RELAXATION AND CHRONIC PAIN
Richard W. Hanson, Ph.D.
Returning to the A-B-C-D model discussed earlier, one important aspect of self-management is learning how to reduce the distressing feelings which can arise in response to chronic pain and stress. This refers to doing something about the "C" component in the A-B-C-D model. Examples of these distressing feelings include frustration, anger, resentment, irritability, sadness, discouragement, guilt, anxiety, worry, fear, and general unhappiness. All of these distressing feelings compound the problem of chronic pain by adding to one's general suffering and misery.
One set of very useful tools to increase your ability to self-manage both chronic pain and the distressing feelings arising from stress is relaxation. Three major types of relaxation can be distinguished: Coping relaxation, time-out relaxation, and relaxing activities.
Coping Relaxation
This type of relaxation is aimed at helping you to cope more effectively with stressful situations, emotional upsets, and intense pain episodes. It can be used anywhere and at any time that you experience physical or emotional distress. It is accomplished by using a simple, but powerful technique called the SIGNAL BREATH.
How to do the Signal Breath
The signal breath is aimed at giving you an immediate experience of relaxation. It is accomplished by creating a slight increase in tension (using your breath), and then letting the tension go (by breathing out).
1. Take in a deep breath and hold it in for a few moments. If a deep inhalation is painful for you, modify it so it is not painful. Also, don't hold it too long. About 3 or 4 seconds is usually long enough.
2. Exhale slowly while at the same time saying to yourself mentally calming words such as "relax," "let go," "easy does it," or any other words that suggest letting go of tension.
3. Also, while you are exhaling, try to let your jaws, shoulders, and arms go loose and limp.
What to Ask Yourself Immediately After Doing the Signal Breath
Immediately after using the signal breath (or series of signal breaths), you should pause briefly to reflect on the situation (i.e., Stop and Think). This may involve asking yourself some important questions. For example, if you are in the middle of a stressful situation and are emotional upset, you can ask yourself:
1. What emotions am I feeling right now?If you are in the middle of a chronic pain flare-up, you can ask yourself:2. What is it about this situation that has triggered these upset feelings?
3. Am I seeing this situation clearly or am I distorting it?
4. What is the smartest and wisest thing that I can do right now to manage this situation? Notice, the question should not be, "What do I feel like doing?" What you feel like doing may get you into more trouble.
5. Can I do anything right now to constructively change the stressful situation, or do I need to regroup emotionally and deal with it at another time after I have had a chance to think it through?
1. Can I identify the immediate cause or trigger for this intense pain? (e.g., Did I overdo it physically?)2. Is there anything I can learn from this pain flare-up?
3. What constructive actions (physical and/or mental) can I take right now that will help me to decrease the pain intensity, or at least get through this temporary episode until it eases up?
Whenever you link the signal breath to this "stop and think" process, you are actually increasing your awareness of the situation in a present-centered, here-and-now manner. The signal breath is not meant to directly solve the problem, whether it be emotional distress or intense pain. Rather, you can use the breath to bring wise attention to the situation you are experiencing. With wise attention you are able to see the situation and your reactions to it from a center of calmness and inner stability. Rather than simply reacting to stressful situations and pain in an automatic manner, the signal breath is aimed at helping you to think more clearly. This will enable you to respond to the situation more wisely and effectively.
Your ability to do this form of coping relaxation (signal breath) and make effective use of it, will increase significantly to the extent that you also learn and regularly practice time-out relaxation.
Time-Out Relaxation
This type of relaxation requires you to take time out from your regular activities and spend time (e.g., 5 to 30 minutes) doing a special relaxation exercise or meditation. It requires that you first find a quiet place where you won't be disturbed so you can devote your full attention to relaxing your mind and body as deeply as possible. Once you find a quiet place, it is important to get your body into a relaxed and comfortable position that will not result in physical strain. Time-out relaxation then involves directing your mind in a passive and non-effortful manner to particular objects, physical or mental, which are conducive to deep relaxation. Physical objects of relaxation may involve focusing on a visual object (e.g., a pretty picture or photograph, a flower, a burning candle, or even just a spot on the wall) or sounds (e.g., the sound of ocean waves, gentle rain, wind chimes, relaxing music, etc.). Mental objects of relaxation include particular thoughts, ideas, suggestions, and mental images that you find relaxing.
Examples of special time out relaxation procedures used in our program include focused breathing awareness, progressive muscle relaxation, passive body scan, relaxing mental imagery, environmental focus (sounds or visual objects), and self-hypnosis exercises. Mindfulness meditation is another useful and potentially powerful technique aimed at increasing your awareness of the present moment. This method involves being fully aware of whatever sensations or thoughts that pass through your conscious mind without trying to judge them or resist them in any way.
Benefits of Time-Out Relaxation
Time-out relaxation can help you to cope with chronic pain in several ways:
1. Relaxing tense muscles. Muscle tension resulting from the pain itself or from emotional stress often increases painful sensations. Therefore, relaxation reduces the amount of pain that is directly caused by tense muscles.
2. Attention diversion relaxation exercises require you to direct your attention to pleasant sensations, thoughts and images. Although you still may feel the pain to some extent, you cannot be fully attentive to your pain and at the same time direct your attention to relaxing thoughts and sensations. Thus, by occupying your attention with something else, relaxation reduces the amount of pain you experience.
3. Increased awareness of tension. Many individuals are tense without being aware of it. Also some people may think they are relaxed when they actually are not. By practicing time out relaxation and experiencing what it feels like to really let go and become deeply relaxed you are also learning to become more aware of your own subtle signs of physical and mental tension. By becoming more aware of tension throughout the day you can learn to use those signs of tension as cues or reminders to use coping relaxation.
4. Help with sleep problems. Many people with chronic pain have difficulties with sleep. Consequently, you may find it harder to cope with pain when you are tired. Time-out relaxation can help you by making it easier to fall asleep or by serving as a restful substitute for sleep.
5. Gain a new perspective on pain. At a deeper level, time-out relaxation in the form of mindfulness meditation, can help you understand and relate to your pain in a different way. Rather than automatically fighting and reacting against pain in a manner that increases tension, emotional distress and suffering, you can actually learn to work with the pain. While most of you would prefer to ignore or distract yourself from pain, you also know that there are times when this does not work. From a center of calmness and inner stability which comes from mindfulness meditation techniques (such as the passive body scan), you can observe the ebb and flow of physical/sensory messages passing through your mind/brain system. These sensory messages may or may not be labeled as pain, and they may or may not convey useful information from your body. As you learn to watch these physical sensations, as well as your thoughts about these sensations, in a more calm and non-reactive manner, you can understand and respond to them in a more detached and appropriate manner. As discussed in Dr. Kabat-Zinn's book on mindfulness meditation (see list of recommended readings), "your pain is not you." Rather than completely identifying yourself with chronic pain and disability, you can see yourself as a whole person who also happens to have a chronic pain condition. Rather than allowing that condition to dominate your life, you are learning to handle and respond to it in a wise and intelligent manner.
Importance of Regular Practice
In order to truly benefit from time-out relaxation, you must do it regularly. Deep relaxation is a skill, and like any other skill, it has to be learned. For some people, it comes easily. For others, it takes longer and more practice. It is important that you be patient with yourself and not always expect immediate, significant results. Paradoxically, you will find that the less goal-oriented you are in your approach to time-out relaxation, the more you will benefit. In other words, just start doing it for it's own sake rather than for expected results. It is easiest to do time-out relaxation initially under more ideal circumstances. Thus, you should practice in a quiet environment and at times when you are experiencing less pain. Most people find it difficult to concentrate on relaxation when they are tired, tense, emotionally upset or are experiencing intense pain. Later, as you become more skilled at relaxation and meditation, you may be able to apply it to more difficult times.
A Beginning Relaxation Exercise: Focused Breathing Awareness
This breathing meditation exercise can be used for at least two reasons. First, it can be used to help bring about a state of deep mental and physical relaxation. Second, it can be used to train your mind to focus awareness on a simple object or process without a great deal of effort in concentration. Both reasons make this exercise very useful as a simple pain management strategy. That is, when you are deeply relaxed and focused on your breathing, you cannot at the same time be fully aware of and responsive to your pain and discomfort. Later, after you master the basic exercise you can introduce modifications which will make it an even more powerful tool in controlling your pain.
Following are instructions for beginning your practice:
Although this exercise is simple to perform, it is difficult to do in a perfectly correct manner. Doing it correctly means that all of your awareness is focused on your breathing. This may require considerable practice. When you first begin to practice it is likely that your mind will become distracted from time to time away from your breathing. Distractions may come from the outside environment (e.g., noises) or from your inside (e.g., distracting thoughts or distracting physical sensations). When you become aware of the fact that you have been distracted, just try to refocus your attention on to your breathing. Each time a mental or physical distraction occurs, keep refocusing your mind on your breathing. Do not try to force distractions from your mind. It won't work. Also, it is unreasonable to expect that when you first begin you will be able to totally eliminate awareness of pain from your mind. This requires much practice. In fact, the only way you can expect significant benefits is to practice this exercise at least two times each day. You may also notice changes in your breathing. As you practice the exercise, your breathing should automatically become slower, deeper, and more regular.
Once you learn the basic procedure you can make some modifications and apply it during more difficult situations (e.g., during times of increased pain or emotional stress). Some like to modify the basic focused breathing procedure by adding mental imagery. For example, you may imagine that each time you exhale, you are actually sending or blowing healthy/purifying/healing air into and through the painful areas of your body. Another example is to imagine that each time you inhale, you are gathering together all of the pain sensations, and then when you exhale you are blowing them all out of your body.
Additional Comments about Time-Out Relaxation
In our program, we make available a number of audio cassette tapes containing various relaxation, guided imagery, and self-hypnosis procedures. While tapes can be useful, it is also a good idea to become proficient at using a time-out relaxation technique entirely on your own. That way, you won't have to depend on having tape equipment available in order to use this technique.
It is important to keep in mind that there is no one single right way or best way to do time-out relaxation. In our program, we expose you to a number of techniques which you can try out and experiment with. What ultimately matters is what works best for you. Some people like approaches which focus on the body (e.g., focused breathing, passive body scan), whereas others do better with mental imagery. We use some guided relaxation imagery exercises with titles such as "Relaxing Nature Walk," "Meadow and Stream," and "Mountain Cabin Scene." However, we encourage you to develop your own relaxation imagery. Think of a specific place or scene from your memory that you find especially relaxing. Close your eyes and try to visualize it as best as you can. Imagine that you are actually in this place at the present moment. Once you develop this scene in your mind's eye, you can use it as your own special personalized place of relaxation and comfort. You can use it as a place that you can retreat to in your mind whenever you need to.
Relaxing Activities
It is also important to find healthy activities that you find relaxing. Although relaxing activities do not allow you to become as deeply relaxed as time out relaxation, they are still valuable in many ways. Ideally you should have a variety of relaxing activities. They should include activities that you can do indoors or out-of-doors, alone or with other people, and those which allow your body to be in different positions (to avoid excessive strain).
What makes a particular activity relaxing depends primarily on your attitudes toward the activity. For example, some enjoy reading while others would much rather be doing something with their hands such as making things or fixing things. Some people enjoy fishing and find it very relaxing whether or not they catch anything. Others find fishing boring or become easily frustrated if the fish aren't biting.
Some activities are relaxing in themselves. Other activities, such as those which involve physical exertion, may lead to feelings of relaxation after the activity is finished. Make sure that whenever you do physical activity associated with relaxation that you are not defeating yourself by exceeding your physical limits.
Benefits of Relaxing Activities
Attention Diversion - Relaxing activities are another way that you can direct your attention away from pain. When your pain is mild or moderate, you may be able to completely "forget" your pain.
Increase enjoyment and positive well being - A balanced life requires that we spend a reasonable amount of time doing things that are fun and enjoyable. This counters some of the negative attitudes that often accompany chronic pain.
Decrease feelings of depression - Depression and chronic pain often go hand in hand. Unfortunately depression usually leads to inactivity, withdrawal and increased preoccupation with pain and misery. Relaxing activities can help to counter many negative characteristics of depression.
Time out from frustration, tension and worry - Along with time out relaxation, relaxing activities can give you a temporary break from these negative feelings.
Concluding Comments
Each of these three types of relaxation are important in the overall self-management of your chronic pain. Ideally, they should all be regarded as life long habits that are useful in maintaining your physical, mental and emotional well-being. It is also important that they be integrated into a larger life routine that involves meaningful activity. After all, it would not make sense to spend the vast majority of your time each day relaxing. In fact, some chronic pain patients spend far too much of their time sitting around relaxing and doing very little. The key here achieving a healthy balance between productive activity and relaxation.
Self-Hypnosis
Self-hypnosis is a related pain self-management tool that typically makes use of time-out relaxation procedures. Unfortunately, there are a number of myths and misconceptions surrounding the concept of hypnosis. It often conjures up mysterious images of "mind control" by another person, or becoming like a mindless robot. Some people automatically resist the idea of being "controlled" by another person and proudly proclaim that they cannot be hypnotized.
According to our view, all hypnosis is ultimately self-hypnosis. No one can make you do anything you don't want to do. In fact, we believe that nearly everyone is capable of hypnosis; however, some are better at it than others. Some have the misconception that people who are the most hypnotizable are weak willed, gullible, suggestible, and easily manipulated. Actually, people who are the most hypnotizable tend to be those who are more creative and imaginative.
Our definition of hypnosis is as follows:
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SELF-HYPNOSIS IS THE PROCESS OF EXPERIENCING CERTAIN THOUGHTS, IDEAS, AND IMAGES AS THOUGH THEY ARE REAL |
According to this definition, self-hypnosis involves a temporary suspension of ordinary reality, and a willingness to experience other thoughts, ideas, and images. Based on this definition, nearly all of us experience hypnosis from time to time, even though we don't call it hypnosis. Becoming absorbed in a good movie or book can involve a hypnosis-like state of awareness.
In pain management, hypnosis is typically used in two ways. First of all, it is used to create an immediate experience of increased comfort and decreased pain. According to the first use, the effects generally last as long as you are in the state of hypnosis. Second, self-hypnosis is used as a tool for modifying your thoughts and behaviors. This second use is accomplished through the use of what are called "post-hypnotic suggestions." In this case, you are trying to "re-program" yourself and change certain bad habits of thinking and acting.
We typically identify three phases in the medical use of self-hypnosis:
1. Initial hypnotic induction. This typically involves attention narrowing and relaxation. Focusing on a spot on the wall or ceiling is one common technique.Types of Working Suggestions for Self-Hypnosis and Chronic Pain2. Deepening. This is a mental device used to deepen the state of self-hypnosis. A common deepening technique is a numerical countdown accompanied by the self-suggestion that, with each number you count down, the deeper you sink into relaxation and self-hypnosis. This technique can be combined with mental imagery such as imagining going down on an escalator, elevator, or spiral staircase.
3. Working suggestions. This involves using those suggestions (i.e., ideas and images) that are aimed at accomplishing your particular goals. The suggestions can by delivered by another person or by yourself.
Those with chronic pain conditions can use any number of suggestions while in a state of self-hypnosis. Following are just a few general examples:
1. Suggestions of increased relaxation and comfort. In this case, self-hypnosis is essentially a form of time-out relaxation and makes use of relaxing self-talk and relaxing mental images.2. Images which alter the sensory aspects of pain. Depending upon the specific quality and location of your pain sensations, you can use specific images which alters your pain experience. Specific mental images can be used to dull sharp pain, cool burning pain, loosen tight areas, numb the pain, move the pain to other locations in the body, shrink painful areas, drain the pain from your body, project the pain to something outside of your body, etc.
3. Suggestions aimed at increasing confidence in your ability to cope with the pain. Through use of positive self-talk while in a state of self-hypnosis you can try to reprogram some of your negative attitudes and expectations regarding the way you cope with your pain.
4. Suggestions aimed at altering bad habits which interfere with your ability to effectively self-manage the pain. You may want to use self-hypnosis to work on changing specific habits which cause you difficulty. For example, you may want to alter your physical activity patterns, maintain an exercise program, lose weight, stop smoking, reduce or eliminate your use of alcohol, communicate more effectively with your family and friends, change the way you deal with interpersonal conflicts, behave more assertively, change rigid and inflexible rules, etc.
Self-hypnosis Training Procedure
In our program, we use a simple self-hypnosis training procedure which begins with the arm levitation technique. This technique involves developing sensations of lightness and floating in one of the arms. Next we do a deepening countdown combined with a relaxing body scan. The procedure concludes with relaxation mental imagery (i.e., imagining yourself at a warm, pleasant, relaxing beach). Once you master the basics, you can add your own working suggestions.