After the meditation we went around the circle and shared how the week had been with the pain levels and the mindfulness practices we were learning. When it was Josie’s turn, she told us that a new flare-up had just started last night, and she couldn’t sleep because she had such a full workweek ahead and worried how she’d make it through. She was also scared it would get as bad as it had been a couple of months ago, when she had to be hospitalized and put on much stronger medication with heavy side effects.

Chronic pain in the US

Chronic pain affects more people in the US than diabetes, heart disease, and cancer combined: more than 100 million adults. More than half of them feel they have little or no control over the pain. It often negatively affects concentration, energy level, sleep, and overall quality of life. More than 80% report feeling depressed because of the pain. It often negatively affects concentration, energy level, sleep, and overall quality of life. More than 80% report feeling depressed because of the pain. And let’s not even mention related health-care costs and overall costs for society including number of sick days, prescription drug abuse, and other forms of self- medication—a syndrome that is well-depicted in the recent Jennifer Aniston movie Cake. While pain medication is a blessing, it often doesn’t relieve all of the pain, and it also comes with serious short- and long-term side effects. One student told me: “Living with chronic pain is like having another full-time job. The extra time it takes me to just get out of the house in the morning, the doctor and chiropractor visits, the extra time I need for soothing and self-care, just so I can still work my regular job. And let’s not mention the extra money I need to spend.”

What is pain?

Let’s start with a simple question: What is pain? We could say pain is the body’s way to tell the brain “Pay attention! There is something wrong.” And, as such, the pain response is immensely helpful. We actually couldn’t have survived as a species without this mechanism. In some rare cases people are born with an inability to feel pain. They might step on a nail and not notice it. They suffer from many infections and often untreated fractures of the bones, because the system to alert them to pain just isn’t functioning.

Acute versus chronic pain

What about chronic pain? My personal theory is that chronic pain could be seen as a malfunctioning side effect of evolution. Think about it: Let’s say you tear your meniscus, the cartilage in your knee. It’s painful. After a while you get surgery because it’s not healing. But after the surgery and healing phase your knee is still in pain. Your doctor says, “Well, there isn’t really anything I can do now. I can give you another prescription for your meds but otherwise you’ll have learn how to live with that.” Wouldn’t it be nice to be able to switch off the pain at this point? You know everything you need to know, so now pain’s job to alert you is done. But no such luck. Instead the pain keeps telling you over and over: “Pay attention! There is something wrong.” This constant alerting is exhausting to the nervous system, as anyone suffering from chronic pain will tell you. And, if that’s not enough, research shows that the pain threshold is lowered over time: At the extreme, even slight touch can be felt by the alerted brain as pain. Pain doesn’t seem to be something we can get used to, allowing it to fade into deep background, like sounds or sights. Instead we have to learn how to live with it. And mindfulness practice is a wonderful opportunity to do just that. It helps to shift the locus of control from the outside (“this is happening to me and there is nothing I can do about it”) to the inside (“this is happening to me but I can choose how I relate to it”). We learn to attend to our experience in a kind, curious manner instead of fighting or denying it. We learn to cope with the pain in new ways. Some studies on pain suggest that the greatest benefit from learning mindfulness meditation is the coping. For example, studies show that the reported quality of life goes up while the “objective” pain ratings don’t change much. A regular meditation practice (which can include short and long sessions and everything in between) is the best ongoing foundation for working with pain. It helps us to hone the skills we need to attend to pain—or any challenging experience we encounter for that matter.

Suffering is optional

Before we look at working with pain in more detail, let’s start out with a bigger picture perspective. You might have heard the saying, “Pain is inevitable, suffering is optional.” While this is an easy-to-remember phrase, most people still wonder “How exactly does that work?” Let me explain. Insight meditation teacher Shinzen Young came up with the following equation: “Suffering = Pain x Resistance.” We can safely say that pain is a constant in life, whether it is physical or emotional pain. And during moments when it’s not affecting you, for sure somebody you care about is in pain. When you’re in pain and you really hate it, what happens to your suffering? It goes up, doesn’t it? And yet, at another time when you have the same or a similar pain but you don’t resist it or you don’t worry about it so much, what happens to suffering? Doesn’t it go down? Of course is does. That’s common sense. At this point I love to be a little provocative to really make the point: According to this equation, if there is zero resistance, what happens to suffering?… Right?? Suffering would turn out to be zero as well! Do you believe that? Can you give me an example where you had pain but zero suffering? When you were okay with it, even though it did hurt? When I ask this question in a class people are often stunned at first but then they do come up with great examples: When I had my baby, it hurt like hell, but I didn’t care, I was so excited to be a mom soon.” “When I lift weights that often really hurts, but it’s okay. That’s how I grow stronger.” “I recently got a new tattoo on the inside of my arm. Super painful, but zero suffering, that’s what it takes.” And even people with chronic pain have told me, “I can be in severe pain, but if my mind is not worried and I don’t fight it, I can feel deeply okay in that moment.” It’s normal to resist pain or to worry about what’s wrong. It’s normal to suffer when we’re in pain. But it feels so normal that we forget pain and suffering are NOT the same. We could say pain and suffering are like twins—fraternal twins, not identical ones. Armed with this equation, we can move into the exploration of pain in a very different manner.

The box we call PAIN

What we call pain is actually a conglomerate of three components: the actual physical sensations, the emotions we have about the pain, and the meaning the pain has for us and our life, which we call “the story.” They are lumped together in our experience as if they only coexisted together in a box labeled PAIN. Let’s imagine we give the sensations, the emotions, and the story each the value of 10. This box and its confinement would be like multiplying the power of its content: 10 x 10 x 10 = 1,000. Of course this is easily overwhelming and many people will try to never look into the box anymore. They just try to avoid the box at all costs. Mindfulness—which you could also call loving awareness—gives us a different approach to work with the content of the box. It helps us to open it up and take what’s in there out into the light. We take the contents of the box out into the open field that mindfulness provides. We turn toward the pain instead of away. We stop either running away or fighting it. We open the door to acceptance in a kind and accessible way. We can now look at each of the three components of pain separately: The physical sensations are different from the emotions I have about the pain, which is different from the story I tell myself about it. Of course they all intimately influence each other. But once I know that they’re not the same I can start working with them separately and they become much more manageable. I can simply feel the sensations for what they are. How strong are the sensations? What are the main qualities right now? Stabbing? Tearing? Pressure? Heat? I can feel what emotion I have about the pain in this moment, and once again in the next moment. Is it sadness or more frustration? Anger? Fear? And I can see how the story, the meaning, deeply influences both how I feel about the pain and how I actually experience the unpleasant sensations. Breaking down the components decreases the ping-ponging back and forth, with its dangerous potential to spiral out of control. It becomes more like a 10 + 10 + 10, which equals 30. I might not be able to handle 1,000, but I can handle 30. I asked Josie to place attention on (or “feel into”) the unpleasant sensations in her belly and asked, “If somebody who never had this pain before was feeling what you feel right now, what would they make of it?” She closed her eyes and felt into her belly. She was silent for some time. Then we could see something change in her face and she started to softly cry. She said, “They would think they have an upset stomach.” In that moment Josie could see that the actual pain was just that: unpleasant, but not overwhelming. And that the overwhelm she had felt came from her worries about what might happen in the next couple of days and even months ahead. Her suffering was mostly from her fear, not from the pain in her belly. And with mindfulness and compassion, she was able to stay in the present moment. One moment at a time. Vidyamala Burch, author of the books Living Well with Pain and Illness and You Are Not Your Pain, has a history of multiple broken vertebrae after a car accident. After a very long period of struggling and fighting with the pain before starting a dedicated mindfulness practice, she reports, “For many years I saw my back pain as a sign of failure and tried unrealistically to find cures instead of taking responsibilities for my reactions to the pain. When I saw that the pain was a natural part of life, I felt relief. I realized my lack of acceptance was far more painful than the back pain itself.” Harnessing the power of self-compassion with the wisdom of mindfulness practice we can approach pain in a new way and get to know it and befriend it in ways never thought possible. Suffering really can become optional. More and more moments at a time.

Two Mindful Practices for Working With Your Pain

  1. Practice Self- Compassion
  1. Ask yourself: What would the kindest response to this level of pain be right in this moment under these circumstances?
  2. Try this simple practice (courtesy of Kristin Neff):• Acknowledge the pain: “Yes, this hurts right now.”• Emotionally and mentally connect to the brother or sisterhood of people with (your kind of) pain. Specific example: “This is what it feels like for a young man to have lower back pain.”• Offer kindness to yourself: “May I be kind to myself,” “May I not close down my heart,” or a similar phrase.
  3. If you are feeling low on resources—maybe tired or stressed out from work—and it feels like way too much, why not distract yourself? Watch a movie, read a novel, call a friend. In short: use the self-medication that works the best for you—and hopefully is not illegal. These activities can also help to recharge you.
  1. Turn Toward Pain If you feel like you can work with the pain, do a quick inventory: How strong are the sensations? The emotions? The story (mental worry)? Which of the three is predominant? If the image works for you, picture a pie chart. Right now, which part has the biggest slice of the pie? Work with that one.
  1. Sensations: Place attention on, or “feel into” (as I sometimes say), the physical pain. Does imagining breathing into it help? Be curious and specific. Stay with what’s there now, not what was there last time or five minutes ago. What is the exact size of the pain? How much of the body is NOT in pain? (I once worked with a student with severe back pain who realized that the pain he experienced as debilitating usually accounted for only a quarter of his sensations—while the rest of his body was pain free. That was a big breakthrough for him.) Where is it located? What are its qualities? Is it sharp, rough, dull, burning, pressing, flashing, undulating, stab- bing, tearing? If you relate to scales: What intensity does it have on a scale from zero to 10—zero being no pain and 10 the strongest pain you can imagine? Stay with the sensation in this way as long as you find it helpful. Experiment with softly naming to yourself what you find. Pay particular attention to change over time. Unexamined pain often feels like it’s unchanging or always present. Prove that wrong by paying attention.
  2. Emotions: What emotions are related to the pain? Work with the most obvious ones but be open to allowing them to shift and change. Feel them in your body and softly name them. Allow them to be here—not because you like them, but because they are here. If you know the practice, work with the RAIN acronym: Recognize Acknowledge Investigate with kindness Non-identify It can be very helpful to use the sentence: “This is what anger feels like,” “…what fear feels like,” “…what sadness feels like.” It’s just an emotion that every human being feels at times. It is not who you are.
  3. Thoughts or “the story”: What is the story you are believing right now? That it will never get better? That you won’t be able to do x? To be y? To become z? Recognize it as just that: a thought. It’s not who you are and we don’t really care much about the content at this point. We can just let the story be and drop into the background, because we choose a different focus, like the breath.