The next time you hit your thumb with a hammer or bang your shin on the car door, you can perform a little experiment in mindfulness. See if you can observe the explosion of sensations and the expanding shell of screamed epithets, groans, and violent body movements that ensue. It all takes place within a second or two. In that time, if you are quick enough to bring mindfulness to the sensations you are feeling, you may notice that you stop swearing or yelling or groaning and that your movements become less violent. As you observe the sensations in the hurt area, notice how they are changing, how sensations of stinging, throbbing; burning, cutting, rending, shooting, aching, and many others may flow in rapid succession through the region, blending into each other like a play of multicolored lights projected willy-nilly on a screen. Keep following the flow of sensations as you hold the area or put ice on it, put it under cold water or hold it above your head, wave it around in the air, or whatever you are drawn to do.
In conducting this little experiment, you may notice, if your concentration is strong, a center of calmness within yourself from which you can observe the entire episode unfold. It can feel as if you are completely detached from the sensations you are experiencing, as if it were not “your” pain so much as just pain, or even not pain at all but intense sensation, not capturable by any words. Perhaps you felt a sense of being calm “within” the pain or “behind” the pain. Perhaps you observed that your awareness of the pain was not in pain at all, and became a place of refuge, not an escape, but merely a vantage point. If you didn’t, you can always investigate how your awareness and intention are in relationship to what we usually call “pain” the next time you are unfortunate enough to bang some part of your body really hard.
Hitting your thumb with a hammer or banging your shin on something brings on immediate intense sensation. We use the term acute pain to describe pain that comes on suddenly. Acute pain is usually very intense, but it also only lasts a relatively short while. Either it goes away by itself, as when you bang some part of your body, or it forces you to take action of some kind to make it go away, such as seeking medical attention. If you experiment with trying to bring mindfulness to exactly what you are feeling in those moments when you hurt yourself accidentally, you will probably find that how you relate to the sensations you experience makes a big difference in the degree of pain you actually feel and how much you suffer. It also affects your emotions and your behavior. It can be quite a revelation to discover that you have a range of options for dealing with physical pain, even very intense pain, aside from just being automatically overwhelmed by it.
From the standpoint of health and medicine, chronic pain is a much more intractable problem than acute pain. By chronic pain, we mean pain that persists over time and that is not easily relieved. Chronic pain can be constant or it can come and go. It can also vary greatly in intensity, from excruciating to dull and aching.
Medicine manages acute pain far better than it does chronic pain. The underlying cause of an acute pain can usually be identified rapidly and treated, resulting in its elimination. But sometimes pain persists and does not respond well to the most common remedies, which are drugs and surgery. And its cause may not be well defined. If it lasts more than six months or keeps coming back over extended periods of time, then a pain problem that started out as acute is said to have become chronic. In the rest of this chapter and in the one that follows, we will be mostly discussing chronic pain and the specific ways in which you can use mindfulness to befriend your pain, strange as that might sound, and explore options for being in wiser relationship with it. This is what is really meant by coping with pain, or learning how to live with it. But we will also touch on what has been learned about pain and suffering from laboratory studies of purposefully induced discomfort.
It is important for the reader to keep firmly in mind the fact that all patients who have medical conditions and diagnoses of one kind or another and are referred to the Stress Reduction Clinic by a health care provider have had a full medical work-up before they are permitted to pursue MBSR training. This is critically important in order to rule out or confirm disease processes that may require immediate medical attention. Listening to your pain includes making intelligent decisions about getting proper medical attention. The work of mindfulness needs to be carried out in conjunction with other medical treatments that may or may not be required to relieve pain. MBSR was never meant to be a substitute for medical treatment. It is designed to be a vital complement to it.
Just as we saw earlier that stress per se is not bad, it is important to remember that pain per se is not a bad thing either. Pain is one of your body’s most important messengers. If you didn’t feel pain, you could do great harm to your body by touching a hot stove or radiator and not even know it. Or you could have a ruptured appendix, for example, and not know that anything was the matter internally. The acute pain we experience under these and similar circumstances tells us that something is the matter. It tells us in no uncertain terms that we need to pay immediate attention and to take action in some way to rectify the situation. It is a healthy alarm reaction. In one case we quickly withdraw our hand from the stove; in the other we get to a hospital as quickly as possible. The pain literally drives our actions because it is so intense.
People born without intact pain circuitry have a terrible time learning the basic safety skills that we all take for granted. Without our knowing it consciously, our experiences with physical pain over the years have taught us a great deal about the world and about ourselves and our bodies. Pain is a very effective teacher. Yet if you were to ask, my guess is that most people would say that pain is categorically bad.
As a society, we seem to have an aversion to pain, even to the thought of pain or discomfort. This is why we are so quick to reach for medicine as soon as we feel a headache coming on and why we shift our posture as soon as a little muscle stiffness generates some discomfort. As you will see, this aversion to pain can be an obstacle to learning how to live with a chronic pain condition.
Aversion to pain is really a misplaced aversion to suffering. Ordinarily we do not make a distinction between pain and suffering, but there are very important differences between them. Pain is a natural part of the experience of life. Suffering is one of many possible responses to pain. Suffering can come out of either physical or emotional pain. It involves our thoughts and emotions and how they frame the meaning of our experiences. Suffering too is perfectly natural. In fact, the human condition is often spoken of as colored by inevitable suffering. But it is important to remember that suffering is only one response to the experience of pain. Even a mild pain can produce great suffering in us if we fear that it means we have a tumor or some other frightening condition. That same pain can be seen as nothing at all, a minor ache or inconvenience, once we are reassured that all the tests are negative and there is no chance that it is a sign of something serious. So it is not always the pain per se but the way we see it and react to it that determines the degree of suffering we will experience. And it is the suffering that we fear most, not the pain.
In fact, very elegant research by the Nobel laureate psychologist Daniel Kahneman and others has shown that we are very poor reporters of our pain after the fact. How much pain we report experiencing in retrospect, say during a colonoscopy procedure, depends not on the pain’s overall intensity or duration but rather, surprisingly, on its peak and on its level at the end of the procedure. This has also been shown to be true for pain induced in a laboratory setting. This observation has profound implications for how we remember painful experiences from the past, and therefore how much suffering we ascribe to them. Kahneman points out that how we remember an event is really our only record of it because the experience itself does not have a voice. “The experiencing self [as he calls it] is the one that asks the question: “Does it hurt now?” The remembering self [his terminology] is the one that answers the question: How was it on the whole?” Our memory tends to generate a narrative that Kahneman’s research has shown is very unreliable. We are highly biased and fickle reporters of past experience, whether of suffering or of levels of well-being or happiness. It is far more accurate to have people report on their momentary experiences and then add them up, rather than to ask them to evaluate an experience retrospectively.*
Of course, nobody wants to live with chronic pain. But it is very widespread. The costs to society as a whole from chronic pain as well as to the people who suffer with it are very high. According to a 2011 report of the Institute of Medicine, chronic pain conditions cost our society between $560 billion and $635 billion per year in treatment and lost productivity. The psychological costs, in terms of emotional distress, are equally staggering.
A lingering pain condition can be totally disabling. Pain can erode the quality of your life. It can grind you down bit by bit, making you irritable, depressed, and prone to self-pity and feelings of helplessness and hopelessness. You may feel that you have lost control of your body and of your ability to earn a living, to say nothing of enjoying the activities that usually give pleasure and meaning to life.
What is more, the treatments for chronic pain conditions are all too often only partially successful. Many people are ultimately told by their doctor or by the staff of a pain clinic at the end of a long and often frustrating treatment course, sometimes involving surgery and usually numerous drug treatments, that they are going to have to learn to live with their pain. But too often they are not taught how to do this. Being told that you have to learn to live with pain should not be the end of the road—it should be the beginning. This is one of the most important roles that an MBSR program can play in a person’s life—and in medical care more generally. It may be particularly important for soldiers and veterans returning from war zones such as Iraq and Afghanistan with physical wounds and blast injuries resulting in traumatic brain injury of varying severity as well as post-traumatic stress, particularly when pain is a part of the picture.
In the best of cases, which is probably still the exception rather than the rule, a person with chronic pain will receive the ongoing support of a highly trained multidisciplinary pain clinic staff. Psychological assessment and counseling will be integrated with the treatment plan, which might include everything from surgery to nerve blocks, trigger-point injections with steroids, intravenous lidocaine drips, muscle relaxants, analgesics, physical and occupational therapy, and, with luck, acupuncture and massage. The goal of counseling is to help the person work with his or her body and to organize his or her life to keep what pain there is under some degree of control, to maintain an optimistic, self-efficacious perspective, and to help the person engage in meaningful activities and work within his or her capacity.
In the early days of our hospital, before the Pain Clinic, run by the Department of Anesthesiology, was ironically shut down for budgetary reasons in spite of pain being one of the central concerns of medical patients, it referred many of its patients to the Stress Reduction Clinic for training in MBSR. The deciding factor in who was referred was a willingness on the part of the patient to try to do something for himself or herself to cope with some of the pain, particularly when it had not responded fully to medical treatment alone. In general, those who harbor the attitude that they just want the doctor to “fix it” or to “make it go away” are obviously not good candidates for mindfulness training. They won’t understand the need to take some responsibility themselves for working with their condition. They might also interpret the suggestion that the mind can play a role in the regulation of their pain to mean that their pain is imaginary, that it is “all in their head” in the first place. It is not uncommon for people to think that the doctor is implying that their pain is not “real” when he or she proposes a mind-body approach to pain therapy. People who know they are in pain usually want to have something done to the body to make the pain go away … in other words, to be fixed.
This is only natural when the model you are working with is that your body is like a machine. When something is wrong with a machine, you find out what the problem is and you “fix” it. By the same token, when you have a pain problem, you would go to a “pain doctor,” expecting to get what is wrong fixed, just as you would if something were wrong with your car.
But your body is not a machine. One problem with chronic pain conditions is that often it is not clear exactly what is causing the pain. Doctors, even specialists, may not be able to say with certainty why a person is experiencing pain. Diagnostic tests, such as X-rays, myelograms, CT scans, and MRI scans, frequently don’t show very much, even though the person may be in a lot of pain. And even if the cause of the pain was known precisely in a particular case, surgeons rarely attempt to cut specific nerve pathways to lessen pain anymore. This is only attempted as a last resort in cases of unremitting, excruciating pain. This kind of surgery used to be performed more frequently, but it usually failed, for the simple reason that pain signals do not travel in exclusive and specific “pain pathways” in the nervous system.
For these reasons, people with chronic pain conditions who seek medical treatment thinking of their body as being pretty much like an automobile and that all the doctor needs to do is to find out why they are in pain and then make it go away by cutting the right nerve or giving them some magic pills or injections are usually in for a rude awakening. Things are rarely that simple with chronic pain conditions.
In the new paradigm, pain is not just a “body problem,” it is a whole-system problem. Sensory impulses originating both at the surface of your body and internally are transmitted via nerve fibers to the brain, where these messages are registered and interpreted as pain. This has to happen before they are considered painful by the organism. But there are many well-known pathways and way stations within the brain and the central nervous system by which higher cognitive and emotional functions can modify the perception of pain. The systems perspective on pain opens the door for many different possible ways to use your mind intentionally to influence your experience of pain. This is why meditation can be of such great value in learning to live with pain. So if a doctor suggests that meditation might help you with your pain, it does not mean that your pain is not “real.” It means that your body and your mind are not two separate and distinct entities and that, therefore, there is always a mental dimension to pain. This means that you can always influence the pain experience to some extent by mobilizing the inner resources of your own mind, one of which is kindness toward yourself.
The above perspective has been corroborated and amplified by recent laboratory studies looking at the effects of mindfulness training on pain induced in volunteers who have no prior experience of meditation, as well as in long-term meditation practitioners. The pain is usually induced by heat or by cold, and in each case great care is taken to insure that no harm or tissue damage is done to the subjects. Overall, the results are showing that meditative practices similar or identical to those used in MBSR can have dramatic effects on pain reports. Much of the research is now trying to identify the brain mechanisms by which pain modulation might occur. One study, conducted by Antoine Lutz, Richard Davidson, and their colleagues at the Center for Investigating Healthy Minds at the University of Wisconsin, found that long-term meditators (with over ten thousand hours of lifetime practice) using a meditative practice known as “open monitoring”—similar to the choiceless awareness we use in MBSR—showed significant reduction in the degree of unpleasantness they reported for a particular level of painful stimulus compared to the control group. However, the long-term meditators did not report any less intensity than did the control group.† In another study, these findings were shown to be associated with changes in brain activity in the experienced meditators in a network known to be associated with the assessment of “salience.” Apparently the meditators were able to reduce fearful anticipatory thinking by staying in the present moment, and thus showed reduced reactivity to the painful stimulus.‡
Such findings underscore the well-known fact that there are different dimensions to the experience of pain: the sensory, the emotional, and the cognitive, all of which contribute to the overall sense of suffering that accompanies physical discomfort. When we recognize these distinct components of the global experience of “pain” within ourselves and can differentiate between them, as we learn to do in MBSR, this can significantly reduce the experience of suffering, as we found in our early studies of people with chronic pain conditions taking the MBSR program,§ and as described in detail in this chapter and the following one.
Other studies, looking at Zen meditation practitioners, have shown that long-term practitioners are less sensitive to both unpleasantness and intensity, and that they show gray matter thickening in specific regions of the brain known to be involved in experiencing pain.‖
Some laboratory studies are even showing that very brief training in mindfulness with the primary focus on breathing, along the lines of four 20-minute training sessions, can dramatically reduce pain ratings of unpleasantness (by 57 percent) and intensity (by 40 percent) and show changes in the brain in areas known to modulate the experience of pain.a
It remains to be seen why different laboratories are reporting somewhat different findings for different meditation practices. This is often the case in science, especially in fields such as this one, which is really in its infancy. However, overall such studies are corroborating and extending the clinical findings from our early studies, now replicated by other groups, which showed dramatic and long-term positive effects of training in MBSR on patients with a wide range of chronic pain conditions.
Before looking further into the ways we can use mindfulness to work with pain, let’s review some of the results obtained in our early studies of people with chronic pain conditions undergoing training in MBSR in the stress clinic. These studies showed that there is a dramatic reduction in the average level of pain during the eight weeks of MBSR as measured by a pain questionnaire called the McGill-Melzack Pain Rating Index (PRI). This is a reproducible finding. We see it in every class, year after year, among patients with chronic pain conditions.
In one study, 72 percent of the patients with chronic pain conditions achieved at least a 33 percent reduction on the PRI, while 61 percent of the pain patients achieved at least a 50 percent reduction. This means that the majority of people who came with pain experienced clinically significant reductions in their pain levels over the eight weeks they were practicing the meditation at home and attending weekly classes at the hospital.
In addition to pain, we looked at how much these people changed in terms of their negative body image (the degree to which they rated different parts of their body as problematic). We found that by the end of the program, on average they perceived their bodies as approximately 30 percent less problematic. This implies that negative views and feelings about one’s body, which are especially strong when people are limited in what they can do because of pain, can improve markedly in a short period of time.
At the same time, these same individuals also showed a 30 percent improvement in the degree to which pain interfered with their ability to engage in the normal activities of daily living, such as preparing food, driving, sleeping, and sex. This improvement was accompanied by a sharp drop (55 percent) in negative mood states, an increase in positive mood states, and major improvements in anxiety, depression, hostility, and the tendency to somatize, that is, to be overly preoccupied with one’s bodily sensations. By the end of the program, people with chronic pain in this study were reporting taking less pain medication, being more active, and feeling better in general.
Even more encouraging, these improvements lasted. In a follow-up study that examined how people with pain conditions were coping up to four years after their experience training in MBSR, we found that, on average, most of the gains they had achieved by the end of the program were either maintained or improved still further.
In addition, the follow-up study showed that the pain patients continued to keep up their meditation practice, many to a very strong degree. Ninety-three percent said that they continued to practice the meditation in one form or another at some level. Almost everybody reported still using awareness of their breathing in their daily lives, as well as other informal mindfulness practices. Some were practicing formally as well when they felt a need. About 42 percent were still practicing formally at least three times a week for at least fifteen minutes at a time three years later, although by four years this figure dropped to 30 percent. All in all, this represents an impressive level of discipline and commitment, considering they had learned the mindfulness practices years earlier.
The pain patients in the follow-up study were also asked to rate how important the training they received in MBSR was to them at the time they were being asked to respond. Forty-four percent (at three years) and 67 percent (at four years) rated the program between 8 and 10 on a 1-to-10 scale (where a rating of 10 meant “very important”), and over 50 percent rated it 10 at four years. Responses for six months, one year, and two years of follow-up fell between these values, from 67 percent rating it between 8 and 10 at six months to 52 percent giving it that rating at two years.
In terms of how much what they learned in the clinic was responsible for their pain reduction at follow-up, 43 percent reported that 80 to 100 percent of their pain improvement at follow-up was due to what they had learned in the MBSR program. An additional 25 percent attributed 50 to 80 percent of their pain improvement to what they learned in MBSR. So by their own reports, the meditation training had lasting effects in terms of their pain improvements.
In another study, we compared two groups of pain patients. All forty-two people in this study were being treated in our hospital’s pain clinic using standard medical protocols as well as supportive therapies such as physical therapy. But one group of twenty-one patients was also referred for MBSR training in the Stress Reduction Clinic in addition to their pain clinic treatments, while the other group had not yet been referred to the stress clinic. Both groups were followed over a ten-week period, the meditators between the time they started and the time they finished the MBSR program; the other group between the time they started their pain clinic treatments and ten weeks later.
We knew from previous studies that we could expect the meditators to show large reductions in pain and psychological distress on our rating scales. The question was, How would the meditators compare with other patients in the pain clinic who were not practicing meditation but who were receiving powerful medical treatments for pain such as lidocaine injections?
What we found was that the non-meditators showed little change over the ten weeks that they were being treated in the pain clinic, while the meditators showed major improvements. For example, the MBSR group showed an average 36 percent improvement in pain on the McGill-Melzack Pain Rating Index, while the non-meditators showed no improvement. The MBSR group showed a 37 percent improvement in negative body image, while the non-meditators had a 2 percent improvement. The MBSR group also showed an 87 percent improvement in mood, the non-meditators only a 22 percent improvement; and the MBSR group had a 77 percent improvement in psychological distress, while the non-meditators had an 11 percent improvement.
Even though this pilot study was not a randomized trial, these results suggested quite powerfully that doing something for yourself—as the people in the Stress Reduction Clinic were doing by engaging in the MBSR classes and in the various mindfulness meditation practices assigned for homework each week in addition to receiving medical treatment for their pain conditions—can result in many positive changes that may not occur or occur as powerfully with medical treatment alone. This finding underscores the potential power of a more participatory medicine, in which the patients are full collaborators and participants in all attempts to help them to move toward greater levels of health and well-being, tapping into their deep interior resources for learning, growing, healing, and transformation through their own systematic efforts to cultivate wise attention and greater intimacy and familiarity with their minds and bodies.
One of the most interesting discoveries we made in the MBSR classroom is that medical patients with very different kinds of pain problems all show similar improvements in their condition when they engage in the regular cultivation of mindfulness. People with low-back pain, neck pain, shoulder pain, face pain, headache, arm pain, abdominal pain, chest pain, sciatic pain, and foot pain, caused by a range of problems including arthritis, herniated disks, and sympathetic dystrophies, were all able to use the meditation practices to achieve major reductions in their pain that endured over time. This suggests that many different kinds of pain conditions and experiences might be positively affected by the MBSR curriculum, which involves, above all, a willingness to turn toward, lean in, and open to the moment-to-moment experience of pain with great self-compassion and kindness, and to learn from it instead of closing oneself off from it and trying to make it go away—in a word, in inviting even unpleasant and unwanted experiences to become your teacher.
Some people have difficulty understanding why we emphasize that they try to enter into their pain when they simply hate it and just want it to go away. Their feeling is, “Why shouldn’t I just ignore it or distract myself from it and grit my teeth, and just endure it when it is too great?” One reason is that there may be times when ignoring it or distracting yourself doesn’t work. At such times, it is very helpful to have other tricks up your sleeve besides just trying to endure it or depending on drugs to ease it. Several classic laboratory experiments with acute pain showed that tuning in to sensations is a more effective way of reducing the level of pain experienced when the pain is intense and prolonged than is distracting yourself. In fact, even if distraction does alleviate your pain or help you to cope with it some of the time, bringing mindfulness to it can lead to new levels of insight and understanding about yourself and your body, which distraction or escape can never do. Understanding and insight, of course, are an extremely important part of the process of coming to terms with your condition and really learning how to live with it, not just endure it. One of the ways we speak about it is that the sensory, the emotional, and the cognitive/conceptual dimensions of the pain experience can be uncoupled from one another, meaning that they can be held in awareness as independent aspects of experience. Once you see that your thoughts about the sensations, for instance, are not the sensations themselves, both the experience of the sensory and the cognitive dimensions of the pain experience may change independently. This is also true for our emotional reactions to unpleasant sensory experience. This phenomenon of uncoupling can give us new degrees of freedom in resting in awareness and holding whatever arises in any or all of these three domains in an entirely different way, and dramatically reduce the suffering experienced.
So, where do you begin? If you have a chronic pain condition, hopefully by this point you have already started experimenting with some of the mindfulness exercises suggested in Part I. Perhaps during your reading or during your experiments with the MBSR practices, you found yourself thinking about your own situation from a different angle or feeling a desire to pay attention to things you may have taken for granted before, maybe even letting yourself become genuinely curious about this phenomenon we call pain. Perhaps you have also begun to practice one or more of the formal guided meditations on the schedule outlined in Chapter 10. If you haven’t, the first thing to do now, if you want to commit to making the MBSR curriculum a part of your life, at least for the next eight weeks, is to make a firm commitment to yourself that you will set aside and protect a stretch of time in your day, every day (or at least six days a week), to practice, whether you feel like it or not! It is best to start with the body scan. Practically speaking, that means using the guided mindfulness meditation practice CD or download of the body scan and giving yourself over to doing what it says to do—again, for at least forty-five minutes a day, six days a week. It also means forming the intention to practice as if your life depended on it, whether you find that you like the body scan or not on any given day, and even if you don’t feel you are “getting anywhere” with it right away.
All of the suggestions in Part I will be just as relevant to you for working with pain as they are to people who do not have chronic pain. This includes cultivating the attitudes described in Chapter 2. Be aware of the tendency to identify yourself as a “chronic pain patient.” Instead, remind yourself on a regular basis that you are a whole person who happens to have to face and work with a chronic pain condition as intelligently as possible—for the sake of your quality of life and well-being. Reframing your view of yourself in this way will be especially important if you have a long history of pain problems and feel overwhelmed and defeated by your current situation and by your past experiences.
Of course, you will be more aware than anybody that having pain doesn’t free you from all the other kinds of problems and difficulties people have. Your other life problems need to be faced too. You can work with them in the same way you will face and work with pain. It is important to remind yourself, especially if you feel discouraged and depressed at times, that you still have the ability to feel joy and pleasure in your life. If you remember to cultivate this wider view of yourself, your efforts in the meditation will have a much more fertile soil in which to take root and give rise to new ways of seeing and being in relationship to your experience, including the presence and intensity of your pain condition. The meditation practice may also wind up helping you in unsuspected ways having nothing to do with your pain.
As we saw when we discussed symptoms in the last chapter, making the pain go away is not a very useful immediate goal. Pain can disappear altogether at times, or it can subside and become more manageable. What happens depends on a great many different circumstances, only some of which are under your potential control. A lot depends on the kind of pain you have.
For instance, headaches are more likely than low-back pain to disappear in a short period of time and not recur. In general, improving low-back pain takes more work over a longer period. But whatever your pain problem, it is best to immerse yourself in practicing the meditation regularly, keeping in mind and even cultivating the attitudinal factors we considered in Chapter 2, and see what happens. Your daily meditation practice will be your pain laboratory. Your ability to regulate or modulate your experience of pain and develop a healthier relationship with it will grow out of practicing the body scan, the sitting meditation, the yoga (if it is advisable for you to be doing it), and out of the mindfulness you are bringing to everyday living, moment by moment by moment and day by day by day.
The body scan is by far the practice that works best at the beginning for people with chronic pain, especially if sitting still or moving is difficult. You can do it lying on your back or in any other convenient outstretched position. Just close your eyes, tune in to your breathing, and feel your belly expand gently on the inbreaths and recede on the outbreaths. Then, as described in Chapter 5, use your breathing to direct your attention down to the toes of your left foot. Start working from there, maintaining moment-to-moment awareness. When your mind is on one region of your body, the idea is to keep it focused on that region as best you can, feeling any and all sensations (or lack of sensations if you don’t feel anything), and breathing in to and out from that region. Every time you breathe out, see if you can let your whole body sink a little more deeply into the surface you are lying on as the muscles all over your body release their tension and relax. When it comes time to leave that region and move on to the next, letting go of it completely in your mind’s eye and dwelling in stillness for at least a few breaths before tuning in to the next region on your journey up through your left leg, then your right leg, then through the rest of your body. The basic meditation instructions about how to work with your mind when it wanders still apply (except when you are in so much pain that you cannot concentrate on anything other than the pain itself; working with this situation is described on this page): when you notice at a certain point that your mind is somewhere else, observe where it has gone, and then gently escort your attention back to the region you are focusing on. If you are using the guided body-scan CD, when your mind wanders off and you realize it, then bring your attention back and pick up wherever my voice or the voice of your instructor is suggesting that you focus.
Move slowly, scanning in this way through your entire body. As you move through a particularly problematic region, perhaps one in which the sensations of discomfort and pain are quite intense, or have been in the past, see if you can treat it like any other part of your body that you come to focus on—in other words, gently breathing in to and out from that region, carefully observing the sensations, allowing yourself to feel them and open up to them and letting your whole body soften and relax each time you breathe out. The basic invitation is to “inhabit” each region of your body with full awareness and put the welcome mat out for whatever arises in the way of sensations, again, with gentleness and kindness toward yourself and toward your body. At the same time, you can invite whatever thoughts and emotions are associated with this region of your body to also be fully acknowledged, felt and met, without having to fix anything at all in this moment, or solve any problem or difficulty. You are simply taking up residence in the region in question, and resting in awareness. Then, when it comes time to let go of that region and move on (you can decide for yourself when that moment is if you are practicing without the guidance), letting go of it completely (if it helps, try saying “good-bye” in your mind silently on an outbreath), and see if you can simply rest in calmness and stillness in this moment. Even if the pain sensations don’t change at all or become more intense, just move on to the next region as best you can, inhabiting it now with full awareness.
If the painful sensations in a particular region do change in some way, see if you can note precisely what the qualities of that change are. Let them register fully in your awareness and keep going with the body scan.
It is not helpful to expect pain to disappear. In fact, it is helpful not to expect anything at all. But you may find that the experience of pain changes in intensity, sometimes getting momentarily stronger or weaker, or that the sensations change, say from sharp to dull, or to tingling or burning or throbbing. It can also be helpful to be aware of any thoughts and emotional reactions that you may be having about either the pain, your body, the guidance on the CD, the meditation itself, or anything else. Just keep up the perceiving and letting go, perceiving and letting go, breath by breath and moment by moment.
Anything you observe about your pain or about your thoughts and emotions is to be noted non-judgmentally as you maintain your focus in the body scan. In the MBSR program, we do this every day for weeks. It can be boring, sometimes even exasperating. But that is okay. Boredom and exasperation can also be seen as thoughts and feelings and let go of. As we have mentioned a number of times, and it is certainly true in regard to the body scan practice in particular, we tell our patients, “You don’t have to like it; you just have to do it.” So whether you find the body scan to be very relaxing and interesting, difficult and uncomfortable, or exasperating, is irrelevant to whether it will serve you well. As we have seen, it is probably the best place to get started in this whole process of befriending your experience and inhabiting your awareness with the body just as it is. After a few weeks, you can switch over to alternating the body scan with both the sitting meditation and with the yoga if you like. But even then, don’t be too quick to give up on the body scan.
Also, it is important not to be overly thrilled with “success” or overly disappointed by lack of “progress” as you go along. Every day will be different. In fact, every moment and every breath will be different, so it is helpful not to jump to conclusions about either the practice or its value to you after one or two sessions. The work of growth and healing takes time. It requires patience and consistency in the meditation practice over a period of weeks, if not months and years. If you have had a problem with pain for a number of years, it is not exactly reasonable to expect that it will magically go away in a matter of days just because you have started to meditate. But, especially if you have tried everything else already and still have pain, what do you have to lose by practicing the meditation on a regular basis for eight weeks, or even longer? Is there something better you could be doing in those forty-five minutes a day than touching base with yourself, no matter what you think or feel at those moments, and, with some degree of kindness and self-compassion (very different from self-pity), dwelling in the domain of being? At times of discouragement, just watch the feelings of discouragement themselves, letting them be and then letting them go too, as best you can, as you keep practicing, practicing, practicing.
When you encounter moments when the pain is so intense that it is impossible for you to direct your attention to any other part of your body, let go of the body scan, shut off the CD if you are using it, and just bring your attention to focus directly on the pain itself in that moment. There are a number of ways to approach pain besides those we have already discussed. The key to all of them is your unwavering determination to direct your attention gently, delicately, but firmly on and into the pain, no matter how bad it seems. After all, it is what you are feeling right now, so you might as well see if you can at least accept it a little bit, just because it is here.
In some moments when you go into your pain and face it openly, it may seem as if you are locked in hand-to-hand combat with it or as if you are undergoing torture. It is helpful to recognize that these are just thoughts. It helps to remind yourself that the work of mindfulness is not meant to be a battle between you and your pain and it won’t be unless you make it into one. If you do make it a struggle, it will only make for greater tension and therefore more pain. Mindfulness involves a determined effort to observe and accept your physical discomfort and your agitated emotions, moment by moment. Remember, you are trying to find out about your pain, to learn from it, to know it better, to become familiar, even intimate with it, not to stop it or get rid of it or escape from it. If you can assume this attitude and be calmly with your pain, looking at it in this way, “befriending” it for even one breath or even half a breath, that is a step in the right direction. From here, you might be able to extend your embrace and remain calm and open while facing the pain for maybe two or three breaths or even longer.
In the clinic we like to use the expression “putting out the welcome mat” to describe how we work with pain and discomfort during meditation. Since pain (or perhaps we should start referring to it as intense and unwanted sensation) is already present in a particular moment, we do what we can to be receptive and accepting of it. We try to relate to our experience of discomfort in as neutral a way as possible, observing it non-judgmentally, feeling what it actually feels like in detail. This involves opening up to the raw sensations themselves, whatever they may be. We breathe with them and dwell with them from moment to moment, riding the waves of the breath, the waves of sensation, resting in our attending, in awareness itself.
We might also investigate a little bit further by asking ourselves the question, “How bad is it right now, in this very moment?” If you practice doing this, you will probably find that most of the time, even when you are feeling terrible, when you go right into the sensations and ask, “In this moment, is it tolerable? Is it okay?” the chances are you will find that it is. The difficulty is that the next moment is coming, and the next, and you “know” they are all going to be filled with more pain.
The solution? You might experiment with taking each moment as it comes, seeing if you can be 100 percent in the present in one moment, then do the same for the next, right through the forty-five-minute practice period if necessary or until the intensity subsides, at which point you can go back to the body scan. You may also discover that the experience of what we call “pain” is not monolithic, that the sensations are sometimes changing moment by moment by moment as we hold them in awareness.
As we have already noted, there are two other very important dimensions of the pain experience that you can investigate in addition to observing the bare bodily sensations themselves. You can also bring awareness to any thoughts or feelings you may be having about the sensations. For one thing, you may come to notice that you are referring to the entire constellation of your experience silently in your mind as “pain.” This too is a thought, just a name. It is not the experience itself. Notice it if you are labeling the sensations in this way. Maybe it is not necessary to call them “pain.” Perhaps it even makes them seem stronger. Why not look and see for yourself whether this is so? Then perhaps you will approach them in a more open, curious manner, with a very light and gentle touch, again, much as you might approach a shy animal sunning itself on a tree stump in a forest glade.
When you start looking in this way at your experience, you may discover that there are also all sorts of other thoughts and emotions milling about, appearing and disappearing, commenting, reacting, judging, catastrophizing, feeling depressed or anxious, yearning for relief. Statements such as “This is killing me,” “I can’t stand it any longer,” “How long will this go on?” “My whole life is ruined,” “There is no hope for me,” or “I’ll never get the better of this pain,” may all move through your mind at one time or another. You may find such thoughts coming and going constantly. A lot of them are fear-based, anticipatory thoughts about how bad the future may be. It is good to notice that none of them is the pain itself.
Can you be aware of this as you practice? It is a key realization. Not only are these thoughts not the pain itself, they are not you either! Nor, in all likelihood, are they particularly true or accurate. They are just the understandable reactions of your own mind when it is not ready to accept the pain and wants things to be different from the way they are, in other words, pain-free. When you see and feel the sensations you are experiencing as sensations, pure and simple, you may see that these thoughts about the sensations are useless to you at that moment and that they can actually make things worse than they need be. Then, in letting go of them, which, you may recall, means allowing them to be as they are, you come to accept the sensations simply because they are already here anyway. Why not just accept them—for now?
However, you cannot reliably let go into accepting the sensations until you realize that it is your thinking that is labeling the sensations as “bad.” It is your thinking that doesn’t want to accept them, now or ever, because it doesn’t like them and just wants them to go away. But notice, now it is not you that won’t accept the sensations, it is just your thinking, and you already know, because you have seen it for yourself firsthand, that your thoughts are not you.
Does this shift in perspective show you another option for facing your pain? What about letting go of those thoughts on purpose, as a little experiment, when you are in a lot of pain? What about letting go of that part of your mind that wants things to be the way it wants them to be, even in the face of incontrovertible evidence that they are not that way right now? What about accepting things just as they are right now, in this very moment, even if you hate them, even if you hate the pain? What about purposefully stepping back from the hatred, the anger, and the catastrophizing and instead not judging things at all, just accepting them, which means, remember, simply letting them be? This is a very courageous stance to take in relationship to intense sensation. It has nothing to do with passive resignation or giving up.
It may also strike you at a certain point, particularly if there is a moment of calmness in the midst of the inner turmoil, that your awareness of sensations, thoughts, and emotions is different from the sensations, the thoughts, and the emotions themselves—that aspect of your being that is aware is not itself in pain or ruled by these thoughts and feelings at all. It knows them, but it itself is free of them. You can check this out for yourself the next time you experience intense sensation or an intense emotion. You can rest in awareness and ask yourself, “Is my awareness of the pain in pain?” or “Is my awareness of the feelings of fear, or anger, or sadness frightened, or angry, or sad?” Even one brief moment of investigation by asking yourself this question and looking to see what is actually so for you can be very helpful in cultivating a greater intimacy and understanding concerning the nature of your suffering and possibly revealing new options for shifting your relationship to it right in this moment.
When engaged in the body scan or any of the other mindfulness practices, you may come to notice that when you identify with your thoughts or feelings or with the sensations in your body, or with the body itself for that matter, there is much greater turmoil and suffering than when you inhabit the domain of alert and affectionate attention, the domain of non-judgmental spaciousness, and simply rest in awareness with no agenda other than to be awake.
We adopt this perspective of open presence and acceptance throughout the meditation practice. However, toward the end of the body scan, you may recall that there is an explicit sequence that encourages the cultivation of choiceless awareness, a disidentifying with the entire play of inner experience, whether it be the breath, sensations, perceptions, thoughts, or feelings. Toward the end of the body scan, after we have intentionally let go of the body, we sometimes invite our thoughts and feelings, our likes and dislikes, our concepts about ourself and the world, our ideas and opinions, even our name, into the field of awareness and we intentionally let go of them as well, as we simply rest in awareness itself. On the CD, it suggests that you tune in to a sense of being complete in the present moment, as you are, without having to resolve your problems or correct bad habits or pay your bills or get a college education or anything else. Can you identify with yourself as being whole and complete in this moment and at the same time part of a larger whole? Can you sense yourself as pure “being,” that aspect of you that is bigger than your body, beyond your name, beyond your thoughts and feelings, your ideas and opinions and concepts, even beyond your identification of yourself as a certain age or as male or female?
In the letting go of all of this, you may come to a point at which all concepts dissolve into stillness and there is just awareness, a knowing beyond any “thing” to be known, a non-conceptual and not merely cognitive knowing. In this stillness, you might come to know that whatever you are, “you” are definitely not merely your body, although it is yours to work with and to take care of and make use of. It is a very convenient and miraculous vehicle, but it is hardly you. Nor are your thoughts and emotions. Don’t your ideas and opinions evolve over time? You may no longer think or like things that earlier you might have been extremely self-identified with. This suggests that your essential self might be more akin to awareness than to anything else in the ever-changing constellation of aggregates that is you, especially when you learn to inhabit awareness as your “default mode,” your natural baseline condition of being, and embody it in your own friendly way from moment to moment, and day by day, through thick and through thin.
If you are not your body, then you cannot possibly be your body’s pain. Your essential nature has to be bigger than the pain. As you learn to take up residency and dwell in the domain of being, your relationship to pain and to intense uncomfortable sensation in your body can undergo profound transformative and healing changes. Such experiences, even fleeting tastes and intimations, can guide you in developing your own ways of coming to terms with the pain you experience, to make room for it, to befriend it, to live with it—as so many of our patients have learned to do.
Of course, regular practice is necessary, as we have been emphasizing all along. The domain of being is easier to talk about than to experience. To make it real in your life, to get in touch with it in any moment, takes a degree of intentionality and effort, as well as determination and, dare I say it, discipline. A certain kind of digging, a kind of inner archaeology, is required to uncover your intrinsic wholeness, covered over as it may be with layer after layer of opinions, likes and dislikes, and the heavy fog of automatic, unconscious thinking and habits, to say nothing of pain from the past, as well as present-moment pain. There is nothing romantic or sentimental about the work of mindfulness, nor is your intrinsic wholeness a romantic or sentimental or imaginary construct. It is here now, as it always has been. It is part of being human, just as having a body and feeling pain are part of being human.
If you suffer from a chronic pain condition and you find that this way of looking at things resonates with you, then it may be time to test this approach for yourself, if you haven’t already. The only way to go about it is to start practicing and keep practicing. Find and cultivate moments of calmness, stillness, and awareness within yourself using your pain as your teacher and guide.
It is hard work, and there will be times when you will feel like quitting, especially if you don’t see quick results in terms of pain reduction. But in doing this work, you must also remember that it involves patience and gentleness and lovingkindness toward yourself, and even toward your pain. It means working at your limits, but gently, not trying too hard, not exhausting yourself, not pushing too hard to break through. The breakthroughs will come by themselves in their own good time if you put in the energy in the spirit of self-discovery. Mindfulness does not bulldoze through resistance. You have to work gently around the edges, a little here and a little there, keeping your vision alive in your heart, particularly during the times of greatest pain and difficulty.
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