Mindfulness and Cancer Pain

Cancer Pain With No Apparent Solution
Mrs B is in her 60s and is fighting for her life. She has a second recurrence of metastatic breast cancer and was recently admitted to rehab after an episode of congestive heart failure and accumulation of fluid around her lungs. She is a determined person who is ready to smile despite her difficult circumstances. She is thin, weak, tired, and has a tube draining malignant fluid from her right lung.

Despite a long-acting fentanyl patch of 300micrograms/hour, she gets episodes of severe right sided low back pain that is not well-relieved by 80mg of immediate release morphine (a dose that would probably kill most people). But the medicine puts her to sleep so she can’t do rehab. She is highly motivated to regain her strength and ability to walk so that she can spend quality time with her loving family. We’ve been unsuccessfully struggling to adjust pain medications and muscle relaxants so that she can have pain relief without sedation.

I walk into the therapy gym and she is sitting up in her wheelchair. She’s trying to walk with the walker. She looks a bit deflated and says she has severe pain in her right side.

A Mind-Body Approach to Pain
I pull up a stool and ask permission to inquire about her pain. She agrees.
I ask her what it feels like in her body…
‘It’s a throbbing, pulsing, pulling feeling’, she says, grinding one hand into the other to demonstrate ‘throbbing, pulsing’

“How intense is it”, I ask.
“About an 8…”, she says, meaning an 8 on a scale of 1-10 where 10 is the worst pain imaginable.

“What thoughts come up when you think about it?” I ask.
“I want it to go away. That I can’t walk if it hurts so much”

“And what feelings or emotions do you feel?”
“that I don’t know how I’m going to get through this”

“I hear. It sounds overwhelming and that you’re not sure if you can make it…”
She nods.

“…So what you said is also a thought: ‘I don’t know how I’m going to get through this’. What about the emotions? Are you aware of emotions, like sad, angry, frustrated, scared, anxious…?”

“It’s a scared feeling, doctor”

“Right. I hear…you feel scared”, I said, tuning into her sense of anxiety that I sensed but now she acknowledge…
She nods….

Then I become aware that since the moment I approached her this morning, she has had her hands clenched together.

I ask her to notice if her hands are tight or relaxed. She extends her arms, and lets her hands and arms drop loosely in her lap. I invite her to let her body be supported by the back of her chair, and she sinks into the backrest. I invite her to let her buttocks be supported by the bottom of the chair, and let her feet and knees be supported by the floor.
Her posture softens along with her face.

After a few moments, I ask about her pain.
“Oh”, she says, looking surprised, “It doesn’t hurt very much now…”

A Simple Process for the Mind-Body and Pain
Mrs B and I spoke about the change that happened. I point out that we did a very simple process:
1. Acknowledged the quality of the physical sensation,
2. Acknowledged the thoughts and beliefs associated with the physical sensation,
3. Acknowledged the emotions associated with the experience, and
4. let go of the obvious physical tension.

She expressed a sense of comfort in knowing she could do that. She said she felt a little less fearful; a bit more optimistic; and more comfortable.

Training in Mindfulness to Enhance Coping and Life
In the mindfulness based stress reduction course (MBSR), we teach patients to develop a quality of mind called ‘mindfulness’. We do that be inviting them to pay attention to the flow of experience (their thoughts, emotions, and bodily sensations) in a non-judgmental, open, compassionate way. The point is to see more clearly what is happening in life. The practice often enables people to respond much more effectively to difficult circumstances. The fact is that our mind can be a powerful ally or a harsh slavemaster. Mindfulness training often enables insight and skill that helps express the helpful, healing aspect of mind, and gives us choice in softening the harshness and judgmentalism.

The practice comes from the observation that much of our suffering is generated by not seeing things clearly. That we suffer more when we live in unconscious reaction to our ideas, preconceived notions, and unconscious emotional and physical reactivity to life experience. Mindfulness enables us to relate to life directly and openly, to shine a light of awareness on the flow of experience. And that offers greater possibility for choice, and greater potential to find the good in our lives.

To paraphrase my colleague Dr Jodie Katz in a dialogue with a class participant who was describing how his back pain was an obstacle for him:

underlying all this “paying attention” which we call mindfulness is a relational quality to our experience which is both a cornerstone of and an ongoing development in practice.  When we label something as this or that, it automatically sets up a particular relationship to experience. Then we have a relationship with the label, that can be reactive and unproductive and increase our suffering.

“Pain” is just such a label.  To a large degree it is a story we tell ourselves about the actual experience we are having, and is a complex mixture of bodily sensation, thought, belief, and emotion. When the mixture is unconscious, it intensifies our suffering, and gets in the way of a deeper knowing and understanding.  What we call “pain” can be a lot of things – in the body it can be experienced as tearing, electric, burning, squeezing, choking or cramping sensation, among others.  In the mind there can be beliefs and thoughts that include judgment, low self esteem, hopelessness, isolation, despair. I the heart there can be painful emotions  – anger, grief, profound fear, depression etc.  All of these are just words too, but they get closer to the actual felt experience.

If we use the label “pain”, it makes the experience more solid than it actually is and makes it far more difficult to approach.

If we inquire into the experience, without the label of pain, then we sometimes find more freedom to choose how to relate to the experience. And that can often dissolve the fear, helplessness, isolation, anger, muscle tension, and other aspects that otherwise make it so solid and unmanageable. The ‘miracle of mindfulness’ is that we can cultivate caring, discerning, healing attention, and that can empower us to help ourselves and help others.

Mrs B went forth into the day with a renewed sense of clarity, possibility, and workability about her situation. She stood up with the therapist, and walked down the hall.