I am going to discuss psychologically based pain management. As a psychologist who works with people suffering a variety of conditions involving physical and emotional pain, one of the first questions I must answer is "What can a psychologist do to relieve my pain?" Many are asking from the point of view of being upset. They have been referred by their physicians and feel that they are being sent to a psychologist because their own doctor thinks the pain is all in their head. I tell them that their pain is real but it is important to consider that with all the tests they have probably undergone, they have not been for a pain test other than their own report of their pain. No objective test to measure pain exists. All pain must go through your perception and awareness to be registered as pain. Regardless of the severity of pain, there is no pain without conscious awareness. There is no pain without the mind.
This is actually good news because we do have some control over the way our mind focuses. In our chat today I would like to make you aware of some of the ways the mind can be used to change the experience of pain. Realize from the beginning that mental pain techniques require some practice. They involve skills that can be learned fairly easily with a little knowledge and practice. But think of all the things you’ve learned already. Of course as life progresses, it becomes harder and harder to squeeze in the the time and effort to pick up yet another habit. But that’s another story.

For now I’d like to talk about pain. You can imagine pain as a table, where the table top is the experience of pain and the four legs are the factors that are needed to produce that experience. What does it take to create that experience we call pain? Perhaps if we know what goes into the experience of "hurting", different types of antidotes will become more apparent.

The first leg of the pain table is the biological source of pain. What is going on in your body that signals this sensation? What problems are the tissues of your body facing that have come to this severe awareness. It could be damage or inflammation or some other impingement on the normal functioning of your physical self that is sending these electrical impulses through nerves and spinal cord to your brain. Here it enters awareness and the mind steps in to interpret and manage. The pain pathway is not just an electrical highway. There are complex biochemical interactions facilitating or inhibiting the course of the pain impulse’s journey.

Most medical pain treatment tries to solve the original problem or use pain medication to intervene in the impulse’s path. Pain medications work on different parts of the communication chain. Some reduce sensitivity at the pain site, others impede the passage of the impulse, still others deaden the brains reception of the sensation. Not only can chemistry be changed by drugs, electrical activity can be changed via the introduction of therapeutically applied electric charges, such as TENS devices. Most of the treatments related to the biological leg of the pain table are physical and medical. However, the biochemistry of the the body and of pain is strongly influenced by our emotions. For instance, heavy exertion or deep relaxation can trigger the release of beta-endorphins, the body’s own pain killer.

The table’s second leg is muscle tension. There is an interesting interplay that goes on between the sensation of pain and the muscles. The usual response to pain is to tense up. Your muscles jump to brace against pain, perhaps attempting to keep you from moving toward further harm and more pain. In the short run, it works. But when pain is constant, the resulting muscle tension can actually increase pain. Chronic muscle tension creates many additional problems, such as spasms, or nerve impingement or the spreading of pain.

Treatment of this problem often includes medication to relax muscles. But there are many non- pharmacological ways to relax muscles- massage, stretching, physical therapy - as well as your own powers of mind. There are many easily learned mental techniques that you can put to work for yourself. It isn't hard to learn to let go of muscle tension and to slip into a more relaxed version of yourself. It is even possible to learn to relax directly into muscles around the pain itself. There are a variety of relaxation skills available. I will go into them in more detail at another time. It is important to remember that, like any skill, relaxing physically and mental takes practice and patience. The rewards are more than worth the effort.

The third leg holding up the experience of pain is your attention. This may seem like a strange component since pain’s main purpose is to get our attention. Pain has an informational function, letting us know when something is wrong and action is needed to stop the damage or to deal with the injury. Unfortunately, when pain has become chronic, its constant thrust into our attention ceases to provide useful information, only annoyance. As strong as pain can be, remember that there can be no experience of pain without being consciously aware of it. For those in intense pain, the unconsciousness of deep sleep can be craved as a blessing.

It may be that medications that alter the brain are actually decreasing the attentional pull of pain. I'm not sure of that, but there are powerful attentional training skills that entail enough control over your awareness to reduce or even eliminate the experience of pain. What we call the conscious mind does not hold very much at one time. It holds only those few things to which we pay attention at any given moment. Interestingly, whatever we do attend to, becomes our experience of that moment. Since we can’t take it all in at once, we can never have a complete experience of any moment’s reality. This is why two people can walk away from exactly the same event with entirely different experiences. They paid attention to different parts of the event and had different realities as a result.

The good news here is that there is always room to change what you are attending to and have a completely different experience of the moment. For instance, notice how paying attention to your posture right now at the keyboard changes your reality. How are you holding yourself? Your arms, your hands? Your head and neck? Your back? This is not an exercise to do anything about this, simply to notice how shifting your focus, changes your experience. You may find that that changing your experience motivated you to adjust your posture.

It isn't possible to pay attention to many things at once, and sometimes, even pain gets squeezed out of our awareness. Most people in chronic pain know that when they get deeply absorbed in something they aren’t aware of the pain. At least temporarily. Another common experience is when a minor injury happens while we are so involved in doing something we don’t even feel the pain until we see the damage.

We only have attention for a limited number of things and if we can learn to control our focus of attention we can learn to shut out pain signals. Meditation is a technique that develops control over attention. Meditation can be extremely useful in controlling pain, however, it requires considerable practice. Other very useful techniques that use attentional control are hypnosis and guided imagery. These both involve becoming absorbed into images that allow us to create as experience without pain. Again I will discuss these in more detail at other talks.

The final leg of the pain table is a bit of a grab bag of psychological goodies: the thoughts, emotions, and attitudes we have in reaction to our pain. Sometimes I call this the suffering leg. There is a big difference between pain and suffering. Pain is actually only a sensation . Suffering is all the interpretation that we give to the pain - the judgments, expectation, attributions, and emotions that often habitually accompany the sensation. Thoughts like, "This is killing me" or "I can’t stand it," "This is destroying my life (day, moment)" are judgments that increase the suffering component of pain and tend to increase the intensity we perceive.

The suffering component of pain is a big factor in other common emotional problems that come with chronic pain like depression and anxiety. It is easy to imagine how these thoughts can lead one to feeling helpless and hopeless, two feelings that readily turn into depression. Continued fear of the many things that might add to already unbearable discomfort can grow into an ongoing anxiety.

Treatment in this area involves learning to become more aware of how the things we think make our experience worse, and then learn how we might change what we think to not suffer so much. There is an old saying - Pain is inevitable, suffering is optional. Of course working with a psychotherapist is one way to work on this. It is often necessary to get an objective voice into our experience to even become aware that what we are thinking isn't the only possible reality. When done properly, psychotherapy can be an exciting path of self discovery. There are other such paths. A form of meditation called mindfulness is a wonderful way to becoming an objective observer of your own mind. Mindfulness takes some instruction and considerable practice, but, fortunately, is becoming increasingly available across the US.

As you can see, three of the four legs of our pain table are clearly territories of your mind. Muscle tension, attentional focus and interpretation are areas amenable to psychologically-based strategies. By learning to kick out these three factors supporting the pain experience, you can take control of pain without medication or with reduced medication. Recognize that mind-based pain control techniques are skills to be developed and require some practice to gain therapeutic effect. but you don't have to be a yogi or shaman. We all have the potential to develop some good control over our mind and over our experience of pain.

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