This week I had a beautiful session with a client that inspired me to write this post.
One of the overarching issues for my clients in persistent pain is a sense of lack of control. Often the pain is so random that it may make it difficult to keep up with plans, be it work plans or even recreational plans. In this post I would like to explore how taking control of our attentional focus might help.
The issue of focusing or distracting
When I teach yoga or Eutony my main guidance is inviting my clients to notice their sensations. Since I started teaching it back in my twenties, before studying pain science more formally, my classes' motto was already "do what you do, not for the sake of doing it, but for the sake of sensing it". And the funny thing was that the clients who remained with me the most, since then, were the ones in pain.
Years later, when I was invited to teach yoga and eutony at the pain clinic in the University of São Paulo, I remember telling my physiotherapist friend Carol: "basically what I do with my clients is to invite them to pay attention to their sensations." And she said: "Well, don't you think that if they are already in pain and pay attention to their sensations, they are going to have more pain?"... I got really puzzled! I knew from my experience that the method helped! However... I could see that she had a point...
I was so intrigued that I decided to write an article about it. While doing my master's program at UBC a few years later I had the opportunity to invest time and energy looking at the scientific literature around this topic. To my dismay I first found many articles prescribing distraction - the opposite of focusing attention - as a well established coping strategy. I learned that distraction can be in fact very effective to decrease pain! In major burns for example, the use of virtual reality is shown to decrease pain significantly during the dressing changes.
I was starting to question my techniques... Further into my lit review, though, I found more recent articles showing that, when it comes to persistent pain, as opposed to acute pain, distraction should be used with caution.
Here are the caveats of distraction in persistent pain:
- we can not be distracted the whole time
- distraction can feed some maladaptive coping strategies, such as pain confrontation and neglect of the painful body part
- distraction can lead to less pain during a challenging activity, but greater post-activity pain
So, this is the apparent bind I realized people in persistent pain may see themselves in: if I distract I have more pain and if I focus I have more pain...
Here is where Yoga, Eutony and Mindfulness can offer a valuable contribution, especially when we feel supported by someone we trust when starting to practice it:
With the help of these techniques we can learn how to take control of our focus, by choosing where to focus on, and how to focus on, no matter what you are doing. You may be practicing meditation, or having a shower, or even walking down the street. Here is a little summary of where and how your attention can help you:
Where: directing attention to specific areas of our present experience:
1- noticing the painful body part, observing aspects of the experience beyond pain (sense of weight, length, temperature, support, etc...)
2- noticing the satellite areas, noticing sensory information other than pain, during pain, such as sense of the skin, bone structure and inner spaces
3- noticing non-sensorial aspects of the present experience, such as:
3.b) muscular states
3.d) autonomic regulation (breathing, circulation, perspiration, salivation, etc...)
4- beyond the target of your attention - where you focus on?- you can also be noticing how you are focusing, noticing the quality of your attention. Sometimes we focus on things in a hyper vigilant way - which usually resonates with a protective mode - and sometimes we focus on things in a mindful way - observing without judging, noticing without interfering. Here is where we can cultivate an accepting attitude in the present moment, where we are not judging ourselves for not doing it right, or for doing too much, but we are exposing our systems to the experience of being in control, by letting go of control. The mental process could go a little like this: "I'm observing my present experience as if I watched it passing in front of me - in my mental screen. And I gain control over it when I choose not to embark on it. I can see the myriad of flavours in this present moment. Sometimes the "bitter note" is very prominent, but I can also notice some "sweetness" somewhere else. This sweetness may be a metaphor for a concrete sense of support, or a sense of warmth, or a sense of my breath, or a sense that I am accompanied by my therapist in this experience, through hearing their voice, guiding me. Sometimes I can notice myself judging myself. Then I can choose to judge that too or accept that. Or I can also notice myself trying to change what I am noticing, adjusting positions in my body, or bringing in new thoughts, and I am still observing it, and my breath is still there. "
Gaining control beyond the bind
At the end of my literature review I could reconcile the dilemma to distract or not distract, to focus or not to focus...
I finally sat with the feeling that both can work well for people in persistent pain, as long as it helps them feel in control. If we are doing distraction to alienate ourselves from the present experience, and feel that we have no other option than to alienate ourselves, that can be detrimental... On the other hand, if we can learn that we may be sore but safe and see the choice in letting go of control, then all our systems will be conveying this message to our brain. And the protective mode will no longer be as needed.
This is the cherry on the cake and the cake's tray:
You don't have to do it alone. These are simple techniques that are yet very different than how we operate in modern life. It may be important to have someone coaching you.
When feeling supported by someone we trust to guide us in this journey of self-discovery, we may gradually gain more control in the regulations of the nervous system- be it through sensations, thoughts, emotions, breathing, or muscular regulation. Facilitating positive neuroplasticity of all the dimensions in our neuromatrix and in our relationships to others and the space around us. In other words, turning DIMs into SIMs.