Pain East and West
Current CDC estimates are that about 20% of the population has chronic pain (50 million) and about 8% have high-impact, disabling chronic pain (pain that significantly limits life activities). Chronic pain rates are higher in older adults, adults in poverty, and adults with less education, rural adults, and adults with public health insurance.
In my previous work in a pain clinic I saw first-hand how a person’s current and past experiences play a significant role in their perception of pain and how they respond to their pain. I saw a person in their 20’s unable to be out of a wheelchair and on high-dose opioids due to perception of pain that on imaging wouldn’t indicate that it should be more than mild, intermittent pain. Another person was paralyzed for five months from lower back pain. Several diagnostic tests couldn’t find an obvious medical source for the paralysis.
The pain clinic patients were referred by their primary care physicians because they had not found a pain management strategy that seemed to work for them, and most were on high-dose opioids because of physician frustration with managing their pain through less severe methods. Opioids mainly work through a general numbing of physical and emotional suffering with a mild euphoric feeling for some before tolerance kicks in.
Most of these patients had become disabled by their pain conditions. They were not working, depressed, and highly resistant to alternative strategies to manage their pain. They often said to me “I don’t need a psychologist; my pain is real.” In researching how to help these patients, I’d come across a lot of pain literature that explained how the patient’s perception of pain largely determines their experience of pain. I’ve heard it said that the way we think about our pain is like the volume knob on the experience of the pain. On the surface it makes logical sense, but there is frequently a denial about this in the patient that borders on delusion.
One of the most important and most challenging things to explain to chronic pain patients is that their very real and solid experience of pain is in part driven by their perceptions. They tend to see this as saying, “it’s all in your head.” Sometimes unskilled doctors do say some variation of this in a judgmental tone as if the patients are consciously intending to do this or that they’re just so stupid that they don’t realize what they’re doing. Either way the doctor sends the message to the patient that they’re not worth their time, to come back when they’ve got something real going on.
The medical community that has been tasked with treating chronic pain has largely failed. In the 90’s the American Medical Association declared pain was the 5th vital sign and that doctors had to take patients’ pain seriously and believe them when they said it was a 10 out of 10. How exactly do you measure pain on a scale? It’s entirely subjective. Then some were held liable for under-treating pain, and many turned to opioids, believing that they weren’t addictive if they were used to treat pain. Insurance companies reimburse medication but typically not meditation or any of the other alternative therapies like acupuncture, yoga, group therapy pain classes, or massage.
The primary model for understanding illness and pain in this country is the biomedical model. This is the one most taught in medical schools, and the entire structure of the physician documenting and insurance billing is based on this model. The biomedical model basically states that your pain has a medical cause and a medical cure or at least treatment. The message often seems to be “just because the imaging hasn’t found the source of your intense pain doesn’t mean we won’t find it with even more invasive imaging.” No doubt imaging does sometimes find the source of pain (for example a broken bone or worse, a tumor), but there are numerous circumstances where it doesn’t, or what it shows doesn’t correlate to the actual felt experience of the pain.
A good example of this is back imaging that shows disc degenerations in the spine. The degree of “spine damage” on MRI doesn’t correlate with the presence or severity of pain. The disc doesn’t have a nerve ending. The degree of spine abnormality doesn’t correlate with presence of pain. In a study done at a recent Olympics, 50 percent of Olympic athletes had moderate to severe degenerative changes in their spine. Thirty-seven percent of people in their 20’s have disc degenerations; most have no idea of this. If one shows the imaging to them then they are more likely to manifest with more back pain than before, believing that the imaging is directly correlated to pain.
Pain is a signal. It can either be from an external or internal source, but it is telling us something is happening. How we interpret it is up to us, but we frequently don’t realize how we are interpreting it. Have you ever stubbed your toe and said “OUCH!” and then realized the pain wasn’t as bad as you were anticipating? One theory says pain is sending us a sign that there is danger. Whether or not there actually is danger, we interpret it this way. On one end of the spectrum is the soldier on the battlefield who has been shot and doesn’t realize it until he’s off the battlefield. His attention and focus were on staying alive, scanning around for enemies, fully focused on “kill or be killed.”
On the other end of the spectrum is an example written up in the Journal of British Medicine of a construction worker who stepped on a nail that went all the way through his boot and he screamed in excruciating pain. He continued screaming in pain as his colleagues rushed him to the emergency room where the doctors cut off his boot and discovered that the nail went right between his toes.
Acute pain like this sends a protective signal. Bend your finger back until it hurts a little. Did you just injure yourself? No. The pain is serving as a warning: “Be careful.” But when we experience pain, particularly repeated pain, we begin to behave as if we’ve been injured. With chronic pain is an insidious decline in functionality.
How does this pain and pain perception relate to Buddhism? Pain is a powerful feeling, one that appears solid and often continuous. Yet when you examine pain, you can see that it isn’t at all solid: we are just projecting solidity and continuity onto it. Even in the face of serious medical conditions that cause pain like cancer or sickle cell anemia, the pain isn’t solid. It is intermittent and variable, but since it is such a powerful experience when it occurs, the person can project solidity and suffering onto the experience. It is the meaning that the person places onto the experience that creates the suffering: “What’s wrong with me, I can’t stand this. I’m afraid that it’ll never end, my life is over, what did I do to deserve this, it’s not fair, I can’t do the things I used to do. I’m not good for anything anymore.” It is not at all uncommon for pain to lead to depression and anxiety, and for people with depression and anxiety to inflate the experience of the pain, otherwise known as “catastrophizing.”
The mind and the body are closely linked, and we feel our feelings in our body. When we are not in tune with what we are feeling emotionally, we are usually going to first notice it in our bodies. Chronic lack of awareness of what is going on leads to chronic avoidance strategies which lead us away from the cues that we need to do something about our situation. Then we develop stress-related illnesses and pain from chronic muscle tension. There is a strong suspicion in the pain treatment community that the chronic stress of the pandemic is going to lead to more people with chronic pain conditions.
Buddhism teaches that people and phenomena are not as fixed and solid as they appear, that everything and everyone comes together and falls apart as a result of causes and conditions. We are projecting solidity onto our experience when it is undergoing constant change.
Pain is one of the translations of the perhaps untranslatable word dukkha, which is also known as the First Noble Truth, that conditioned life is suffering.
There are three types of suffering talked about in Buddhism. These are explained by Tsenzhab Serkong Rinpoche
- The suffering of suffering. This refers to all states of unhappiness. We can easily put physical pain here. This type of anger leads to repulsion or anger toward this type of suffering.
- The suffering of change, or tainted happiness. We can’t hold onto anything or anyone. We could see the persistence of chronic pain as a manifestation of the suffering of change from a previously healthy state or the suffering of the longing for a change back to the healthy state.
- All-pervasive suffering. This refers to a tainted neutral feeling. That general background of anxiety and insecurity that is there even in the best of times.
According to Alexander Berzin: in general terms, tainted phenomena constitute what is known as “samsara,” the uncontrollably recurring situations of rebirth under the influence of impulses (karma) and disturbing emotions and attitudes, and which entail suffering.
Going back to the all-pervasive suffering, Tzenshab Rinpoche explains that an example of this is the five tainted aggregates of a mind with grasping for the truly established existence of the peak of samsara. Zen teacher Bernie Glassman has given a useful interpretation of the five aggregates:
- The first aggregate is form, or our direct experience, through the senses of the physical world.
- Next is feeling, which is our simplest internal response to any sensation: like, dislike, or neutral.
- Next is reaction based on our feeling, which can be an instinctive reaction or a complex emotional reaction, like anger, fear, or envy.
- Then we have recognition or interpretation, where the mind catches up to the sensation and applies a label to it.
- The fifth skanda is ordinary human consciousness as ordinary people experience it. However, this is where we download the storehouse of past experiences and concepts and thereby obscure the direct experience of the first skandha (sensation), often creating confusion and suffering in the process.
In seeing the fifth skanda as the story that we make of the first skanda (form or sensation), we can see how our meaning and interpretation of the sense information creates the reality that we experience. Our suffering in this case is caused by confusing reality with concepts and judgments based largely on past experience—by our conditioning, in other words—importing fear and other painful emotions into an otherwise neutral or even benign moment. Therefore, the person with chronic pain may interpret a sensation based on past conditioning and inflate the suffering of that sensation.
A classic example of this is found in the Sallatha Sutta.
When touched with a feeling of pain, the uninstructed run-of-the-mill person sorrows, grieves, & laments, beats his breast, becomes distraught. So he feels two pains, physical & mental. Just as if they were to shoot a man with an arrow and, right afterward, were to shoot him with another one, so that he would feel the pains of two arrows.
The first arrow is a cause or condition that generates the sensation of pain. The second arrow is our reaction to it, especially if that arrow is filled with resistance, catastrophizing, etc. It’s the second arrow that turns the volume knob up on our pain, that makes the felt sense of it so much worse. Pain plus resistance equals suffering. These reactions to pain can become so conditioned that they feel automatic and mere recognition of them can’t just turn them off like a light switch.
Physical pain again is just one example of the pervasiveness of suffering that defines samsara. In Buddhism one uses suffering as a means of motivation to bodhicitta, the spirit of awakening. One generates compassion for all beings who suffer as they do, and they practice diligently to acquire the wisdom to lead them to enlightenment in order to truly help other beings out of suffering.
Zen Buddhist teacher Thich Nhat Hahn wrote that you can’t have a happy, successful life without some suffering. The lotus flower must grow from the mud. He wrote that a big part of happiness is learning how to “suffer well.” We don’t want to make our suffering worse than it needs to be.
Sacramento Buddhist teacher Lama Yeshe Jinpa has talked about looking at pain sensations as discontinuous. When we’re in pain we make it very solid and project permanence onto it. But when we pay attention, even if it sticks around for a long time, it eventually morphs into less pain, a different kind of pain, or often an absence of pain. Bodily sensations are constantly occurring, we are just attending usually to the most noxious and annoying ones.
We can place the pain in a larger container of all of the bodily sensations, thoughts, and emotions, and general perceptions of the sense organs. It removes the hand from the face and begins to distance it so we can see around it.
One of the early pioneers in Buddhism and pain was psychologist Jon Kabat Zinn. Kabat Zinn studied meditation with Thich Nhat Hahn and other Buddhist teachers and began to bring it to patients at Mass General hospital. He developed a secular form of “mindfulness meditation” and studied its effects on various conditions, including pain conditions. He found statistically significant effects on reducing pain intensity and unpleasantness with mindfulness meditation and he developed a treatment called Mindfulness-Based Stress Reduction (MBSR).
In his book The Mindful Solution to Pain, Kabat Zinn writes, “From the perspective of mindfulness, nothing needs fixing. Nothing needs to be forced to stop, or change, or go away.” Kabat-Zinn is making the case for awareness of a sensation, without the overlay of our thoughts, to elicit healing. He goes on to say “…It is only awareness itself that can balance out all of our various inflammations of thought and the emotional agitations and distortions that accompany the frequent storms that blow through the mind, especially in the face of a chronic pain condition.”
In general, meditation allows us to see how our thoughts carry us away on a stream of interpretation of our lived experience. We create meaning of our perceptions through our thoughts. Our thoughts feel so solid and yet they come from nowhere and go back to nowhere. Thoughts are self-liberated. The meaning we put on our experience creates our suffering.
One can think about obsessive-compulsive disorder as an extreme manifestation of this. “If I step on a crack, I will break my mother’s back.” “If I don’t count by fours to one hundred my family will die.” Anyone, including the person with OCD, can see the logical fallacy of these thoughts, but they still feel powerfully compelled to perform the compulsion as a means of quelling the thought and its overlay of horrible meaning to their existence.
A good meditation for mindfulness of pain is the body scan meditation. Kabat-Zinn writes “The body scan can allow us to use our bodies to experience present-centered, non-judgmental awareness. We can learn to be aware of whatever sensation arises in our bodies, particularly the painful ones, and then we learn to notice the difference between the direct experience of these sensations and the indirect perceptions that we add on to that experience. The body scan allows us to non-judgmentally identify what we are feeling and where we are feeling it as we narrow our focus on each detailed part of our body. Yet, we also begin to train our minds to broaden our focus away from the intricate body parts to a broader and more spacious awareness of the body as it exists, with different co-existing parts and sensations. A greater understanding of what our body endures allows us the opportunity to see what it feels, accept it, and cultivate compassion for it, without immediately judging it or trying to escape it.”
The so-called “third-wave” of mindfulness-based mental health therapies such as MBSR and acceptance and commitment therapy hew closely to Buddhist principles while translating them for a more secular audience. Understanding the broader context behind pain and relief from pain is often a key for people in living with and moving beyond chronic pain.
This reminds me of the 8 worldly dharmas: pleasure and pain, gain and loss, praise and blame, and fame and disgrace. These are four things we like and become attached to and four things we don’t like and try to avoid. When we get caught up in the 8 worldly dharmas, we suffer. Obviously we don’t like pain and our natural instinct is to avoid it.
Pema Chodron says “We might feel that somehow we should try to eradicate these feelings of pleasure and pain, loss and gain, praise and blame, fame and disgrace. A more practical approach would be to get to know them, see how they hook us, see how they color our perception of reality, see how they aren’t all that solid. Then the 8 worldly dharmas become the means for growing wiser as well as kinder and more content.
“To begin with, in meditation we can notice how emotions and moods are connected with having lost or gained something, having been praised or blamed, and so forth. We can notice how what begins as a simple thought, a simple quality of energy, quickly blossoms into full-blown pleasure and pain. We have to have a certain amount of fearlessness, of course, because we like it all to come out on the pleasure/praise/fame/gain side. We like to ensure that everything will come out in our favor. But when we really look, we’re going to see that we have no control over what occurs at all. We have all kinds of mood swings and emotional reactions. They just come and go endlessly.”
So how do meet pain instead of turning away from it? We meet it with wisdom and compassion, otherwise known as bodhicitta, the spirit of awakening.
“Stephen Levine wrote of a woman who was dying in terrible pain and feeling overwhelming bitterness. At the point at which she felt she couldn’t bear the suffering and resentment any longer, she unexpectedly began to experience the pain of others in agony: a starving mother in Ethiopia, a runaway teenager dying of an overdose in a dirty flat, a man crushed by a landslide and dying alone by the banks of a river. She said she understood that it wasn’t her pain, it was the pain of all beings. It wasn’t just her life, it was life itself.”
“We awaken this bodhicitta, this tenderness for life, when we can no longer shield ourselves from the vulnerability of our condition, from the basic fragility of existence. In the words of the 16th Gyalwa Karmapa, “You take it all in. You let the pain of the world touch your heart and you turn it into compassion.”
This is otherwise known as tong-len. When we separate ourselves from others, we think it protects us from them. Instead it only hardens our hearts. We can and need to use our pain as a means of connecting us to others, to our and their suffering in order to motivate us in our suffering to attain enlightenment in order to benefit all beings and bring them into enlightenment as well, the mind free from obscuration and the mind free from pain.
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Nirvana is the realization of emptiness, that phenomena and persons do no inherently exist from their own side, they are empty of inherent existence.
Norman Fischer writes: Emptiness is sunyata in Sanskrit. It comes from a root word suggesting swelling, something puffed up and hollow, with nothing inside, like a balloon. (Yes, I know there is air inside a balloon, but no “thing”). Emptiness implies a kind of deception. Beings, all things, thoughts, ideas, feelings—these are all deceptive. They may seem to be big and full, like a balloon, but when you prick them, they pop, Wizard of Oz-like. Like the Wizard, they are empty, completely lacking the substantiality they appear to have. Everything is like this, including and especially one’s self and others.
When the balloon of being pops, it’s an unsettling experience. The emptiness of all phenomena is a disturbing fact of life. The Heart Sutra includes a litany of things that are popped, empty, nonexistent. The list includes eyes, ears, nose, tongue, body, and mind.
If a being is empty, what then is it empty of? What is it full of? It is empty of svabhava, own-being. Our mistaken notion of svabhava is what ties feeling-sensation in a painful knot. Without knowing we are doing it, we viscerally impute to things a deeply, almost physically held sense that they are there in a way they actually aren’t. If we truly appreciated that things aren’t there in a way we think they are, that they are there in some completely different way, we would not react to them in the way we normally do. Our pain would disentangle from its false support. We would not long for something we can’t ever have. Things are empty of the own-being we crave in them.
So then if beings are empty of own-being, what are they full of? Interdependence. They are so radically interdependent that they cannot exist in their own right as separately existent identities. There are in fact, no things: there is only the endless ebb and flow of being.
Add the 8 verses commentary by HH, especially verse 8 and talk about the 8 mundane concerns.
Add Lojong slogans
Samsara is our deluded perceptions, it’s not an external phenomena. Our fundamental ignorance causes the other two poisons, attachment and aversion. These of course cause us to cling to what we want and to push away what we don’t want. Pain would fall into the aversion category. Remember pain plus resistance equals suffering. It is the aversion that is the suffering. It is so conditioned for us to avoid that which we don’t like that we don’t even realize when we’re doing it most of the time. Anxiety tried and true treatment is exposure therapy, but exposure in a tolerable way, building up to higher and higher levels of tolerance.
Pain as a means of increasing compassion. Who among us hasn’t felt pain?
We are all of the nature to grow old, sick and die. Few of us will escape from experiencing severe physical pain at one time or another.
Pain as causing aversion and clinging
Reya Stevens is a Boston-based practitioner of Theravada Buddhism who teaches Buddhist approaches to dealing with illness. “Clinging,” Stevens says, referring to the Buddha’s second noble truth, “is all about not wanting something to be the way it is, or wanting something to stay the way it is—which can’t happen because everything is constantly changing.”
It’s natural to reject what’s unpleasant, but this often boomerangs. “If you get into a struggle with something, like trying to get rid of something or push it away, it has a tendency to actually make the thing worse,” Stevens says.
Shantideva Verse 12: The cause of happiness is rare, and many are the seeds of suffering. But if I have no pain, I’ll never long for freedom. Therefore, oh my mind be steadfast.
- In general, we have to make a great deal of effort to obtain happiness, while suffering comes naturally.
The very fact of having a body inevitably involves suffering. Sufferings are numerous and their causes abundant. A wise person can achieve happiness by transforming the causes of suffering into favorable conditions. We can use suffering as a means to progress. As Shantideva says, “If I have no pain, I’ll never long for freedom.” It’s only natural that we dislike suffering. But if we can develop the willpower to bear difficulties, then we will grow more and more tolerant. As it is said in the text, verses 14 and 16, “There’s nothing that does not grow light through habit and familiarity. Putting up with little cares, I’ll train myself to bear with great adversity. Heat and cold, the wind and rain, sickness, prison, beatings, I’ll not fret about such things. To do so only aggravates my trouble.”
HH: If we are very forbearing, then something we would normally consider very painful would not appear so bad after all. But without patient endurance, even the smallest thing becomes unbearable. A lot depends on our attitude. If we can develop patient endurance, we can learn to bear great difficulties when they come our way. To be forbearing means that even when we are confronted with great suffering or harm, we do not let it disturb our minds. Of course, it is difficult to regard sufferings as desirable and to transform them into favorable conditions. We have to be patient as we wage a war on negative emotions, such as hatred, the worst of enemies.
Verse 31 “
The process of cause leading to result is due to the coming together of conditions. Nothing is independent. If we understand this, then the happiness and suffering we normally perceive as real and solid will be seen as something insubstantial, like magical illusions. In light of this, we should try not to be angry with anyone.
Even though pain is illusory, we still suffer from it. And we certainly do not want it. The same is true of happiness. It is an illusion, but it is still something we want. Thus, illusory antidotes are used to get rid of illusory sufferings. Just like a magician uses one magical illusion to counteract another.