How to survive chronic pain, one moment at a time
Strategies from dialectical behavioral therapy that help with chronic pains.
Posted Mar 24, 2013
Once we accept the reality of the current moment (however unpleasant it may be) for what it is, and not what we wish it were, we can turn our attention to ways to improve it. The following suggestions to improve the moment come from dialectical behavioral therapy (DBT) a hybrid of cognitive behavioral therapy and zen Buddhism. DBT was created by psychologist, Marsha Linehan, to reduce the distress associated with intense emotional pain. However, its principles and strategies can also apply to ongoing physical pain. Moreover, physical and emotional pain are often interrelated: Living with physical pain can be emotional taxing! Plus, pain symptoms are often exacerbated when we feel emotionally vulnerable.
If you live with chronic pain, you may discover that you are already using DBT skills, without realizing it. Consider the following, whether as new ideas or gentle reminders:
- Distraction: Participate in activities that take the focus from your pain.
Research shows significant reductions in people's experience of pain when they participate in activities they find positively engaging. This has been demonstrated with functional scans of brain activity. You may have also noticed this effect in your own life: pain can take a back seat when you succeed to engage in something engrossing. For example, I used to assign a "pain rating" to movies based on the extent to which I would forget my pain while watching them. Some movies worked better for me than others. Notice, for yourself, the moments when your pain succeeds to slip into the background. Create a list of the most effective distractions! These not only decrease your perception of the pain in the moment, but provide important breaks that can add up and shift your experience of your day. When you hurt it is easy to want to avoid everything. Knowing what helps provides incentive to include in your day activities that you will find meaningful or enjoyable, even when you "don't feel like it." This practice can improve your overall outlook, providing something to look forward to that you know will be beneficial.
- Self-soothing: Engage all of your senses in pampering activities.
People with chronic pain can benefit substantially from deep relaxation. Unfortunately, an instinctual response to pain is to tighten muscles and to breath more shallowly, "stress responses," which intensify pain. These occur without awareness, yet increase suffering.
In contrast, you can engage deliberately in practices that elicit a relaxation response, slowing your breathing, unclenching muscles, and bringing about autonomic nervous system changes that elicit well-being. It can help to lie down or "chill out." However, to receive the fulll benefit of relaxation, tune into your body with awareness.
Start by lying down or sitting, well supported, and as comfortably as possible, in a safe place. Turn your attention to your breathing. Allow yourself to inhale slowing, filling your belly (not your chest), then wait until your body feels ready to exhale, and feel your body relax on the exhale. This practice, called diaphragmatic breathing, can promote relaxation. As you breathe in and out, slowly, allow your body and mind to rest. It can help to focus on the breath itself. As thoughts arise, practice noticing them, then gently and nonjudgmentally, returning your focus to your breath. This practice in itself can soothe the body and mind.
From this peaceful place, your can also engage your senses in ways that can bring your body greater relief and even pleasure. Some ideas include soaking in hot water, listening to music, inhaling the scent of rosemary branches or other aromas you enjoy, taking in the beauty of nature, savoring bites of sumptuous chocolate, engaging in gentle massage or intimate touch, or whatever soothes your system.
Sometimes we do not engage in soothing activiites because of undermining self-talk, such as, "I don't have time" or "Why bother - the effects don't last anyway," but consider the alternative. Without compassionate respites, pain and exhaustion can multiply. Experiment with deep relaxation and notice the effects this can have on how you feel. See what happens when you carve out five minutes to practice deep relaxation. The more you practice this, the more rejuvenated you can feel.
- Core Mindfulness: Practice deliberate awareness.
Developing deliberate awareness is at the core of effective change. You can think of mindfulness as a flashlight: any any moment, it is your choice where you shine the beam of light. Notice the effect of attending to particular thoughts, feelings, sensations, or aspects of your experience or environment. Mindfulness involves taking a step back and seeing the choice in each moment. This is an alternative to being mindless, scattered, or feeling powerless. It also emphasizes the ever-changing nature of the present moment. This holds tremendous power, reminding us that all we ever have to get through is the present moment, which is always fleeting.
You can use mindful awareness to notice times when you may be wallowing in negatives or fretting over what may happen next, and practice bringing yourself back to the present moment. Focus on the facts and any "story" you may be telling yourself about them. With practice you can train yourself to choose where and how you want to devote your attention.
Mindful awareness, thus, can increase the effectiveness of "distraction" and "self-soothing" strategies for pain relief. You can practice directing your focus to the pleasure that arises when you engage your senses or while in a particular activity, while practicing un-mindfulness of the distress.
- Observing and describing nonjudgmentally: See things as they are.
Much suffering comes from judgmental thinking. Once we form judgments, we trend to ignore or gloss over inconsistent or contradictory information. So if you judge something to be "awful," someone as "selfish," or yourself as "pathetic," you are more likely to experience it that way, and miss out on seeing the richer reality of the situation.
You can think of judgments as spontaneous evaluations of yourself, others, or situations. Judgment is a pervasive habit. We often move quickly to whether something is "good" or "bad," "beautiful" or "ugly," or whether it is the way that it "should" be. Yet in any moment, there are infinite interpretations one could have.
Practicing nonjudgmental observation involves noticing thoughts that arise as thoughts, not facts. It can be liberating to realize that you don't have to believe something just because you thought it. It opens you up to creating a story of the moment that is fact-based and also meaningful, inspiring, or encouraging. This practice allows us to escape unhelpful mental patterns.
- Let go of suffering: Notice your experience without attaching to it.
This skill is about being able to observe one's emotions as waves, rather than denying them or keeping them around by feeding them with negative self-talk. This practice begins with awareness of emotions as effemeral and constantly changing. This applies equally to strong negative emotions that can overcome us as well as flare-ups of physical pain. You can practice this by slowing your breath and reminding yourself that however it may feel, you are much more than your current painful feeling.
Intense pain is hard enough to deal with. Experiencing it judgmentally compunds the suffering. Even when pain is severe, you can practice noticing the sensation of pain, along with any thoughts and emotions that may accompany it, without judgment. Notice what arises, Try to observe any judgments that arise as judgments, not facts. You do not have to buy into thoughts, like "I cannot stand this," or "it is always like this," which will intensify and prolong suffering. Instead, see if you can notice these as thoughts that come and go. When pain is at a level that demands full attention, experiment with accepting the feeling for what it is in the moment. You can slow your breath and practice noticing your experience as sensations with particular qualities, rather than all encompassing "pain," and see if you can move your attention away from suffering.
- Acting opposite: Doing things you don’t feel like but know will help.
Pain can be a powerful pull to disengage. This skill emphasizes people's abiltiy to encourage themselves with evidence of things that have helped in the past. Often this requires pushing yourself to do something that will help, even when you may feel staying in bed or otherwise avoiding. When you hurt, it can be exhausting to consider engage in anything at all, even when you recognize it holds at least a marginal benefit. By thinking of "acting opposite" as a skill, we can try it out and see the result. This is particularly effective once you have acquired evidence of the positive effects of particular activities, and as new habits form. (For more on how to figure out what helps, you can read my earlier post on treating pain as an experiment.)
- Effectiveness: Identify a goal and then do just enough—not too much or too little—to be effective.
This is crucial when you have to conserve your energy. Consider what you will find effective and take small, deliberate steps. The trick is to figure out your top priority, and then keep your focus, rather than being derailed by judgments, such as the unfairness of the situation or the many "shoulds" that can arise. Select a goal that feels realistic and whatever adaptations that can help.
Let's say you are facing a series of errands or chores. Saying to yourself, "I need to do all of these today!" can feel immediately overwhelming, and more than likely will kick off a negative spiral--whether it comes from emotional turmoil from avoidance or physical suffering from engaging in stress-based activity and overdoing it.
Being effective, in contrast, is all about figuring out what you are able to do. Rather than trying to "do it all," start with the piece that is most important. Think, "what is it that I really need to do here?" Take small, effective steps. Make a key phone call, order a part, have an important conversation, wash a couple dishes. Be gentle with yourself. By devoting some thought to what is really needed, rather than jumping into a situation that may be mired with "shoulds," you can achieve a feeling of accomplishment.
- Radical acceptance: Practice the willingness to see things as they are, thus reducing suffering that comes from fighting reality.
Chroinc pain is a daily challenge. It makes sense that to want things to change. At the same time, acceptance can bring great relief. Acceptance does not mean you like or approve of the situation or that you have given in or given up. Instead, acceptance is the acknowledgement of the current moment for what it is. The idea of "Radical Acceptance" is that the acceptance runs deep. This level of acceptance allows you to stop fighting reality and open yourself to ways to embrace and improve the moment for what it is. This means seeing pain for what it is, without intensifying it with fighting thoughts like, "I can't take this anymore," or "if only it would stop.." Radical acceptance allows you to see the choices that exist in the current moment. This approach is consistent with the Serenity Prayer that seeks “the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference.”
Living well with chronic pain requires the capacity to accept the moment for what it is, while at the same time working toward positive change. For more on the simultaneous focus on both acceptance and change at the heart of DBT (dialectical behavioral therapy), see my post on the Pain Dialectic,
You can also find more information on improving life with chronic pain in my book Paintracking: Your Personal Guide to Improving Life with Chronic Pain and its companion website, with its free, customizable tracking tool.
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