering, the trusting hands become part of the way we communicate our concern and caring before using them to ‘listen’ to the body through touch. This is not an alternative view but instead a way of gaining further understanding of how that person’s body is responding to movement and touch (mechanical forces). We can feel and see the existence of guarding, which demonstrates that protect state is ‘on’ and monitor how this changes as the individual begins to feel safer and more confident. This is in the knowledge that there is no harm or damage associated with the pain, the pain being an indicator of a perception of threat, not a gauge on injury.
The way in which the hands touch the body from the initial contact to the strokes or pressures applied will all imply a certain message. This is why the clinician needs to be aware of their intent and be present when laying on hands. The trusting aspect comes via experience. In other words, the trust results from the recipient knowing that the purpose of touch is to make him or her feel better by changing their experience. They will most likely have some preconceived ideas as to how hands on therapy works and the therapist may have to tweak this thinking in line with what we actually know. In a nutshell, we are seeking to change the way in which the brain predicts the causes of the sensory information coming from the area we are treating. Through this new prediction, or update, as a consequence of an explanation that sets the scene and primes in the right way (think of ploughing a field before sewing the seeds) and then the applied treatment, the person has a new experience, one that is feeling better. I usually explain to people that the feeling better aspect gives them a new reference point so that they know their body can feel different and good. They then use their programme strategies (Pain Coach Programme) to re-enact this feeling over and over as a new habit, which is getting better.
The trust element comes from the whole approach to the person, viewing and treating them as a whole and not a ‘body part’. Respecting their views, beliefs, values and validating their story is vital in creating a trusting partnership. Within this context, the hands play the trusting role of communicating compassion as well as effecting the benefits that have been well studied. Hands on therapies are part of a complete programme of care, and used wisely can facilitate many of the other aspects of the training and treatment.
Each session should result in the person having had a positive experience, feeling inspired and encouraged to practice their training and strategies in their world, their reality. What happens in the clinic is a bubble, often of safety, and then the person needs to take that across the bridge into their world and live. In this way, to resume living a meaningful life requires us to do just that. You get back to living by actually living and knowing how you can do this each day, gradually building up the things you can do and starting to re-engage with things you have stopped doing. With working knowledge of your pain you realise that you can do this with increasing confidence, the fear dissolves and the focus is upon getting better using the strengths that you already have and know. The trusting hands have a role in this science and compassionate based approach to chronic pain.
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Recently 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 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.
Recently 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 are 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.
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
Walk 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.
Mindfulness practice is a part of the Pain Coach Programme for overcoming pain | contact us by email: [email protected] or call us 07518 445493