Reducing Suffering Related to Chronic Pain
How we respond to what happens to us determines the quality of our experience.
Posted Sep 30, 2020
This game is 90% mental, the other half is physical. — Yogi Berra
Acute pain is a healthy sensation triggered in the nervous system to alert you that something is wrong that requires attention and is situation-specific and time-limited. Chronic pain is different in that it persists, as pain signals continue to flare in the nervous system for 3-6 months, or even years.
Chronic pain can relate to an underlying disease or health condition, an injury, medical treatment (such as surgery), inflammation, or a problem in the nervous system (neuropathic pain), or even an unknown cause. Chronic pain can affect quality of life and productivity, and it may be accompanied by compromised physical movement/functioning, disturbed sleep, anxiety, depression, and other problems. It is an often wearying, onerous, and persistently challenging burden. It's like a smoke detector that goes on and becomes stuck in the “on” mode, continuously sounding a harrowing alarm at high volume. The economic cost of chronic pain in the United States, including both treatment and lost productivity, has been estimated at up to $635 billion—annually.
In the Diagnostic and Statistical Manual of Mental Disorders (DSM), there are hundreds of diagnosable conditions. Each of them is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that causes current distress (such as painful symptoms) or disability (impairment in one or more important areas of functioning)—in other words, suffering. Behavioral health treatment, including psychotherapy, exists to help people find relief from their suffering and lead healthier, more satisfying lives.
The Four Noble Truths of Buddhism address suffering as innate to the human condition. The First Truth is that suffering is a part of life. Suffering in all its forms represents discontentment and lack of satisfaction/contentment/fulfillment. The Second Truth is that suffering is caused and exacerbated by attachment to/desire for something different than “what is.” This includes having things we don’t want, as well as wanting things we don’t have. The Third Truth is that, though a part of life, suffering is not inevitable. And the Fourth Truth is that there are paths out of suffering.
From an early age, through effectively downloading data from everything we observe and experience, we are conditioned to categorize experiences, including emotions and physical sensations, in terms of whether they are “good” or “bad.” Sadness, anxiety, fear, and physical pain are viewed as bad or negative, while happiness, joy, and being discomfort and pain-free are perceived as good or positive. Consequently, it becomes natural to want to avoid experiences judged to be bad, negative, or painful. When we experience pain, whether the source of that pain is emotional or physical, we generally attempt to avoid it. After all, who wants to be in pain?
Addiction frequently originates as a way to escape from, numb, and ultimately avoid pain via mood-altering substances or behaviors (such as gambling, eating, and sex) that then become reinforced and habituated through repetition. Ironically, these efforts to keep emotional and physical pain at bay end up creating even more of it. All attempts at avoidance—through whatever strategies we attempt—ultimately fail because pain is an inevitable part of life. It is an essential aspect of being human. Everyone experiences uncomfortable, painful thoughts, emotions, and physical sensations. Avoiding pain is quite simply impossible. It is in how we choose to respond to the emotional and physical pain we experience that determines whether we are able to get through that pain, or unwittingly extend and amplify it.
Discouragement, isolation, feelings of inadequacy and worthlessness, grief/loss, desperation, guilt, shame, and often self-loathing ensue from the experience of being enslaved by debilitating repetitive behaviors and chronic conditions. These emotions generate yet another layer of pain to fend off, ratcheting up reliance on avoidance strategies that are doomed to fail. Suffering is both a cause and an effect of the full range of emotions associated with chronic pain—anxiety, irritability, anger, fear, depression, frustration, guilt, shame, loneliness, hopelessness, and perceived helplessness.
Trying to escape painful thoughts, feelings, and physical sensations may work temporarily, but in the long run, it only prolongs those experiences and intensifies the suffering connected to them. Suffering is a function of how people think and feel about the emotional and physical pain they experience, and the beliefs they attach to it. Whenever the belief exists that someone shouldn’t be in pain or that pain is something to be avoided at all costs, and in turn, they feel angry or depressed about being in pain, then that person will experience suffering. There is a direct correlation between the amount of effort expended to avoid pain and the degree of suffering experienced—the harder someone works to avoid pain, the greater his or her suffering tends to be.
Common misperceptions about life that exacerbate mental and emotional suffering include that we “should” be happy, that life should be as we want it, and that it shouldn’t be messy, uncertain, confusing, or painful. And yet paradoxically, seeking happiness, things as we want them to be, or certainty in the form of specific outcomes is a prescription for suffering. Buddhist/Taoist philosopher Alan Watts referred to this dynamic as the law of reverse effort or "backwards law” —essentially the harder you try to grasp a particular experience, the more it eludes you.
By adjusting our thinking it is possible to change our emotional responses, the extent to which we suffer (or not), and in turn, the experience of emotional and physical pain. The premise that thoughts have significant effects on feelings and behavior and that shifts in thinking lead to emotional and behavioral changes is the basis of Cognitive Behavioral Therapy (CBT). This knowledge has an extensive history, having been a topic of discussion among Stoic philosophers in ancient Greece and Rome (notably Epictetus and Marcus Aurelius).
CBT techniques are used to help individuals identify their maladaptive cognitive patterns and beliefs, such as discounting the positive in a situation by focusing on the negative; blowing things out of proportion; thinking in rigid black-and-white/all-or-nothing extremes; and placing unreasonable and unrealistic expectations on oneself, other people, and situations—“I should be/feel better than this;” “This traffic must go faster.” Getting caught in these cognitive traps escalates emotional and physical pain, and invariably gooses the experience of suffering.
CBT seeks to replace such distorted thinking with more realistic and effective thoughts to reduce emotional distress and self-defeating behaviors. The process of replacing problematic cognitions with those that are more healthy and adaptive is known as cognitive restructuring. Cognitive restructuring is sometimes contrasted with cognitive defusion—a related but divergent set of techniques that draw on mindfulness practices and are emphasized in Acceptance and Commitment Therapy (ACT). ACT is an evidence-based adaptation of CBT that emphasizes psychological flexibility and features mindfulness and internal values-congruent practices.
While the aim of cognitive restructuring is to actively change distressing thoughts and patterns of thinking, cognitive defusion focuses on observing and accepting uncomfortable thoughts without automatically buying into or attaching any particular value to them. Cognitive restructuring and cognitive defusion share a common foundation of bringing unhealthy automatic thinking to conscious awareness. They each change the nature of the relationship we have with our thoughts and thought process.
Cognitive restructuring and cognitive defusion share a common foundation of bringing reactive, automatic thinking to conscious awareness. By facilitating detached witnessing, these techniques change the nature of the relationship we have with our thoughts and thought process – loosening the grip our thoughts have on us. Deepening awareness and nonjudgmental acceptance of one’s thoughts fosters a new relationship with them, creating the space to shift mental focus away from the ruminative thought patterns that pave the road to suffering.
When it comes to chronic pain there are a number of essential takeaways:
- There are no magic bullets or quick fixes.
- There are many approaches, practices, and techniques that can have a meaningful therapeutic effect and contribute to the process of healing from chronic pain.
- All experience has structure—change the structure and the experience will change.
- Changing how people respond to their pain effectively changes their experience of it.
- Focus on improving functioning and overall quality of life.
- Prioritize moving from avoidance of your pain—both physical and emotional—toward acceptance of it.
- As much as possible, utilize and amplify the mind-body connection in the service of healing.
- Learn and practice the skills of accepting and living with the full range of life’s discomfort & uncertainty as gracefully as possible.
As John Bruna, one of my favorite mindfulness teachers often expresses it, “we can choose to water the flowers or the weeds of our experience.” In letting go of the distorted thought/belief/wish that things should be different than they are, we are freed up to practice radical acceptance of the reality of what is. Mindfulness and the wisdom it cultivates reminds us that we don’t have to like anything in order to accept it. In fact, we can deeply dislike something—even a chronic pain condition—and still come to a place of acceptance with regard to it.
Copyright 2020 Dan Mager, MSW