Welcome back to the Healing Pain Podcast with Karlyn Edwards, MS

On this episode, we’re talking about the relation of self-compassion to functioning among adults with chronic pain. Our expert guest is Karlyn Edwards. She is a clinical psychology graduate student at the University of New Mexico working with Dr. Kevin Vowles and Katie Witkiewitz. She studies important psychological factors that impact chronic pain as well as psychological interventions that can improve the lives of those living with chronic pain. She also studies how opioid and other substance misuse issues affect chronic pain, specifically how pain impacts medication treatment for those living with co-occurring opioid use and chronic pain. She also just completed one of the few studies that exist out there on how self-compassion can help people with chronic pain as far as a treatment intervention. Karlyn has also provided you with her free gift to accompany this episode. What she did was she summarizes all of the research as well as how self-compassion helps people with chronic pain into one nice concise document. To access that, all you have to do is text the word, 146DOWNLOAD, to the number 44222, or you can open up a browser on your computer and type in the URL, www.IntegrativePainScienceInstitute.com/146Download and you’ll receive that right to your inbox absolutely free. I’m excited to introduce Karlyn to all of you, as well as share her work and her research. I know you’re going to find it valuable.

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The Role Of Self-Compassion In The Treatment Of Chronic Pain with Karlyn Edwards, MS

Karly, welcome to the show. It’s great to have you here.

Thanks for having me, Joe.

You published a great study in the May 2019 European Journal of Pain. The title of that study is The Relation of Self-Compassion to Functioning Among Adults with Chronic Pain. The reason why I reach out to you is because I read a lot of research on chronic pain. There’s not a whole bunch out there on self-compassion. I think before we delve into this compassion is a word that people thrown around a lot. Self-compassion is even another layer deeper into that. Can you start us out by explaining what self-compassion is?

Self-compassion is made up of three different facets. It’s self-kindness, common humanity and mindfulness are the three facets that we look at when we’re looking at self-compassion. Self-kindness specifically is essentially what it says, being kind to yourself during instances of difficult experiences when you’re experiencing setbacks. When you’re experiencing any failure or there’s any setback. What we look at is that it’s different than self-criticizing, so it’s the opposite. They’re self-criticizing and self-kindness. There’s common humanity which is understanding one’s own experience as connected to the larger human experience.

Seeing yourself as part of the larger human body that I’m experiencing something that a lot of other people experienced too, that I’m not alone in what I’m feeling. Mindfulness is also one of those words that’s thrown around a lot that we use often. In the context of self-compassion, mindfulness is thought of as holding and staying in contact with painful experiences, not avoiding them, not pushing them away and also not over-identifying with them. Over-identifying with them can be looking at them as part of your identity or saying “This is going to be around forever. I’m not going to be able to get out of this.” It’s those three facets that make up self-compassion.

A lot of that was started by Kristin Neff?

Yes, she was the first one to move it into more of a psychological construct that could be studied.

As well as from probably centuries of contemplative work and lots of different areas. I guess that influenced your work. Did you study mindfulness and contemplative approaches at all?

I do actually. I study mindfulness-based relapse prevention, so that’s in the context of substance use, but certainly we use mindfulness a lot in acceptance and commitment therapy, in acting what I practice a lot also in chronic pain.

How and why is self-compassion related to chronic pain?

That gets at the heart of that study that you were talking about that I published. What we wanted to look at is that there’s a lot of work in self-compassion in a lot of different chronic health conditions, but we don’t see a lot of that in chronic pain specifically. That’s where this paper came in. I wanted to look at the role of self-compassion in these important markers of treatment outcomes for people with chronic pain. What we looked at in this paper is we took self-compassion scores and saw are they associated with better treatment outcomes? Things like depression, pain anxiety or how afraid you are of your pain, pain acceptance if you’re accepting of your pain.

Even as far as engagement in meaningful activities, things that are valuable to you and pain coping strategies. Based on both pain control and relaxation. Also, on acceptance-based approaches, allowing and noticing your pain for what it is. What we did is even controlling for pain intensity. What people were feeling in the moment as they were filling out these assessments and also controlling for pain duration. How long was pain sticking around for this person? We saw that higher levels of self-compassion were associated with lower levels of depression, pain anxiety, physical and psychological disability, higher levels of pain acceptance and engagement and meaningful activities and use of pain coping strategies.

What this study was looking at is laying the groundwork, “Is self-compassionate associated with better outcomes?” What we found is it is associated with better outcomes. The interesting part of the findings was that we saw that self-compassion was related more to psychological distress. Those are depression, pain anxiety, psychological disability and engagement in meaningful activities. Where it was less related to things like physical disability and strategies you use for pain control, reducing pain intensity. That was the interesting part that came out of all of this.

I found that interesting too. I was reading through your research. I was probably a little disappointed on some level. I was hoping that there was a little bit of positive shift toward some of the physical disability and that there may be if we measure in a different way and population might see more of that. The coping part, I also found interesting in the study. It can be a little challenging to work with patients with regard to pain coping skills from the lens of an acceptance-based approach because they may and especially depending on how a practitioner also utilizes the intervention. They may look at it as a way to control or eliminate pain versus cope with pain. Can you talk about that a little bit and how that added a different layer to the study? I don’t usually see in most of them.

We did see a little bit of bump in physical disability or these pain control. It’s not to say that it’s not adding nothing. There’s some additive effect there, but certainly not as big as we see in the other areas. You’re exactly right that it’s hard when people are in the room with you to say, “We’re going to focus on acceptance-based things,” and they’re like, “How can you make my pain go down?” I think when we’re looking at self-compassion specifically. I like to think of it as two different categories. One is focusing on primary suffering and secondary suffering.

Primary suffering is what we think of as those difficult times in life that we can get rid of, grief, loss, pain is certainly in that category for people with chronic pain. There’s more secondary suffering looking at ways in which we respond to those things. How we talk to ourselves, the behaviors we engage in on a day-to-day basis. Self-compassion is helpful in aspects of secondary suffering. How can I even with all of this stuff going on still continue in a way that I’m living my best life even with all this other stuff going on? In the aspect of a physical disability that physical disability is hard no matter what intervention you’re using to eliminate and pain I would say falls in that category for chronic pain folks.

That primary and secondary, if you follow contemplative approaches, they would call out the second-hour effect. The ACT looks at things like clean and dirty pain. I was never crazy about the word dirty pain, but it’s an interesting way to look at it. Self-compassion is helping with the second-hour if you’re following contemplative approaches or the dirty pain if you’re following the ACT. We look at it as the psychosocial aspects of it. With regard to the secondary aspect of the suffering, one of the things that I’m curious about is how does its practitioner start to apply that. Mental health professionals probably will pick up on this faster, maybe it’s a nurse, a physician, a physical therapist or an occupational therapist. How did they start to look at that?

Sometimes the farthest is modeling. For people to in the room with physicians, nurses, psychologists or whoever’s in the room taking care of the patient, modeling, self-compassion for them. Both from your own experience saying like, “I’ve had a tough day and I’m a little bit exhausted but I’m doing okay.” Also, on the flip side of that, catching patient language. When they’re beating up on themselves and they’re saying, “I had a rough day. Everything sucks. Pain is the worst.” Using that as an opportunity to reframe their language can be helpful for patients to see, “Someone else is being caring and compassionate towards me that might be a better response than maybe beating myself up.” That continual shaping of language and modeling can be helpful for patients to hold up a little bit of a mirror to themselves and say, “I’m beating myself up a lot. Maybe there’s a more compassionate view I can take.” That’s definitely stepping one and it’s easy for lots of people to implement no matter what profession you’re in.

I want to come back to that because language is so important, especially when you work with people with chronic pain, but not just pain. Any type of chronic elements, whether it’s physical or mental. Does someone need to have a seated meditation practice? I’ve had some people say ten minutes is fine, some people say no, you need 40 minutes. Do we have to develop a seated meditation practice to either cultivate compassion in ourselves or to help our patients and clients cultivate self-compassion?

It’s a tough line to walk. Sitting down to meditate is not going to hurt anyone, so I definitely recommend it to clients if they’re able to sit down. Even if they can just get one minute down, that is so much better than zero and two is better than one and etc. I don’t think there’s any magic number. I don’t think it’s 10 minutes or 40 minutes. I think any sitting formal meditation practice is going to be helpful. That said, at least in the realm of self-compassion, even quick on the go mindfulness practices can be helpful too that don’t necessarily require you to sit down. Take five minutes out of your day. I know for some people they don’t have five minutes. These quick informal practices are helpful when you don’t have a lot of time to sit down. What that looks like is just checking in with yourself. Taking a quick moment to say, checking in with maybe body sensations, “Why my heart’s racing. I’m feeling a little sweaty.” Checking in with emotions, “I’m feeling a little anxious and tightness in my chest.” Checking in with thoughts, “My thoughts are racing,” and moving forward with the rest of your day. Just allow you to regroup and it only takes a couple of seconds. That’s usually where I start with clients is, can we work in just a little bit of informal practice throughout your day and then maybe work our way up to sit for five minutes or ten minutes?

Just taking a moment to notice what’s happening in your mind and in your body. Obviously, those two things are intimately connected. When I reflect back on some clients I’ve had, at times there’s a lot of behavior change that has to happen with someone who has chronic pain. We have all the tools to help people, but the behavior can be tough. With that, people can be tough on themselves sometimes. How do they start to cultivate self-compassion themselves?

One aspect of that is meditation. Even though it’s quick informal practices and checking in with yourself, can give you a picture of where am I at? There are other little things that you can maybe cue yourself and ask yourself after you’ve done that small little check-in. Something along the lines of the common humanity piece wholeheartedly believes that I’m not alone in what I’m feeling. I think what that does is breaks down that isolation, especially people with chronic pain feel a lot. They often find themselves socially isolated, not feeling they’re connected to a community. Even if a lot of people experienced chronic pain, I’m not alone in this, but I think that goes a long way to feel like, “I’m not the only one in the entire world that’s feeling this.”

Along the lines of thinking about how can I cultivate self-compassion is asking yourself, “How would I treat a friend in this situation? If someone came to me and said, I’m a lot of pain. I wasn’t able to get out of the house. What would I tell my friend?” I’d probably tell my friend, “It’s okay. It was a tough day, maybe try again tomorrow,” rather than, “I have the worst and pain dictates my whole life.” That’s an easy question to ask yourself. At the heart of it too is noticing in our language coming back to that those shoulds and have tos. Whenever you find yourself talking to yourself in the sense of, “I have to do this or I should do this.” Those are always little cues for me, especially as a clinician when I’m in the room with patients to say, “Is that true? Do you have to?” Take a moment and assess that because usually it’s not true. Usually, there’s not a have to or should.

Breaking down and catching those little nuances in languages is helpful. Lastly, I think something that Kristin Neff who talked about creating self-compassion as we know it in the more Western world talks about that love is more powerful than fear. I think what she’s getting at there is that when we are motivated by love, that is so much more sustainable than when we are motivated by fear. Fear can be, “I’m scared of what pain’s going to do and I’m scared of putting myself out there in a new situation versus, I’m ready to connect. I’m interested in getting my health a little bit better, whatever the decision is that we as humans are much able to sustain important activities when it’s fueled by love, whether it be for ourselves or for others, rather than this more fear-based decision making.

Not a lot of people talk about love on my podcast, which surprises me. I probably need to focus on it a little bit more. The field of psychology is so huge, but when you have someone break it down into those two things, love and fear and someone can look at it and say, “I have two things that I can look at or focus on or relate to.” It is important within the worlds of chronic pain that I think that word should be used more and more, so I thank you for using it. Do values work tie into that over theme?

I think values definitely fall into the love piece. It falls in there in the sense that values are usually things that are important and meaningful to us that when we engage in those activities that they fuel us. They get us going and lightness up and bring meaning to our lives. Whatever word you choose to use, love, values, positive reinforcement if you’re more behavioral analytics. Those are what is sustainable and that more fear-based decisions or things that all into, I have to or I should, usually fall in there too. Usually, it motivates us, but they’re not self-sustainable. They’re more negative reinforcement. The research tells us that that is much less sustainable and keeping up behaviors, but certainly values are more driven in that love field for sure.

Are we at a place yet where we can pre and post-tests measure compassion in clinical practice where let’s say something we want to measure, whether we know if our intervention is working and targeting self-compassionate?

There have been a few studies, specifically one I’m thinking of in ACT where they looked at the mediating mechanism of self-compassion. Meaning changes in self-compassion during treatment are those related to good treatment outcomes. An ACT specifically, we’ve seen that changes in self-compassion lends itself to better treatment outcomes in chronic pain and that ACT a specific intervention can target self-compassion quite well. There’s only been one study to my knowledge that’s looked at that. We certainly need more and I’d be interested in looking at other mindfulness-based interventions to see if that pre, post self-compassion and changes and self-compassion lends itself to better treatment outcomes. That is the direction that we’d like to start moving for sure.

Is there research that traditional forms of CBT may have that in there somewhere that we maybe haven’t measured or looked at specifically?

Not to my knowledge. I’m sure your audience is familiar with CBT relatively, but that’s what we aimed at is going afterthoughts. Changing thoughts and behaviors to line up and it is very effective for lots of people. Also, it’s different than ACT though where we’re aimed at more acceptance-based approaches and persisting in behavior even when the stuff is tough, even when thoughts are all over the place. I don’t think we have a good sense yet if CBT builds up self-compassion in the same way that ACT is, but that would be a great study to carry out because I don’t think there’s been a lot of work in that.

I hear a little voice in my mind wanting to ask. You’ve mentioned CBT doesn’t have it in there necessarily, but ACT does. There are some flavorings of that in ACT, probably in all the processes and psychological flexibility. Does someone then need to study compassion-focused therapy or empathy-focused therapy? There are lots of different types of therapies out there. Is ACT enough or is mindfulness enough if I can phrase it in that way?

I don’t think we have an answer to that yet. Research is just starting to get going in compassion-focused therapies. Even looking at things as small as a brief intervention. Can we have someone have one or two sessions of self-compassion focus and it’s not enough to get some people up and moving and in a better place? I think that’s definitely a direction that the research is going. There’s not a lot of work yet in chronic pain in that area. I’d like to see more and hopefully I might carry out more of that. Definitely, there’s room to grow there and coming back to the CBT piece. The intervention might not specifically have empathy or compassion written in the manual, but I think that’s where the provider can model self-compassion. It’s not to say that because the intervention doesn’t have self-compassion written in that that’s not getting translated to the patient. That potentially by the provider being empathic, listening, and correcting patient language that that’s still coming across. I don’t think it’s written as clearly in CBT as it may be as an ACT or mindfulness. There’s still room to understand self-compassion more in a CBT framework and to look at that, is it more provider-based or is it more treatment-based? I don’t think we know yet.

Interesting thoughts because if it is provider-based, then how do we cultivate that in providers so that they can leverage that more and more in treatment? You mentioned brief interventions. Maybe if you look in the research, the average cognitive intervention, no matter what type of therapy looking at is maybe between seven and fourteen sessions. The brief would be as far as a number of weeks, as far as the time. It could it be brief as far as the first ten minutes of your intervention might be compassionate? What does all that look like?

What’s being looked at is a few different brief interventions. There’s one that’s like a web-based that’s not delivered by a provider. That’s even interesting to think about as we were talking about this might be translated by the provider or maybe we don’t even need the provider and a web-based intervention can do it. Looking at web-based, there are a few modules a person who can complete. Maybe three to four hours over the web. There have also been brief interventions to look at maybe like an hour for two weeks is the other one. Two hours of your time once per week that would come in with a provider. Something that would be interesting that I would like to move the field in is looking in to see if we can train providers to do what you’re saying a brief ten minute intervention with someone before they jumped into maybe their medical appointment or before they jumped into their PT appointment or to see if that also might get us some outcomes or movement in these important outcomes too.

I’d be curious to see that because I think we know from contemplative approaches that it’s wrapped up in there. I’d love to see someone like, “What’s going on in that closed eye practice and take that and figure it out?” “Here’s between a 10-minute and 30-minute intervention that you can work into practice.” We’ve talked a lot about self-compassionate and its importance for people with chronic pain. How important is it for the providers that treat them?

I would say it’s important in burnout. That is something that we talk a lot about in these more helping professions, whether it’s PT, psychology, nurses or doctors. Self-compassion is starting to grow a lot specifically when we’re looking at burnout in those careers. I think for caregivers it’s sometimes almost important, but it’s certainly as important as it is in the patients. What we know is that when we take care of ourselves, we’re able to better take care of others as well. I think of it as I use it with clients sometimes like a cut metaphor. I have to fill my cup before I can fill yours. Often that clicks with people to say, “If I have an empty cup, I’m not going to be able to help my fellow whoever I’m with.” Thinking about filling your cup before you’re able to go out and help others. Not only helps the people that we’re helping and making sure that they get the best care, but also taking care of ourselves and not running ourselves into the ground.

Karlyn, I know you’re still in training and there’s a whole couple of years ahead of you still, but what’s in the near future for you?

In the near future, I’ll be finishing up my graduate training at the University of New Mexico. I am moving into the field of chronic pain and substance use and looking at interventions to see if we can target both of those things at once. Because we know chronic pain, there’s often a hand in opioids and we see substance use also. Also, career trajectories, I’d love to work in interdisciplinary care. I think that that is important, especially when we’re working with folks with chronic pain who have a lot of complex needs that psychology can fill all the time. We need lots of other providers on hand. Working in some interdisciplinary setting where I can be in a pain clinic and implementing this research that we’re talking about and looking at little brief interventions and self-compassion would be helpful.

I want to thank you for your time and for the great study that you did. If people want to learn more about you and what you’re up to, where can they read all about you?

Look me up on Google Scholar. I’m Karlyn Edwards at ResearchGate and at the University of New Mexico on their Grad student website.

I want to thank Karlyn for being on the show to discuss self-compassion and chronic pain. It’s an important topic that we have not talked about a lot in this episode. Please make sure to share it out with your friends and family on social media. If there’s a Facebook group where people are involved in mindfulness and compassion or chronic pain, drop it in the group there so they can share and they can check it out. It’s a pleasure being with you and we’ll talk to you next time.

Important Links:

• Karlyn Edwards
• The Relation of Self-Compassion to Functioning Among Adults with Chronic Pain
• Kristin Neff
• ResearchGate – Karlyn Edwards
• https://www.NCBI.nlm.nih.gov/pubmed/?term=The+relation+of+self%E2%80%90compassion+to+functioning+among+adults+with+chronic+pain
• www.IntegrativePainScienceInstitute.com/146Download – free gift

About Karlyn Edwards

Karlyn was born and raised in Seattle, Washington, and completed her undergraduate degree at the University of Puget Sound. She is now currently a clinical psychology graduate student at the University of New Mexico, working with Drs. Kevin Vowles and Katie Witkiewitz.

She studies important psychological factors that impact chronic pain as well as psychological interventions that can improve the lives of those with chronic pain. She also studies opioid and another substance misuse in the context of chronic pain, specifically how pain impacts medication treatment for those with co-occurring opioid use disorder and chronic pain.

In her spare time, Karlyn enjoys travel, snowboarding, surfing, and yoga. She plans to pursue a career where she can continue carrying out research examining important psychological factors and effective interventions for chronic pain and substance misuse.