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Mindfulness Meditation and Persistent Pain - Role of Occupational Therapy

The following was originally published in OT Now. Stroh-Gingrich, B. (September 2012). Occupational Therapy and Mindfulness Meditation: An intervention for Persistent Pain. OT Now. Special Issue.


Mindfulness meditation (MM) has recently gained momentum as a promising treatment for chronic pain. This article asserts that MM is an effective intervention to use within occupational therapy to assist individuals with persistent pain to increase their participation in occupation. The following describes MM, reviews the evidence, and outlines why it is well suited to occupational therapy. The article discusses current evidence and my personal experience with persistent pain. The term persistent pain will be used as an alternative to chronic pain as it is congruent with evidence on the impermanence of pain and represents a client-centered approach by providing hope that pain can change.


Mindfulness meditation

There are various forms of meditation, however, MM is the most common form used within clinical practice (Gardner-Nix, 2009). Current use of MM has been within programs that are an adjunct to standard care, such as the Mindfulness-Based Stress Reduction program (MBSR) (Kabat-Zinn, 2000). MM is described as a practice of cultivating awareness of the present moment and observing one’s internal state in a nonjudgmental, nonreactive manner (Ludwig & Kabat-Zinn, 2008). The goal of MM is to “maintain awareness moment by moment, disengaging oneself from strong attachment to beliefs, thoughts, or emotions, thereby developing a greater sense of emotional balance and wellbeing” (Ludwig & Kabat-Zinn, 2008, p. 1350).


Current evidence

When compared to relaxation techniques, meditation has been shown to be more effective in diminishing stress reactivity by developing an increased ability to regulate and appraise distress (Jain et al., 2007). Studies have found that MM affects areas in the brain responsible for regulating attention, awareness and emotion (Creswell, May, Eisenberger, & Lieberman, 2007; Farb et al., 2007; Tang et al., 2007). Having capacity to use one’s mind to change their brain suggests neuroplasticity is a mechanism of change in meditation (Greeson, 2009). MM has been shown to decrease the anticipation of and reactivity to pain by cultivating a sense of acceptance and nonjudgmental awareness (Brown & Jones, 2010). Selfregulation and metacognitive skills can be developed by objectively observing fluctuating negative and positive thoughts, feelings and sensations when they arise. This can decrease the tendency to limit engagement in activity, which can result from a fear that the pain will be dangerous (Greeson, 2009). MM teaches to let go of attachment and the desire to be pain free and to accept one’s mental, physical, and emotional experiences without labelling or judgment (Selfridge, 2011). The proven long-term effectiveness of MM provides people with an effective life skill that enables selfmanagement of health (Merkes, 2010).


Occupational therapy and meditation

A recent review stressed the need for occupational therapists to go beyond education and talk-based interventions, and move towards evidence based task-orientated interventions (Robinson, Kennedy, & Harmon, 2011). As occupational therapists strive to address all elements of a person’s health and well-being, meditation integrates the physical, cognitive, psychological and spiritual components and also fits a biopsychosocial approach to pain management (Gatchel, Peng, Peters, Fuchs, & Turk, 2007). Meditation supports the occupational therapy focus of providing strategies that enable clients to increase participation in meaningful daily activities. The act of meditation can be both an occupation on its own, as well as a tool to use while doing an activity (Gutman & Schindler, 2007). One outcome of MM is mindful awareness, the ability to consciously observe your habitual thoughts and actions, which can be transferred into other daily activities. Both the process (mindful practice) and outcome (mindful awareness) of engaging in meditation can positively affect neurological functions that promote health (Shapiro, 2009). The act of doing meditation allows a person to be with themselves while reflecting on their true nature and become different or transform themselves from moment to moment. This description of meditation fits well with the concept of ‘doing, being and becoming’, postulated by Wilcock (1999). She states there is a need for a balance between these three elements in order to maintain health and well-being. The process of ‘doing, being and becoming’ in MM results in change within a person. Theoretically, this change within the person will affect their engagement in other occupations, and therefore continue the process of ‘doing, being and becoming.’ When suitable to client goals, occupational therapists should apply the enablement skills of advocating and educating (Townsend & Polatajko, 2007) to support the integration of MM as an effective evidence-based intervention within standard care for persistent pain. Occupational therapists providing MM would require training and would need to maintain a meditation practice themselves. If providing MM within occupational therapy services is not possible, therapists can offer referrals to community MM practitioners.


My personal experience

I changed how I perceived my persistent pain after participating in a 10-day Vipassana meditation course. Vipassana is a non-sectarian MM practice that focuses on self-observation of one’s thoughts, feelings, judgments and sensations. Through direct experience, one realizes the interconnection between the state of the mind and the body, and thereby increases their awareness and self-control (Ontario Vipassana Centre, 2012). Following the Vipassana course, I began to see my socalled ‘chronic’ pain as something that could change, despite being previously told that it was permanent. I learned to see my persistent pain objectively and observe other sensations in my body, without holding onto the pain. Once I developed this skill, I applied the same principles to my everyday life. As a result, I learned how to manage my health and began to engage more in my meaningful occupations. Participating in meditation training and developing my personal meditation practice allowed me to experience for myself the impermanence of the pain. I still experience pain, but rather than avoiding it, I have learned how to appreciate it as an internal monitor to keep me balanced. Additionally, the meditation gave me a tool to address the depression that came following the pain. I learned how to accept, nonjudgmentally observe and let go of my emotions when the pain is high. Finding hope Those with persistent pain often fall through the cracks in the health-care system. This, combined with persistent pain commonly referred to as ‘chronic’, may give people who are experiencing prolonged pain little hope that their pain will ever change. As a ‘survivor’ of persistent pain, and as an emerging occupational therapist, I see hope at the forefront of changing the way people manage pain. Integrating a form of MM into occupational therapy practice is one intervention that could develop this sense of hope.


Acknowledgements

I would like to acknowledge Suzanne Martin (MScOT) for her contribution to the research process of this article. I would also like to acknowledge our supervisor, Catherine Donnelly (B.Sc. (OT), MSc), for her support during the writing process.


References

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Creswell, J. D., May, B. M., Eisenberger, N. I., & Lieberman, M. D. (2007). Neural correlates of dispositional mindfulness during affect labeling. Psychosomatic Medicine, 69, 560-565.

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Gardner-Nix, J. (2009). Mindfulness-based stress reduction for chronic pain management. In F. Didonna (Ed.), Clinical handbook of mindfulness (pp. 369-381). New York, NY: Springer New York.

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Robinson, K., Kennedy, N., & Harmon, D. (2011). Is occupational therapy adequately meeting the needs of people with chronic pain? American Journal of Occupational Therapy, 65, 106-113.

Selfridge, N. (2011, May 1). Mindfulness based stress reduction: Non-doing for well-being. Alternative Medicine Alert, 32. Shapiro, S.L. (2009). The integration of mindfulness and Psychology. Journal of Clinical Psychology, 65 (6), 555-560.

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Townsend, E.A., & Polatajko, H. J. (2007). Enabling occupation II: Advancing an occupational therapy vision for health, well-being & justice through occupation. Ottawa, ON: CAOT Publications ACE.

Wilcock, A. A. (1999). Reflections on doing, being and becoming. Australian Occupational Therapy Journal, 46, 1-11.

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