Long-term physical conditions, including chronic pain, can have a devastating impact on our mental health.
It’s been two months since David’s heart attack. Although the emergency medical procedure he underwent greatly reduced the risk of him having another attack, David feels scared. Although he used to jog regularly, he now feels extremely apprehensive about exercising, despite having been told that exercise will help him stay well. Planning for the future seems impossible, too, for in the back of his mind is the niggling worry that his life could be whisked away at any moment. Nothing feels the same anymore and David often finds himself feeling hopeless, bleak and tearful.
Amal fell off her bike two years ago and has had severe lower back pain ever since. Although she manages to get through her day, the pain worsens at night to the point where she can’t sleep. The daytime ache becomes more of a roar every time she tries to lie down. She has undergone numerous treatments but the doctors have now told her that there is nothing more that they can do, that she has to find a way to live with the pain. Normally a cheerful person, all Amal feels at the moment is despair that her life will be spent gritting her teeth against the pain, which is getting harder and harder to do now that the painkillers seem to be working less and less.
Long-term Physical Conditions and Mental Health
It will come as no surprise that long-term physical conditions, including chronic pain, can have a devastating impact on our mental health. In turn, this can have a harmful impact on many areas of our lives, affecting our relationships, work and overall well-being. Although we can feel very alone when dealing with a chronic health condition, according to the Department of Health, more than 15 million people in England suffer from one or more long-term physical health conditions. Most strikingly, 30% of people aged 45 and older will have a chronic health condition, and by the time we are 65 and older, 80% of us will have at least one chronic health condition. This older age group is also much more likely to have multiple conditions. As we live longer, there is clearly a need to find ways to learn to live with the challenges of ill health and ageing.
The list of long-term physical health conditions is, of course, a long one, but the most common examples include diabetes, arthritis, asthma, cardiovascular diseases and certain cancers. The most common symptoms are pain, fatigue and reduced ability to function day-to-day.
Those of us with long-term physical conditions are two to three times more likely to have mental health problems than the general population. If we have two or more physical health problems, then we are seven times more likely to have depression than people who don’t have any long-term physical conditions. Particular physical health conditions – including cardiovascular disease, diabetes and chronic musculoskeletal disorders – seem to have an especially strong link with worsening mental health. A growing body of evidence has found, for example, that:
- Depression is two to three times more common in those of us who have cardiovascular diseases such as cardiac disease, coronary artery disease, stroke, angina, congestive heat failure, or after a heart attack. Anxiety is also more common if we have cardiovascular disease.
- If we have diabetes, we are two to three times more likely to have depression than the general population.
- Depression is common in those of us with chronic musculoskeletal disorders. Up to 33% of women and more than 20% of men with arthritis may have co-morbid depression.
The link between physical health and mental health is a two-way street. Not only does physical health affect our mental state, but our mental state can affect our physical health. This mind-body connection is well evidenced but, as yet, not fully understood. Depression, for example, puts us at much greater risk of getting coronary artery disease. Chronic stress can harm our cardiovascular, nervous and immune systems, leaving us more exposed to certain diseases. Those of us with mental health problems are more likely to die prematurely. Seen in this light, looking after our mental health in the face of long-term physical conditions is not a luxury, but a potentially life-enhancing necessity.
The Impact of Chronic Pain
Pain is a hard-to-ignore signal from our bodies that something is wrong. It is part of our evolutionary defense system and although unpleasant, it is vital to our survival. When we feel pain or discomfort, our instincts urge us to remove ourselves (i.e. our flight instinct) from the source of the pain as quickly as possible, so that we can recover and heal. But what happens when we experience pain for months or even years, sometimes long after the original accident, illness or trauma is over, and we are supposedly cured? This can be the case with many long-term health conditions, such as back pain, and is incredibly difficult to cope with.
How Can Mindfulness Help?
Needless to say, we can’t always escape pain and illness no matter how hard we might wish to, and some of us have to live with a chronic physical condition for our entire lives. However, although the suffering might not ever totally go away, it doesn’t have to overshadow our lives. We have choices regarding how we interact with our suffering so that even extreme pain can become more manageable, enabling us to live our lives with greater happiness.
There is strong evidence that mindfulness-based practices can help us better manage our chronic pain. By helping us develop a new relationship with our physical condition, mindfulness can increase our awareness of the thoughts, feelings and bodily sensations that arise within us from moment to moment. This might sound like a bad idea, since most of us assume that focusing on our pain makes it worse.
Mindful awareness, however, is a very different sort of awareness. Our minds have an unfortunate habit of clinging onto negative thoughts, feelings and physical sensations to the point where, far too often, we find ourselves unable to think about anything else. We may try to ignore our problems or brood on them to seek a solution, which doesn’t help where there is no physical cure, as is the case with many chronic health conditions. In fact, dwelling on our condition tends to lead to more suffering, leaving us more anxious and distressed. We end up not only dealing with the actual physical pain/discomfort, but also our reaction to it. We discuss this more in the section below entitled, The Two Arrows of Suffering.
Mindfulness uses mindfulness-based practices such as body scans, breathing exercises and movement to help us develop a more compassionate awareness of our thoughts, feelings and bodily sensations as they are right now, not as we wish them to be. It teaches us to be aware of difficult thoughts and feelings as they arise within us, but without engaging with them. As we practise mindfulness, we come to understand that our thoughts are just thoughts. They are not real, and we have a choice about whether to engage with them or to let them go. This letting go is not a form of suppression or avoidance, but a gentle acknowledgment of our thought, feeling, or bodily sensation, followed by an active decision not to participate with it.
Mindfulness-based practices include focusing on the breath and body and the development of a more mindful attention to everyday activities. All of these practices help us learn to recognise the feelings and patterns of thinking that cause unhappiness. Mindfulness-based practices all use the breath as an anchor to the present moment, for no matter what we are doing, thinking or feeling, our breath is a constant. This is important for the simple reason that when our mind wanders during a practice – as it inevitably will – we simply bring our focus gently back to the breath, our anchor to the present moment.
During the practice, we do not have to do anything but breathe, allowing thoughts, emotions and bodily sensations to arise, but without engaging with them, or trying to change them. What we begin to notice, with friendly curiosity, is that although feelings, thoughts and sensations arise, they also pass when we don’t engage with them. We may feel sleepy, bored, irritated or even angry as we practice. We may feel physical pain and discomfort. When we have a present-focused attention, we allow ourselves the space to be aware of what is really happening within ourselves in terms of our emotions, thoughts and bodily sensations. We can then watch the ebb and flow of whatever is arising within ourselves with friendly curiosity and kindness, without judging or trying to change anything. Those of us with long-term health conditions may, in time, develop a different relationship with our condition as we learn to separate pain and discomfort from our reactions to it.
The Two Arrows of Suffering
The first arrow: things that happen to us
The first arrow represents things that happen to us. An inescapable truth is that just by being alive, we will always have to deal with situations. The situation can be challenging, such as chronic pain, or pleasant, such as receiving a present or watching a sunset.
We tend to deal with events or situations (stimulus) in our lives by either reacting or responding. A simple example of a reaction is when we have an itch. Our immediate impulse is to scratch it. We don’t think about scratching it; we just do it. The same is when we hear our name called; we immediately turn to see who said it. Very often, the stimulus and our reaction to it are so inter-twined that they are indistinguishable. The speed with which we react to the stimulus happens quite automatically and fast.
Reactivity is automatic, relying on deeply ingrained, well-rehearsed ways of perceiving, understanding and behaving. When we are responsive, though, we don’t just immediately react. Instead, we use more flexible ways of perceiving, understanding and behaving. As mentioned in the quote above, there is a space between the stimulus and response; this space gives us time to figure out how we want to respond to whatever stimuli/situation that we are facing.
This quote beautifully illustrates this concept:
Between stimulus and response there is a space.
In that space is a choice about how we respond.
In our response lies our growth and freedom.
There is tremendous freedom in this space since it allows us to respond skilfully and compassionately, instead of reacting mindlessly. With the example of the itch, mindfulness teaches us to observe the sensations of the itch, how it grows and strengthens, accompanied by feelings of discomfort and frustration, as well as thoughts such as, “I’ve got to scratch this itch. It’s driving me crazy.” Within this mindful pause, we can observe how compelled we are to scratch, and then choose not to. As we simply sit and, seemingly, do nothing, we allow ourselves the space to notice how the sensations of the itch ebb and then flow away. We can learn a lot by doing nothing – we can observe both how the itchy sensations inevitably change and fade away and also how our minds react to it.
The second arrow: our suffering
Our minds tend to compare our experiences, constantly assessing stimuli as pleasant, unpleasant or neutral. We evaluate our experiences against how we feel they should be, how they were in the past, how we would like them to be in the future. We are likely to feel disappointed, distressed and unhappy when we think that there is a discrepancy between how things are and how we feel they should be. When we believe that things are falling short of our expectations (e.g. why does my back hurt so much, why can’t I do the things I used to do), we are immediately hit with the second arrow of suffering. This arrow can be emotional suffering (anger, disappointment, sadness) or physical suffering, since the mind-body connection means that our emotions can influence how we perceive our pain.
Radical as it sounds, however, the second arrow of suffering is optional!
The space between the first arrow and the second arrow
The first arrow (reacting to stimuli) is automatic and will happen regardless. We are alive, therefore things will happen to us. There is a space, however, before the second arrow is fired, and in that space there is a choice, to recreate and perpetuate the experience with a second arrow (how we emotionally/physically deal with things) or to step back and choose to let it be, not to fire this volley. This is a space of insight and wisdom; it is the space that transforms reactivity into responsiveness. Mindfulness opens this gap between stimulus and response and in that gap we have a choice about how to respond in ways that positively shape our mental health.
Let’s return to Amal, whom we met at the beginning of this page. Amal spent her nights unable to sleep because of back pain. Her back pain was the first arrow that she had to deal with. In the dark hours of the night, her entire focus narrowed like a laser beam to her back and the pain that radiated from there. Trying to do the opposite – ignoring the pain – also didn’t help and she found herself in a push-pull battle between trying to push the pain away and an almost hyperawareness of it. She was immediately hit with the second arrow of suffering. In her distress, her breathing and heart rate sped up, her face became tight with tension and her body hunched in on itself as though trying to ward off an attack. Not surprisingly, Amal’s mental state was anguished, and her thoughts and emotions coloured with despair and frustration, which only amplified her perception of her pain in a vicious cycle. As she pictured herself experiencing this night after night for months or even years – without hope of relief – she was brought to a very low point where she couldn’t see any hope of improvement. By this point, she was pierced with many second arrows of suffering.
Mindfulness and mindfulness practices, however, taught Amal new ways to deal with her pain. She learned to observe it without getting caught up in the associated thoughts and emotions that made the pain worse. Although the physical root of the pain was still there (the first arrow), she gained control over her response to it, which is a very powerful thing to experience. As a result, the second arrow of suffering, which amplified her feelings of distress and pain, was never fired.
For example, when Amal started to feel her frustration rising in the middle of the night, she chose to do a simple breathing practice. Sitting or lying down, Amal closed her eyes and focused on her breath as it flowed in and out, connecting with each in-breath and then each out-breath as it entered her mouth or nose, down her throat and into her lungs. She didn’t not try to change anything and would meet each breath as it came.
Not surprisingly, Amal’s mind sometimes started to wander. She became aware that her chest felt tight and that her back ached, triggering difficult thoughts and emotions. She would think to herself, “this isn’t working, I can’t live like this for the rest of my life.” She would sometimes feel her anger rising and become tearful. As she became aware of that the second arrow of suffering was clocking in readiness to fire at herself, she used mindfulness to gently and without judgment bring her focus back to her breathing. She experienced this cycle of mind wandering (and/or rising emotions) followed by a return to the breath over and over, but that was ok. This ebb and flow is central to mindfulness practice and Amal came to understand that thoughts are just thoughts, and that she didn’t have to engage with them. All she had to do in the present moment was to breathe and not try to change or fix anything.
The point of the breathing practice is that we learn to let thoughts, emotions and bodily sensations rise and then flow away, always returning the anchor of our breath. As we become more experienced with mindfulness practice, we learn to recognise more easily when challenging thoughts and feelings emerge, so that we can pause and re-group before we get overwhelmed. This moment of pausing gives us precious time to respond skilfully instead of reacting in unhelpful ways that might make things worse. Although mindfulness won’t take away our chronic physical condition, it can give us a powerful new tool for dealing with it.
David also found great benefit in learning about mindfulness and mindfulness practices. Despite his doctor’s assurances, he was afraid to return to exercising in case he has another heart attack. Just the very idea of exercising triggered panicked feelings and thoughts (e.g. What if the doctor was wrong having a heart attack was awful I don’t want to die). Mindfulness taught David to recognise his pattern of runaway thoughts and feelings (the second arrow) so that he made calmer, more reasoned choices about what to do.
When To See Your GP
Presumably you have already visited your GP and other medical specialists about your physical condition. If you are feeling increasingly low and/or anxious, however, this could be a sign that your mental health is being negatively affected. You may wish to visit your GP so that an assessment can be made to figure out what is needed to help you with your mental health.
Tips For Living With Chronic Physical Conditions
There are numerous resources that can help you live with your chronic physical condition, including:
Join a mindfulness course. Depending on where you live and whether you are physically able to get there, you might wish to consider joining a mindfulness course. Most courses meet once a week for eight weeks. These courses can be enormously helpful, since you will be guided by an experienced mindfulness teacher within a supportive group atmosphere. Although not intended to be group therapy, participants are encouraged to speak honestly about their weekly experience with mindfulness and mindfulness practices. As the mindfulness-based interventions field grows, courses are being adapted more specifically for different people.
Books and CDs. There are also many excellent mindfulness books and CDs available, including but not limited it, the ones on our Resources Page. One highly recommended book is Mindfulness for Health: a practical guide to relieving pain, reducing stress and restoring wellbeing by Vidyamala Burch and Danny Penman.
Organisations. Organisations that deal with specific health conditions usually have websites where you can access information and resources. A few examples are: