The first time I encountered the term mindfulness in relation to chronic pain was when I read a paper by Jon Kabat-Zinn published in 1982 in the journal General Hospital Psychiatry. This was a study describing the preliminary effects of mindfulness-based stress reduction (and relaxation) taught over 10 weeks and involving 51 people with chronic pain. The participants included people with a wide range of pain locations (we used to do this in the olden days!), and these early results showed 65% of participants obtained a reduction of more than 33% on the Pain Rating Index (Melzack, 1975).
The MBSR programme has since gone on to be one of the many types of approach for chronic pain led by psychologists, and at the time, claimed to be teaching ‘the how of living with chronic pain.’ Kabat-Zinn presented theoretical arguments for the effect of mindfulness meditation on pain perception, attention and the interaction between the two. Kabat-Zinn had personal experience of mindfulness, but chose this approach because traditional meditation literature described how to use mindfulness to handle pain during ‘intense’ meditation practice (particularly long duration).
In this paper, two forms of mindfulness are described: the Transcendental Meditation form (focused attention on a single point and holding it for 20 – 60 minutes); and the broader form based in Buddhist practices where detached observation, ‘from one moment to the next’ of a ‘constantly changing field of objects.’ The latter form is described as “concentrating on one primary object (commonly the successive flow of inbreaths and outbreaths), until attention is relatively stable, and then allowing the field of objects of attention to expand (usually in stages) to include, ultimately, all physical and mental events -body sensations, thoughts, memories, emotions, perceptions, intuitions, fantasies-exactly as they occur in time”(Kabat-Zinn, 1982, p. 34).
He goes on to say that ‘the mind has a strong tendency to wander…’ and participants in this programme were taught to begin by paying attention to breath, then expanding the attention more broadly, and as the mind wanders off, returning to the breath. The process of noticing when the mind has drifted off – and then returning attention to the original focus – is the key skill, along with noticing without judgement. Kabat-Zinn states that ‘detached’ (the original term used for noticing without judgement) is defined as ‘intentionally regarded with an effort to avoid judgement or interpretation, or to be aware of judgement or interpretation if they occur.’
At the time of writing, functional MRI did not exist, and Kabat-Zinn theorised about how mindfulness might influence the pain experience based on theoretical explanations developed by Sternbach (1978) and Melzack & Wall (1965, 1970). The ideas included Melzack & Wall’s notions of motivational and cognitive contributions to pain needing to be considered ‘on an equal footing with sensory pathways and mechanisms’ with the gate control theory providing the psychophysiological model for explaining how distraction, attention, suggestion (hypnosis), trance, anxiety, depression, past experiences, cultural traditions, family attitudes and so on influence perception and interpretation of pain. Some of today’s commentators may disagree on whether pain is perceived, and yes, gate control theory has been revised and reviewed (science, right?!). Essentially, however, the influence of ‘psychological’ and ‘social’ factors on our pain experience has been clearly demonstrated.
So how might mindfulness as described by Kabat-Zinn influence pain? He drew on the extended mindfulness practices and what was written to instruct meditators to deal with discomfort arising from these extended periods, and thought they’d be useful for people with chronic pain. This advice included focusing on painful and unpleasant experiences and discouraging efforts to escape them through distraction or being immersed in another experience. Maintaining an observing stance rather than a judging stance – the ‘it’s killing me’ thought, accompanied by thinking ‘it’s going to last forever’, can lose potency just by being observed as separate from the sensation. I’ve cut and pasted the original explanation below (from Kabat-Zinn, 1982, p. 35).
The cool thing for me now is that with fMRI, we can see that these theoretical processes actually do occur – see Sezer et al., (2022) for a recent update. While this does excite me, I am also aware that fMRI studies are only correlates – they do not tell us about what it is like to experience pain during meditation practice!
To begin with, mindfulness is weird. Mindfulness comes with a whole heap of jargon that can get in the way of having a go. A there are those who say the form of mindfulness that’s become popular is ‘McMindfuless‘ – a kind of blithe ignoring the causes of life’s challenges and a focus on becoming detached from them and plodding on. I don’t entirely agree – using mindfulness to ‘tolerate’ the ills in our society may be one element of how mindfulness can help, but this steps outside of the purpose for which mindfulness was introduced for people with chronic pain. For so many of us, changing the course of our chronic pain is not possible – it is there, and we have no existing magic wands to fix it, so developing a neutrality towards our pain so it doesn’t dominate our actions, thoughts, or emotions is a practical way forward.
I start with little dips into being present moment aware. Focus is not my favourite thing, given my ADHDness (unless it’s a hyperfocus!), so extended forms of meditation have taken practice and discipline. My little dips begin as I sit writing this blog: what do I notice in my body right now? The pressure of my fingertips on the keyboards as I type, the tapping sound the keys make, the weight of my butt on my saddle chair, the pressure of the floor on the soles of my feet, my computer fan whirring, the cool air in my nostrils as I breathe in, the warmth as my breath leaves my body… I start my day sipping quietly on my coffee, the warmth of the blankets over my legs, the fuzzy softness of my dressing gown on my skin. Bringing my attention back to sensations, opening up to the burning in my hip, the firm hug of pain around my lower back, the tingling like a glove around my toes and feet.
And each time I notice my mind drifting off into a commentary or worry – I notice, and gently bring my mind back to the weight of my butt on the chair, my fingertips hitting the keyboard… And this I do periodically throughout the day. It’s an ongoing practice. An ongoing noticing. An opening up to those sensations that I might want to change, being OK to sit with them before moving my body. And an ongoing noticing of my train of thought, wandering off into thinking about the coming day, what needs doing over the next few weeks, what I haven’t done… and back to noticing what I am actually feeling in this moment.
No outcome to be achieved. No aim or intention except to bring my mind to what I choose to attend to. To repeatedly do this. To train my recalcitrant mind to simply be present when I choose it to be. To be mindful rather than mindless. To do this for a minute. Thirty seconds. Ten minutes. An hour. Another 5 seconds. I’m an absolute beginner here. I might have practiced mindfulness for decades but I’m still a beginner. My mind is a labrador puppy – curious about everything – and I’d love to be more zen, more like a cat! And yet this is where I am in my mindfulness development, and it is what it is.
Want to join me?
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. https://doi.org/http://dx.doi.org/10.1016/0163-8343(82)90026-3
Melzack R: The McGill Pain Questionnaire: Major properties and scoring methods. Pain 1:277-299, 1975
Melzack R, Wall PD (1970). Psychophysiology of Pain. Internat Anesthesiol. Clinics 8:3-34.
Melzack R, Wall PD. (1965). Pain mechanisms: A new theory. Science 150:971-979.
Sezer, I., Pizzagalli, D. A., & Sacchet, M. D. (2022). Resting-state fMRI functional connectivity and mindfulness in clinical and non-clinical contexts: A review and synthesis. Neurosci Biobehav Rev, 135, 104583. https://doi.org/10.1016/j.neubiorev.2022.104583
Sternbach RA: Clinical Aspects of Pain. In Sternbach RA (ed), The Psychology of Pain. New York, Raven, 1978, pp. 241-264