A relational approach to chronic pain

What could a relational approach to chronic pain look like?

There are so many methods and approaches to working with chronic pain/pelvic pain. One that I’ve found particularly useful for clients is actually learning about the biological mechanisms of pain, and then learning how to relate to the pain differently overtime. If you’re someone who suffers from chronic pain, I think it’s always helpful to ask-What are my assumptions about what pain “means” or how it acts in my body? What thoughts, feelings, and behaviors come up when I think about my pain? As we start to elucidate some of these associations with pain, we can get clearer about what’s actually happening in the body, and have more agency in terms of how to work with it.

When I start asking clients questions about their assumptions about pain, it’s often assumed that pain is a result of something bad in the body that needs to be “fixed.” For many years, rehab clinicians and manual therapists have said “the issue’s in the tissues,” but we know that’s only part of the truth.

Pain is not just “in your head” but it’s not just “in your body” either/Pain Science 101

Take a moment to pause and consider what you understand about pain. It’s really easy to think that pain is something that comes from the skin or tissues when we consider a paper cut. There’s a painful stimuli that shows distinct damage to some part of the body, followed by unpleasant sensations.

The body itself does not have pain neurons. The body itself does not “detect pain”. We have what are called nocioceptors, which help detect danger. These neurons then send this signal through the spinal cord, and into the brain. The brain then interprets, based on many factors and associations, whether or not to make this stimuli “pain.” We’re talking about memories, contexts, social factors, past experiences of pain, etc. In a split second, the brain can then “decide” to send neurochemicals back down to the body, which we then experience as pain.

With chronic pain, the central nervous system becomes more intensely attuned to these danger signals. Chronic pain is thus an evolutionarily protective response, designed to help protect us from experiences that could threaten our lives.

So once we understand that pain does not necessarily mean distinct tissue pathology, that something is “wrong” or “broken”, we can get really curious. It may help to redefine chronic pain. What if we defined chronic pain as a mind-body system habitually and automatically attuned towards protecting us from uncomfortable and negative stimuli?

We know through neurobiology research that we are hardwired to notice and remember negative stimuli/memories more than positive stimuli/memories. This is why, although research is still burgeoning, I’m interested in somatic approaches to chronic pain. If we can orient the nervous system towards pleasure or neutrality, can we build more positive associations with sensation and embodiment, thus shifting some of the brain’s interpretive networks around pain?

This is where I’m working on developing a relational approach to working with chronic pain/chronic pelvic pain. When folks hear about embodiment or somatic approaches, I think there’s often shame or confusion about “how much” or “how often” a person is “supposed to be” embodied. I think this can create its own kind of hypervigilance about this way of being in the world. But when we think of embodiment as an output of curiosity, creativity, and relating, more space opens up.

I sometimes give the analogy of building a budding friendship. Consider questions like, what makes me feel drawn to this person? How does that interest show up in my nervous system?

And making a new friend can feel vulnerable. So when you’re thinking about reaching out, maybe you delay it when you’re in a weird spot, have increased stress, or have family in town.

And think about pacing when building a new relationship. Most people don’t decide to be friends with someone and then start texting them all day. It takes time, and it’s a dance of connection and disconnection, space and togetherness.

And when we’re developing a new friendship, it’s often easier when we have older, easier relationships to return to. This helps us remember who we are and how we like to be with others.

So how can we similarly think about building a somatic relationship with chronic pain? You can get really curious about the pain. Build a slow rapport with your dynamic felt sense over time. Give it space and allow yourself to disconnect. Gradually develop more easy access to pleasurable resource within the nervous system.

We can then start to think of relating to sensation in the body as part of a larger ecosystem or community. When pain flairs, what else is there to support you? Finding new, felt-sense ways to build relationship with this web of support can bolster you when pain inevitably arises, and possibly change the brain’s perception of pain overtime. We can then also consider our wider webs of support outside the body, which could include: the relationship you have with a therapist or rehab professional, social supports, spiritual resource, and more.

Understanding pain management as relationship building can give us the opportunity to learn new, gentler ways of approaching chronic pain. This can allow us find organic ways of “being with” our pain that doesn’t overextend or deplete us. We can learn to follow our subtle impulse in connecting to our body, expanding our capacity to stay embodied when pain inevitably arises. When we can access the creativity and curiosity that relating requires, it can bring us out of our stress responses associated with a pain flair, and into a space where there might be more agency over our direct experience.