"The critical thing is to face our fears—to stay with an emotion we're having difficulty with, or to stay with the physical pain—and discover: everything's impermanent; this doesn't last forever.”
A Conversation with Dr. Ron D. Siegel, PsyD | Driftwood Interviews
Breaking the Pain-Fear-Avoidance Cycle
Pain has an element of blank;
It cannot recollect
When it began, or if there were
A day when it was not.
The onset of chronic pain can be, in the words of one Driftwood alumnus, "soul-crushing."
Pain makes the sufferer's world smaller. It intrudes on relationships, from the most casual to the most intimate. And when a doctor tells a patient that the pain is unlikely to subside—or can be managed only with drugs that cloud the mind—one natural reaction is despair.
All of these are reasons why people living with chronic pain are at a particular risk of retreating into addiction.
"Many pain treatment programs," according to Dr. Ron Siegel, "take the attitude: 'let's first try to resolve your pain—including, historically, with the use of opiates. Once you feel better, we can work on rehabilitation, can make you physically stronger, can help you engage more fully in your life.' Meanwhile, the research is pretty overwhelming: approaching chronic pain from this angle doesn't work very well."
Dr. Siegel—currently Assistant Professor of Psychology at Harvard Medical School, and a board and faculty member at the Institute for Meditation and Psychotherapy—advocates for a different strategy, one that "draws upon cognitive, psychodynamic, and behavioral techniques along with mindfulness-based exercises, combined with everything we know about aggressive rehabilitation."
"Almost everybody who's caught in chronic pain syndromes," he says, "has fallen into some degree of what we call kinesiophobia: the fear of movement. Whether it's because of medical advice, or because they've noticed that certain activities seem to hurt, they start avoiding activity in the hopes of feeling better."
Sedentariness causes deterioration. As Driftwood Wellness Director Connie Cole put it last month: "If you're not moving every day, you're degenerating."
Inactivity "makes people anxious about using their bodies normally," Dr. Siegel says. "Pain sensations," in turn, "are amplified by fear," creating a kind of feedback loop.
"If you put somebody's hand in ice water, and you tell them that they'll have to keep it there for thirty seconds, and you ask them, after fifteen seconds, to rate their pain, they'll say: 'It's not too bad.'" When a person is instead told that their hand must stay in the water for ten minutes, "they'll tell you after fifteen seconds: 'it's freezing! This already hurts."
To find lasting relief from isolating, debilitating pain, people must refuse to be governed by fear.
Dr. Siegel is the author of several acclaimed books—some for lay readers, others for professionals—on mindfulness, psychotherapy, and mind-body treatment. Since late 2019, he has consulted periodically with Driftwood Recovery's clinicians, helping them create individualized programs of recovery for people with co-occurring pain and substance abuse disorders.
"On a case-by-case basis," he says, "we consider the factors and forces that are creating the chronic pain for an individual. We pay close attention to the individual's personal history, family background, psychological dynamics, cultural background and physical condition: any challenges that might relate to the chronic pain, or to possible pathways out."
Those pathways typically begin with a concept familiar to anyone who has spent time at Driftwood: courageous surrender.
"Pain times resistance equals suffering," Dr. Siegel says. "This turns out to be the case across the board: not just with pain disorders, but with virtually all psychological difficulties."
"Say a person is struggling with anxiety. If the person is willing to feel it—to accept anxiety but participate fully in life—their life is not derailed. But if they, for example, refuse to fly on airplanes because they don't want to feel anxious—well, then, they have an anxiety disorder. Our attempts to avoid discomfort are at the heart of so many of our problems."
Nowhere is this truer than in the realm of addiction. "Virtually all substance abuse disorders," Dr. Siegel says, "involve turning to a substance to avoid feeling something unpleasant."
Your pain is the breaking of the shell
That encloses your understanding.
"The reason mindfulness practices are proving to be so helpful for such a wide variety of psychological difficulties," Dr. Siegel says, "is that they turn our attention toward whatever we're experiencing, whether that be physical pain, or sadness, or fear, or joy, or love or appreciation."
"It's about opening to experience."
"The vast majority of chronic pain," Dr. Siegel says, "has a big psychological component." In the case of back pain—the subject of Siegel's bestselling Back Sense—there is surprisingly little correlation between reported pain and the physical problems revealed by MRIs. Many people have bulging or herniated discs, but claim that they have never experienced more than two consecutive days of back pain. "In other words: people who are pain-free often have the spinal abnormalities we point to as the cause of pain." On the flipside are the "countless patients" who have gone through successful back surgery, but find that their pain persists.
"The therapist's task," in such cases, "is to figure out what other process is causing chronic muscle tension, preoccupation with a particular part of the body, and the withdrawal from normal activities that can cause stress and depression, that can tank a life."
Mindfulness-based therapies, Dr. Siegel says, can break the "pain-fear-avoidance cycle." With pain management—as with addiction treatment—meaningful recovery begins with acceptance and psychoeducation: "Understand what's keeping you trapped in your difficulty. Understand how your mind and heart work. Chances are, you'll end up saying: 'Oh, I see. The coping strategy that I've been using doesn't work very well.'"
The search for a replacement strategy is, in a sense, a search for new resources.
"That search can start at a place like Driftwood, with the support of a new community that reassures us what we're going through is okay. It can start with self-soothing strategies like talking to a friend, or getting a massage, or being in nature."
"The critical thing," Dr. Siegel says, "is to face our fears: to stay with an emotion we're having difficulty with, or to stay with the physical pain, and discover: 'everything's impermanent; this doesn't last forever.'"
"It's your knowledge that you can take on a frightening challenge—that you can enter a wave of pain, pass through, and come out on the other side—that will give you the strength to free yourself."
· The Science of Mindfulness, Dr. Ron Siegel's introductory lecture on mindfulness-based psychotherapy, which has been viewed more than 360,000 times
· A collection of recorded meditations recommended by Dr. Siegel
· Jake Knapp's interview with Dr. Siegel on the popular podcast The Science of Success
· New research indicates that even a 30-minute introduction to mindfulness can significantly relieve pain: “It’s as if the brain were responding to warm temperature, not very high heat.”
· As doctors become more interested in mindfulness-based solutions to health problems like hypertension, "scientists [may] need to develop new metrics to analyze a potential medical intervention . . . rooted in ancient Buddhist philosophy."
· A JAMA study finds that "an online version of mindfulness-based cognitive therapy" may aid in the treatment of anxiety depression.