Category: Health and Pain
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Living Well with Pain: A 9-Step Program

Living Well with Chronic Pain:  a 9 Step Program

By Dr. Serena Patterson

I am one who has lived with pain for over 20 years now.  There are ups and there are downs; times when it recedes into the background and times when it seems relentless and exhausting, distracting me from what I want to accomplish and shortening my patience to deal with the setbacks.  I try to consider the pain to be a gift or a companion.  But if it is a gift then I want to send it back to the store for a something else; and if it is a companion then it is a whiny, tiresome one. 

Readers with chronic pain will know what I’m talking about.   Giving up the pain is not an option, nor is giving up on life.  The search for something better is on. 

Recently, I ran into the best book on pain I’ve read yet:  The Pain Chronicles by Melanie Thernstrom.  I cannot recommend it highly enough. 

I am working now on a distillation; a short list of steps that are helping me to claim a full and beautiful life with pain as a companion.  This my work-in-progress. 

Here are the steps (thus far): 

 

1.     Stop apologizing.  Chronic Pain is not a personal failure.  It is a disease.

2.     Accept pain as part of the human experience.  Embrace it. 

3.     Develop a Language to communicate about pain.

4.     Re-arrange your life to realistically accommodate your pain.  

5.     Be curious about your body; learn all that you can about it.   Develop a physiological understanding of how your pain works. 

6.     Build your personal repertoire of pain relief and feeling better strategies. 

7.     Pay attention to what you love about life—not what you wish for, but what is there already. 

8.     Watch what stories you tell about your pain.  Don’t let your pain represent the tragedies of life through your body; remember, it’s just pain.  

9.     Build a spirituality of beauty, gratitude and wonder. 

Stop apologizing. 

We live in a pain-phobic time and culture.  Therefore, if you are in pain, you are likely to be treated as the problem—deeply shamed, socially rejected, and economically marginalized.  That’s the way it is; but not the way it should be. 

There is a common stereotype about people with chronic pain:  we are portrayed as whining, demanding, weak-natured, addicted, lazy, and parasitic.  Even in the training that doctors receive, these negative stereotypes are too-often repeated and reinforced as though they were true.  

Yet these views are bigoted and wrong, like racism.  They stem from the fear of pain that won’t go away, and from cultural ideas we have that deny weakness and even mortality.  

As children, we absorb the shaming associated with expressing pain.  We are told not to cry or whine.  “Suck it up, Buttercup”, “Poor muffin,”  and “My heart bleeds for you” are responses that deem all complaining to be weak and illegitimate.   By the time we are adults we are fully indoctrinated in the rejection, not only of our own pain, but of anyone  who has the audacity to claim suffering as their own.   

Short-term pain with a purpose (like childbirth), or following an injury is acceptable,  if one is “brave” and doesn’t suffer overly long or loudly.  But chronic pain, which does not have a clear-cut or straight-forward relationship to injury, is definitely NOT OK. 

People with chronic pain are sometimes treated badly.  They lose friends, jobs, and income.  They often lose their very closest relationships that they had before the pain—marriages and families are strained not only by the pain but also by the stigma and judgment that accompanies it. 

Within the insurance and health care industries, the bias against chronic pain takes a cruel spin.  Insurance companies force the pain patient to prove the unprovable—that one is feeling terrible despite looking “fine”.  There is a political and financial stake in perpetuating a biased and negative psychological view of “the pain patient” as a cardboard stereotype of the failed human being—there is no obligation to treat the untreatable.  Shamed into silence, the pain patient fades from view. 

Pain Disorder is still listed as a Mental Illness in the DSM-IV TR (the diagnostic handbook for Mental Disorders that is used by insurers and health care institutions almost exclusively across North American and much of the world) , and there is a less formal but pervasive belief among physicians that Chronic Pain is a personality disorder, rather than a physical illness. 

A little bit of perspective is useful here:  Epilepsy, Asthma, Stomach Ulcers, and Diabetes have all been widely considered to be emotional disorders in the not-so-distant past.  In every case, as medical knowledge and treatment effectiveness has advanced, the stigma has dropped, and these disorders have come to be understood and treated as physical, not emotional, in origin. 

I believe that medical breakthroughs in the treatment of Chronic Pain are close.  With new (profitable) treatments, Chronic Pain will gain new respectability.  For better or worse, it is the profit motive which often moves medicine forward, knocking old stereotypes out of the way as it goes. 

Until then, reclaiming quality of life has to start here—by refusing the shame. If we are treated badly, then the shame belongs to those who dish out the lies and the abuse; not to those on whom it is heaped.  Throw it off, and back where it belongs.

Never, ever apologize again for the fact that you are feeling pain.  It is not a sign of weakness.  In fact, it takes great strength to get up every morning with pain, facing the day with hope and purpose.  Carry yourself with pride. 

Accept and Embrace Pain as part of the human experience.   

Pain has always been with us. Our experience of physical and emotional pain lies at the heart of all religious and philosophical systems.  We have minds that allow us infinite hopes and dreams, but bodies that confine us in the limits of flesh.  “How are we to live in a world of pain, of limitations, and of death?”  is the question that drives us to look for something that is more than mortal—something greater than ourselves to believe in and to follow. 

Pain is like an inner wilderness, unknown and full of dark and scary places.  The cross-cultural anthropologist can show that societies have approached wilderness with two somewhat contradictory strategies:  Some, primarily Aboriginal societies, seek to understand, to know, and to live in harmony with wilderness.  Others, primarily those societies that have descended and spread from Western European traditions including Capitalism, Colonialism and Industrialism, have sought to conquer and destroy it.  So it is with pain; the desire to conquer it and the desire to understand and live in harmony with it are at odds, and are evident throughout the records of human history and pre-history. 

Yet whatever one thinks about clear-cutting and destroying wildernesses (and this is generally frowned upon now, as we see the true loss to our planet), those of us who live with chronic pain must admit defeat when it comes to banishing pain.  We can reduce it, but we can’t “clear cut” destroy it.  We can sometimes transcend it, but we can’t conquer it.  It is the price we pay for living in physical bodies.  And as frustrating as it is to be of this physical, embodied nature, it is all that allows us to live at all.  Without our bodies, we don’t exist.  Pain lies at the heart of it all:  the paradox of being human. 

If we can find grace in a life with pain, even chronic pain that is debilitating or severe, then we can find grace in life.  We can be blessed amidst anything—loss, confusion, and even the certainty of death. 

Pain is a guide.  Pain is a gift.  Pain is. 

Develop a language of Pain. 

 

Communicating pain is difficult.  Oh, how often I have longed for a Pain-Ometer for my forehead, so that my loved ones could just read my pain state like the weather report, and I wouldn’t have to do the reporting and the explaining day after day.  “Cloudy with a 60% chance of migraine”, it would read.  “Current pain index:  3/10; highly unstable and reactive to noise”. 

Alas, I have to tell them.  And every time we give the “weather report” of pain, it’s like coming out of the closet, again, with that thing about us that others find so difficult—we are chronic pain patients.  We have special needs.  We are not just like everyone else. 

Just remember step one, and NEVER APOLOGISE FOR YOUR PAIN. 

A very accessible starting point is the 10-point scale of pain intensity.  Typically, nurses use this, asking patients to think of “the worst pain you’ve ever experienced” and label that a 10.  Zero is no pain.  Where is their pain now? 

This is good, but a better version of the scale uses some observable and fairly universal “anchors” to help us to navigate between the poles of denial (“it’s better now; just a 1 or 2, so let’s forget about it.  Sorry I complained”) and panic (“it’s a 12, for the love of God!  A 13!”)  My pain scale goes like this: 

0=I’ve done a good checkin with my body, and no pain found.  This almost never happens. 

1=Pain is perceptible if I stop and tune in to it. 

2=Between 1 and 3.

3=Pain is perceptible even if I’m doing something else, but it’s not too distracting. 

4=Pain is mildly distracting.

5=Pain is interfering with my ability to stay focused on other things.  Thinking is harder, and I have to stop and concentrate to answer a questions well.

6= Between 5 and 7.

7=Pain is dominating my experience; it’s the main thing I’m able to think about. 

8=I could cry, and I can’t do anything “productive” right now except to hurt.  I need help with basics like cooking dinner.  I’m at high risk for making mistakes on my medication (taking it out of the bottle, but leaving it on the table, for instance). 

9=Sweat and/or nausea accompany the pain.

10=Pain causes vomiting, cold sweats, and/or symptoms of shock. 

Beyond intensity, pain has other characteristics. It can be burning, prickling, or aching.  It can feel pointy or round, sharp or dull, focused or diffuse and widespread.  It can be felt deep in the body or just under the skin.  One patient describes her fibromyalgia as feeling like an envelope of burning pain that follows the contours of her entire body, just under the skin.  Another describes her irritable bowel pain as squeezing, or as an urgent need to eliminate but finding there is “no poop there” (wonderfully described in medical literature as “non-productive urgency”).    Some people use colors to describe their pain, and/or color it onto a human body shape on paper when they talk to their doctors or their loved ones about it.  It takes practice to develop a language for the qualities of pain, but the pay-off in mutual understanding is great. 

Most people with pain are afraid of “whining”.  They fear that they will be perceived as childish, demanding, or just plain annoying.  Here are some tips that help to minimize the fear of whining: 

1.     Use a low tone of voice; avoid high pitches.  Be matter-of-fact in tone.

2.     Keep to the anchored scale; don’t dramatize or exaggerate. 

3.     Say “thank you” when people listen and respond appropriately.

4.     Use paper and pencil charts or notes; paper is very patient while we work out finding “just the right words”.  Also, writing it down means we don’t have to repeat it. 

And speaking of doctors and loved ones, chronic pain patients need to take a trusted person with them every time they see the doctor.  This person can take notes, witness, and even speak up to help the doctor understand the impact of pain on the person’s life. 

Re-Arrange your life to realistically accomodate pain. 

 

Flexibility is not our natural strength when we are in pain—rigidity and withdrawal tend to come with the territory, as our brains click into “fight or flee, freeze and appease” mode.  We try to push on through bull-headed stubbornness, and/or to avoid the conflicts with others that life changes, big or small, might involve. 

Still, pain greatly impacts by the one’s life, and to ignore this is to risk disaster.   

Time management is probably the most universal challenge with chronic pain.  There is a limited supply of energy now available for doing things.  To ignore this basic fact is to set ourselves up for repeatedly running ourselves to the point of pain flare-ups and setbacks.  We have to manage our time and our energy very consciously because there is no “fudge factor” of spare time, or of staying up late and pushing ourselves through to meet deadlines. 

Given a reduced resource of productive time, what will we prioritize?  Whatever gives us maximum meaning and quality of life.  For some, this will be driven by pleasure: do what makes you feel best.  For others, it will be driven by duty:  do what you are most committed to.  For most of us, there should be a balance between these things.  Put what will let you feel most good about yourself at the end of the day on the top of your list, and do this early when you feel at your best.  Eliminate whatever falls toward the bottom of the list.  Delegate—to your partner if you have one, your paid assistant if you are extremely blessed, your colleagues, your children, and, of course, to God and/or The Universe; whichever you prefer.  To the latter goes all worry time. 

A second site of much change after chronic pain is relationships.  Marriages and/or romantic partnerships may end.  Some friends will quit you; others, who are able to handle it, will stay by your side.  It’s not personal.  You will find new sources of love.  Chronic pain is a great acid test for relationships; learn to be grateful for its power to save you from wasting your time on people who cannot handle you—pain and all.  You are now a high-maintenance person to be involved with, and you are worth it. 

A third site of change and adjustment is making a living.  Some continue their previous careers.  Some manage to get on to disability payments of some kind.  Others change careers, finding something that they can still do, usually for less money than they made when able-bodied.  All of us fear falling off of some edge into poverty.  Like all fears, this one is best faced boldly and without shame.  Reduced circumstanced may be mandatory; shame is not.  Low income need not equate to poverty.  But living well on a small income does require creativity. 

Living with any disability is an art form.  This is even more true for invisible disabilities without accepted protocols, strategies or props (like wheelchairs and white canes) to let us, and others, know what is expected. 

There are no expectations for living with Chronic Pain.  No rules.  No roadmap.  As a chronic pain patient, the main social expectation is that you disappear and/or conform to a negative stereotype—this is impossible.  So you create a life.  If every answer is “wrong”, then at least you are absolutely free to choose the ways you be wrong.  You are free from “normal”; you are an artist.

Art is the attitude, but the practice of surviving and thriving is concrete and practical.  Make soup—it’s easy, creative, comforting, and cheap.  Make something every day—no matter how small.  Give yourself bonus points if your “art supplies” cost nothing.  Go to the library.  Have one part of your home that you can make as warm as you like without driving the whole home heating bill to the sky.  Don’t skimp on services like massage or home help if they keep you in the saddle for your paid job.  Maybe you know someone who will cook in bulk for you once a week if you pay them.  Brainstorm and budget.  Take pride in what you create as a lifestyle and DON’T APOLOGISE.

Be Curious about your body.   

There is so much to learn about human bodies in general, and about chronic pain in particular! 

Far too much health education is couched in lists of “should” and “don’t”.  “ Do exercise.  Don’t eat potato chips. Get to the gym.  Get off the couch.  Eat vegtables.”  Red wine and chocolate?  The jury seems to be out.  Why? Perhaps because “do” lists are, deep down, shaming devices.  “You wouldn’t be in pain if you had kept in shape,” say the nasty voices in society and in our heads.  That, of course, is bull.  We’re in pain because we have a pain disorder. 

Any list of “should” and “don’t” intended for the masses is going to be oppressive to those who march by the beat of their own drum.  We chronic pain patients are made differently, and will have to find our own ways of making it through to a good life. 

We can drop right now any shaming voices in our heads about how badly we’ve screwed up on the “should” list.  Remember Step One:  you didn’t get chronic pain because you failed.  It’s a disease, not a cosmic commentary on our life performance. 

Better than “shoulds” is an attitude of curiosity and learning.  Probably the first thing to look up is the difference between Chronic Pain and Acute Pain.  Acute pain has a nice, clear relationship to tissue damage.  It also has a nice, clear evolutionary purpose (it causes us to retreat from action and guard the injured part of ourselves so that healing can occur; it also teaches us what experiences to avoid, like hot stoves and nettles).  Inflammation is part of the Acute Pain response—inflammation of muscle, skin, and particularly of nerve cells themselves.  Psychological factors greatly impact the experience of Acute Pain.  The excitement of a sport event will dull the perception of pain; lying alone injured on the road will exacerbate it.  A loved one’s face decreases the need for morphine after surgery. 

Chronic pain also involves inflammation, although sometimes only the nerve fibers are inflamed (everything else looks infuriatingly normal).  Inflamed nerve fibers may not be clearly visible even on the most sensitive MRI imaging reports, and even if we can determine where along the pain pathway to look for them. 

The pain perception system, in other words, is working much like it would in the case of an acute injury.  With two important exceptions:  There is no injury, and the pain response loops around in a positive-feedback  system that makes it stronger and more sensitive over time.  The pain response has become disordered; that is the disease of pain.  The pathways along which pain messages travel from the parts that “hurt” to the brain and back are strengthened and deepened with each experience of pain; the system teaches itself to be more and more sensitive.  The more we hurt, the more we hurt. 

Psychological factors apply as well—why would they not?  Emotions and thoughts happen to use the same information highway in the body that tissues use to communicate about pain—the Central Nervous System.  Whatever else is happening on the CNS “highway” that day is going to impact the message.  Inflamed and damaged nerve fibres send faulty and disorganized messages along the highway, and this sometimes will cascade into whole-system “pile-ups” with the emotional, physical, cognitive and stress messages of the day.  

Pain researchers are making very promising inroads in understanding the micro-mechanics and chemistry of pain perception.  There are working models of understanding for how this works, and these will eventually work their way into common knowledge among physicians, physiotherapists, and others who still claim that, as one family doctor put it to me, “you hurt and we don’t know why.” 

With such an exquisitely sensitive system for perceiving pain, it behooves us to learn more and more about whatever parts of our bodies happen to be squeaking out for attention.  Got irritable bowels?  Read up on digestion, and on possible inflammatory influences in the gut.  Learn about the wonderful and fascinating world of intestinal flora and fauna—you’ve got an entire ecosystem in there.  Got phantom limb or pain?  Read up on how severed nerve fibers regenerate in unpredictable and disorderly ways.   This tendency also underlies the phenomenon of chronic pain developing in the months following surgery:  a nicked or severed nerve can wreck havoc. 

I have an unusual and cheeky mantra when it comes to pain education:  Don’t tell me what to do.  Pain patients are told what to do almost every day of their lives.  Everyone they come out to about their pain has a very good suggestion that they are certain will fix everything.  And it doesn’t; and then the well-meaning friend who suggested it feels awkward, maybe even judgmental. “Maybe you didn’t try hard enough,” they say.   And the pain patient thinks, “maybe I didn’t try hard enough.”  The friendship suffers and so does everyone’s self-esteem.  So don’t tell me what to do.  

Tell me how things work.  Explain the system to me.  Let me develop a working theory about my own body.  Then, if people have suggestions, I can think about them carefully, asking myself, “does this make sense?  Is it likely to work?  Why or why not?  What will it cost me to try?  Is it worth the money, the time, the hope?  Or should I thank them and move on?”  

Build a repertoire of Pain Relief.

Gradually, we get a list of strategies that help.  There is no cure; no miracle treatment.  Not yet, anyway.  Just symptom relief. 

What worked yesterday may not work today, and visa versa.  What works for your friend with the same condition you have may not work for you, and visa versa.  

Medication dosages may work best delivered on a schedule so that they can kick in before the pain gets going; or you may prefer to manage it more flexibly around periods of flare-up and remission. 

Massage helps most people.  Other methods of creating counter-stimulation and increased circulation at the skin and/or muscle level include brushing the skin with a natural bristle brush, taking hot showers, and bathing in espon salts.  Hot tubs help some and make others hurt more. 

Warmth helps some, especially radiant warmth from a woodstove, an infared sauna, or Moxa packs (available at natural pharmacies and as small hand-warmer packets in outdoor wear stores).  Electric blankets, not so much. 

Accupuncture and Chinese Medicine help many.  Stretching helps many, and it’s cheap.  Physiotherapy is a good place to learn, and to pick up new ideas. 

Gentle walking helps most people most of the time, but there may be days to avoid the great outdoors with its icy blasts, bright sunlight and potential for wet feet.  Walking with a dog is often better than walking alone, and there is the extra benefit at home of radiant dog-body heat next to you on the couch. 

Finding lists of suggested things to do for pain relief is not hard; they abound.  The key is to find balance between keeping an open mind vs. jumping in for a miracle, and not becoming cynical in the face of limited results.  Some relief is of course better than none, and life gets better little by little. 

As we get a list of things that work, it helps to write them down and put them on the front of the refrigerator (if that is where one looks for help).  Putting the list in view helps because when we have pain flare-ups, we aren’t very good at remembering how to help ourselves. 

Pay Attention to what you Love .

 

As I write this, I am watching the birds at the suet feeder by my window.  I love those birds with all of my heart.  I wish them every bird blessing.  Their lives are not long, and I have seen them suffer in winter.  But what joy they have, too!  They fly, for heaven’s sake!  How cool is that?  Some sing, and some (ravens and crows) talk. They court, and once in a while I get the dramatic experience of watching a family hatch and fledge—oh, what exquisite hope and danger! 

There are three very good reasons why we need to pay attention to what we love.  First, doing so guides us in Step 4, which was to rearrange our life to get more of the good stuff.  Whatever we love IS the good stuff. 

Second, when we pay attention to it, we deepen the experience of what gives us joy.  Those feeling-good neural pathways, like the pain neural pathways, get deeper and stronger the more they are activated.   The principle involved is called neuro-plasticity; the brain “rewires” itself constantly, strengthening the pathways that are used and weakening those that are not.  The more we feel good, the more we feel good.

Third, we will care about and protect what we allow ourselves to love.  Love keeps us engaged with life.  It brings us out of ourselves into places of wondering and wonder.    

Watch the Stories that you Tell about your Pain. 

 

We are story-telling, meaning-making creatures.  Something as life-changing as chronic pain demands a story, and we will create one.  This is natural and almost inevitable, but it carries with it a spiritual danger.  

Physical and emotional pain interact.  Whatever physical pain we are experiencing when a tragedy strikes us is amplified.  Conversely, tragedies compounded by physical pain are harder to manage.  Losses get associated with the physical pain, and the pain reminds us of our loss. 

If the story we tell is that our pain is caused by an emotional event,  then the story we tell ourselves about our pain will deepen the connection between the two kinds of pain.  If our story says, “This (physical) pain is here because my marriage ended badly”, then every time the pain flares up we relive the bad ending to the marriage as though it were etching itself into the very fibres of our being; which, in a way, it is. 

It is very understandable and natural to construct our pain story around such big loss events.  Emotional and physical pain inhabit the same nervous system, using some of the same neural pathways and many of the same chemical messengers.  We use the same language to describe them;  it’s pain.  And because most of us have never gotten a good physiological explanation for our physical pain, it’s origin has been a mysterious void to us.  We don’t like mysterious voids.  We fill them up with stories—in the case of pain, these will be painful stories.  If we are blamed for the pain, then these will stories filled with themes of personal failure, trauma, and/or betrayal by those whom we once trusted.    

Probably the kind of life experiences that are most likely to get confused with Chronic Pain are those associated with betrayals in close relationships.   It has long been observed that patients with chronic pain are much more likely than those without to have been abused by their parents as children.  People with chronic pain are also inclined to have great increases in the pain when important relationships break up.  And when pain flares up, many people find themselves ruminating upon the ways that they have been mistreated by people they trusted—the parent who abused them, the sibling who humiliated them, the partner who cheated on them, or the doctor who misdiagnosed and then blamed them. 

But the truth is that Chronic Pain, like Diabetes or Asthma or Epilepsy, is a disease.  All of these things flare up worse during times of loss or stress; Chronic Pain isn’t so very special this way.  If we didn’t have the disease of Chronic Pain, then stress would just be stress.  It might affect us physiologically in other ways, like a headache or unstable blood sugars or a crashing immune system and bronchitus. None of these things ARE stress; none of them ARE personal failure or humiliation or abandonment.  They are the body’s weakness showing up in times of stress. 

So it is important to have a story about body pain that lets us separate life history from the disease.  Then, when we have a flare-up, we can think of the trigger event as  just a trigger event, and the disease as just a disease.  No punishment, no blame, no shame.  Pain isn’t anger, or grief, or humiliation.  It’s just pain. 

 

Build a Spirituality of Beauty, Gratitude and Wonder.

The life of a person living with Chronic Pain becomes smaller in scale.  Extroverts may even become introverts.  We rarely have to be told to stay home from the bars; night life is just too stimulating and probably too expensive.  Simplicity becomes the rule of the day. 

How does one cultivate contentment on such a simple scale?  The answer is not particularly difficult; it is by tuning in to the natural world around us and within us.   If we can’t make it to the mountains this year, the palm of our own hand is miracle enough—what a wonder of natural technology it is.  The way the different kinds of tissue—bone, muscle, cartilage, nerves, blood vessels and skin—are laid out and interact.  The worlds within worlds of individual cells.  Whatever one’s religious faith (or no religious faith), one can’t escape the conclusion that this is amazing.

Chronic Pain is not a disease with a happy ending for most of us.  It’s a disease of coping over many years.  But it does not define us, or rule out very happy moments.  It does not rule out love. 

Perhaps it is a gift of Chronic Pain to slow us down, turn us inward, make us think carefully and observe deeply.  The earth is still worthy of our presence—to witness the sometimes heartbreaking beauty of it all; we are still worthy of the honor. 

Food for thought

Food for Thought

Food for Thought

“What man of you, if his son asks him for bread, will give him a stone?”
Matthew 7. 9

It’s a rainy November morning, and Serena sits at the kitchen table, writing, as Monika transforms Jack-o-Lanterns into soup, muffins, pie, and freezer bags of pumpkin mush. She fills jars of cabbage to ferment into sauerkraut. She processes the last of the local tomatoes, peppers, and cilantro into salsa, then seals it into half-pint jars. Monika puts up the harvest, and Serena writes about it. Each is invited to sample, edit, comment on or enjoy the other’s work. It’s a sort of collaboration, but it’s not without its tensions.

We actually thought of writing about food this month because it’s what we’ve been arguing over the most lately. Maybe it was the night that the pantry shelf collapsed. Or the never-ending stream of obesity-related news headlines (do we need to say that none of these headlines proclaim good news for the pear-shaped among us?) Or Serena’s “forgetting” to carry lunch, again, and buying sweets.

We are both, to borrow a phrase from Alexander McCall-Smith’s Botswanan character Mma Ramotswe, “traditionally built ladies”. We are struggling to be healthy, and to nurture ourselves well despite the onslaught of cultural and familial concern that our bodies are, by definition, signs of failure.

Here is something that we agree about. Shaming people for their body size is wrong. Yes, obesity is often a sign of a body in trouble. And yes, obesity has been on the rise for several decades now. But the shame that is heaped upon individuals, the fear of fat and the blaming of “obesity” (although they really mean “the obese”) for everything from rising airline costs to the collapse of socialized medicine, is wrongheaded and destructive.

Shaming assumes that somehow, if we could just make fat people realize the error of their ways, they would stop overeating and become thin. Or perhaps they would get on their bicycles and become thin. Obesity is treated as an individual failure that could be reconciled if the fat people would simply curb their appetites and work harder.

The first problem with this is that it greatly oversimplifies the causes of body shape (be it linear or round). Each individual’s shape is the product of several factors: their genetic heritage, their daily habits and opportunities for movement, their general health, conditions that affect the metabolism and storage of fat (such as an under-functioning pancreas developing into diabetes), and, perhaps least powerful biologically but most meaningful in the social context, what and how much they eat. The roundness of one body may result from an entirely different combination of factors than the roundness of another body. In short, if you haven’t lived in the body you are looking at, don’t judge how it became the shape that it is. You could well be wrong.

The second problem with blaming individual weakness is that it is working at the wrong level of analysis. The overall average size and shape of people in the post-industrial world has increased dramatically. This indicates a problem at the systemic, not the individual level. To use the language of medicine, there may be a problem, but we’re looking to treat the wrong patient.

Post-industrial society has an illness, a dis-ease. The symptoms include obesity as well as cancers, heart disease, family breakdown, depression, and chronic anxiety. One root cause is the devaluation of labor, which creates a time famine among working people, along with a proliferation of cheap consumer goods, and cheap fast food, to throw into the gap where nurturance and creativity belong. Another root cause is the mobility of the industrial workforce, which has broken the ties of extended family and replaced communities with vast expanses of urban anonymity. The nature of business has changed, as local stores and cafes have given way to chains of look-alikes. Our sense of place and belonging, both within the web of human relationships and within the web of nature itself, is endangered.

Time is expensive but mass-produced goods are cheap. It’s no longer a sign of wealth or success to buy prepared food; it’s a sign of poverty in the commodities that we are most short of: time, energy, creative zest, and knowledge of how to make things ourselves. Yet mass-prepared (fast) food is designed not to truly nourish, but to silence a craving. So the craving is fed, but not the body, and the nutritional deficit gap remains.

Food is about nurturance in its most primal form, and nurturance is tied to deeper issues still about being loved and worthy. Just how comfortable are we with nurturance? Do we know what nurtures our bodies, our minds, our hearts, and our loved ones? What are we afraid or ashamed to take in or to give? Food can be part of a universal language for expressing the full range of human needs. What are we hungry for?

The issue of being worthy of good things is, of course, closely tied to shame. It is interesting to watch people (ourselves included) when we eat alone; when we have to take care of our own nourishment needs without reference to other people. Do we cook for one? Do we seek out company by leaving home and going to a café or fast food joint? Do we hide, hoping that no one will see us eat? Do we remember to eat? Do we read, watch TV, read the paper, or concentrate on experiencing the food itself? If we are ashamed to need nourishment, then our relationship with food will be affected. Whether we respond by tuning out the voice of hunger, or whether we stuff that voice with low-nutrient, quick fixes of fast food, the issue is still, “what am I hungry for?”

We are hungry for so many things: movement, creativity, the outdoors, spirituality, and, of course, time. The technology boom was supposed to at least give us time. But it didn’t. Driving replaced walking—to the store, to work, to school. As adults abandoned the outdoors for their cars, it became an unsafe place to play. Television, Game boys and X-Boxes fill the craving for play, but they lack in so much that is nourishing. And they are a major contributor to the rise in numbers of overweight children and adults.

We see obesity as a symptom of unique forms of post-industrial famine. Famines of time, zest, worthiness for nourishment and the knowledge, including the self-knowledge, that is necessary for creativity. Famines of connection: with each other and with the outdoor world. Famines of spirit. Fast fixes, including drive-through food, temporarily relieve the symptoms but actually increase the real deficits.

What can we do, as individuals, to resist the lure of fast fixes that fill us up but don’t nourish? What can we do about the risks of obesity, and the famines that underlie it? We can:

o Stop, listen, and think before impulse buying. Ask, “what am I most hungry for? How will this nourish me? What impact does it have on my world?”
o Rediscover or reinvent the ritual of saying thanks for food. This reminds us that food is sacred. And if it feels wrong to bless the food in front of us for the nourishment of your body, maybe it’s the wrong food.
o Support local food. Buy local produce. Choose a locally-owned restaurant for lunch. Get to know the people who produce and create the food we eat on a personal basis. Say thanks to them, too.
o Cook. Better yet, teach someone else to cook. Cook for the whole week on Sunday, if that helps the time crunch through the week.
o Plan. If you are inclined to forget to eat until your body is desperate enough to reach for a vending machine, make sure you have some alternatives handy: nourishing foods that you can eat right away.
o Get out and play. Or walk. Or just sit on the stoop and watch. Invite children.
o Forget words like “skinny” and “obese”. Banish shame. Cherish every body as the temple of a spirit, and as lovely and worthy of good things that both satisfy and nourish.

frost

Pain

Pain

This article was first published in the Island Word in 2010.  Since then, Dr. Patterson has made private practice her full-time job, re-inventing her work to fit a quieter pace and environment. The creative project of living a good life with chronic pain continues, as does our teaching on this subject.  In the Comox Valley, a wonderful resource for people living with Chronic Pain is the Comox Valley Nursing Center (https://www.viha.ca/comox_valley_nursing_centre/#).

Serena has made a big decision this month: after 19 years of loving what she did, she is leaving her college teaching job. Serena has fibromyalgia, and her days have become increasingly shaped by the presence of pain in her body. When she reaches a certain intensity of body pain, the multi-tasking part of college teaching and the noisy environment of a full classroom become too demanding of her attention. It’s like, she says, trying to think clearly through a curtain of dense fog, and it is exhausting. Change has become unavoidable.

We have spent several months, even years, contemplating this together. We have planned strategies for increasing her role in the counselling office. We have gone over, many times, the exact nature of her pain—the things that magnify and diminish it, the activities that she can still do well, the need for physical movement to keep it at bay and the need for creative time to transform it into things of beauty. We have added dietary changes and the best recommendations of our herbalist, our Chinese Medicine doctor, and our Western Physician. We hope that an improved quality of life will allow her also to do the things that bring cash into the family budget, since we are far from financially retirement-ready. In short, we have first-hand knowledge that complements (and often contradicts) what the text books have to say about living with pain. And we are still convinced that chronic pain does not rule out love, beauty, zest, and meaningful work.

We do, however, live in a culture that is intensely uncomfortable with pain. There are many reasons for this discomfort, and it affects us all in many ways. Modern pharmaceuticals are a wonderful tool in pain management, but perhaps they have also contributed to a general squeamishness and denial toward pain as a natural facet of life.

Pain is chaotic, intrusive, unpredictable, and can ruin the best of plans. Modern life does not deal well with unpredictable sources of chaos. From the time we start Kindergarten we learn to accept the neat division of time into weeks, hours, and minutes as a naturally occurring event. Productivity and punctuality go hand in handd. Pharmaceuticals may allow us to continue to accept and function within this artificially scheduled productivity schedule, with of its tidy predictability, without questioning, falling out, or “failing”. Pain shatters this illusion.

Pain also reminds us of our mortality. To be mortal is to have physical limits: we cannot leap tall buildings in a single bound, clean the house in the wink of an eye, single-handedly bring world peace, or deliver that quarterly report by tomorrow morning. Mortal beings also will one day die. Pain teaches us that we do not belong to a modern world of steel and reinforced glass; we belong to the ancient world of things that live and decay.

Next to pharmaceuticals, the other commercial business that contributes to the cultural denial of pain is that of insurance. The insurance industry helps to ameliorate unpredictable losses, but it also plays upon unrealistic dreams of immortality. When bad things happen, we are told, loss is escapable. Pain need not follow. Perhaps it is not surprising, then, that loss of insurance coverage and the denial of benefits are two big problems that chronic pain sufferers nearly always run up against. Insurers tend to deny the reality of chronic pain without visible tissue damage, and the emotional damage of being treated as liars when applying for benefits compounds the inner confusion and turmoil of having the pain in the first place. Fighting the insurance company has a certain righteous appeal to it, but a focus on proving the pain is very risky to personal happiness. Sometimes walking away from false security and into diminished financial resources is, in fact, taking the more life-affirming path.

Finally, unavoidable pain messes with our notions of a just world. The desire to preserve the belief that pain comes to those who are too lazy or too stubborn to have avoided it in the first place is great. “If those people are inferior to me,” goes the thinking, “then I can avoid pain by living my life the right way.” Physicians are, by no means, immune to this need. They are sometimes the first to distance themselves from, or to display hostility toward, the patient of chronic pain who “fails” to get better with treatment.

Being somewhat contrary by nature, Serena is inclined, on her better days, to accept chronic pain as a spiritual path, if not a gift. We who hurt may be the suppressed cultural voices of mortality. We learn, and can teach, the practice of cherishing life in all of its fragility. It may be a lonely a misunderstood path, and there are many who, with the very best of intensions, will argue that it is unnecessary and avoidable. We who suffer from pain may find ourselves losing friends and falling off of party invitation lists. Still, for all it is a thorny life path, it does have roses.

So how does one go about living a good life in the presence of pain? There are many things that we have found helpful. Some of these are simple, but most of them form the basis for a lifetime of practicing and creative improvisation.

A good place to start is to develop a good vocabulary for describing your pain. Pain has at least three dimensions to it: intensity, quality (or color), and emotion.

A simple 0-10 scale is a great tool for communicating the intensity of pain. One way to anchor this scale is to say that “10 represents the worst pain you have ever experienced, and 0 is no pain at all.” For us, the scale is improved by adding some more observable anchors to it, since one person’s experience may not be easily transferred to the next as a reference point. At our house, pain under level “3” is present but can be ignored, sometimes with effort. At “5”, the pain begins to interfere with concentration and thinking. At “7”, doing other things besides hurting becomes difficult; at “8”, experiencing the pain is just about all one can do. At “9” and “10”, the body itself reacts to pain through secondary symptoms like nausea, sweating, trembling or involuntary crying.

Being able to communicate pain intensity very much improves the quality of our family life, because others have a chance to accommodate their expectations of the person, and to avoid taking a wince or an exit from the dinner table personally.

Quality of pain is harder to describe, but a facility with metaphor helps. There is dull pain, squeezing pain, itchy pain, sharp-like-an-ice-pick pain, and sharp-like-a-needle pain. There is cold pain, hot pain, stinging pain, heavy pain, and pain accompanied by lights. There is pain fitting close to the skin like a tight clothing, pain that is deep inside the body, pain that stays in one spot, pain that radiates to other places. This kind of vocabulary-building is best practiced when we are in a pain-free state, so that we can make maximum use of our creativity. Laughter is optional, but helpful.

Finally, pain perception and emotion are very closely intertwined. On the one hand, we are hard-wired to read pain as a signal of distress and the need to DO SOMETHING QUICK! On the other hand, think of the child whose “owie” is magically cured by Mama’s kiss. Fear, anxiety, and suppressed anger are all pain-multipliers. Loving feelings and laughter are pain-reducers.

Many pain management techniques teach the skill of observing our pain while letting go of emotion and judgment, as in, “I have a strong, needling sensation in my elbow; how interesting.” In the case of chronic pain, where the pain sensation is disconnected from the actual health or wholeness of the tissue, this technique can be immensely helpful. In therapeutic language, it goes by the name of “mindfulness”. On the other hand, when we are affected by the pain-multiplying emotions to the point where we are in a negative-feedback loop, it pays to be able to communicate this to someone who can help us to calm down. Just the act of saying, “I’m in pain and it is freaking me out,” relieves some of the pressure, and helps the other person know what to do.

Once we become good communicators, we can begin the long and constantly shifting task of accommodating our lifestyle to the presence of pain. The point is not to allow pain to run our lives, but to rediscover faith in ourselves, our inner experience, and our right to happy, rich lives alongside this uninvited but familiar companion. There are usually shifts in relationships, friendships lost and found, changes in how we spend our leisure, and even in how we make our living. Disposable income almost always plummets. Sill, when the pain staying where we are outweighs the pain and fear of change, then we will make changes. Learning to overcome our fear of stigma and to communicate clearly about pain means that we don’t have find our way through these changes all alone.

Dr. Serena Patterson is a Registered Psychologist and Monika Grünberg is a Registered Clinical Counsellor. Besides raising a family and writing together, they also practice as GrunbergPatterson Counselling and Psychological Services. Their phone number is 250-339-3269, and their website is www.grunbergpatterson.ca.

ivy on tree

Is it addiction, vice, or hobby?

Addiction, Vice, or Hobby?

This ariticle first appeared in the Island Word in spring, 2009.

Serena has been spending a lot of time on her Farmville page lately. There is something satisfying, and escapist, about pink sheep, green cows (they give “milktonium”) and banana trees in the snow. At the same time, we are both over-extended with work and kids, underexposed to sunshine, and wearing thin over this rainy winter. There seems to be little time to reconnect, get some exercise, and make healthy food. Ergo, there really isn’t much time for Farmville. Shouldn’t she be doing something more constructive? Is this a healthy respite from the pressures of work and family, or is it, as most Farmville “residents” joke, an addiction? That depends…

An addiction is something that we feel strongly compelled to do, even if it is bad for us and causes us significant losses and/or pain. We do it change our inner state from agitation and despair to peace. But it doesn’t belong to us, the way a skill or a spiritual path does; it is outside of ourselves and comes at some cost to our long-term health or survival. It stops feeling like something that we choose to do, and begins to feel like something larger than our own free will that pulls us in, again and again, to repeat a cycle of suffering, longing, obtaining, and relief that doesn’t last.

Once in a while, research comes together that adds a significant piece to our understanding of addiction. In his book, “In the Realm of the Hungry Ghosts” Gabor Mate draws connections between genetics, child development, love, and brain chemistry that come close to resolving the old battles between medical and moral models of addiction. The piece is called “self-regulation”, and it is the ability to calm one’s own intense, negative emotional states.

The road between anguish and comfort consists of a chain of brain cells that runs from just behind the forehead, where decisions are made and impulses can be suppressed, to the midbrain, where all that our senses gather encounters the seat of physiological arousal (high alert, sleep, and all states in-between) and the master controls of the hormone system. The midbrain sits between the cerebral cortex, the “modern brain” with its impressive ability to remember and to “think”, and the brain stem, the “ancient brain” that keeps us breathing, circulating blood, digesting and eliminating exactly like we did back when we were fish and reptiles. The midbrain is the seat of passions. recalled from our Biological Psychology classes as the “4 F’s”: feeding, fighting, fleeing and fornicating. Being ruled from the midbrain is fine when we are infants, and have parents to hold us and keep us from doing too much damage. But when we grow up, we need the frontal lobes to override our midbrain impulses; else we would regularly embarrass ourselves, to say the least. The frontal lobes also calm and modify the raw emotions of the midbrain—rage, despair, hunger, longing, and even ecstacy, allowing us to tolerate the each other’s company and to share empathically with one another’s trials and joys.

But the pathway from the frontal lobes to the midbrain is only roughed-in by the genetic blueprint that we are born with. Our brains come equipped with many more cells than we will ever use, but very few connections between those cells. For the connecting pathways, we await experience.

The pathways from distress to comfort are built as our parents hold, feed, sing, rock, and talk us, again and again, from states of raging need to peaceful satisfaction. Eventually, we “walk” the paths on our own, having learned the way in our parents’ arms. The more we go through these steps, the deeper and wider the way becomes; like a path in the forest, it can be followed by habit and through the dark. Self-comfort becomes automatic. In brain development, this happens gradually between babyhood and the mid-twenties, with upheavals during the teen years that can best be described as a “remodeling” period (that explains a great deal, but it’s better left for another column).

If the frontal lobe functions are strong, the limbic system passions are no more than moderate in strength, and the pathway between chaos and calm is well formed, then all is well. Like a horse with an expert rider, our emotions inform, energize and color our life, but the purposeful human “self” of the cerebral cortex is in charge. Such a person does not need an addiction to reach the place of inner peace; they can get there on their own. Alcohol, drugs, and compelling behaviors like gambling, sex, and online games may have entertainment and experimental value, but the risk of addiction is low.

A mismatch between the passionate “horse” and purposeful “rider” can occur in more than one way. Some are born with a temperament inclined to intense emotions. Passionate and sensitive, these people often make wonderful teachers, communicators, and artists. But they need to spend a lifetime developing strong “horsemanship”. Others have a more moderate temperament, but early experiences of trauma overwhelm the system before a proper path can be built; chaos without comfort becomes a normal experience and the child does not know what it feels like to have control over emotions and impulses. Most unfortunate, but very common, is a combination of intense temperament and poor early experience. Imagine a parent who is ruled by the intensity of mid-brain emotions, raising a child who is has powerful, negative, and difficult-to-sooth emotions of her own. The parent is too preoccupied with her or his own pain to help the child build a path for inner comfort.

Once we are grown, if the passions are in charge, and inclined to run away with the rider, then the pain of poor emotional regulation is overwhelming. We have outgrown the big adults who could rock and sooth us. But if an overwhelmed “rider” discovers substances or behaviors that can lift them from despair to peace, instantly, it feels good; very good. The hard work and anguish of bushwacking that pathway through the wilderness feels over; one can relax into the arms of this like a child who has found its lost mother. An addiction has begun.

There is, of course, more to the story. Genetics influence how we metabolize certain psychoactive substances (eg alcohol) and experience high-adrenalin states and risk-taking activities. In addition, some people “self medicate” chronic conditions of biochemical imbalance. Vulnerability to addiction is complex. But the ability to get from despair to inner peace is a newly understood part of it, and this may revolutionize how we work with addictions.

Addictions, it is said, erode character, maturity, and courage. Because addiction by-pass the natural routes of comfort and impulse control, they allow whatever pathway from the frontal lobes to the midbrain that did exist to atrophy. It’s as if weeds grow up into a disused path, and clearing it again (or for the first time) requires wholistic rehabilitation.

In some cases, we need to first alleviating the causes of pain before we can expect the person to develop, on their own, the means to comfort themselves. For example, living in a tent in wintertime is not a good situation for rehabilitation. In other cases, it is the self-comfort system that needs support, either temporarily, or permanently through some kind of addiction-substitute that does not carry the cost of self-destruction. Because the process of learning to live ethically, productively and at peace with our strongest inner passions is life-long, the addict who said, “recovery is never over” was right.

Finally, another word for achieving inner peace is spirituality. Appealing to that which is Sacred, by any name, seems be essential to healing from addiction. Twelve-step programs begin with admitting our powerlessness, and turning to spirituality for help. Harm reduction programs build upon empowerment of the person rather than the help of “higher powers”, but strongly affirm an ethical and meaningful approach to life. Whether it is a walk in nature, prayer, meditation, kayaking, running, or going eye-to-eye with someone we love, each of us must find ways to remember the steps to inner peace when the weeds of daily hardships appear to have covered the path. Counselling is the art, and the privilege, of assisting people to find and to walk that path, again or for the first time.

feathers

The Patient was upset

The Patient was upset

This article was first published in the Herbal Collective in 2004.

After her visit to the family physician, the patient was upset. “Counselling? Why counselling? My pain is real—doesn’t my doctor believe me?”

Why, indeed? Does a referral to a counselor for chronic pain mean that the pain is “all in one’s head”, imaginary? And isn’t this adding insult to injury, when, after all the medical tests and interventions available, the person is still in pain?

Actually, the idea that pain is either in the body or in the mind is one of Western society’s more damaging and wrong-headed prejudices, and it is no longer believed by most doctors. Technically, all pain is a product of the nervous system—without nervous system activation, we would feel no pain even in the face of grievous bodily injury. The nerves signal the brain of damage or illness for a very good reason; pain is an important message that tells us when, and how, to take care of our bodies. People without the ability to feel pain (a rare condition) live short lives.

But communication within the nervous system is affected by many things, including not only the condition of the body, but also emotional states, fatigue, competing sensory input, and even our thoughts. Far from being a straightforward experience, pain is affected by literally everything in our lives. In return, as anyone living with chronic pain will attest, pain affects everything else that we are experience. It’s a full-circle deal.

The role of counselling in the management of chronic pain is not to take the place of more body-centered treatment (conventional and/or complementary medicine), but to enhance its effectiveness in two ways. First, counselling can help to identify and alleviate conditions that tend to exacerbate pain. Negative emotions, unhelpful beliefs and thought patterns, stress-producing behaviors and muscle tension can be reduced, thus “turning down the volume” of a pain-activated nervous system. Second, counselling can help us to manage better within the limits of our health. Prioritizing what is most important, focusing on our strengths, and restoring a sense of control and choice in our lives are some of the ways that counselling can help to bring joy and fulfillment back to a life that has been negatively affected by pain.

Physicians know that the majority of people who feel limited, frustrated, angry or very sad about living with chronic physical pain can be helped by a qualified and skillful counsellor. A physician who refers a patient with chronic pain to see a counselor is not expressing doubt about the reality of your experience. Instead, she or he is expressing faith in our ability to live fully even when all the medical options have failed to stop the hurting, and to transform a pain-filled life into one with room, once again, for joy.

Monika Grünberg is a Registered Clinical Counsellor who specializes in individual and family counselling for adults and children experiencing life stresses, including illness, injuries and pain. Dr. Serena Patterson is a Registered Psychologist who specializes in psychological assessment and treatment of adults experiencing difficulties in living, including chronic pain and challenges to physical health. To contact them, they can be reached directly in the Comox Valley at 339-3269, or toll free at (877) 339-3269.

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Grünberg Patterson Centre for Counselling & Assessment has been providing services in counselling, psychotherapy, and education since 2004.

It is an honour and privilege to live and work in the traditional territory of the K’ómoks First Nation.

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