As we emerge from the COVID pandemic and look forward to the New Year, we can bring joy and happiness though through simple acts of kindness.
I just received an email from the Rick Hansen Foundation that inspired me to share its recommendations. In 1957 at the age of 15, Rick Hansen injured his spinal cord and was paralyzed from the waist down. He is an inspiration for all of us. In these crazy times of sheltering in place, experiencing social isolation, anxiety, depression, racial bias, and also happiness and joy, he recommends the following TED talks to increase resilience, overcome racial bias, and achieve self-acceptance. Enjoy watching the talks as they suggest strategies to deal with adversity and offer hope for the New Year.
3 Secrets of resilient people by Dr. Lucy Hone, Co-director of the New Zealand Institute of Wellbeing & Resilience and adjunct fellow at the University of Canterbury in Christchurch, New Zealand.
How racial bias works-and how to disrupt it by Stanford University social psychologist, Jennifer L. Eberhardt
To overcome challenges, stop comparing yourself to other by wheelchair athlete Dean Furnes
Adapted from the book, TechStress: How Technology
is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics, by Erik Peper, Richard Harvey and Nancy Faass.
Peper, E., Harvey, R., & Faass, N. (2020), TechStress-How Technology is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics. Berkeley, CA: North Atlantic Books.
We are excited about our upcoming book, TechStress-How Technology is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics, that will be published August 25, 2020.
Evolution shapes behavior — and as a species, we’ve evolved to be drawn to the instant gratification, constant connectivity, and the shiny lights, beeps, and chimes of our ever-present devices. In earlier eras, these hardwired evolutionary patterns may have set us up for success, but today they confuse our instincts, leaving us vulnerable and stressed out from fractured attention, missed sleep, skipped meals, aches, pains, and exhaustion and often addicted to our digital devices.
Tech Stress offers real, practical tools to avoid evolutionary pitfalls programmed into modern technology that trip us up. You will find a range of effective strategies and best practices to individualize your workspace, reduce physical strain, prevent sore muscles, combat brain drain, and correct poor posture. The book also provides fresh insights on reducing psychological stress on the job, including ways to improve communication with coworkers and family.
Although you will have to wait until August 25th to have the book delivered to your home, you can already begin to implement ways to reduce physical discomfort, zoom/screen fatigue and exhaustion. Have a look the blogs below.
How evolution shapes behavior
How to optimize ergonomics
Hot to prevent and reduce neck and shoulder discomfort
How to prevent screen fatigue and eye discomfort
How to improve posture and prevent slouching
How to improve breathing and reduce stress
How to protect yourself from EMF
Breathing affects every cell of our body and should be the first intervention strategy to improve physical and mental well-being (Peper & Tibbetts, 1994). Breathing patterns are much more subtle than indicated by the respiratory function tests (spirometry, lung capacity, airway resistance, diffusing capacity and blood gas analysis) or commonly monitored in medicine and psychology (breathing rate, tidal volume, peak flow, oxygen saturation, end-tidal carbon dioxide) (Gibson, Loddenkemper, Sibille & Lundback, 2019).
When a person feels safe, healthy and peaceful, the breathing is effortless and the breath flows in and out of the nose without awareness. Functional and dysfunctional breathing patterns includes an assessment of the whole body pattern by which breathing occurs such as nose versus mouth breathing, alternation of nasal patency, the rate of air flow rate during inhalation and exhalation, the length of time during inhalation and exhalation, the post exhalation pause time. the pattern of transition between inhaling and exhaling, the location and timing of expansion in the truck, the range of diaphragmatic movement, and the subjective quality of breathing effort (Gilbert, 2019; Peper, Gilbert, Harvey & Lin, 2015; Nestor, 2020).
Breathing patterns affect sympathetic and parasympathetic nervous systems (Levin & Swoap, 2019). Inhaling tends to activate the sympathetic nervous system (fight/flight response) while exhaling activates the parasympathetic nervous system (rest and repair response) (Lehrer & Gevirtz, 2014). To observe how breathing affects your heart rate, monitor your pulse from either the radial artery in the wrist or the carotid artery in your neck as shown in Figure 1 and practice the following.
After sensing the baseline rate of your pulse, continue to feel your radial artery pulse in your wrist or at the carotid artery in your neck. Then inhale for the count of four hold for a moment and gently exhale for the count of 5 or 6. Repeat two or three times.
Most people observe that during inhalation, their heart rate increased (sympathetic activation for action) and during exhalation, the heart rate decreases (restoration during safety).
Nearly everyone who is anxious tends to breathe rapidly and shallowly or when stressed, unknowingly gasp or holds their breath–they may even freeze up and blank out (Peper et al, 2016). In addition, many people habitually breathe through their mouth instead of their nose and wake up tired with a dry mouth with bad breath. Mouth breathing combined with chest breathing in the absence of slower diaphragmatic breathing (the lower ribs and abdomen expand during inhalation and constrict during exhalation) is a risk factor for disorders such as irritable bowel syndrome, hypertension, tiredness, anxiety, panic attacks, asthma, dysmenorrhea, epilepsy, cold hands and feet, emphysema, and insomnia. Many of our clients who aware of their dysfunctional breathing patterns and are able to implement effortless breathing report significant reduction in symptoms (Chaitow, Bradley, & Gilbert, 2013; Peper, Mason, Huey, 2017; Peper & Cohen, 2017; Peper, Martinez Aranda, & Moss, 2015).
Breathing is usually overlooked as a first treatment strategy-it is not as glamorous as drugs, surgery or psychotherapy. Teaching breathing takes skill since practitioners needs to be experienced. Namely, they need to be able to demonstrate in action how to breathe effortlessly before teaching it to others. Although it seems unbelievable, a small change in our breathing pattern can have major physical, mental, and emotional effects as can be experienced in the following practice.
Begin by breathing normally and then exhale only 70% of the inhaled air, and inhale normally and again exhale only 70% of the inhaled air. With each exhalation exhale on 70% of the inhaled air. Continue this for 30 seconds. Stop and note how you feel.
Almost every reports that the 30 seconds feels like a minute and experience some of the following symptoms listed in table 1.
Table 1. Symptoms experienced after 30-45 seconds of sequentially exhaling 70% percent of the inhales air (Peper & MacHose, 1993).
Even though many therapists have long pointed out that breathing is essential, it is usually the forgotten ingredient. It is now being rediscovered in the age of the COVID-19 as respiratory health may reduce the risk of COVID-19.
Simply having very sick patients lie on their side or stomach can improve gas exchange. By lying on your side or prone, breathing is easier as the lung can expand more which appears to reduce the utilization of respirators and intubation (Long & Singh, 2020; Farkas, 2020). This side or prone breathing approach is thousands of years old.
One of the natural and health promoting breathing patterns to promote lung health is to breathe predominantly through the nose. The nose filters, warms, moisturizes and slows the airflow so that airway irritation is reduced. Nasal breathing also increases nitric oxide production that significantly increases oxygen absorption in the body. More importantly for dealing with COVID-19, nitric oxide, produced and released inside the nasal cavities and the lining of the blood vessels, acts as an anti-viral and is a secondary strategy to protect against viral infections (Mehta, Ashkar & Mossman, 2012). During inspiration through the nose, the nitric oxide helps dilate the airways in your lungs and blood vessels (McKeown, 2016).
To increase your health, breathe through your nose, yes, even at night (McKeown, 2020). As you practice this during the day be sure that the lower ribs and abdomen expand during inhalation and decrease in diameter during exhalation. It is breathing without effort although many people will report that it initially feels unnatural. Exhale to the count of about 5 or 6 and inhale (allow the air to flow in) to the count of 4 or 5. Mastering nasal breathing takes practice, practice and practice. See the following for more information.
Watch the Youtube presentation by Patrick McKeown author of the Oxygen Advantage, Practical 40 minute free breathing session with Patrick McKeown to improve respiratory health. https://www.youtube.com/watch?v=AiwrtgWQeDc&t=680s
Listen to Terry Gross interviewing James Nestor on “How The ‘Lost Art’ Of Breathing Can Impact Sleep And Resilience” on May 27, 2020 on the NPR radio show, Fresh Air.
Look at the Peperperspective blogs that focus on breathing in the age of Covid-19.
Mehta, D. R., Ashkar, A. A., & Mossman, K. L. (2012). The nitric oxide pathway provides innate antiviral protection in conjunction with the type I interferon pathway in fibroblasts. PloS one, 7(2), e31688.
Peper, E., Gilbert, C.D., Harvey, R. & Lin, I-M. (2015). Did you ask about abdominal surgery or injury? A learned disuse risk factor for breathing dysfunction. Biofeedback. 34(4), 173-179. DOI: 10.5298/1081-5937-43.4.06
Peper, E. & Tibbetts, V. (1994). Effortless diaphragmatic breathing. Physical Therapy Products. 6(2), 67-71. Also in: Electromyography: Applications in Physical Therapy. Montreal: Thought Technology Ltd
This blog is based upon our breathing research that began in the 1990s, This research helped identify dysfunctional breathing patterns that could contribute to illness. We developed coaching/teaching strategies with biofeedback to optimize breathing patterns, improve health and performance (Peper and Tibbetts, 1994; Peper, Martinez Aranda and Moss, 2015; Peper, Mason, and Huey, 2017).
For example, people with asthma were taught to reduce their reactivity to cigarette smoke and other airborne irritants (Peper and Tibbitts, 1992; Peper and Tibbetts, 2003). The smoke of cigarettes or vaping spreads out as the person exhales. If the person was infected, the smoke could represent the cloud of viruses that the other people would inhale as is shown in Figure 1.
Figure 1. Vaping by young people in Riga, Latvia (photo by Erik Peper).
To learn how to breathe differently, the participants first learned effortless slow diaphragmatic breathing. Then were taught that the moment they would become aware of an airborne irritant such as cigarette smoke, they would hold their breath and relax their body and move away from the source of the polluted air while exhaling very slowly through their nose. When the air was clearer they would inhale and continue effortless diaphragmatically breathing (Peper and Tibbetts, 1994). From this research we propose that people may reduce exposure to the coronavirus by changing their breathing pattern; however, the first step is prevention by following the recommended public health guidelines.
- Social distancing (physical distancing while continuing to offer social support)
- Washing your hands with soap for at least 20 seconds
- Not touching your face
- Cleaning surfaces which could have been touched by other such as door bell, door knobs, packages.
- Wear a mask to protect other people and your community. The mask will reduce the shedding of the virus to others by people with COVID-19 or those who are asymptomatic carriers.
Reduce your exposure to the virus when near other people by changing your breathing pattern
Normally when startled or surprised, we tend to gasp and inhale air rapidly. When someone sneezes, coughs or exhales near you, we often respond with a slight gasp and inhale their droplets. To reduce inhaling their droplets (which may contain the coronavirus virus), implement the following:
- When a person is getting too close
- Hold your breath with your mouth closed and relax your shoulders (just pause your breathing) as you move away from the person.
- Gently exhale through your nose (do not inhale before exhaling)-just exhale how little or much air you have
- When far enough away, gently inhale through your nose.
- Remember to relax and feel your shoulders drop when holding your breath. It will last for only a few seconds as you move away from the person. Exhale before inhaling through your nose.
- When a person coughs or sneezes
- Hold your breath, rotate you head away from the person and move away from them while exhaling though your nose.
- If you think the droplets of the sneeze or cough have landed on you or your clothing, go home, disrobe outside your house, and put your clothing into the washing machine. Take a shower and wash yourself with soap.
- When passing a person ahead of you or who is approaching you
- Inhale before they are too close and exhale through your nose as you are passing them.
- After you are more than 6 feet away gently inhale through your nose.
- When talking to people outside
- Stand so that the breeze/wind hits both people from the same side so that the exhaled droplets are blown away from both of you (down wind).
These breathing skills seem so simple; however, in our experience with people with asthma and other symptoms, it took practice, practice, and practice to change their automatic breathing patterns. The new pattern is pause (stop) the breath and then exhale through your nose. Remember, this breathing pattern is not forced and with practice it will occur effortlessly.
The following blogs offer instructions for mastering effortless diaphragmatic breathing.
Peper, E. & Tibbetts, V. (1994). Effortless diaphragmatic breathing. Physical Therapy Products. 6(2), 67-71. Also in: Electromyography: Applications in Physical Therapy. Montreal: Thought Technology Ltd.
When you woke up this morning, how did you feel? Were you looking forward to the day anticipating with joy what would occur or were you dreading the day as if once again you had to step on the treadmill of life?
Whenever I ask this question of college students in their junior or senior year at an urban university about 20% will answer that they are looking forward to the day. The majority answer, “Well not really”, or even “Oh shit, another day”. For many students the burden of working 40 plus hours a week to pay for rent and tuition, worrying about financial debt, the challenge of commuting, and finding time to do the homework is overwhelming. Focusing on quality of life is not only a challenge for students, but for all of us.
Each day ask yourself, “Am I looking forward to my day and my activities?” If the answer is “No,” begin to explore new options. Ask yourself, “What would I like to do? Start to explore and imagine new options and then begin to plan how to implement them so that you are on the path to where you want to be.
Creating a worthwhile life is an ongoing challenge. An inspiring essay by Steven James articulates this by exploring factors that contribute to sickness and health during the height of the AIDs epidemic. He outline rules that contribute to 1) how to get sick, 2) how to get sicker (if you are already sick), and 3) how to stay well (or get better, if you are not so well to begin with).
|Steven James’s Totally Subjective, Nonscientific Guide to Illness and Health: Ten-Step Programs
How to Get Sick
· Don’t pay attention to your body. Eat plenty of junk food, drink too much, take drugs, have lots of unsafe sex with lots of different partners—and, above all, feel guilty about it. If you are overstressed and tired, ignore it and keep pushing yourself.
· Cultivate the experience of your life as meaningless and of little value.
· Do the things you don’t like, and avoid doing what you really want. Follow everyone else’s opinions and advice, while seeing yourself as miserable and “stuck.”
· Be resentful and hypercritical, especially toward yourself.
· Fill your mind with dreadful pictures, and then obsess over them. Worry most, if not all, of the time.
· Avoid deep, lasting, intimate relationships.
· Blame other people for all your problems.
· Do not express your feelings and views openly and honestly. Other people wouldn’t appreciate it. If at all possible, do not even know what your feelings are.
· Shun anything that resembles a sense of humor. Life is no laughing matter!
· Avoid making any changes that would bring you greater satisfaction and joy.
How to Get Sicker (If You’re Already Sick)
· Think about all the awful things that could happen to you. Dwell upon negative, fearful images.
· Be depressed, self-pitying, envious, and angry. Blame everyone and everything for your illness.
· Read articles, books, and newspapers, watch TV programs, surf the net, and listen to people who reinforce the viewpoint that there is NO HOPE. You are powerless to influence your fate.
· Cut yourself off from other people. Regard yourself as a pariah. Lock yourself up in your room and contemplate death.
· Hate yourself for having destroyed your life. Blame yourself mercilessly and incessantly.
· Go to see lots of different doctors. Run from one to another, spend half your time in waiting rooms, get lots of conflicting opinions and lots of experimental drugs, starting one program after another without sticking to any.
· Quit your job, stop work on any projects, give up all activities that bring you a sense of purpose and fun. See your life as essentially pointless, and at an end.
· Complain about your symptoms, and if you associate with anyone, do so exclusively with other people who are unhappy and embittered. Reinforce each other’s feelings of hopelessness.
· Don’t take care of yourself. What’s the use? Try to get other people to do it for you, and then resent them for not doing a good job.
· Think how awful life is, and how you might as well be dead. But make sure you are absolutely terrified of death, just to increase the pain.
|How to Stay Well (Or Get Better, If You’re Not So Well to Begin With)
· Do things that bring you a sense of fulfillment, joy, and purpose, that validate your worth. See your life as your own creation and strive to make it a positive one.
· Pay close and loving attention to yourself, tuning in to your needs on all levels. Take care of yourself, nourishing, supporting, and encouraging yourself.
· Release all negative emotions—resentment, envy, fear, sadness, anger. Express your feelings appropriately; don’t hold onto them. Forgive yourself.
· Hold positive images and goals in your mind, pictures of what you truly want in your life. When fearful images arise, refocus on images that evoke feelings of peace and joy.
· Love yourself, and love everyone else. Make loving the purpose and primary expression of your life.
· Create fun, loving, honest relationships, allowing for the expression and fulfillment of needs for intimacy and security. Try to heal any wounds in past relationships, as with old lovers, and with your mother and father.
· Make a positive contribution to your community, through some form of work or service that you value and enjoy.
· Make a commitment to health and well-being, and develop a belief in the possibility of wholeness. Develop your own healing program, drawing on the support and advice of experts without becoming enslaved to them.
· Accept yourself and everything in your life as an opportunity for growth and learning. Be grateful. When you fuck up, forgive yourself, learn what you can from the experience, and then move on.
· Keep a sense of humor.
As you go into the New Year, remind yourself that life has choices.
Adapted from: Peper, E., Pollack, W., Harvey, R., Yoshino, A., Daubenmier, J. & Anziani, M. (2019). Which quiets the mind more quickly and increases HRV: Toning or mindfulness? NeuroRegulation, 6(3), 128-133.
Disruptive thoughts, ruminations and worrying are common experiences especially when stressed. Numerous clinical strategies such as cognitive behavioral therapy attempt to teach clients to reduce negative ruminations (Kopelman-Rubin, Omer, & Dar, 2017). Over the last ten years, many people and therapists practice meditative techniques to let go and not be captured by negative ruminations, thoughts, and emotions. However, many people continue to struggle with distracting and wandering thoughts.
Just think back when you’re upset, hurt, angry or frustrated. Attempting just to observe without judgment can be very, very challenging as the mind keeps rehearsing and focusing on what happened. Telling yourself to stop being upset often doesn’t work because your mind is focused on how upset you are. If you can focus on something else or perform physical activity, the thoughts and feelings often subside.
Over the last fifteen years, mindfulness meditation has been integrated and adapted for use in behavioral medicine and psychology (Peper, Harvey, & Lin, 2019). It has also been implemented during bio- and neurofeedback training (Khazan, 2013; Khazan, 2019). Part of the mindfulness instruction is to recognize the thoughts without judging or becoming experientially “fused” with them. A process referred to as “meta-awareness” (Dahl, Lutz, & Davidson, 2015). Mindfulness training combined with bio- and neurofeedback training can improve a wide range of psychological and physical health conditions associated with symptoms of stress, such as anxiety, depression, chronic pain, and addiction (Creswell, 2015, Khazan, 2019).
Mindfulness is an effective technique; however, it may not be more effective than other self-regulations strategies (Peper et al, 2019). Letting go of worrying thoughts and rumination is even more challenging when one is upset, angry, or captured by stressful life circumstances. Is it possible that other strategies beside mindfulness may more rapidly reduce wandering and intrusive thoughts? In 2015, researchers van der Zwan, de Vente, Huiznik, Bogels, & de Bruin found that physical activity, mindfulness meditation and heart rate variability biofeedback were equally effective in reducing stress and its related symptoms when practiced for five weeks.
Our research explored whether other techniques from the ancient wisdom traditions could provide participants tools to reduce rumination and worry. We investigated the physiological effects and subject experiences of mindfulness and toning. Toning is vocalizing long and sustained sounds as a form of mediation. (Watch the video the toning demonstration by sound healer and musician, Madhu Anziani at the end of the blog.)
COMPARING TONING AND MINDFULNESS
The participants were 91 undergraduate college students (35 males, 51 females and 5 unspecified; average age, 22.4 years, (SD = 3.5 years).
After sitting comfortably in class, each student practiced either mindfulness or toning for three minutes each. After each practice, the students rated the extent of mind wandering, occurrence of intrusive thoughts and sensations of vibration on a scale from 0 (not all) to 10 (all the time). They also rated pre and post changes in peacefulness, relaxation, stress, warmth, anxiety and depression. After completing the assessment, they practice the other practice and after three minutes repeated the assessment.
The physiological changes that may occur during mindfulness practice and toning practice was recorded in a separate study with 11 undergraduate students (4 males, 7 females; average age 21.4 years. Heart rate and respiration were monitored with ProComp Infiniti™ system (Thought Technology, Ltd., Montreal, Canada). Respiration was monitored from the abdomen and upper thorax with strain gauges and heartrate was monitored with a blood volume pulse sensor placed on the thumb.
After the sensors were attached, the participants faced away from the screen so they did not receive feedback. They then followed the same procedure as described earlier, with three minutes of mindfulness, or toning practice, counterbalanced. After each condition, they completed a subjective assessment form rating experiences as described above.
RESULTS: SUBJECTIVE FINDINGS
Toning was much more successful in reducing mind wandering and intrusive thoughts than mindfulness. Toning also significantly increased awareness of body vibration as compared to mindfulness as shown in Figure 1.
Figure 1. Differences between mindfulness and toning practice.
There was no significant difference between toning and mindfulness in the increased self-report of peacefulness, warmth, relaxation, and decreased self-report of anxiety and depression as shown in Figure 2.
Figure 2. No significant difference between toning and mindfulness practice in relaxation or stress reports.
RESULTS: PHYSIOLOGICAL FINDINGS
Respiration rate was significantly lower during toning (4.6 br/min) as compared to mindfulness practice (11.6 br/min); heart rate standard deviation (SDNN) was much higher during toning condition (11.6) (SDNN 103.7 ms) than mindfulness (6.4) (SDNN 61.9 ms). Two representative physiological recording are shown in Figure 3.
Figure 3. Representative recordings of breathing and heart rate during mindfulness and toning practice. During toning the respiration rate (chest and abdomen) was much slower than during mindfulness and baseline conditions. Also, during toning heart rate variability was much larger than during mindfulness or baseline conditions.
Toning practice is a useful strategy to reduce mind wandering as well as inhibit intrusive thoughts and increase heart rate variability (HRV). Most likely toning uses the same neurological pathways as self-talk and thus inhibits the negative and hopeless thoughts. Toning is a useful meditation alternative because it instructs people to make a sound that vibrates in their body and thus they attend to the sound and not to their thoughts.
Physiologically, toning immediately changed the respiration rate to less than 6 breaths per minute and increases heart rate variability. This increase in heart rate variability occurs without awareness or striving. We recommend that toning is integrated as a strategy to complement bio-neurofeedback protocols. It may be a useful approach to enhance biofeedback-assisted HRV training since toning increases HRV without trying and it may be used as an alternative to mindfulness, or used in tandem for maximum effectiveness.
TAKE HOME MESSAGE
1) When people report feeling worried and anxious and have difficulty interrupting ruminations that they first practice toning before beginning mindfulness meditation or bio-neurofeedback training.
2) When training participants to increase heart rate variability, toning could be a powerful technique to increase HRV without striving
TONING DEMONSTRATION AND INSTRUCTION BY SOUND HEALER MADHU ANZIANI
For the published article see: Peper, E., Pollack, W., Harvey, R., Yoshino, A., Daubenmier, J. & Anziani, M. (2019). Which quiets the mind more quickly and increases HRV: Toning or mindfulness? NeuroRegulation, 6(3), 128-133.
Kopelman-Rubin, D., Omer, H., & Dar, R. (2017). Brief therapy for excessive worry: Treatment model, feasibility, and acceptability of a new treatment. Journal of Psychotherapy Integration, 29(3), 291-306.
van der Zwan, J. E., de Vente, W., Huizink, A. C., Bogels, S. M., & de Bruin, E. I. (2015). Physical activity, mindfulness meditation, or heart rate variability biofeedback for stress reduction: A randomized controlled trial. Applied Psychophysiology and Biofeedback, 40(4), 257-268. https://doi.org/10.1007/s10484-015-9293-x
Erik Peper, PhD and Rachel Zoffness, PhD*
KM was 14 years old when he came to my (Zoffness) office for treatment. He’d been diagnosed with migraine and cyclical vomiting syndrome and had been in bed for about 3 years. He had long, unwashed hair; was a sickly, pasty white; and rocked himself back and forth from the pain. He’d seen 15 doctors and had been prescribed 30 medications, including occipital nerve injections and Thorazine. Nothing had worked. Like most teens with chronic pain, KM was depressed, stressed, and terrified he’d never get his life back.
We started Cognitive Behavioral Therapy (CBT), beginning with pain neuroscience education. This involved teaching KM and his family how pain works in the brain, and how thoughts, emotions, physical sensations and behaviors work together to trigger and maintain flares. He then learned a variety of cognitive, behavioral and mind-body techniques to help manage and change pain. His parents received parent-training to support him behind the scenes. After a few weeks of treatment, KM was able to get out of bed and walk to the corner mailbox. After a few more weeks, he was able to walk his dog to the dog park and get a haircut. Within a few months he was jogging around the block, then running. As his functioning increased, his brain desensitized and his body strengthened, his pain started to recede. Gradually he returned to school and social relationships, eventually rejoining his soccer team. I attended his high school graduation a year ago. He got onstage and told the audience that, if you’d told him 4 years ago that he’d graduate high school, he’d never have believed you. He is currently in college, successfully managing his pain, living his important life.
Chronic pain (CP) in teens can be devastating. Teens are already tasked with managing the turbulence of hormone changes, social stress, academic stress, social media, family dynamics, and developing autonomy and independence. CP impacts not only the teen, but also the entire family. Because CP is framed as a biomedical problem, it is frequently treated with opioids and other minimally-helpful (and sometimes harmful) medications. Opioids are ineffective for long-term treatment of chronic pain, and are only useful in acute crises or to control pain at the end of life (Dowell, 2016; King et al, 2011).
Although we typically think of chronic pain as an issue primarily affecting adults coping with issues such as post-surgical pain and arthritis, CP affects up to 1 in 3 youth in the USA – more than 10 million children and teens (Friedrichsdorf, 2016; ). Pain impacts self-esteem, hope, and functioning, relegating teens to their beds and denying them normal educations and healthy social interactions. Like adults, teens often feel powerless and blamed. In a superb workbook, The Chronic Pain & Illness Workbook for Teens, psychologist Rachel Zoffness describes what pain is; how pain is constructed by the brain; how mind, body and emotions interact to affect pain; and offers a sequence of assessments and practices to reduce pain and improve health in language children and teens can easily understand. The approach combines cognitive behavioral therapy (CBT) with imagery, mindfulness, breathing, handwarming with biofeedback, and somatic practices (Turk & Gatchel, 2018; Peper, Gibney, & Holt, 2002).
This simple graphic of the pain cycle is helpful to clients (see Fig. 1).
Fig 1. CBT Pain Cycle
The pragmatic practices in this book offer tools and guided instructions that any child or teen can use for themselves, with parents, or with health providers. Therapists can use and adapt these activities with their clients of all ages. Although these scientifically-supported pain management techniques are written for teens, they can equally be used with adults. Below are two of many different practices described in the book that are useful for chronic pain.
Practice 1: Assessment: What sets off your pain?
The first step is to help youth identify factors that “trigger” – or set off – their pain. It’s helpful to define a trigger as a difficult emotion, situation, or event that causes pain to increase. Difficult situations and events of all kinds – biological, social, etc (situational triggers) can trigger difficult thoughts and emotions (cognitive and emotional triggers), and vice versa. For example, Adam was recovering from back surgery (situational trigger), got into a big fight with his sister about the car (situational trigger), and became angry and frustrated (emotional trigger). He felt the anger in his body, his muscles got hot and tight, and his back started spasming. Gina is an example of the reverse. She believed that nothing could cure her fibromyalgia (cognitive trigger), which made her feel depressed and hopeless (emotional trigger). She stayed home for weeks on end without school, friends, or distractions (situational trigger), and started feeling worse.
We can help youth with pain by asking:
- What emotions trigger your pain?
- What situations trigger your pain?
- Not getting enough sleep
- Arguing with family members
- Inflammation after physical therapy
- Missing fun events because you’re sick
- Thinking about upcoming exams
- Doctor’s appointments and hospital visits
Sometimes, the teen needs to keep a log for a week to identify the situations or triggers related to the pain. Once these have been identified then the teen can explore strategies to reduce the negative reactivity triggered by the emotions or situations.
Practice 2: Changing the voice of pain (Note: this is a summary of a longer activity)
One technique we use in CBT for chronic pain is identifying and tracking cognitive distortions, also known as “thinking traps.” I (Zoffness) call these traps “Pain Voice.” This is the catastrophic, pessimistic, critical, and negative voice that tells us awful, worrisome things, particularly about our pain or health.
Pain Voice pretends she can predict the future, and says it’s going to be terrible. She says: “You’ll never get better. Nothing will ever help you.” But since she can’t predict the future (who can?), Pain Voice is a liar! Pain Voice is also very bossy about what you can and can’t do: “You can’t see your friends this week,” or “You can’t go for a bike ride, and you definitely can’t have any fun.” Science teaches us that negative thoughts increase pain by turning up the brain’s “pain dial,” so we must make sure not to listen to or believe them. To stop Pain Voice, we first catch negative thoughts.
As soon as you learn how to recognize Pain Voice, you gain the power to change negative thoughts into more helpful “Wise Voice” thoughts. One way to bust Pain Voice is to start tracking your negative thoughts. First, list these critical, self-defeating, catastrophic Pain Voice thoughts. Notice if they’re helpful or harmful. Then check and question them, thoughtfully determining whether they’re the truth or a trap. Next, gather evidence as to why Pain Voice might be wrong by asking yourself, is this thought a fact? What evidence do I have that this thought might not be true? What else might happen other than what I’m predicting? Write out your Wise Voice responses, and use them to fight back every time you hear Pain Voice!
Jason’s example: Jason had terrible, daily back pain and hadn’t gone outside in 6 weeks. His friends texted, inviting him to watch a movie. Immediately he heard the thought, “I can’t go, I’m broken. If I leave my house my pain will spike and I won’t be able to function.” He recognized this as his Pain Voice and knew he had to fight back. He sat down with his worksheet and filled in the answers: yes, the thoughts were harmful, not helpful, and they were trying to trap him! He examined the evidence and wrote the Wise Voice thought, “This negative prediction is not a fact, it’s a trap. I’ve had back pain for 2 years, and sometimes going out and seeing friends actually reduces my pain.” Tuning into his Wise Voice gave him the strength to get the social support and distraction he needed to feel a little better! He went to his friend’s house, watched movies, ate popcorn, giggled, and had a great time. For the first time in 6 weeks, his pain went down. An example of his log is shown in table 1.
|Helpful or Harmful?||
|Returning to school after missing 3 weeks||If I go back to school, I’ll be so far behind that I won’t understand anything the teacher is talking about.||Harmful||Trap||This negative prediction is not a fact. I’m smart and competent, I’ll probably understand some things. Last time I was behind, I made up the work and everything was fine.|
|I can’t handle this!||Harmful||Trap||This negative prediction is not a fact. I’ve had 42 pain flare-ups this year, and I handled all of them. I’ve proven that I’m strong and resilient. There is a 0% chance I can’t handle this.|
Table 1. Example from Jason’s log
Summary: There is hope for youth with chronic pain. Interventions like CBT, mindfulness, biofeedback and other mind-body approaches are scientifically-supported and have evidence of effectiveness. Adhering to the biopsychosocial model – targeting biological, psychological and social factors – is proven to be the most effective treatment for chronic pain across conditions and ages. For more information, see Rachel Zoffness’ book, The chronic pain & illness workbook for teens, for pragmatic treatment practices and user-friendly pain education.
Friedrichsdorf, S. J., Giordano, J., Desai Dakoji, K., Warmuth, A., Daughtry, C., & Schulz, C. A. (2016). Chronic Pain in Children and Adolescents: Diagnosis and Treatment of Primary Pain Disorders in Head, Abdomen, Muscles and Joints. Children (Basel, Switzerland), 3(4), 42. doi:10.3390/children3040042
King, S., Chambers, C., Huguet, A., MacNevin, R., McGrath, P., Parker, L., & MacDonald, A. (2011). The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain, 152(12), 2729-2738.
*Dr. Rachel Zoffness is a pain psychologist, consultant, writer and educator in Northern California’s East Bay specializing in chronic pain and illness.