Pain is such a complex event and the recently published guidelines in the Lancet on the treatment of back pain asks both practitioners and the public to change their views on the treatment of pain. It is recommending far less surgery, no more injections, less pain killers and to understand that pain means understanding the whole person in pain and not simply the pain in the person. A blogger recently put it well by saying that instead of looking at someone under a microscope, we need to look at them under a macroscope.
Despite this complexity I thought the other day of one word that almost seems to summon up those living with persistent pain. That word is AGENCY.
This philosophical, sociological and psychological term basically means we are able to act in our environment, that we exhibit free will that allows us to perceive something, think about it and perhaps have some emotions attached to it, then move our bodies to complete a task that we see as necessary. We are goal driven and our movements in the world are purposeful.
However the world can throw up curve balls and challenge us. The world though mostly safe for us in the West, can be uncertain and even frightening. Our brains are geared by natural selection to be worried about things- ” he looks strange, I think I will cross the street”, ” that driver might not have seen me, I need to be cautious”. These thoughts are often unconscious and guide us to make good choices as we move towards our goals.
Although the world may be uncertain and at times fear inducing, generally throughout our lives, we have bodies that we can rely on. We have faith in our bodies to be able to carry out our will. Then persistent pain or indeed chronic illness comes along and it may be the first time that we realise that our bodies are not behaving the way we expect them to. This can be a massive source of stress, bewilderment, frustration and fear. Suddenly the one thing we thought we could truly trust appears to have let us down.
What this creates is the need to start paying a good deal more attention to our bodies. I have used this analogy from phenomenologist/ philosopher Anthony Chemero before , but it serves serves this blog well so I shall repeat. He likens it to having a ride on a bicycle; when the bike is working well our thoughts are on the journey, our destination, the scenery or the lights ahead. However if the gears start slipping or the breaks are not working well we have to start to pay attention to the bike. So pain can not only frighten us, but can get us to think a lot about our bodies, to lose trust in them and to start ruminating. Indeed one of the strongest predictors of ongoing back pain, far more predictive than an MRI (which actually has quite low predictive value), is the Pain Catastrophising Scale and within that scale the ruminative questions are the most predictive of future pain (examples being “I cannot keep the pain out of my mind” and “I keep thinking how badly I want the pain to stop”).
So modern treatment of pain aims not only to alleviate the degree of pain (which is actually the most difficult aspect of pain treatment), but to reduce fear, reduce rumination, to get people moving towards their goals again, doing the things they used to do that gave them pleasure, and through this and a good understanding of pain, to start to learn to trust their bodies again. In other words, to restore our sense of agency
The last thing I want to say comes from watching a panel of chronic pain sufferers take questions on their experiences of pain and their treatment, from attendees, who are therapists working in the pain field, at The San Diego Pain Summit. Although they said many things that were profound, one particular speaker made a statement that really hit home. When asked about his feelings of what mattered most in the road to healing, he said you have to learn to own your pain and to truly accept it before healing can start. This can be quite a harsh statement to many living with pain. But I do feel when I treat some people who have been really struggling with their pain, that they often have the view that their pain is something that is like an alien invasion and something that needs to be ejected from the body. Of course this will set up a lot of suffering remembering that pain in life is inevitable but suffering is optional. Pain, like the dark thoughts we sometimes have, are as much a part of us as love and joy, but are unwanted. However as the Buddha teaches us, the more we fight it, the more it sticks to us.
This understanding bought me to undertake the Masters in Mindfulness. I wanted to use it to help people with this very difficult aspect of living with pain. Interestingly though, it turned out I needed a fair bit of healing myself, so my mindfulness practise has been an ongoing journey into getting to know all aspects of myself, including embracing those aspects that I might have wished were different.