Compelling talk from Dr Alex Cahana at a TEDx a few years back
[youtube https://www.youtube.com/watch?v=VF_WQK0eWik?rel=0&w=560&h=315]
“…Pain is not something that you feel…
it is something that you DO”
Dr Cahana is an Affiliate Professor in Anesthesiology and Pain Medicine and a Professor in Science, Technology, Education and Health Studies at the University of Washington. He’s written some interesting papers taking a phenomenological look at pain, including his PhD thesis – Why Does Pain Hurt? Husserlian Phenomenology as a Method to Investigate the Experience of Pain, and on the ethics of pain treatment. Dr Cahana wrote a Clinical Update for the IASP on Pain and Philosophy of Mind which is a good read, if you are into that kind of thing…
Despite the fact that everybody knows intuitively that pain hurts, neuroscience today is incapable of explaining (knowing) why this is so. To bridge this gap, a new approach is needed. This approach (referred to by some as the “enactive” approach) posits that cognitive science, with its array of new concepts, models, and experimental techniques that advance knowledge of the mind beyond earlier stages of psychology and philosophy, has lost its grounding in the human subjective experience. This loss has created an unbridgeable chasm between the subjective mental state of the whole person and the subpersonal cognitive routines implemented in the brain. This breach between mind and meaning, subjectivity and consciousness is not trivial. It impedes progress in understanding consciousness in general and pain in particular.
There’ll be a bit more philosophising in some coming posts.
-Tim Cocks
Thanks Tim – Looking forward to more posts like this.
We always teach and articulate pain as an output, a construction, something you make so pain as “something you do” resonates. It gives choice too – i.e. you don’t have to do it.
David
Pain as a verb is a useful convention to adopt. And good philosophy is absolutely indispensible. I can see a time in the not-so-distant future where philosophy will overtake science in the treatment of chronic pain because it will have proven itself as being more practical and powerful.
The thoughts that cause pain need to be reframed, but first they need to be identified. This can be difficult because the problematic thoughts will necessarily reside in the subconscious. One needs to be very skilled at observation if the offending thoughts are to be identified without the client’s awareness.
I like to use the following general sequence (in order):
– Get the meds right. A good GP or specialist can check dosing and type.
– Stack the SIMs. Don’t worry too much about addiction potential at this stage. Pile up anything which creates a feeling of goodness and/or safety. If a client says that eating chocolate cakes makes her feel safe, I’m fine with that as a short term measure.
– Be willing to relax the body with movement. Letting go of ‘body armour’ and getting used to the vulnerability. Move from vulnerability to safety by relaxing even more.
– Utilize the relaxed state to introduce suggestions which reframe the negative beliefs.
– If the above is not enough, maybe introduce meditation. I’m still reluctant to teach this because of my lack of attainment, but will do so occasionally. Meditation can also be used to identify subconscious DIMs, since they tend to bleed through when one starts practising properly.
EG
I could be wrong, but I’m starting to think that the whole chronic pain thing might be a lot simpler than we recognize. Not necessarily easy, but probably quite simple.
On any given day, 60-70+% of our thoughts are negative. Negative means fear-based. And fear is the single most powerful cause of pain issues. So if most thoughts are negative, and such negativity causes chronic pain, then the solution is just to think less. Can anyone disagree with this?
When I read about how powerful knitting was for people with chronic pain, I was quite stunned. But I can see how such a flowing, repetitive, high-concentration activity would cause thinking to reduce…. and with it, pain. Just like meditation, only easier.
Can the pain equation be reduced to the following? “We feel pain when we have too many negative thoughts”. Can this be disproven? I know it sounds ridiculously simple, however I think it might be true.
If it is true, do we need more research or just more time helping clients to practice?
Yes I can disagree and I think we need a lot more research EG, in fact heaps more research. For example, who says 60-70% of thoughts are negative, or that negative must be fear based or that negativity causes chronic pain?. Positivity can be fear based as well
The “formula” that has been proposed and discussed in recent articles and handbooks (eg The Explain Pain Handbook) sounds deceptively simple – “we will have pain when our brain’s credible evidence of danger to our body is greater than credible evidence of safety to our body”
It includes the key and perhaps complex notions notions of credible, danger, to our body, the danger/safety balance.
Cheers
David
PS – I have always had a wide view of the term “research”. Its real meaning is to “investigate systematically” and the term has been hijacked somewhat by the positivist numbers people, ie you are not doing real research if you aren’t doing something with an aim of getting it into a particular journal. Healthy growing discussion as we aim for on noijam is research in my view. I suspect you may agree?
Cheers
Hi Dave,
That 60-70% number was from something I had in my notes, but since I can’t find the reference, let’s forget that and use logic instead. The logic is actually more convincing.
The natural resting state of the mind is a very high-level happiness. We know this from meditators who manage to temporarily put a stop to all discursive thought, and as a result experience bliss. This means any mood other than bliss must be caused by the overlay of negative thoughts.
You say “positivity can be fear based as well”. Yes, particularly so! If positive thoughts WEREN’T based in negativity then the ‘Positive Thinking movement’ would have been a huge success… instead it’s failed dismally.
You argue for the complexity of the “notions notions of credible, danger, to our body, the danger/safety balance”. Why does it have to be complex? I don’t think it’s complex at all!
‘Credible’ just means it’s likely to be believed as opposed to not believed. Belief = expectancy, and we know how powerful expectancy is from all the placebo studies.
‘Danger/safety’ – saftey we don’t need to worry about because it doesn’t cause pain. Danger, or credible danger is just fear, ie. expectancy of threat or pain. Fear has been identified as the one huge, overiding element in the pathogenesis of chronic pain.
You ask “who says ….negative must be fear based?” They’re synonymous, aren’t they? I can’t think of a single negative thought which is not based in fear.
Even a benignly negative statement like “I don’t like the weather today” hides an anxiety. The fact that he doesn’t like the weather mirrors a very slight expectancy of discomfort.
I want someone to see if they can rip apart the following statement, because I’m confident this is how things work: “We experience pain when there are too many negative thoughts”.
Can we allow it to be that simple or do we need it to be complex? If it’s just plain wrong, tell me where it’s wrong.
Regards, EG
Hi EG
“nobody loves me” or “I hate myself” or “i’m good for nothing” might be considered negative thoughts, but are they fear based? Certainly one could probably find a way to reduce them, via a series of seemingly logical steps, to fear, but why – why reduce everything down to an arbitrary negative thought=fear?
Is “benignly negative” perhaps an oxymoron?
In regards to your challenge….
1. “Too many” compared to what?
2. “negative” in what way, “negative” according to whom?
3. Only conscious ‘thought’?
4. What about the case of an acutely sprained ankle in an individual who really understands pain, knows that the ankle will fully recover in a matter of weeks, knows how to initially protect, and then gradually rehab the ankle, knows that her friends, family and employer will all support her and so on, will the ankle still hurt? I suspect it might (but with all these SIMs present perhaps less than in someone with no knowledge, support, understanding etc)
I think fear is a factor in pain – i think it has to be, but the *only* one, I’m not so sure.
Thanks as always for provoking thought and discussion here
My best
Tim
“Certainly one could probably find a way to reduce them, via a series of seemingly logical steps, to fear”
Ahh, you know me well! That’s exactly what I would have done. I like to reduce anything complex because when it comes to practice, complexity doesn’t fly (for me anyway). So long as I am confident that I haven’t lost anything in the process, I need a very simple processes to follow. I can’t be entertaining complex thought patterns when I’m with the client. If anything I want to do the opposite.
“why reduce everything down to an arbitrary negative thought=fear?”
I probably wouldn’t have thought of doing this myself, but a couple of guys I read made very elegant arguments for the way fear underlies all our problems. So I like to use their work. It made perfect sense to me, and again, it’s easy to use in a practical sense.
I like your other questions. Well considered. You should write more stuff on here!
1. “Too many” compared to what?
Compared to a threshold level. Trip the threshold and pain appears.
2. “negative” in what way, “negative” according to whom?
It’s not me as therapist making the determination. ‘Negative’ is determined by the body and mind of the sufferer. The body and mind both suffer when thoughts are negative (proven). It works well to think of ‘negative’ as”lack of the positive opposite”. eg. feeling insulted = lack of respect. So rather than one focussing on feeling insulted, one is free to win respect. It opens things up.
3. Only conscious ‘thought’?
I think powerful emotions tend to be the domain of the subconscious, which is why symbolism and metaphor work so well.
4. What about the case of an acutely sprained ankle…
…or perhaps any accidental pain where the sufferer appears to be a very positive and supported person?
Yes I considered that. I don’t want to be too explicit here, but say you have a team of sports people. Not everyone in the team sprains his/her ankle over the course of the season. The example you gave – she will recover fully and quickly. She won’t develop chronic ankle problems.
Regards, EG
Hi EG,
For me its just TOO simple. If 60-70% of our thoughts are negative, why aren’t 60-70% of people in pain. I also think your hypothesis needs fleshing out – as it is, it is belittling to some people in chronic pain. and I am sure this is not your intention. Perhaps you could find your papers, write it up, defend it and submit it somewhere?
Cheers
David (en vacances)
En vacances… hopefully not in the Pacific! Satellite images are amazing.
But the meditation research is convincing in terms of there being a natural resting state of high-level happiness. This happiness is then disturbed by a preponderance of negative thoughts which we all do constantly. To me, this logic is quite watertight – joy is our natural, undisturbed state. In this sense, joy is not something to be achieved. In fact it can’t be achieved, only uncovered.
“If 60-70% of our thoughts are negative, why aren’t 60-70% of people in pain?”. Firstly, I’d argue that we ALL live in a markedly sub-optimal state because of this tendency towards negativity. And when either 1) the percentage or 2) intensity of negative thoughts gets beyond a threshold level, then pain appears. Maybe the percentage threshold is 90%? Maybe the intensity threshold is 8/10?
Belittling? I’ve seen this process in myself, and I’m quite ok with it! I don’t feel embarrassed or ashamed about having pains which appear and disappear as my thoughts change. More importantly, what I see in clinic corroborates this very strongly. The most spectacular and rapid resolutions of severe and chronic pain have always been as a result of reframing negative thought patterns.
But, I never do this directly. I never mention thoughts or pschology or anything like that as part of treatment. It’s just not the way to go. It must be done without the client’s awareness, otherwise it triggers shame/embarassment. If I could say one thing to new graduates it’s this – learn to do this stuff in a very subtle way without triggering the client’s ego defenses.
Hi Tim,
In answer to the question “What if pain was a verb?” Then let’s first understand what a verb is…..
“A verb, from the Latin verbum meaning word, is a word (part of speech) that in syntax conveys an action (bring, read, walk, run, learn), an occurrence (happen, become), or A STATE OF BEING (be, exist, stand)”….my emphasis added.
If we can accept the fact that one can BE in a STATE of pain, “paining” then one has to accept that other thoughts, other feelings and other emotions can influence our pain. If one then accepts this then one can accept that our reasoning can change our “paining”. Thus, ultimately we have the power to rule over our pain rather than be ruled by it, just as we have a chioce over each and every emotion as to whether we take it nto the realms of the positive or negative.
As the words love and hate are verbs so too is pain. Paining is an emotion, a STATE of being over which we have choices……..
DB
London 😱😳😃
Hey David
Thanks for your thoughts. I think the analogy to love is quite pertinent – something that we *do* rather than some ‘thing’ that we do (or don’t) *have*.
How important the notion of choice – perhaps very tough for anyone who has experienced pain for a long period of time without up to date knowledge, but it brings in further notions of changeability and freedom of expression – two of our favourite ideas at NOI as you know.
TC
NOI HQ (While the cat’s away…)
Hi Tim?
Yes knowledge is key and the more knowledge we have the more choices we have. Without the knowledge that I have acquired through NOI and beyond my daily paining would still be way up on the “Protectometer” pain scale.
DB
London 😀
Alex in the video is saying that stressed mice become hypoalgesic, and draws a parallel between that and the ‘wounded in battle’ scenario of men at war.
‘Threat to body’ obviously cannot be part of the ‘pain equation’. I argued this point on the ‘Self Matters’ thread, that it’s the self, not the body which determines whether pain is experienced.
There’s also this statement (taken from http://www.ncbi.nlm.nih.gov/pubmed/24278302): “The repetitive nature of social conflicts seems to favor an induction of hyperalgesia OR hypoalgesia, both in rodents and humans.
It can go both ways? Hypo or hyper-algesia? It’s obvious what’s going on. Chronic psychological stress causes hyperalgesia. To the degree that the experimental mice then dissociate, so they then trip into a hypo-algesic state. It all depends on the degree of self-referencing. Perhaps this tells us mice have a primitive ability to self-reference.
People under enromous duress have been heard to say: “I’ve gone numb”. Reduce the amount of stress and the pain will start to become apparent…pain that has been caused by a pile up of negative thoughts.
Anyone with pain, please note that by saying that ‘chronic pain is caused by an excessive load of negative thoughts’, this does not apportion ANY blame or responsibility onto you for what’s going on. If anything I hope that my contributions here give hope for recovery. Pain is a not a static thing – it’s created afresh every waking moment.
Hi EG
Interesting paper – thanks for the link.
Tim
Since Tim has kindly introduced the topic of phenomenology in this thread, I’d like to link to an interview of the subjective experiences of an extremely experienced meditator.
Why is this important? Well, the process of complete meditative absorption causes the self to vanish. Why is this important? Because the self causes pain, and pain is our concern as therapists and patients.
Note in particular his response to question (9). Allow for the fact that he is not versed in modern pain science (he is unaware that a crushed disc and tooth decay can exist as pain-free conditions), and consider instead the rest of his response regarding pain. Kidney stones are regarded as ‘extreme’ on the pain scale, as most health professionals are aware.
Allow also for a few unusual Pali words and references – it’s just part of the territory when you look at any spiritual practice, unfortunately. I’m not encouraging anyone to take up Buddhism or an ‘ism’, ok? I feel like I have to say that every time. Its just that the early buddhist dudes did look into the nature of mind on an extraordinary level, and by comparison, modern philosopy of the mind looks quite feeble.
http://possiblyunknown.blogspot.com.au/2009/11/personal-experience-of-ecstasy-jhana.html
Hey EG
Have you read any of Evan Thompson’s work – reckon you’d love it. He has considered meditative practices in a modern philosophical and neuroscientific light. I’ve got a number of his papers, email me if interested.
My best
Tim