Today I worked with a person who is very analytic, and finds it quite difficult to feel emotions or experience sensations without thinking about them. He has persistent pain that he calls ‘frustrating’ or ‘unbearable’ – emotions that for me are quite poles apart!
His overall anxiety levels are quite high, and at one time it was suggested that he use biofeedback to learn about things like his muscle tension so that he could manage his headaches. Somehow this didn’t seem like the right thing to do today, so I tried two things from the ACT approach to see how they worked. My post yesterday looked at some of my difficulty finding a way to explain in simple and practical terms how mindfulness worked – for this man, explanation would give him ‘head’ knowledge, but not ‘heart’ knowledge, so I decided to step right on in there and just do it!
The first thing I did was see what good things and not so good things he could identify about his usual way of coping with pain. This approach is based on the Motivation Interviewing approach I’ve posted about before. I did this to help develop intrinsic motivation for a change from experiential avoidance to allowing himself to begin to approach his pain without the ‘mind chatter’ he has.
The problem was that although he had stopped his work, wouldn’t drive, walk more than 5 minutes, and spent most of his time sitting with his feet higher than his heart, he couldn’t identify any ‘not so good’ things about these strategies! He found it so hard to identify with any emotions, that he rationalised his coping strategies as being ‘helpful’ despite their interfering with normal activities.
So I changed tack, and talked about what was important to him – his values. He really values being able to work, support his family and his independence. By helping him see the discrepancy between his coping strategies and his values, he was able to acknowledge (to a certain extent anyway) that his coping strategies were not working (creative helplessness!).
BTW Experiential avoidance is ‘a process involving excessive negative evaluations of unwanted private thoughts, feelings, and sensations, an unwillingness to experience these private events, and deliberate efforts to control or escape from them (Hayes, 1994; Hayes, Strosahl, & Wilson, 1999).’ in Kashdan, Barrios, Forsyth & Steger (2005).
I proposed the thought that perhaps he was working quite hard to avoid experiencing pain – and in discussing a specific situation, he was able to identify some automatic thoughts relevant to his pain, although he continued to find it hard to identify the emotions related to those thoughts.
The next step I took was to go through a mindfulness script with him to help him become more aware, and more discriminating of, the sensations he was experiencing. My assessment of him was that he was ‘globalising’ his pain – in other words, he described his pain as ‘everywhere’ rather than being able to discriminate exactly what sensations he was experiencing. I’m not sure whether ‘globalising’ is a word – but it works for me in the sense that it describes what happens when someone attributes an entire experience with one word – it’s all awful, or pain is everywhere, my legs are all burning. It’s different from catastrophising, which is seeing the worst possible outcome, and from black and white thinking in that it’s more of a ‘short-hand’ than a strategy of thinking ‘all good’ or ‘all bad’.
The problem with that approach is simple: it becomes one massive and difficult-to-manage experience, which seems to engender the ‘freeze’ response aspect of the fight, flight, freeze trio.
So… we started with a simple body awareness process, leading to awareness of sounds, and finally to awareness of breath. Actually what sounds like a simple process is incredibly difficult to do! Especially for someone who rapidly and without awareness flicks into ‘analysing’ any sensation/experience (thinking about thinking).
While I can never be entirely certain that someone really ‘has it’, what I noticed was that he identified some profound ‘lightbulb’ moments in that the sensations he experienced were different in different parts of his body. For example, he could feel a tingle in one part of his foot, but a warmth in his heel. He also noticed that when he was aware of one part of his body, he was unaware of parts he wasn’t attending to. This from a man who had told me ‘I try to ignore my pain but it won’t go away’.
Ignoring is actually a process of trying to avoid experiencing – and it simply doesn’t work.
He also found that directing his attention gently to the sensations involved in breathing worked to still his mind. Previously he had found it very difficult to ‘relax’, so active focus works more easily than passive ‘relaxation’.
I notice some interesting things here – experiencing worked more easily than attempting to explain. So rather than trying to ‘convince’ him that his coping strategies weren’t helpful, it was more helpful to elicit his own understanding of the conflict between his values and his current strategies. Then by moving straight on to a different way of experiencing his pain, we were able to circumvent his over-used analytical strategies. At some point in our work together it might be appropriate to discover why he avoids emotions (the function this has for him), but at this stage it’s enough to have worked out that there is an alternative.
This session has provided the following:
- he now has a relatively straightforward ‘mission’ for home practice (being aware of breathing while doing any task, and gently attending only to the sensations rather than commentating on the experience)
- our working alliance has become stronger
- he was able to remain on-task and focused on his sensations rather than being distracted by thinking and analysing
- I have discovered that sometimes explanation doesn’t need to happen, doing it can work just fine…
A nice explanation of mindfulness for chronic painJust say Ouch
Some great recordings for developing mindfulness A.R.T. – please note that I’m not endorsing this, just letting you know it’s out there – and that there are many others available too
One script for developing mindfuless – and again, there are many out there! For example, this is one from Center for Mind-Body Medicine (2003). MindBodySpirit Medicine: The Professional Training Program. Minneapolis, MN, October, 2003.
And there are several different ones, all in pdf (like this one) from All About Depression’s Relaxation section.
More tomorrow – let me know if you’re finding this interesting, or have questions! And remember you can subscribe using the RSS feed above (left hand corner, just click and follow the directions), or you can bookmark, and it would be wonderful if you could find time to comment!