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.

What it means to be a dissociation friendly provider

I’ve been reflecting a lot on the moniker of “trauma-informed” and wanting be really specific about what that means and how it shows up in my work. As a pelvic health provider, there are so many reasons why a client might be experiencing some level of dissociation in our work together. Whether that be related to gender dysphoria, sexual trauma, or religious upbringing, many folks come to see me who are disconnected from their pelvis.

Tune into your hands and try to feel them. You might find that there’s a vast array of sensation that emerges. That’s because the brain's sensory map for your hands is quite large (and seems to be larger for folks like violinists #yayneuroplasticity). The sensory map of your pelvic floor is verrrry small. For many folks, trying to tune into this small muscle group can feel hazy, fuzzy, less specific. Add in a history of trauma and chronic pain, and this map in your brain becomes even more smudged.

So what does it mean to be a dissociation-friendly provider? We know there’s a high correlation between sexual trauma and pelvic pain, yet most of the interventions taught in traditional pelvic rehab curriculums assume that it’s safe for the client to connect with their body, as well as receive manual therapy. Although I’ve always seen consent for internal work highly emphasized in these teaching environments, I’ve found throughout my clinical experience that consent needs to be a much more present part of a client’s whole rehab experience. So what does that look like?

• Identifying if someone is experiencing dissociative symptoms

Most folks don’t use clinical words to describe their experiences. I have many clients that tell me about their dissociation using that word specifically, and I have other clients who use other words, like feeling numb or disconnected. I try not to ascribe the word “dissociation” to a person’s experience, but rather provide some education on dissociation as a common trauma response and see if that resonates with them.

Many times when working with someone, I start to get curious if they’re moving towards dissociation if they start to get suddenly very sleepy, if they close their eyes, or if they start talking a lot and intellectualizing their experience. These aren’t necessarily indicators that someone’s dissociating, (i.e. someone might close their eyes because they’re trying to focus or relax) but something to track throughout a session.

• Use education as validation

Many people experience shame around their dissociation, so I like to provide nervous system education as a form of validating their experience. One of the first things I usually say is that dissociation is an ADAPTIVE COPING RESPONSE, so we can’t change it by shaming ourselves out of it or by forcing ourselves into a more embodied state. We have to work with it collaboratively.

• Provide Options

Breathwork, restorative exercise, and manual therapy can all contribute to dissociation. So if someone is experiencing dissociation, I like to give 2-3 options for alternative interventions. It helps to be really concrete, without overburdening the person with too many choices to consider. At this point, instead of focusing on interoceptive or felt sense-based ideas, I offer things related to nervous system settling that relate either to visually orienting to the environment, connecting the body to another object (tactile-based exteroception), sensing into gravity, or sensing into the distal extremities (especially feet).

• Be mindful of facilitator vs fix it mentality

I think working with dissociation as a pelvic health provider is a great opportunity to challenge our “helper” identities as clinicians. If you start to have thoughts like “this person is going to think this session is pointless” or “are these interventions even relevant to this person’s goals” (even if you know in your evidence-based and client-centered heart that they are), then it’s possible you need to challenge some of your beliefs around how you think you’re supposed to perform as a clinician. I think for rehab clinicians, because our work tends to be more concrete than say psychotherapy, we can place ourselves in boxes in terms of how our work should look. I think this limits creativity, takes energy and agency away from you as a clinician, and saps confidence. Ask yourself: Am I trying to “fix” this person’s experience, or am I trying to collaborate with them to make their experience more easeful? Notice how each of those approaches live in your body.

• Embrace divergent treatment plans rather than linear approaches

This is connected to the above point, but I think it’s really important to let go of how we think a session is “supposed” to look. We tell our clients that healing is not linear all the time, but how can we grant ourselves the permission to “go off course” a bit, for the sake of establishing trust between you and the client, and between the client and themselves? Rather than always prioritizing moving towards the person’s goals at all cost, what if we allowed ourselves the flexibility to prioritize that person’s moment-to-moment needs, knowing that they’re always changing? This helps establish consent between client and clinician as a more active process, rather than only using it as a tool when connected to internal work.

Dissociation is common, normal, and part of our bodies’ natural wisdom. If you feel confused and nervous about acknowledging when dissociation is happening in your clinic, then I highly suggest connecting to folks with more training or expertise around this topic.

Somatic consent for pelvic floor therapy-finding your full-body “yes”

Many folks with chronic pelvic pain have experienced medical trauma of varying degrees, especially for queer & trans folks/people of color/folks with historically marginalized identities. 

Maybe you’re considering pelvic floor therapy because a doctor suggested it. Maybe you’ve tried lots of other creams, nerve blocks, medications, even surgeries, and things haven’t helped. 

It’s useful to consider at this point in your healing journey--what’s my relationship to healing? How do I define it for myself? In what ways is my healing journey creating further stress and tension in my life, and where am I finding new ways to self-advocate, be kinder and gentler to myself, etc? 

It’s really challenging to feel empowered in your healing journey when you’ve tried so many things with little success, so it’s important to check in with yourself when you’re starting to feel some healing burn out. If pelvic floor therapy is feeling like your “last resort,” like it does for many people, how can you still ensure that you’re listening to your body’s need for consent and trust? 

For many people with chronic pelvic pain, an internal pelvic floor assessment can feel daunting, stressful, and retraumatizing. Maybe you feel like you need to just “push through it” so that your pelvic floor therapist can get “as much information as possible.” 

An internal assessment can only give a clinician so much information. I learn a lot by listening to the tone of the tissues of the lower abdominals, and doing an external musculoskeletal assessment. I look at where your breath falls in your body. I learn a lot through asking questions, like do you experience one-sided hip tightness? How are your bowel habits? If you menstruate, do you use tampons, menstrual cup, or pads? 

For folks with chronic pelvic pain, I would never start treatment at the level of the deep pelvic floor muscles, because I presume that there’s already a high-guarding pattern and tension. So I don’t need to assess here initially. 

If you’re working with a pelvic floor therapist who seems rushed, unfocused, or unattuned, or if you’re going into pelvic floor therapy with a fully clenched jaw and a “no pain, no gain,” attitude, I invite you to try to tune into your body’s way of communicating consent. 

How can you tell if your body is ready for internal treatment? What bodily cues help you realize that you can access a sense of safety? What information do you need to know before you can book an appointment? Making space for a clear “yes” or “no” from your body can help you gain clarity about what kind of therapeutic approach is right for you. 

A somatic exercise for finding a “yes” 

Orient to the room around you. Let your eyes wander where they want to go. 

Let your eyes rest on something pleasurable or satisfying. Maybe it’s a picture, a plant, the window, or the way the light hits at a certain angle. 

Tune into your body. How has it signaled this satisfaction or pleasure? Without trying to analyze it, can you just sense 5% into what this “Yes” feels like? 

Let go of this object, orient to pleasure, and sense again. 

Taking small sips of pleasure throughout the day can help support your nervous system in differentiating between wanted and unwanted sensations. From here, listening to your body’s cue for consent is hopefully easier and clearer. 

Developing a relationship with your pelvic pain

“Killing the Pain”

From a pain science perspective, those with chronic pain, (including pelvic pain, endometriosis, interstitial cystitis, etc) can have a heightened sense of imminent danger as their body attempts to protect them from new experiences of discomfort and suffering. This guarding can create added patterns of muscle bracing, tension, and holding. Learning to work with chronic pain is a process of trusting your body’s capacity for neutral and pleasant sensation. Sometimes this means that it’s not necessarily the pain itself that changes or “goes away,” but rather our relationship to it that evolves over time. As a practitioner, I can’t promise that we’re gonna “kill the pain” or “destroy the pain” (I don’t abide by these metaphors, because I see pain as a necessary protective mechanism that deserves respect), but I can promise that we can shift the relationship to it. 

That’s why when I give out exercises and homework for clients, we work collaboratively to see how it can fit into their everyday routines, and how much capacity they have for different practices. I use words like “play” or “experiment” instead of giving out prescriptive routines. Engaging in the “work” of healing in a way that supports curiosity rather than resentment or guilt for not “doing your exercises” helps folks engage in a new orientation to listening and taking care of their body.

Define a healthy relationship for yourself. Some key ideas that come to my mind are: collaborative, attentive, honest, warm, fun, patient. Developing this orientation to our relationship with healing, as well as the sensation of pain, can help support us to take care of ourselves in a different way. When “healing” becomes relational, even within one’s own body, it allows us to take on a more expansive meaning of the term. Rather than bullying our chronic pain, which will most likely only reproduce patterns of bracing, tension, and discomfort, we can see healing as an ongoing process of listening and responding with care.

Is “Wellness” ableist?

Often when I close emails, I write, “Be well.” And I mean it. I imagine the person filled with joy, energy, and a sense of abundance. But I struggle sometimes with what “wellness” really means in our culture, who gets to define it, and what it means for the world of pelvic health. What does “wellness” mean in a culture that’s foundationally built on the violence/exploitation of marginalized populations?  Where is the line between taking personal responsibility for your wellbeing and recognizing the consistent toxic and unhealthy messaging we’re all enculturated with? “Wellness” in our culture is built on the success of the individual to develop healthy habits and behaviors, rather than on systems and relationships that allow people to flourish organically. The “wellness influencer” emphasizes their disciplined habits, intense fitness regimes, “clean” eating, etc. The picture of “wellness” is often portrayed as a thin, white, able-bodied person. We develop this static, unattainable image of what health and “wellness” looks like. This can negatively add to other extreme material barriers people face. 

As a healthcare professional, I am very careful to balance a person’s capacity to grow and change, with the acknowledgement that the barriers to joy and fulfillment are very tangible and heavy. 

What does “wellness” mean when healthcare is unaffordable, food deserts are abundant, and people need to spend their “free time” on a second job, rather than resting or feeling nourished? When “wellness” is only portrayed through a series of habits and products, rather than liberatory systems and relationships that can hold the complexity of all of our experiences, it becomes something taunting rather than a goal to strive for. Wellness to me means access to housing, prison abolition, and thriving art spaces. It means universal healthcare and disability justice. As healthcare professionals, it’s our responsibility to acknowledge the limitations of our services in the face of larger oppressive structures. This offers me hope rather than despair, because it allows me to feel more expansive and creative about what “wellness” looks and feels like for each individual. This humbles me and allows me to see each person in their own unique complexity, rather than projecting a constructed idea of being “well” onto them. 

How do you define wellness for yourself? Where do you draw inspiration for images of “wellness”? How do you see “personal responsibility” amidst collective experience?

For further reading, I recommend the works of Fariha Roisin, Jenna Wortham, Bayo Akomolafe, Leah Lakshmi Piepzna-Samarasinha, and Tricia Hersey.