The goal of many approaches to pain management is pain reduction. If this cannot be achieved then the patient is told that they have to "learn to live with it". This is usually heard as "nothing can be done to help you and therefore you will have to put up with this for the rest of your life". Indeed, a patient can be assisted 'to get on with their life' in spite of the pain and an outcome of this approach may be pain reduction. However, in my experience patients don't hear the expression 'learning to live with it' as 'getting on with your life'. Instead, they hear it as a life sentence of pain. Most pain-management programs aim to restore function and improve coping strategies so that people in pain can return to work or other fulfilling occupations: in other words 'get on with their life'. A large part of my work is directed to this end but increasingly I adopt an attitude of non-intervention as a complement to teaching self-management programs. Rather than learning to cope with the pain or ignore it, the pain becomes the focus of therapy. Moving in on the pain becomes the goal in itself.

As the pain is explored the person's reaction to it is revealed. Frequently, the first discovery is the separation of affective and sensory components of the pain. This can be a direct demonstration to the person that pain is not only a physical phenomenon but is linked to an emotional response. Deeper exploration can lead to deeper meanings and attitudes being exposed. Paradoxically this can lead to an immediate reduction in pain or a sense that the pain is present but not so bothersome. By focussing on the pain with an attitude of curiosity, instead of finding distractions or absorbing activities, pain reduction can follow. Several short case studies will be presented to illustrate this process.

Non-intervention is rather a novel idea suggesting that we don't need to do anything. Indeed it is the urgency to do something/remove the pain/fix it which drives so much treatment and therapy. The paper questions the need to intervene to relieve the pain and the patient's assumption that the pain must be removed or relieved. Intervention can take many forms including invasive procedures, manipulative therapy, cognitive-behaviour therapy, exercise programs, relaxation training, Feldenkrais Method and massage. It can be hands-on or hands-off. The intervention can provide symptomatic relief or functional restoration but whatever it is, the practitioner is changing something, suggesting change, or doing something. This paper discusses a way of working with pain that doesn't involve doing anything, merely exploring and observing. There is no attempt to remove the pain or suggest ways of getting on with life in spite of the pain. It is an approach which can complement other interventions in an attempt to unravel the complexity of the pain response.

Practitioners working with people in pain know how demanding they can be in terms of their expectation that you remove the pain. Practitioners may not question their role as a person who attempts to do that because training focuses on determining the cause of the pain and ways of alleviating it. Correct diagnosis is a hallmark of good management. A feeling of impotence can arise when diagnosis is not possible or is complex and treatment options are even less clear. An assumption behind the demand for pain relief is that pain is bad and can't be tolerated; even that it should not have to be tolerated. When the demand is not met the person in pain can be disappointed, frustrated or angry. The emotional response of the patient becomes more intense as time passes and pain relief continues to be elusive. The practitioners response can range from a feeling of impotence through to anger.

Doing something is replaced by a process of observation. Pain as a threat or an alarm signal can become something to be curious about. An attitude of curiosity can enhance dissociation which is known to assist with pain reduction. An assumption that pain is bad and something to be avoided can be replaced by an attitude of non-judgement and an enquiry about what can be learnt from it. Exploration of the pain by the patient, not doctor or machines, can provide a form of diagnosis and paradoxically, pain relief at the same time. Both the patient's and practitioner's attitudes are put under the microscope in this process of observation. The practitioner may choose to share his/her response when appropriate. Sometimes a solution emerges spontaneously and transformation happens simply by watching. Both the patient and practitioner need to learn to be comfortable with 'not doing'. The art of 'not doing' and 'not trying' is fundamental to the practice of meditation. This way of 'being' is open to all practitioners and can assist in the process of finding pain relief and handling the emotional response of both patient and practitioner.

Mindfulness And Meditation
Relaxation is commonly taught in pain-management programs. There are many techniques including progressive muscle relaxation and the use of visualisation or imagery. They can assist in direct pain relief but many people in pain find them too difficult and avoid practising them because they experience an increase in pain. They become more aware of the pain and hence experience it more intensely. At this point they give up. Meditation and particularly the practice of mindfulness can take a person in pain beyond that pain experience. By encouraging them to stay with the sensation and explore its qualities they learn to separate sensations and feelings. By experiencing pain as a sensation, a spontaneous dissociation frequently occurs and with this comes pain relief or a sense that pain is present but not as bothersome. Muscle tension resulting from the pain, and emotional response to the pain, begins to release spontaneously. As the holding around the pain releases, the pain experience changes. While resistance to and avoidance of the pain dominate the pain experience will only increase in intensity. With an awareness of this response and a willingness to let go of it, pain reduction can follow. Learning to 'be with the pain' leads to a reduction in the person's reactivity to the pain. They may cease to panic or catastrophize about it. It becomes a way of reversing the pain amplification or sensitisation state, both the physical and psychological components of it. This approach is used by Kabat-Zinn (1991)1 in his stress reduction program at the University of Massachusetts Medical Centre. The approach of mindfulness is well described by Borysenko (1988)2 and Hanh (1976)3. It can be taken a step further when working with pain using a body-centred approach to psychotherapy as described by Kurtz (1990)4.

Body-Centred Psychotherapy
An important foundation of this work is mindfulness or being present from moment to moment. Peak performance is characterised by a state of mindfulness whereas our everyday experience tends to be characterised by a scattered focus or thinking about one thing whilst doing something else. An activity can be performed mindfully and mindfulness can be brought to a person's internal experience. This is the heart of a body-centred psychotherapy. Using such an approach, attitudes to pain and life are revealed and with continued observation transformation frequently occurs. Change is not suggested or imposed. The following case studies illustrate the use of a body-centred approach to psychotherapy.

Case Studies

Case 1: Not Trying
Ellen arrived for her session talking rapidly and complaining that the pain had increased since she had started Feldenkrais and also said that she was not satisfied with her meditation practice. She had been making remarkable progress putting long hours into relaxation practice and exercising daily. I started to get caught up in her concerns and began to think of solutions. I stopped myself and asked the question "What's happening?". I said to her, "Your mind seems to be working overtime". I paused again and found myself saying "I wonder what would happen if you stopped trying to make it happen?" She stopped for a moment and then returned to her previous deliberations. I asked her to close her eyes and experience my question. I noticed her body soften and shoulders drop. She reported these changes also, and the relief that she experienced at letting go of trying so hard. She also noticed her fear of progressing too slowly. This was a powerful lesson...she could use her determination to maintain her practices but do this with a more relaxed attitude. It could be called effortless effort.

Case 2: Attitudes Behind the Pain
Pamela had attended therapy intermittently and returned this day after two years absence. She had reluctantly resumed medication for long standing depression and, in combination with use of a morphine mixture, had been able to return to work. She told me that she pushed herself, wouldn't let the pain beat her and wasn't feeling depressed. We began work with Pamela lying on her side to be comfortable and I invited her to move into a state of mindfulness and begin self-observation. The first thing she noticed was a feeling of unhappiness which appeared as a hole with no light. When asked about other feelings she said she noticed anger. I asked her whether she could locate the anger anywhere in her back. I helped her explore her back by moving my hands over it, also observing areas of tension. I stopped on the lower back, the centre of her pain and she said that the anger was located here. From our earlier discussion and my sense of what was happening in her life I asked her to watch her response as I said the words, "I have to do it all on my own". She immediately replied that it had been like that until a few months ago but that she was learning to let others help. She noticed a reduction in her pain as she said this and experienced the relief. I felt a reduction in tension. As we continued I felt a return of some tension and she said there was a sense of confusion. Again I asked her to listen to a simple statement and notice her response. I said "I never really get it right". The response was immediate as she realised that she did get it right at work but not at home. Interestingly the pain diminished further.

Case 3: Releasing Tension by Observation
Max seemed restless as we opened our session this day. He was clasping his hands and twiddling his fingers. I invited him to lie down and make himself as comfortable as possible. I noticed that he chose to lie on his back with his legs crossed. One approach would have been to take him through a muscle relaxation or hypnosis but I chose to discover more about why he adopted this position. He had injured his right hip and buttock when knocked off his motorbike by a truck. The position he had chosen seemed to increase the tension in this area. I asked him to uncross his legs to experience the difference. He immediately clasped his hands tightly and said that he felt insecure. What we discovered was that he gained temporary comfort, and therefore a reduction in his pain, by crossing his arms or legs. He agreed that he was covering up his pain but he was not aware of any increase in tension by doing this. Further exploration revealed more holding patterns and I realised that Max did not see them as bad habits and that teaching him to let go of the holding would be wasted when he gained immediate comfort and a reduction in pain by holding tight. Our exploration continued around good and bad habits and how a parent or teacher may view something as a bad habit whilst a child or a student may not. We explored the concept of short term comfort from breaking a diet as opposed to the long term benefit of weight loss if the temptation was resisted. We explored ways of finding comfort which did not involve holding tight. As we did this he became still and restful. At this point he said that he could see a connection between his habit of crossing his arms or legs and increasing his tension. I asked him to think about his students and the look on their faces when they discovered something new. He came out with the phrase, "It is a window to another world - somewhere I would rather be". Spontaneously he crossed his legs and said "It does create tension in my back and hips".

Whilst some aspects of the work this day may be considered an indirect form of therapy there was still no intention to change anything. It was through a process of exploration and discussion that he came spontaneously to see the connection between the crossing of his legs and the state of tension in his hip and back. Without actually taking him through muscle relaxation or suggesting other changes he also became quiet and restful simply through the process of exploration.

Case 4: Not Knowing
Jan looked worried as she told me that she was having a lot of difficulty with her meditation. She was trying to not try. I invited her to become mindful and paused before I said, "It is OK to stop trying". Initially her throat became tight and she was hot. I encouraged her to stay with the feeling. It then began to release and she saw changing colours. She became aware of a play between the colours and tightness and as she concentrated on the colours she didn't notice the tension. She also noticed a spontaneous shift in her spine followed by a conscious adjustment. I said notice the "trying" and "not trying" and she said that she really released, feeling heavy, giving in and yielding. After I repeated the original statement she noticed a more neutral response and felt that she didn't have to work with it; she could just hear it. I asked her to stay with that feeling and she said it was like being a "blob". I invited her to notice what it was like to feel like a "blob". She said that it was a nice feeling but worrying as well. The session continued and she noticed the fear behind the worry of being a "blob" and the throat tightening. The fear was about "not knowing". I continued by offering the statement, "It is OK to not know". Towards the end of the session she realised that she couldn't ask for comfort both because she had forgotten how to and didn't allow herself to receive it.

By simply staying with her responses and noticing more about them, a story unfolded. The drive to 'know' was controlling her life keeping her frenetically busy and intent on achievement. She was unable to ask for support and comfort and lived with a hidden fear of not knowing.

Concluding Remarks
Non-intervention is not dismissing the person or problem but paying close attention to both. Instead of following an impulse or imperative to do something an attitude of mindfulness can bring insight, awareness and pain relief. 'Not doing' is an active process of exploration and observation without an objective of changing or fixing anything. As the person's reaction to the pain is revealed and attitudes behind the pain discovered, solutions can emerge spontaneously and transformation follows. Reactivity is replaced by enquiry but both patient and practitioner have to learn to be comfortable with 'not doing'.

References

1. Kabat-Zinn J. Full Catastrophe Living. New York: Delta, 1990.
2. Borysenko J. Minding the Body, Mending the Mind. New York: Bantam Books, 1988.
3. Hanh T.N. The Miracle of Mindfulness: A Manual of Meditation. Boston: Beacon Press, 1976.
4. Kurtz R. Body Centred Psychotherapy: The Hakomi Method. Mendocino: Life Rhythm, 1990.