Dear Jon and Peggy: I have many aches and pains but I feel great. I was able to shovel my driveway, which is 250 feet long. Breathing, meditating, and frequent breaks for arms, legs, back, and neck exercises. I had muscle soreness but nothing to incapacitate me. In thirty years I never before attempted to shovel my driveway. Thank you. Pat.
People who have never had a problem with chronic pain have no idea how much living with a pain condition changes your whole life and everything you do. Many people with back injuries are unable to work, especially at jobs that require lifting or driving or standing for long periods. Some spend years on workman’s compensation while trying to recover sufficiently to be able to get back to work and lead something resembling a normal life, or to be certified as disabled so that they can receive disability payments. Often there are legal problems and battles in order to receive benefits. Living on a fixed and very reduced income, coupled with being stuck in the house in pain for days, weeks, months, sometimes even years, unable to do what one once could, is extremely frustrating and depressing, not just for the person in pain but for his or her entire family and circle of friends. It can make everybody feel angry, defeated, and helpless.
Whether you are disabled by your pain at all times or just have a chronic “bad back” that you have to be careful of, the effects of low-back pain on your life can be debilitating and depressing. Just bending over the sink when brushing your teeth, or picking up a pencil, or getting into the bathtub or out of a car can trigger days or even weeks of intense pain that may force you onto your back in bed just to bear it. Not only pain but also the threat of pain if you make a wrong move constantly affects your ability to lead a normal life. Thousands of things have to be done slowly and carefully, taking nothing for granted. Lifting heavy objects may be out of the question. Even lifting very light objects can cause major problems. And at those times when you are not in pain, the strange feeling of instability and vulnerability in that central region of your body can still lead you to feel insecure and precarious. You may not be able to stand up straight or turn or walk in a way that feels normal. You may feel a need to brace yourself or guard yourself against people or circumstances that might throw your body off balance. It is very hard to have your body feel “right” when its central fulcrum feels unstable and vulnerable.
Sometimes your back can go out even when you are being careful. You may not have noticed anything in particular that you did, but even so, there are times when your back muscles can go into spasm, triggering a setback that may last for days or weeks. One minute you can be relatively okay, the next minute you are in trouble.
People with chronic back pain tend to have “good days” and “bad days.” Often there are very few good days. It can be very discouraging to live from day to day uncertain about how you will feel tomorrow or what you will or won’t be able to do. It is hard to make definite plans, which makes it almost impossible to work at a regular job and makes it hard socially as well. And if you do have a good day now and again, you can feel so exuberant because your body feels “right” or normal for a change that you might well overdo things to compensate for all the times you were unable to do anything. Then you wind up paying for it later. This can be a vicious cycle.
A back problem almost forces you to be mindful because the result of being unaware of your body and what you are doing can be so debilitating. In order to work systematically around the edges of your limitations, in order to get stronger and healthier and to be able to do at least some of the things you want to do, mindfulness becomes absolutely essential.
The people in the Stress Reduction Clinic with chronic pain who are the most successful in learning to live with and regulate their pain cultivate a long-term perspective on rehabilitating themselves. Big improvements in mobility and pain reduction may or may not come about in the eight weeks of the MBSR program. You are better off thinking in terms of six months, or even a year or two, and proceeding patiently and persistently, no matter how well things go at first. However, the quality of your life can begin to improve from the very first time you practice the body scan, as we saw in the case of Phil (Chapter 13). This is especially true if you are willing to work with your body and your back problems slowly and systematically. Such a commitment and strategy should include a reasonable vision of what you might be able to accomplish with consistent work. It may help to imagine how your back might be in three years or five years if you were to keep up a steady, mindful physical exercise program, encouraging your whole body, not just your back, to grow stronger and more flexible. One very successful scientist I know who has severe pain “puts his body back together” for an hour every morning before he goes out to face the world.
It might help if you think of yourself as in long-term training, like an athlete. Your project is rehabilitating yourself. Your starting point, of course, is your condition in the moment you decide to engage in befriending your body as it is and to work with it from here on out, for life, if necessary, all puns intended. There is simply no other place to begin. The deep meaning of the word rehabilitation comes from the French verb habiter, which means “to dwell,” “to inhabit.” So rehabilitation doesn’t just mean to reenable. At an even deeper level, it means to learn to live inside again. That, it turns out, is profoundly reenabling.
A long-term approach to rehabilitating your body as a whole, and in particular your back if you have a chronic back condition, might include mindfully working to strengthen your back by doing the physical therapy exercises prescribed for you or by practicing as much of the yoga as you are able to manage. First check with your physical therapist or doctor to make sure that these specific exercises are appropriate in your case. Modify them in whatever ways seem appropriate, even day by day, including skipping certain postures entirely and adding others. You don’t have to do it all. Just do the exercises that you are able to do and avoid those that your doctor says are unwise for you or that you sense are not right for you now. As we have seen, any moving you do is yoga, and any postures you adopt are as well, if you engage in them mindfully and lovingly.
Any program of mindful body work that you decide to engage in needs to be approached particularly slowly and gently, especially when you have a back problem. A physical therapist who works with many of our patients once commented that she loves to work with people after they have been through MBSR. She says they are noticeably more responsive, relaxed, and tuned in to their bodies during their physical therapy sessions than people who do not know about mindfulness—people who have never been taught how to breathe with their stretches and their movements, and how to work with the body and with painful sensations instead of against them. And the participants themselves say the same thing: that physical therapy changes once they know how to use their breathing as they lift and bend and stretch.
Taking care of the whole of your body through regular exercise is even more important if you have a back problem than for someone without one. Remember, “If you don’t use it, you lose it.” It is important not to let your back problem become an excuse for not taking care of the rest of your body. As a complement to whatever you find useful within the practice of the mindful yoga, perhaps you could strengthen your body overall by walking regularly or by using a stationary bicycle a few times a week, or by swimming or doing flowing movement exercises in a pool. In the spirit of MBSR, if you intend to do whatever you can to rehabilitate your body, it is important to do something to stretch and strengthen your body every day, or at least every other day, as described in detail in Chapter 6, even if it is just for five minutes at first.
On top of working with your body in these ways as best you can, we suggest you practice the body scan daily, as described in Chapters 5 and 22, as the core of your rehabilitation strategy. Use the body scan, whether you like it at first or hate it, as a time to “rebody” yourself by getting deeply in touch with your body from moment to moment, in stillness, working with whatever sensations arise, and putting the welcome mat out in particular for whatever discomfort or pain you may encounter, and befriending them as best you can. It is helpful to keep bringing to mind the foundational attitudes of MBSR, and in particular, a willingness to be kind and gentle with yourself. Even though you may be very attached to “making progress,” which of course is only natural, seeing if you can bring yourself to practice the body scan moment by moment and day after day for its own sake, without any attachment to outcome. This may be the best short- and long-term strategy for having things grow and deepen over time in the direction of true healing and true rehabilitation.
If you are out of work or retired, you will have plenty of time for this. Time can weigh very heavily on us when we are stuck in the house or feel in any way that life is passing us by. You may find yourself feeling bored and frustrated, uncomfortable and irritable, or even sorry for yourself. Anybody would. But none of those assessments is based on the truth of things. They are themselves just more thinking. If you intentionally make up your mind to use some of the time that you have during the day in the service of your own rehabilitation and healing, by practicing the meditation and the yoga, you can transform a bad or isolating or fear-inducing situation into a creative one. You obviously didn’t ask for your back problem to happen, but as long as it has, you may as well decide that you will use your time to good advantage in order to rehabilitate yourself as best you possibly can and taking a long-term perspective on how that will unfold. Remember, it’s your body and nobody knows it as well as you do, and nobody depends on it as much as you do for your well-being, whatever your circumstances, whatever your age.
One of the most healing things you can do for your body during the day is to use your breath periodically to bathe and embrace the region of pain or discomfort and invite it to soften in the same way that we use the breath in the body scan practice itself, as described in the previous chapter. You can do this by consciously directing your breath in to the painful region, feeling it as it moves into and blends with your back, for instance, and then visualizing and/or feeling the painful sensations softening and dissolving as the breath releases and the whole body, including this region, relaxes to whatever degree it does. It is important to take a day-by-day, even moment-by-moment perspective, purposefully reminding yourself to take each day as it comes, each moment as it comes, and letting go as best you can of any expectations that you should feel a certain way or that the pain should lessen. Instead, we are just watching the breath do its work, and bringing as much kindness and compassion and acceptance to ourself and our situation as possible, moment by moment by moment, and breath by breath by breath. If you need to modify the position of your body in the body scan so that it works more effectively for you, then by all means, be creative in this regard. That would include your decision about what surface you choose to lie on, whether the floor on a thick pad or on your bed, or whether you sometimes feel the need to practice curled up on your side rather than lying on your back in the corpse pose, or anything else that you intuitively feel would be of help in supporting your ongoing practice. Remember, I am not joking when I say that it is important to practice as if your life depended on it. It does.
Healing is truly a journey. The road has its ups and downs. So you should not be too surprised if you have setbacks and sometimes feel as if you are taking one step forward and then sliding two steps backward. This is the way it always is. If you are cultivating mindfulness and seeking ongoing advice and encouragement from your doctor and others who are supporting your efforts, you will be able to catch things as they change and be flexible enough to modify what you are doing when necessary to accommodate your changing situation and the limitations of the moment, whatever they might be. We all have limitations. They are worth befriending. They teach us a lot. They can show us what we most need to pay attention to and honor. They become our cutting edge for learning and growing and gentling ourselves into the present moment as it is. The most important thing is to believe in your own ability to persevere through the many ups and downs, and to not lose sight of your intrinsic wholeness, right in this moment, and your commitment to realizing it fully in the only moment you possibly can, this one. For beyond all efforts at progress and getting someplace better—even though progress and healing can and do unfold over time—the fact of the matter is that in some very deep way, whatever you are looking for or hoping for is already here. You are already whole, you are already perfect, including all your supposed imperfections. There truly is no place to go, nothing to do, nothing to attain. When you practice with this attitude, it is like an oxygen line straight into the heart. Then, paradoxically, great attainment is possible. This is the power of non-doing and non-striving embodied. Another word for it would be wisdom.
Bringing mindfulness to your daily activities is particularly valuable, in fact indispensable, when you have a back condition and back pain. As we have seen, sometimes even lifting a pencil or reaching for the toilet paper the wrong way (isn’t it amazing that there may be a “wrong way” for you to reach for the toilet paper?), opening a window, or getting out of a car can trigger back spasms and acute pain. So the more you are aware of what you are doing while you are doing it, the better. Doing things on automatic pilot can lead to serious setbacks. As you probably know, it is particularly important to avoid lifting and twisting simultaneously, even with very light objects. First lift, always bending the knees and keeping the object close to your body, then turn. It helps to couple all your movements with awareness of your breathing and your body position. Are you twisting and standing up simultaneously when you get out of the car? Don’t. Instead, do one first, then the other. Are you leaning over at the waist to push up a window? Don’t. Instead, get in close to it before you attempt to lift it. Mindfulness of little things like this can make a big difference in protecting yourself from injury and pain.
Then there is the challenge of getting things done around the house. There will be times when you can’t do any work at all. But there may be other times, depending on the severity of your back condition, when it may be possible to do things if you do them in moderation and see them as part of your program to build up your strength and flexibility. Take vacuuming, for instance. Lifting and pulling the vacuum cleaner can be dangerous if you have a back condition. But if you are going to do it, you can devise ways to do it mindfully. The movements involved in vacuuming can be very hard on the back. But with a little attention and imagination, you can make the movements of vacuuming into a kind of mindful yoga. You can do under the bed and under the couch on your hands and knees or squatting if that is possible, bending and reaching with awareness, using your breath to guide your movements, just as you would when doing the yoga exercises. If you vacuum this way, and you do it slowly and mindfully, chances are you will know when the body has had enough, and you will listen to its message. Then you might stop and do a little more in a day or two. After you stop, try doing some yoga for five or ten minutes to relax and “distress” your body and stretch some of the muscles that may have tensed up.
Needless to say, this is not the way most people vacuum, or do anything else. But if you experiment, you are likely to find that a little awareness, coupled with the skills that come from your regular yoga and meditation practice, can go a long way toward transforming drudgery into therapy and frustrating limitations into healing opportunities. You work at the edges of what is possible, listening to your body. As you do, you might find yourself growing stronger over the weeks and months. Of course, people who don’t have pain might avoid back injuries by vacuuming in the same way. And if vacuuming is out of the question for you, you might try some other household chore and work with it in a similar way.
In the Stress Reduction Clinic, we suggest that people with back pain take a very cautious, experimental approach toward reclaiming those areas in their lives that are most compromised by their condition. Just because you have pain doesn’t mean you should give up on your body. It is all the more reason to work with it to make it as strong as it can possibly be so that it can come through for you when you need it. Giving up on sex or walking or shopping or cleaning or hugging is not going to make things better.
Experiment mindfully! Find out what works for you and how to modify things so that you can engage in the most important activities of daily living, at least for short periods. Don’t automatically deprive yourself, out of fear or self-pity, of the normal activities that make life meaningful and that give it coherence. Remember, as we saw in Chapter 12, if you say “I can’t …,” then you certainly won’t. That thought or belief or statement becomes a self-fulfilling prophecy; it creates its own reality. But since it is only a thought, it is not necessarily completely accurate. Wouldn’t it be better to catch yourself at those moments, see through the “I can’t …” or the “I could never …” thoughts and try instead “Maybe, somehow, it just might be possible. Let me try it … mindfully.” I cannot tell you the number of people who, over the years, have come up to me and told me that working in this way “saved my life.”
Recall Phil, the French Canadian truck driver who had injured his back and whose experience with the body scan in the first few weeks of the program is recounted briefly in Chapter 13. It took him several weeks before he learned how to be in his body during the body scan in such a way that his relationship to intense discomfort shifted, and he experienced a dramatic and enduring reduction in his pain. He experienced many ups and downs in those first weeks but kept up the practice anyway. Finally he wound up feeling much more able to modulate his back pain, and also more in control in other areas of his life as well.
Before he started meditating, Phil had been wearing a TENS unit daily, which the pain clinic had prescribed for him as part of his treatment.* He had felt he couldn’t get along without it and wore it all day long, every day. But after a few weeks practicing the body scan, he found he could go two or three days without wearing it. He was very pleased to be able to regulate his pain on his own like that. To him it was a sign of his own power.
But when it came time for the class to do the yoga, once again he came to a crossroads. After the program was over, he described it this way: “You know, I almost gave it up again in the third week when you started talking about yoga and all that stuff. I said, ‘Oh my God, that’s going to kill me to do that,’ but then you said that if it bothers you, don’t do it, so I mostly did the body scan. But I did do some yoga too, and I did a lot during the all-day session. It bothered me at times, some of the exercises bothered me to do them, like the leg raising and the folding yourself up and rolling backward on your neck. I can’t do a whole lot of that. The things I can do that don’t bother me, I do them every so often. I am definitely feeling more flexible.”
In reviewing his experience at the end of the eight weeks, Phil said, “No, the pain is not gone, it’s still there, but you know, when I start feeling it too much, I just sit aside somewhere, take ten, fifteen, twenty minutes, do my meditation, and that seems to take over. And if I can stay at least fifteen or thirty minutes or better, I can walk away and not even think about it for maybe three, four, five, six hours, maybe the whole day, depending on the weather.”
He also noticed that things were different at home with his wife and children. In his own words: “We had a bit of a problem when I first came here [to the clinic]. We had problems, ya know. I had this pain problem so much on my mind and about finding another kind of a job without the education I figured I needed for most jobs or whatever … this stuff all built up pressure and, without realizing, I was like a madman, ya know? I mean, my wife was just like a slave working for me, more or less, and we sat down one night and I got kinda frustrated and I told her, ‘We gotta talk.’ There wasn’t much sex life going on, and that’s driving me up a wall. I’m not a person who goes weeks without it, ya know, and so I said, ‘Come on now, let’s …,’ so she finally made me realize what was going on. She says, ‘How long since you told me you love me? How long?’ We sit down—we’ve got a double recliner, ya know, like a love seat—and she says, ‘Let’s sit down and watch TV together.’ But when I’m watching TV, I’m watching TV. She’ll talk and I go, ‘Uh-huh, uh-huh,’ but it goes right through me, ya know. She’ll say, ‘Well, I told you …,’ and I’ll say, ‘Well, I’m sorry, I wasn’t listening, I was watching my boxing’ or whatever. Well, she finally made me realize what’s going on. After I started in the Stress Reduction Clinic, I says, ‘Wow, ya know, I do realize it now, ya know. So we got away from the TV now. At night we don’t sit down and watch TV no more. We go outside. We have a campfire every night when it’s nice, with the neighbors. We sit down and talk, ya know, and sometimes we’re with another couple, sometimes just talking or sitting watching the fire, and it just draws my attention. And the first thing you know, they’re talking, but it’s just like they’re a distance far away. I can find myself getting to the breathing exercise automatically, and I feel so much better after this. And it beats watching that boob tube. My relationship with my wife has improved a hundred percent, and with the kids too.’ ”
On the subject of trying new things, Phil also observed, “One other thing I got from the program … Before, I was never able to talk in public the way I did in the classes. Anytime I ever tried before, I could feel my face burning, turning as red as a tomato, because I am bashful and shy, I always was. I don’t know what made me be able to talk in the classes the way I did. You see, what I did say, whenever I said something, I had a good feeling about it. It didn’t come from my mouth, it came from inside, ya know? From the heart.”
It is no accident that meditation practice has something to teach us about coping with pain. Over the past 2,500-plus years, practitioners of meditation have had a lot of experience learning from pain and developing methods to transcend it. Intensive training in meditation has traditionally been the province of monasteries and retreat centers set up for that explicit purpose. Long-term meditation practice can be very painful physically and emotionally, as well as uplifting and liberating. Imagine going off somewhere and doing what we do in our all-day session (see Chapter 8), but staying in silence for seven days or two weeks or a month or three months. People do just that on meditation retreats set up for that very purpose. In fact, it is a very profound gift you might give yourself, when you are ready.
When you sit without moving, especially cross-legged on the floor, for extended periods of time, typically for between half an hour and an hour, and sometimes even longer if you choose, and you do this maybe ten hours a day for days or even weeks at a time, your body can begin to hurt with excruciating intensity, primarily in the back, shoulders, and knees. The physical pain eventually diminishes by itself most of the time, but sitting through even a few days of it can be quite challenging. You tend to learn a lot about yourself and about pain from putting yourself in this kind of situation on purpose. If you are willing to turn toward the pain, accept it, observe it, and not run from it, it can teach you a great deal. Above all, you learn that you can work with it. You learn that pain is not a static experience; it is constantly changing. You come to see that the sensations are just what they are and that your thoughts and feelings are something apart from the sensations. You come to see that your mind may play a large part in your own suffering, and it can play a large role in freeing you from suffering as well. Pain can teach you all of these things.
People attending meditation retreats invariably have to face the physical pain that comes up during long sittings. It is unavoidable in the early stages of a retreat. It comes out of sitting still in postures we are not used to. It also arises when we become aware of the accumulated physical tension we carry around with us, unnoticed, in our bodies. In many ways, the qualities of this type of pain strongly resemble the spectrum of sensations that occur in many chronic pain conditions: the aching, the burning, the episodes of sharp, shooting sensations in the back or the knees or the shoulders. You could stop the pain at any time by getting up and walking, but mostly, if you are a meditator, you choose to stay and be mindful of it as just another experience. In return, it teaches you how to cultivate calmness, concentration, and equanimity in the face of discomfort. But it is not an easy lesson to learn. You have to be willing to face the pain over and over again, day in and day out, and observe it, breathe with it, look into it, accept it. In this way, meditation practice can be a laboratory for exploring pain, for learning more about what it is, how to go deeply into it, and ultimately how to come to terms with it.
As we saw in the previous chapter, recent studies of experienced meditators suggest that they may have a much higher tolerance for pain intensity than novice meditators, since they rate the sensations as much less unpleasant than the novices at the same degree of intensity. They also show thickening in certain parts of the brain associated with mapping sensation and regulating emotional expression in the body. Meditators seem to be able to uncouple the sensory dimension of the pain experience from the emotions and thoughts that so often accompany it and that compound the experience of suffering. They see it as bare sensation, and do not take it so personally. This uncoupling of the sensory from the emotional and cognitive dimensions of the pain experience may result in significant reductions in the degree of suffering associated with exposure to a painful experience. We see this happening every day in the MBSR classes.
Like meditators, endurance athletes also know a certain kind of self-induced pain firsthand. They too know the power of the mind in working with their pain so that they are not defeated by it. Athletes are constantly putting themselves into situations that are bound to produce pain. You cannot run a marathon at your fastest pace and not face pain. In fact, few people could run a marathon at any speed and not encounter pain.
Then why do they do it in the first place? Because runners, and all other athletes, know from firsthand experience that pain can be worked with and transcended. When the body is screaming out to stop because the metabolic pain (from the muscles not being able to get enough oxygen fast enough) toward the end of a race is so great, whether it is a 100-meter sprint or a 26.2-mile marathon, or an ultramarathon or a triathlon, whether it is swimming or biking, or running, or something else, an athlete has to reach into himself or herself and decide virtually moment by moment whether to back off the pace or to find new resources for going beyond what a normal person would consider an absolute limit.
In fact, unless a physical injury occurs (producing an acute pain-of-injury that makes you stop, and rightly so, to prevent further injury), it is invariably the mind that decides to quit first, not the body. Athletes can be plagued by lapses of concentration, by fears and self-doubts, and by the knowledge that they face certain pain during training and competition. For these reasons as well as many others, many athletes and their coaches now believe that systematic mental training is every bit as necessary as systematic physical training if they hope to be able to perform at their peak. In fact, in the new paradigm, there cannot be complete physical fitness and optimal performance of any task without mental fitness. These need to be cultivated together.
In 1984, I had an opportunity to work with the United States Olympic men’s rowing team, training the rowers in the same meditation practices that the pain patients use in MBSR to cope with their chronic pain conditions. These world-class athletes were able to use mindfulness strategies to improve their ability to face and cope with pain during training and competition, just as the patients are able to use it to work with their pain, even though these two different groups of people are working at opposite ends of the physical fitness spectrum.
Readers with chronic low-back problems might be interested to know that John Biglow, the single sculler on the 1984 U.S. Olympic rowing team, achieved his position as the best male American sculler that year in spite of a chronic back problem resulting from a herniated disk when he injured himself rowing in 1979. Following his injury, and then a serious setback in 1983 when he reinjured himself, he was never able to row hard for more than five minutes at a time, after which he would have to rest for three minutes before he could row hard again. Yet he was able to rehabilitate himself by training very carefully using the knowledge of his own limits, to the point where he was able to demand of his back the enormous effort required to compete at the world-class level. In order to be the single sculler on the Olympic team, Biglow had to race against and beat all the fastest, strongest, and most competitive rowers in the country. (Races are 2,000 meters and are completed in about five minutes.) Imagine the faith, determination, bodily intelligence, and mindfulness necessary for someone with a chronic back problem to even set out to work toward such a goal, not to mention achieve it. But the goal he set for himself was meaningful enough to sustain him along the extremely arduous, painful, and lonely road he followed.
In the 2012 Olympics, held in London, an Iranian super-heavyweight lifter, Behdad Salimikordasiabi, lifted 545 pounds in his first try in what is called the clean and jerk. Along with his score in the event called the snatch, his total score was so high that he had clearly already won the gold medal for that event. Since he was still entitled to two more attempts, the crowd went wild, urging him to go for breaking the world record, which had been set by his own teacher and mentor. After one failed attempt, he declined to go for it, in spite of the crowd’s urging, the intoxicating heat-of-the-moment feeling, and the fact that he had lifted much heavier weight in practice sessions. He said later that he had rested too long between lifts and that his body had “gotten cold,” making it unwise to go for the world record. He said there would be plenty of other occasions to attempt to break the world record. This is a remarkable example of someone being mindful of his body and being able to both recognize and respect its limitations of the moment, in spite of all the emotion from the crowd and perhaps in his own mind. We may not be capable of lifting much in the way of weight, but each one of us has that very same capacity to heed our own interior messages from the body and work with them in ways that further our overall goals. In that way, we are all athletes of the possible.
Each of us, in our own way, no matter what our situation or disability, is capable of such achievements if we can define meaningful goals for ourselves and then work intelligently toward their fulfillment. Even if we don’t achieve the goal completely, the effort itself can be sustaining and healing if we find meaning in the process itself and work with awareness, moment by moment and day by day, honoring our limitations but not being imprisoned by them. If you have any doubts about this, just watch the wheelchair athletes in local road races, or the Paralympics on YouTube. It could bring you to tears of uplift and admiration.
Most headaches are not signs of brain tumors or other serious pathological conditions, although such thoughts can easily enter your mind if you suffer from headaches that are constant, chronic, and severe. But if headaches persist or are extremely severe, it is always important to go through at least one full diagnostic work-up to rule out such pathology before trying to control them either with medication or meditation. In such cases, a well-trained physician will make sure this is done before referring a headache patient for MBSR training. Most of the patients in the Stress Reduction Clinic who have problems with chronic headaches come with diagnoses of either tension headaches, migraines, or both. All have had a full neurological examination, which usually includes a CAT scan to rule out a brain tumor.
The majority of people who are referred to the clinic with chronic headaches respond well to the meditation practice. One woman came to the program with a twenty-year history of migraine headaches, for which she took Cafergot every day. She had been treated at numerous headache clinics with no relief. Within two weeks of entering the program, she had a two-day stretch with no headaches. This had not happened to her in twenty years. She remained headache-free for the duration of the course and for some time afterward.
You only need one experience of having a headache disappear that has been chronic and constant to know that it is within the realm of possibility for such a thing to happen. This can completely change the way you think about your body and your illness, and can provide you with renewed faith in your ability to control and regulate what previously seemed uncontrollable and unmanageable.
One elderly woman told her class recently that the idea of putting out the welcome mat for her migraine struck her as particularly appropriate. So the next time she felt one coming on, she sat down to meditate and “talked” to her headache. She said things like “Come in if you want to, but you should know that I am no longer going to be ruled by you. I have a lot to do today and I just can’t spend much time with you.” This worked quite well for her and she seemed pleased with this discovery.
There is a place on the body-scan CD, after we have gone through the entire body, that suggests breathing through an imaginary hole at the top of your head, much as a whale breathes through a blowhole. The idea is to feel as if your breath could actually move in and out through this hole and then be present for how it actually feels, however that is, with full awareness and acceptance. You are not trying to make anything happen, but just being playful and experimenting.
Many people with headaches have used that “hole” as a release valve for their headaches. You just breathe in and out through the top of your head and let the tension or pressure or whatever the sensations are in that region flow right out of the body through the hole, to whatever degree they do. Of course it is harder to do this if you have not been developing your ability to concentrate through regular meditation practice. But if you have been practicing breathing this way every day as part of your work with the body scan, when you do have headache-like symptoms, you may find that they can be dispelled easily, before they build into a full-blown headache. But even if you have a full-blown headache, this method can be effective in taking the edge off it or shortening its duration, or even dissolving it.
As they get into practicing the meditation on a regular basis, whether they have a headache or not at the time they do it, most people who come to the Stress Reduction Clinic with headache problems report that both the frequency and the severity of their headaches decrease.
As your practice deepens, you may notice that your headaches do not come out of nowhere. There are usually identifiable preconditions that trigger their onset. The problem is that we only poorly understand many of the physiological triggers, and we often ignore or deny the psychological or social triggers. Certainly, stressful situations can give rise to headaches, and many people, especially those with muscle tension headaches, are at least aware of this connection. But many other people report that they wake up with headaches or that they get them when they are not under obvious stress, when everything is going well for them, on the weekends, or at other times in which they don’t feel stressed.
A few weeks of mindfulness practice often generate new insights in these individuals about their headaches and why and when they get them. Sometimes people discover that they may be a lot more tense and keyed up than they thought they were, even on the weekends. Sometimes they see that a particular thought or worry might precede the onset of a headache. This can even happen as you wake up in the morning and are getting out of bed. One anxious thought can make you tense before your feet touch the floor, although you may be completely unaware of the thought. All you know is that you “woke up with a headache.”
This is another way that being mindful as you go through the day can be useful. It helps you to tune in to your body and to your breathing from the very first moment that you know you are awake in the morning. You might even try saying to yourself as you wake up, “I am waking up now” or “I am awake now,” and feel how it feels by bringing awareness to your body as a whole, lying in bed, for at least a few breaths, before you move to get up. You can even remind yourself that you are greeting a brand-new day, filled with possibilities that you cannot possibly know but can be ready for by being open and awake for whatever may transpire as the day unfolds.
Over time, this ability simply to rest in awareness can lead you to make connections that may have previously gone unnoticed, such as realizing the link between a thought you wake up with or a situation that occurs early in the day, perhaps even in the first few minutes that you are up, and a headache later on. This can lead you to intentionally try to short-circuit a possible headache-producing chain of events by bringing awareness right to the thought as it arises, seeing it as a thought, and letting it go. Or you can take action to change your relationship to a bothersome stressful situation and monitor the results of your efforts. It may also be that you will become aware of times and places where you are more likely to get a headache and in this way identify environmental factors such as pollution and allergens that might play a role in triggering some kinds of headaches.
For some people, chronic headaches may really be a metaphor for everything that is disconnected and disregulated in their lives: body, family, work, environment, the full catastrophe. Their whole life could be described as a headache. They usually have so much stress in their day-to-day lives that it is difficult to know where to start thinking about why they might be getting headaches. If this describes your present situation, it may be helpful for you to know that you do not have to solve any of your problems in order to get started. All that you really need to do is begin paying more careful attention from moment to moment during your day to what is really going on, headache or no headache. In other words, practice being more fully present and more fully embodied, awake, and aware. With time, movement toward self-regulation happens naturally, as we have seen. Allostasis is restored, and you may find that the headaches literally and even metaphorically dissolve as if on their own. It may take years to work yourself out of such a situation completely, but the attempt itself, coupled with a willingness to accept where you already are and be patient, can lead to dramatic improvements in your headaches long before the rest of your problems have been resolved.
The two stories that follow are examples of ways in which chronic headaches may serve as a metaphor for a person’s entire life situation at a particular point in time, and how this dilemma can be worked with and perhaps turned around to lead, ultimately, not only to relief of the headaches but, even more importantly, to some insight and resolution of the larger situation.
Fred, a thirty-eight-year-old man, was referred for anxiety associated with sleep apnea, a condition characterized by temporary cessation of breathing during sleep. The apnea was due to his obesity. Fred was five foot ten, and at the time he weighed 375 pounds. In addition to his anxiety and his sleep apnea, Fred had chronic headaches. Whenever he felt stressed, he got a headache. Getting on a bus would always result in a headache. He hated buses (“they make me sick”), but he had no car and depended on them to get around. He lived with a roommate and worked managing a concession stand. His weight was so great that his neck would prevent him from breathing properly when he was lying down. This is what caused his sleep apnea. His pulmonary doctor had told him he would have to have a tracheotomy if he didn’t lose weight right away. This prospect caused Fred a great deal of anxiety. He did not want to have a tracheotomy. A colleague of ours who was counseling him for weight reduction suggested he attend the Stress Reduction Clinic’s classes in MBSR to deal with his anxiety.
Fred came to the first class and didn’t like it at all. He said to himself, “I can’t wait till this session is over. I won’t be back.” At the time he had agreed to go, it hadn’t quite hit him what it would be like to be in a class with about thirty other people. He had always been uncomfortable in crowds and had never been able to talk in a group. He was shy and instinctively avoided any kind of situation that might lead to conflict. But as he described it to me when the program was over, some “gut feeling” brought him back to the second class. He found himself saying, “If I don’t do it now, I’ll probably never do it” and “Everyone else has got problems or else they wouldn’t be here.” So, in spite of his feelings about the first class, Fred decided to keep coming. He started practicing the body scan that first week because it was assigned for homework, and by the next class he already knew that it was “going to work” for him. As he put it, “I really got into it right away.” He was even able to say something in the class about how relaxing he had found it to tune in to his body.
From the time he started doing the body scan, Fred’s headaches disappeared. This happened in spite of the fact that the stress in his life was increasing as it became more and more obvious that he was gaining weight, not losing it, and would have to have the tracheotomy. Yet by just “relaxing and going with the flow and enjoying it,” he was able to ride on the buses without getting headaches or feeling sick.
He also became more assertive. He was able to ask his roommate to leave when he stopped contributing to the rent. This was something he felt he would have never been able to do before. As he became more self-confident, Fred also started feeling more relaxed in his body. The yoga bothered him because of his weight and he didn’t do much of it. But although he gained some weight during the program, he did not get depressed. Previously, gaining even a minuscule amount of weight would send him into a severe depression.
Fred also had high blood pressure. At one point prior to joining the MBSR program, his blood pressure was measured at 210/170, which is dangerously high. Usually it averaged around 140/95 on blood pressure medication. When he completed the program, it was averaging around 120/70, lower than it had been for fifteen years.
As a postscript, he underwent not one but two attempts at a tracheotomy in one week, but they didn’t work because his neck was so thick they couldn’t get the tube to stay in. Both times it fell out after a few days. So he never did get the tracheotomy.
When I saw him again a month after the course ended, he was on a diet and had lost a noticeable amount of weight. He was continuing with his meditation practice. He said he had never felt so sure of himself in his life. Losing the weight gave him a major boost in self-confidence. He said he was feeling happy for the first time in years and that his sleep apnea had diminished with his weight loss. And he had had only one headache since he finished the course.
In another class, a forty-year-old divorced woman named Laurie was referred by her neurologist for migraine headaches and work stress. She had had migraines since she was thirteen, often four times in a single week. These included seeing lights in front of her eyes, usually followed by nausea and vomiting. Although she was on medication, the drugs often did not help her headaches unless she took them at exactly the right time, before the headache built up. This time was always hard for her to judge. In the four months preceding her referral to the clinic, Laurie’s headaches had gotten worse, to the point where several times she had sought help in the emergency room of the hospital.
When Laurie took MBSR, on occasion we asked the class participants in the fourth week to fill out the Holmes and Rahe Social Readjustment Rating Scale, in addition to continuing with their daily meditation practice. As we saw in Chapter 18, this scale is simply a list of life events. The assignment was to check off those items that happened to you in the past year. The list includes such things as death of a spouse, change in work status, illness in the family, marriage, taking out a large mortgage, and a number of other events. Each item has a particular score, which is supposed to be related to how stressful it would be to have to adapt to such a change in one’s life. In the instructions for this scale it says that a total score of over 150 means that you are under considerable stress and need to make sure you are taking steps to adapt to these situations effectively.
On the day we discussed that homework assignment in class, Laurie had the highest score on the life-events scale of anyone in the class. She told us how she and her boyfriend had both tallied their scores one night in disbelief. She scored 879 and he scored in the 700s. Their response was to laugh when they saw how high their scores were. They figured they must be stronger than they thought because, as she put it, looking at their scores, “It’s a miracle we are not both dead.” She knew they could easily have been crying rather than laughing. She said that she saw laughing as a good sign, a healthy response in itself.
Laurie’s life at that time was dominated by fear that her ex-husband was trying to kill her, which, according to her, he had actually attempted to do. On top of this, her two sons had recently been injured in a car accident, although not seriously, and she was going through a very stressful time at work.
She worked as a middle manager in a large corporation that was going through a major restructuring that made everybody feel insecure and under a lot of pressure. Her situation was made more complex by the fact that she, her boyfriend, and her ex-husband all worked for the same company.
In the fifth class, she said that during that week she had seen the prodromal “lights” that usually signal the onset of a big migraine headache. But for the first time, she had become aware of them early on. There were only a few lights, not the overwhelming array that usually meant that the headache was less than an hour away and already, as she put it, “unstoppable.” She decided then and there to take one pill and then get into bed and do the body scan, thinking that maybe she could avoid taking the other three pills that she was supposed to take in sequence over several hours to control the headaches with medication.
What Laurie reported with some pride was that for the first time since she was a girl, she had been able to short-circuit a headache on her own. She never took the other three pills. She did the body scan, fell asleep toward the end, and woke up feeling completely refreshed. She attributed her success to two things: First, she felt that practicing the meditation over the preceding weeks had helped her to become more sensitive to her body and to what she was feeling. This is why, she surmised, she was able to be aware of the early warning signs of the migraine several hours before the full-blown headache was upon her and to take some action. Second, she now had something she could do at such a moment when she recognized the warning signs early enough. At least she felt she now had something she could try out as an alternative to taking a drug to control her headache. She had approached the impending headache in a new way, experimenting with drawing on her own inner resources for regulating it and herself through her mindfulness practice.
Laurie continued to be headache-free over the next four weeks, even though her life was in a state of perpetual upheaval. She put the problem of the nine dots up on the wall in her office, and she tried to respond to the stressors in her life instead of reacting to them.
In the week following the end of the program, Laurie had another big migraine headache. It came on the day before Thanksgiving and continued through the next day. She wouldn’t let herself be taken to the emergency room, although she was in the bathroom throwing up more than she was with her family. They were begging her to let them take her to the hospital. But in her mind, her sons had come home for Thanksgiving dinner and she could only think of how awful it was that she was so sick on the one day that she was getting to see them.
When I saw her the next morning, she was pale, distraught, and tearful. She said she felt like a “failure” after all the good results she had had during the course. She had been hoping that her doctor would take her off Inderal if she was able to remain headache-free. Now she felt she had “blown that possibility completely.” Even worse, she also felt like a failure because she had no idea why she had gotten the headache. She said that she hadn’t felt stressed by the thought of Thanksgiving. On the contrary, she had been looking forward to it. But as we talked more about the days leading up to the holiday, it became clearer to her that it did have a special meaning for her that year, and that she had had higher expectations than usual because her boys were coming and she had been feeling that she hadn’t been seeing enough of them. She also recalled that on Tuesday, before the headache came on with full force, she had been seeing the lights and spots of the prodrome but that they just hadn’t really registered in her awareness. She recalled that her boyfriend had asked her at a certain point what she wanted to do for dinner and she had said, “I don’t know, I can’t think. My mind is a blank.”
This was probably the critical point for her. It was an early warning signal from her body that a migraine was coming on. But this time, for whatever reason, the message just did not get through. She said later that she was probably feeling too busy, rushed, and tired to listen to her body, even though she had had the successful experience of short-circuiting the last one by taking immediate action when she had felt the early warning signs.
After her upset with herself had subsided, she was able to realize that this horrible headache did not mean that she was a failure. If anything, it meant that she might benefit from being even more tuned in to her body’s messages. She began to see that perhaps it was unrealistic to expect that after twenty-seven years of problems with migraine headaches, she would learn to control them in four weeks to the point where they would never be a problem for her again, especially given the current upheavals in her life.
By not generalizing from this one headache into making herself a failure, Laurie was able to see that having this particular headache at this particular time was teaching her something she hadn’t yet fully realized and that, in that sense, it could be seen as helpful. It was teaching her that she needed to honor how much of a crisis her life was in at that time, what with court dates coming up, her problems at work, and her anger at her ex-husband. It was teaching her that such pressures don’t go away just because a holiday is coming up. In fact, they can make the holiday more of a loaded situation emotionally and lead to unconscious but strong expectations and desires that things go a certain way.
And most importantly, the headache was teaching her that, at that point in her life especially, she couldn’t afford to ignore or override her body’s messages. She needed to honor them and be even more prepared than she had been to stop what she was doing when the early warning signs came on, take her medication, and practice the body scan immediately. If this was what the full catastrophe of her situation demanded of her, she realized that nothing less would do if she hoped ultimately to come to greater harmony in her life and to free herself from her headaches, literally and metaphorically.
* A transcutaneous electrical nerve stimulator (TENS) is a device worn on the belt that delivers mild electric shocks to the skin that reduce the experience of pain.