Excerpts from About Pain

Dr. Rachel B. Aarons LCSW

Santa Barbara Therapist and Author

Excerpts from About Pain

Click here to order About Pain

You can get a glimpse of the book by looking at the following excerpts:

Contents

Foreword

Part One: The Inside View

Reflections on Pain
Voices of Pain: Eleven Patient Stories

2. Part Two: The Outside View

3. Part Three: Rising Above

Conclusion

About The Author

Bibliography

From Part One: Reflections on Pain

Pain changes the world you experience.

However you lived before, once you are in pain you can be sure things will be different. There will be things you used to do that you can’t do anymore – such as, in my case, playing baseball with my sons or going to a high-impact aerobics class. There will be dreams that need to be revised or abandoned – such as retiring and spending my days digging, weeding and planting in my garden. There will be what can only be regarded as “necessary adjustments.”

That is because pain sets limits. Sometimes gradually, sometimes suddenly, a wall comes up. You can’t move in the same way you did before – the way you probably took for granted when you could move like that. Now it hurts. Perhaps a little, perhaps a lot.

If the pain is bad enough, you will feel your body pulling back, contracting, and resisting. Your mind will either be enveloped in it or plotting a way to get out or, at least, to get less pain. A new thought pattern gets launched in your head and develops into an ongoing rumination about how to manage in the world with the least amount of pain.

Depending on the illness, the details will be different. It might be about the distances that need to be traversed from one place to another and whether those distances involve hills or slopes or steps. It may be about the smoothness or hardness of the terrain. Or, almost inevitably, it will be about the weather. Is it cold? Is it damp? Is there rain or snow? Is it windy? Is it hot? Do you have your water bottle? Sunglasses? Sunscreen? Jacket? Scarf? Mitts? Umbrella? Hat? Cane? And all the necessary medications? How close is the parking? How close are the rest rooms? Is there an elevator? Wheelchair access? Will there be stairs to climb? And which is worse? – climbing up the stairs or climbing down? What is the seating like when you get there? Are the chairs comfortable or will you be squirming in your seat throughout the whole event and then unable to get up when it is done? Will the ambience be frenetic or soothing? A hair shirt or a velvet cloak? Will you disturb other people around you with your grunts and groans? What if you get tired and just want to go home?

There seem to be a million details you can be busy obsessing about. Nowhere in this litany of worries and concerns is the anticipation of pleasure. It is all about minimizing the pain. You are now absorbed in a negative, downright boring, and seemingly endless train of anxious thoughts. And if it is negative and boring to you to think this way, just imagine how negative and boring it must be to listen to. Now you can top it all off with a load of guilt. You are miserable and you are making others miserable too.

But the thoughts are compelling. The walls and limits are real. Different conditions will involve different limitations. But all pain involves limitations of some sort. Perhaps we can aspire to rise above them, but we need to begin by acknowledging their inescapable reality.

No longer is the world experienced as a delightful smorgasbord of possibilities inviting you to step up and enjoy. It has become, instead, a morass of irritating problems to be solved, a jungle of practical challenges to be overcome.

Not the least of these challenges may be financial. Being sick can be an expensive proposition. When you are ill, you likely can’t work for a period of time – or perhaps indefinitely – so your income stream dries up. At the same time, the medical expenses mount.

Depending on the needs of your particular illness, there may be special devices that are required such as wheel chairs, crutches or hospital beds, and special services such as visiting nurses, around-the-clock caregivers, rehabilitation or physical therapy. Some of this may be covered by insurance – if you have it – and some may not. The time spent dealing with insurance companies can be staggering. It is almost a full time job to fight for coverage and one that is as exhausting as it is time-consuming at a time when your energy is in short supply.

As your finances dwindle, so do the options in your life. You not only are physically incapable of pursuing many things you used to enjoy; you may no longer be able to afford them. How many of the country’s homeless population are in this position because of astronomical medical bills? It is frightening to entertain the possibility that at any time illness and pain can suddenly rob you of the style of life that has been yours up to that time.

From Part Two: The Outside View

To the caregiver

By and large, (with some notable exceptions,) it is safe to assume that caregivers have the best of intentions. They want to deliver the best of care not only medically but also in terms of emotional support. Therefore, it is in the interest of maximizing their quality of care that the suggestions in this section are offered, not in the interest of attack or criticism. Sometimes it is helpful to know the ideal we are pursuing even if we can’t be perfect in achieving it.

Think of the following questions as signposts on the road.

1. How is your energy?

If you let yourself absorb the information in Part One on a heart and gut level and are beginning to understand the internal world of a person in pain, this will make a dramatic difference in itself. Genuine empathy is felt in the room. It is a spirit of loving kindness that reaches into the hearts of those who suffer and lets us feel seen. It is altogether different from the forced cheerfulness of the caregiver who bursts in with an “everybody up for volleyball” kind of enthusiasm. With empathy, we feel met rather than blasted with another’s presence.

I remember being woken up at six a.m. in hospital after three or four hours’ sleep with a glaringly bright light in my eyes and a nurse announcing stridently: “It’s time to take your blood pressure!” I silently wished I could punch her and then push her out the door. It is a nasty shock to the system to be woken up like that. It might even be seen as sadistic.

Each one of us has an energy that we bring into the field. Being a therapist requires being attuned to this energy in ourselves as well as in the other. Emotions are contagious. Research on mirror neurons shows that we are activated by emotions in the other even when they are not outwardly expressed. Part of the work of caregiving is tuning into the impact of your presence on the other as well as theirs on you.

Like therapists, people in pain tend to be acutely sensitive to the energy of each person who enters their space and either soothes or agitates them. Yet too often caregivers seem to be oblivious to the impact they have. Some come in with a cold robotic professionalism, others with a dark gloomy cloud over their heads, and still others with a bustling impatience to do what they came for and be done with you. Perhaps they are carrying problems on the ward or in their personal lives that have nothing to do with you. They are human beings after all. Nonetheless, the bottom line is the care of the patient. It must be recognized that it can have a decidedly negative impact on the vulnerable patient to be treated in these ways.

One of the nurses had a cold sullen expression. She handled me roughly and she never smiled. This was at a time when I was at my worst. I was stretched to the limit just dealing with my own condition. I found myself dreading her appearance at the door. I felt myself cringing when she came near my bed. To make matters worse, that week she was working three days in a row. The prospect of three days with her as my nurse raised feelings of dread in me.

My son and I decided as an experiment to see if we could cheer her up. That would be a win- win for both sides. We found out that she really liked ice cream but hadn’t had any in a very long time. My son went to Coldstone Creamery and got some fancy ice cream for her. She seemed pleased and was softer after that. I’d vote for ice cream for all the nurses if it would help them put aside their problems for the sake of patients who may already have more than they can handle dealing with their own pain.

Being present with another so that you are focused on them and fully engaged in listening and responding to their state of mind at the moment is a skill. It is a skill that is part of our training as therapists and is needed by medical practitioners as well. It means putting aside your personal issues and responding only within the context of the patient. Ultimately, it implies a centeredness and self-assurance that may be more of a constant striving than an accomplished goal. However, it is what we are there to do as caregivers. It is an essential part of the job.

If it is required by the job and difficult to do, there is a need for education and training. Possibilities might include workshops, group or individual communication sessions, feedback about the caregiver’s impact, supervision and maybe even (last but not least) therapy. This may sound idealistic and impractical. However, if hospitals and insurance companies came to see that the energy with which we care for patients has a direct relation to their healing and, specifically, the length of time they spend in hospital, it might appear cost-effective to invest in training of this sort.

2. How is your touch?

Touch is an element that is often overlooked or minimized. Yet it plays a crucial role in the health and well-being of each of us.

From the beginning, infants require touching and holding as much as they require food, water, and warmth. The needs for emotional and physical closeness are not a luxury but occupy a position on a par with basic physiological needs. The research of French psychologist René Spitz during the Second World War revolutionized psychology by establishing this point. War-orphaned infants who were fed, clothed and cared for on a physical level nonetheless sickened and even died because they were not rocked and held by the beleaguered staff of the orphanage. We can never again conceptualize human beings as purely physical creatures. We need to be touched and held to survive, not to mention, to thrive.

My son David spent all sixteen days in the hospital with me, mostly lying beside me on the bed. Since the time my sons were little, I always had a bedtime ritual of lying beside each one in turn, reading, singing or playing games every night before they went to sleep. I have always regarded it as a very important and meaningful ritual. Even now that they are adults, we often have our deep conversations lying side by side on the bed. It is a way of bonding that combines physical and emotional closeness in a powerful healing way.

One day as we cuddled together on the bed, the head-nurse on the floor marched in and demanded that David get up and sit in the chair. “You can’t be there!” she declared with muted outrage, implying that we were doing something blatantly wrong. My son quietly and calmly replied: “This is healing for my mom and it makes her feel better so I’m not moving.” “You’re refusing to move?“ the nurse repeated, obviously in shock that her order was not being immediately obeyed. “Well, then,” she said with a tone of dark foreboding, “you’ll have to talk with the supervisor!” “Fine,” we both answered at the same time.

The supervisor showed up the next day to investigate our questionable behavior. We reiterated our truth. It was healing and it did help me to have him close beside me. She looked at us both lying there smiling at her and, to her credit, she said “okay” and went away. We were never bothered about it again.

From Part Three: Rising Above

Working with Pain

We have visited in depth the essential components of the pain experience and how it simultaneously affects both the body and the mind in a myriad of negative ways. Now it is time to address the compelling question: What are we to do about it? How can sufferers learn to live with their pain in the most constructive and promising manner? How can caregivers guide their patients toward acceptance and, whenever possible, the reduction and relief of pain?

1. Being on your own side

While it is natural to turn against the body when it causes us to suffer such intense agony, it is not helpful to do so. It is like waving a cape at a raging bull: it just causes it to charge even more fiercely. It is incumbent on us to learn to quiet the raging bull and, as Tara Brach says: “to move from fight/flight to tend and befriend.”

According to Brach, illness may be understood as being down on oneself and identifying with a sense of deficiency – the belief that “something is wrong with me” – rather than supporting oneself with a compassionate attitude expressed in her words: “It’s okay, sweetheart.”

One way is through mindfulness meditation where we simply notice what is happening in the moment and allow it to be. We pay attention to the physical sensations of pain while practising an attitude of openness, kindness and non-judgment. In this process, we move toward a more peaceful coexistence with what is hurting and transform resistance into acceptance of the experience of pain. This is currently a very popular approach.

I myself use a different approach to shift from self-attack to self-love and compassion. It involves learning to silence the critical voice inside which I call the “superego,” that part inside that is not your friend.

We all have a voice inside which criticizes and condemns, attacks and berates us. It represents the internalization of negative messages we received about ourselves originating in our families of origin and carried forward in time through our own thought processes. This voice was there in the background when, in Part One, we spoke about feeling guilty for the irritation and grumpiness which often accompanies illness and the constant presence of pain. It was present behind the scenes in the description of the shame of being seen as a person in pain, someone different from and less than healthy people. And it has been there in my mind since I wrote about the recent flare-up of fibromyalgia I experienced during the writing of Part One. The possibility of its being “psychosomatic” conjured up a superego image of myself as neurotic, histrionic or, in some undefined way, psychologically damaged. It made me feel bad about myself.

Then, when I trouped off to Italy still in the throes of a fibro flare-up, I began to doubt myself. Was I an intrepid warrior who refused to give up or a pathetic cripple limping my way down cobble-stoned streets revealing my helplessness to the world? The superego took the latter, considerably less appealing point of view.

What I practice myself and what I teach my clients is not to succumb to the superego but to fight back. Ways to do this vary from undermining the authority of the superego, recognizing the manipulative ploy of the superego, identifying the source of this strategy in our family of origin, denying the truth of the message we are receiving, or bypassing the message entirely by affirming the self. With each client, we identify the specific superego messages they are receiving on a regular basis and then we go through a series of proposed counter-attacks until we find the ones that are the most effective for each specific individual. The way you will know that a particular counter–attack is effective is the fact that, at least temporarily, the superego voice goes silent. Then, for a brief time, the mind is empty.

In this spaciousness, we cultivate a new and different voice that advocates for the self. I call it the “sympathetic witness.” It is an inner voice that is on your side, holding your best interests, and treating you with loving kindness. It is, no doubt, the voice that Tara Brach quotes as saying to herself: “It’s okay, sweetheart.”

The implication is that, as well as the various outside people who provide care to the patient, there needs to be a caregiver inside each person in pain, who is the kind of empathic caregiver we were promoting in Part Two. From this perspective, Part One and Part Two may be regarded as addressing the same person.

The more you hear this compassionate voice in place of the critical superego voice, the more centered and peaceful you will feel. Being on your own side is an essential step to integrating a self divided.

2. Focusing on the positive

We have seen that the more you focus on pain, the more pain you feel. Sometimes we may have no choice when pain takes over every fiber of our being. But when it is possible, it is helpful to put our focus elsewhere.

During the long ordeal in hospital, I often needed a way to raise my spirits and find something positive to focus on. My son and I frequently downloaded movies to watch on our computer. We brought in dinner from outside and ate it out on the patio with a vase of flowers on the table. We found a cache of chocolate bars tucked away in a drawer on one of the wards and turned that into a treat to look forward to. But the best time by far happened on a night that was particularly grueling for me. On the edge of despair, I complained to my son that I really needed something to lift me up. It was feeling all too much for me. He found a desk chair on wheels, plunked me down on it, and pushed me up and down a deserted corridor at break neck speed, wheeling me around as I howled with laughter. That was an amazing feat of ingenuity on his part.

When it is a matter of focus, hypnosis is a powerful tool for teaching us to focus our attention where we want it to be and not where the mind tends to take it. Also known as “selective perception,” hypnosis allows us to go to our own special place that is tranquil and calming where we can deeply relax. To the extent that we are able to relax, we will feel less pain.

In contrast to many practitioners who teach self-hypnosis, I train my clients in deepening techniques in addition to basic methodology so they can choose the level of hypnotic state that is needed in the moment. Basic methodology will work for average circumstances but, for the aversive ones, we may need to go deeper in order, as in the case in point, to get beyond severe pain.

In addition, there are pain reduction methods that utilize self-hypnosis to regulate the desired level of our pain. Here are some examples. We can visualize being below the level of our pain by imagining ourselves warm and dry in a burrow at the bottom of a river while the pain churns above us like a raging river. Or, we can float above it like a cloud in the sky while our body lies on the bed below. Or, as another alternative, we can put the pain at a distance from us by projecting it on to a TV screen while we operate the remote control. We can pause it or fast forward it or turn it off altogether.

Another favorite technique is “color bath” in which we imagine bringing a soothing color down from the top of our heads into each muscle and organ of our body. If any area resists, we let the color play around and in and out of the area of tension as if we were massaging ourselves with soothing, healing color.

Finally, a very effective technique is to begin by identifying the qualities of the pain we are experiencing – the size, shape, texture, temperature, and associated imagery – and then proceed to change these qualities to ones that are more benign and comfortable. For example, a back pain that is six inches across, shaped like a picket fence with sharp edges and a rough surface, that is boring into our muscles like iron spikes may be converted into one that is, say, two inches across, soft, smooth, and more like a warm hand on our back. As an interesting note, most people choose to keep a small amount of pain and not eliminate it entirely, perhaps to remind themselves to be careful or, perhaps, because they have become identified with the pain and can’t imagine completely letting it go.

In this regard, author Rick Hanson explains how the brain is predisposed to negativity and will retain negative experiences in long term memory while positive experiences wash through and are forgotten. This “negativity bias,” as he terms it, is rooted in our biological need for survival. The amygdala is constantly scanning for threats of harm to the organism and keeps this information in implicit memory to arm and protect us. In his words, the negative experiences are like “Velcro” to the brain whereas positive experiences are like “Teflon.” However, according to Hanson, we can learn to reverse this tendency and turn passing mental states into stable neural traits in order to benefit ourselves and other beings. He offers recommendations for locking in positive experiences so that they become a solid part of who we are and inform our sense of self through memory. As psychologist Donald Hebb is often quoted as saying: “Neurons that fire together wire together.” In other words, it is what we focus on that becomes real for us. Hence it is important, in Hanson’s words, to “take in the good” – that is, to ensure that the positive experiences of each day are committed to memory. As the title of his latest book suggests, we are, in effect, “hardwiring happiness.” As a result, we will experience more self-esteem and less depression, more pleasure and less pain.

Hanson says: “Given the negativity bias of the brain, it takes an active effort to internalize positive experiences and heal negative ones. When you tilt toward what is positive, you’re actually righting a neurological imbalance. And you’re giving yourself today the caring and encouragement you should have received as a child, but perhaps didn’t receive in full measure.“

If we recall the results of the ACE study that we talked about in Part One about how adverse experiences in childhood lead to mental and physical illnesses in adulthood, this approach can be seen as offsetting the effects of early childhood abuse and neglect by installing new positive feelings that become part of the structure of the brain. “Consequently, positive feelings have far-reaching benefits including a stronger immune system and a cardiovascular system that is less reactive to stress. They lift your mood; increase optimism, resilience and resourcefulness; and help counteract the effects of painful experiences, including trauma.” Focusing on the positive shifts the balance away from pain and illness in the direction of health and well-being.