Mindfulness, CBT and ACT for Chronic Pain Part Two

This blog post is designed to accompany the previous oneI wrote on mindfulness, CBT and ACT for chronic pain. In that post, I discussed two key factors that are typically missing in programs that use mindfulness, CBT, and ACT for chronic pain. These are 1) recognition that chronic pain is usually caused by neural pathways that have been learned and are potentially reversible by changing the patient’s (and therapists’) viewpoint of pain as being primarily structural and irreversible; and 2) development of hope and optimism regarding the transitory nature of chronic pain, which is necessary for full use of the healing (placebo) effect of the mind.

As I mentioned in the last post, many people recover from chronic pain simply by understanding that the pain has been created by the brain and can be reversed by thinking differently about the pain and “instructing” your brain and body to release the pain and move on with your life. There is often great relief in knowing that the pain will abate and joy in beginning to see changes in the pain upon embarking on this path.

Unfortunately, the role that the mind plays in the development and persistence of chronic pain is virtually unknown in the modern world of pain. I have given lectures to pain professionals, both physicians and psychologists, who are not only surprised to hear these concepts, but who often actively reject them.

These concepts are based on years of experience by Dr. John Sarno and several others who have followed in his path, including Dr. David Schechter and Dr. John Stracks (both family physicians), Dr. David Clarke (a gastroenterologist), Dr. David Hanscom (a spine surgeon), Dr. Kevin Cuccaro (a pain anesthesiologist), Dr. Allan Abbass and Dr. Peter Zafirides (both psychiatrists), Georgie Oldfield (a physiotherapist) and many psychologists and social workers, including Francis Anderson, and Eric Sherman in New York City, Alan Gordon in Los Angeles, and many great therapists who practice Intensive Short-Term Dynamic Therapy around the work, particularly Patricia Coughlin, Jon Frederickson and many others. They are also based upon a tremendous amount of clinical and experimental research (see Dr. Coughlin’s book, my book, and a forthcoming book by Allan Abbass).

However, many chronic pain patients in my experience need more than this change in mental outlook characteristic of the “Sarno approach”to recover. Here’s why.

The first reason is that the vast majority of people with chronic pain will never be exposed to these concepts. They will see physicians, mental health providers, and physical therapists who reinforce the often mistaken ideas that their pain is due to purely physical causes. In addition, even if they are made aware of the mind body connection and the research in this area and the possibility of recovery through psychological work, most people are frankly not interested. I have found that it is extremely difficult for someone to truly understand that the brain could actually cause pain that is so severe, chronic and debilitating. There remains a stigma to having a psychophysiological disorder, which is unfortunate, but completely understandable.

The second reason why many people do not recover from chronic pain simply by developing an awareness of the non-structural underpinnings of the pain has it roots in the psychological basis for the pain. As I have written about on this website, many people with chronic pain have had highly stressful life events that have created the right conditions in the brain for chronic pain. They have had activation of the fight of flight reaction in powerful ways, often early in their lives, that has sensitized their brain to traumatic events. Many, but certainly not all, of my patients with chronic painful conditions have been exposed to childhood events such as neglect, abuse, abandonment or bullying, and sometimes events in their teen years, such as sexual abuse or difficult parental divorces. This is often compounded by later life events such as harsh bosses or co-workers, drug abuse by a partner or spouse, as well as car accidents or other injuries that have triggered pain. By the time I see them, their brain has been operating in a chronic fight or flight state for years, their self-esteem has suffered greatly, and they often feel helpless and hopeless.

As a result, they are often unable to stand up for themselves nor, most importantly, to be able to feel compassionate towards themselves. These two areas, being powerful in their life and feeling self-compassion, are often major blocks to recovery from pain.

This understanding leads to the next steps in recovery from chronic pain: psychological work to reverse these two deficits. The chronic fight or flight reaction is another term for living in fear. Fear triggers pain; and pain triggers more fear, which can spiral into an abyss of increasing pain over time. Pain is a message from the brain to our consciousness letting us know that we are in danger. When the brain interprets an injury as being dangerous, the brain produces pain to alert us to take protective action. This is what occurs when we sustain an injury. However, the pain pathways in the brain are also triggered by an emotional injury or insult, so that the trip to a sibling’s home when that sibling is likely to be judgmental and disapproving, might easily provoke a headache or abdominal discomfort. In a chronic situation, ongoing stressful experiences accompanied with great fear of pain, frequently leads to chronic and severe pain. This pain often spreads to other areas of the body and can lead to other symptoms, such as insomnia, anxiety, depression, tinnitus, dizziness, and disturbances of bowel and bladder.

Reversing fear is a critical step in reversing chronic pain. Changing the notion of the cause of pain from a structural problem to a mental process can begin this reversal. However, resolving fear from stressful life events requires changing the emotional response to those events. For current life stressors, there may be actions that one can take. However, for past life stressors, obviously one cannot undo what has happened. The usual approach taken by the dominant pain therapy, cognitive-behavioral therapy, is to attempt to rationalize the traumatic events and change how we think about them. Patients are taught to avoid thinking about them, to recognize that there is nothing they can do about them, to forgive themselves and the perpetrators, and to move on. Mindfulness and acceptance and commitment therapy teach patients to fully accept what has happened and to be compassionate with oneself (and the perpetrator if possible) in order to let go and move on.

It is my view that this approach is a very helpful and very necessary as part of the solution to chronic pain. However, because of the emotionally traumatic causes of chronic pain in many people, those with chronic pain are often the least likely to be able to benefit from this approach, especially in the early stages of recovery. As mentioned, the patients that I see are likely to have low self-efficacy and little self-compassion. They are stuck in the emotional responses to their traumatic life events.

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While it is obvious that one cannot change one’s past, it turns out that our past consists of our memories of the past. And scientists studying memory have discovered that our memories of the past are not fixed; in fact, they are constantly changing. Our memories of the past have at least two components, explicit memory (which consists of our memory of the actual events that happened) and implicit memory (which consists of our emotional response to those events). It is our emotional (implicit) memory that acts to trigger the fight/flight and pain pathways.

Newer therapies that target this memory are often called trauma-informed therapies, and they attempt to help people change their emotional responses to the events. There are a variety of ways to doing this. Peter Levine developed somatic experiencing and Pat Ogden established sensorimotor psychotherapy. EMDR and EFT and TFT and Havening are all methods of dealing with trauma by attempting to alter brain reactivity to prior events. However, the therapy I have found most useful for my purposes in treating patients with chronic non-structural pain is Intensive Short-Term Dynamic Psychotherapy (ISTDP). ISTDP was developed by Habib Davanloo, MD, a psychiatrist from Montreal and was used successfully by Arlene Feinblatt, PhD, the psychologist who worked with Dr. Sarno in New York as he began his work in the 1970’s.

ISTDP helps patients to actually uncover and feel the feelings that have often been suppressed from stressful life events. It turns out that there are two general types of feelings that when experienced and expressed are key to reversing chronic pain. These are resentment/anger and grief/compassion. When one is hurt or traumatized, resentment is always a component of the emotional response, even if it not recognized as being present. Trauma typically occurs to those who cannot defend themselves and therefore the anger that arises often has no physical outlet and tends to be held in (producing pain, anxiety or depression) or is channeled into angry outbursts, eating disorders or drug use. ISTDP encourages patients to experience this anger and express it in ways that alter the emotional responses to prior events. Over time, this changes their sense of self from one who is a helpless victim to one who is more powerful and has more control over their fate. This shift is usually a necessary component in the recovery process.

The following examples use principles of ISTDP, but should not be construed as a complete version of this therapy. See books by Patricia Coughlin, Jon Frederickson, or Allan Abbass for a complete description of ISTDP.

I saw a woman with chronic neck pain of three years duration. She did not have significant trauma in her early life. The neck pain began after a fall at work, occurring when her boss’ dog attacked her. There was no significant damage done during the fall, however her pain became persistent. Prior to this event, she had told her boss that she was afraid of dogs and asked her boss to keep the dog restrained. When I saw her, I examined her neck and found no significant restrictions of movement and reviewed her MRI’s, which showed nothing more than typical changes of normal aging for a 55-year-old woman. There was no evidence of nerve root irritation or damage on neurological exam. I explained to her that her chronic pain was not due to a structural cause (the original injury had healed), but due to the fear she carried of the pain itself and her unexpressed feelings about the boss and her dog.

I coached her through a session where she revisited the incident in her mind and allowed her deepest feelings about it to rise. She was able to express anger towards the boss verbally (imagining telling her off in no uncertain terms) and towards the dog (imagining kicking the dog aside and not allowing it to scare her or hurt her). Her neck pain was improved immediately following this release of emotions and gradually resolved completely over the course of 3 weeks.

In addition to reducing fear of pain and fear stemming from past events, the other key component of emotional healing has to do with compassion. Of course, compassion is an essential component of mindfulness practice. Yet, being able to be compassionate towards one self is often very difficult for individuals who have histories of childhood abuse or neglect. Therefore, encouraging people to practice being compassionate to self is often not enough to break through the layers of low self-esteem and/or built up resentment.

I saw a man with back pain for five years. The pain was often severe and caused him to miss work and limit his normal activities. There was no evidence of nerve damage on his physical examination. The pain began at a time when one of his daughters was going through very difficult times as a teenager. She acted in ways that were dangerous and my patient couldn’t stop her. He was incredibly angry with her at the time, yet had no outlet for this anger. I explained to him that the pain was not due to the minor changes in the MRI that were present, but that the emotions he felt at that time caused the brain to create pain, which had become learned and chronic. He began to challenge the pain and engage in more activities, however the pain persisted. Two weeks later, I facilitated the following exchange. In a private setting (no one else present), I asked him to mentally go back in time to when his daughter was out of control and voice his feelings towards her. With some encouragement, his anger started to rise and he began speaking directly to her (as if it was 5 years earlier). He voiced great anger, which rose to a pitch as he called her some horrible names and finally yelled, “I wish you were never born.” At that moment, he began to sob tears of guilt and regret. He was able to speak through these tears directly to her, saying how sorry he was, how he didn’t know how to parent her, and how much he loves her and needs to tell her that. During the next week, he spent some quality time with her (in the ensuing five years, she had become much more mature and responsible). When I saw him a week later, his pain had decreased by about 90% (it gradually went away completely after that). Accessing the anger allowed him to access the guilt he had also carried with him, which opened up the door for compassion that he could now fully express for her, and that allowed him to forgive her and forgive himself. Releasing anger and guilt along with discovering compassion allowed his brain to turn off the neural pathways of pain.

I saw a woman recently who also had incapacitating back pain, which had not responded to pain medications, surgery or injections. In addition, she had a history of a traumatic childhood. The back pain was severe and worsened upon standing up or walking. It was very hard for her to believe that her pain was not due to the structural abnormalities her spine doctors had identified, even though her surgeries were deemed successful in fixing the instabilities. She had little hope that the pain would ever go away and her pain was getting worse by the year. After her first visit with me, she continued to have great fear of the pain and was making little progress in challenging the pain with increased activities. At the second office visit, I asked her to identify a time in her life when she had felt particularly isolated, alone or hurt. She went to that place in her mind and I asked her to picture the little girl who was her. As she began to cry, I asked her to have her current grown up self “go” to the little girl to comfort her. She imagined herself holding this younger version of herself, and she spoke to her, giving her as much love, understanding, and encouragement as she possibly could. She began to relax as the little girl heard this and started to feel loved in a way that hadn’t occurred in real life. She spent several moments in this situation, in effect, beginning to change the traumatic memories to ones of increased safety, caring and peacefulness. She breathed deeply and slowly for a while. As she came out of this visualization, I told her that this could change the fearful pathways in the brain that have caused pain. I asked her to stand up and walk around the office a bit. She arose and was speechless. Her pain was just a fraction of what she had expected. Over time, she was able to reverse the emotional hurt and the physical pain.

There is a pathway out of chronic pain for most people. It involves several steps:

1. Getting a careful medical evaluation to determine if the pain is caused by neural pathways, as opposed to structural damage.
2. Developing hope for pain reversal, as opposed to simply coping with it.
3. Taking steps to challenge the pain and the fear that causes it.
4. Doing emotional work in order to express anger, access guilt (if present) and move towards compassion.
5. Relaxing about the pain, separating from the pain, and tolerating it while understanding that it is a transient situation, knowing that it will improve over time.

Treatment of chronic pain in pain centers who use CBT, ACT or mindfulness typically does not include the first four steps. However these three modalities, particularly mindfulness, are excellent methods of accomplishing the fifth step. Once the first four steps have been undertaken, I strongly encourage mindfulness practice to finish the treatment program. At this point in the program, individuals are much better able to understand that their pain is a transient phenomenon and that it’s OK to tolerate it for the moment knowing that it will pass. As they learn to tolerate the pain, they can separate from it and react less, which helps to reverse the pain pathways. They can have hope and optimism and a sense of agency and control that they didn't have before. And they are less burdened by the emotional weight of the past so that they can more easily access compassion for self and others.

Mindfulness, CBT and ACT are always useful and often necessary in the treatment of chronic pain. However in my experience, they are rarely sufficient. The research does not show them to be strongly effective therapies for chronic pain as singular treatment. Yet, as a component towards the end of the type of mind body treatment program that I have described, they can be invaluable.

To your health,

Howard Schubiner, MD