Resolving Chronic Pain: Some exciting news

Here at Resolving Chronic Pain I have some very exciting news to share: the textbook on chronic pain which I have been working on for several years has finally been published!

Entitled Psychophysiologic Disorders: Trauma Informed, Interprofessional Diagnosis and Treatment, the book is a collection of chapters written by experts in the field and edited by David Clarke, Howard Schubiner, myself, and Allan Abbass.

Sixteen practitioners, experts and patients contributed to eighteen chapters to create both an inspiring blueprint for existing health practitioners and a roadmap for medical students about to embark on their careers.

Psychophysiologic Disorders (PPD) is a term used to describe chronic or unexplained pain for which stress is the root cause, also sometimes known as ‘Stress Illness’. Part One of the book describes the condition and its history from ancient times up to recent medical scholarship. Part Two is a collection of essays from medical practitioners writing about the integration of PPD into their professional practice.

My involvement in the book has been hugely challenging and exciting in equal parts, both as an editor with input into the curation of the text as a whole, and as an author contributing to a chapter on the history of PPD and another wholly devoted to Resolving Chronic Pain.

Other chapters in Part Two focus on topics including diagnosis and treatment in Primary Care, the psychology of pain, stress illness recovery and expressive writing. Contributors from five different countries each bring a unique perspective to the book from their own particular field. From a neuroscientist to a gastroenterologist to a psychiatrist to an orthopaedic spine surgeon, the authors reached a consensus on a core set of principles and applied them to their own experience.

The idea for the book was conceived in April 2015, germinating from the seed of Dr John Sarno’s work in the 1980s-2000s. The initial idea was followed by many exchanges between myself and the other editors – tentative in the beginning, and then more and more assured and rewarding as the book evolved. David Clarke in particular has been a privilege and an inspiration to work closely with. I think we both agree there is enough fascinating history of this condition to fill an entire book, and deciding what to include or leave out was a real challenge at times.

It is now available to purchase online from Amazon, by following this link in the UK, and this link in the US. All proceeds will go to the Psychophysiologic Disorders Association, a non-profit dedicated to research into the diagnosis and treatment of stress illness.

Telling stories

I often talk about how we frame our stories in Resolving Chronic Pain sessions. It’s said there are two sides to every story, but how often do you remember that when thinking about your day to day life?

The ‘story’ to which there is more than one side is not just the tales you recount to your friends over a cup of tea, but also applies to the stories you tell yourself.

This is a view shared by Lori Gottlieb, an American therapist who also writes an advice column called ‘Dear Therapist’.

She believes that all of our lives are made up of a series of stories we tell, which are all shaped by our own opinions and prejudices. She explains in a TED talk how this realisation can be immensely freeing, as it allows us to consciously re-shape the stories we tell about difficulties we encounter.

As an example Lori speaks about a woman who wrote in to her ‘Dear Therapist’ column to ask for help with a problem in her marriage – she felt disconnected from her husband, and suspected he was having an affair as he was spending a lot of time on long late-night phone calls with a woman at his office. ‘What should I do?’ she asked Lori.

But Lori looked at the problem from a different perspective. She read out another letter, from a man who felt disconnected from his wife, and found she was not listening to him or giving him the support he needed so he was having to turn to the only friend he could speak to – a colleague at work. While the second letter was invented by Lori, she says the situation is inspired by problems she sees every day.

She explained: “I have to be really careful when I respond to these letters because I know that every letter I get is actually just a story written by a specific author, and that another version of this story also exists. It always does. And I know this because if I’ve learned anything as a therapist it’s that we are all unreliable narrators of our own lives.

“I don’t mean that we purposely mislead. Most of what people tell me is absolutely true, just from their current points of view. Depending on what they emphasize or minimize, what they leave in, what they leave out, what they see and what they want me to see, they tell their stories in a particular way.”

Lori continued: “All of us walk around with stories about our lives. Why choices were made, why things went wrong, why we treated someone a certain way – because obviously they deserved it – why someone treated us a certain way – even though obviously we didn’t. Stories are the way we make sense of our lives.

“But what happens when the stories we tell are misleading or incomplete or just wrong? Instead of providing clarity these stories keep us stuck. We assume that out circumstances shape our stories, but what I found time and again in my work is that the exact opposite happens. The way we narrate our lives shapes what they become. That’s the danger of our stories, because they can really mess us up, but it’s also their power. Because what it means is that if we can change our stories, then we can change our lives.”

We have the power to think differently about the stories we tell ourselves, and examine them from another point of view. It isn’t possible in every case – there are some more serious instances when it isn’t helpful to doubt yourself or the harm another person is inflicting on you. But it is always a good idea to be aware of the stories you tell yourself, and the fact that you, and everyone around you, are sometimes an unreliable author.

Learning something new

We often say that you learn something new every day, but in practice this generally means odd things picked up accidentally – the capital city of a far-away country, the date of a historic event or why milk is white (it’s the emulsified fat droplets apparently). Most of us associate dedicated, focused learning with school or university. But learning something new is a wonderful lifelong ambition – and not just because it improves your skills or employability.

Learning new things is good for you – for your brain, and also for your mind. It gives you something interesting to focus on, a goal to work towards, and a sense of achievement with a new piece of information learned or a new skill gained.

This is backed up by medical research. The Mental Health Ireland website cites a 2004 study of 145 adults in which people who were involved in more learning reported feeling higher levels of self-esteem, self-confidence and purpose, and a better ability to cope with stress.

Learning new things is one piece of advice given by writer Laura Freeman in her memoir about using reading as a route to recovery from Anorexia, The Reading Cure.

She says: “There are too many self-help guides that say: get fit, lose weight, make friends, find a hobby, revamp your wardrobe. Clear the clutter to clear your mind. Eat right – and right is always avocado, chia and other whatnot – to ‘improve your mood’. Better they should say: feed your mind. Learn something, read something, see something new: a painting, a church, a bird, a rose garden, a park, a monument, a castle moat white with swans and hidden perch, a mews of hooded merlins, an elephant with ivory tusks and a palanquin throne on his back. Fill your thoughts with the world and what wags it.”

Freeman echoes this again at the end of the book, with the final advice: “Learn something. It is the best medicine. It is the only thing that never fails.”

Learning something new needn’t mean enrolling in a class – while this is a great option, it might not be financially or logistically viable for everyone. It could be learning to cook a new dish, how to fix a frequent DIY problem yourself rather than calling your go-to helper, learning a language online or finding a non-fiction book which sparks your interest.

So what could you learn?

Winter, the Danish way

October is here, and while we may still officially be in autumn, it certainly feels like the winter months are drawing in. Around this time last year I visited Denmark with a friend - the Nordic countries are famous for long, harsh winters, and people living there have had to get used to coping with them. While we were there we picked up a few tips.

Many people find they can struggle more with feeling sad or low in winter, and it’s no wonder: the weather is gloomier, we all get less sunshine, and people are far less likely to get out and socialise when it’s colder and darker. At this stage in October it can feel like the gloom will go on forever, as the comfort of the festive season is still quite a long way off.

That’s why it’s worth taking a moment to prepare for the winter season before it really hits , even if it seems like a very simple and obvious thing you’re planning for.

One of the biggest culprits for winter blues is the fact that people go out less. It’s cold, it’s dark, and an evening by the sofa beckons… But while a night curled up on the sofa is a lovely prospect, spending every evening until May either alone or with the same one or two people may not be the best thing for your mental health. A good motivation for getting out of the house every once in a while is to book something in advance – whether it be an evening class, a film, a one-off talk, or a free community event. If you’ve bought a ticket or told someone else you’re going beforehand, it will give you that extra bit of motivation to get those gloves on when the moment comes.

Exercise can also be more difficult if running or a walk in the rain doesn't appeal. Think about signing up for an exercise class or give in to the inevitable wet and take up swimming!

When winter hits, it’s all too easy for someone working office hours to go through an entire week without once seeing daylight. Get to work before the sun really gets up, eat lunch at your desk, leave work after dark. This is a terrible habit – your body needs daylight, whether or not the sun is shining, and just going for the odd walk at the weekends isn’t enough. Make a rule that you must get outside for 10 minutes or so every day – whether it’s at lunch time or a few minutes snatched between meetings. If you feel guilty stepping away from work, compare yourself to other people in the office who are smokers (if you aren’t one yourself). It’s considered perfectly fine to leave the office several times a day to go for a cigarette, so why can’t you go outside to get the vital daylight your body needs?

On that note, an important trick the Danes have mastered is taking vitamin D tablets in winter. If you live in Ireland it’s almost impossible for you to get the required amount of vitamin D from sunlight during the winter – there just isn’t enough sun! 

Finally, it’s worth bulk cooking a few meals you can stick in the freezer in advance – stews, soups, casseroles and the like. Good, nutritious, warming food for those cold days when you feel a bit lethargic and can’t manage to bring yourself to get the pots and pans out – they’ll make you feel better than reaching for a frozen pizza (although there’s nothing wrong with having one of those every now and then too!)

The mental health charity Mind has some advice on preparing for winter if you find you often feel adversely affected during this season, which can be found here. Bear in mind that there is a medical condition, Seasonal Affective Disorder, which is a type of depression influenced by the time of year. The advice given here is just for helping you to get through the odd low mood in winter – if you think the problem might be a bit more than that, it's good to talk about it - perhaps consider speaking to your doctor. One helpful way of distinguishing between low moods and depression is to keep a diary, and monitor how often these low moods are happening. 

Best of luck in your preparations, and remember, not everything about winter is negative! It can be very lovely too – what are your favourite things about Winter? Comment below to share your thoughts.

Why would you ski to the North Pole?

“I was the only human being in an area one-and-a-half times the size of America, five-and-a-half thousand square miles.

“It’s a journey that is right at the limit of human capability. I skied the equivalent of 31 marathons back to back, 800 miles in 10 weeks. And I was dragging all the food I needed, the supplies, the equipment, sleeping bag… everything I needed for nearly three months.”

On May 11, 2004, the English explorer Ben Saunders reached the Geographic North Pole, becoming only the fourth person ever to have got there in a solo expedition. He was dragging 180kg of food and fuel in two sledges, and had to navigate sub-zero temperatures, headwinds, ridges and hills formed by the ice and stretches of freezing open water.

Even he admits the expedition was “bonkers”… so why on earth did he do it?

It may be a similar question to why Shackleton went to Antarctica, or why Irish explorers Mike O’Shea and Clare O’Leary attempted to be the first Irish team to walk to the North Pole in 2012.

It’s the question Saunders attempts to answer in a TED talk called ‘Why Did I Ski to the North Pole’, which he gave a few months after successfully returning to the UK.

“I’m not an explorer in the traditional sense, I’m not skiing along drawing maps. Everyone knows where the North Pole is,” he said.

“This for me is a chance to explore and really push the limits of my own potential and see how far they stretch.”

“And on a wider scale it amazes me how many people go through life just scratching the surface of their potential, just doing three or four or five per cent of what they’re truly capable of. On a wider scale I hoped this journey was a chance to inspire other people to think about what they want to do with their potential, and what they want to do with the tiny amount of time we each have on this planet.”

Tapping in to your own potential doesn’t have to be about breaking records. You don’t have to become the fastest person to sail round the world, trek to the north pole or climb Everest in order to achieve something that matters. As mentioned in previous blogs, you are enough already and there is no need to reinvent yourself.

Success is about building on your own capabilities, not comparing yourself (more often than not unfavourably) to the achievements of others. For Ben Saunders, pushing himself meant skiing to the North Pole. For you, it might be running 5k, hitting a goal with a new language, getting to the supermarket on your own, or remembering to put the bins out on the right day four times in a row.

As Ben Saunders ends his TED talk: “I think if I’ve learned anything it’s this: that you’re the only person who decides how far you go and what you’re capable of.”

Looking good, feeling great

The advice that “when you look good, you feel good” is too often touted by beauty salons and make-up manufacturers only interested in selling you their services. It can be a shallow concept - or even a harmful one, when appearance or body image image takes on too much importance and becomes an obsession. 

But without going that far, there is truth in the idea that taking care of yourself and making sure you look presentable can be a benefit to your mental health. This doesn’t mean wearing a ridiculously expensive suit, spending all your time in the gym or slathering on layer upon layer of makeup, but simply a moderate commitment to presentability. 

There has been some research into the area, and one 2015 study led by Abraham Rutchick at California State University found that wearing formal clothing changes the way people think and makes them feel more powerful. 

Good-looking formal clothing  has been in the news recently, as Meghan Markle has released a new clothing line in partnership with charity Smart Works. For every item in the five-piece line purchased, the same item will be donated to the charity to be worn by a woman in long-term unemployment at a job interview. The idea is to create a sense of community between women helping women, and empower long-term unemployed women to feel more confident. 

The Princes Trust, a UK-based charity working with young people from disadvantaged backgrounds has long been offering a similar service, providing grants to young people for smart new clothes to help them ace that interview.

It’s not just clothes which are important for looking and feeling good. Another UK charity, ‘Look Good Feel Better’, runs workshops for cancer patients offering beauty treatments and advice for taking care of their appearance. “The effect a Workshop has on appearance and confidence is life enhancing during such a difficult time,” says Dr Natalie Doyle, a Nurse Consultant. “It allows people to take control of how they look and feel, when everything else feels like it’s outside of their control.”

Dr Doyle makes an important point about taking care of your appearance helping you to feel in control, and it can be applied to anyone, whether they are struggling with cancer, Chronic Pain, or any other illness. It’s worth making that extra effort to find a new pair of trousers that you feel comfortable in, to iron that crumpled shirt, or get that haircut you’ve been putting off for so long. And remember, you don’t need to look good for anyone else, just for you!

Ready, check, go!

The long summer days are beginning to fade, and while we have high hopes for September sun there’s no denying that Autumn is almost upon us. To me though, there’s comfort to be found in the rhythm of the seasons and the ‘back to school’ feeling of September – whatever your age!

It’s not surprising that many of us associate routine and comfort with feeling safe. What is surprising is that until recently medical operations were not subject to routine, and there were many negative consequences as a result. In June 2008 the World Health Organization (WHO) launched the surgical safety checklist. It is: 'a simple tool designed to improve communication and teamwork by bringing together the surgeons, anaesthesia providers and nurses involved in care to confirm that critical safety measures are performed before, during and after an operation'.

The American surgeon Atul Gawande explains in his TED talk how his team were asked to look into why the mortality rate was so high in surgical operations. He recognised that surgeons were expertly skilled and brilliantly trained so the usual solution of introducing more training was not appropriate. So what could be?

He looked at other highly skilled professions for ideas and came across an unusual improvement; the introduction of a checklist for pilots. It was devised after a test flight in 1935 went wrong, and two pilots died in the resulting crash. Afterwards engineers were shocked to realise there had been no mechanical error – the pilots, operating a cutting edge new system, had made a mistake despite both being very experienced. As a result, management introduced the pre-flight checklist, and there were no more accidents in that model due to human error.

Gawande makes a distinction between errors of ignorance (mistakes we make because we don’t know enough), and errors of ineptitude (mistakes we made because we don’t make proper use of what we know). He comes to the conclusion that experts need checklists - written guidelines that walk them through the key steps in any complex procedure. His research team has taken this idea, developed a safe surgery checklist, and applied it around the world, with staggering success.

Between October 2007 and September 2008, the effect of the checklist was studied in eight hospitals in eight cities across the world. Researchers found the use of the checklist reduced the rate of deaths and surgical complications by more than one-third across all eight pilot hospitals.

Further improvements include cost savings and better communication between staff members, and similar checklists are now also in use in a range of other clinical areas, including childbirth, emergency departments, and intensive care units.

As you detect the first signs of Autumn, perhaps now is a good time to think about checklists and routine. You most likely have everyday tasks or moments in which you need to remember a set of steps or list of items. It may seem unnecessary or simplistic, but how much weight would a checklist take off your shoulders? Sometimes the simplest solutions are the most effective.

Have you taken your culture vitamins?

Most people agree that culture is good for us. But have you ever thought about culture as something necessary to treat a specific problem, something that can be prescribed? That’s exactly what Denmark’s Kuturvitaminer or ‘Culture Vitamins’ program does.

Part funded by the Danish health authority and organised by local jobcentres, Culture Vitamins facilitates engagement in cultural activities for people who are unemployed or on state sick leave. It’s currently in trial stage, with pilot schemes operating in the municipalities of Aalborg, Silkeborg, Nyborg and Vordingborg.

Participants, many of whom are struggling with stress, anxiety or depression, complete a 10-week culture crash course in the local area. They take part in two or three activities a week, with eight different options for activities in total. These include singing and listening to music as a group, and participants are also taken to Aalborg Symphony Orchestra rehearsals and performances. The group visits the local art museum and takes part in creative workshops, as well as going to the  theatre. They are also given coaching sessions from actors about body language, to increase their confidence in job interviews.

According to the program conveners, many students have gained in energy and self-confidence, strengthened their ability to establish and maintain relationships, and been able to complete internships or enter the job market again. Students get a break from their illness, and end up with more self-care and more energy, they say.  The process helps to remove focus from the disease and instead create new self-images of people with skills, who want something from life.

There are likely three reasons why the program is so successful. The first is the exposure to culture, to art or music or theatre, and it’s hard to say how large a share of the success culture is responsible for. The others are the sense of community created by experiencing culture as a group, which helps to tackle loneliness and isolation; and the structure of having a set number of excursions at a set time each week, organised and facilitated by someone else.

I think all three are probably responsible for the good results felt by program participants, and all three could be replicated by the rest of us, whether by scheduling regular visits to the nearest museum or art gallery or by making the effort to join a choir, team or community group.

The unexpected superpower

“Let me persuade you to follow my example, and take a turn about the room – I assure you it is very refreshing after sitting so long in one attitude.”

This, said by Miss Bingley to Miss Bennet, is one of my favourite lines from Jane Austen’s Pride and Prejudice. If you aren’t familiar with the book, or with any of Austen’s work, this is quite a good example of a lot of the subject matter: two young women taking a walk together so they can gossip about eligible young men, in this case rather bizarrely around the inside of a sitting room.

A life spent doing nothing but trying to get yourself married off does have its drawbacks, but one advantage of these young ladies over most people’s lives today is that they got a lot more walking done. Books from the period are full of episodes of the upper classes ‘taking exercise’, around their enormous estates. While most of us don’t have several acres of land to proudly survey, we can get just as much benefit from walking in public parks or along busy city pavements.

We already know that walking is beneficial – it’s a good form of exercise, and also involves getting outside for some fresh air. But Shane O’Mara, Professor of Experimental Brain Research at Trinity’s Institute of Neuroscience in Dublin, has gone further in his research to try and explain exactly what walking does to the brain and why we should do more of it. He believes walking can improve brain activity, and even called it a ‘superpower’ in a recent interview with the Guardian UK!

“One of the great overlooked superpowers we have is that, when we get up and walk, our senses are sharpened,” he said. “Rhythms that would previously be quiet suddenly come to life, and the way our brain interacts with our body changes.”

O’Mara points to great thinkers and writers who used walking as a means to generate ideas, including Bertrand Russell, William Rowan Hamilton and Friedrich Nietzsche.

Some people don’t consider walking ‘proper’ exercise, but O’Mara argues that what we really need is to be more active generally over the course of the day. It doesn’t make any sense, for example, to go to the gym for an hour in the morning, then sit still at a desk all day. If you have an office job it’s important to make sure you move around – get some water, go to the loo, or go and visit a colleague rather than sending yet another email!

It may seem counter-productive to take time away from your desk, but research suggests it will make you work better. “Getting people to engage in physical activity before they engage in a creative act is very powerful,” O’Mara said. “My notion – and we need to test this – is that the activation that occurs across the whole of the brain during problem-solving becomes much greater almost as an accident of walking demanding lots of neural resources.”

A lot more research is needed on the benefits of walking, but there’s already overwhelming evidence that is does improve brain activity. Have you ever had a difficult email to send, problem to solve or decision to make, and found yourself going for a walk to think about it? O’Mara’s research may go some way to explaining why this is effective. You can read more about it in his recently-published book, In Praise of Walking.

Stop searching for your passion

Have you found your passion yet? 

If not don’t worry, there are hundreds of books, talks, and articles out there to help you on your way - there’s even a WikiHow page on how to find your passion, featuring a self-help guru and a ‘vision board’!

From every side we’re bombarded with the idea that we need to ‘find our passion’, as if everyone has one, immovable thing they’re passionate about locked inside them just waiting to spring out when we eventually discover the key.

 This interpretation of finding one all consuming passion is very similar to the idea of finding ‘the one’ - that there is only one romantic partner out there for us, and we won’t be happy until we’ve found them. But just like relationships are about falling in love with someone who is compatible with you, ‘passion’ is about developing feeling for something already in your life. Passions align with personal beliefs and values, and people are likely to feel passionately about more than one thing.

 Passions can also change over time. There is still a pervasive idea that you need to find your passion as soon as possible, and follow it for the rest of your life. This can create huge pressure, especially on young people entering work for the first time who feel they have to immediately find a job they want to do for the rest of their lives. It can also bring misery a few years down the line, as those a decade or two into their working lives think they’ve ‘failed’ if they haven’t yet found their passion.

 As Terri Trespicio says in her TED talk ‘Stop Searching for Your Passion’, “passion is not a plan, it’s a feeling. And feelings change.”

 Like many graduates, when Trespicio left university she was paralysed by the feeling that she had to take a job that led her to her passion.

 “I was turning away perfectly good full-time jobs. Why? Because I was afraid. I was sure that I would pick the wrong one and get on the wrong train headed to the wrong future. My mother begged me, she said, “please, take a job, any job. You’re not going to be stuck, you’re stuck now! You don’t create your life first, and then live it. You create it by living it, not agonizing about it.”

 Trespicio’s mother was right, of course. The idea of ‘finding your passion’ is outdated, as these days most people change jobs and even industries several times during their working lives. In addition, it’s easier than ever to discover a new hobby or interest later in life. Trespicio points out it’s also elitist, as only the most privileged have the luxury of being able to think about passion when choosing a career, rather than just paying the bills.

 “Passion is not a job, a sport, or a hobby,” Trespicio says. “It is the full force of your attention and energy that you give to whatever is right in front of you. And if you’re so busy looking for this passion, you could miss opportunities that change your life.”

 Passion is not something you uncover within you by reading a self-help book or going on a weekend retreat, passion is something you discover by doing things and realising the effect they have on you.

 Everyone needs time for reflection to consider what they feel passionately about, and our life experiences shape what we feel. It takes time to recognise what brings us joy - working out the basics of earning a living and developing a social life come first.

 Trespicio’s final word of advice rings true: “Don’t wait… Just start doing. Because to live a life full of meaning and value you don’t follow your passion, your passion follows you.”