Welcome back to the Healing Pain Podcast with Joe Tatta, PT, DPT, CNS
By now, you know that I’m a big fan of mindfulness and acceptance-based approaches for the treatment of chronic pain and I’m pretty sure I’m not the only one. If you look at studies, an increasing number of Americans are using some type of integrative or contemplative practice on a daily or a weekly basis to improve upon their physical health, as well as their mental health.
One of the reasons why I love mindfulness and acceptance-based approach so much is because, as practitioners, we’re faced with an increasingly complex, more chronic, and more disease professional landscape. The other reason is I believe we’ve arrived at a place where we can no longer separate the brain from the body or the mind from the body, however you’d like to look at it.
Consider for a moment that there’s a well-known, backed by evidence and science, strong positive association between living in a state of stress, which then turns into emotional distress and then finally, on to mental illness. There’s a bi-directional relationship between mental illness and physical illness that’s inseparable.
Currently, 1 in 5 Americans lives with a mental illness, that’s about 52 million people and there have been surveys of physical therapists working in the general orthopedic practice where 75% report treating comorbid mental health problems on a daily or weekly basis. Mindfulness and acceptance-based interventions are a family of methods that emphasize a present moment awareness, nonjudgmental stance, and employ values-based living.
The techniques and exercises embedded in these methods teach you how to cope with stressful thoughts, stressful emotions, and even painful physical sensations. The goal is not to clear the mind or to prevent difficult emotions or thoughts from occurring. We don’t have a great way to do that. It’s about learning how to relate differently to all your experiences, even the distressing ones as part of our human experience.
These methods are useful in clinical practice, especially if you’re aiming for health promotion, improving physical function, injury prevention, pain management, modulating the immune system, alleviating noncommunicable disease, and even improving sports performance. Mindfulness is much more than meditation. These are thoroughly investigated, science-backed, and proven methods of health behavior change.
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Using The Power Of The Mind To Control Pain
We begin with meditation teacher, Sharon Salzberg. How do you describe or define mindfulness?
It is described in a lot of different ways. My common description would be a quality of awareness of your experience in the present moment that your perception of what’s happening is not distorted by bias. Sometimes say a certain emotional word arises, and we don’t like it. We don’t want to admit we have it and we shove it away a little better. We might well have the habit of projecting into the future and especially around uncomfortable, painful, difficult emotions or physical sensations. I certainly have that habit. When painful feeling arises, I see my mind right away saying, “What’s it going to feel like in five minutes? What’s it going to look like in ten minutes?”
I’m not being with what is, which may be difficult enough, but I’ve now added a warm future and I try to bear it all at once and I feel overcome. That’s the habit that we all have one form or another of. We’ll arise very commonly, but we can see it in mindfulness. We can see it and let go of it. We come back to our original experience in a much cleaner way.
Up next is Dr. Kristin Neff. Weaving mindfulness work into those with chronic pain is important. The concept of compassion and especially self-compassion, which people have to start to open the door and peek into when it comes to living with chronic pain or chronic illness. The best way to lead into this nowadays is to give us your definition of what self-compassion is and why it’s important.
Especially for people with chronic pain, self-compassion is key. There’s a lot of overlap between mindfulness and self-compassion. In fact, the first step of self-compassion is to be mindful that you’re in pain, either emotional pain or physical pain, and to be able to relate to that pain with an accepting stance instead of fighting it, “I wish I wasn’t feeling this pain.” Sadly, we know makes things worse, accepting, “This is the reality. I’m feeling pain and giving it space is very key.” We don’t want to stop there. We want the heart to be involved as well, not just our awareness.
What self-compassion does is it adds two components to mindfulness. First is warmth and kindness. In other words, you could acknowledge you’re in pain and you don’t want to fight it, but at the same time, it’s like, “It hurts. I’m so sorry. I’m in pain.” That tenderness and care like if you have a friend or a child who’s in pain, you naturally say, “I’m so sorry.” There’s a warmth, tenderness and concern that goes toward the person in pain.
We can do that with ourselves and it also helps us hold the pain. We’re able to have that warmth and tenderness toward ourselves. If you want to be non-scientific about it, it is love but then there’s another element that’s crucial and that’s remembering humanity connectedness. If you look up the root of the word compassion, it means compassion. Suffer what passion means. Suffer means what? Inherent to the state of compassion is some sense of this is the human condition. We’re all imperfect. We all lead imperfect lives.
It’s onto Harvard Neuroscientist, Dr. Sara Lazar. When we talk about mindfulness, we talk a lot about the brain and pain on this blog. When we talk about mindfulness, what types of effects do we see that mindfulness has on the brain?
We have done a lot with brain structure. We have shown both in long-term meditation practitioners and the novices that there are differences in brain structure. By that, what we mean is we took people who never ever practiced meditation before. We randomized them to either go through meditation or go through such weightless control. Insulation, we scan the meetings apart, but we didn’t do anything between those eight weeks. What we saw is that the people who went through the meditation program had an actual increase in gray matter in their brain, in certain brain regions, compared to the controls who didn’t go through the program.
A lot of them are like, “This is amazing.” It’s well known that if you transmit to do something new, their brain will change. The fact that the brain is changing was not necessarily or shattering other than most people thought that I mentioned to you, “You’re sitting there. You’re not doing anything.” A validation for them that meditation is something active and then what we were interested in aware change because ideas is important clues as to what’s happening during meditation.
The areas that we saw changing, what was at the campus, which is an area involved in learning and memory, one is a PCC, which has to do with self-reference and how is it relevant to me. Another region is down in the brainstem. It’s an area involved in releasing neurotransmitters. We saw the change in that region correlated with well-being. People reported being happier if that region change and then the last region we found was the amygdala. The amygdala got smaller. It was all about fight or flight and fear and stress. As that got smaller, people reported less stress, these changes are consistent with the self-report what people are talking about and how it impacted them.
Now it’s meditation teacher and fellow New Yorker, Emily Fletcher. Talk to us about the time factor because that’s oftentimes the first obstacle or the biggest barrier for people. Would you start people out with a certain amount and then build them up, or do you recommend they continue with a certain amount for a period of time? What’s the frequency and duration of the dose that you are recommending in your program?
You’re right. The devil’s in the dose and the details matter. For people that don’t have any meditation training, who’ve never taken a class, read a book, or taken an online course, I would recommend zero minutes of meditation. I know that seems crazy, but it is a skill. It’s a skill like any other, and you would not challenge yourself to a 21-day Japanese challenge if you would never learn to speak the language Japanese. I don’t understand why people are challenging themselves to meditate if they don’t know how to meditate. First, acknowledging that it is a skill and once you learn it and you have a technique that’s designed for you and not a monk, then it’s ridiculously enjoyable and simple, and it can give you a return on your time investment.
I find what a lot of people are doing in this day and age when meditation has become so popular, there’s many apps, drop-in studios, and free YouTube videos is that people are trying to dumb down the experience or almost placate the not interested by being like, “Do one minute, do one mindful breath.” That’s better than taking a shot of tequila, but it’s not going to change your life. One mindful breath. It might keep you from having a stress reaction, but it’s not ultimately going to usher you into higher states of consciousness. It’s not ultimately going to increase your cognitive performance. If you’re interested in up-leveling your physical and mental game, you’re going to have to make an investment. You’re going to have to surrender something.
What I recommend is once you have some training at Ziva, we teach fifteen minutes twice a day. I know that sounds like an extraordinary amount of time, but it’s fifteen minutes before coffee, breakfast, or computer and then about fifteen minutes before your evening meal. Where you would have had the coffee, the chocolate, or the nap, that’s where you want to seal away and do your second meditation. I did the math on this, it’s 2% of your day.
That’s two 15-minute chunks, which is 2% of your day. When you frame it like that, when you ask the question, “Am I willing to invest 2% of my day so that the other 98% can be more productive, more fun, more amazing so I can get better sleep, better sex, better parking karma, reverse my body age, decrease my pain receptivity?” The answer is I would do that but if we think about meditation as like a cute pedicure for your brain, like something that you’ll get around to when you have more time.
A lot of people think that because the types that they’re doing are not designed for them, they’re designed for monks. They’re not seeing a return on their time investment and you don’t have time for something that’s not going to give you dividends or investment. Long story short, if you get a technique designed for you and not a monk, and you get some training, then you should be seeing a legit ROI. You should start to have more time in your day because your sleep should get more efficient. Your serendipity, your creativity, flow state, all of that stuff changes precipitously and quickly and then you actually see like, “How could I not meditate?”
We have Psychologist, Ronald Siegel. How mindfulness can be used as a tool to increase our awareness?
Even though probably most of your readers are somewhat familiar with it, a lot of people have a little bit of confusion about what we mean when we talk about mindfulness. As I’m using it here, talking about any awareness of present experience with loving acceptance. It means being alert, being in the present moment, and having this open attitude of loving acceptance toward whatever is occurring. As it turns out, most of what we see when we start doing mindfulness practices, which are activities such as following the breath or walking in and noticing the sensations of the feet, touching the ground, when we do these practices that involve stepping out of the thought stream and coming back to moment-to-moment sensory experience.
One of the things that happen is we develop metacognitive awareness. We develop the ability to see thoughts as thoughts rather than as realities that we identify with a principle found, for example, in most act approaches to treatment. We also start to notice certain phenomena such as every time I resist some experience, whether it be a sensation of pain, thought, an image, a memory, the very act of constricting and resisting that experience amplifies it and turns it from being a transient event that arrives in passes to being some kind of event that the organism becomes stuck in where we get caught in some recursive pattern in which we’re resisting it so much. The very resistance fuels it and then we resist more and we get stuck in that pattern. Mindfulness practices give us insight into those kinds of mechanisms, but they also give us insight into how we construct our sense of self by talking to ourselves all day long.
When we practice stepping out of the thought stream alone, we start to notice that, “When the thoughts do arise, most of the thoughts are about me, about what I want, what I’m hoping will go well, what I’m hoping won’t go well, right now thinking, ‘Am I staying on the theme? Am I remembering what your question is? Is this going to be useful to readers?’” This is what’s going background, even as I’m speaking in this moment. Mindful awareness is noticing that this is occurring and also noticing that all of this chatter about ourselves is, as the card pointed out years ago, therefore I am how a sense of me is constructed out of all of this thought.
Up next is Canadian Physiotherapist, Shelly Prosko. Tell us what compassion is? We have a little bit of context as we move forward through this episode with you.
There’s no one agreed-upon definition in The Oxford Handbook of Compassion Science, which is a huge compendium of anything and everything that you need to know about compassion in the working definition they used in there is a definition that is recognizing the suffering and then with the motivation to alleviate the suffering. That could be the suffering or the struggling of others, or even within yourself. Compassion includes self-compassion. Turning that recognition or acknowledgment of struggle or suffering, turning that onto yourself as well, and then having the motivation to alleviate it.
Compassion, sometimes it’s described as an emotion, sometimes as a behavior, sometimes as a motivation. It’s like language with anything. It can be semantics as well talking about what is it. For what I use it as I go with what’s in that Oxford Handbook, which it’s a combination of the recognition, the feeling, the emotion and then wanting to alleviate it and do something about it, there’s the behavior aspect.
The interesting distinction that I hear you making there is, there are many people when they talk, they may say, “I feel bad. I feel remorseful. I feel sad about that person, that situation, or this happening that’s going on.” The human drive to then change your behavior and help to affect that or to change that is what sets compassion in motion.
Joan Halifax introduced that name here and you’ve had her on your show before, too. She has this inactive model of compassion. She has a little bit of a different definition and talks about compassion being more of a wisdom that emerges. You can have this desire and these feelings of maybe even empathizing with someone or feeling kindness towards someone, but then you have to go beyond that.
There’s another aspect of doing something in the behavior, but with Joan’s model, she says there’s a little bit more to compassion, even just motivation or behavior. She says that it’s an emergent process and it’s contextual. If you look at the therapeutic interaction, you’ve got the patient. You have the healthcare provider. What might be a compassionate response in this moment might be completely different later on that day or the next.
It’s not just something that is linear. Here’s what someone said or her feeling and here’s what would be the appropriate response. It doesn’t necessarily work that way because humans are dynamical systems. You’re an ecosystem. I’m an ecosystem. We have different experiences in this moment. When we come together, what emerges is this more of this compassionate wisdom.
Australian Psychologist and Researcher, Dr. Melissa Day. Tell us the difference between traditional cognitive behavioral therapy and a mindfulness-based approach to pain. Maybe we should talk about it from a psychological intervention. Mindfulness meditation, you can go to a mindfulness center, maybe working with someone who’s certified in mindfulness, in your case, we’re talking about licensed professionals who have a license to evaluate and treat patients who are working with pain. What’s the difference in the two different types of approaches and their delivery in clinical practice?
That’s an important point because there are many apps out there and there’s no problem with those apps, but it’s very different from receiving a clinical intervention from a trained professional where you’re learning techniques. You’re learning techniques to apply them specifically for pain management. That’s a big difference right there. Coming back to your question about cognitive behavioral therapy, CBT is the gold standard. Research has been accumulating on this approach since the ‘80s, massive amount of efficacy and what that treatment is targeted to do in brief is that we’re looking at. We know that unhelpful cognitions and unhelpful behaviors predict worse outcomes with chronic pain over time. We’re looking at cognitions like pain catastrophizing, which is one of the most robust predictors.
Pain catastrophizing is a negative mental set about actual or anticipated pain. With cognitive behavioral therapy, a key technique is cognitive restructuring and that aims to change those coalitions. It’s explicitly designed to change the cognitions. The behavioral techniques in CBT, those are also explicitly designed to change behaviors. We know that sedentary behavior, inactivity previously, we used to say, “Risk.” When you have low back pain that we know that’s one of the worst things that we can do with low back pain. CBT targets changing those behaviors.
Mindfulness-based approaches, on the other hand, come at it from a different perspective. While CBD is quite change-focused, mindfulness-based approaches are focused on not changing the experience per se, whether that be pain or cognitions, but shifting the way that we relate and respond to those experiences. In that way, we’re learning that we can’t change pain. If we could change pain, we could cure it and we wouldn’t have any need for psychological interventions, but what we’re learning here is that instead of seeing pain and go, “I hate it. I don’t like it. This is ruining my life,” we can see all that and we can mindfully notice that observe it. Instead of adding that extra baggage onto the pain, with meditation, we’re learning to let go of that extra baggage, which we know loads up pain. I find it interesting because even though CBT and mindfulness come at it from different angles, I feel like the different pathways to perhaps ultimately the same destination.
Here’s more with Licensed Clinical Social Worker and meditation researcher, Eric Garland. What does savoring mean to you and how does that impact on states of chronic pain?
To put it simply, savoring is the process of focusing attention on pleasant everyday events and not only appreciating the pleasure that can be derived from the sensory features of that event, how it looks, how it smells, how it sounds, its touch, texture, but also becoming aware of how encountering this pleasant experience is affecting you. How is it affecting your emotions? How is it affecting the bodily states of pleasure that can arise when you’re having a good experience?
That second part of savoring is crucially important and involves this process of mindfulness because when we’re savoring something, let’s say a beautiful sunset or nice weather, breeze on a warm summer day, you can appreciate the experience, but at a certain point, it starts to affect you. You start to notice those positive emotions of contentment, relaxation, maybe joy, or appreciation. Then those emotions also have this impact on the body.
We start to notice pleasurable sensations in the body. As this occurs on a neurophysiological level, there’s activation in reward circuitry in the brain that is in part mediated by the endogenous opioid system and that happens to be involved in the body’s natural painkilling process. You asked what the connection to chronic pain treatment? Part of the connection is there, that one we’re deeply and mindfully emersed in a pleasant everyday experience, that experience becomes rewarding that it can relieve pain. The neurocircuitry of pain and pleasure are intimately intertwined.
Now it’s on to my good friend and colleague and Professor of Physical Therapy at Temple University, Professor Annette Willgens. What is complex neuroscience? If you go into the ledger and start to read about mindfulness and how it works, it’s very complicated neuroscience. How do you begin to break that down into bite-sized chunks for either your student body or for patients and explain here’s how mindfulness works?
To be over-simplistic, forgive me in advance if you’re a neuroscientist, I talk to my students about the left prefrontal cortex, the happiness center of the brain and the right prefrontal cortex. The right prefrontal cortex, I called the caveman brain or the cavewoman brain, if you will. It is miserable if he or she is sitting on the side of the road, scanning for threats. There are direct connections to the caveman brain or that right prefrontal cortex to the amygdala, the fight-flight fear center of the brain.
When we tap into sensation, the body, the breath, we disconnect from that right prefrontal cortex and connect to the somatic sensory cortex, which is activated and has been shown on functional MRI scans of the brain that shows a dampening of beta waves and a functional shift to that left side of the brain and the happiness center with more direct connections to the executive functioning, to our ability to make choices, rather than again, be enslaved by emotion.
Interestingly, you can change the structure of your brain by pausing, by meditating, even for up to eight minutes a day. I teach my students, download an app, do it right before bed. If you fall asleep, great and if you don’t, then you’ve done your 5 or 10 minutes of guided meditation. Sara Lazar, out of the University of Massachusetts, did a study in which she looked at people who have never meditated before and ask them to meditate about a half-hour a day. After only eight weeks, the participants had different brains. Their insular cortex had more density.
The insular cortex is that part of the brain that provides us accurate self-assessment. What is happening? Am I doing what I need to be doing right now? The posterior cingulate, which is the area of the brain that has to do with mind-wandering, self-focus became less dense. The hippocampus, more dense. We know that has to do with learning and memory. The temporoparietal junction. It has to do with empathy, compassion, perspective-taking more dense. The pons, which is the home of regulatory neurotransmitters, more dense. The amygdala trunk and the study after only eight weeks. I find that incredibly exciting.
Now we hear from the great Vidyamala Burch. The pro and con of an app, so to speak, is that someone’s talking to you or someone’s guiding you when it’s going into your ears, but depending on what their instruction’s like, it may be a type of approach where we’re still separating the mind from the body. Especially in the world of chronic disease and chronic pain, it’s important to tie these together. Do you find that there are a lot of approaches that are just focusing on the cognitive aspects of mindfulness and they’re not bringing it to that mind-body connection aspect?
There are some, but to be honest, the only ones that are effective are the ones that integrate the mind and the body and increasingly in my teaching now I draw out the fact that the head is a limb of the body because when people think they had a separate from the body, but it’s not. It’s like your arms are limbs, your head as a limb. In your head, you had a brain which isn’t an organ and the brain happens to be the place where it feels like thoughts are located. Whether that’s true or not, I’m not going to go there. I might use imagery, like letting your brain be soft and imagine that all your thoughts are having a lie down in the brain, in the body. This is a very Western thing. This mind-blood-body separation.
Problematic with chronic pain and chronic disease management because if your body is hurting, you do not want to be there. You think, “I can be in my head. I avoid the body by being in my head.” You have a body. We’ve all got a body. Trying to blank out doesn’t work. Mindfulness has this incredible counter-intuitive element where we’re learning how to come closer to the body, which is where we think the pain resides.
We’re having to come closer to the thing that we don’t want to inhabit, but as we come closer with a loving-kind, soft-gentle awareness, then we come closer to what we think is pain as a thing, as a noun, it’s a label and you realize it’s unpleasant sensations that are flowing and changing all the time just as the breakfast flowing and changing all the time. You can literally deconstruct this concept of pain, which is entirely mind created as an object and rest within the flow of experience moment by moment.
To take us home is Physical Therapist, Dr. Stephanie Carter Kelley. In some of your training, you teach about cueing and how that cueing relates to mindfulness, pain science, or other aspects. Can you give a couple of examples of those and how they relate to some of the topics that we’re talking about?
The format of my classes, and I’ve explained this to my students, we start by slowing down first. We start with breathing as the meditation to get the nervous system in a state that it can now pay attention. I lead people through, especially my beginners, a very long breathing practice because awareness of breath is the first accessible way to meditate, pay attention, be mindful. I lead them through three-part breath, deepening the breath, then a longer exhale, which is to deactivate that sympathetic nervous system and move them into that parasympathetic state.
I told my students, “I know this is a little bit,” because eventually, we’re going to start moving a little bit more vigorously. “I don’t want to take you into vigorous movement and unless you’re ready to pay attention to what you can do on this day. Much of my not cueing is to feel where you are today. Do you have energy or are you tired today? Are you sore from what you did yesterday?” We don’t do yoga every day, but I have people that walk and do other types of exercise. “Did you have a stressful event yesterday, emotionally, and now you’re not ready for that?” It is guiding them all the way to the correct parasympathetic response so that they can pay attention. They can connect their bodies to their brains.
Important Links:
- Sharon Salzberg
- Dr. Kristin Neff
- Dr. Sara Lazar
- Ziva
- Ronald Siegel
- Shelly Prosko
- The Oxford Handbook of Compassion Science
- Joan Halifax – Previous episode
- Dr. Melissa Day
- Eric Garland
- Annette Willgens
- Vidyamala Burch
- Dr. Stephanie Carter Kelley
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