Chapter 12

Awareness of Your
Sensations, Emotions,
and Thoughts

When it comes to understanding how we experience chronic pain, we need to turn our attention to the way that our brain reflects pain in our body.

Our brain not only perceives—it also predicts.

Until recently, our thinking has been that the brain is an organ that accurately reflects and reacts to stimuli from the outside world. For example, if a glass pitcher falls from a table near you, your brain allows you to hear, see, and feel the impact. However, if you are watching a movie scene where a glass pitcher falls from a table but the sound is off, your brain can still generate a version of these sensations. Therefore, you may be startled at the scene of a glass pitcher falling off a table even though you don’t hear it or feel the vibration of the shattering glass hitting the ground.

What does this mean? It reflects that our brain helps us perceive the world around us by combining sensory information in the moment with memories of similar experiences from the past and anticipation of how the pain will be in the future. In other words, our brain not only perceives—it also predicts. This is why, for example, many people flinch when they are about to receive a shot at the doctor’s office. They haven’t even had the needle puncture their skin, but their brain is already predicting pain, based on earlier memories of needles.

Similarly, someone suffering for years from chronic low back pain who experiences a twinge of discomfort may feel more than strictly the result of a tight muscle and irritated sciatic nerves. The pain experience is also colored by a brain which both predicts how severe the pain will be and remembers past memories of similar painful experiences. The sum total is a combination of past pain and predicted future pain, as well as the effect of strained muscles and nerves in the present moment.

It is indeed amazing how our brain remembers the past and predicts the future, to help us effectively perceive the world. But it causes a major problem for chronic pain sufferers. Feeling the ache of chronic neck pain, the stab of chronic migraine pain, or the pulsing twist of low back pain is bad enough. But when your brain adds to this by remembering past incidents of overwhelming pain and projecting expectation of future suffering, the net result can be overwhelming. This is where state-dependent memory (refer to chapter “The Science of Chronic Pain,” p. 27) can wreak havoc on the chronic pain sufferer. The more the pain is amplified by past memories and future expectations of pain, the worse the cycles of chronic suffering become.

There is a way to break these vicious cycles of pain and suffering. The goal is to curb your brain’s tendency to respond to pain with bad memories and predictions of distress. This requires training your brain to bring its attention to the sensations and thoughts of the moment.

Sensory Awareness, Emotional
Awareness, and Thought (Cognitive)
Awareness of Chronic Pain

Chronic pain affects us powerfully and simultaneously on the levels of sensation, emotion, and thought. To make sense of the experience of chronic pain and to establish tools for coping, we need to first break this phenomenon down into its component parts. We will first look at each one of these dimensions separately, to get to know and observe them more effectively. Finally, I will show you how to bring awareness to the sensations, emotions, and thoughts that comprise your experience of chronic pain.

Sensation

Sensation refers to the physical feeling in your body. When you are in pain, some of those sensations may include aching, tingling, burning, stabbing, tight, electric, buzzing, numb, muffled, fuzzy, raw. It’s important to remember that you may perceive multiple sensations simultaneously.

Some people feel flooded with sensations throughout the day and night. Others may actually have difficulty identifying a sensation in their body. The goal is to be able to notice various sensations as they occur in your body. Not just “thinking about” the sensation (as in, “I know I feel this aching pain all the time”), but paying attention to it right now, in real time.

For all the following brief exercises, have either a pen and paper or a laptop computer close by so you can record what you start to notice.

Brief Exercise for Somatic Awareness

Sit in a comfortable chair. Notice a neutral sensation somewhere in your body. It might be the feeling of your forearm and hand resting on your leg. It might be the feeling of some part of the chair resting against your back or seat. Or it might be a mild tingling or warmth in your foot or your thigh. Just observe the sensation, describe how strong the sensation is (from 1 being extremely mild to 10 being extremely intense). Make a brief notation marking this.

Emotion

Examples of emotions include happy, sad, angry, bored, irritated, betrayed, ashamed, excited, tender. These can be triggered by something external in the present (such as a stressful day at work) or by something internal (such as an unpleasant memory or ongoing patterns of perceiving yourself negatively).

Remember that the only place that we can perceive emotion is in the body. Fear may manifest as tingling in the stomach. Excitement reveals itself as a quickened heart rate. Anger presents with your jaw stiffening, or a surge of energy up your spine. Sadness may appear as a heaviness in the chest.

Brief Exercise for Emotional Awareness

Sit down with a piece of paper and pen. Take a few slow deep breaths. Ask yourself, “What am I feeling emotionally right now?” Allow a few minutes if necessary for the awareness of the feeling(s) to emerge. Some examples may include, “I feel…tired, weary, tense, happy, hopeful, anxious, etc.” Write this feeling down, without any need to explain “why” you feel the particular emotion.

As a variation on the above exercise, identify the emotion connected to your chronic pain. Start by identifying the area of pain in your body (for example, a moderate feeling of aching in your legs). Then, ask yourself, “What emotion do I feel in response to this leg pain being here right now?” Allow time for the awareness of the feelings to emerge. Again, write the feeling down, without any need to explain “why” you feel it.

Thought

A thought is a mental experience, a mental image, a memory, or a string of words. Our ideas, opinions, and beliefs about ourselves. Thoughts are racing through our minds all the time, often hiding in the background under our conscious awareness. They are, however, coloring our perceptions of ourselves as well as of our pain.

What makes these thoughts more problematic is that over time they become more automatic and may often continue below our conscious awareness. In other words, “under the radar.” The goal, with practice, is two-fold. First, to bring conscious awareness to the thoughts that have been recurring under the radar, so that you can be aware of what has been affecting you. Second, being aware of these thoughts opens the opportunity to provide a rational alternative. For example, once you are aware that you have concluded that a worse headache means there is no hope, you can respond with the statement that says, “Even though my headache is worse today, I have often felt the pain improve the next day, and it can improve again.”

Brief Exercise for Thought Awareness

Sit in a comfortable chair. Take a few deep breaths. Start to listen in to the ongoing noise of your thoughts. As soon as you begin to notice some of the thoughts, stop for a moment and jot them down on laptop or paper.

Examples of thoughts you notice about your pain may include:

•“This exercise is silly—why do I even need it?”

•“This is too much effort.”

•“I just remembered I need to pick up cheese and bread at the grocery later.”

•“What time is my doctor appointment next week?”

•“Am I doing this exercise properly?”

•“I resent the way my boss scolded me in front of the staff last week.”

•“This pain is hopeless—It will never get better.”

•“The fact that my headache is worse this week is proof that there is no hope.”

•“It doesn’t matter that my back pain reduced from a 6 to a 4. It isn’t better unless it is entirely gone.”

•“I hate this neck pain because it means I’m just like my sick father.”

•“I am a failure because I haven’t been able to get rid of this chronic joint pain.”

The goal, with practice, is to be able to develop the ability to sit back and just observe the ongoing noise of your thoughts without judging them as good or bad.

“Dear Diary”—A Powerful Tool
for Building Awareness

Writing in a journal can be a powerful tool for improving your ability to access awareness of your sensations, emotions, and thoughts.

It seems so deceptively simple to think that writing thoughts and feelings in a journal could provide much of any benefit. And yet we now know that journal writing can contribute to profound improvements in emotional and physical health. Journal writing has been demonstrated empirically to reduce chronic pain, improve immune function, decrease stress, improve mood, decrease depression and anxiety, and improve problem-solving skills. It can help you to notice important gradual changes in your symptoms. It can help you to notice side effects caused by your pain, medications, or other interventions. It can help you identify patterns in your pain and identify other potential triggers for your pain symptoms. It can help you to better identify what treatments are helping—or not. And it can help you to provide more accurate communication to your healing team about your progress.

Psychologist Dr. James Pennebaker has done well-designed research on journal writing. He has found that writing in a journal regularly can decrease the symptoms of pain from difficult-to-treat conditions such as rheumatoid arthritis.

When I explain the benefits of journal writing to one of my patients, I often use a metaphor of listening to music. Imagine that you are listening to one of your favorite musical artists in your living room on high-quality headphones. You’re really getting into the music, immersed in it. Suddenly you feel a tap on your shoulder, and somebody asks you, “Hey—what are you listening to?” Being able to answer that question requires you to apply a few different types of awareness. First, you need to take a moment and step back from the experience that you were immersed in. Then, you need to be able to tune inside to your feelings to even know what the experience is (e.g., feeling “in the groove,” “joyful,” “like I gotta dance,” etc.). Then, you would need to find the words to express in words what that experience is. “I was listening to my favorite U2 album and I felt so happy and energized!”

Part of what makes journal writing so useful is that it requires the writer to develop these same awareness skills. When you are immersed in the experience of chronic pain, feeling sore, tight, annoyed, and exhausted, imagine how useful it could be to be able to take a step back from the experience and observe it with some distance. And then to be able to tune in and perceive the sensations, emotions, and thoughts going on in that challenging moment. And then, to find the words to accurately describe the experience. This is how journal writing develops indispensable skills for awareness, coping, and healing.

The journal writing that I recommend you do combines awareness of your physical sensations with noticing the emotions, thoughts, and perceptions that occur before, during, and after experiencing pain.

To begin, start by filling in a sheet that lists the following categories:

•Date and time; activities you’ve been involved in since the last entry

•Where in your body you feel the discomfort

•Whether any self-care activity (e.g., stretching, taking a warm shower, etc.) helped

•What thoughts you have in response to the pain, and what emotions you felt in response to the pain

When you measure the discomfort, remember to use the 0−10 scale we discussed before, where 10 is “the worst pain I have ever experienced” and 0 is “no pain at all.”

Then, have another section for brief, freestyle comments. This might include something like, “Today I could sense that my back calmed down a little after practicing the 30-to-1 breathing exercise, and what I feel about that is a little hopeful.”

Here is a suggestion to supercharge your journal writing. Be sure to include the feeling associated with whatever you’re experiencing. So, instead of writing, “My back pain is at a 5 out of 10 today,” write, “My back pain is at a 5 out of 10 today, and what I feel about that is frustration and disappointment.” We know from multiple studies of journal writing that the benefits are greatly increased when whatever is described is associated with emotional expression. If you find it difficult to identify which emotions are surfacing for you, start with using the acronym “SASHET,” which stands for sad, angry, scared, happy, excited, tender. Of course, this is far from an inclusive list of all emotions, but you may find it to be a helpful starting point.

Like any important new skill, journal writing takes practice, and you’ll get better at it as you do it more. Many patients who utilize journal writing as a coping strategy for pain tell me that they start to look forward to their journal writing, feeling like they have another tool to exercise helpful control over their healing.

Tying It All Together

Now that you have brief exercises and journal writing available to become aware of the sensations, emotions, and thoughts associated with your pain, you can start to use these exercises to disrupt your brain’s cycles of remembering and predicting. Doing so will take some of the sting out of your pain episodes.