Coping with physical pain

Full disclosure: I'm pretty good at dealing with physical pain. I bear pain silently and stoically. Mostly. 

But as somebody said, "Pain is inevitable. Suffering is optional." Pain and suffering are not the same thing. Pain is a physical sensation; suffering is how we choose to experience it. Bhikkhu Bodhi wrote,

The Buddha compares being afflicted with bodily pain to being struck by an arrow. Adding mental pain (aversion, displeasure, depression, or self-pity) to physical pain is like being hit by a second arrow. The wise person stops with the first arrow.

In the dentist's most people don'g even wait for the first arrow. They jab themselves with second one -- aversion, displeasure, depression and self-pity -- as soon as I hear "open wide." Obviously, this points to an area of my practice that needs more work. This example also shows us that pain and suffering really aren't the same thing, because we can have suffering without pain. Can we also have pain without suffering?

The word suffering has a special significance in Buddhism. In his teachings of the Four Noble Truths, the Buddha said that life is suffering. Of course, the Buddha didn't speak English; what he really said was that life is dukkha. Dukkha is not just about painful things. Anything that is temporary, limited or imperfect is dukkha. The most pleasant experience you ever enjoyed was dukkha, because it ended.

Although we associate the word suffer with unpleasantness, the word means many things -- to abide, to accept, to bear, to endure, to support, to sustain, to tolerate, to experience, to feel, to know. In other words, suffering is about relating to something else. In order to have relationship, there must be at least two things -- a sufferer and an object of suffering.

And here we touch on the heart of the matter -- Who is it that suffers? What is the self? And,What is separate from the self? Suffering depends on self-reference, with perceiving oneself as a finite entity plagued by some outside Other. Perhaps suffering isn't a bad translation fordukkha after all.

We read in the Tripitaka (Visuddhi Magga):

Mere suffering exists, no sufferer is found.
The deeds are, but no doer of the deeds is there,
Nirvana is, but not the man that enters it.
The path is, but no traveler on it is seen.

When touched with a feeling of pain,
the ordinary uninstructed person
sorrows, grieves,
and laments, beats his breast,
becomes distraught.
So he feels two pains,
physical and mental.

Just as if they were to shoot a man with an arrow and,
right afterward,
were to shoot him with another one,
so that he would feel
the pains of two arrows.

–The Buddha

Let’s start with a basic question: What is pain?

Physical pain is the response of the body and the nervous system to a huge range of stimuli that are perceived as noxious, damaging, or dangerous. There are really three dimensions to pain: the physical, or sensory component; the emotional, or affective component— how we feel about the sensation; and the cognitive component—the meaning we attribute to our pain.

Let’s say you’ve got a pain in your back. You can’t lift your children; getting in and out of the car is difficult; you can’t sit in meditation. Maybe you can’t even work. That’s the physical component. But you’re having to give up a lot, and you’re going to have feelings about that—anger, probably—and you’re susceptible to depression. That’s the emotional response. And then you have thoughts about the pain—questions about what caused it, negative stories about what’s going to happen. Those expectations, projections, and fears compound the stress of the pain, eroding the quality of your life.

There is a way to work with all this, based on Buddhist meditative practices, that can liberate you, to a very large extent, from the experience of pain. Whether or not you can reduce the level of sensory pain, the affective and cognitive contributions to the pain—which make it much worse—usually can be lessened. And then, very often, the sensory component of the pain changes as well.

You mean that once you’ve changed your relationship to the pain, the physical discomfort may decrease?

That’s the key point: You change your relationship to the pain by opening up to it and paying attention to it. You “put out the welcome mat.” Not because you’re masochistic, but because the pain is there. So you need to understand the nature of the experience and the possibilities for, as the doctors might put it, “learning to live with it,” or, as the Buddhists might put it, “liberation from the suffering.” If you distinguish between pain and suffering, change is possible. As the saying goes, “Pain is inevitable; suffering is optional.”

There have been studies looking at how the mind processes acute pain at the sensory level. Subjects are randomized between two groups, then given the cold pressor test, where a tourniquet is placed around your bicep, then you stick your arm into ice water. There’s no more blood flow, so your arm gets very painful very fast. They measure how long you can keep your arm in the water as a function of whether you are given an attentional strategy, such as paying attention to the sensations and really moving into them and being with them as nonjudgmentally as you can—a mindfulness strategy, in other words—or a distraction strategy, where you just try to think about other things and tune out the pain. What they found was that in the early minutes of having your arm in the ice water, distraction works better than mindfulness: You’re less aware of the discomfort because you’re telling yourself a story, or remembering something, or having a fantasy.

But after the arm is in the cold water for a while, mindfulness becomes much more powerful than distraction for tolerating the pain. With distraction alone, once it breaks down and doesn’t work, you’ve got nothing.

The Mindfulness-Based Stress Reduction program uses the body scan as well as sitting meditation to manage pain. Can you explain how the body scan works?

The body scan is a variation on a traditional Burmese practice called sweeping, from the school of U Ba Khin, that S. N. Goenka teaches in his ten-day Vipassana retreats. The traditional method involves tuning in to sensation in a narrow horizontal band that is slowly brought down through the entire body, as if you were giving yourself a CAT scan. This is analogous to the way certain metals, such as zinc, are purified in a circular zone furnace. I thought it would be hard for people in chronic pain to sit for forty-five minutes, so I modified the practice. It is done lying down, starting at the toes and moving up through different regions of the body.

This practice is a way of getting out of the head and developing intimacy with the body. The challenge is, can you feel the toes of your left foot without wiggling them? You tune in to the toes, then gradually move your attention to the bottom of the foot and the heel, and feel the contact with the floor. Then you move to the ankle and slowly up the leg to the pelvis. Then you go to the toes of the right foot and move up the right leg. Very slowly you move up the torso, through the lower back and abdomen, then the upper back and chest, and the shoulders. Then you go to the fingers on both hands and move up the arms to the shoulders. Then you move through the neck and throat, the face and the back of the head, and then right on up through the top of the head.

And all the while, you’re in contact with the breath. I tend to have people feel the breath moving in and out of the body region they’re attending to, so that there’s a sort of dual awareness. As you move up the body, you’re learning how to focus on a particular region, then let go of it and move on. It’s like cultivating concentration and mindfulness simultaneously, because there is a continual flow. You’re not staying with one object of attention.

Does the body scan work like a relaxation practice?

The body scan is a meditation practice, not a relaxation exercise. Relaxation is done with a goal in mind. Meditation is about nonstriving and emptiness. If you get into thinking, “I’m doing this meditation to take away my pain,” you’re coming at it with the wrong motivation. Meditation doesn’t “work” or not “work”; it’s about being with things as they are.

What if your pain is so bad that it’s hard for you to concentrate on anything else?

You have a number of choices. Let’s say you have lower back pain. You can say, “I’m going to try to focus on my toes, even in the presence of back pain. The back’s always there; I’ll get to it sooner or later. Why don’t I see if I can really learn to focus my attention where it’s being asked to focus?” Often, when you do that, the felt sense of the pain in the back lessens.

But if the pain is too great, you can go to the region where the pain is and let the breath merge with it. Breathe in and feel the breath, or in your mind’s eye see the breath moving down into the lower back. Then on the out-breath, as the breath lets go, see if you can allow the mind to let go. You’re not trying to shut off the sensations from the lower back—just to experience the fullness of whatever happens as you let go.

Then in the next moment, the sensations and the feelings and the thoughts might all come flooding back, and you’ve got the next in-breath to work with. So it’s a practice.

You develop an observer’s attitude toward the pain?

Basically, you’re intentionally bearing witness to the pain rather than distancing yourself from it; we’re not teaching mindfulness as a dualistic practice. Nevertheless, there’s a sense that there’s the pain, and there’s the observing of the pain. It’s important to understand that as an intermediate step toward ultimate liberation. It means that I can rest in awareness, then ask myself, “Is the awareness in pain in this moment?” And the answer invariably is, “As I look at it right now, the awareness of the pain is not in pain.” When you realize you can rest in this awareness, the pain may be just as intense, but you’re now cultivating equanimity and clear comprehension. You’re seeing the pain as it is, as sensation. There is a knowing that it is not pleasant. But the interpretation that the pain is killing me, or ruining my life, and all the emotions and stories that go with that, are seen for what they are. In that seeing, they often go into abeyance.

What do you tell people who say, “My practice isn’t working: I’m still in pain”?

When you think that your practice should be working, then you’ve already fallen out of your practice and into expectations that the practice is going to achieve some kind of prefigured, desirable result. This need to get rid of is its own form of ignorance, and we need to look at our “I” statements. A worthy object of attention and inquiry is: Who is suffering? Who is in pain? We can ask that, but rather than coming up with an answer qua thought, we can drop into not-knowing and experience simply being aware.

Not that “simply being aware” is easy. When pain arises, the same challenge occurs as when the breath arises. That’s one reason to practice when we’re not in a lot of pain - to cultivate strong practice so we can rely on it when it becomes extremely difficult to practice.

You seem to be saying that pain is just like the rest of life, only more so.

If you pay attention to the little episodes of pain in your life, you can learn how to work with the bigger episodes because you learn about anicca, impermanence; anatta, no-self; and dukkha, suffering. The meditation orientation is not about fixing pain or making it better. It’s about looking deeply into the nature of pain - making use of it in certain ways that might allow us to grow. In that growing, things will change, and we have the potential to make choices that will move us toward greater wisdom and compassion, including self-compassion, and thus toward freedom from suffering.

Some forms of pain are harder to deal with than others, aren’t they? Lower back pain, for example.

Lower back pain tends to be more complex because every time you stand up or move in any way, you may be exacerbating the inflammation or instability. But over time, you can actually dramatically transform your relationship to your back. What we’re talking about is the deep structure of rehabilitation.

The deep meaning of “rehabilitation,” which is related to the word “habitation,” is “learning to live inside again.” And the deeper Indo-European root is ghabh-e, which means “giving and receiving,” like tonglen, the Tibetan Buddhist practice. So rehabilitation is an exchange, in which you’re willing to move into the interiority of your being and work at the boundary with what is, with full awareness and compassion. If you work that edge patiently, with perseverance, motivation, and kindness, if you give yourself over to it with mindfulness, there is the very real possibility of returning home to your body and learning to live inside. We all need to learn to live inside again. We don’t have to have pain to wake up to the fact that we might be happier if we inhabited the totality of our lives.