The ABC’s of Chronic Pain

By Dennis Bell, MA, MLP

Introduction

Throughout my years as a mental health therapist, chronic pain is one of the most common issues I see in clients, though they don’t usually bring it up without my prompting. We often think of pain as something to share with our primary care doctors or a specialist, thinking—Why talk about a physical health issue with a mental health provider? But in reality, chronic pain impacts our mental health in many ways, and there are a variety of mental health approaches that can help manage it.

In a class I used to offer on the topic, I introduced the following five-pronged approach to managing chronic pain: awareness, biofeedback, coping skills, diet, and exercise. As you read through these five descriptions below, please keep in mind the high degree of overlap and interaction between them. They should be considered as parts of a whole approach toward chronic pain management instead of as separate topics in and of themselves.

Awareness

Many people with chronic pain try to find treatments that distract them from their lived experience. As such, awareness of their pain is the last thing that comes to mind when they consider how to manage it. But there are benefits to tuning in.

A mental health treatment approach called Mindfulness Based Stress Reduction (MBSR), developed by author and professor emeritus of medicine Jon Kabat-Zinn, is based on the premise that mindfulness and enhanced awareness helps people better cope with chronic pain conditions. Kabat-Zinn’s (2013) meditation-based approach encourages individuals that suffer from chronic pain to acknowledge the obvious negativity of their experiences while also providing space for the good.

MBSR emphasizes that when we try to avoid feeling any bad feelings, we often block out the good ones as well. Therefore, by allowing ourselves to be aware of pain that is already there, we can save the energy we’ve been unknowingly using to block it out and put that toward something more productive.

Kabat-Zinn also points out that our thoughts influence our experiences. For example, if we think “I can’t do this” or “It would kill me to be aware of how much I hurt,” we tend to be right. But if we put in some work in shifting our response to pain, we can recognize that those negative or anxious thoughts aren’t the pain itself—these thoughts may be enhancing how much we register the pain (Kabat-Zinn, 2013).

Biofeedback

Clinically, “biofeedback” refers to a process where therapists use electronic monitoring to help patients gain control over physiological functions, such as heart rate or muscle tension. I am using the term here, though, to describe how developing a mindful awareness of pain patterns can help those who suffer from chronic pain learn to better regulate their responses.

For example, a big realization for many people that I’ve worked with, once they’ve started to build more awareness of their pain patterns, is that pain is not as constant as they tell themselves it is. There are bad days and good days, or at least there are better days; but without awareness, sufferers of chronic pain have a tendency to lump it all into the same static experience of ‘bad.’ Allowing ourselves to have awareness of how pain ebbs and flows means we can start to adjust or adapt our behaviors, utilizing coping skills to head off a bad peak when it’s getting worse, or recognizing what types of diet or activities will help us feel better or worse.

Coping Skills

One of the primary coping skills recommended by Kabat-Zinn is what he calls the body scan. This is a practice that is part coping skill and part awareness-building tool. It is described as follows:

The body scan meditation is commonly practiced by lying on your back and moving your mind systematically through the different regions of your body. We start with the toes of the left foot and slowly move through the different regions of the foot and left leg, inhabiting each region for a stretch of time in full awareness, tuning in to any and all sensations we might encounter. Move up through the leg to the hip and then start with the other foot, next is the torso, low back, abs, upper back, chest, shoulders, armpits, hands, arms, neck, throat, and finally the face, back of the head, and top of the head (Kabat-Zinn, 2013).

Another coping skill, that may be a less obvious approach, is exposure to nature. Author Meghan O’Rourke (2022) describes this as being helpful on her own personal path of chronic illness in her book, The Invisible Kingdom: Reimagining Chronic Illness. O’Rourke highlights a study in her book in which hospital patients recovering from surgery who had window views of nature healed faster than those who could only see the building’s brick walls (Ulrich, 1984). This study may provide hope to those sufferers of chronic pain who find that going outside is no longer within physical reach; it turns out that even just looking at nature is a potential source of relaxation and healing.

Deep breathing exercises are another example of coping skills that can reduce suffering around chronic pain. My recommended standard is 4-4-8 breathing. The instructions for this method are to breathe in slowly through the nose for a count of four, hold the breath for another count of four, and then breathe slowly out through the mouth for a count of eight. This breathing technique can reduce anxiety and tension. It can even cut off a developing increase in symptoms, especially if the person is aware of them starting to build up.

Diet

Diet is an area of discussion that often falls through the cracks for people with chronic pain as medical doctors may avoid making recommendations and mental health therapists may compartmentalize it as a medical topic. But research shows a wide range of potential positive impacts on pain through dietary interventions. In a meta-analysis from 2020—a study that pools evidence from multiple studies on the same topic to draw conclusions—researchers pinpointed a number of dietary changes that can lead to positive shifts in pain, including calorie restriction and fasting, low carb diets, low fat vegetarian diets, high protein diets, and elimination diets (Dragan, et al., 2020).

As our awareness of the interaction between physical and mental symptoms increases, we can keep track of what we eat in a food journal. This tool can help us determine which foods increase or decrease our pain and then decide if the risk of that pain is worth the tempting but often-unhealthy food choice. If being overweight or having diabetes are contributing factors to the chronic pain, our diet will have an even more profound effect on how we feel on a daily basis.

Exercise

Research results are mixed on the impact exercise has on chronic pain. In a meta-analysis 2017, researchers found that “exercise did not consistently bring about a change (positive or negative) in self-reported pain scores at any single point.” However,  a more consistent positive impact on overall physical functioning was reported, indicating that exercise may not necessarily shift the subjective experience of the pain, but it can help increase functioning and confidence in managing physical tasks (Gennen, et al., 2017). We can better conceptualize this through considering the way runners or other consistent athletes describe themselves as experiencing pain while competing but also knowing, through their training, that it’s pain they can handle. The same may apply to those of us dealing with chronic pain as we find our limits through exercise.

In Conclusion

If you are dealing with chronic pain, I hope you find these ABC’s helpful. Remember that awareness of your pain is not the enemy, and that utilizing it can assist you in better understanding the factors that contribute to pain, thereby helping you maintain greater stability with your condition. I also hope that you will experiment with diet and exercise to find what works best for you, knowing that both factors can play a role in the daily management of pain.

Remember to practice your coping skills, such as actively engaging with nature and employing breathing techniques, during times when your pain is more relaxed so that when you are in distress, they will feel more natural and accessible to you. Finally, if you are already seeing a mental health therapist, consider talking to them about your thoughts and feelings around your pain. Research is proving more and more that the phrase, “pain shared is pain lessened,” is not just a wishful adage, but in fact a biological truth.

 

Works Cited

Dragan, S., Serban, M.C., Damian, G., Buleu, F., Valcovici, M., Christodorescu, R. (2020). Dietary patterns and interventions to alleviate chronic pain. Nutrients, 12(9), 2510. doi: 10.3390/nu12092510.

Geneen, L.J., Moore, R.A., Clarke, C., Martin, D., Colvin, L.A., Smith, B.H. (2017). Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database of Systemic Reviews, 4(4), 011279. doi: 10.1002/14651858.CD011279.pub3

Kabat-Zinn, J. (2013). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. Bantam Books.

O’Rourke. Meghan (2022). The invisible kingdom: Reimagining chronic illness. Riverhead Books.

Ulrich, R.S. (1984). View through a window may influence recovery from surgery. Science, 224(4647), 420–421. doi: 10.1126/science.6143402