The premise that thoughts have significant effects on feelings and behavior and that shifts in thinking lead to emotional and behavioral changes is the basis of Cognitive Behavioral Therapy (CBT). This knowledge has an extensive history, having been a topic of discussion among Stoic philosophers in ancient Greece and Rome (notably Epictetus and Marcus Aurelius). CBT techniques are used to help individuals identify their maladaptive cognitive patterns and beliefs, such as discounting the positive in a situation by focusing on the negative; blowing things out of proportion; thinking in rigid black-and-white/all-or-nothing extremes; and placing unreasonable and unrealistic expectations on oneself, other people, and situations—“I should be better than this,” “This traffic must go faster.” (I’ve learned how not to “should” all over myself, and I’m no longer a habitual “must”erbator.) Getting caught in these cognitive traps escalates emotional pain and invariably gooses the experience of suffering. CBT seeks to replace such distorted thinking with more realistic and effective thoughts to reduce emotional distress and self-defeating behaviors. The process of replacing problematic cognitions with those that are more healthy and adaptive is referred to as cognitive restructuring. Cognitive restructuring is sometimes contrasted with cognitive defusion—a related but divergent set of techniques that draw on mindfulness practices and are emphasized in Acceptance and Commitment Therapy (ACT). ACT is an evidence-based adaptation of CBT that features mindfulness and internal values-congruent practices. While the aim of cognitive restructuring via CBT is to actively change distressing thoughts and patterns of thinking, cognitive defusion via ACT focuses on observing and accepting uncomfortable thoughts without automatically buying into or attaching any particular value to them. Cognitive restructuring and cognitive defusion share a common foundation of bringing unhealthy automatic thinking to conscious awareness. They each change the nature of the relationship we have with our thoughts and thought process. Both of them play an important part in the pain recovery process, though one may gravitate towards a specific techniques. Through awareness and practice anyone struggling with chronic pain can develop the skills to disengage from the habitual unconscious cognitive routines that activate suffering. Learning to recognize pain- related patterns of negative thinking and relate to them more adaptively through constructive disengagement—viewing them as passing events in the mind—diffuses the influence of those patterns. Deepening awareness and nonjudgmental acceptance of one’s thoughts fosters a new relationship with them, creating the space to purposefully shift mental focus away from the ruminative thought patterns that pave the road to suffering. For those struggling with addiction, the upcoming exit on that road may well be relapse. Thoughts occur so naturally and automatically that we are oriented to see them as part of ourselves. We become so closely identified with our thoughts that we believe there is no separation; our thoughts are us and we are our thoughts. And yet, the reality is that we produce our thoughts; they are mental products generated in our minds. We are also inclined to believe in the inherent truth or accuracy of our thoughts. Assuming our thoughts are facts—that they are all true and valid without examination—is one of the reasons we often find ourselves out of balance. This is particularly true when people are challenged with chronic pain and/or addiction. Self-talk is an off-shoot of our thinking and refers to what we tell ourselves about events—both internal and external. Our self-talk defines our beliefs about those events. The more consciously aware of this process we become, the more we are able to develop the capacity to accept and, if we chose to, intentionally adjust our thinking, self-talk, and beliefs. Thoughts are like images on the video screen of the mind. The first thoughts that come into our minds are like the channel that the television is turned to when we first turn the power on. While we may be powerless over the automatic thoughts that first enter your mind, we aare not powerless over what we do in response to them. When we turn on the TV, we observe the channel that’s on and notice its content. Then we make a decision to take some sort of action in response to it. It’s important to be aware that no action is an action unto itself, and not making a decision is, in fact, making a decision by default. We can choose to leave the channel where it is, or if we don’t care for what’s on, we can lower the volume, mute the sound altogether, or change the channel to something more to my preference. In the same way, as we become more consciously aware of our thoughts, we can witness them without judgment; accept them with detachment and let them pass; question their accuracy; and/or dispute or challenge them, or modify them. Awareness opens up the possibility of multiple options that give us the power of conscious choice. In pain recovery, with the aid of mindfulness practice, we learn that we are not what we think. We have thoughts; however, we are not our thoughts. We can observe them without identifying with them, and we can dispute them by not buying everything they are trying to sell us. Progress toward healing and recovery from chronic pain also requires acceptance that, although we cannot control our thoughts, we nonetheless have choices about how to respond to them and how much influence to accord them. Paying attention to our thought process and consciously observing, questioning, and challenging our thinking are indications of mental health. Mental balance involves moving away from rigid unconscious patterns of thinking and developing flexibility (open-mindedness) in how we think and how we think about our thought processes. In recovery from addiction and chronic pain, emotional healing starts when we begin to connect consciously with and accept our feelings. Trying to avoid or suppress painful emotions is similar to being mired in quicksand. The harder we struggle to get free, the more stress and tension we create, the deeper we sink and the more stuck we become. It is only when we stop judging and struggling and allow what is there to simply be, that we can free, as distressing feelings lose their grip and dissipate on their own. Feelings always find a path to expression. If we don’t allow ourselves to feel them and, as necessary, talk about them; if we avoid or suppress those feelings, then they invariably come out “sideways”—in indirect forms via our behavior. When feelings are expressed through behavior, they typically operate unconsciously, outside of our awareness and ability to steward. When this happens we’re on autopilot, doing things we don’t want to do and that we know won’t work for us, but have no idea why we keep doing them. It’s similar to a pressure cooker. Pressure cookers are instruments of balance inasmuch as a lid is required to keep the contents from spilling all over the place, but a means to release the accumulating pressure is also necessary. If there is no release valve to provide it a safe path to expression, what happens? The pressure builds up until the vessel can no longer contain it and it explodes, causing potentially serious damage. In the same way, if we do not provide our feelings a safe (though at times uncomfortable) path to expression by feeling and talking about them consciously, they will still find a way out often through some sort of unhealthy, self-defeating and/or explosive behavior. Feelings, especially powerful disturbing ones, can seem as though they will last forever. However, whether they are positive and bring smiles to our face and laughter to our lips, or painful and bring hurt to our hearts and tears to our eyes, feelings are always temporary. They come and go like guests who come to visit: some are welcome and we’re delighted to see them; others, not so much. Sometimes they leave sooner than we would like; other times they stay way past the point when we want them to leave—but eventually they all leave. As we say in twelve-step recovery, “this too shall pass.” Dialectical Behavior Therapy (DBT) is an evidence-based cognitive behaviorally oriented treatment approach that blends a problem-solving focus with emotional regulation, distress tolerance, acceptance, and mindfulness strategies. DBT was originally developed to treat people with borderline personality disorder and those who are acutely suicidal— populations that are extremely emotionally intense and labile. These individuals are unable to manage feelings internally and are frequently intensely angry, frustrated, depressed, or anxious. Many people struggling with chronic pain and/or addiction present with an emotional hypersensitivity—a pronounced difficulty tolerating painful feelings. This heightened sensitivity means emotions are felt more deeply and rapidly than by most other people. As a result, distressing feelings such as anxiety, fear, anger, guilt, shame, sadness, and depression, as well as physical pain are not only felt with great intensity, they are often experienced as overwhelming, almost suffocating. Using substances becomes a way to turn down the volume of such feelings and to numb them in order to survive them. Distress tolerance is about enduring and accepting discomfort, learning to bear pain skillfully. Distress tolerance skills are an outgrowth of mindfulness practices, and involve the ability to nonjudgmentally accept both oneself and the current situation in spite of the emotional and physical distress experienced. It is important to clarify that acceptance does not equate to approval. We can learn to tolerate thoughts, emotions, physical sensations, and situations that we don’t like at all, and may even deeply dislike. Distress tolerance enhances coping capacity by strengthening resiliency—the ability to adjust to change. Emotional regulation relates to identifying the emotions that are being felt in the moment, and observing them without being overwhelmed by them. Emotional regulation skills include self-soothing techniques that provide a calming effect. These are self-care activities that help to reduce emotional intensity such as meditation, deep breathing, listening to music you enjoy, progressive muscle relaxation, taking a walk, reading something pleasurable or spiritual, singing a favorite song, exercising, visualizing a comforting/relaxing image, journaling, etc. Emotional regulation is aimed at modulating feelings in order to strengthen the capacity to manage impulses so as to not behave in reactive, self- defeating, and destructive ways. Allowing oneself to feel, accept, express, and coexist with uncomfortable, often painful emotions is essential to recovery from chronic pain and addiction. Feeling and accepting emotions also takes less energy than running from or stifling them, making more energy available for recovery- supportive pursuits. Emotional balance is achievable when we allow ourselves to feel whatever comes up, without suppressing or being overwhelmed by it, and learn to accept those feelings without judgment. Because our feelings are a part of us, accepting them as they are is integral to the process of accepting ourselves as we are. Many people struggle with self-acceptance, but those afflicted with chronic pain and/or addiction incur extraordinary challenges. This lack of self-acceptance is another factor that contributes to suffering. Hence, recovery involves progress toward being fundamentally okay with oneself. Whatever positive changes you want to make in your life, acceptance of how and where you are in the present moment is one of the keys to moving forward. Dialectical thinking is based on the view that all things are interconnected and even elements that seem to be the antitheses of one another share a relationship. Dialectic is a dynamic process wherein apparent opposites move toward an integration that brings them into harmony and creates a greater whole. Pain recovery, the Twelve Steps, DBT, and ACT all utilize the dialectic of acceptance and change, recognizing the therapeutic value of accepting one’s current status and moving toward healthy change to generate growth and healing. This dialectic is elegantly encapsulated in the Serenity Prayer:
- Grant me the serenity to accept the things I cannot change; The courage to change the things I can;
- And the wisdom to know the difference.
Simply recognizing which grouping a challenge at hand (be it physical, mental, emotional, spiritual, or interactional) belongs in makes our lives more manageable. Beyond that, if the challenge is something we cannot change—such as the fact of being in pain or the actions or attitude of another person—we need to accept it, and the issue becomes how best to facilitate that acceptance. If, on the other hand, the challenge is something we can change—how we are responding to the pain we have or how we are dealing with that other person—the issue is about what we need to change and how to most effectively make it happen. One thing that we can always change (as difficult as it can be at times) is how we respond to that which we cannot change. Such principles and practices successfully generalize to a range of life challenges, including addiction and/or chronic pain. Working the twelve-step program as the foundation of our addiction recovery process only strengthens our capacity to live with chronic pain, addiction or other challenging conditions. It gives us access to multiple strategies and tools that we can use to better tolerate emotional and physical pain, and accept feelings of all kinds without acting on them in ways that make the situation worse and create suffering for myself or others. Twelve-step programs can nurture cognitive defusion to separate oneself from one’s thought process, as well as cognitive restructuring to replace negative, unhealthy thoughts and beliefs with those that support recovery. It advances a framework for practicing new recovery-oriented behaviors and encourages connecting with others who share similar experiences for mutual identification, understanding, and support. Further, it encourages the development of positive spirituality and recommends the application of spiritual principles such as acceptance, tolerance, open-mindedness, perseverance, humility, and gratitude, as a means to diffuse self-centeredness, increase feelings of well-being, and prompt additional opportunities for conscious contact with that which is beyond oneself—of belonging to a greater whole, of connection to others, as well as to the world as a whole. Prior to treatment, thinking usually feeds irrational beliefs about pain: “I shouldn’t have pain.” “This is intolerable!” “I have to take more pain meds!” Through pain recovery, one learns alternative ways to approach their pain, including how they think about it, interpret it, and react to it. As they learn in their clinical hypnotherapy training, all experiences have a specific structure. If that structure changes, so will the experience. The structure of their experience of pain includes how they think about it, the beliefs they attach to it, and how they react to it emotionally. By modifying that structure, our experience of pain will shift dramatically. Most will still have chronic pain following treatment. It is an onerous, dogged, often enervating presence in an individual’s life. Some may have pain 85–90 percent of the time—at least when they are awake. Ten to fifteen percent of the time they are graced with the absence of pain, and that is always a great blessing. Yet, approximately 65–70 percent of the time, their pain may be the “normal” uncomfortable nagging dull ache; 10–15 percent of the time it’s worse than usual, barking louder and cutting into the individual’s conscious awareness more noticeably; and 10 percent of the time it’s worse; requiring the individual to be especially mindful in terms of how he or she takes care of it. However, pain recovery can position a person to where their pain rarely debilitates them or dictates their activities (though it certainly influences them), and no longer controls their life. The tone for their continued recovery from addiction and chronic pain can be set each day through extensive multimodal practices described in previous blog posts, combining spiritual reading, meditation, nondenominational prayer, self-hypnosis, Egoscue stretching, and chi kung exercises. Depending on the individual, one might continue to utilize certain aspects of conventional Western and complementary alternative medicine, including ibuprophen, to mitigate pain and inflammation, and targeted use of ice packs and heating pads, which besides helping to decrease pain sensations and deflect an individual’s attention from them, have the therapeutic benefits of reducing swelling and increasing blood circulation respectively. Some have intermittent chiropractic and massage treatments, and have portable inferential stimulation and traction machines for home use as needed. One of the problems that comes with chronic pain is lack of movement. It can hurt too much to move, and the desire to protect oneself from pain is natural, so movement is often minimized and avoided as much as possible. Unfortunately, the less you move, the more pain you have when you do move, incentivizing you to move even less. It becomes one more vicious circle. Exercise consistent with one’s capacity is an important part of the pain recovery process. Physical movement is the body’s lubricant. This blog post is an excerpt from Some Assembly Required – A Balanced Approach to Recovery from Addiction and Chronic Pain by By Dan Mager, MSW; Published by Central Recovery Press (CRP).