Welcome back to the Healing Pain Podcast with Ronald D. Siegel, PsyD
We are talking about how to use mindfulness to treat or alleviate chronic pain. Our expert guest is Dr. Ronald Siegel. He’s an Assistant Professor of Psychology at Harvard Medical School where he has taught for over 35 years. He’s a longtime student of mindfulness meditation and serves on the board of directors and faculty of The Institute for Meditation and Psychotherapy. He teaches internationally about the application of mindfulness practice in psychotherapy and maintains a private clinical practice in Lincoln, Massachusetts. Dr. Siegel is co-editor of the critically acclaimed text, Mindfulness and Psychotherapy, author of a comprehensive guide for general audiences called The Mindfulness Solution: Everyday Practices for Everyday Problems, co-editor of Wisdom and Compassion in Psychotherapy, co-author of the professional guide, Sitting Together: Essential Skills for Mindfulness-Based Psychotherapy and co-author of the sub-treatment guide called Back Sense, which integrates Western and Eastern approaches for the treatment of chronic low back pain.
Dr. Siegel is also co-director of the annual Harvard Medical School Conference on Meditation and Psychotherapy. We will discuss how mindfulness helps chronic pain, Dr. Siegel’s own personal journey of finding mindfulness, as well as overcoming chronic low back pain and how mindfulness fits into clinical practice, whether you are a mental health professional or a physical medicine professional. Dr. Siegel also created a free download to accompany this called How Mindfulness Works, Avoiding Avoidance. This download goes over how mindfulness helps with anxiety, helps with chronic pain, helps with depression as well as how mindfulness is the antidote to avoidance. To access this free gift, all you have to do is text the word, 144Download, to the number 44-222 on your smartphone. If you’re on your computer, you can open up a browser and type in the URL, www.IntegrativePainScienceInstitute.com/144download. I know you’re going to enjoy this as much as I did. We go through a ton of information on mindfulness and how mindfulness works to alleviate chronic pain and the suffering that’s associated with it. Dr. Siegel’s a master at mindfulness and psychotherapy. I learned so much from him, so I recommend that you follow his work and take notes. Let’s begin and let’s meet Dr. Siegel.
Watch the episode here:
How Mindfulness Works For Chronic Pain with Ronald D. Siegel, PsyD
Ron, thanks for joining me.
Thanks so much for having me.
I was excited when you decided to join and talk about mindfulness, specifically for chronic pain. It’s a topic we’ve talked about before, but not one that we’ve really delved into. With some substantial evidence as well as both the psychotherapy perspective as well as more of a contemplative perspective, you’ve been doing this for a long time, over 35 years. You’ve written five books on mindfulness, both for people who are interested in practicing mindfulness, as well as practitioners integrating mindfulness into their practice. Tell me how you first got started in mindfulness.
The way I first got started in mindfulness practice, there’s the old story and then there’s the newer story. I’ll share with you the newest story, which I’m only sharing because times have changed somewhat culturally. I got involved with them as a kid experimenting with psychedelic drugs, encountering certain states of mind, particularly transpersonal states, states of openness, states of access to unconscious materials that were fascinating to me and seemed very important. At the time as a kid, I thought, “Who has a map for these? Who understands these? Who’s explored and written about these?” It turned out that it was folks with deep meditative practices and wisdom, traditions and contemplative practices that knew something about these transpersonal states. They knew something about their contours and how one might live the lives that incorporate them or at least that is aligned with some of the insights that come from them.
The reason why I’m telling that story instead of it was just in the Zeitgeists at the time, which it was when I was growing up because I grew up in the countercultural era, is because now the use of these psychedelic substances is in phase two and phase three FDA approved clinical trials at major medical centers throughout the US and in many studies in Europe. We’re finding that they’re very useful for treating everything from trauma and intractable depression to things like end of life issues. Now that it’s become a little bit more mainstream to talk about the effect of the substances on consciousness, you can know the true story.
We appreciate truth and I’m sure that story was harder to tell maybe in the ‘80s when it wasn’t as widely accepted. There’s more and more research on controlled psychedelics, let’s call them, versus people just experimenting with street drugs on treating different types of psychopathology. I appreciate you bringing it to the forefront. It’s not something we’ve talked about, but I’m curious to know, did you find that mindfulness enhanced those types of experiences? How did you use mindfulness as part of that?
It was more that I discovered certain states of awareness and certain capacities to access emotion using the substances and then thought you don’t have good executive functioning when involved in these substances. One also needs to be able to go to graduate school and know your ZIP code. What are alternate means of pursuing some of these insights that don’t impair executive functioning? It turns out that mindfulness practice is one such means. In fact, that was largely its role. Traditionally, its role was not things like chronic pain treatment. Its role traditionally was to examine how we construct our sense of self and by seeing clearly how we construct our sense of self, we can identify the patterns that create psychological suffering across the board, emotional suffering as well as physical suffering and seeing those mechanisms. How might we free ourselves from them?
The sense of self is interesting. We’ve talked about it a little bit on this more than the context of ACT because ACT talks about self as context or self as process. They have a couple of different terms in ACT. Can you talk to us a little bit about how mindfulness can be used as a tool to increase our awareness?
Even though probably most of your readers are somewhat familiar with it, a lot of people have a little bit of confusion about what we mean when we talk about mindfulness. As I’m using it here, I’m talking about any awareness of present experience with loving acceptance. It means being alert, being in the present moment and having this open attitude of loving acceptance toward whatever is occurring right now. As it turns out, most of what we see when we start doing mindfulness practices, which are activities such as following the breath or walking in and noticing the sensation of the feet touching the ground. When we do these practices that involve stepping out of the thought stream and coming back to moment to moment sensory experience, one of the things that happen is we develop metacognitive awareness. We develop the ability to see thoughts as thoughts rather than as realities that we identify with. A principle found, for example, in most ACT approaches to treatment.
We also start to notice certain phenomena such as every time I resist some experience, whether it be a sensation of pain, a thought, an image, a memory, the very act of constricting and resisting that experience amplifies it. It turns it from being a transient event that arises and passes to being some event that your organism becomes stuck in. Where we get caught in some recursive pattern in which we’re resisting it so much, the very resistance fuels it and then we resist more and we get stuck in that pattern. Mindfulness practices give us insight into those kinds of mechanisms, but they also give us insight into how we construct our sense of self by talking to ourselves all day long. When we practice stepping out of the thought stream a lot, we start to notice that when the thoughts do arise, most of the thoughts are about me and about what I want, what I’m hoping will go well, what I’m hoping won’t go well. Right now thinking, “Am I staying on the theme? Am I remembering what your question is? Is this going to be useful to readers?” This is what’s going on the background even as I’m speaking at this moment.
Mindful awareness is noticing that this is occurring and also noticing that all of this chatter about ourselves is, as the court pointed out years ago, “I think, therefore I am,” how our sense of me is constructed out of all of this talk. It’s constructed out of the way in which we build what we might call a narrative self where I say, “I’m Ron. I’m a father and a psychologist. I treat chronic pain disorders. I’m participating here.” As opposed to a moment to moment experiential self, which is simply noticing my heart rate’s a little bit elevated because I’m doing public speaking. I’m noticing that it’s a little warm in the room now because it happens to be summertime in New England, feeling my feet on the ground, this kind of thing. There are many elements to this. There’s the developing metacognitive awareness. There’s the noticing what we resist persists. There’s this seeing how we’re constructing the sense of self. The more clearly we see this, the main advantage to this is all of the self-esteem preoccupations we have. “How am I doing? What do people think about me? Am I successful or not? Am I loved? Am I popular? Am I pretty? Am I ugly?” All that stuff which preoccupies us and fills a lot of our emotional landscape, that stuff starts to loosen up.
There’s another component to it, which I think we’ll drill into what I’m talking about chronic pain, which is simply practicing being with discomfort moment to moment on a sensory level. Whether that’s an itch or an ache or a feeling of hunger or the feeling of sadness in the heart or the feeling of fear in the chest. Being with the sensations is moment to moment sensations and learning that by doing that and by not fighting them, they arise and pass. This greatly increases both our affect tolerance, our ability to be with emotions, including difficult emotions, as well as our capacity to be with physical pain. When we dig into the physical pain side of this, what I’m going to propose is that mindfulness practices aren’t about reducing physical pain, not as a first-order intervention. They’re about increasing our tolerance for physical pain so that we can break the recursive loops that maintain most physical pain syndromes. Once we’ve broken the loop by no longer getting caught in resistance, then the syndrome has a way of resolving on its own.Mindfulness meditation improves pain, stress, anxiety, depression symptoms, and improves quality of life! Click To Tweet
I want to talk about both the cognitive and affective aspects of pain as well as the more physical pain aspects of chronic pain. The first time you had it, how did you segue from the more mindfulness psychotherapy into helping people with chronic pain?
I did it by getting caught in one of these loops myself. I was a patient years ago. I spent four and a half months flat on my back with a herniated disc diagnosis. In those days, the prevailing opinion on the part of orthopedics and neurosurgeons was if you have a bulging or herniated disc, you need to remain horizontal as much as possible and hope that this heals and wait for three, four months. If it doesn’t, have surgery, which had very iffy statistics and still do. Maybe you’ll get lucky and it will heal. I was following their advice because I was quite frightened of this. Day after day, week after week, I totally wasn’t getting better. I thought, “There must be a more active approach.” I went to see a sports medicine doc and he took one look at my CAT scan. This was before we were using MRIs clinically. There was such an era for younger folks. He said, “If you don’t stay off your feet, you’re going to be begging me for surgery in six months.” I stayed off my feet.
Bad medical advice.
Right, but very much the prevailing advice at the time. I wasn’t getting better. At a certain point, I thought, “I’m a psychologist. I’ve got a pretty sedentary profession.” I began a bizarre parody of the classical psychoanalytic scene. I had folks construct like a platform bed in my clinical office and in my private practice office. I would be lying down while my patients are sitting up wondering about my pathology and my prognosis. This went on for months. I finally got work. A fellow named John who happen to be a social worker said, “You’ve got to talk to Linda.” Linda was another social worker. I knew she ran a residential treatment facility for kids. I thought, “Linda is very nice. She’s a good clinician. She runs a great program. What does she know about chronic back pain that these orthopedists and neurosurgeons at Harvard Medical School don’t know?” He kept pushing me. I called up Linda and I said, “Hi, Linda.” She said, “Hi, Ron. I heard you had a back problem.” I said, “Yes.” She said, “What are you doing?” I said, “I’m lying down. It’s all I ever do.” I was a real peach at the time. She said, “You get up and buy groceries. Your wife will appreciate it.” I thought, “What?”
I’m completely unable to move. I thought this is some feminist cabal. I’m a postmodern guy. I go to the supermarket but it’s like, “No, I can’t do anything. How could I possibly groceries?” She said, “Just do it. Go back to your life.” At that point, I had an appointment scheduled with a well-reputed surgeon because I hadn’t gotten better. It was months into this. I thought, “Before I go for the surgical consult, I’m going to do what Linda suggested. Linda’s rationale for this was saying this is essentially a psychophysiological disorder. These disorders are often created and certainly very often perpetuated by in essence, our fear of the disorder and the behavioral adjustments we make in response to the disorder. If we go back to our lives, the chances of recovery are increased. I thought, “I’ll at least try walking.” At that point in my life, I could walk about a city block and I’d get serious sciatic pain shooting down my leg. I thought, “I’m going to push it a bit.” I walked my city block, right on cue, got the sciatic pain down my leg. I thought, “Courage, Ron. Just try it. Linda seemed convinced. She apparently got out of one of these disorders.” I walked in another city block.
To my utter surprise, in addition to the pain shooting down one leg, I developed pain shooting down the other leg. I thought, “That was great advice.” It was because according to the CAT scan report, the disc was herniated laterally, as they often are. I’m supposed to have pain down one leg, but I wasn’t supposed to have pain down the other leg. The reason I knew this was I read the radiology report pretty much every night before bed. I was obsessed and terrified of this disorder. If I’m having pain down the other leg, what does this mean? My first hypothesis is I’ve shattered my spine entirely and it’s all over. My second thought was, “Could Linda be right? Could it be that the pain is being caused by some mechanism other than the herniation? If I were to understand that, might I get out of this?” I thought, “Go for broke. For the next couple of weeks before you see the surgeon, just treat it like a sack of physiological disorder. Treat it as though your fear of this and your behavioral adjustments and your psychological reactivity to the pain is what’s perpetuating it and see what happens.” Two weeks later, I was done. I was sitting up in my chair seeing patients. I was starting to do yoga again. I was exercising. It was like, “This was all a bad misunderstanding. How could that be?”
A year later, I’m still fine. I started communicating with people who had been writing about this. It was a very small group of people many years ago who were talking about this. They started connecting with physicians in the Boston area who were not so much taking the psychophysiological angle, but they were doing aggressive rehabilitation to get people back into their lives. Together we started developing programs based on this. Mind you, in this entire miraculous story of recovery. I didn’t mention mindfulness. I’d been doing mindfulness practice since I was seventeen. Frankly, when I was in this disorder, I felt so depressed, frustrated and frightened that I’d practice a little bit but it was like, “I’ve got to cure my body.”
Once I got over this thing and once I understood the mechanism of it, at least in my case, I started realizing the principles and practices that come from mindfulness traditions would have been extremely useful had I had them in the right cognitive context. Had I understood the disorder differently and saw that it was my reactivity to my fear that was the engine driving this. I could have used mindfulness practices to see my fear more clearly, to tolerate the pain more readily and to move toward re-engagement in a full life. That’s how I got into treating this and that was 30-odd years ago and I’ve been seeing patients ever since.
It’s a beautiful story, Ron, and I know it’s not beautiful to be in pain. It’s nice to be out of it. It’s a beautiful story because what Linda did for you in the world of pain, there’s not only one thing cognitive that usually helps people with pain. She helped you with reconciling that your scan has little to do with the pain you’re experiencing. Now the pain switched sides and moved around. It was unpredictable. If it was just purely of a musculoskeletal origin, pain is not unpredictable like that. She helped point you toward things that are meaningful to you and valuable like your relationship with your wife and doing activities that support whatever it was your marriage or relationship. Having you do the activity is a good way to alleviate pain. Probably the biggest thing you mentioned, and I want to talk to this in the context of mindfulness, is fear and fear avoidance specifically enough. There’s a lot of research around fear avoidance of pain. Talk to me about avoidance in general as far as human beings and how mindfulness can help alleviate some of that.
My pal, John Briere, who’s a trauma researcher and a clinician at the University Southern California, he likes to say, “The only thing you need to avoid in life is avoidance.” It’s simple. Avoidance is this posture. Another colleague of mine, a fellow named Jud Brewer, who’s doing wonderful research on the neurobiology of mindfulness and its relationship to addictions at Brown these days. Jud boils it down to something very simple. Are you in a posture of constriction or are you in a posture of openness? Every time we move into avoidance, we move into this posture of constriction. If we look at the emotions that are most problematic to us, and even you might join me in this and our readers, take a moment to pantomime fear and fear as quintessential avoidant reaction like, “I’ve got to get out of here.” Just do it. Pantomime it like you were scared for a moment in your body. If you were to do anger, which is another avoidance of sorts because it’s about getting rid of the bad threat. If we pantomime anger, what do we get? What’s happening to our musculature in both of those conditions?
Everything is tensing and constructing.
What we call psychological constriction is the same thing as musculoskeletal or muscular constriction. It is what occurs when we’re angry and when we’re frightened, when we’re saying no to an experience in some way. We call it the fight and flight response. We’re either running or repelling, but they’re both highly avoidant states. The opposite of avoidance is allowing, being with, accepting, feeling. In that state, we don’t have the same levels of muscular tension and we have an additional super important asset, which is we don’t get stuck. Emotional states and pain states get stuck when we fight them. When we don’t fight them, they arise and they pass like all other phenomena. One of the insights that come to mind from this practice is impermanence. Noticing that all phenomenon, constant flux.
The Buddha pointed this out some 2,500 years ago, but you don’t have to be a rocket scientist or a saint to get it now. Just notice, does any experience they have the same? Do any phenomena stay the same? No. The closest thing to things staying the same that we can get is getting stuck in one of these avoidance cycles. The way this plays out quite simply or the most skeletal outline in terms of chronic pain disorders. Let’s take the back pain that I was in. What was happening was I was so terrified of this pain that I was, one, avoiding activity, which would have allowed me to use my musculature normally but even more, I was so tight. I was so scared and I was constricting, trying desperately to get this to stop. As soon as I’m frightened, that’s going to tense muscles. As soon as muscles become tense, there’s going to be pain.
Tense muscles simply hurt after a while. We know this. When these muscles tighten up, we know that if we’ve ever had a Charley horse in our calf, the only difference is when it’s these muscles on our calf, we typically think it’s harmless. It’s okay, it’s just tension. When it’s our back and we live in a society that has an epidemic of chronic back problems, we think it’s something serious. My mom, when I was thirteen, spent practically a year on her back. I remember her using a bedpan. As a thirteen-year-old boy, your mom with a bedpan is not exactly an image that’s easy to reconcile. Her symptom was sciatica, so when I got my sciatic pain, I interpreted it with a level of fear that was probably greater than the average bear I would have had because I had this memory. Others have other associations to back pain from people we’ve seen who have had their lives derailed by this.
When we have the sensation of pain, it brings up all sorts of thoughts about our structural damage and how badly injured we are and how really in danger we are because this can derail our life. Those thoughts lead to more of the fear, leads to more of the tension and you could easily see how this becomes a perpetual loop that we get caught in. It’s exacerbated because we lose strength, endurance and flexibility because usually we stop using our body normally. Our muscles are more vulnerable even though they may have not been when we first got into the cycle. If we can use mindfulness practice to simply observe the fear and observe these frightened thoughts and have an increased tolerance for the pain sensations without being reactive to it. To approach all of this with an attitude of loving acceptance, it’s not easy but that’s what we try to cultivate. You could see how that would interrupt the cycle quite nicely.
Your colleague, Linda, also said something or what she did for you. With regard to chronic pain, ACT talks about rulemaking. The rule you had in your mind at that point was, “If I rest, then my pain will go away, then I can get back to my life.” What Linda helped you with it sounds like one maybe quick phone conversation. Once you return to life, once you get moving again and get back to life, then your pain starts to subside. How do you reconcile that through the lens of a mindfulness contemplative approach?
Let me talk about it in that context but let me talk about in another context for us because you’re raising an interesting and important point. As I’ve encountered them, the majority of pain treatment programs, at least in the United States, have as their metric in their goal, reduction of the sensation of pain. To my mind, that’s problematic because of precisely the mechanism that you just outlined. Linda’s approach was different. Linda’s approach was if you can re-engage fully in your life, you will be less afraid of your pain. You will not be fearful of disability. You will be less inclined to get into one of these fear pain avoidant loops and that will walk you out of it. Where you begin is critically important. Frankly, some of the mindfulness, there’ve been quite a few research studies on the use of mindfulness to work with chronic pain and they show what I would consider modest effectiveness. They work. They’re helpful about at the same level at CBT of various sources.
Most of the psychosocial interventions seem to be on par with one another. What has distressed me as a clinician working in this field for many years is they have very rarely paired with aggressive rehabilitation. They’re very rarely paired with something that says, “No, let’s get you back into your lives.” Once you’re able to see that you can have a full life, even though the pain is there, you will be less frightened of the pain. You will have less impulse to restrict and the thing will resolve by itself, which is the course that I’ve seen the vast majority of my patients follow. The role of mindfulness in this then is to make it so that we’re less frightened of the pain when it arises. It’s best paired with a rehabilitation program. Let’s say I start walking again and I haven’t been walking because I’ve been afraid it’s going to hurt my back or I start lifting things.
A woman who I worked with said, “I started emptying the dishwasher myself instead of having my husband do it because I’m ready to face my fears and get back into life.” When the twinge comes, when the spasm comes, when the fearful thought of, “What if I become incapacitated and can’t work or can’t lift my child?” When those thoughts come, we use mindfulness practice to work with that. We simply feel the sensations of the muscles tightening. We simply notice the catastrophic thoughts arising and passing. We use our mindfulness practice to allow us to tolerate the difficult aspects of resuming a normal and full life. The mindfulness practice supports that. As we get into our life more normally with less fear and constriction, these disorders tend to take care of themselves.
I’m going to flip hats. I’m going to put on my strong clinician hat. There are a couple of things coming to mind as you’re talking that I’m noticing come up for me. One is in the realm of physical therapy as well as some pain psychology. There are pain education approaches that helped people re-conceptualize what pain is. Instead of them thinking that it’s a problem in their body that they’re not damaged, that it’s a problem in the nervous system. There’s great evidence on it very similar to CBT and minimal to moderate effects. When you combine it with other physical rehabilitation, then you see moderate to larger effects.
That approach does leave you at times grappling with changing someone’s thoughts or beliefs. Similar to the fact that traditional CBT, you would take someone’s thoughts in essence and again, help reframe them or restructure them. What are your thoughts on things? I know you’ve studied both. Obviously, you’re a trained psychologist. How does that or does that not fit in with mindfulness? As a psychologist who’s reading this or another mental health professional may say, “I love mindfulness. I recommend mindfulness all the time for my clients, but I have a hard time fitting it into my CBT practice or I have a hard time fitting it into my DBT practice.” What are your responses to those types of questions?
As I understand it, mindfulness is the experience of mindfulness practice on the part of many practitioners that has helped open up what is often called the third wave in behavior therapy. The movement from straight behavioral interventions, whether through classical conditioning and paradigms or changing reinforcement contingencies in an operant paradigm, what we call behavior modification broadly. People think in ways that rats probably don’t. Let’s address cognitions. We have the whole realm of CBT, which as you put quite clearly, is about changing maladaptive, irrational thoughts into adaptive rational ones. There’s this third wave of which ACT is a significant component, which is about, “Can we see thought as thought? Can we notice?” As I understand that, and I’ve run this by several researchers in the field of cognitive science, non-clinicians, as I read their cognitive science literature, it’s two big findings that have come out of the last fifteen years.
The first is we are holy and hopelessly irrational in our thinking. Our thinking is driven by our feelings. All we need to do is glance at the political arena to see this. Whatever side of the divide any of us might be on, think of the way you view the people on the other side of the divide. Notice the way all of their thoughts are shaped by their feelings. You can see it quite clearly when looking at the other people, which ties into the second major finding in cognitive science. We all believe ourselves to be rational actors. We don’t believe that our feelings are influenced by our emotions, even though all the data says that they are. Putting these together, thought becomes extremely unreliable, particularly in contexts that are emotionally charged. When we’re in pain, it is highly emotionally charged.
Our belief that we’re damaged, our belief about what’s going to happen becomes quite powerful. There are different ways to work with that. You could work with it with traditional CBT and argue against the premise that you’re damaged. I think that plays a role in treatment. Even though I’m not big at arguing with patients in general in my life, I will argue with folks. I will point out the fallacies in some of their logic about their pain disorders. I’ve had people literally tell me that their back went down and I asked them what’s their model, what’s their understanding of what happened. “It was a week ago I drove over a pothole.” The person had a Mercury, one of these boats, like all the American cars. You drove over a pothole a week ago on your Mercury and that’s what caused it. I must avoid potholes. I’ll do traditional CBT and take on that to examine how plausible is that really? More often from a mindfulness-oriented perspective, the task is to notice the connection between affect and thinking.
Notice the way this changes. We see this quite clearly in other disorders like depression. If you talk to somebody who’s not always deeply sunk in depression but struggles with it, you ask them how do they view the world when they’re feeling depressed? They’ll tell you it’s hopeless, it’s negative, all of this. You say, “How did you view it a couple of weeks ago when you weren’t so depressed?” “I was fooling myself back then. My more optimistic vision was diluted back then. Now I see reality.” You flip that and you talk to somebody who’s come out of depression and they’ll say, “Back then when I was depressed, that was my depression talking. That’s why I saw it so negatively. Now I see things more clearly.” Helping people to see that the way we construct our universe is so deeply dependent on our emotional state at the time. That becomes very powerful for loosening this up. There’s a mindfulness-oriented approach, which is a more contextual approach. It is much more about developing metacognitive awareness. There is a role for sometimes challenging people’s belief systems, particularly when they have belief systems that lead to, “I mustn’t lift, bend, participate in my life.” Listening to those beliefs is such a powerful factor in maintaining the disorder that it’s worth challenging them directly.
I love the way you folded all that together. Often, it’s easy for everybody to pick a camp, “I’m in the CBD camp. I’m in the mindfulness camp, I’m in the ACT camp.” When you’re able to fold, and very few practitioners can do what you just did, and hurdle all different aspects and know when to apply it. I appreciate that. I think it shows your skill and your years of expertise because some of these things can be difficult to start to implement with people if you’re holding onto that one approach.
Wilhelm Reich, who you know was in a sense the original mind-body therapist who’s Freud’s follower, who spoke about character armor. Everything came out of Reich’s work, he arguably got into some pretty crazy territory at the end with his Orgone box. Before going off the deep end in that way, he said, and I thought it was brilliant, “I’ve never come across a psychological model that wasn’t true to some degree and wasn’t useful to some degree in giving us some explanatory value.” That’s my sense we’re all looking at this amazingly multi-barrier complex being a bigger human being. There are so many different ways to story this, all of which are somewhat useful and all of which give us a slightly different perspective.
There is a myriad of different ways to help people with their mind and of course their body as well because they are highly interconnected. I think mindfulness is important for practitioners who treat pain, as well as other chronic health conditions. How can a practitioner who trains in mindfulness improve themselves as a practitioner and in turn help their outcomes with their patients?
Mindfulness practice is one of those things. I sometimes joke with audiences, “What do the following three things have in common: swimming, making love and eating a gourmet meal?” What would you say?
They’re all pleasurable.
It probably depends with whom you make love potentially. Anything else come to mind?
Not particularly, no.
My thought from my peculiar mind is those are three things in which doing them is very different from talking about them. Mindfulness practice is very much in that camp. There are people who say, “I want to teach my patients mindfulness practice.” It’s a little bit like saying, “I want to be a cello teacher.” “Do you play the cello?” “No, I don’t.” “Have you played the cello?” “No, I never have but I want to teach it.” It’s very hard to do it. You can read the scripts, but as soon as people start having interesting and challenging experiences, which means very early on in the process of teaching this, you have to have personally experienced a lot of those challenges yourself, struggled with them some, found ways through some of them. You have to have lived it to teach it. The first place to begin as I see it, is pick up the practices. Try this yourself. These practices were not originally designed to treat particular disorders that show up in the DSM. They were designed to treat the fact that we evolved brains and minds. They didn’t talk about in terms of brains 2,500 years ago. They talked in terms of minds, but we evolve minds that inherently bring a tremendous amount of psychological distress.
Our minds are constantly complaining. They’re constantly wanting things to be other than as they are. They’re constantly self-preoccupied with how am I doing. Mine’s doing it right now and I’ve been doing this stuff for years. They have these propensities that lead to psychological suffering. These practices are designed to help eliminate those and give us pathways through. They’re of use to us even if we’re not treating patients but they’re particularly of use to us as clinicians if we want to share these practices with folks. That’s where it begins. The second thing which is quite important is to understand that anything powerful enough to be useful is powerful enough to make trouble. Fire being the most commonly used example of this principle. It’s great when it’s contained in an internal combustion engine or a stove, not so good when it gets out into the living room.
What we know from mindfulness practices is that they’re like this. They are quite powerful change agents. They can shift how we understand ourselves. They can soften the repression barrier and give us access to all sorts of emotions that where we otherwise weren’t in contact with. Let’s start that because that’s another important function of them. These are the chronic pain we can come back to. They help us to be present. They help us to be more related, all sorts of positive things. What we’re finding, and I credit my friend and colleague, Willoughby B. Britton at Brown University, has done a ten-year study on the adverse effects of mindfulness practices.
She’s a serious mindfulness student. She’s not a hostile person who thinks what we should be doing is all watching television all the time. She’s been cataloging the things that go wrong and people get stuck in states of dissociation. They encounter states of high anxiety. They encounter all sorts of difficulties. The second thing is to be aware of whom these practices are most suited when. To have something of a differentiated clinical understanding of when they would be useful and when they would not be useful so that we don’t inadvertently help people connect with thoughts, feelings, experiences that they’re not equipped to work with right now and re-traumatize people and overwhelm them. The two first orders of business are, do the practice ourselves and learn about indications and contraindications and then we move into their various applications.
You had a star there. Do you want to get to that star?
Let me mention that. To step back and look at an approach to chronic pain and we package this into something we call the Back Sense program and wrote a book several years ago on this. At that time, the research was based on like a little bit novel. It wasn’t the mainstream. Now it’s all become quite mainstream. It’s been quite heartening to see this. We had four steps to this. The first was the obvious one. You want to rule out dangerous, treatable medical conditions. Some people have back pain because they’ve got a kidney infection. Some people have cancer of the spine. We don’t want to start treating those things like psychophysiological disorders. We want to rule out the dangerous stuff. The second part is the cognitive restructuring that you’ve spoken of. How can we come to understand this differently? If I can answer one of your questions a little bit more thoroughly.
Mindfulness practice has also helped with cognitive restructuring because as we develop metacognitive awareness and see thoughts arising and passing, we become less attached to each individual thought. We become a little bit more flexible and a little bit better able to entertain new thoughts, novel ways of looking at situations, to think outside the box. The more we practice mindfulness, the better for that. The third component that I haven’t addressed so far is sometimes people will get back into their lives. They will develop the courage to start moving normally and their pain persists. One hypothesis is, “There is a structural issue going on that needs to be addressed or perhaps can’t be addressed and the person has to live with it. Another hypothesis, which very often seems to be operative in my clinical experience, is there’s some emotional state, some emotions that are difficult to integrate, that are difficult to allow into awareness. What’s happening is the person is chronically tensing up, is chronically in a fight or flight state, not fearing the tigers out there or even perhaps at this point fearing their pain so much because they worked this through.
They’re afraid of the sadness or they’re afraid of the anger or they’re afraid of some sexual feeling, which in their particular cultural or family context is unacceptable. For me, having grown up as a guy, I learned not to cry publicly pretty early on by seeing what happened to other guys who did that. I learned not to cry it all shortly after that. When I’m generally anxious, stressed and tight, if I’m a bit mindful and I turned inward and I asked myself the question, “What feeling might be under this?” There’s almost always a wave of sadness. There’s almost always some unintegrated sense of loss, vulnerability or tenderness. If I can connect with that, very often the whole fight or flight stress response lets go. I’ll share one of the stories on that. I know I’m rolling a little bit. I had an incident of chronic back pain on a family vacation in Turkey and it was our last vacation, I have twin daughters before they were going to go off to college. It’s a point in time in our lives in the sense that we were going to face the empty nest.
I love my kids. It was like, “What’s that going to be like? Will I miss them?” I’m climbing out of the Bosporus in Turkey and suddenly my back goes out and it’s horrible. It’s one of these can’t tie my shoelaces back episodes. I’ve been doing this work for quite a long time. I remember, I forget the guy’s name, but the orthopedics who used to edit spine, who was at Dartmouth-Hitchcock. His wife’s back had gone out the same way, like couldn’t tie your shoelace and she said, “Honey, what should I do?” He said, “You should go for a run.” She said, “Are you nuts? I can’t go for run. I can’t tie my shoelaces.” “Just go for a run.” I was moved by that. This is along the same lines we’ve been talking and I thought, “I’m in Turkey. I can’t tie my shoelace, but I jog for exercise. I’m going for a run.” I went for a run, but I did it. I kept doing it. I flew back home and kept active. About a week later, it’s hanging on for a long time. I’m thinking, “This is weird,” because I am fully back to activity, but it’s still hanging on. I didn’t think there was something structural. I just climbed over some rocks in the Bosporus.
I was in the basement and doing laundry, a further example of living your life normally despite this thing. Suddenly this wave of sadness comes up about my kids leaving home like, “They’ve grown up. I can’t believe it. Everything does change. I’m going to miss them so much.” This powerful wave of sadness. There was a release associated with that wave of sadness. By that evening, it was gone. I thought, “What an important lesson here.” Having learned not to cry in junior high, carrying that through as a life character posture. Here, sometimes you can get over the fear of movement and get over all that and you have to address these other emotional things. There are many pathways to doing that. Mindfulness practice isn’t the only one. Mindfulness practice is one way to tune in, notice what emotions are happening of felt sense in the body and open to them. That too becomes a very important component of this treatment process.
When I first started doing loving-kindness practices, I was amazed at how much anger would come up in these practices when I thought I would be sitting down and feeling good and wishing everyone in loving this and kindness. I was like, “Why is there anger, frustration and rage and all these other things that are in there that I didn’t know were in there?” When you sit with yourself for a certain period of time and you’re guided through those practices, other things come up and you start to see the different colors of those rainbows that you hope are going to be all loving. They’re not always like that. Once you get beyond that or you just learn to be with that and notice it, it does get better. Things do start to change from that.
Sometimes these heart-centered practices are very powerful in this way. A good friend of mine that we’ve done a lot of writing and work together. Chris Germer, who’s with Kristin Neff, developed the Mindful Self-Compassion program. He coined this term backdraft. He didn’t coin, he borrowed it from firefighters who when they enter a room, they feel the door first before opening. Before entering the room, they feel the door to see if it’s hot because if it’s hot, there are smoldering embers in there. You open the door, the oxygen comes in and you have this conflagration. That’s exactly how we operate. You see the little kid who skinned his or her knee frozen on the ground until a loving adult comes up and gives them a hug and that’s like it’s all out. We’re all that way. When we do these loving-kindness practices, whether it be, “Wah or argh or ow,” or whatever it might be that we’ve locked away, it comes to the floor. I’d argue that is extremely important for treating these chronic pain disorders. That’s what allows us not to chronically hold our muscles always in this state of contraction because we’re trying to block out the tigers within.
When people tell me, “I love loving-kindness practice. I do it all the time. I feel great 100% of the time,” I’m like, “Something’s wrong.” You’re not doing it right or you’re not approaching it with what you think it should be doing. It’s not working in that sense. You mentioned the book, Back Sense, which of course is a book that talks about mindfulness from a chronic pain perspective with regards to back pain. You also have a course coming up with Praxis in September. If people want to check that out, you can go to www.PraxisCET.com and the course is called Clinical Applications of Mindfulness and Compassion, which fits perfectly with a lot of the things we’ve talked about. Can you tell us what the aim of that course is, what practitioners can learn from that?
The aim of that course is to take this integration of mindfulness practices to talk about what I think is the growth edge of this. When we first wrote back in 2005, we wrote Mindfulness and Psychotherapy. It was one of the early texts about integrating mindfulness practices into psychotherapy. It was all quite novel back then. Years later, a lot of clinicians are familiar with this but there are some implications of these practices that I’ve alluded to in our talk here that have tremendous therapeutic potential. Like the way in which they can get us to reconsider our whole sense of self and what is all this self-preoccupation about? How do I construct it and how do I to put it in an ACT framework, limit my psychological flexibility by believing that I am this self and not that self? In many ways, we are made up of a constantly changing kaleidoscope of selves and how mindfulness practice can help eliminate that.
The course also delves in some depth to how do you tailor these practices to meet the different needs of different clients or patients because these are not one-size-fits-all practices. We’ve already mentioned two in the course of our discussion. You’ve emphasized the loving-kindness practices and when I was talking more about mindfulness is awareness of present experience with acceptance. It’s more about the awareness of wisdom practices. These practices, in many of the traditions from which they derive, are designed to create wisdom, clear seeing, clear cognition and compassion and open, vulnerable, quivering, loving heart. How to use these practices to develop both for different people who may be stuck in different ways as well as people from different cultural backgrounds in the light. The course delves in a lot to what are the basic mechanisms of action? We’ve touched here on a few of the mechanisms of action. These are the chronic pain, but there are similar mechanisms of action for anxiety, for depression, for relational difficulties and the likes. The course tries to take what’s developed over many years and talk about what at least I see as some of the growth edges to the field.
You can learn all about Ron by going to his website directly, which is Mindfulness-Solution.com. Ron, it’s been great having you. Let us know what you’re up to in the future because we’d love to have you back on, talk about mindfulness and chronic pain, all the different things you have to talk about. It’s been a pleasure working with you.
Thanks so much and thanks for your thoughtful questions. It’s so clear that you’ve been doing this work yourself, in which you ask your questions and the perspectives you have. I appreciate that. Thank you so much for having me.
Thank you. Make sure to share this with your friends and family on Facebook, Twitter, LinkedIn or drop it in a Facebook group where there are people who are interested in mindfulness and CBT, pain education and chronic pain. They’ll definitely get something from this and all around, it’s great resources.
- Mindfulness and Psychotherapy
- The Mindfulness Solution: Everyday Practices for Everyday Problems
- Wisdom and Compassion in Psychotherapy
- Sitting Together: Essential Skills for Mindfulness-Based Psychotherapy
- Back Sense
- How Mindfulness Works, Avoiding Avoidance
- Mindful Self-Compassion program
- Clinical Applications of Mindfulness and Compassion
- Ronald Siegel on Twitter
- Ronald Siegel on Facebook
About Dr. Ronald D. Siegel, PsyD
Dr. Ronald D. Siegel is an Assistant Professor of Psychology, part-time, at Harvard Medical School, where he has taught for over 35 years. He is a long-time student of mindfulness meditation and serves on the Board of Directors and faculty of the Institute for Meditation and Psychotherapy. He teaches internationally about the application of mindfulness practice in psychotherapy and other fields and maintains a private clinical practice in Lincoln, Massachusetts.
Dr. Siegel is co-editor of the critically acclaimed text, Mindfulness, and Psychotherapy, 2nd Edition; author of a comprehensive guide for general audiences, The Mindfulness Solution: Everyday Practices for Everyday Problems; coeditor of Wisdom and Compassion in Psychotherapy; coauthor of the professional guide Sitting Together: Essential Skills for Mindfulness-Based Psychotherapy; coauthor of the self-treatment guide Back Sense, which integrates Western and Eastern approaches for treating chronic back pain; and professor for The Science of Mindfulness: A Research-Based Path to Well-Being produced by The Great Courses.
He is also a regular contributor to other professional publications and is co-director of the annual Harvard Medical School Conference on Meditation and Psychotherapy.
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