Addressing the Pain: Learning to Be "Present" in the Pain Experience

   Now is the only time over which we have dominion.  - Leo Tolstoy
   Every situation, properly perceived, becomes an opportunity to heal.  - A Course in Miracles

   Pain. Ask any patient, clinician, or human being for that matter, and you will get a different set of descriptors for categorizing pain. Often however, pain - or the mere precursory thought of pain - is considered categorically "bad," setting off a series of stress-induced and psychoneurological changes in our bodies. Much of our learned response is tied to the fear, helplessness, and negativity associated with pain.

   If we have truly evolved to consider pain as the fifth indicator or vital sign, it is imperative that we delve deeper into the human experience. Pain, as an indicator, is the body's way of signaling to the mind that a problem exists - a protective mechanism that forces awareness of the potential for re-injury if we continue along the same course. The conventional approach to pain is to fight the symptoms. The homeopathic approach is to work with the symptoms, as they are the body's way of heightening our awareness.¹ Our society as a whole is quick to numb the pain - to mitigate it and eradicate it - sometimes before we even allow our mind to interpret the signal. We are a society in search of a pill, a cream, or a dressing that quiets the pain enough so we can go about our daily business or at least get through the next 4 to 6 hours. Pain hurts. It slows us down. Shouldn't it though? Isn't this the only way that the body can send a wake-up call to the mind that something has to change?

   Only when we learn to be "present" in pain can we see pain as an opportunity for personal growth, to shatter beliefs we have had such as, "I can't handle this," or "There is nothing I can do to stop this."² Certainly, pain can be debilitating, depressing, and frustrating. But experiencing the symptoms rather than focusing on the feelings about the symptoms offers us tremendous insight into addressing pain.³ At some point, patients need to examine their pain experience so they can articulate the type, severity, and duration of the symptoms.⁴ They must be present in order to self-assess.

   Too often, we as clinicians hear global statements such as, "It hurts all the time," or "I am dreading this treatment or dressing change." In these instances, the patient has already placed judgment on the experience. He or she may be personalizing the pain experience, labeling it as "my leg pain"; thus, becoming absorbed by the emotional feelings elicited by anticipating pain. Reframing is a way of observing the body experiencing pain and recognizing it as a dynamic process.³ It is not telling patients that they must live with the pain, but rather, it is teaching them how. Rather than rushing to get rid of the pain and later becoming frustrated when the pain is not completely gone, the pain must be reframed. The patient should be guided to consider the following thoughts: What is my body experiencing at this moment? Feel and describe the waves of sensations. What can I learn from this experience? This exercise will help the patient acknowledge that growth and healing take time.³ The challenge is to help the patient stay in the present and not dread what is coming next.³ Patients may find it helpful to ask, "Can I tolerate this moment?" And then to go on from there.

   Krasner⁴ proposes the chronic wound pain experience model, which separates noncyclic acute pain (eg, from sharp debridement), cyclic acute pain (eg, from daily dressing changes) and chronic pain (persistent discomfort).⁴ With this model in mind, patients should be encouraged to describe the intensity, duration, and specific pain characteristics of their experience. Getting to know their pain will help them identify areas of consistency and predictability. This ultimately lays the groundwork for developing effective coping strategies.

   Jon Kabat-Zinn³ has extensively studied pain management by teaching mindfulness. We typically experience "mindless reactions" to pain in contrast to a "mindful recognition" that allows response to pain. This pause or space creates an opportunity for the individual to seek alternative ways to respond to the pain. Mindful recognition empowers the individual, fostering openness and acceptance of each moment. One particularly helpful coping strategy is the acknowledgment that "whatever has happened has already happened. It is already in the past."³ By maintaining a focus on the present, one can alleviate the stress associated with dwelling on a prior experience.

   In trying to extract a meaningful account of pain, clinicians must attempt to recognize different coping strategies exhibited by patients. Typically, three categories of copers are recognized: repressors, amplifiers, and social copers. Cipher, Clifford and Schumacker⁵ confirmed the existence of these three categories in a study of outpatient clients with back pain. They concluded that these categories of copers could be found in other types of chronic pain patients.

   Repressors often demonstrate increased tolerance to pain, appearing reserved. However, studies have shown that this type of coping actually impedes immune function because these patients deny the negative effects and are less in touch with the stressors.⁶ Amplifiers tend to complain without reservation, expressing increased levels of anger and distress.⁵ They demonstrate emotional and physical suffering and even disability. Social copers were found to be confident, sociable, and emotionally stable, exhibiting the least psychosocial distress.⁵

   This is similar to the hardy personality observed in transformational copers as described by psychologist, Suzanne Kobasa.⁷

   Cipher et al⁵ also found their study supports previous research regarding compliance with treatment strategies. Repressors respond best to strategies that focus on proving mind-body connections (eg, biofeedback and scheduled relaxation sessions); thereby, validating the relationship. In contrast, amplifiers respond best to interventions that relieve emotional suffering immediately (in this case, relaxation tapes and self-hypnosis.).⁵ The angry and difficult patient demonstrated the least compliance with treatment.⁵

   Similarly, Oz¹ notes that self-hypnosis, auditory therapy, and meditation for pain mitigation work best in patients who take responsibility for their health and wellness. These methods tended to effectively serve as mental preparation and visualization during high anxiety periods, such as before treatments or procedures.¹

   Body scanning is another helpful technique in mindfulness practice.³ The patient lies in a restful position and visually feels each region of the body, starting with toes and slowly working up toward the top of the head.³ Through scanning, patients become aware of areas of tension or pain and can focus attention and breathing to those areas. Once they are aware of the painful areas, they can learn to rest into the discomfort and note any changing qualities.

   Because dressing removal is considered by practitioners to be the time of greatest perceived pain,⁸ it becomes critical that the patient be actively involved in the event. This includes the clinician's offering a detailed explanation of the procedure and expectations in an effort to reduce fear and anxiety. Furthermore, the clinician should suggest that the patient engage in rhythmic breathing, visualization, or actual participation in the dressing change. These strategies for increased patient-centered control should be offered in addition to medication, not as absolute substitutes for medication.^4,9 A combination of pharmacological and non-pharmacological strategies will be effective as long as the patient is open to understanding pain - not as a punishment but as a symptom the body is experiencing due to the process of injury or the path to healing.

   With mindful recognition, one can observe the facets of the pain experience and begin to work with the symptoms rather than fight them. A comprehensive pain assessment will guide clinicians to a more thorough investigation of the nature of this experience. Rather than set expectations for the disappearance of pain, patients can learn to become "present" in pain in order to note changes in intensity, sensations, and thoughts. The clinician can help the patient examine pain as a dynamic process of healing and work to determine the most effective strategy to empower the patient in this mind-body experience.

1. Oz M. Healing from the Heart. New York, NY: Penguin Group;1998.

2. Borysenko J, Borysenko M. The Power of the Mind to Heal. Carlsbad, Calif: Hay House, Inc.; 1994.

3. Kabat-Zinn J. Full Catastrophe Living. New York, NY: Dell Publishing;1990.

4. Krasner D. The chronic wound pain experience. Ostomy/Wound Management. 1995;41(3):20-25.

5. Cipher DJ, Clifford PA, Schumacker RE. The heterogeneous pain personality: diverse coping styles among sufferers of chronic pain. Alternative Therapies. 2002;8(6):60-69.

6. Esterling BA, Antoni MH, Kumar M, Schneiderman N. Emotional repression, stress disclosure responses, and Epstein-Barr viral capsid antigen titers. Psychosom Med. 1990;52:397-410.

7. Kobasa SC, Maddi SR, Zola MA. Type-A and hardiness. J Behav Med. 1983;6:41-51.

8. Moffatt CJ, Franks PJ, Hollingworth H. Understanding wound pain and trauma: an international perspective. EWMA Position Document: Pain at wound dressing changes 2002:2-7.

9. Pasero CL. Nondrug measures for painful procedures. Am J Nurs. 1997;97(8):18-20.