Pain Management Workshop:

(This transcript is in part a recollection of the workshop presented in November 1999. Human and technological error resulted in part of the original tape being unusable. It is hoped that this version will be an adequate replacement).

I will start by giving you a brief background to myself, I am predominantly trained in cognitive behavioural therapy. I have a private practice in Geelong, and Torquay, my Geelong practice is purely pain management, and associated issues such as, anxiety, depression, anger, and occasionally trauma, but that's not something I particularly choose to work with. From a personal level, I have degenerative disc′s in my back and in my neck, and so I have developed some of these skills, particularly through personal experience. And certainly that helps me understand the client's perspective. It clearly creates a relationship of understanding and empathy that would be different if I didn′t have this personal experience of pain. It is also important not to assume that I know the experience of the other person. My pain is my experience and may have no relationship to that of my client. It would be naive of me to assume my pain is the same as theirs. But it is not naive to assume we share the same suffering and causes of suffering.

I would like to comment that I am not a Buddhist. I do not present myself as a Buddhist, because I see little value in defining myself in those terms. This may be a reaction to my strong Catholic upbringing, but I don′t think so. I have strong interest in Buddhism, particularly in relation to therapy, my personal journey through life and its evolution as a western tradition

I think it is important to acknowledge that I certainly don't have one hundred per cent success with clients, and pain is extremely difficult area to work in. It's not uncommon to see clients who have created their own identity around pain, and as a consequence, have difficulty in letting go of the pain, because without it, then there is very little else that they have. They have lost their jobs, often lost their friends and may have lost their families and the pain is the primary blame for all of those things, if they were to lose the pain, through their own personal intervention, then the blame would start to fall on them, and obviously that's a difficult thing for people to accept.

I have had situations with clients where through applying these techniques the pain would disappear. For one particular client the pain dissappeared and would not reappear for over four hours, He would then apply the meditative technique he used again, and that would be enough, to relieve the pain, and so that particular client was able to go off their medication, and use the meditative practise to help them manage their pain. Another client who had a severe shoulder and upper back pain, was able to relate that sensation that they had been so overwhelmed by, as if it was a warm coat. Now, obviously once something becomes a warm coat, it is no longer the difficult and traumatic sensation that it was as the previous painful sensation. My clients range from no improvement, through to minor improvements such as, sleeping more effectively and generally manage their anger and depression through to reducing their contribution to their pain, therefore the pain becomes significantly less impactful or destructive.

In order to understand and treat pain I break the pain into two components. The first component is the sensation, and the second component is the associated mental construct. It is through these two levels that I try to work. I attempt to help clients to differentiate between what is the sensation that they are experiencing, and what is the mental construction that overlays that sensation. Differentiating between their reaction or resistance to a sensation or experience. It's interesting that just mentioning the word “pain“, is enough to create a physiological response in clients where their muscles will tighten, and they will react to the word pain in a habitual/conditioned way. I try not to use the word pain at all with clients, although you have to start with them where they are at, so pain is a term that we would use in early sessions. As the client learns to differentiate between these two levels we tend to use the language of sensation and reaction.

Sleep is a useful example for exploring the distinction between sensation and reaction/mental construction of pain. The client′s sleep patterns are typically disturbed by their experience of pain. I will talk about the routine of tossing and turning, trying to find a comfortable position, and yet they know they're not going to find a comfortable position, or at least after trying for five minutes, it would be fair to say there was no comfortable position available to them. Clients know there is no comfortable position, they have been doing this for years, they've never found one, so it's unlikely that they'll get one. And so, what is the point in tossing and turning looking for a comfortable position. This is part of their routine reactivity. A pattern that they have got into that contributes nothing in a helpful way. We also discuss the mental reactivity, what is happening in their mind when they are trying to get to sleep. I ask them, “what chance do you think you have of getting to sleep if you keep tossing and turning, and this mental stuff just keeps happening?“ They respond saying that there is absolutely no chance of getting to sleep. Then we talk about the possibility that the pain may not be keeping them awake, but it's their reactivity to the pain, the tossing and turning both physically and mentally. It maybe that the sensations that they are experiencing aren't stopping them from sleeping, it may well have woken them up as they moved and the intensity of the sensation woke them, but the primary reason for them not getting to sleep is possibly their physical and mental reactivity to a sensation, and so sometimes we will work on that early on. The relationship to psychological disturbances/vulnerability and sleep deprivation are well documented, so helping achieve sound sleep patterns is instrumental in their rehabilitation.

There are a number of critical factors that I found in working with pain. Firstly, I avoid working with the pain initially. I find that anger, stress or even depression are more effective in developing the skills, understanding and confidence for these techniques to work effectively. Invariably every client who comes to see me is stressed, angry or depressed. Often as a result of the system that they are in. The insurance companies, Workcover and their employer, are all perceived to be contributing significantly to their stress, and exacerbating their experience of pain (I do not pretend that the system is not flawed by emphasising the clients perception of the situation).

I work with stress, depression or anger, because people start to relate to the construction of those experiences with this particular approach. Pain seems to be more difficult to apply these approaches in the developing stages of one′s skill acquisition. The sensation of pain is just so seductive and the in the patterns of reactivity to strong that many clients struggle to apply these principles to pain. There are some fundamental skills that I will talk about in a minute that are necessary in applying these principles. If the client doesn't have the foundational skills then they are going to struggle. Developing these skills is useful and meditation plays a significant part in that.

MEDITATION

Meditation is a practice ground, an opportunity to sit and practice learning to develop four core skills. Developing a flexibility of awareness (let things go/be), developing concentration, witnessing one's experience (mindfulness) and being non-reactive. Meditation is like Tuesday night's tennis practice, or Saturday morning's golf lesson where you go into a controlled, contained environment and practice your skills, and as you get better, then you go out into the game and apply these skills. It is an opportunity to develop skills that can be applied in day to day activities. This is a very practical and applied perspective of meditation. The therapeutic environment is similarly, an environment where these skills can be practiced. Formal meditation in and of itself are not essential as these skills can be practiced in day to day activities or situations. I find that meditation is a useful practice forum and so I encourage my clients to use it. It is not essential though. Some clients have no interest in formal meditation practice. For these clients I encourage practice in daily activities. For example, a form of listening meditation, reading meditation or dish washing meditation.

The Core Skills

Flexibility of Awareness

The first skill that we try to develop is flexibility of awareness. Writings in Buddhism often refers to letting go. In the Hinayana path is one of renunciation. Renunciation is merely letting go, renouncing your attachments in a systematic way. In becoming a monk you would learn to let things go, you let go of your family, you let go of material possessions, you let go of all of the things that form the normal lay person's life patterns. The precepts are about letting go. The development of compassion in the Mahayana tradition is about letting go (or re-conditioning) of habitual patterns of selfishness for a compassionate approach. Letting go or non attachment can be thought of as a mental skill. I refer to this as flexibility of awareness. Lets try an example,

• pick an object to your right
• now pick an object maybe six feet away to your left
• move back to the object on your right
• now shift your awareness to the object on your left
• shift to the right
• back to the object on your left

How difficult was it to shift your awareness? (generally it is agreed that it wasn't very difficult). It might have been, depending on the object, but generally speaking you can move your awareness from one object that has no particular significance to another object with effortless ease. It becomes more difficult if for some reason the object of your awareness is more seductive to you either from a habitual or instinctual perspective. We know from personal experience that it is not always easy to let things go. However it is that type of flexibility of awareness that I am encouraging my clients to develop the ability to shift their awareness effortlessly across a broad range of objects including mental objects. But also physiological ones, and so if they can develop that flexibility to shift from one to the other with no difficulty, with no effort and with no resistance then that's going to be a significant shift in their ability to manage their pain. And manage many other emotional, physical and psychological issues.

Meditation is extremely useful in practicing this flexibility of awareness. From letting go of traffic noise or the sound of the clock, to letting go of a habitual thought pattern that may be causing the continuation of depression. So you take your awareness from a distraction and bring it back to the chosen object of awareness, your breath for example. You notice a distraction then bring the awareness back to your breath, notice a sound, bring it back to your breath, and so I believe that that is one of the most fundamental skills that you are trying to develop, this ability to flexibly shift your awareness, to let things go. Dr Jon Kabat Zinn from the Stress Reduction Clinic in Massachusetts emphasises this in his technique, which we will do in a moment. His book Full Catastrophe Living outlines the technique and is a useful outline of the program and useful reading for clients. It is in his journal publications that you get an understanding of the rationale behind the techniques.

BODY SCAN ( adapted from Full Catastrophe Living by Jon Kabat - Zinn)

Sit comfortably, just take a couple of deep breaths, and just allow your awareness to move down to your left toes, and just be aware of the toes of your left foot, aware of whatever sensation appears, not trying to get rid of any sensation or make any sensation appear or disappear. Just be aware of whatever sensation appears when you move your awareness to your left toe.

(lengthy pause, allow your client to rest their awareness on the sensation)

Letting go of the sensation, in your left toe, and now just move your awareness to whatever sensation appears in your left ankle.

(lengthy pause, allow your client to rest their awareness on the sensation)

Taking your awareness now to whatever sensation appears between your left ankle and your left knee, letting go of the sensation in your foot, and now just become aware of whatever sensation arises in your lower leg.

(lengthy pause, allow your client to rest their awareness on the sensation)

Moving your awareness up into your left thigh, let it go of any sensation in your lower left leg, and now move it up to your thigh.

(lengthy pause, allow your client to rest their awareness on the sensation)

Moving your awareness now into your pelvic region, let go of any sensation that appears in your left thigh, and now just focus your awareness on whatever sensation appears as you move your awareness into your pelvic area.

(lengthy pause, allow your client to rest their awareness on the sensation)

Letting go of any sensation in the pelvic area, move your awareness to your trunk, to anywhere in your stomach, lower back area, just be aware of whatever sensation arises, not trying to make anything happen, not trying to get rid of any sensation, just notice if your mind is caught up in thinking, or wanting something to happen or not happen, and just let that go, and bring your awareness back to the sensation itself, as it appears.

(lengthy pause, allow your client to rest their awareness on the sensation)

Now moving your awareness into your chest and upper back area, letting go of awareness of any other sensation, and try and bring your awareness back up the body into your chest or upper back area.

(lengthy pause, allow your client to rest their awareness on the sensation)

Now taking your awareness to your left shoulder, just be aware of whatever sensation appears letting go of any other sensation, other than that that appears in your left shoulder.

(lengthy pause, allow your client to rest their awareness on the sensation)

Now taking your awareness into your left upper arm, above your elbow. Just be aware of whatever sensation appears.

(lengthy pause, allow your client to rest their awareness on the sensation)

Moving your awareness down into your lower arm, to your forearm, be aware of whatever sensation appears, not trying to create anything, not trying to make anything disappear. Accept whatever sensation appears and just be aware of it, and if there is no sensation, just be aware that there is no sensation. Experience the sensation of nothing in particular being present.

(lengthy pause, allow your client to rest their awareness on the sensation)

Now move your awareness to your left hand, be aware of any sensation in your fingers or your hands.

(lengthy pause, allow your client to rest their awareness on the sensation)

Take your awareness to your neck, just be aware of whatever sensation appears in your neck.

(lengthy pause, allow your client to rest their awareness on the sensation)

Now into your head, just be aware of the sensation, any sensation that appears in your head.

(lengthy pause, allow your client to rest their awareness on the sensation)

Allow your awareness to let go of any sensation in particular, let go of sensations, and bring your awareness now back into the room, maybe you are being aware of sitting, maybe being aware of thoughts, and when you are ready open your eyes.

That was a shortened version, and we used only the left side of the body. Normally I would use the right side, as well. Depending on the person's injury site, you would be thoughtful of the types of words you used as you approached that area. In particular encourage them to be non reactive to that area. That would take approximately forty five minutes for them to do. Now sometimes I may only instruct them in a twenty minute time frame, sometimes it might be forty five minutes. This would depend on the individual and the issues that present in the session. The critical factor for me is to emphasise this flexibility of awareness. This is a skill which with practice will enable the client to become more skilful and effective in future techniques and applications.

I discuss this ability to just notice that something arises in your experience, and you focus on that without any reactivity. I emphasise that you are not trying to get rid of it, and you are not trying to keep it, just observe what happens. The reactivity is also the thought pattern, or even the muscle tension that might occur. You are trying not to get into those reactive patterns. If they enter your awareness then, notice them and return your awareness to the sensation. Your objective is to stay just purely with the sensation that arises, and not get into what that sensation means. For example possible thoughts include, the fact that you can't work, or it's back again, I thought it had gone, or it's getting worse and I don't like, I don't want it to be there, I wish it would go away. And so the idea is not to get caught into this reactivity, and what it might or might not mean, to your past or your future, but to be present in the moment, to the sensation.

Concentration

The skill of concentration in relation to pain management is useful. However I find that my clients merely reinforce a low sense of self-esteem if I emphasise this aspect of skill development. Invariably clients (and most people) struggle to develop high levels of skill in concentration. This is not surprising as monks spend many years of intense practice to achieve single pointed concentration. I emphasise the value in gradual improvement and that any improvement will be instrumental in dealing with pain. If people could focus their concentration on one object, then it seems plausible that the pain would not exist, because the awareness would be totally focused. There is some interesting research that I came across, and I have not seen the original work, I have just read a of secondary source (internet), and they mention that there is some evidence to suggest that pain, chronic pain creates neural pathways that are separate to normal processing of sensory information. Now that has some interesting implications for concentration and whether there becomes some sort of parallel processing, as opposed to serial processing of pain, and so if you focus on an object, will in fact the experience or the sensation of pain, continue parallels with that. My suspicion is that it is serial processing, and that the individual rapidly shifts from pain to the object of concentration and back.

In relation to concentration techniques, a client particularly comes to mind. He stated that he always had the pain, no escape from it. I always explore people's experience of their pain and the sensation, and try to identify where there might be an exception to the stated experience. In this case the stated experience was constant pain. So we tried to explore when it wasn't there. It eventually came up that when he was cutting wood, with his bench saw, he didn't experience the pain. Because of his injury he couldn't lift large bits of wood, so he only worked with small bits of wood. He had made the bench saw himself, and it didn't have any of the safety mechanisms that you would traditionally have with commercial products. This meant that his fingers were at great risk, which required him to focus all his attentional capacity onto the sawing of the wood, and the safety of his fingers. At that point with that focus, he had no pain. Now he was then able to harness that experience, and apply it in things like mowing the lawn. The complication of concentration techniques is that if applying them to active tasks, people can actually push themselves beyond what they should. This results in damage to tissue and increases the sensory activity.

Important issues with concentration techniques include, selecting a non moving object. I think this is quite important. Therefore the breath is no longer a useful object of concentration. Movement in the object of concentration can encourage movement of the mind. If you can select an object of concentration that is immobile, that is still, then it is more likely from my experience that they will be able to stay with that object, and be still with it. I think encouraging any movement is just opening the doorway for your mind to move, onto something else. I think finding static objects, such as roses or a rock. I had one person pick a saint, she had a Catholic upbringing and this particular saint was important to her. I tend to encourage something small. An object, that you can visualise in just one image, rather than the feeling that you have to move around to take it all in. Again, because if you are moving around the image, then there is movement in the mind, which could encourage movement away from the point of concentration.

The breath is also not useful because it is physiological. There are two things about moving and physiology, the physiology obviously is again bringing them into that mental space where the sensation is at the physical level. Choosing a non physical focus of their concentration, for example a mental construct like an image of a rose, is more useful. In some ways, they need to transcend that physical plane for a concentration technique to work. Using a non physical object of concentration seems to be useful in this process.

Activity

Meditation - Single Pointed Concentration

Close your eyes and focus on an imagined object. Select an object that is small, so that you can concentrate on it without having to move around the object to take it all in. It should be a static image. That is it does not move. Keep your attention on the object for the next five minutes. If you notice you are distracted then just return your awareness back to the imagined object.

Five minutes later,................... so how difficult was that?

Generally people find that it is extremely difficult to be completely single pointed in their concentration, what I would often do with clients is get them to do maybe one minute, of concentration really intense, not so intense that it is going to give them a headache or tension. Then a break of maybe one minute with focusing on the breath, then repeat this cycle for 10 - 15 minutes. So using this strategy of focussing for short periods and building up those periods of concentration and reducing the periods of less focussed concentration, seems to be useful as people get a sense of the developmental nature of concentration.

People will often say to me that they can not meditate and invariably, that means that they can't concentrate, and they are not able to stay focussed on one thing. I think that's one of the biggest difficulties of meditation, in it's traditional presentation. It's often been presented as purely a concentration technique. This precludes the other skills of the flexibility of awareness, the ability to witness and observe, to be present, to be in the moment, and the ability to be non reactive. I see these skills as potentially equally important. And in fact I find myself questioning the value of emphasising concentration. Firstly because it tends to disempower people. This is something they should be able to achieve and they can′t do it right, so this further weakens self esteem. Meditation can often be a very negative experience from this perspective and I don′t think that is helpful.

Self awareness

The skill of observer, the witnessing one's experience allows us to see our habitual patterns and the resultant outcomes of their activation. It is a process focus rather than content. It is like the Gestalt process of looking at the how rather than the why. How does this depression arise? How does the pain intensify? Ivan Milton's talk on dialectical behaviour therapy (an earlier workshop) referred to developing this way of viewing one′s experience. Mindfulness, the awareness of what is present in your experience, and your ability to notice and be aware.

Insight into the habitual patterns that influence our experience is critical. In Buddhism the topic of the 12 Limbs is useful to understand. We don′t have the time to explore this topic here, but I would encourage you to read about this and apply it to pain. Basically suffering follows a cyclical pattern. This pattern has its foundations in ignorance. Insight clearly reduces ignorance. Seeing the habitual patterns that excacerbates our pain helps free us from the cycle. If you follow an habitual pattern then you will end up in the same place. For me this links in Karma. I see Karma more simplistically that it is presented in Buddhist presentations. Karma for me is simply cause and effect. If you have an action a reaction will follow. If you have a thought then the habituated response to that thought will follow. If you have an action then the habituated response to that action will follow. So the cycle continues indefinetely, until the chain is broken. Seeing the chain is an important step. As a person meditates, they have the opportunity to see the habitual patterns emerge as they sit and observe.

Non-reactivity

Merely witnessing ones habitual patterns may not be enough. Consciously working towards not reacting to triggers or the patterns as they emerge may be necessary. In meditation we do this by not reacting to habitual thoughts “this is boring“ or sensory stimuli like the telephone ringing or a physical itch. Not itching is an example of not reacting in a habitual, mindless way. Not reacting to frustration as it arises when your mind continually wanders is an example of being non reactive to an emotion or desire.By practicing this non reactivity in a meditation session, one develops the skills to deal with more complex patterns.

I mentioned in the title of this workshop the term equanimity. Equanimity is defined by Geoffrey Hopkins in Meditation on Emptiness, p 253 which says that

“equanimity is an evenness of mind, a dwelling in a natural state and a spontaneous abiding discordant with the afflictions. It is associated with non-attachment, non-hatred and non-ignorance and has the function of not allowing the opportunity for the afflictions.“

For me, this represents sitting with the experience, without trying to change it, there is no acceptance and no rejection. It's just experience of things as they are. If you need to accept something, it's almost like there is an active process of accepting, whereas my experience of equanimity is that there is no accepting and no rejecting, it just is, that's what's there. If I need to accept something, there is a duality. A process where the concept of rejecting and accepting is taking place. It is in this duality that the sensation takes on its painfulness. In experiencing equanimity, the sensation is present, and there is neither accepting nor rejecting it. There is no correcting of cognition′s ……. “I don′t like this“, “I wish this would go away“, “not today, of all days“. These thoughts would not exist in an equanimous mind, or if they did they would not be the subject of reaction. This is a key objective of pain management. With neither rejecting nor accepting, there is this calmness that comes from just sitting with the experience as it is, no mental construct, purely sitting with the experience. This requires concentration, flexible awareness, non-reactivity and insight.

I think these four skills combine to create a new relationship between the client and their experience. Specifically I think the fundamental change occurs between the thinker and the thought. I am not the thought and the thought is not I (this sounds familiar but I am not aware of the source). This shift in this relationship appears to have a major impact for people experiencing pain (panic, anxiety and depression).

I use the word sensation, and actively avoiding the word pain, because the word pain creates a mental construct which has a lot of other associations beyond the pure sensation that arises. Invariably, the sensation changes, so people's experience will be that even the sensation at their injury site, which they believe to be a constant, and always the same, in fact isn't always the same, it is in a constant state of change. And my understanding of the neural system is that the nervous system requires energy for it to continue, and it fatigues like muscles fatigue, and so for a nerve, or for any experience of sensation to be the same all the time is actually unlikely because physiologically, the sensation has to change, purely because the nerves that are firing are going to stop firing from fatigue, so other nerves will take it's place. And it's interesting for a client to start to explore what is actually the pure sensation, and what is their reactivity, at a muscular level to that, so the muscle tension and the tightening, that then restricts oxygen flow to that area, and the impact of tension and subsequent lactic acid associated with constant muscle tension is not helpful. The objective is to get them to see the experience for the sensation that it is, and not get the associated or secondary reactive responses. This enables them to be free of it, to be free of the “added on“ experience of it.

As examples, some of my clients have expressed the experience without the reactive patterns as being warm, like Dencorub of which is less difficult for them to manage. Although it should be noted this is still in the realm of mental construction, but a more helpful one compared to their original construction of agonising and unbearable pain. So the client started to experience the sensation of warmth, as opposed to the mental construct of pain. The absence of reactiveness that occurs around the sensation, makes things extremely more tolerable, and in fact, sometimes peaceful, when constructing is absent. This could be expressed in Buddhist terminology as the experience of sunyata or emptiness/transparency.

I have had a number of clients who have had the experience of sensation that they say are absolutely unbearable, absolutely intolerable, which we know isn't the case, because they are actually tolerating them, often with strong reliance on medication. Through this process, I have had clients tell me that the actual sensation itself is quite peaceful and restful, which is very different to their original experience with the sensation. Often at this point the sensation can disappear (this is not the objective nor is it necessary for the relief of their suffering).

I'm thinking specifically of one client who had the experience of intense burning sensations and electrical shocks continuously running through his body. These sensations would persist over a number of days. The diagnosis for his condition, or this particular condition was muscular dystrophy. Through the application of these techniques and the development of these skills, he was able to allow the sensation to arise, he would sit with the sensation. It would become quite peaceful and relaxing. A times he would fall asleep, and wake up and the sensation would be gone. He could then get on with his life. So the sensation that would last for days, and result in intense discomfort and often include great psychological distress and anger which was expressed in verbal and destructive behaviours, was now gone in a matter of hours. The client presented with numerous physiological issues, but this was the most destructive personally and systemically. This experience has lasted a couple of months. Historically the symptoms would appear weekly at a minimum. Previously when the muscular dystrophy took hold, it would last a couple of days, he would lose his temper, get into fits of rage, break things, yell at people. He was extremely difficult to live with and through this process. He had learned to be able to accept the sensation and not allow his conditioned reactive approach of fighting the sensations appearance. This non-reactivity, resulted in him being able to allow the experience to take its natural course, which is impermanent and in a state of constant change. He was also I believe able to experience the emptiness, transparency or openness of his experience and able to experience a calmness in amongst the discomfort. The calmness existed in the experience once he was able to let go of the mental constructs that was imbeded in his resistance to his experience. We will do this particular technique a bit later, it is a variation on Jon Kabat - Zinn′s technique, but the same principle of focussing on the sensation and learning to let it go, developing the core skills. I am not aware that we train these skills in any other systematic way. Typically in our lives we haven't developed these skills at all.

In support of these skills and their more subtle distinction from traditional cognitive therapy can be seen in a recent study I recently read. It is an unpublished research manuscript, by a Medical Practitioner completing a master's in psychotherapy. He compared what he called attentional control training versus traditional cognitive behavioural therapy in the treatment of depression. Attentional control training was fundamentally a meditation technique of focussing on an object, noticing when your mind drifts off, bringing your awareness back to the object without any entanglement with the content of thought. He concluded, that cognitive behavioural therapy was quite a complex process that was not necessary, and that really what was necessary was that people learned to witness their experience without getting caught in it, without getting worked up by things, and that fundamentally a thought is just a thought, and that really does not have to be reacted upon. I've used this approach, that I use with pain, with people with depression and found that to be highly successful, in that people see themselves getting sucked into the process of depression so they get into the habit as it were of depression, see it happening and then just notice what they are doing and just in the noticing, it can just lose it's power or momentum. It might last moments rather than long term. And so they start to see depression as just an experience, and they can distinguish between the experience and the mental construct of it.

One of the difficulties Western society is having and will continue to have, is differentiating the cultural influences and the essence of Buddhism, and the specific Western cultural needs in dealing with the essence of Buddhism. This was something Jung alluded to in his caution to Westerners who became drawn to Buddhism. Clearly, Buddhism elucidates a path with clear directions for freeing oneself from suffering. However, some of these approaches are culturally specific and may not be relevant or useful in the West. Psychotherapy has a lot to offer in this transition or integration. This itself could form a workshop/presentation. For this discussion on pain, it is relevant because, my role is to help a client free themself from the burden of pain. Sometimes traditional Buddhist practices are not adequate. I find the principles themselves to be generally valid, but the practices are not always adequate. For example a client who is untrained and unexposed to Buddhist practices may be unable to let go of thoughts or reactions. A role I play as a psychotherapist/psychologist is to assist them to let go of unhelpful conditioned reactions to their pain. Western strategies for helping people let go/accept their experience are useful. These western approaches may be more culturally sensitive and therefore more appropriate in the Western context. I think it is important to keep this in mind when exploring Buddhist appproaches.

An observation that would not be new to you is that allowing them to tell their story can be therapeutic. In our culture people often do not have someone whom they can share their story. Particularly without judgement, interruption or avoidance. One of my flaws is that I can get caught in being too focussed on what I see as being a useful strategy/process, and not allowing people to tell their story. Buddhist practices encourage letting go, refocussing one′s attention and training the mind not to get into unwholesome thoughts. I agree with these practices, however the way to develop the skilfulness to achieve these ends may be culturally different from East to West.

I think that telling the story can be an effective way of externalising the issues so that the individual is able to be with their experience without reacting to it. It would be more skilful to just be with it without suppressing it, but not to, exaggerate it. In some ways just talking about the issues is a way of buying into it. Narrative therapy talks about externalising the problem. It may be that the way in which the client talks about their issues is important. If they need to work through the issues, it is necessary for the therapist to guide them in a way that would skilfully explore them and not lock them into habitual patterns of relating to their issues. I think Buddhism has numerous links with narrative therapy, the fact that Gregory Bateson had a strong influence on Michael White's work and Gregory Bateson being a Zen Buddhist has got to have some interplay there. In reading some of Michael White's work, it seems that he had some Buddhist influences there. It is not difficult to link Narrative concepts to Buddhist concepts. His concept of externalisation is one of those similarities. It is different clearly in practice. Buddhism uses meditation to externalise, Narrative Therapy uses dialogue. In Buddhism there is an externalisation of the thought process, so that thinking is just thinking. The referent “I“ is not inherently existing and therefore there can be no “my thought“ or “I am the problem“. So everything becomes external because the self even becomes external in that it is a mental construct, it's actually not you, because you don't exist other than being a mental construct.

The whole concept of externalisation, if followed through to a logical conclusion, could be encapsulated in the Buddhist concept of non self. Where the self exists purely as a reference point. Allowing clients to tell their story in a way that allows them to externalise their issues and frees them to let go and accept their experience in an open and non reactive way then that may be useful. Buddhist meditation teachers may encourage their students to “come back to their breath“. However some people just can't let things go, and so traditional therapeutic approaches are useful at helping people learn to let go.

BUDDHIST CONCEPTS AND PAIN: Some thoughts.

The other Buddhist concept that I find extremely helpful for me is the concept of impermanence, that everything is always changing. When a client comes to me and says the pain is always there, I know that the sensation is not always constant. This does not deny their experience of always being in pain. It merely acknowledges that they experience a mental construction of permanency of pain/emotional turmoil. This locks them into experiencing their world as constantly in pain, and prevents them from experiencing the impermanence of the sensation. Experiencing the impermanence of their sensation starts them exploring their experience without their habitual reactiveness that holds them “in pain“.

Sensation does not persist, it does not last. What is happening for them is, the sensation is no longer truly experienced, and it is the mental construct or habitual reactiveness of that sensation that has taken over. The experience of pain as always there. When a clients says the pain is a constant throbbing, I'm thinking, what is happening in between the throbbing? It is likely that throbbing has got some space in between. Assuming impermanence, I know that that sensation that they are experiencing is not permanent and so the mental construction is the permanent experience. The mental construction that they have created around it, and I have had numerous examples of clients witnessing or experiencing that, where they have felt the pain was always present and once they start to loosen the construction, and experience the sensation itself, they see that it isn't always the same.

The great strength that I get in understanding impermanence is that when I ask clients to focus on the sensations, (we will do this exercise in a few moments), I have a strength of conviction that it will give them a chance to experience the sensation and to allow it to change, disappear or increase. If I thought it was permanent, it would be a masochistic exercise. Certainly some clients struggle with this activity, as initially it can make the pain worse. This is a valuable insight into how they can increase the pain. If they can increase it through awareness, maybe they can reduce it?

Not that I am expecting it to disappear, but it certainly can, but I know it will change, and so that is where they become more empowered, within that experience of change. They start to see how they might construct their experience around it, and this whole concept of construction is extremely important in Buddhism particularly in relation to the concept of emptiness. The experience of sensation as a sensation can be an experience of emptiness. To experience the sensation without the mind constructing that it is going to get worse. Without the creation of a fantasy, based on the sensation, of what my future holds, and my worthlessness the client begins an experience of deconstructing the pain experience fantasy. Resulting in the insight of the lack of any inherent existence of the fantasy and by association the pain. This is seen by clients in their experience of anger. Clients often claim “The pain makes me angry“. I respond with “How does the pain cause the anger?“ It is not to difficult for clients to realise that the sensation has no guaranteed link to anger, and that it is through their reaction to the sensation that the anger appears. So the anger has no inherent existence. It is empty.

Identification or ego grasping is another Buddhist concept that is relevant. I am the pain, I am experiencing the pain. In narrative therapy they talk about externalisation and in psychoanalysis the process of free association (accepting my limited knowledge of psychoanalysis and narrative therapy). I think these are an attempt to loosen ego grasping or identification with “I“. This is achieved by the externalising of people's experience. In psychoanalysis they sit there and they free associate with their mental experience, and their emotional experience, and express that, without attachment, without identifying with it, and that then allows them to externalise it. This process is supported in part through modelling by the therapist. Through this process of non-reactivity (non-grasping, non-attachment), the clients experience no longer has the hold on them that it had previously.

I think Buddhism has a lot to offer particularly around deconstruction, and non grasping/non identifying with the mental construction. To see the sensation for what it is, just a reference point. There is no attachment to the identity that is being lost. The strong, independent, masculine, income provider, carer etc. The struggle to maintain the “I“ that was present before the injury, often results in re-injury, through persisting with doing inappropriate things, like lifting a heavy object…… “I didn’t want to bother anyone“, “I just wanted to feel normal“. If the client continues to buy into the “I“, then the sensation means I am not going to be able to do all the things I want to do, like I'd like to maybe be more active in the garden, I like renovating houses, I can't do that anymore, I can't run, I can't go to the gym, I can't do this, so all this ego grasping identification continues through this process. Then the anger arises. Then the blame, either self blame (I should have said no) or perpetrator blame (often employers) arises. Invariably with the anger and/or blame comes an increase in muscle tension and ultimately pain.

ACTIVITY

This is a useful exercise/techniques that I use with clients. It's not one that I would use in the first session. It is something that I would do over a number of sessions. I might start introducing it as just a couple of minutes, just to provide me with some data of what happens when the person does it. I would generally introduce it after six to ten sessions. The foundations of those early skills discussed earlier, that is flexible awareness, concentration, mindfulness/self awareness and non reactivity, or equanimity are useful prerequisites. If the client has developed these then this activity appears to be significantly more successful.

The aim of this exercise is for the person to focus on the sensation without changing it, or without wanting to get rid of it, or wanting to keep it. The issue of secondary gain is an important issue in pain, the not wanting to keep it. What happens if this pain goes?

I presume most of you don't have any pain, so that is not very helpful, we really need some pain. That is one of the reasons why I consider sitting on a cushion, is a useful practice, because you are learning to deal with physical discomfort. I would never get my clients to do that, mainly because they would never be able to get up again, and they don′t need any more pain, they have got enough. With you here today, you have no pain, so I thought about how I could create pain for you that would not inflict too much pain? So I have come up with these bulldog clips. What you do is you just place them on your skin. Preferably not too big a chunk, because if you get too big a chunk of skin, it seems to reduce the pain quite quickly, so just get a small amount of skin in the bulldog clip. That will sustain the pain or the sensation for a long enough period. Now there are some medical restrictions for this. If you are over fifty, if you are a diabetic, and if you have peripheral vascular disease you should not do this. Now I don't know why that would be the case but I was told by a doctor that the bulldog clip on the skin is contraindicated. I would imagine a haemophiliac should also not do it. If you have one of those conditions, what I would prefer you to do, is to sit on the floor, and make yourself uncomfortable that way, if you are able to do this. And if you can't make yourself uncomfortable you may have to just get a sense of the activity.

So what I want you to do now is just close your eyes, this is not essential, but in a group setting like this it is probably useful to close your eyes. Now what I want you to do is to take your awareness to the sensation of discomfort. Just focus on whatever sensation is most obvious to you at this moment, and just keep your awareness there. Don't allow your awareness to drift to something else, stay with that sensation. If it disappears stay with the fact that there is this sense of absence of that sensation. Just watch whatever it is that tells you that it's not there.

The task is not to get rid of the sensation, it is not to keep it, it's just to gently direct your awareness on that sensation and experience whatever happens to the sensation as you do that. Also notice whatever happens in your mind as you do this exercise. Your mind might start getting in to thinking about the sensation. Just notice that, and then come back to the sensation. Your mind might get into a conversations like ……. “I don't like it“, or “I want it to go away“. Just notice that your mind has drifted off the sensation, and come back to the sensation. Simply try to experience whatever it is that happens to that sensation as you focus on it. We are going to spend five minutes on this task. Whenever you notice your mind wander off the sensation, just bring it back.

I am encouraging the client to get some insight into what their mind does when they focus on the sensation and also just what happens to the sensation. Without the mental construction or the reactivity to it. Noticing their reactivity to the pain can be quite insightful for some clients and quite threatening for others. To witness how they get tense (mentally and physically) when they construct “I wish this would go away“, “it′s getting worse“ or “I can′t cope with this“. What's often quite significant for people in their experience of this task, is that they notice that even when they focus on the sensation, their mind drifts away from the object of concentration (sensation). Yet invariably in their day to day life, they try to concentrate on something other than the sensation, like listening to someone or read the paper, their mind just keeps going to the pain. So this is quite unique for them, because they keep seeing the sensation of pain as being a magnet that draws them all the time, now it isn't a magnet. In fact it is repelling.

A lot of things happen for people when they do this the first time, generally they get caught in mental constructions, they want to get rid of it and so on. I find this difficult work, in that it's a real challenge to talk about something that is happening in their head, and I don't know what they are doing so I am trying to explore it, but also in their language you can often pick up, that they haven't focussed on the sensation, that they have got into the mental construction. And usually saying things like I don't like this, I couldn't stay with it. Often people will use distraction when they are asked to focus on the sensation, because that's been their major strategy for dealing with pain. Most western psychological approaches have encouraged them to distract, and here you are saying, no don't distract, focus on it, go with it, get into it. Invariably their mind will go to blocking it out, or trying to get rid of it, thinking of something else, and so they will converse in that sort of language. This the challenge of actually trying to help the client see these experiences just as sensation without everything else that is bound up with it. When clients do that, the sensation isn't as traumatic as the mental suffering that is added to the sensation and the associated implications (lost income, lost identity, lost dreams) are diffused. Sometimes the sensation disappears and sometimes it just moves to another location in the body. This is a confusing experience for clients as it is difficult to explain why the “pain“ is now somewhere else other than their injury site. Again, giving them the experience that the pain is not always the same. It is impermanent.

Initially the sensation might intensify, because they have taken their awareness to it, but often when it intensifies it is because of their reactiveness to it, their getting into mental constructions about it, the trauma of it, or how bad it is, but sometimes it will go up, just because you have taken you awareness to it. There is an appearance of intensity, that won't last. So encourage them to continue to practice non reactivity and gently focus on the sensation. Sometimes it completely goes away, just disappears, so there is quite a variation in people's experience. Others just experience a sense of calm. Which is a contrast again to what they have typically experienced . I merely discuss the clients experience over a number of repetitions of this exercise. I am trying to get sense of what happened to them when they did it, and usually I would start with maybe five minutes on that, just to get a sense of what's happening as they do it. If it seems to be working, in that they are able to be non reactive to the sensation and/or are able to collect data about their reactiveness then I would make it last a little longer.

Now there are a lot of cues that the client will give out, when you are sitting there, things like movement, sometimes even swearing or groaning because they are reacting to their experience. Their breathing can give you some indication. For example, their breathing becomes shorter and shallower, when they are fighting it and so you may say to them, “try not to fight the sensation, just go with it, just witness it“. When they are in their day to day life and the sensation starts to dominate their experience, they can then witness their reactivity to it, and they just don't get lost in their reactivity. Often their reactivity is not passive but rather aggressive, it is them continuing to work through their pain to complete some task that it would be more appropriate for them to stop. I like to talk to my clients about being skilful. That is doing what is going to give the best possible outcome.

Invariably clients will catastrophize their experience through the focussing on the sensation and so it takes quite a few attempts at this activity for them to start to untangle and gain insight into their reactivity. I encourage them to experiment and to explore what it is like if they don't fight it. Let's play with that and see what we come up with, I talk to them about the construction of their pain, “what is your mind saying about this sensation, when you do this activity?“. I find a whiteboard extremely useful, just documenting step by step the process of constructing experience, as it is written up and they see it, in all it's glory that is presented there. They often say “gee you know, none of that is helpful, that is not getting rid of it, it's just locking me in to making my life miserable“. The gain some insight into what I refer to as the secondary pain (ie depression, anger, frustration) to the actual sensation and that is part of their circle of influence.

I often do a white light meditation, healing meditations with people so when I say white light what they are doing is they're breathing in light into themselves, as an energy, a healing force, if they have a religion I try to link it into that, so variably what they would do is breathe in the white light and blow out pain and tension, as a blue smoke. I would get them to take the white light into their chest, their heart area and to feel the intensity and to just progressively move that through the body, ultimately I would have that white light completely engulf them, and surround their entire body and so that the white light has gone into their body, now comes out of the pores of their skin and out of their fingers and toes and the top of their head, it just completely engulfs their entire body and so they are completely surrounded.

This has varying degrees of value for people some just find it useful to get to sleep, some find it useful too when the pain is really intense, and others find it really does help heal. I think much of the healing comes from them not fighting and allowing their body to just take on board the experience. It is important to recognise the value of relaxation or the lack of it in their experience and exacerbation of pain. I tend to down play the relaxation aspect of my work. This is due to the tendency in Western Psychology to see meditation as merely a relaxation technique. As I hope I have presented here, I see meditation as an opportunity to develop and practice mental skills. Through meditation insight can be achieved and mastery of essential mental skills. One necessary outcome of these skills and insights is relaxation. In pain clients are extremely tense. Their muscles are tight all over their body. Massage helps, but often this muscle tension has its source in the mind and it is necessary that clients explore the experience of relaxation, not merely to avoid or distract from the pain, but to see and learn to reduce their reactivity to the pain (which some muscle tension is).

When a client is doing a sensation focus activity, what I would do is what's traditionally called Tong Len practice. A good reference for this is the Tibetan Book of Living and Dying, by Sogyal Rinpoche. He clearly outlines this technique, basically what you are doing is, you are breathing in the suffering of the other person, the client in this case, so you breathe in their suffering as black smoke, taking it into yourself, and then blowing out white into the client. I find that a useful practice to do when I am with the client, and they are doing their technique, I'm sitting there doing that. I have no scientific basis for its use but it seems to me that when I am doing that, and I have a strong sense of the practice, that clients get more out of their experience, than when I am not doing it. Now it is important I think here, as was highlighted to me by Dr Karen Kissel Wegela, when I was researching in America, that you are not actually taking their suffering into yourself, because the self does not exist, it is a construct, so what you are doing is taking it into emptiness. This could have a negative impact on you. I think this is a useful strategy for therapists to learn to develop, or acquire. It is another topic altogether, the contribution Buddhism can make for the therapist personally. My research in the US clearly highlighted this as the most significant area of Buddhist influence on therapy.

The concept of breathing in your clients pain and sucking it into emptiness is quite important and so the meditations on emptiness are very important in this process. So that this practice will not do any harm to you. When I interviewed psychologists in America, they have used Tong Len with clients to get them to take on other people's suffering and in doing that that has freed them from their suffering. I have not as yet tried this with clients. But it appears for clients to let go of their own suffering, their own process, their mental construction and it's freed them. I'm interested in exploring this, and want to think about how I might put that into practice, but I know certainly that some of my clients not pain, a number of my clients have read some of these practices (particularly Metta practices) in books that I would give them, and they have found it useful. I am going to leave it there because of time.

Postscript

I find it difficult to say what is Buddhist views and what are the views of Michael Anderson. I will leave this to you the reader to decide. I only hope that you find this work of some use. I would also like to add that this work is constantly evolving. Since doing this workshop I have expanded this work in ways I was not aware of at the time of presenting. I am sure this process will continue.