Relaxation

Being mindful about mindfulness


I’m generally a supporter of mindfulness practice. It’s been a great discipline for me as I deal with everyday life and everything. I don’t admit to being incredibly disciplined about “making time for meditation” every day – that is, I don’t sit down and do the whole thing at a set time each day – but I do dip in and out of mindfulness throughout my day. While I’m brushing my teeth, slurping on a coffee, driving, sitting in the sun, looking at the leaves on the trees, cuddling my Sheba-dog I’ll bring myself to the present moment and take a couple of minutes to be fully present. Oddly enough I don’t do this nearly as often when I’m cold (like this morning when it’s about 8 degrees in my office!), or when I’m eating parsnip (ewwwww!), or waiting to see a dentist. Or perhaps that’s not odd at all, because I wonder if we have a skewed view on mindfulness and what it’s about.

My reason for writing this post comes from reading Anhever, Haller, Barth, Lauche, Dobos & Cramer (2017) recent review of mindfulness-based stress reduction for treating low back pain. In it, they found “MBSR was associated with short-term improvements in pain intensity (4 RCTs; mean difference [MD], −0.96 point on a numerical rating scale [95% CI, −1.64 to −0.34 point]; standardized mean difference [SMD], −0.48 point [CI, −0.82 to −0.14 point]) and physical functioning (2 RCTs; MD, 2.50 [CI, 0.90 to 4.10 point]; SMD, 0.25 [CI, 0.09 to 0.41 point]) that were not sustained in the long term.” There were only seven RCTs included in the study, with a total of only 864 participants, and many of the studies had no active control groups, so my interpretation is that there are flaws in many of the studies examining MBSR, and that it’s difficult to draw any conclusions, let alone strong conclusions.

Where do we go wrong with mindfulness? The first point about the studies included in Anhever and colleagues paper is that there is a difference between mindfulness in general and mindfulness based stress reduction – and although the difference may be minimal, it’s nevertheless worth understanding. MBSR is a full programme that includes mindfulness as one element (Kabat-Zinn, 1982). Mindfulness is a key component, yes, but the programmes include other elements.  The second point is that perhaps we’re assuming mindfulness to be something that it isn’t –  I suspect, from reading numerous articles in both the popular media and research papers, that mindfulness is being applied as another form of relaxation.

Relaxation training was introduced as part of a behavioural approach to managing stress. In pain management it’s been part of programmes since the 1970’s, particularly using forms of progressive muscle relaxation (See Dawn & Seers, 1998). The intention is to provide an experience that is incompatible with tension, and to develop the capability to down-regulate the body and mind to mitigate the stress response that is so often part of persistent pain.

Relaxation training can take many forms, and breath control is a common component. I use it often for myself, and when working with clients – I’m aiming to show people that although they may not be able to control heart rate or blood pressure, they can control breath and muscle tension. It’s useful especially as part of sleep management.

The thing with relaxation training is it’s entire purpose is to help downregulate an upregulated nervous system. Mindfulness, on the other hand, is not.

What is mindfulness about if it’s not about relaxation? Well, mindfulness has been defined in many different ways, but the one I especially like is by Kabat-Zinn (1990) “a process of bringing a certain quality of attention to moment-by-moment experience”.  This definition can be further unpacked by examining its components: “Mindfulness begins by bringing awareness to current experience—observing and attending to the changing field of thoughts, feelings, and sensations from moment to moment—by regulating the focus of attention.” (italics are mine) –  this quote is from Bishop, Lau, Shapiro and colleagues (2004) and is from a paper looking at defining mindfulness in an operational way (so we can be aware of what it means in practice, or as we teach others). These authors go on to say that this process leads to a feeling of being very alert to what is occurring in the here and now. I like to remind people that it’s about being here rather than remembering or anticipating what might.

So at least one part of mindfulness is learning how to attend to what YOU want to attend to, rather than being dragged back to memories, or forward to predictions, or to experiences or moments that you don’t want to notice at that moment.  The definition also points to noticing and experiencing what is happening, rather than thoughts or ruminations about what you’re experiencing. For people living with persistent pain, I think this is an invaluable tool for dealing with the interruptive effects of pain on attention.

A second aspect of mindfulness is an attitude – one of curiosity. When being mindful, you’re not trying to produce any particular state, instead you’re being curious about what you are experiencing, whether it’s something you’d ordinarily want to experience – or not. This approach to experience is really similar to what we’re aiming for in persistent pain management – acknowledging and being willing to experience what is, rather than attempting to avoid that experience, or quickly change it to something more palatable.

Now this aspect of mindfulness is often brought to bear on new and pleasant experiences – sometimes people are asked to mindfully eat a raisin, or mindfully examine a ballpoint pen (one of my favourites). But it’s also just as valid to bring this attitude to bear on less than pleasant experiences like my cold fingers and legs (it’s cold in my office this morning). Or to pain and where it is – and where it isn’t.

So I wonder if part of our approach to using mindfulness in pain management is incorrect. If we’re intending people to come away from mindfulness feeling relaxed and calm, perhaps we’re doing it wrong. If we think people should feel better after mindfulness, again, perhaps we’re doing it wrong. Sometimes, yes, these are the effects we’ll have. Other times, not so much. What we will always develop, over time, however, is better ability to focus attention where we want it to go, and more openness to being present to what is rather than struggling against it. And I think those are incredibly valuable tools in life, not just persistent pain management. And perhaps, just perhaps, if we began viewing our use of mindfulness in these ways, the outcomes from RCTs of mindfulness might show more of what it can do.

 

Anheyer, D., Haller, H., Barth, J., Lauche, R., Dobos, G., & Cramer, H. (2017). Mindfulness-based stress reduction for treating low back pain: A systematic review and meta-analysis. Annals of Internal Medicine, 1-9. doi:10.7326/M16-1997

Dawn, Carroll, and Kate Seers. “Relaxation for the relief of chronic pain: a systematic review.” Journal of advanced nursing 27.3 (1998): 476-487.

Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your mind to face stress, pain and illness. New York:Dell.

Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General hospital psychiatry, 4(1), 33-47. doi:http://dx.doi.org/10.1016/0163-8343(82)90026-3

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Managing Migraines without Medication


ResearchBlogging.orgAhhh, migraine – psychedelia without the high… nausea without the alcohol…

The diagnostic criteria: A) At least 5 attacks fulfilling B-D; B) lasting untreated 4-74 hours; C) two of the following: unilateral, pulsating, moderate or severe pain intensity, worsening with physical activity; D) one of the following: nausea and/or vomiting, photophobia or phonophobia; E) not attributed to another disorder. (International Classification of headache disorders, 2004) (go here for one of the most comprehensive sites on migraine)

The main treatment for migraine is to use medication – best evidence to date suggests:  “Only two pharmacological treatments have been shown to be effective in placebo-controlled randomized trials: topiramate and local injection of botulinum toxin. Both therapies are effective in patients with chronic migraine with and without medication overuse. “ (Diener, Holle, Dodick, 2011)

As one of the many people who have migraine to NOT find these two medications helpful, and someone who has slightly unusual migraine symptoms (my main symptom is nausea, with headache being secondary), it’s taken a long time for me to reach a clear-cut diagnosis for migraine.  In the meantime I’ve had to learn to “live with” my migraines without pharmacology.  No easy matter when even the best say “Most of the time migraines resolve with sleep. Occasionally, and especially in children, vomiting stops migraine.” (from Migraine Aura Foundation)

What helps migraine – apart from sleep and vomiting?

I’m going to start with the approaches that I commonly use in the Pain Management Centre for people with migraine.  Please note: these are NOT a panacea for all migraines, and they work most effectively in combination.  Please don’t use what I’m writing as a substitute for seeing a health care provider – you and your health care provider need to work together.

  1. Assessment: Step one for managing migraines is carrying out a good assessment to identify triggers (antecedents).  This is one occasion when diaries for recording headaches and activities over a month or so.  I’m generally not keen on pain diaries because they so often focus the person on their pain, but in the case of intermittent headaches the diary method is really useful.  It’s helpful to briefly record activities, “stress” level, aura, headache intensity, sleep and food/drink intake.  This might help identify triggers – but having identified them, avoiding them is not always the best approach!  Instead, it might be more preferable to consider ways of managing the overall vulnerability to migraine – more on this below.
  2. Self-regulation training: Self-regulation refers to a wide range of strategies to influence alertness and ability to achieve a given activity.  In the context of migraine management, it usually refers to using things like biofeedback modalities to help train the person to up and down-regulate their physiological activity.  I find this has to be conducted alongside cognitive therapy so the person remembers to use self-regulation, and to help manage the automatic thoughts that often occur both because of having a migraine and as a response to using different strategies.
  3. Cognitive therapy: This refers to recognising automatic thoughts, intermediate beliefs/attitudes, and core beliefs, and working with these to interpret events in a different way.  This approach helps people to reflect on why they feel the way they do about situations and establish whether these are “working” to help them achieve what is important and valued in their life.  Even if an interpretation of a situation is accurate, it may not be helpful.
  4. Effective communication: This might seem a strange one to put into migraine management, but something I have found is that emotional stress from interpersonal conflict is one of the “hidden” triggers for migraine.  Effective communication can be called “assertive” communication, but I find this to be a very value-laden term.  Being able to communicate effectively involves listening, hearing, interpreting then developing an honest and respectful response.
  5. Activity management: Yes, that old standby of timetables, planning, prioritising and putting off – oh, perhaps not that last one!  Seriously though, establishing a paced activity pattern that avoids “boom and bust” patterns, or “pain contingent” patterns really helps, especially on a day when a migraine has started.  Stopping everything isn’t an option for many people, so maintaining a “minimum” plan for those days can be useful.

Self-regulation training – some details

While learning self-regulation without biofeedback is perfectly fine, for some good reasons, various biofeedback modalities enhance the learning.

Biofeedback involves monitoring physiological processes usually considered involuntary or that are modulated outside of conscious awareness. The three most common forms of biofeedback for headache treatment are: thermal, electromyographic (EMG), and electrodermal.  I tend to use Galvanic Skin Response (GSR) rasther than electrodermal, simply because it’s available to me and also because it gives me (and the person I’m working with) a good “overall” assessment of alertness.

There are many things that you can do with biofeedback, but I usually begin by attaching the leads and showing the graphs on the computer monitor.  We talk for a while until the person’s graphs show they’re stabilising into a baseline state.

I then usually begin with a Stroop test to establish “working under stress”.  This is a test where people are asked to read words for colours, with the words printed in different colours from how they read.  For example GREEN RED BLUE.  This gives me some information on the parameters the person usually demonstrates “stress”.

I then progress to learning to breathe.  “Not so difficult”, you say – well, it’s surprising how few people demonstrate effective breathing and control of breathing.  I almost always begin with respiration – to firstly use diaphragmatic breathing, then to slow the breathing down, and finally, with a respiration monitor around the person’s chest, I might help them look at the S pattern they create on the monitor.  This helps them to create slow, regular and full breathing that smoothly inflates and deflates the lungs.

Then I often move onto some animated programmes – one of my favourites is the Wild Divine set called “Relaxing Rhythms”.  It monitors heart rate, heart rate variability and GSR, and has a number of really good animations that help people to develop control.

More on migraine management soon!

Grazzi, L., & Andrasik, F. (2010). Non-pharmacological approaches in migraine prophylaxis: behavioral medicine Neurological Sciences, 31 (S1), 133-135 DOI: 10.1007/s10072-010-0306-5
Paola Schiapparelli • Gianni Allais • Ilaria Castagnoli Gabellari •
Sara Rolando • Maria Grazia Terzi • Chiara Benedetto (2010). Non-pharmacological approaches in migraine prophylaxis: Part ii Neurological Sciences, 31 (S1), 137-139 DOI: 10.1007/s10072-010-0307-4

Making self-help more helpful


ResearchBlogging.org
One of the things that appeals about self-managing chronic pain is that it doesn’t require endless appointments. If life is for living, why spend it sitting in a waiting room? (they never have up-to-date magazines anyway!)

Our problem as health providers is that we don’t know whether all our great self-help recommendations actually get done by the people we see. After all, we’re not there in the morning when they get up, or late at night when they’re trying to get to sleep! Most of us simply hope that –

  • the person is sufficiently motivated (thinks what we’re advising is both important and they’re confident they can do it)
  • can organise themselves to ‘get around to it’ before they forget what we’ve suggested
  • they’re telling us the truth when they say they’ve been doing whatever it is we’ve suggested

Quite a while ago I read about a very simple strategy to help people be more likely to carry out their exercises – and posted about it here. In that study by Christiansen,  Oettingen, Dahme, and Klinger (2010), two 30-minute sessions involving identifying the reasons for making a change (to increase physical activity), and the potential obstacles to actually doing it, were held.  For four of the obstacles identified, the participants were helped to generate solutions that would help them get around the obstacle and engage in exercise.  To do this, ‘if-then’ statements were developed.

An ‘if-then’ statement involves identifying a specific situation such as ‘when I get home from work’, then indicating the behaviour that will occurI will get my running shoes out and go for a walk.’

In the study I’ve looked at today, the same strategy was applied when delivering a self-help booklet for people with anxiety. In this study, Varley, Webb and Sheeran contacted (via email) the students and staff at a university in the UK.  People who were already being treated for anxiety were excluded, and the remaining participants (251 of them) were randomised into three groups.  All of them completed baseline Hospital Anxiety and Depression Scale (HADS, developed by Zigmond and Snaith, 1983) and the state version of the State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, Lushene, Vagg, and Jacobs, 1983).

One group received no input, while the other two groups were asked to go to a web page where they downloaded a self-help booklet.  Both of the booklets were the same eight-page booklet containing psychoeducation, diary sheets for self-monitoring triggers and feelings, and two relaxation techniques – a breathing technique that could be used anywhere, and a longer relaxation exercises that could be used daily at home.

The experimental group, in addition to the booklet, were also asked to develop two ‘if-then’ plans – one that involved the participant identifying a specific anxiety-related symptom and to associate it with using their newly learned breathing technique. eg “If I feel my heart racing, then I will use my breathing technique to relax.” The second plan asked participants to identify when they might be able to do their deep relaxation technique into their daily routine. eg “when I get home at night, then I will do my deep relaxation.”

When the participants were reviewed eight weeks later, as expected, neither the control group nor the standard self-help group differed very much.  However, the self-help group that received the implementation intentions (if-then) supplement had significantly lower scores on the HADS and the STAI.

Interestingly, the experimental group also thought the booklet was more ‘user-friendly, used the relaxation techniques more frequently, were better at detecting the triggers of their anxiety, and experienced the benefits of using the relaxation techniques.’ So basically, quite an effective and yet simple strategy!

For readers with a critical eye for statistics and methodology, this study is a nice example of the use of multiple statistical methods to determine outcomes – a combination of ANOVA, Sheffe post hoc tests, multivariate analysis, correlations, and bootstrapping to test direct effects – and what’s more, they also reviewed ‘caseness’, or whether the changes that were statistically significant were also clinically significant.  This was achieved through identifying participants with scores over 11 on the HADS at pre- and post-testing.

OK, so lovely for people with anxiety: how might this apply in self-management of pain?

Well we’ve already had one demonstration of this method on exercise for people who have chronic pain (Christiansen and colleagues), and I wonder if it might not make an effective addition for people who have high pain-related anxiety.

One of the effects of anxiety about pain is to reduce how readily people can bring coping strategies to mind (go here for some of the references to the Pain Anxiety Symptoms Scale).  If we identify people who have trouble thinking straight when they’re sore, we can help them generate specific ‘if-then’ statements to help them get by.  Here’s an example:

Jenny gets worried when her pain starts to increase, especially when she’s busy at work.  Her therapist helps her identify the ‘early warning signs’ that signify the potential for difficulty coping.  These are:

  • several deadlines occurring together
  • jaw tightening and frowning
  • multiple interruptions

She chooses one of these, and with her therapist, identifies several strategies:

  • breathe and let go
  • stand up and stretch
  • assertively setting a limit

She then constructs an “if-then” statement like this:

  • “If I have several deadlines occurring together, then I will stand up and stretch”

She writes this down and puts a copy of it beside her computer at work.

The good things about this strategy are that:

  • it’s generated by the person (who therefore gets involved in identifying personally relevant cues and solutions);
  • it’s brief (so easy to remember!);
  • it does the thinking and problem solving beforehand (when thinking can be much more creative, and the situation may even be pre-empted);
  • it involves a different behaviour (it’s an action, which is much easier than a cognitive strategy when anxiety is elevated)

Give it a go with your patients – and see whether it’s something they might find helpful.  Or even use it yourself!

Varley R, Webb TL, & Sheeran P (2011). Making self-help more helpful: a randomized controlled trial of the impact of augmenting self-help materials with implementation intentions on promoting the effective self-management of anxiety symptoms. Journal of consulting and clinical psychology, 79 (1), 123-8 PMID: 21171737

Friday in Christchurch


Despite the devastation, there are some wonderful sights in Christchurch right now.  This one (above) made me smile today.

And this one was taken in Nelson after we had turned back to return to Christchurch last week.  Cheerful things, sunflowers, and glorious colour on a rather gloomy and very grim day.

Friday Meditation


As you know, Friday is about getting ready for the weekend.  Today I decided not to pass on some of the horrendous puns shared with me by one of my esteemed colleagues (although I may drop just one in because I can!).  Instead I thought this poem is a chance to consider being ‘in the now’, something clinicians working in pain management really need.

Salutation To The Dawn

Look to this day!

For it is life, the very life of life.

In its brief course

Lie all the verities and realities of your existence:

The bliss of growth,

The glory of action,

The splendor of achievement,

For yesterday is but a dream

And tomorrow is just a vision,

And today well lived makes every yesterday a dream of happiness

And every tomorrow a vision of hope.

Look well, therefore to this day!

Such is the salutation to the dawn.

Kalidasa

 

Oh, a pun?  As you read this, remember I have to work with the person who passed it on…sigh…

She was only a whiskey maker, but he loved her still.

A rubber band pistol was confiscated from algebra class, because it
was a weapon of math disruption.

No matter how much you push the envelope, it’ll still be
stationery.

A dog gave birth to puppies near the road and was arrested for
littering.

I wondered why the baseball kept getting bigger.  Then it hit me.

Two fish swim into a concrete wall.  One turns to the other and says
‘Dam!’

Sleep – Posts from 2010


Sleep is so important for wellbeing (ask any young parent!), and yet many people with chronic pain have really poor and unrefreshing sleep, and very poor sleep habits.  Some pain conditions show changes to the quality of the sleep stages (such as fibromyalgia for example), to the point where these changes can almost be diagnostic, while many people with chronic pain also have low mood in which sleep disruption is a common feature.

I’ve written about sleep several times over the past year, and today I provide links to some of these posts for your education and enjoyment.

Sleep problems in chronic pain and what helps – Pain can be associated with a sense of poorer quality sleep, and could well have been a factor influencing the onset of insomnia, it’s often other factors that maintain unsatisfying sleep.

Thinking about sleep – or not – CBT responses to common thoughts and beliefs when introducing sleep management.

Oh, to sleep – CBT for insomnia in chronic pain – Cognitive-behavioral therapy for insomnia (CBT-I) is a well-established approach for helping people return to a refreshing sleep pattern, this study describes research about four strategies.

If you’re not asleep, get out of bed! – Sleep restriction as a strategy for optimising time in bed actually asleep.

To sleep, perchance to dream – different types of pain problem can link to different types of sleep problem.

Don’t forget that an effective strategy for helping with sleep onset is deep relaxation, and mindful attention to sensations such as the contact of the body on the bed, the breath in and out, and attending to each body part without necessarily changing the position can all help to ease into sleep.  I’ve also used ambient sound recordings – for me the sound of the sea is particularly relaxing – and recordings like this can mask street noises provided that the recording can remain on all night.  It’s better to learn to send yourself to sleep without external aids like recordings where possible, because if you wake during the night and haven’t learned the art of going to sleep by yourself, you’ll need those same aids at that point in time too.

Sleep problems in chronic pain & what helps


ResearchBlogging.org
I have written about sleep problems in people with chronic pain several times. It is one of those aspects of dealing with pain that inevitably arise as I talk with people about energy, their activity through the day, and their mood. Many people blame the pain for their sleep problems, which is unsurprising really – once you’re awake in the middle of the night, there’s not a lot else to think about! But it seems like while pain might be associated with a sense of poorer quality sleep, and could well have been a factor influencing the onset of insomnia, it’s often other factors that maintain unsatisfying sleep.

What are those factors?
Well, one of the first ones is ‘general affective disturbance’ – in other words, feeling low or flat, whether frankly depressed or not, can lead to changes in sleep architecture. Sleep architecture refers to the patterns of brain activity that are normal and expected in people throughout their sleep. People who are depressed demonstrate shortening of the time from sleep onset to the appearance of the first REM period (short REM latency), while people with fibromyalgia show specific and distinctive abnormalities in the stage 4 deep sleep. During sleep, individuals with fibromyalgia are constantly interrupted by bursts of brain activity typical of being awake, limiting the amount of time they spend in deep sleep.  It’s also thought that people with central sensitisation syndrome (such as CRPS, irritable bowel, pelvic pain, migraine etc) have similar changes to their sleep pattern – and fatigue is often a feature characterising these problems.

It’s not only disorders that affect sleep architecture: some medications and common substances also affect sleep, including alcohol, coffee and common sleeping pills.

While we can’t ‘fix’ the chronic pain condition, we can treat depression, and we can help people identify any of the substances that might alter sleep patterns.

More often than not there are other things that also contribute to maintaining poor sleep.  Some studies suggest that poor sleep is maintained by the amount of attention focused on pain, the ways in which pain is interpreted (particularly sad, or irritated responses to pain), and thought patterns particularly before going to sleep (rumination or brooding on pain).  These are aspects of sleep management that may not always be addressed in general pain management programmes which often provide sleep hygiene.

A thorough assessment of sleep problems is an important part of developing an appropriate management strategy.  Sleep assessments in this case don’t refer to being wired up at night btw – and I’m not referring to sleep problems caused by sleep apnea or snoring.

A sleep assessment should cover things like:

– time of going to bed, and the pre-sleep rituals

– time to sleep onset, number and timings of sleep awakenings as well as the length of time awake at these times (not to mention what the person does at these times such as eating, getting out of bed, having a smoke or coffee …)

– waking time, and how refreshed the person feels at this time

– naps and timing of exercise during the day

– coffee, alcohol, tobacco and other substances taken

These relate directly to ‘sleep hygiene’ aspects of sleep 0r things like keeping the bed as a place associated only with sleep (not worrying, watching TV or arguing with others), and developing a regular pattern to going to sleep including relaxation.  This is another good handout on sleep hygiene.

Now while simple sleep hygiene can be helpful for many people, there are several other strategies that have good evidence to support their use in insomnia.

These methods are all included in what is called Cognitive Behavioural Therapy for Primary Insomnia.  This is described by Tang as ‘a multi-component treatment that seeks not only to teach patients about sleep and factors affecting sleep (eg homestatic regulation, circadian rhythm, age, social and work schedule) but also to work with the patient toward minimisng unwanted arousal at bedtime and altering sleep habtis to increase  sleep propensity and regularity.  More cognitively oriented therapy involves interventions that aim to address worries and beliefs about sleep, particularly anxiety-provoking thoughts like ‘I’m losing control over my sleep’ and safety seeking behaviours (like drinking extra coffee or spending longer in bed).’

CBT-I can include psychoeducation, sleep hygiene, relaxation training, cognitive therapy, sleep restriction, stimulus control therapy, paradoxical training, biofeedback and imagery training. Of these strategies, relaxation, sleep restriction and stimulus control therapy have the most support from research as stand-alone interventions.  CBT-I has been repeatedly shown to be effective for remedying insomnia, and found as effective as hypnotics in the acute treatment phase, with the benefit of providing long-term results.

Despite this positive finding, between 43% to 85% of people don’t respond to even intensive CBT-I treatment when stringent outcome criteria are applied.  When Tang reviewed the content of three RCT’s for insomnia for people with chronic pain, she found that much of the content relied upon behavioural interventions – but research in other population shows that it’s just as important to address beliefs and attitudes about sleep.  Maybe this is an area to focus on a little more in pain management programmes also.

Tomorrow I’ll discuss some of the cognitive strategies and especially the sort of thoughts and beliefs that people can have about sleep – but I’ll write about this after I’ve had a sleep!

Tang, N. (2009). Cognitive-behavioral therapy for sleep abnormalities of chronic pain patients Current Rheumatology Reports, 11 (6), 451-460 DOI: 10.1007/s11926-009-0066-5

An accidental form of control: when mindfulness produces happiness ACTing Well, Living Well iv


I’ve had some success while working with a man I’ll call Peter.  He’s got chronic pain, and has been incredibly fearful of what it might mean – in fact, you’d probably call him a classic catastrophiser because each time his pain flared up he immediately thought it was something like cancer and he would rush off to his GP or the Emergency Department to have it checked out.  Luckily any scans he’s had haven’t shown anything operable because I’m sure with the amount of distress he was been experiencing, he would have been able to persuade a surgeon to operate had there been anything odd-but-common found.

We’ve been using mindful breathing as a way to get in touch with the sensations, emotions and thoughts that occur to him, and especially ‘making room for’ the thoughts his mind has been telling him of needing to check his body for symptoms, for the nauseous feeling he gets when his mind starts to worry, and for the painful sensations that he experiences throughout his body.  It’s been a real learning experience for him to find that he can be willing to experience these symptoms without judging them, and, as seems to happen for many people, he’s been finding that they disappear or reduce over the five minutes or so we do the exercise.

Now this is a trap for young players and older ones too.  While it’s nice to find that sometimes mindfulness can produce peace, relaxation and calm – that’s not the point of being mindful!  The point of being mindful is to be open to experience whatever happens.  And for those people who do experience a reduction in negative emotions, sensations or thoughts, the very reduction can begin to form a subtle type of control.  The thinking goes something like this

“I feel uncomfortable.  Quick! I’ll do some mindful breathing – and then that feeling will go!”

Sounds a lot like ‘experiential avoidance’ – although perhaps slightly more effective than running around keeping busy to avoid the negative feeling, or trying very hard to ignore the feeling, or perhaps catastrophising.

Why would we worry about this?  Does it really matter if someone does start to use ‘mindful breathing’ as a way to reduce symptoms?

Well yes.  There will be times when even though the person is using mindful breathing to ‘sit with’ something negative, the negative experience doesn’t reduce, doesn’t fade, and may even increase.  That’s not the point of mindfulness – it’s about accepting whatever happens, allowing it to be there AND CONTINUING TO COMMIT TO ACTIONS that move in valued directions.

The problem with hoping that mindfulness will reduce symptoms or thoughts is that when it doesn’t reduce these, the temptation can be to feel distressed – and stop the mindfulness.  And after stopping the mindfulness it can be very difficult to carry on doing the actions that will ultimately enact values.  That wonderful mind can kick in and accuse the person of ‘being stupid’, ‘wasting time’, ‘doing this dumb thing that doesn’t even work’ – this usually brings more negative emotion along for the ride, and ultimately doesn’t help.

So what to do?

I’m still learning this, but I think I’m going to mention that mindfulness is about allowing what will be to be.  And being ready to carry on with valued actions despite this.

I think this might be one of the hardest things to do – I’ll let you know how I go!

Relaxation…how, why & the evidence


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Over the weekend a discussion about relaxation and the how’s and why’s came up in a discussion group I belong to. Several members of the group, including me, contributed our ‘list of do’s and don’ts’, much of it based on years of clinical experience – until I thought (as I do!) what about the literature? What does research tell us about precautions and effectiveness of relaxation?

I have to say that my searches in the literature so far have failed to consider many of the practical tips that the group came up with, but I have found some really helpful reviews of relaxation that support its use in pain management.  One of those more recent references is the one I’m focusing on today.

At the same time as wanting to briefly look at the evidence base for relaxation, I’m still musing on the clinical and experiential information that this group of therapists came up with, mulling over a few things like:

  • how does this clinical information get passed on from clinician to clinician?
  • how ‘true’ are these nuggest of applied wisdom?
  • if I’m trying to identify the evidence for these gems, how do I go about it?
  • how much of this information is ‘common sense’ – and then again, how much holds up when examined under the light of systematic enquiry?

That last one is especially important to me because so many of the myths about, for example, low back pain are based on ‘common sense’ – like that it’s ‘common sense’ to change the way we lift and move things because ‘everyone knows that the biomechanical models show that it makes sense not to lift things that are too heavy’.  The problem is that while ‘common sense’ application of biomechanics to manual handling seems helpful, in practice the model doesn’t make a difference to whether low back pain develops, and can give people a misunderstanding about how ‘safe’ it is to actually move their backs.  Common sense – and theoretical models – need to be tested in clinical practice to see whether their predictions hold true.

The group came up with a few tips that I hadn’t considered, such as not driving for 30 minutes after a relaxation session, or avoiding relaxation for two hours after a meal – but by and large the tips and tricks were very similar.  Here’s a few that I came up with:

Rationale for introducing relaxation

  • Elevated scores on pain-related anxiety and measures such as the TSK and PASS can be indicators for the usefulness of relaxation training.
  • Reports of physiological arousal can be a rationale for introducing relaxation
  • It can be used as a strategy to delay escape or avoidance behaviour in the presence of an aversive stimuli such as increased anxiety around a particular movement, or during periods of negative affect
  • It’s useful to reduce physiological arousal when considering sleep management, and relaxation can form part of the ‘going to bed’ ritual to help with insomnia

Some researchers suggest relaxation is a cognitive strategy for coping with a situation – it provides the individual with a sense of self efficacy and control (ie ‘something to do’) when they’re in a situation they don’t feel comfortable with.  Others base the rationale on the inability to maintain both physiological arousal and the relaxation response at once (a behavioural rationale).
There is some evidence to suggest that diaphragmatic breathing increases descending inhibition in some pain disorders (but not fibromyalgia) (Zautra, A., Fasman, R., Davis, M., & Craig, A. (2010). The effects of slow breathing on affective responses to pain stimuli: An experimental study Pain DOI: 10.1016/j.pain.2009.10.001)

Guidelines and precautions

  • beware of getting up too fast – BP reduces during relaxation, and it’s important to stretch to restore a normal BP or you may end up with dizziness from postural hypotension
  • be aware of paradoxical arousal when carrying out relaxation with an individual who is very hypervigilant and anxious, as they may hyperventilate and/or become distressed due to sensations of ‘floating’, ‘tingling’ and/or being unable to feel the body
  • be wary of using imagery without discussing the content of that imagery first, with individuals who have experienced trauma (rape or accidents etc), as it can remind them of the situation they were in
  • always remind the person that at any stage they are in complete control, and that they can open their eyes at any time, they will respond to external cues such as telephone or fire alarm.   I often describe that relaxed state a person might be in when coming out of the movie theatre or reading a good book as comparable to a relaxation state
  • some individuals experience relaxation induced headache especially if they’re not used to diaphragmatic breathing, it’s useful to check this with the individual after relaxing, and encourage them to breathe a little less deeply the next time they carry out a relaxation

There are many different types of relaxation training – while the two that have most research attention are Jacobsen Progressive Muscle Relaxation and Mindfulness Meditation, there are many others.  In my clinical experience, it can often be a process of trial and error to identify the method that is most effective, practical and useful for an individual.

I have several strategies for going about relaxation training, depending on the clinical rationale for introducing it:
1.  Breathing is the most portable and discrete strategy, and forms the basis for almost all of the relaxation techniques we use (with the exception of mindfulness meditation)  I don’t progress beyond this much with a lot of individuals. I also focus mainly on the out breath because the in-breath will always happen (just try it and see what I mean!)  For many people this is the easiest strategy to use while working or engaged in activity.

I usually won’t introduce other techniques unless they’ve ‘got’ the breathing part first.  I often pair breathing out with a cue word and/or cue movement (eg finger to thumb).  This is usually a relaxation response I work with the person to develop once they’ve achieved a light hypnotic trance, and I often use hypnosis and posthypnotic suggestion to strengthen the conditioned response to the outbreath and cue word.
2.  Postural awareness and becoming aware of the contact of the body against the surface they’re resting on is often the next most important strategy, and I still use Laura Mitchell ‘Simple relaxation’ as one of the easiest to remember and integrate with normal activity as it can be carried out in most positions, and even while driving!
3.  I rarely use Jacobsen or the Progressive Muscle Relaxation because it involves tensing then relaxing, which is hard to do. Try it yourself: clench your fists, then relax them.  Then make your fingers long, then relax them – which one leads to a more relaxed experience?  Tense/release is useful for individuals who have little kinaesthetic awareness.
4.  I move quickly from a long and deep relaxation technique to briefer ones that can be integrated within a working situation. While I provide people with a CD of a long relaxation, this is best used prior to going to sleep, rather than one they can use at work, but it is useful when teaching someone the difference between being really relaxed and their usual state.
5.  I often use biofeedback (particularly skin conductance and BVP, or heart rate variability) as a monitor for myself to determine how deeply relaxed an individual is, but primarily use it to demonstrate to people with limited body awareness or difficulty ‘getting’ the idea that body and mind are linked to recognise that they have control over what is usually not something they’d be aware of.  The main difficulty with biofeedback is that people can’t take it home to practice with it.
6. I’m increasingly using mindfulness meditations now, because of their usefulness for attention management and the literature supporting its use in regulating emotions, physiological arousal, and maintaining engagement with negative experiences such as pain in a nonjudgemental way.

Persson, Veenhuizen, Zachrison & Gard (2008) reviewed 12 studies of relaxation techniques, in which at least 25 individuals were studied, the studies were RCT’s, relaxation techniques as single treatment, or combined with education, and participants were active in the treatment (ie not passive recipients of ‘relaxation’ by therapist).

It’s a good indication of the lack of systematic study of relaxation training in pain management that these authors found only 12 studies that met the inclusion criteria! Does this reflect the lack of ‘status’ of nonpharmacological pain management? Or simply that there is much less funding available for interventions that don’t involve pharmacology or surgery?

Positive effects were found regarding decreases in pain intensity, anxiety, depression, and fatigue (in fibromyalgia), and even reduced health care and medication costs.  Participants were more mobile and seemed to use more coping strategies when they’d learned relaxation.

The studies themselves were only of moderate quality – they didn’t always include a training protocol (so it’s not clear whether each participant actually received the same relaxation intervention); control groups weren’t matched for age, gender, or even control intervention; and follow-up periods were fairly short.

It looks like a rich field for further study, despite the long history of relaxation as an intervention for pain and for psychiatric conditions.  In the meantime, hopefully this post will introduce some of the ‘tips and tricks’ that could be useful.

Persson, A. L.,, Veenhuizen, H.,, Zachrison, L.,, & Gard, G (2008). Relaxation as treatment for chronic musculoskeletal pain a systematic review of randomised controlled studies Physical Therapy Reviews, 13 (5), 355-365