This article first appeared in the July/August 2009 issue.
Chronic pain often has a clear physiological cause, arising out of an accident, an injury, an illness, or a surgery. But these days, more and more people are being referred to therapists with pain conditions that persist for months and years beyond the time when damaged cells, muscles, and tissues show every appearance of having healed and medical practitioners have pronounced that the initial accident, injury, or illness has been “cured.” At this point, when traditional medicine seems to have done everything possible, people come to our offices hoping to find another way to understand why they’re still in pain and—more important—what to do about it. Amy, a successful commercial artist in her late thirties, was such a client.
In our first session, she looked at me warily over the rims of her reading glasses as she clutched a thick folder in her lap. She was eager to tell me her story. “I’ve had five surgeries now for endometriosis,” she began. “The first one was in 1990. I was having terrible, shooting, pelvic pain during my periods. They found a cyst on my ovary, and I had laser surgery to remove the cyst and some of the endometrial tissue. I felt immediate relief. But then slowy the symptoms came back again. In the next two years, I had more pain and two more surgeries, which helped temporarily. And then several years later, I started having bladder symptoms and two more surgeries, including a full hysterectomy.
“I’m worried about depression, yet the antidepressant I’m on has caused weight gain. I’ve been on medical disability from my job for the last six months, and though I’m practicing yoga, meditation, and walking one and a half miles per day, I feel no better and no closer to coming off disability. Do you think you can help me?”
When I see pain patients for consultation, it’s all too common to hear this type of litany, in which the person describes becoming worse and worse, in part because of the interventions intended to repair the problem. At this point in the interview with Amy, I asked my standard questions.
Was there family history of this problem? “Yes,” Amy told me. “Both my mother and sister have had endometriosis that’s traveled a similar route. But they’re out of pain now.”
Was there other family history relevant to her pain? “I’ve been anxious all my life,” she replied. “My father was alcoholic and physically abusive, and my mother busied herself with four younger children. I’d lie awake at night and listen to them argue, worried that things would really fall apart—that the family wouldn’t survive.”
We covered other topics, too. What was her relationship history? Her first marriage had ended in divorce, she said, when her daughter, Suzanna, now 23, had been 2 years old. She’d been married to her current husband, Jim, for 20 years, and it appeared to be a good marriage for them both. However, she was sad that there’d been no sexual intimacy for a long time, except when she’d taken heavy pain medication—which had led to an unsatisfying experience for both of them.
As empty nesters for the last several years since Suzanna had left for college, Amy and Jim had both worked 12-hour days in demanding jobs. Her increase in pain in the last two years had coincided with her boss’e retirement and her decision to take on the work of accounts manager while she continued to do “hands-on” commercial art projects.
“What helps?” I asked. She said she got relief from heat applications, Neurontin and Vicodin as pain medications, Paxil for depression, and Ambien and melatonin for sleep. Being in nature was healing for her, she added. She had several satisfying close friendships and enjoyed bicycling, needlework, reading, and going to the movies.
“What are you most scared about?” I asked next. Her eyes filled with tears as she whispered, “I’m scared I’ll never get out of this hell of pain—that I’ll only get worse with time, because that’s what’s happened so far. I’ve been a commercial artist my whole life, but I may not be able to do that job anymore. I’m afraid I’ll have to stop and won’t be able to find something else that I can be good at.”
Locating the First Portal to Relief
After taking a thorough history, I’ve found it helpful with patients suffering from pain to find a simple technique for self-practice in the first session that has an impact on the pain symptoms and requires little effort. This simultaneously communicates to patients an experience of being helped by me and of helping themselves. Such an intervention builds trust and hope, and sets the stage for further success.
I gave Amy an overview of the tools I recommend for alleviating pain, including hypnosis, EMDR, interactive guided imagery, Energy Psychology, and Somatic Experiencing, and how I use them. Amy was already interested in Energy Psychology. In fact, she’d taken several classes that taught some of the methods, and had especially enjoyed learning about the chakras—the body’s seven energy centers crucial to Eastern wellness systems. Since she’d had this positive experience, we decided to explore whether this approach might relieve her pain, which she evaluated at that moment as a 7 on a 10-point scale.
I asked her to place her hands at the base of her pelvis, and then use her breath to find the felt sense of this area, known as the root chakra, believed to be related to safety and survival needs. As she kept one hand on the root chakra at the base of the pelvis and moved the other hand above that area related to the womb/sacral chakra just below the belly button, Amy reported that this second area seemed more open than the first onecrucial to eastern wellness systems. Since this was the area where her pain usually lodged, she was surprised at how easily it seemed to relax as she focused on her breath.
We continued in this fashion until she reached the crown chakra, across the top of her head. As she placed her hand there, she told me that she had an image of Laguna Beach, where she’d played as a child. Amy said she could imagine wading out into the water and feel energy moving up her feet and legs. I suggested that she try to bring the water further up her body with her breath each time she inhaled, and she responded that the water level was now up to her thighs, but seemed stuck there. I wondered out loud whether a special flotation device might make it comfortable and safe for her to sink into the water, and after a moment, she responded, “This is amazing! I’m now just sitting in the water and the action of the waves is massaging my abdomen. With this life vest on, I can just let go and relax.”
As Amy left my office, we both felt encouraged. When a patient is able to achieve significant positive results in the first session, it’s usually an accurate prognosticator of success to come.
Breathing is a powerful antidote to stress and pain because it enhances conscious, mindful attention, which becomes an immediate bridge between mind and body. When we tune in to our breathing, we’re intervening at the basic infrastructure of pain and trauma in the reptilian area of the brain, known as the brainstem, which is linked to our basic life functions. When we breathe with awareness beyond the constricted, limited patterns of pain, we take charge of our healing in a primal way.
Sustaining Initial Change
Amy was all smiles when she appeared for her second session. “I had a good week,” she said. “I used my life vest whenever my pain went up, and that helped. I was able to lower my pain medications a little bit because I didn’t feel so desperate about taking them, which felt good. And . . . Jim and I had sex for the first time in a long time. It didn’t hurt, and I even enjoyed it!”
As delighted as I was by these developments, I knew that we wouldn’t be able to sustain this progress until we knew the triggers that increased her pain and the inner barriers that blocked efforts to resolve it. When I inquired about these issues, Amy replied that she felt her daughter, Suzanna, was somehow involved. “She got angry at me a few months ago and said she wanted to Ôdivorce’ me, but then she had her appendix out, so I ended up taking care of her. She won’t talk about our problems, and I’m not sure what to do.”
I pointed out that, while she was telling me about her daughter, she’d bent over her abdomen, and asked if she was aware of that reaction. “Yes,” she acknowledged, “my daughter is really a problem for me. I never wanted conflict with Suzanna because of how my parents’ fighting affected me.”
“Amy,” I said, “tell me what you’re aware of in your body when you think and talk about Suzanna.”
“It’s a terrible pain,” Amy said, closing her eyes. “And it’s burning and aching. And there’s this terrible anxiety in my chest.”
I asked her to use the chakra technique we’d already used, focusing on the breathing and the imagery of the ocean and her life vest to see whether any of these aids could help. After a pause, she said, “I think I need to swim. I need to move.” Moments later, she added, “Okay, I’m doing the crawl. I feel a little bit better, but my pelvic pain is still high.”
We then had a discussion about how emotional distress can affect physical pain, and how trauma is linked to all physical pain problems. “Pain usually begins because of the trauma of an accident, injury, or illness like endometriosis and the surgeries used to treat it,” I explained. “Then, after awhile, if the pain doesn’t stop or gets worse during recovery from surgery, the pain in and of itself becomes traumatizing. And if you’ve had trauma that predates the onset of your pelvic pain, like the emotional pain of growing up in an alcoholic family, that can make you more vulnerable to pain later in life.
“What you also may need to know,” I told her, “is that physical and emotional pain are identical in terms of how they work in the body. I think your body is showing us today how your heart pain about your daughter, and your own experience as a daughter and mother, are affecting your pelvic pain.”
As we worked together, Amy began to understand the connection between her sadness and grief about the trauma in her family and the feelings of helplessness linked to her pelvic pain. For a few months, we struggled with the roller-coaster of her pain. Her hard-won improvement was thrown off by two minor injuries incurred when she increased her exercise program too rapidly as she began feeling better and by other stresses in her daily life. As Amy commented, “The stress seems to go right into my pelvic area. Until I stop and rest and use one of the tools I’ve learned here, the pain persists. When I decide to stop to rest, my body feels more permission to rest also.”
Reversing Chronic Pain
In helping patients gain relief from chronic pain, I teach them some or all of 10 different building blocks or skills I’ve found to be powerful antidotes to pain—(1) regulating the breath, (2) developing a felt sense of the body, (3) relaxing, (4) imagining a new inner reality, (5) becoming mindful, (6) working with the body’s energies, (7) body movement, (8) healing the unconscious connections between trauma and pain, (9) opening channels of love, and (10) building on success. Amy and I worked with all 10 skills for her self-treatment program.
The first two—learning to breathe in ways that create an effective mind-body partnership and developing the felt sense of her body (based on the focusing work of Eugene Gendlin)—served as the foundation for the remaining skill areas. Because many pain patients learn to disconnect from their somatic experience, it’s essential that they find a way to reconnect, to tap into their mind-body resources that can help them recover.
The third skill, learning to relax, is effective in counteracting the effects of everyday anxiety and stress, which tend to push pain levels higher. Herb Benson’s research on the relaxation response has provided evidence that individuals who practice relaxation regularly are less reactive to various stress hormones, even at times when they aren’t practicing the techniques.
For Amy, giving herself permission to relax was a huge accomplishment. For years, both as a lonely adolescent and as a single mother, she’d pushed through stress, fatigue, and pain, both to succeed and to avoid feeling the emotional pain that arose when she wasn’t busy. Gradually, she developed a daily routine that provided more balance.
Her next focus was managing some of her anger toward Jim for working overtime on weekends without telling her in advance. They had huge, unproductive fights about this issue, and she felt continually devastated that he seemed to devalue their time together. I asked her to imagine the kind of time she’d most like to share with him on the weekends. “I have this picture of us on our back deck, drinking coffee and reading the paper; just relaxing and enjoying the garden we’ve worked so hard on,” she said without hesitation. “Why not invite him to share your fantasy this weekend?” I suggested.
Amy later told me that my question had stayed with her for several days. Then she had the idea to create an invitation that she carefully inscribed, requesting that Jim join her for coffee in the garden at 9:00 a.m. on Saturday morning. She enjoyed getting ready for this event, feeling like a little girl having a tea party. Jim appreciated the attention, and out of Amy’s imagination grew a ritual they continued for subsequent weekends.
The fifth skill Amy mastered was mindfulness. The mindfulness practice that seemed to work best for her was one in which she named and accepted all the sensory experiences she became aware of during a 5- to 15-minute period. This practice helped improve her sleep, which had been disrupted during most of her chronic-pain cycle. To harness her body’s energies (skill six), she used energy-meridian protocols, such as the Emotional Freedom Technique (EFT), a protocol for stimulating 11 specific points along various meridians, to manage sudden increases in her pain when she couldn’t identify the trigger and to clear emotional distress related to family members. With practice, she developed enough confidence that during strained gatherings with her siblings or parents, she could withdraw for a few minutes, practice the techniques, and return to the group in a more centered state. She used EFT to help her gradually diminish her pain and sleep medications.
Amy also needed to develop skill seven: learning to make the right moves for her body. Like many pain patients, she struggled to resist the impulse to work out beyond her limits as she began to feel better physically and was more desperate to lose weight. She found that the structure of working with the Pete Egoscue physical therapy program, which emphasizes stretching and strengthening, as well as with a personal trainer, helped her pace herself more realistically.
Healing the connections between trauma and pain (skill eight) occurred throughout our time together. Amy used the pendulation method developed by Peter Levine as part of his Somatic Experiencing model, learning to focus her attention back and forth between places of expansion and comfort in her body and places of constriction and pain to release some of the past trauma of the surgeries and an earlier car accident. We used EMDR successfully to resolve some of the early attachment issues related to her parents—which freed her to develop healthier present-day relationships with both of her parents, her daughter, and husband.
Love, the ninth skill area, flowed from these positive changes in all of her relationships. She was surprised to discover that she could develop authentic love for herself, especially for the little girl-self who’d felt so neglected, abused, and afraid. As she left my office after one of our last sessions, she told me that she felt softer in every way and that, through our work, her heart had opened.
The ability to build on success (skill ten) is with Amy still. I received a note from her several months ago telling me that she’s in better physical shape than ever before, and that she’s now in training to teach classes in intuitive eating and mindfulness. She’s off nearly all her pain medications, and her pelvic pain is almost nonexistent. When there’s unexpected and intense stress, she’s been able to reapply the self-treatment strategies she learned to reverse the trajectory of the pain in a day or two. “I have the confidence now that I’ve always wanted. When something gets me down or causes me to hurt, I know I can take care of it.”
Success in reversing chronic pain may not be as complete as this for all patients. Since current research clearly shows that no single method can address the complexity of a chronic pain condition, a multimodal approach like the one described here, based on simple, portable skills that build on each other to promote permanent healing, may prove the most effective and efficient way to remove the hurt for those who suffer.
Case Commentary
By Ronald Siegel
Maggie Phillips lucidly illustrates the successful treatment of a remarkably common problem—getting stuck in chronic pain as a result of trying to get relief through drugs, surgery, and rest. Pain, which may have begun with an injury or illness, becomes exacerbated and entrenched by emotional trauma, stemming, in part, from failed medical interventions. Phillips’s 10-point program flexibly combines relaxation, turning attention to somatic experience, exploring the unconscious connections between emotional trauma and physical pain, and developing avenues of emotional support and encouragement. Together these approaches help relieve the fear, tension, anger, and aversion that create pain signals (often by increasing muscle tension) and amplify those signals (through hypervigilance and fear). The program worked well for Amy, and I trust that it would be effective for many others.
Sometimes, however, the very quest to become free from pain—what brings a client into our office—is at the heart of his or her problem. In these cases, well-meaning interventions designed to reduce pain actually multiply clients’ miseries by keeping their attention focused on their pain level. Every behavior, treatment, and other life choice is judged by whether it seems to increase or decrease the sensations of pain.
For these clients, an effective alternative is to help them give up the quest to become free of pain and focus attention on becoming free of disability instead. This entails practicing mindful acceptance of the coming and going of pain sensations while embracing the goal of behaving like a normal, healthy person—free of pain-related limitations. For most clients, this means learning to treat pain like the weather: destined to change, but not ultimately under our control.
To accomplish this, clients learn to use mindfulness practices to let go of the aversion responses to the pain (such as wincing, grimacing, and wishing for relief) and to approach pain sensations with interest and curiosity, rather than as problems to be solved. Clients are invited to view concerns about whether their pain is increasing or decreasing as passing thoughts, not calls to action. At the same time, they’re encouraged to pursue a sensible, incremental program of increased exercise and activity, with the goal of functioning like a healthy person of their age, build, and level of physical fitness.
Developing this sort of radical acceptance of pain sensations can dovetail nicely with the other aspects of treatment that Phillips outlines—particularly the exploration of past trauma. Whether stemming from medical interventions or unrelated traumatic events, integrating these experiences and the emotions surrounding them is an important step in breaking free from a chronic pain syndrome. Otherwise, unconscious fear that these thoughts and feelings will erupt into consciousness causes increased muscle tension and increased pain. Mindfulness practices can be used to facilitate this integration, while loving-kindness (metta) practices can be introduced to help clients feel safe and supported as they embark on this sometimes difficult work.
Maggie Phillips, Ph.D., is the author of Reversing Chronic Pain and the creator of a multimedia online program for professionals and those with pain conditions, offered at www.reversingchronicpain.com. Her previous books are Healing the Divided Self and Finding the Energy to Heal. She’s a fellow of the American Society of Clinical Hypnosis and of the International Society for the Study of Trauma and Dissociation.
Ronald Siegel, Psy.D., is an assistant clinical professor of psychology at Harvard Medical School and serves on the board of directors and faculty of the Institute for Meditation and Psychotherapy. He’s the author of the step-by-step self-treatment guide Back Sense: A Revolutionary Approach to Halting the Cycle of Chronic Back Pain; coeditor of Mindfulness and Psychotherapy; and author of a forthcoming book for general readers, The Mindfulness Solution: Everyday Practices for Everyday Problems
