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Back in Control: A Surgeons Roadmap Out of Chronic Pain by David Hanscom MD
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You can start right away with ‘expressive writing.’ You simply spend fifteen to thirty minutes in the morning and again at night, writing down, in longhand, any thought that comes into your head. After you’ve written out each one in graphic and descriptive language, you immediately tear it up. Neurological research has shown that this creates a separation between the brain and the thought, so that you can begin re-training your brain to lay down new more positive neural pathways that wire around the old destructive ones.
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had developed sixteen symptoms of what you will learn to recognize as NPD (neurophysiologic disorder), including a severe case of obsessive-compulsive disorder (OCD). In 2002, I happened to pick up a book that recommended doing some simple expressive writing exercises, which involved getting any thoughts onto paper and tearing them up. I did the exercises, and within two weeks I began to pull out of my tailspin. Six months later, all of my sixteen symptoms had essentially disappeared, as I learned and practiced more of the concepts you will read about.
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It wasn’t until 2011 that I found out that what I’d been suffering from was an over-adrenalized nervous system with each organ in my body responding in its own way.
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The DOC process includes some of the following strategies you can use to solve chronic pain: •Separate from anxiety by breaking the cycle of negative thoughts. •Identify stress-inducing anger triggers. •Give up victim status. •Become more proactive about your care. •Understand your medications so you can make better decisions with your doctor about how to optimize them and minimize their side effects. •Create a vision for recovery and living a productive life.
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The roadmap out of chronic pain consists of three steps: 1.Understanding that chronic pain is caused by both physical and emotional factors
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Conversely, you may have no anatomical problem, but you feel pain nonetheless—possibly because your body is reacting to a stressful situation. For instance, if you are yelled at by your boss or coworker, your body will respond with adrenaline and other stress chemicals. Adrenaline decreases the blood supply to your stomach, so you might have a stomachache. In other words, you will experience physical symptoms without any change in the structure of your digestive tract. The symptoms usually will resolve after the situation cools down—unless you keep thinking about it.
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Thoughts Are Sensory Input Thoughts elicit the same chemical responses as any other sensations. The responses can be pleasant, neutral, or unpleasant, with corresponding results very similar to other kinds of sensory input.
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Emotional pain is equivalent to physical pain, especially when it comes to the body’s chemical response.
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The major difference between thoughts and other sensory input is that you cannot escape from the former. All the other sensory input, such as taste, smell, and touch can be avoided or controlled. Neither of these strategies is effective in controlling unconstructive repetitive thoughts (URTs). The more you attempt to avoid or control them, the stronger they become.
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Neuroscientists have a saying: “Neurons that fire together, wire together.”
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Pain has at least two parts: The “somatosensory component” localizes the pain to the specific body part, while the affective component provides an emotional response.
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The overlap between emotional and physical pain is greater than originally thought.
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•Factors that increase social pain will increase physical pain. When you are upset for any reason, your brain will
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heightened as much as possible when there is a potential threat. •Factors that increase physical pain will increase
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in pain. No one is happy on a bad day. When you are in pain and
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However, it has now been shown on fMRIs to directly decrease the activity of the pain circuits in the brain.
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They looked at the levels of a substance called C-reactive protein (CRP), which is elevated in the presence of inflammation; it’s often used to determine the presence of a hidden infection. Chronically elevated levels also indicate a stressed and overactive immune system. It is not desirable to have an elevated CRP. The study revealed that children who had been bullied had significantly elevated levels of CRP compared to those who had not been bullied. Being bullied as your introduction to the real world is not a great start.
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There are endless problems created by your personal scanner, which is always on high alert. Scanning the environment for danger is your body’s main priority, which creates several problems.
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Although it took a while to evolve, that moment of awareness helped me begin a process of letting go and engaging in the moment I was in.
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Fourth, if you cannot truly relax on a given day without worrying, when are you going to regenerate? It is critical to relax when you have the opportunity.
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Descent into the Abyss—An Overview Chronic pain is a complex neurological problem that is being more clearly understood with modern dynamic brain imaging studies. We are finding that the following areas need to be considered: 1.The source of the pain (Chapter 2) It may or may not be readily identifiable. 2.Sensitization (Chapter 3) The unconscious brain responds to repetition by recruiting more neurons. 3.Memorization (Chapter 3) Occurs quickly, as pain impulses fire rapidly. 4.The “modifiers” (Chapters 4 and 5) Sleep, anxiety, and anger each heightens the perception of pain by altering the body’s chemistry. The level of your pain is determined by your brain’s interpretation of the pain signals, as well your body’s chemical state. Keep in mind that mental pain and physical pain are processed in similar parts of the brain, so it’s possible that a constant stream of negative thoughts are contributing to—or even the source of—your chronic pain. Understanding how you became enmeshed in this mess is the first step toward your freedom.
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Classification of Pain Sources Dr. Howard Schubiner helped me conceptualize the following potential sources of pain.
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1. Tissues (including bones, muscles, ligaments, fascia) a. Structural: an anatomical abnormality identifiable on a diagnostic test with matching symptoms. b. Non-structural: a lesion resulting from conditions such as inflammation, micro-tearing, or overuse, which cannot be seen on a diagnostic test; or symptoms that do not correspond to an identified structural abnormality.
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2. Nervous System Neurophysiologic disorder (NPD): causes you to experience painful symptoms whether or not you are injured. It occurs via the direct triggering of nerve pathways and/or the body’s secretion of adrenaline and cortisol due to a stressful situation.
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Back pain is what we call a “non-specific complaint” and is almost always a non-structural problem.
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A condition called degenerative disc disease is often cited as a structural source of chronic lower back pain (LBP). Multiple research studies, however, have shown this to be inaccurate, regardless of the severity of the degeneration.
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Degenerative disc disease is a condition in which the discs between the vertebrae lose their water content, narrow, and often collapse. As the bones of the spine move closer together and the disc dehydrates, the spine becomes less flexible. When I am required to perform surgery on a collapsed disc, they are essentially fused together and I have to use a large chisel to break them apart.
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there is little correlation between the presence of degenerated discs and low back pain.
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has been consistently documented. If you take volunteers who have never experienced low back pain and obtain MRI scans, about half will have some disc degeneration by the age of fifty. By the time an asymptomatic person is sixty-five years old, the incidence of disc degeneration is around 100 percent. This also applies to bulging discs, herniated or ruptured discs, bone spurs, facet arthritis, and arthritis.
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the spine is stable, whether or not it is curved, it is not considered a structural problem, so it is an unlikely source of pain.
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Central Nervous System—Neurophysiologic Disorder (NPD) When you are under stress for any reason, all of the fifty trillion cells in your body are bathed in adrenaline, cortisol and other stress chemicals, and each organ system will react in its own unique way. Consequently, there are over thirty physical manifestations of this situation.
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Dr. Howard Schubiner is a leading authority on NPD, and his preferred term for this diagnosis is mind-body syndrome (MBS). Others include: •Tension myositis syndrome (TMS)
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Here are thirty-three symptoms that Dr. Schubiner lists in his book, Unlearn Your Pain. 1.Heartburn, acid reflux 2.Abdominal pains 3.Irritable bowel syndrome 4.Tension headaches 5.Migraine headaches 6.Unexplained rashes 7.Anxiety and/or panic attacks
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In addition to the direct physical symptoms created by an adverse chemical makeup, NPD has the indirect effect of causing you to neglect your health.
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pain impulses can become permanently embedded into our nervous systems. As the weeks and months go by and the impulses are repeated over and over, profound chemical and neurological changes take place.
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The term for this phenomenon is cognitive distortions. Examples include labeling ourselves and others, “should” thinking, mind reading, and emotional reasoning. Another descriptive term is “fast thinking” as opposed to rational or “slow thinking.” Humans jump to conclusions based on their own past experience, without analyzing all the data all of the time. Often these assumptions tend to be negative and inaccurate. When they are repeated quickly and frequently enough they may become programmed into our brains as our reality. But it is reality only from our individual perspective. Unfortunately, when our brains process these negative assumptions, the body’s protective chemical reactions are the same as if it were responding to physical pain. The stress reactions become sustained and are extremely unpleasant over time.
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When the brain is hammered with unpleasant emotional or physical impulses day after day, week after week, it becomes more and more efficient in processing them. Subsequently, it takes less of an impulse to elicit the same response in the brain. It’s this process, called sensitization, that causes patients to complain that their pain is getting much worse in spite of the lack of additional trauma.
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It has been demonstrated that chronic pain and acute pain exist in different parts of your brain.
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Pain Pathways To understand the development of chronic pain, it’s helpful to look at the concepts in the book The Talent Code by Dan Coyle. The Talent Code focuses on the idea that our most basic method of learning any skill is repetition. Coyle explains that the three aspects of creating talent in any skill are: 1) deep learning; 2) ignition (obsessive repetitions); and 3) master coaching.
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Coyle also links this process to the production of myelin in the nervous system. Myelin is a substance that coats nerve cells and improves conduction of impulses, similar to what insulation does for an electric wire. The more repetition, the thicker the myelin, and the faster the impulses.
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This is one of the reasons chronic pain always worsens over time (usually without further injury)—your body becomes more “skilled” at processing it.
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Feeding Repetitive Negative Thoughts We learn many ways to deal with repetitive negative thoughts, but most of them are ineffective over the long term. Instead of getting rid of the thoughts, these methods only feed them. Think of these common coping mechanisms in terms of how they affect the neurological pathways in the brain: 1. Suffering 2. Suppressing 3. Masking
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Your brain will develop wherever you place its attention, and any energy spent tracking or discussing your troubles is counter-productive.
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Now I am aware that many, if not most people in pain, spend the majority of their time complaining.
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Once you’ve acknowledged your negativity, you can substitute a more appropriate response. This is a more positive approach than simple positive thinking.
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One research study conducted in 1987 sheds a fascinating light on what happens when we try to suppress our thoughts. The study was outlined in a paper titled, “The Paradoxical Effects of Thought Suppression,” written by Dr. Daniel Wegner, a Harvard psychologist. The experiment he devised is commonly referred to as “White Bears.”
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Wegner’s experiment demonstrated that trying not to think about something will markedly increase the chances of your thinking about it.
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Masking Masking your reaction to stress is a third way of dealing with repetitive negative thoughts. Masking is behavior that’s used to cover up uncomfortable emotions, where you do something to get your mind off of a negative situation. Although it may be effective in the short-term, it’s not sustainable. Categories of masking include: •Addictions −Chemical ⋅Prescription or illicit drugs ⋅Alcohol ⋅Cigarettes −Work −Sex −Gambling −Over-eating •Getting caught up in a “good cause” (The cause might be excellent, but the driving force behind it could be suspect if carefully examined.) •Hoarding •Excessive involvement in hobbies −Gardening −Reading −Sports •Extreme belief systems
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The first two strategies for dealing with unpleasant thoughts—suffering and suppressing—don’t work. If you’re continually suffering with your mental and/or physical pain, these circuits will be reinforced.
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Masking pain-related thoughts might work for a short time, but the pain and distress will still be there after the masking activity is over.
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This sequence is intertwined with another series of events I call “the modifiers,” which are sleep, anxiety, and anger. The modifiers heighten your physiological response to unrelenting pain. Patients in chronic pain understandably become anxious, frustrated, and angry; their stress levels rise and they lose sleep.
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Cortisol’s effect is more lasting. It maintains a state of body alertness to fend off threats. The net effect is that your pain receptors and nervous system now exist in a different chemical environment even though there’s no additional physical injury, or perhaps none to begin with. What’s the ultimate result? All your senses are on high alert and you will experience even more pain. Animal studies have shown that stress increases the conductivity of the peripheral nerves by 30 to 40 percent.
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Since adrenaline diminishes the blood supply to the frontal lobes (thinking centers), your decision-making skills are also affected. That’s why it’s crucial to calm down your central nervous system before making a surgical decision,
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Lack of sleep is an absolute block to recovering from chronic pain.
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“It is not true that people stop pursuing dreams because they grow old. They grow old because they stop pursuing dreams.” —Gabriel García Márquez
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This is what happens with chronic pain. Repetitive negative thoughts about your pain produce anxiety and create challenging neurological circuits. Once the circuits associated with pain are established in your nervous system, they cannot be eliminated. It’s possible to influence your own thoughts, however, and create detours around these disconcerting pathways. This is the basis of a branch of psychotherapy called cognitive behavioral therapy (CBT).
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As part of our discussion, we talked about Holt’s choices. I had read William Glaser’s book, Choice Theory, a few months earlier. It’s an excellent book about how to effectively deal with adverse circumstances.
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Self-esteem is a subtle form of masking. Scoring achievements and gaining possessions doesn’t help you get rid of anxiety or anger; they only cover them up.
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It’s excellent to strive for excellence and be a productive human being, but it has nothing to do with decreasing your anxiety and frustrations.
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The Lifetime Progression of Anxiety Untreated anxiety will always progress. I can’t make that point strongly enough. The natural progression of anxiety is: •Alertness (normal, appropriate response to a situation) •Nervousness •General anxiety (being a worrier) •Anxiety reactions −Exaggerated physical responses −Panic attacks •Obsessive Compulsive Disorder (OCD)
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The Genealogy of Anger There is a sequence of events that causes anger: 1.Circumstance (real or imagined) 2.Blame 3.Victimhood 4.Frustration and anger
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An almost incomprehensible story is that of Viktor Frankl, a Jewish Austrian psychiatrist and author of Man’s Search for Meaning. Frankl, who survived three years in World War II concentration camps, was at one point slated to undergo human medical experimentation. Instead of going into the victim role, he asked himself the question, “What is life asking of me right now?”
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There are many ways to fall into and remain in the Abyss, including: •Needing validation
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The need to be validated causes and drives frustration. It is much stronger than you can perceive. Our need to be validated begins as soon as we have consciousness and a sense of self.
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16 percent of the patients who did poorly stated that they would choose to undergo the surgery again. A scar on one’s back is a strong justification for suffering.
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There are many creative ways to be a victim and also endless ways to conceal it, both from others and from one’s self. Here are some of the ways: •Having strong opinions—being “right” •Feeling sorry for
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An article by Allan Abbass succinctly points out that if you are disconnected from this set of negative emotions, then you will experience symptoms in other parts of your body. Everyone has anxiety; it is necessary for survival. But you cannot solve a problem that you are not aware of having.
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Here are the “benefits” of playing the victim: •Others expect less of you •You expect less of yourself
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Failing to Recognize that Victim is your Baseline
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Dr. David Burns in his book, Ten Days to Self-Esteem, points out that the gap between your concept of perfect and your reality is the degree of your unhappiness.
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Perfectionism Seems to Be Everywhere
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So what is the solution? I would like to present one principle regarding solving perfectionism—get happy.
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The Ultimate Modifier—Anger—Final Thoughts Anger is the greatest obstacle to creating a healthy, pain-free life. It separates you from yourself, those closest to you, and life, and it is impossible to move forward until you are able to use strategies to process it and move forward.
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The victim role is universal. The willingness to take an honest look at it is not. Asking yourself all the above questions will help you get closer to moving out of this role—and out of the Abyss. The only way out of it is through you. If you are not aware you’re in it, you will remain there.
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Processing Stress Contrary to popular belief, stress is not the primary source of our unhappiness. Rather, it’s our reaction to it that drains our energy.
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am defining a stressor as any situation or circumstance that causes an automatic mental and physical survival reaction.
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Situational Stress I have discovered with just minimal questioning that many (if not most) of my patients have incurred a major personal loss around the time that their pain flared up.
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A patient’s pain will frequently resolve once they have recovered (or have started recovering) from their loss, even in the presence of a significant structural problem.
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Two Aspects of Managing Stress There are two aspects of dealing with stress. One is caring for yourself and building up your reserves, and the other is becoming aware of what drains your energy and plugging the drain.
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Plugging the Drain? The way that most of us are taught to plug the drain is to avoid complaining and think positive thoughts. This approach plays out in many destructive ways.
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later learned that being tough, however, doesn’t yield a full and satisfying life. Neither does positive thinking. Toughness is actually a variant of positive thinking, and there are prices to pay for both. Being tough and/or positive is like pushing a rock up an endless hill.
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The first step is to recognize your automatic reaction to adversity, which will always be an adrenaline survival response. Then you must create space between yourself and the stressor in order to substitute a better response. The sequence is awareness, separation, and reprogramming. Creating distance from and learning to live with adversity instead of fighting it is what plugs the drain.
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When you are stressed, it’s important to allow yourself to feel the full impact of it. Then you can process it more rapidly and not remain in the hole. Eventually you will dive into the Abyss less often and emerge more quickly.
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Hurricane Gustav as it approached New Orleans. As I watched the satellite and radar pictures, a metaphor evolved in my mind. The whirling wind represented my racing thoughts, and the further away I was from my “center,” the greater impact these thoughts were having on the quality of my day. Historically, I have attempted to slow down or suppress these thoughts. I wasted a lot of energy, and as I became drained, the thoughts would race even faster.
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The key with both racing thoughts and our life circumstances is to use tools to pull ourselves into the center. You cannot stop a hurricane, and once you quit wasting your efforts trying, your energy levels will soar.
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Defining Awareness Awareness is seeing the world as it actually is—not your interpretation of it.
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Consider the following: •Anxiety clouds awareness, but we are often not aware of our anxiety until it becomes disruptive. •Anger covers up the feeling of
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Chronic pain is resolvable if you become aware of its nature, your reactions to it, and the relevant variables that affect your perception of it. The first step in becoming aware is understanding when you are not aware.
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The problem, in retrospect, was that I was connected to my identity—how I wanted to see myself and how others saw me—instead of to my true self. No one picked up on it, including me.
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How can you tap into your unawareness? One way is to look for cues in certain behaviors and attitudes that may mean you’re out of touch with how you’re feeling. Some examples: •Having a rigid opinion about almost anything: religion, politics, someone’s character, etc. •Being told you’re stubborn or not listening •Interrupting someone to offer an opinion before you’ve heard theirs in total •Being “right” •Consistently thinking about something besides what you’re doing •Judging yourself or others negatively or positively −Being persistently critical of your spouse, partner, and/or children −Giving unsolicited advice •Feeling anxious or angry •Thinking you’re wiser than your children •Acting on impulse
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Once you have placed a label on anyone or anything, you can no longer see clearly.
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The definition of awareness that resonates most with me is “being fully present in the moment.” In other words, I’m most aware when I’m able to listen, feel, and observe multiple cues and then appropriately respond to the person or situation. It requires stillness and silence in one’s head.
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Breaking through patients’ unawareness of their abusive behavior is extremely difficult because they don’t recognize their anger and don’t see their actions toward those close to them as abusive.
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Often people who are abusive make up for it by being pillars of the community or church.
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Being regularly critical is the essence of it, but it’s inherent in other behaviors as well: withholding words of affection, being silent, or not saying anything to actively help family members enjoy their day. Also, whenever you blame someone for creating your unhappiness and let them know it, you’re probably being verbally abusive. You are the only one responsible for your happiness—end of story.
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To improve your relationship with your family, my advice is to refrain from giving any advice to anyone for a month and to focus, instead, on listening.
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consider awareness from four perspectives: •Environmental
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Environmental awareness is becoming aware of as much detail as possible about what is right in front of you. The most effective method for accomplishing this is using what I call “active meditation,” which is an abbreviated form of mindfulness. This practice involves briefly placing your attention on sensations.
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There are three steps and it just takes five to ten seconds.2 Here are the steps: 1.Relax: I often begin by relaxing my shoulders; you can use any body part. Or I take a deep breath. 2.Stabilize: just feel the body part you relaxed for a few seconds before going to Step 3. 3.Focus on one sensation: taste, feel, sound, pressure, etc. Feel the vividness
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I’ve found environmental awareness to be very helpful, but note that it can work in the opposite direction and markedly increase, instead of decrease, your pain. If much of your attention is focused on your discomfort, your nervous system will progressively feel more pain.
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being completely immersed in an activity you are passionate about is the closest way to achieve complete environmental awareness.
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Emotional Awareness Connecting with your emotions and becoming aware of your reactivity is particularly critical. If your emotions are out of control, they will inflame your pain. Ideally, we’d all be aware of our emotional state at any given moment, but there are several obstacles.
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So how do we become more emotionally aware? The first step is to allow yourself to feel anything and everything. This includes anxiety. Anxiety represents being vulnerable
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We don’t realize that our anger response is a result of being triggered by a circumstance. We are responsible for our own anger even though it sometimes feels like someone else’s fault. This is a challenge to comprehend—in fact, it’s the most difficult part of understanding anger and dealing with it. One book that I’ve found helpful in understanding anger is The Way to Love by Anthony deMello. He teaches that you must learn to thank your enemy because they are a window into who you really are.
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Robert Hoffman (co-developer of the Hoffman Process) used the psychological term “transference” for the phenomenon of being triggered. Here is Hoffman’s definition of transference: Transference distorts relationships. Transference is reacting to and perceiving another person as if they are the mother and father from our childhood. Usually we are not aware that we are doing it. We believe we are really seeing that other person in the present moment. When we are in transference with another person, we often feel a certainty that we know who they are. We usually feel we know what they are feeling and thinking, what their intentions are, and what we can and cannot expect from them. When we are in negative transference (a much more common occurrence for most of us), we feel the energy of certainty about the other person’s wrongness. At times, the transference is triggered by an actual behavior of the other person. They don’t look us in the eye, or they do. They criticize our work. They are sarcastic or late or forget to do something. Many times the transference is triggered only by our perception that they did something wrong and our interpretation of what that means. We go into a vicious cycle within ourselves. We feel that another person has done something wrong to us. We think we know all about them, what they did, and what they will do, think, and feel. They are powerful—we give them the power to affect our lives—and we are powerless. We often feel little, like a child in the face of a negative parent. That’s where we went internally even if we do not recognize it consciously. Actually we have the power, if we choose to use it, to change the dynamic, to stop reacting. The actions of others trigger us because we have the patterns in us.
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Judgment and Storytelling A third level of awareness revolves around judgment and storytelling. On this level, you create a “story” or a judgment about yourself, another person, or situation that tends to be rough and inflexible.
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The brain is programmed to look for danger and will first focus on negative judgments.
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Burns calls these negative thoughts “ANTS,” which stands for “automatic negative thoughts.”
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Then there is the error of “labeling.” For example, a frequently late spouse becomes “inconsiderate.” A forgetful teenager becomes “irresponsible.” By labeling, especially negative labeling, you can no longer see them because you are only projecting your version of reality onto them.
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Suddenly, I understood the connections between the words. •If you are whole, you don’t have to expend energy filling gaps. The result is power to live your life.
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Awareness—Final Thoughts Awareness is the first step in reprogramming your brain. It’s important to spend as much time as possible doing active meditation, being fully aware of every stimulus coming into your brain. In other words, try to live your life in the first level of environmental awareness. When you wander into the second level of emotional awareness, just watch your emotions pass by and then pull yourself back into seeing, hearing, and feeling, as quickly as possible. The third level of judgment/storytelling—for example, “the story”—is the most difficult for me. Once I am sucked into that level, it’s hard for me to pull back. I will use active meditation but also have to use other methods, such as writing and visualization. You need an outside perspective to become aware of ingrained patterns. It’s impossible to see yourself clearly through your own eyes. Resources include psychologists, good friends, spouses, children, books, and seminars. Becoming aware is much more interesting than constantly expressing and reinforcing your own views on life. Open yourself up to the world! The possibilities are infinite.
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Stimulating Your Brain to Change—Neuroplasticity Your brain is in a continual and dynamic state of change depending on how much it is stimulated, or not stimulated. There is a name for this process—it’s called neuroplasticity, which is defined as “the brain’s capacity to adapt and change at any age.” There is an incredible upside potential for us in the arena of neuroplasticity, as the nervous system has an almost unlimited capacity to evolve.
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Laboratory studies have revealed that that the brain actually shrinks in the presence of chronic pain. It makes sense to me that if much of your brain is stuck in repetitive negative thought patterns, other areas—the ones connected to time with family and friends, enjoyable experiences, etc.—will atrophy. Additionally, adrenaline decreases the blood flow to your brain, which could be a factor.
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Facilitating Neuroplasticity There are two aspects to consider to successfully address the central nervous system component of pain: 1) the chemical environment and 2) the structure of the circuits. You must calm down the central nervous system to de-adrenalize it and stimulate the brain to rewire new circuits through neuroplasticity.
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There are three aspects to forming alternative neurological pathways:
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Awareness is the essence of living an engaged, rewarding, and enjoyable life. As you become more aware of every positive and negative detail of your reactions, you can choose to go in whatever direction you wish.
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the first two steps of reprogramming: awareness and separation. I call it “mechanical meditation.” Getting my thoughts on paper clarifies what’s in my head and also separates me from them. It gives me the space to consider my reactions and substitute a more functional response. Verbalizing your thoughts aloud (in private)has a similar effect.
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The effectiveness of expressive writing has been documented in over two hundred research papers. A 2005 paper reviewed the benefits for both adolescents and adults, which included improvements in the following areas: •Immune system function
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Thought suppression is the antithesis of awareness. There is a growing body of evidence showing its damaging effects and it is considered to be the root cause of many illnesses and addictions.
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Separation You are not your thoughts. Many philosophers have taught this concept for centuries. Thoughts are real but not your reality. I feel the reason that we give them so much attention is that our bodies chemically respond to every thought, whether it is positive or negative. We feel relaxed or agitated; we don’t just think it.
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Separation is creating space between the stressor and your response.
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Expressive writing creates awareness and separation in one step. Your thoughts are now on paper and the separation is connected to you by vision and feel.
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The author David Burns’s three-column technique accomplishes separation as you categorize your thinking into one of the ten errors of thinking. As you write and classify the thoughts you can more clearly see the irrational nature of these universal cognitive distortions.
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Thinking before you act or speak also creates a separation.
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Forgiveness Forgiveness is the ultimate strategy for achieving separation and creating the space you need between stressor and reaction.
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Awareness and separation begin the process of rewiring your brain by allowing you to see your programming. Once you have this level of awareness, you can engage in reprogramming your nervous system via positive substitution, the final and necessary step in this sequence.
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When you’re in chronic pain, visualization can help you see a new life for yourself.
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The energy spent on trying to deny and cover up his real feelings would have taken away from the energy and focus he needed to perform. Instead, he chose an alternate neurological pathway that was the one he needed to maximize his performance.
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Play can and will pull you upward out of the Abyss. It requires creativity that will light up an immense part of your brain.
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Section 3 Your Road map Out of Pain
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There are three parts to the DOC process, which is the self-directed program to define your own care: understanding chronic pain, addressing all the relevant variables, and taking charge of your own care.
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The Variables The DOC process addresses six core areas, all of which have been shown in hundreds of research papers to significantly affect both surgical and non-surgical outcomes. They are: •Education—awareness of the problem and solutions •Sleep •Medication •Physical condition •Stress •Life outlook The DOC process will be presented in four stages: •Stage 1: Laying the Foundation
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When you’re in pain, the fuel for the fire includes lack of sleep, adrenaline stimulated by anxiety and anger, inflammation, stiff tissues, lack of conditioning, high-dose narcotics, and dwelling on your pain. There are so many factors—it’s not logical to think that there would be one solution for your pain, such as surgery.
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Overview of the Process Stage 1—Laying the Foundation
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Stage 1 consists of these four steps: 1.Begin doing the expressive writing exercises for five to fifteen minutes, twice a day. Write freely, preferably by hand, any positive or negative thoughts, paying no attention to grammar or legibility. When you’re done, rip up the paper immediately; this will allow you to write with freedom. Expressing your thoughts out loud, in private, is also effective; but writing is the foundation and starting point of the DOC process. I want my patients to begin writing the night of their first appointment with me, even before they have done much reading. It is remarkably powerful, especially in light of its simplicity.
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2.Start doing active meditation exercises, drawing attention to your senses in the present moment. Practice this mindfulness activity five to fifteen seconds, as many times as you can throughout the day.
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3.Consistently get a good night’s sleep. Refer to Chapter 14 for specific recommendations. Adequate sleep is one of the pillars of the DOC process; I won’t proceed with any operative intervention in an elective case until a patient is sleeping well.
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4.Understand the neurophysiologic nature of chronic pain. If you have stuck with me this far into this book, you are well on your way.
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Stage 2—Forgiveness and Play When the book Forgive for Good by Dr. Fred Luskin became a core part of the DOC process a few years ago, more patients began to become free of pain.
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Play is a powerful reprogramming tool. Like pain pathways, play pathways are permanent, buried somewhere in your brain. Reconnecting with these circuits is the fastest way out of your pain. By “play” I am not referring to obsessive recreation; rather, it’s about having fun and adapting a playful attitude to life.
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Stage 3—Moving Forward If your life has been disrupted—or destroyed—by pain, it’s necessary to regroup. The DOC approach enables you to start this process, and usually people feel much better somewhere between Stage 1 and Stage
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Some practical ideas to stay on track include: 1.Create a vision for your life. You cannot travel anywhere without knowing where you want to go. 2.Address family issues. Anger destroys almost everything—especially your family. Rebuilding your family support system is important for your healing but also for your family’s well-being. 3.Get organized. Your life has been focused on your pain and much of your life is in a state of disrepair. Getting organized is a skill that you can learn from books, seminars, or the Internet. 4.Commit to a daily practice. Changing neurological pathways requires repetition. By committing to a daily plan that can be as short as five to ten minutes, you will continue to heal. 5.Think about the life you desire and connect with it. The further along you get with the DOC process, the more energy you will have to do this.
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Stage 4—Expanding Your Consciousness
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The Paradoxes of Resolving Pain The ultimate paradox of dealing with chronic mental or physical pain is that it becomes unresolvable by trying to resolve it.
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But with chronic pain the sequence is different. It goes like this: become aware, separate from the stressor, and move in a new direction.
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Keep in mind that any time spent trying to “fix” your negative pathways by eliminating them is counterproductive, because in paying more attention to them, you reinforce them.
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Flawed Strategies There are several commonly used approaches to resolving pain, all of which are counterproductive. They include: •Positive thinking •Mind over matter, or sheer determination •Talking it to death
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Positive thinking has long been touted as one of the keys to a happy life. Unfortunately, this is a misconception;
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Positive thinking is a form of suppression.
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Positive thinking occurs in the conscious part of the brain and has no chance of suppressing your body’s powerful survival reaction.
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The “mind over matter” approach creates the same problem as positive thinking. You cannot will yourself out of chronic pain; you will still be doing battle with monstrous circuits. You might as well be punching a wall or pushing a rock up a hill.
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Treating chronic pain is similar. The harder you try to escape or push through the pain, the more you will become enmeshed in it. Conversely, if you use the tools to calm your nervous system, you will have started the healing process.
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If you’re in chronic pain, it may be tempting to discuss your pain with anyone who will listen. But this actually prevents healing. Why? 1) It reinforces pain pathways; and 2) the time you spend complaining takes away from time spent on enjoyable and creative experiences.
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Stage 1—Laying the Foundation The goal of this chapter is to help you become aware of your situation, learn the basic tools of the DOC process, and prepare yourself for the rest of the journey.
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Here is an overview of the five steps: Step 1: Learn About What’s Affecting Your Pain (Awareness) •Confirm your diagnosis •List how many NPD symptoms you are experiencing. •List the factors affecting your pain −Sleep −Stress −Medications −Physical conditioning −Life outlook Step 2: Begin expressive writing (awareness and separation) Step 3: Practice active meditation (reprogramming) Step 4: Don’t share your pain (reprogramming) Step 5: Sleep (reprogramming)
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non-structural, NPD, or a combination. If the source of your pain cannot be identified, that’s good news; it means that your problem is more resolvable.
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To calm your nervous system, you must first identify the “triggers” to your past traumas.
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Keep in mind that there is an important difference between becoming aware of a trigger and analyzing it. Spending time defusing the trigger won’t work.
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Other Factors What are the other variables that are affecting your pain? •Sleep −How many hours a night are you sleeping? −Is it restful or interrupted? −Are you tired the next day? •Stress −Anxiety ⋅How anxious are you? ⋅Rank it on a scale from one to ten. ⋅List ten situations that make you nervous. −Anger ⋅What are you upset or frustrated about? Make a list of things that upset you. −Circumstances ⋅It has been well-documented in multiple research studies that stress causes disease. Make an exhaustive list of any stresses you have been struggling with in the last twelve months, including both positive and negative events. A famous study done in 1964 created a list of 43 stressors and quantified them. Many of them are positive experiences, such as a new child, marriage, promotion, etc. Stress is stress. •Medications −Make a list of prescription and over-the-counter medications and categorize them according to the reasons they have been prescribed for you. ⋅Pain control ⋅Decreasing anxiety ⋅Improving sleep ⋅Decreasing nerve pain ⋅Medical problems ⋅Other
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Step 2: Begin Expressive Writing (Awareness and Separation) The first action I have my patients take is to start expressive writing. They write down their thoughts and then immediately destroy the paper. That allows them to write with freedom. Other suggestions include: •Write either positive or negative thoughts or feelings. •Write down specific thoughts and emotions exactly as they come to you. •Just get your pen onto paper. Your writing doesn’t have to be legible or logical. Scribbling or symbols will work. •Write once or twice a day for fifteen to thirty minutes per session.
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David Burns, in his book Feeling Good, suggests an exercise where you stand in front of a mirror and talk to yourself using the self-critical voices in your head. You would never talk to another human being that way.
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what not to do when writing: •Don’t journal or keep these writings; it’s counterproductive. I feel it represents the need to control these thoughts. Remember this is a separating and letting-go process and not a problem-solving one. Journaling is fine, but it is a different endeavor that does not accomplish the needed separation. •Don’t keep a notepad to
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Unhooking from the Train Picture yourself as the engine of a long, loaded freight train. You can pull a tremendous amount of weight. It’s similar to how we drag our past into the current day. Expressive writing disconnects you from the past immediately. When I write, I become aware of my thoughts. The space created between the thoughts on paper and me is the separation process. It is as if I unhooked the first car from the engine. There is no rule of life that says I have to stay connected to that huge load. And I still have the same power of an engine that is now pulling nothing. The creative energy that becomes available is almost limitless. The constraints on creativity then become time and physical capacity—not anxiety.
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The first third of Feeling Good describes cognitive behavioral therapy. One of the tools is the “three-column” technique, which represents the three phases of reprogramming: 1) awareness, 2) separation, and 3) creation of a new pathway. The three columns are: Negative thought Error in thinking Rational thought
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By writing your negative thoughts in the first column, you are increasing your awareness of the problem.
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An error in thinking could be any number of things, including “should thinking,” “labeling,” “mind reading,” “catastrophizing,” etc. Categorizing your error initiates the separation process. You are separating from your initial reaction. You then have a choice to either continue that line of thinking or to restructure your thoughts.
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third column, the more rational follow-up thought is written down, creating a new neurologic pathway.
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Step 3: Practice Active Meditation (Reprogramming) Free writing creates awareness and separation. The third part of the sequence, reprogramming, can be accomplished in thousands of ways such as spending time with friends and loved ones, pursuing a hobby, listening to music, playing sports, and more.
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Active meditation consists of simply placing your attention on sensations. Any one will do—taste, feel, sound, pressure, etc. There are three steps and it just takes five to ten seconds per time. •Relax: I often begin by relaxing my shoulders; you can use any body part. Or I take a deep breath. •Let yourself stabilize:
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Traditional Meditation and Mindfulness Traditional meditation practice is a tool that accomplishes all three steps. You become aware of your thoughts as you try to quiet your mind and train yourself not to react to them. Then you reconnect to the present moment, using whatever method you are the most comfortable with.
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When you fully experience every aspect of the activity you are involved in at the moment, you are using mindfulness—living your life in a purposeful and connected manner. Connecting with physical sensations is a significant aspect of this practice.
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Step 4: Don’t Share Your Pain (Reprogramming) Your brain will develop wherever you place your attention. Complaining will keep you stuck on unpleasant circuits.
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Step 5: Sleep (Reprogramming) Sleep is the number one priority in the rehabilitation process.
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Not one major decision regarding your spine care, especially surgery, should be made until you feel rested during the day.
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Stage 1 Suggested Reading Feeling Good by David Burns, M.D.: Read at least the first one-third of the book, to learn the three-column writing technique. The Talent Code by Dan Coyle
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Stage 2—Forgiveness and Play Both hard work and creativity are important for devising new ideas and implementing them, both personally and in the business world. New ideas stimulate us and help us to thrive. One thing that stands in the way of this activity is anger. In fact, it’s almost impossible to be creative if you’re angry; it could be argued that anger is the antithesis of creativity.
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Reactive vs. Creative ReaCtive Creative The difference between these two words—and these two concepts—is that in the word “creative,” the “C” (which can mean see) is at the beginning. In “reactive,” the “C” (see) is buried in the middle of the word. It’s impossible to be creative when you are in a reactive mode.
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Steps to Reconnecting with Your Creativity Here are six suggested steps to help you break away from your automatic reactive survival patterns. AWARENESS Step 1: Understand the impact of anger on your life Step 2: Acknowledge your disguises SEPARATION Step 3: Admit your victimhood Step 4: Choose not to be a victim Step 5: Forgive REPROGRAMMING Step 6: Play
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While you are in the midst of feeling angry, you feel very little, if any, anxiety. I also feel that anxiety drives depression. In the short term my patient did feel more anxiety and depression. However, in the long-term she will have missed the opportunity to connect with herself and with the potential of living a better life.
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Step 2: Acknowledge Your Disguises None of us likes the idea that we might be acting like a victim. We don’t even like the word, and there are an infinite number of ways to disguise it,
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Step 3: Admit Your Victimhood Use the following sequence to get in touch with your victim role: 1.Ask yourself, “What person or circumstance is upsetting me?” Be specific. 2.Acknowledge that you are blaming that person or situation for making you angry. 3.Write or speak out loud to yourself, “I blame [so-and-so or such-and-such] for making me upset.” 4.Understand that you are now in the victim role, a universal feeling. 5.Write or speak, “I am allowing myself to be a victim of [so-and-so or such-and-such].”
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Clearly differentiate whether you are: 1) being truly victimized or 2) basing your victimization on a perception that comes from a “story” in your mind.
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Step 4: Choose Not to Be a Victim Once you get a clear sense of the depth of your anger and victimhood, make a simple decision not to be a victim anymore. •Write down, “I choose not to be a victim.” Date it and put it where you’ll see it every day. Remember that: −It’s an intellectual choice that needs to be accompanied by reprogramming tools in order to be effective. Victimhood is so powerful that you will never wake up one morning and feel like, “I don’t want to be a victim anymore.” You just have to make a mental choice. −You will repeatedly fail, and that’s okay. Don’t stop your efforts. −Commit to being honest with yourself. •”Do” vs. “Try” (Hoffman Process concept) −“I will try” is the ultimate victim phrase. Write “try” on a piece of paper, cross it out, and hang it on your refrigerator. −Write “Do” on another piece of paper and hang it on your bathroom mirror.
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Many books have been written on the subject over the centuries, but the book that’s been the most effective for my patients and me is Forgive for Good by Dr. Fred Luskin. In fact, it was a patient who first told me about it. Dr. Luskin, director of the Stanford University Forgiveness Project, has conducted four major research projects on this topic. In his book, he discusses the nature of true forgiveness and provides steps for achieving
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The first thing Dr. Luskin explains is that forgiveness is only for you; it has nothing to do with the perpetrator.
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You do not have to like the person who harmed you. But you also do not have to mentally drag that person along with you for the rest of your life.
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•“Change the channel.” You can choose the way you view a person or situation. •Learn to view the world through your enemy’s eyes. •Understand that the person who angered you is not the problem. He or she triggered a pathway in you and your anger is your problem. Anthony de Mello, in his book, The Way to Love, takes it a step further by stating that it’s important to learn to mentally thank the person who angered you, as he or she has provided you with insight into who you are. •It is critical to take 100 percent responsibility for your anger, period. •If you have complained about a situation more than three times to others, you have developed a “grievance story” where you are the victim. Get over it and move on. •
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Blocks to Forgiveness Forgiveness and acceptance are difficult for me. It helps for me to keep in mind a few strategies that don’t work: •Positive thinking
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It is documented in the literature⁵ that if you are not connected to your emotional pain it will be physically manifested in another part of your body.
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Stage 2 Suggested Reading The Way to Love by Anthony de Mello Forgive for Good by Fred Luskin, PhD
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Stage 3—Moving Forward Your success in becoming and staying pain-free depends on continuing to engage in the practices from Stages 1 and 2—the ones that helped you reprogram your brain and let go of anger. When you feel better, you may want to stop, but it’s important to use the tools on a regular basis, indefinitely.
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Stage 3, where you consolidate your gains, develop organizational skills, and regain control of your day-to-day life. Five Steps Step 1: Commit to a daily practice Step 2: Create a safe haven—family Step 3: Get organized Step 4: Connect with the life you want Step 5: Create your vision
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Step 1: Commit to a Daily Practice Repetition is the key to reprogramming your nervous system.
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Step 2: Create a Safe Haven—Family Pain equals frustration. With chronic pain, frustration is intense and you will disconnect from your immediate surroundings. Your awareness goes to zero, which leads to abusive behavior. You may not consider your behavior abusive, but your family may see it differently.
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Here are several suggestions for fostering healthy, loving interactions with family members and close friends: •Read Parent Effectiveness Training by Thomas Gordon. This classic has had a big impact on my life. Read it even if you don’t have children. It will increase your awareness not only of your children’s needs but also those you work and live with. •Never engage with your family when you are angry. Wait until you are completely calm. •Ask your family what it’s like to be around you when you’re upset. −Write their answers down and look at what you’ve written, or bring it to mind whenever you’re tempted to interact with any of them while you’re angry. •Listen to your children without giving advice or an opinion unless you’re asked. (This action step is courtesy of Hyde School.) −I usually ask my patients to commit to doing this for a month to begin the process. It should evolve into a lifetime habit. •Work with all members of your family to create a vision of what they’d like their family life to look like. •Institute a tradition of having a family meeting with an agenda once a week. (Hyde School again.) −You need your family or close circle of friends for your support. Don’t become a living weapon with them as your target.
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picked up a book, The Organized Executive by Stephanie Winston, and was quickly able to put the principles she presented into practice.
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The analogy he uses is putting all of our to-do lists on a “hard drive.” Most of us keep our tasks in our RAM (random access memory), which means it keeps spinning around in our heads. This not only ineffective; it wears us out. (And it also reinforces obsessive patterns of thinking.)
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Getting organized in the context of your chronic pain problem accomplishes several things, including: 1) Enabling you to decrease your stress by gaining better control of your environment; 2) Clearing creative space in your head so you can better solve problems; and 3) Helping you to move forward on as many fronts as necessary.
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Step 4: Connect with the Life You Want One of the final steps in resolving your pain is to reconnect with your vision and the best part of who you are. These circuits are far removed from the Abyss and when you plug into them, they will build on themselves. It does require a deliberate effort, however.
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Step 5: Your Vision—Ask Three Questions
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Where Am I? Figuring out where you are is critical. To answer this question in terms of a business, you would start by assessing your current skills and assets. In the context of chronic pain, this step entails gaining an understanding of your problem and what you can do about it.
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Where Do I Want To Go? Now that you’ve assessed where you are, it’s time to figure out where you want go—this is your vision.
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How Do I Get There? The next step is to develop a personal “business plan.”
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Stage 4—Expanding Your Consciousness
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There are five steps in this final stage, Stage 4: Step 1: Pass through the ring of fire Step 2: Step into your new life Step 3: Fail well Step 4: Look up—your spiritual journey Step 5: Give back
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He pointed out that there are three core categories that allow us to function as humans:
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Picture a circle with two progressively smaller ones inside of it. The outer ring represents our “doing and achieving.” The middle one is “threat and self-protection” and the center circle is “contentment and feeling safe.” Many of us spend a lot of time trying to stay out of the middle ring of angry, anxious, and vulnerable by living in the outer ring of excited, driven, ambitious, and successful. It takes a tremendous amount of effort.
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focused on your own journey, and not on someone else’s: •Become aware of any energy you spend on trying to “fix” those around you. Instead, commit to your own growth. •Develop an awareness of your own shortcomings and learn to accept them. •Read an excerpt from The Art of Living, which is the teachings of Epictetus, a Greek Roman slave and philosopher, as translated by Sharon Lebell. His focus is almost completely on the journey inward.
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have a few suggestions to help you formulate your own ideas about how to give back: •Stay committed to your own journey •Remain aware of the fact that aside from yourself, your highest priority is your immediate family •Make a random list of ideas about giving back that are interesting to you and then: −Pick the top five −Prioritize them −Develop a specific plan for how you are going to make them happen −Do it!
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We are what we repeatedly do. Excellence, then, is not an act. —Epictetus
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Stage 4 Suggested Reading and Resources The Art of Living by Epictetus, translated by Sharon Lebell Healers, psychologists, psychiatrists, seminars, church, etc. A somatic workshop such as the Hoffman Process The Way to Love by Anthony de Mello
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read The Promise of Sleep, an autobiography by William Dement, who was a physician at Stanford.
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Lack of sleep not only increases the perception
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Bibliotherapy is learning about a therapeutic approach from a book, and treating yourself. David Burns’s book, Feeling Good, turned out to be the key to breaking me out of a fifteen-year tailspin of depression and chronic pain.
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landmark study performed on 17,337 members of the Kaiser Health Care System in 1998 divided childhood trauma into eight categories. They were termed “Adverse Childhood Experiences” or ACEs. The categories were: •Emotional abuse
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Effective Rehabilitation Effective rehabilitation is a crucial part of my patients’ recovery, and it can’t be effective without active, motivated participation. In this chapter, we will talk about the components of effective rehabilitation. I use the spine as the basis for discussion but these rehabilitation principles apply to any part of your body. Here is an overview of the principles: Begin With a Calm Nervous System
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Choose Effective Physical Therapy (PT)
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Nurturing Gratitude The book The Art of Happiness, based on extensive interviews with the Dalai Lama, explores the concept that we compare ourselves to others whom we perceive as having more than we do and, as a result, feel frustrated and unhappy.
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Reading History Read any history of almost anything and it will—or should—wake you right up. There is nothing in our modern era to complain about, compared to the ordeals of the past.
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One example is Man’s Search for Meaning, Viktor Frankl’s first-hand account of living in a concentration camp. Frankl was a Jewish Austrian psychiatrist who survived the horrors of Auschwitz, including losing his family.
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Exploring a Spiritual Path The Journey of 1,000 Moons One concept that I’ve found helpful to gaining perspective is a project called “The Journey of the 1,000 Moons,”
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The Hoffman Process The Hoffman Process is one example of a personal growth program that allows you to powerfully expand your consciousness in a short time. Hoffman-trained teachers explain how to break up entrenched neurological pathways and reprogram your responses to the events that trigger them. In other words, instead of experiencing stimulus, then response; the pattern becomes stimulus, then choice of response.⁴
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There is clear research showing that only about 25 percent of patients significantly benefit from a spine fusion for lower back pain (LBP).
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Flawed Studies There have been many studies done on fusions for LBP, but most of them share a major flaw: a high percentage of the subjects didn’t participate in study follow-up and/or could not be located at the two-year post-surgery point that is the standard follow-up time for most clinical research projects.
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One Washington State study revealed an overall re-operation rate of 19 percent for all spine surgeries. Another glitch: most studies define a successful outcome as a 25 percent improvement for pain and function. My bet is that if you are getting a spinal fusion, you’re expecting to become pain-free, not just 25 percent better. Lastly, none of the studies compared surgery to carefully planned structured rehab.
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Dr. Peter Fritzell’s research paper is the one I hear most often quoted in support of using fusion for degenerated discs in the lower back. The study was funded by a spinal implant manufacturer.
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Part of the tragedy of chronic pain is that once you have a failed back surgery, it’s harder to get help. The surgeons who performed the surgery are not trained or comfortable in dealing with chronic pain. Other surgeons are reluctant to get involved in managing another surgeon’s failures. The non-surgeons do the best they can to improve your quality of life, but they often take on a survival mentality for chronic pain patients, not a proactive one.
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