Linda Cummings
Batteries Included BBS 
3321 Harris Avenue
Montgomery, Alabama  36110
1-205-264-8000 (BBS Number)
1:375/34 (Node Number)
1-205-265-3488 (Home Number)

**************************************************************************
*    The following messages contain information given to me by the       *
*   Birmingham Pain Clinic and my feelings about going through their     *
*    chronic pain program.  I have also documented what was done so      *
*    that someone who has not been through a pain clinic program may     *
*             be able to better understand chronic pain.                 *
**************************************************************************




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Message date:  Mon 3 Feb 92 
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Well, I got the preliminary material in the mail the other day as 
to what I am to expect at the Birmingham Pain Clinic (UAB School 
of Medicine).  One good thing.......I won't have to pay one red 
cent!  Seems my Medicare and supplement takes care of everything. 
I understand that UAB owns Senior Partners Complete Health.  It's 
a nice feeling to know that everything will be taken care of, 
especially since my husband, Eddie, has been laid off.

Quoting from the letter:

1.  Medical Evaluation:  This evaluation will be performed by a 
medical doctor who will also review your previous medical 
records.  This physician will be your "managing physician" the 
day you are in the clinic.

2.  Physical Therapy Examination:  This examination is performed 
by a physical therapist.  He/she will perform a physical 
evaluation to assess any functional impairment.   Based on this 
evaluation, a treatment program may be individually structured 
for you to improve function.

3.  Psychological Examination:  This examination is performed by 
a psychologist.  We realize that pain can cause many changes in 
an individual's personal, vocational, family, and social life.  
It is important to understand how your pain has affected your 
life and others around you so that we can individualize your 
treatment.  The psychological evaluation will include personality 
test battery.

The above evaluations are followed by a Pain Team conference, at 
which time the various findings are discussed and recommendations 
for treatment are made.  You and your family will be fully 
informed of your diagnosis and of our proposed treatment plans.  
You also will be given every opportunity to have your questions 
and concerns answered so that you may have as complete an 
understanding of your problem as possible.

End of quoting.

Then, they sent a map, and informed me that I should be prepared 
to spend the better part of the day there for the evaluation.

So, I'll make sure that my neuro sends my records ahead of me and 
then I'll wait for the 12th of February to get here.  I'll keep 
everyone updated.



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Message date:  Fri 14 Feb 92      
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February 12, 1992 - First visit to the Birmingham Pain Clinic.  

Upon arriving at 7:45 a.m., and after signing in and making sure 
that all the pertinent information was correct (like who was 
going to pay them), three of us were escorted into a room where 
we received an orientation. This included briefing us on who we 
would see and approximately how long it would take, along with
informing us of written psychological tests we would be required 
to take (ugh).

I started on the tests and was called back about a quarter of the 
way through to see the Psychologist.  She was an extremely 
pleasant person and a person with whom I felt comfortable.  
Both of us were laughing before the session was over.  She told 
me that she felt I was very well adjusted for being in the amount 
of pain I was in. In other words, I wasn't nuts and she believed 
me that I was in a great deal of pain.

Back to the testing when the Physical Therapist called for me.  
This little whisp of a girl put more pressure on my sore spots 
than any doctor ever had!  I mean, this P.T. was about 5'4" tall 
and probably weighed 100 pounds soaking wet!  Her examination was 
as thorough as any exam I ever had by a Neurosurgeon.  She had a 
hard time accepting the fact that my legs wouldn't respond to her
banging on them with that blasted hammer, though.  I guess maybe 
with the lack of response, she expected me to be in a wheelchair 
or something.  She just kept shaking her head and had a puzzled 
look on her face.

Back to the testing when the doctor called me back to talk with 
her. She kept apologizing to me whenever she had to ask me a 
personal question (like something to do with sex) before she even 
asked the question. She's probably from India.  Very friendly and 
talkative doctor.  She was extremely grateful that I had given 
them my complete medical history that I keep on the computer
(updated) whenever I see a doctor. She said it helped her a great 
deal to know what I had been through and the different 
medications I had tried.

Back to the testing and then to the waiting room.  Boy, those 
tests were really something.  If you haven't taken one, you 
should just to see what kind of stupid questions they ask you.  
There were 556 true/false questions.  Oh, like, for 
instance....You hear voices but don't know where they're coming 
from?  Or.....You think people are out to get you? Or.....you 
like tall women? Or.....you like to inflict revenge on people?  
Sheez...come and bring those white coats with the buckles on the 
back!  But, of course, they posed the questions in a manner where 
perhaps true or false would fit according to how you answered the 
rest of the questions.

The three people I saw got together and discussed my case.  Then, 
the doctor called us in (Eddie was finally allowed in on this 
one). Basically, it boils down to this:  I have chronic pain and 
will probably have chronic pain for the rest of my life!  (I 
didn't want to hear that.)  The problem with the new pain in my 
neck, middle of my back and down my arms would best be evaluated 
here in Montgomery, so they wouldn't address that problem.  The 
doctor felt it could be caused either by a disk problem or maybe 
spurs, etc.  Since x-rays would be required, and since they are 
"out-patient" only, it would be best to get an opinion in 
Montgomery where I live.

I would visit the Pain Clinic once a week for about 6 or 8 weeks. 
During this time, I would be involved in a group session with 
others with chronic pain.  I would also be taught some relaxation 
techniques.  Next week, we will try acupuncture, but only because 
one of the doctors here in Montgomery suggested it.  The doctor 
there has little hope that it will help me.  They don't think
that hypnosis would help me (but I will ask why next time).  
Physical Therapy also won't do me any good. I've been through too 
much of it with no success.

She put me on an anti-depressant, hoping that it would help 
relieve some of the pain.  The generic name of it (since I try to 
get generic whenever possible) is Trazodone, 50mg.  We'll wait 
and see if it helps with the pain and with my unsound sleep.

So, next Wednesday I go back and get the results from the testing 
and I get to go into the group therapy.  After that, we do the 
acupuncture. I'll keep you updated.



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Message date:  Fri 28 Feb 92 
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19 February 1992

While in the waiting room, several people came in from "group."  
It seems these waiting rooms have a different air about them than 
most doctors' office's.  Everyone there at the pain clinic 
*wants* to talk with each other and find out why everyone is 
there.  There's a lot of laughing and story telling.  Seems
these people just got out of "group" (they don't call it group 
therapy anymore), and several had a little (get this) "mood dot" on 
their hand between their thumb and forefinger.  It sort of works 
on the old mood ring theory and is supposed to tell you how 
stressed out you are.  See what I have to look forward to?
[smile]

I was called in by the Psychologist.  Remember all those 556 or 
so questions I told you about that I had to answer?  I believe 
it's called the MMPI test or something like that.  Well, modern 
technology has finally arrived!  He had a computerized report in 
front of him that resembled a biorhythm chart.  My "high" points 
were flagged and that's what we discussed.

The report showed that, "I'm depressed."  No sh*t, Sherlock!  If 
you'd been in chronic pain for the past 9 years, I'd bet you'd be 
a little touchy from time to time, too!  [grin]  I told him I 
knew I was, but that I handled it.

The second hot spot was that I felt like I was helpless to do 
anything about myself physically.  Well, blow me down with a 
feather!  After two partial laminectomy's and an implanted Spinal 
Cord Stimulator, and having all the experts tell me there was 
nothing else that could be done, I think I have the right to feel 
that I am helpless to do anything about my condition physically,
don't you?

The third and last hot spot was that I hold in my emotions and my 
problems and don't discuss them.  Yup!  I know I do that and I 
also know it's not good for me.  But, who wants to live with a 
constant b*tch all of the time?  Eddie says I'm that way anyway. 
[smile]  One of the 10 commandments of living with chronic pain 
says, "It is your problem." Well?

After our little discussion about my hot spots, I told him how I 
handled my chronic pain...by BBS'ing!  Was he interested!  Seems 
he works part time at a rehabilitation place and that's just what 
they've been looking for.  I gave him Bill Freeman's name and 
phone number.  (I knew I'd find a way to get Bill.) [big smile]  
We talked more about that than my (ahem) so called problems.

Then, orientation to let me know what would happen in the six-
week "group."  We (there was another guy there with me in 
orientation) were handed three cassette tapes.  The first is 
called "Introduction to Relaxation."  It teaches you the
difference between tense muscles and relaxed muscles.  Now, I've 
had some difficulty with this one.  Seems when I do exactly what 
the tape says, the tense muscles make me hurt so darned much that 
the pain increases so drastically that I can't hardly benefit 
from the last two tapes.  I'm going to ask about this next 
Wednesday when I go back for acupuncture and talk with the
doctor.

The second tape is called "Breathing."  It teaches you about deep 
breathing and how to control your breathing to help your body 
relax to its' fullest.

The third tape is called "Eye Fixation."  This, in my opinion, is 
a step toward hypnosis.  You look at a spot across the room on a 
wall or on the ceiling while she's talking to you on the tape.  
You've learned about breathing and not to tense your muscles.  
She takes you through scenes and her talking becomes *very* slow 
and relaxed.  Then, she has you close your eyes (if you already 
had not by the time she says it) and you are completely relaxed.  
The first time I listened to the tape, either I fell asleep for 
just a moment, or I was hypnotized.  I don't know which one.  
It's happened all but one time at the exact same spot on the tape.

So, I'm supposed to listen and do these tapes twice a day (but 
I've only been able to do them once a day).  At least I'm doing 
them.  I'm cutting out the first one on my own so I can 
concentrate more on the other two until I talk to the doctor 
again.

After orientation, I got acupuncture.  It wasn't bad at all, 
except for the one in the coccyx area.  I jumped on that one.  
Funny thing happened while I was laying there for 20 minutes with 
those tiny needles sticking in me...the pain sort of increased 
and my left leg became very weak.  Afterwards, I had to
have Eddie walk to the van and bring it to me because I didn't 
think I would be able to make it a block and a half.  I'm going 
to tell her about that Wednesday.

The doctor had to leave before I was finished with the 
acupuncture treatment, so I was not able to ask her questions I 
had wanted.  But, you know me...I had typed up my questions and 
left them for her.

So far, I see no results whatsoever.  In fact, Wednesday, I was 
so incapacitated and the pain level was so high, that I was "this 
far away" from having Eddie take me to the Emergency Room and I 
was going to *beg* for a block.  But, two pain pills and a few 
more Tylenol later, the pain finally eased up a bit.  The day 
before, I was a bad girl, though and sat at the computer much too 
long at one time.

So, when I go back next time, I will get acupuncture and 
hopefully I will be able to have a somewhat long talk with the 
doctor.  I'm going to try to see if she won't give me something 
just a little bit stronger for the pain until I can get into 
group.  Also, I see no difference with the anti-depressants now 
and before I started taking them.  Of course, it's only been two 
weeks and I've heard that sometimes they take longer to work.  
I think I'll ask about Flexaril, also.  I've heard conflicting 
reports as to whether or not they're addictive, so I will ask and 
see what she says about them.

I'll try to let you all know what happens Wednesday a little 
earlier than I did this time.  I was busy with the Adanet 
Newsletter.



********** **********


10 Commandments of Chronic Pain


Given to me at the Birmingham Pain Clinic


 1. It is my problem.

    I accept this pain as my problem.  I am the only one who can 
    control it.


 2. There is no need to fear my pain.

    I find that I no longer need to fear my pain, as I learn more 
    about myself.


 3. I will do what I really want to do.

    I do not give up anything I want to do, or anything I love, 
    because of this pain.  I learn to do these things given my 
    knowledge of pacing.


 4. I will maintain my exercise program.

    I keep my body limb, my muscles toned, and get the proper 
    amount of activity and rest.


 5. I will take medication only as prescribed.

    I take only that medication which my physician prescribes.


 6. No everyone needs to know.

    Generally, I try not to show others that I have pain.


 7. I will adjust my lifestyle.

    I make gradual lifestyle changes (in work, in play) to help 
    me control my pain.


 8. Others will not suffer.

    I do not cause my family, friends or anyone to suffer because 
    of my pain.


 9. I will pace myself.

    I learn to pace myself, to relax, to be assertive.  My motto 
    is moderation and determination.


10. Pain will not rule me.

    I do not let pain rule my life.  My life and happiness are 
    more important than anything.


********** **********


SOME SUGGESTIONS FOR COPING WITH CHRONIC PAIN (by the Birmingham 
Pain Clinic)

*   KEEP ACTIVE AND OCCUPIED.  Unfortunately, drastically reduced 
activity is a common reaction to chronic pain - a reaction which 
usually increases pain in the long run.  A necessary for normal 
bodily functioning and must be maintained despite the pain.

*   LEARN TO PACE YOURSELF APPROPRIATELY.  Moderation, 
consistency from day to day, and determination are keys to 
success.

*   LEARN WAYS TO CONTROL YOUR PAIN rather than allowing pain to 
have complete control over your life.  This mans learning 
relaxation, imagery and distraction, and other proven techniques 
for coping with pain.  For most people it also means doing a 
little more than you feel like doing on "bad" days and doing a 
little less than you feel like doing on "good" days.

*   NOT EVERYONE NEEDS TO KNOW THAT YOU ARE SUFFERING.  While it 
is important to know that at least one other person truly 
understands your pain, it is usually not helpful for most other 
people to know about your pain.  Also, the more you complain, the 
worse you feel.

*   LEARN TO ADJUST YOUR LIFESTYLE in recognition of the real 
limitations imposed by your physical condition, but refuse to 
give up those things which are really important to you.  Instead, 
learn new ways of doing what you don't want to give up.

*   ACCEPT THE PAIN AS YOUR OWN PROBLEM - a problem with which 
you can learn to cope - and avoid "sharing the burden" by 
increasing the suffering of those around you.  This also means 
requesting and accepting assistance without quilt whenever it is 
absolutely required.

*   AVOID ISOLATING YOURSELF FROM OTHER PEOPLE and the world 
around you. It is natural to want to withdraw and be alone when 
in pain, but it is also detrimental to your health.  It often may 
be necessary to force yourself to remain socially active and in 
the mainstream.

*   Perhaps most important of all, KEEP AN OPEN MIND AND A 
POSITIVE ATTITUDE.  If you don't believe you can learn to control 
your pain, then you probably can't.  On the other hand, your 
chance of success is virtually 100% if you believe in yourself.



********** **********


CHRONIC PAIN - ISSUES, DIAGNOSIS, MANAGEMENT (from the Birmingham 
Pain Clinic)


When acute pain becomes chronic, it:

    *   loses its function (warning signal)
    *   produces emotional changes
    *   becomes a disease in itself

Definitions:  Chronic pain is a constant and/or recurring 
negative sensation with both physiological (bodily) and 
psychological (emotional) components persisting beyond 3 months.

Causes: 1.  Myofascial syndrome
        2.  Injury (e.g. trauma, fall, burns, slipped disc)
        3.  Inflammation (e.g. arthritis, cancer, acute sprain on  
chronic)
        4.  Neuropathy (e.g. diabetes, shingles, alcohol, vitamin 
deficiency)
        5.  Headaches (vascular, tension, mixed)
        6.  Disuse (e.g. frozen shoulder)
        7.  Neuralgia (in abdomen, pelvis, back)
        8.  Central pain (e.g. stroke, phantom limb)
        9.  Unknown factors

Effects:    The "Five D's"

    *   Depression
    *   Disuse
    *   Dysfunction
    *   Disability
    *   Drugs

    These can result in:

        *   Helplessness/Depression
        *   Fear of change
        *   Increased Dependency
        *   Anxiety over the unknown
        *   Negative thinking
        *   Alteration of self-concept

Management: Although complete cure is not always attainable, pain 
can definitely be CONTROLLED, and people can learn to feel better 
as they learn to do this.



********** **********


SOME FACTS ABOUT RELAXATION (by the Birmingham Pain Clinic)

(This paper went along with the three relaxation tapes given to 
me.)


Anyone can learn to relax.

One of the first techniques you will learn in Relaxation Training 
is a progressive muscle relaxation technique.  Once you learn it, 
it will allow you to discriminate between tense and relaxed 
muscles, and also to reduce the amount of tension in your 
muscles.  It results in reduction of electrical activity in your 
muscles and it may eventually allow you more effective control
of your pain.

The first sessions may not always be successful; it is most 
important that you do not allow yourself to become discourages.

Relaxation training is a complex skill that may take you some 
time to learn.  Don't expect immediate results, but in a few 
weeks or so expect to see some positive effects of relaxation.  
Because it is a relatively complex skill, it requires practice.  
Generally speaking, the more you practice the better you will 
get.

    You can be in a light state of relaxation or sometimes you 
    can feel deeply relaxed.

    You may develop a feeling of detachment.

    You may experience pleasant feelings of lightness or 
    heaviness.

    You may get a feeling of peace and calmness.

    You may not even feel any definite change (at these times, it 
    may just seem as if you had your eyes closed and were able to 
    hear everything at all times).

    If you aim for a deeply relaxed state, you will reach it 
    eventually.

    Whenever you practice, SEE yourself going deeper and deeper.  
    At first, it may be difficult, but as you continue practicing, 
    you will be able to picture yourself deeply relaxed.

    Do these exercises in your own time and practice them 
    regularly.

    When you practice these relaxation exercises, it is very 
    important that you always alert yourself at the end rather than 
    just going off to sleep.  You will find that you get better 
    results this way.



********** **********


Group schedule:


WEDNESDAY GROUP (9:00 A.M. - 12:00 NOON)


March 25  Facts and Fallacies about Pain

--Patients, physicians, and the public at large hold many misconceptions 
about pain, especially chronic pain.  This session addresses some of the 
more common misconceptions about pain and makes an important distinction 
between acute and chronic pain.  Did you know that too much rest can worsen 
chronic pain?


April 1   Mind/Body Relationships

--The mind and the body always interact in determining our reactions to the 
environment, including physical illness.  This topic addresses important 
and exciting new discoveries about the mind/body interaction and lays the 
groundwork for learning to use the mind to control the body.  Did you know 
that you can learn voluntary control over "involuntary" processes such as 
blood pressure, body temperature, and muscle spasm?


April 8   Managing Sleep Problems and Regulating Activity Level

--Most individuals with chronic pain have sleep problems, and most have 
unknowingly made their pain worse through the improper regulation of 
activity level.  This session will show you how to improve sleep without 
sleeping pills and how to pace your activities to reduce pain.  Did you 
know that all organ systems of the body begin to malfunction when activity 
level is seriously reduced?


April 15  Stress Management

--In this session we explore what makes an event stressful and explain how 
stress affects both physical and mental health, including pain.  Did you 
know that poor stress management can contribute to physical diseases such 
as cancer and heart disease?  Or that people under the greatest stress are 
often least likely to notice it?


April 22  Pain and Emotions

--Most people with pain have noticed that pain makes them more emotional, 
and that strong emotions make the pain worse.  In this session we explore 
the relationship between pain and emotions and offer suggestions for more 
effectively dealing with emotions.  Did you notice that you can't have pain 
without emotion?


April 29  Pain Behavior:  Effects on Self and Others

--It is perhaps obvious that your pain affects those around you, often in 
adverse ways.  In this session we look at some of the less obvious ways 
that people in pain express their pain and the effects it has on others.  
Did you know that the way you express your pain also affects the way you 
feel or experience pain?



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Message date:  Wed 11 Mar 92 
Pain Clinic Visit #3
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March 4, 1992

Dr. Xavier performed the acupuncture treatment.  This time, it 
did seem to help a little bit.  When we arrived back home and 
went to Walmart for the prescriptions, the walking around part 
wasn't too bad at all.  As a matter of fact, the right leg hurt 
more than the left (which is a first).  But, as all good things 
come to an end, it didn't last very long and the same intensity of 
pain returned to the left sciatic nerve.  She did give me a little 
present, though.  I asked her if I could have one of the needles 
she used and she gave me two new disposable needles so I could 
show everybody who's been asking me about them what they looked 
like. I thought that was really nice of her.

Dr. Xavier upped my anti-depressant to two before bedtime and I 
do believe I am sleeping a little better.  She also gave me a 
prescription for Flexaril.  Example:  one morning, upon 
awakening, my back wanted to go into spasms.  I took a Flexaril. 
It stopped the spasms.  She also gave me Tylenol #4 and it
seems to be working much better than the Wygesic.  Of course, I 
try not to take more than 2 tablets a day.

We discussed the possibility of just *considering* going to UAB 
(University of Alabama at Birmingham) SPAIN Clinic as an in-patient.
She explained that the "groups" may not help me because of the 
amount of chronic pain I am in and the fact that for people like 
me (so long in chronic pain), the "groups" may not be of much 
benefit.  We're going to see what I get out of the groups, first, 
though.

Next appointment is March 25th at 9:00 a.m. (ugh).  First the groups 
(from 9:00 a.m. until 12 noon) and then acupuncture.  Then it will be 
once a week for five more weeks of "groups."

I'll keep you updated.



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Message date:  Wed 25 Mar 92 
Re: Birmingham Pain Clinic Visit #4
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March 25, 1992

At 9:00 am, our "group" was taken from the waiting room, out the 
building, down the street, across the street, and into another 
building.  Whew!  That was *enough* exercise for the day.

In the first hour, Dr. Frank Brotherton, Psychologist, explained 
to us what we would be doing in the group sessions.  The first 
hour would be under his guidance and among other things, we would 
learn about coping with our chronic pain and receive training.  
The second hour would be led by a Physical Therapist and he would 
give us gentle exercise techniques, etc.  The third hour would be 
learning how to relax, under the guidance of another 
Psychologist.

Dr. Brotherton explained to us the difference between acute and 
chronic pain.  Simply, "acute" is pain experienced less than 3 
months and "chronic" is pain experienced for more than 3 months.  
He said that people with chronic pain go in a vicious cycle, 
i.e., you have pain so you rest. The resting sometimes leads to 
depression.  Depression leads to increase in pain.  Increase in 
pain leads to more resting, etc.  You have to learn to break this 
cycle.  One way to do this is by taking short rests instead of 
immobilizing yourself.

I found out I am a Type A person.  These people are "time 
pressure people."  They press themselves with deadlines (real or 
imaginary). They overwork themselves and push themselves beyond 
their limits.  He explained that your personality affects how you 
deal with your pain and that you must learn to adjust to the pain 
and ways to cope with the pain.

Something very interesting was explained to us.  He said that 
there is something called "blaming the victim" that goes on from 
spouses, family members, and friends.  We all do it, usually 
unknowingly.  For instance, if I were to push myself beyond the 
pain level I should, and then complain that I am in pain, Eddie 
might say, "Well, you shouldn't have done so and so...it's your
own fault!"  This is wrong for someone to do this to a chronic 
pain person.  Since Eddie was with me, I hope he was listening to 
this part! [smile]

Chronic pain people who are taking narcotics are in danger of 
becoming addicted.  They (the pain clinic) try to get you off 
medication by the time the course is completed.  The body will 
produce more and more pain to get more and more narcotics until 
the person winds up in de-tox.  He intends to teach us different 
ways to decrease the pain (hopefully) so we won't have to rely on
narcotics.  Sometimes the doctors will give their patients 
methadone along with the pain medication instead of a stronger 
medication because of the addition possibility of the stronger
medication.  But, methadone is also addictive.



********* **********

The second hour was led by Bernard Harris, Physical Therapist.  
He discussed the value of exercise (even moderate).  He explained 
that exercise must be a vital part of a chronic pain persons' 
daily routine. The muscles must not be allowed to become 
atrophied and the blood circulation is important.  He also said that a
person must have value.  If a person doesn't feel good about himself, 
then others will not perceive them the way they want.  A person 
must find and enhance their strong side.

He showed us a drawing of a cycle...a cycle that must be broken 
at some point along the way.  Picture a spiral, if you will.  At 
the outside and end of the spiral are the words "Pain."  Going 
around the spiral you find "Fear" is next; then "Reduced 
Activity," "De-conditioning," "Pain on Mild Effort," and "Further
Inactivity."  Now, actually inside the spiral, you see "Further 
De-conditioning," "Pain on Minimal Effort," and "Further 
Inactivity."  The very inner spiral has "Further De-conditioning," 
and finally at the center point, "Continuous Pain."


********** **********

The last hour was spent with Karen Kramer.  She explained a 
relaxation technique and took us through a session, with lights 
dimmed and the door locked so there would be no disturbances.  
She stressed that at home, you had to find a quiet place to relax 
where you would not be disturbed. She said it was important to 
learn about your pain and get medical treatment, but relaxation
was just as important in combating the pain.  She gave us a copy 
of an article (part one) on "Coping with Pain."

The "handouts" will be copied here in future messages for you.

The acupuncture today was better than 3 weeks ago.  The diminished
pain lasted about 4 hours whereas last time it only lasted 
about 2 hours. Dr. Xavier and I discussed the fact that the 
Flexaril was helping with the spasms and cramps in my legs and 
she wants me to continue taking that medication.  She also wants 
me to continue, for now, the Tylenol #4.  I am also benefitting 
from the anti-depressant by sleeping more soundly at night.

Next week, in group, we will concentrate on Mind/Body 
Relationships.


********** **********


True or False?

From the Birmingham Pain Clinic

See if you can answer these True or False questions correctly!


1.  Pain always means that I am hurt and need to rest and take 
care of myself until I get better.

2.  If physicians cannot cure my pain or find out exactly what is 
causing it, then my pain must be in my imagination.

3.  Someday, somewhere, someone will find a cure that will 
quickly make my pain go away, once and for all.

4.  If I can make my pain less by psychological self-control, 
then the pain was "all in my head" to begin with.

5.  I have had pain for so long and suffered so much that I am 
beyond help.  I have tried everything and nothing works.

6.  No one wants to hear about my pain.  I would be better off 
staying by myself until I feel better.



********** **********


Consent for Acupuncture

This is a copy of the form that I have to sign every time I have 
acupuncture.  Just thought it might be of interest.

I, the undersigned, realize that Acupuncture may be considered as 
an investigative procedure in the United States of America.

Acupuncture needles are disposable and used only once with 
sterile technique being utilized throughout the procedure.

Electrical devices used may be from China, Hong Kong, Macao, 
Korea, Japan, or America.

Every attempt will be made to protect the patient from harm but 
there may be unfavorable skin reaction, unforeseen nerve damage, 
burns, electrical burns, electrolytic burns, possible infection, 
unexpected bleeding, skin blistering and/or other complications 
not anticipated.

The nature of the treatment has been explained to me and I fully 
understand that there is no stated or implied guarantee of 
success of effectiveness of a specific treatment or series of 
treatments.

I realize that I may withdraw from the program at any time.



********** **********

FROM "CENTERPIECE"

COPING WITH PAIN


True or false:  It would be great if you could feel no pain.  

Pain is determined solely by the severity of the wound or injury.  

If your pain is all in your mind, it's not "real" pain.

All are false, as explained below.


We've come a long way in our understanding of pain:  ancient peoples 
generally interpreted it as the work of evil spirits or as punishment by an 
offended god.  Only in this century, with discoveries about the nervous 
system, have scientists begun to explore the physiology of pain.  
Strangely, the more we learn, the more it appears that complex 
psychological factors are equally important.  Research into this link 
between the mind and health, though still in its early stages, is 
suggesting an array of new approaches to the relief of pain.


Where does it hurt?

Pain is a puzzling combination of the physical and the mental.  Consider 
the following paradoxes.  There have been classic reports of severely 
wounded soldiers who feel no pain and refuse morphine.  Similarly, some 
people whose X-rays show significant physical damage (for instance, 
arthritis or the spine) experience no pain whatsoever.  Conversely, there 
are cases in which diagnostic tests reveal no physiological explanation for 
the pain that's felt.  Pain can continue long after an injured site has 
healed, sometimes because of damage to the nervous system itself.  An 
extreme example of ths is the pain an amputee may continue to feel in the 
missing, or "phantom," limb.  What is "real" pain then?  Pain is a 
perception.  You can never "know for sure" if someone else is in pain -- 
all you can go by is his subjective report.  In other words, if you don't 
feel pain, there is no pain.  Thus when his dentist asked him, "Where does 
it hurt," the philosopher Bertrand Russell purportedly replied, "In my 
mind, of course."

It is hard to define pain beyond the fact that it's an unpleasant sensation 
usually resulting from injury or infection.  We describe a pain by its 
location and character.  We perceive pain as being located somewhere on the 
body, whether this is a localized spot or a vaguer, more extensive area.  
We commonly refer to a precisely located pain with terms such as stabbing, 
shooting, or piercing, and less sharply located pain as aching or 
radiating.  Sometimes, however, the perceived site is misleading.  In the 
case of some internal organs, for instance, pain is often "referred" away 
from its actual site -- thus angina may be felt as pain in the arm, 
shoulder, or jaw (since the nerves bringing sensations from the heart 
converge in the same segment of the spinal cord as those from the arms and 
neck).  Some organs have no pain fibers at all.


From nerve endings to the brain

How is pain communicated to the brain?  Let's say you burn your finger.  
The pain message starts with the stimulation of special pain fibers in the 
nerve endings embedded in the skin.  The message is a series of 
electrochemical nerve impulses:  the greater the stimulation, the more 
frequent the impulses.  Certain chemicals released in inflamed tissue (such 
as bradykinin, prostaglandins, and substance P) help sensitize the nerve 
endings and thus heighten pain.  The nerve fibers from the skin join up and 
form larger and larger cables until they enter the spinal cord.  
Immediately there's a spinal reflex that makes you remove your hand from 
the heat.  Simultaneously, the pain signals are modified in the spinal cord 
and travel up nerve fibers to the brain, where information about the 
location, intensity, and nature of the pain is interpreted.  The result:  
you "feel" the heat and pain, become frightened or angry, and your body 
reacts to the danger with an increase in blood pressure, heart rate, and 
respiration.


A four-part experience

Various models have been proposed to help explain the complexities of pain.  
One describes pain as a four-part experience:  activation of the nerve 
endings (called nociception), pain, suffering, and pain behavior.  Each of 
these is usually evoked by the preceding elements.  While pain is the 
mind's perception of the nerve signals caused by an injury, suffering is 
the negative way in which we respond to the pain.  Alarm, anxiety, anger, 
and depression are just a few components fo suffering that can augment the 
pain.

Some chronic-pain sufferers engage in what psychiatrists call pain 
behavior.  This helps them obtain fringe benefits (secondary gains); they 
can perhaps win sympathy and attention, control others, avoid some 
distressing activity, or escape day-to-day responsibilities.  The motive 
here is unconscious.  In contract, when symptoms are deliberately 
exaggerated, often for monetary benefit, it's called malingering.  Pain 
behavior generally calls for psychiatric help.


What good is it?

Ironically, in a sense, pain is good for all living creatures.  It is an 
essential way we learn what's going on in the world, how to appreciate 
threats, and how to cope with them.  Without pain, life would be dangerous 
and perhaps impossible.  It provokes a potentially lifesaving urge to 
escape from danger or otherwise terminate the sensation.

To understand what life would be like without the protection afforded by 
pain, you need only look at people born insensitive to pain -- a rare 
neurological disorder.  Because they experience no pain, they repeatedly 
injure themselves without knowing it.  They twist and fracture joints, burn 
and cut themselves, bite their tongues, and suffer all sorts of serious 
injuries since they don't react to prevent or minimize the damage and to 
seek treatment.  Some diabetics face similar dangers because they lose 
nerve sensitivity in their feet; thus they may be unaware of foot injuries 
and delay seeking treatment until severe damage has occurred.


How you respond to pain

Why does the pain experience differ from person to person?  Why, in some 
cases, do innocuous stimuli cause excruciating pain and great suffering, 
while in others severe injuries result in no pain?  One factor is the 
body's own pain-modulation system, which can reduce or enhance the 
perceived intensity of the injury.  But most often differences in the pain 
experience and the ability to tolerate it can be largely attributed to 
variables in circumstances and personality.  Some of us automatically play 
down pain's significance, others magnify it.  Here are some of the 
interconnected factors that help shape our pain experiences and coping 
mechanisms:

"Circumstances."  People react differently to pain in different situations.  
Strong emotional reactions may block the perception of pain.  It's not 
uncommon for an athlete, for instance, to be unaware of a broken ankle in 
the thick of an important game.  But the same player may find the injury 
unbearable if he's forced to sit out the game.  If you're ill, even minor 
pain may seem unbearable.  Studies have shown that the more attention 
people pay to pain, the worse it seems; this often helps explain why pain 
is worse at night.  Conversely, when people are distracted they are better 
able to tolerate pain.  Some people who "haven't got time for the pain" -- 
as the jingle for one painkiller goes -- simply don't feel it.

"Significance assigned to pain."  The intensity of the pain experience is 
inevitably influenced by how you perceive it.  If you know or think the 
pain is due to a trivial cause, the discomfort may not seem particularly 
intense.  If you attribute it to a serious ailment, such as cancer, it may 
seem unendurable.

"Age."  Older people tend to experience more pain, but at the same time 
pain tolerance usually increases with age.

"Gender."  Men nd women often react differently to pain.  Studies show 
that women generally report more minor pain and other bodily symptoms.  
But when it comes to chronic pain, men may not be the "stronger sex."  For 
instance, in a recent study of patients with chronic arthritic pain, the 
men were significantly more anxious, fatigued, hostile, and depressed than 
the women, and they held themselves in lower esteem for having to submit to 
pain at all.  Men and women may well react differently to pain because of 
the roles society has thrust upon them.  Most women are allowed, or even 
encouraged, to be sensitive to their bodily sensations, to acknowledge 
their symptoms and report them to others, and to admit frailties.  In 
contrast, men may be taught to ignore minor pains, or at least to be silent 
about them.  But men may react more strongly than women to serious pain 
because they feel powerless and resent having to depend on others.


"Family."  All of us have learned different ways to cope with pain and 
express our suffering, based on our past experiences as well as on the 
behavior of those around us -- especially family members.  Researchers at 
the University of Georgia have observed, for instance, that students who 
are prone to persistent or recurrent pain tend to have been exposed to 
similar "familial pain models"  -- in other words, relatives who complained 
of chronic pain.


"Ethnic and cultural background."  Though ethnic groups are hardly 
homogeneous, research has shown that their reactions to pain tend to be 
different.  Studies have found that Americans of Italian or Jewish descent, 
for example, are more likely to give a full and emotional description of 
their pains, while "Old Americans" (white, of English descent, usually 
Protestant) and Americans of Irish, Chinese, or Japanese descent tend to be 
more stoical and play down their pains.  However, when people move to a new 
country, they and their children tend to develop the behavioral patterns of 
that area -- which indicates that these differences in pain response may be 
cultural rather than biological.


"Anxiety and depression."  Almost inevitably the greater your anxiety, the 
greater your reaction to pain.  Often there's a vicious circle:  pain 
produces anxiety, and anxiety augments pain.  Thus, when anxiety is 
reduced, pain is also reduced.  Fear, depression, and anticipation, closely 
related to anxiety, also heighten pain.  Furthermore, some researchers 
suggest that general unhappiness with life and job is a good predictor of 
who will suffer most from chronic pain.  The unhappy mind facilitates the 
unhappy body, and vice versa.


"Marriage and social support."  Surveys suggest that married people and 
those who have strong social support are better able to cope with pain and 
other stressful situations than people who are single or have no support 
system.


"Sense of control and self-esteem."  A sense of helplessness and lack of 
control feeds into the vicious circle of anxiety and depression, which 
magnifies pain.  There's some evidence that people who feel in control of 
their lives tend to live longer and remain healthier.  It is not surprising 
that they also tend to cope better with pain.  Bearing this out are studies 
showing that when subjects are given control over the intensity and timing 
of electric shocks, they are able to tolerate higher levels of pain.  In 
natural childbirth, one objective is to enhance a womans feeling of 
control in order to minimize pain.

Being aware of the emotional and psychological aspects that influence the 
pain experience may help a person cope better with it.  For instance, if 
someone in pain can be shown that he may be too bound up in family 
patterns, or that he is overreacting to the pain because of the meaning he 
has assigned it, he may be freer to deal realistically with the situation.  
He may also be better able to take advantage of various methods of pain 
control that involve pain's "psychic overlay" -- including relaxation 
techniques, hypnosis, and acupuncture.  


Feeling no pain

Our ancestors undoubtedly lived with much more pain than we do today.  But 
they probably complained less.  Today many people believe that there's a 
treatment for almost every pain and ailment, according to Dr. Arthur 
Barsky, a psychiatrist at Harvard Medical School and author of "Worried 
Sick."  Any pain that can't be cured is considered "a mistake, an 
injustice, a failure of medical care."  This only amplifies the discomfort, 
since pain that we think is curable and unnecessary hurts more than pain 
that we believe is unavoidable and inevitable.

Some pain is an inescapable part of life, and ultimately there's no one 
"correct" way to react to it.  The goal is not to anesthetize ourselves, 
but rather to learn how to minimize pain or put up with it -- and go on 
with our lives.



********** **********


ASSIGNMENT FOR NEXT SESSION


1.  List three misconceptions you held regarding chronic pain
    and explain how they have negatively affected your behavior:

    Misconception:

    Effect:

    Misconception:

    Effect:

    Misconception:

    Effect:


2.  The topic for our next meeting is "The Relationship Between the
    Mind and the Body."  In order to prepare you for this topic, we
    would like for you to think about some of the ways that mental
    events (thoughts, ideas, images, feelings, emotions, memory,
    attention) can affect the experience of pain.  Mental events
    can increase or decrease pain.  Think of three ways that your
    own mental events have influenced your pain and describe these:

    A.

    B.

    C.



********** **********


This sheet was given to us to be filled out during the week and to be 
brought back to "group."  Copying this and filling it out may help you 
understand your activity (or lack thereof) and when you pain increases.

               ====================================




UAB PAIN TREATMENT CENTER

ACTIVITY SHEET


HOW MUCH TIME IN MINUTES OR HOURS DID YOU SPEND DOING EACH OF THE FOLLOWING?

____________________________________________________________
                |     |     |     |     |     |     |     |
DATE____________|_____|_____|_____|_____|_____|_____|_____|_
DAY             | SUN | MON | TUE | WED | THU | FRI | SAT |
                |     |     |     |     |     |     |     | 
SLEEPING        |     |     |     |     |     |     |     |
                |     |     |     |     |     |     |     |
RESTING IN BED  |     |     |     |     |     |     |     |
                |     |     |     |     |     |     |     |
SITTING         |     |     |     |     |     |     |     |
                |     |     |     |     |     |     |     |
RIDING IN CAR   |     |     |     |     |     |     |     |
                |     |     |     |     |     |     |     |
HOUSEWORK       |     |     |     |     |     |     |     |
                |     |     |     |     |     |     |     |
ON THE JOB      |     |     |     |     |     |     |     |
                |     |     |     |     |     |     |     |
SHOPPING        |     |     |     |     |     |     |     |
                |     |     |     |     |     |     |     |
WALKING         |     |     |     |     |     |     |     |
                |     |     |     |     |     |     |     |
SWIMMING        |     |     |     |     |     |     |     |
                |     |     |     |     |     |     |     |
BIKING          |     |     |     |     |     |     |     |
SPECIFIC        |     |     |     |     |     |     |     |
EXERCISES       |     |     |     |     |     |     |     |
                |     |     |     |     |     |     |     |
OTHER           |     |     |     |     |     |     |     |
                |     |     |     |     |     |     |     |
                |     |     |     |     |     |     |     |
                |     |     |     |     |     |     |     |
                |     |     |     |     |     |     |     |
                |     |     |     |     |     |     |     |
                |     |     |     |     |     |     |     |
PAIN LEVEL      |     |     |     |     |     |     |     |
( 1 - 10 )      |     |     |     |     |     |     |     |





Signature                                 Week No.         




-----------------------------------------------------------------
Message date:  Thu 2 Apr 92 
Birmingham Pain Clinic Visit #5
-----------------------------------------------------------------

April 1, 1992

This week was a little more interesting in "group."  More people 
felt more at ease and participated much more than last week.  
However, it seemed that about half of the people either could not 
make the second group session, or dropped out.  We will see next 
week.

Dr. Frank Brotherton, Psychologist, explained the difference 
between "Hope and expectations."  We all "hope" that someday 
there will be someone or some procedure that will help us get rid 
of or diminish greatly our chronic pain, but it is wrong to 
"expect" a cure.  Most people take a "mechanical" look at
the process of medical attention.  We tend to look at ourselves 
the way we look at fixing a problem with our car.  We *know* that 
there's *got* to be a mechanic out there *somewhere* that can fix 
our car.  At the same time, we feel that there has just *got* to 
be a doctor *somewhere* that can fix our chronic pain by doing 
something "mechanical."  Not so.  In fact, less than 5% get
"quick cures," but usually it is more like 85% to 95% that get 
"some" pain relief.  Then, there are some people who receive 0% 
benefit from any given mechanical procedure.

Promising a "cure" is pure *quackery!*

Dr. Brotherton also explained how a TENS unit worked:

1.  The electrical pulses help set off a reaction in the body 
which help produce endorphins (just like the acupuncture does).  I 
was unaware that acupuncture did this.  He also said that you can 
run out or have diminished endorphins.

2.  The TENS unit acts as a "Gate Control Theory on Pain."  Since 
all sensation, movement, etc., is controlled by the spinal cord, 
the TENS unit sends "signals" to the brain through the "Fast 
Fibers."

     These are the large nerve tracks.  Since the brain receives 
signals through the spinal cord, it also receives the pain 
signals through the spinal cord.  If the TENS unit can block part 
or all of those signals, then the brain can not perceive the 
pain.  By the way, this is also the theory behind the implanted
Spinal Cord Stimulator (SCS) that I have.

3.  The TENS unit acts as a distraction to the brain.  I'll give 
the example he gave us.  Say right now, there is a very large 
explosion outside.  The explosion is so large that it breaks your 
windows.  At that exact moment, would you feel your pain?  No!  
Your attention would be distracted away from the pain and all 
your brain activity would be directed at the explosion.  By 
feeling the electrical impulses, the TENS unit is distracting the 
mind away from the pain.

Now, here is something very interesting he told us about.  There 
is something called "Retrograde Amnesia and Anterograde Amnesia." 
The retrograde amnesia is loss of memory usually immediately 
preceding a trauma.  Have you ever noticed that later, after an 
accident, it may be hard to remember what you were doing?  Ever 
wonder why so many people can't remember the details if they 
witness a mass shooting?  This is retrograde amnesia.  

Anterograde amnesia affects the short-term memory and impairs new 
memory events.  Every time a person is given anesthesia, there are 
usually some brain cells destroyed.  In some people, this will 
affect short-term memory.  We all lose brain cells everyday (that 
are not replaced).  We are born with a certain amount...enough to 
usually last us a lifetime with no ill effects by losing some 
everyday. But, in some people, they will lose the wrong ones and 
be affected by short-term memory loss.

Anyway, the session was mostly devoted to how the brain can 
control pain and other bodily functions.  The article given to us 
explains it in detail and I will copy it in the next message(s).  
The mind is a powerful organ and we have not yet fully mastered 
using it.


********** **********

Bernard Harris, the Physical Therapist, spent most of his hour 
continuing the discussion that Dr. Brotherton started.  But, he 
did have a few words of advice for us concerning exercise.  He 
said that the best time to exercise would be right after a warm 
shower.  Also, they now have found out that in most cases, "ice" 
is better for the relief of pain than heat.

He explained to us that getting muscle spasms/cramps, is usually 
a result of muscles that get tight and have trouble getting 
enough blood and oxygen.  Contrary to popular belief, it is even 
better to apply ice to a spasm than it is heat.  Then, before his 
hour ended, he told us that he would like for us to exercise 
about 15 minutes each day by raising our arms above our head and 
then dropping them; to put our arms out at our sides and make 
circles first forward and then backwards; and to take our hands 
and pull up our knees toward our chests as comfortable as we 
could...first the left, and then the right.


********** **********

Karen Kramer then gave us all our "Biodots."  These are little 
dots that were placed on our hand near the intersection of the 
thumb and forefinger. According to body temperature, they would 
change colors.  According to her, the more relaxed you became, the 
more the color would change.  She then took us through a 
relaxation technique (similar to one of the tapes she had given 
me prior to attending "groups").  After the relaxation, we were 
to observe our Biodots to see how much they had changed.

Now, Eddie was given one of these dots, too.  His turned deep 
blue (which indicated "calm").  Mine was amber when it was placed 
on my hand and it was amber when I looked after relaxation.  That 
meant "tense." I can see I have a lot of work to do to learn to 
relax!

For those of you who would like to try this, here is the body 
temperatures and what they mean:

    94.6    very relaxed        violet
    93.6    calm                blue
    92.6    relaxing            turquoise
    91.6    involved (normal)   green
    90.6    unsettled           yellow
    89.6    tense               amber
    87.6    very tense          black

Eddie and I discovered that when we went outside (it was a very 
windy and cold day in Birmingham), that both of our dots turned 
black.  Skin temperature has everything to do with the color of 
the dots.  But, she told us that the more relaxed a person is, 
the warmer their skin will be.

At home, I laid back on the couch and listened to a relaxation 
tape. As soon as I opened my eyes, I got so excited because my 
dot was finally "green." Eddie said that probably people with 
chronic pain had a harder time relaxing than people with no pain 
at all.  I think he's right.  On the way home, with him driving, 
his dot turned green to almost turquoise.  Husbands!  And, relaxed
ones at that!  Sheez.

I do intend to ask her something next week.  I have a body 
temperature lower than the "normal" 98.6.  I'm going to ask her 
if that will make a difference in the dot (which I'm sure it 
will).  Maybe when I get to a blue, it will be like other 
people's violet.  I think I'll try to find myself a *mood ring!*


********** **********

Biogenics Program

Place yourself in a comfortable position.  Uncross your arms and 
legs.  Close you eyes.

Take a deep breath in and out slowly (*very slowly*).

Repeat the following phrases slowly, five times each with a slow 
deep breath:

BREATHE IN                  BREATHE OUT
----------                  -----------

A.  I am....................... relaxed.

B.  My arms and legs........... are heavy and warm.

C.  My heartbeat............... is calm and regular.

D.  My breathing............... is free and easy.

E.  My abdomen................. is warm.

F.  My forehead................ is cool.

G.  My mind.................... is quiet and still.



The above was given to us for help in relaxation at the 
Birmingham Pain Clinic.


********** **********

THE RELATIONSHIP BETWEEN THE MIND AND THE BODY
Handout from the Birmingham Pain Clinic on 4/1/92

Rene Descartes was a great 17th Century French philosopher and 
scientist who proposed a view of the relationship between the 
mind and body known as *dualism*.  This view basically holds that
the mind and body are separate and distinct.  The body is 
material, physical and mechanical and can be understood by 
applying the principles of scientific investigation.  The mind, 
on the other hand, is spiritual, nonmaterial, and mystical.  If 
the mind obeys any laws or principles, they are different from 
the physical laws of the body and are not knowable through 
application of the scientific method.  While dualism was a
view prominent in early philosophy and should be mainly of 
historical significance, it is still the dominant view held by 
many nonscientists.  This dualistic view of the mind and body, 
separate and distinct, has caused a tremendous amount of 
confusion in our understanding of ourselves in general, and 
chronic pain in particular.  The following statements or beliefs 
all reflect this basic misconception that the body is one thing 
and the mind is something totally different:

    1.  My pain is real; I'm not imagining it.
    2.  His pain is "all in his mind."
    3.  I can't find anything wrong; you ought to see a  
psychiatrist.
    4.  If the doctors can't find anything causing my pain, then 
it must be all in my head.
    5.  Just ignore it and don't think about it and it will go 
away.
    6.  Don't try any of that psychology business on me; my pain 
is real.

The *modern view* of the relationship between the body and the 
mind holds that the mind is the brain.  Of course, the brain is 
an organ of the body.  In a sense, it is the master organ for it 
controls the rest of the body all the time.  Mental events 
(thoughts, feelings, emotions, images, etc.) are the result of 
biochemical events in the brain, and bodily changes (heart rate,
blood flow, digestion, etc.) are directly and indirectly 
influenced by the brain.  Thus the mind and the body are 
interacting parts of one and the same overall system, and each 
influences the other.  According to this modern view, the mind 
and the body are one, and any event is a product of the  
interaction of both.  Pain, for example, is an experience with 
both mental and physical components and can be looked at as being
both 100% emotional and 100% organic.  The remainder of this 
handout presents examples of how the mind and body interact to 
determine ones experience, especially the experience of pain.

One interesting example of this interaction comes from research 
on *biofeedback*, which is teaching us that the mind can have a 
tremendous effect on altering our physiology.  There are 
physical processes that no one ever thought could be controlled 
mentally that we now know can be controlled, such as heart rate, 
blood flow and muscle tension.  As a matter of fact, many of 
these functions were thought to be involuntary and under the 
complete control of the autonomic nervous system, meaning that 
they were automatic.  Many painful conditions, as you know, are 
aggravated by muscle tension and by abnormal circulation 
patterns, and it has become very clear with biofeedback that we 
can learn to alter our blood flow and our muscle tension on a 
partially voluntary basis.  Research in the area of *stress* is 
teaching us that stress affects virtually every system of the 
body, including metabolism, muscle function, blood pressure, 
circulation, and even the functioning of the immune system that 
protects us against disease.  For example, recent research has 
shown that individuals under a high degree of stress are more 
likely to become ill.  One recent study looked at thousands of 
widowers and found that during the first year of being widowed, 
men were much more likely to develop cancer than were other men 
of the same age who had not undergone that stressful experience.  
Research on *depression* is showing us that our emotions, 
thoughts, and activities have an important effect on 
neurotransmitters --
substances in the brain that allow nerve impulses to be 
transmitted from one cell to another.  People suffering with 
depression often have an associated chemical imbalance involving 
these neurotransmitters.

Moreover, we know that physical activity helps to bring these 
neurotransmitters into better balance and can thereby serve as an 
antidepressant.  On the other hand, we also know that chemicals 
introduced into the body can have a profound affect on the way we 
think and feel.  There are drugs that relieve depression, drugs 
that cause depression, drugs that make us pessimistic, drugs that 
make us optimistic, and even drugs that make us see and hear 
things that are not there! 

Just in the last ten years, there has been some exciting research 
regarding the relationship between our mind, our behavior, and 
our experience of pain.  It has been discovered that there are 
substances that are produced within the brain that are very 
similar in their chemical structure to morphine and which
have the ability to directly decrease the experience of pain.  
These chemicals are called *endorphins and enkephalins*.  It has 
been found that these endorphins and enkephalins are present in 
very large concentrations when an individual is exposed to a 
painful stimulus, such as a bodily injury.  It has also been 
found that there is another chemical called naloxone that 
prevents the brain from producing endorphins and enkephalins, and 
if naloxone is injected into an individual, pain can become 
overwhelming.  What is fascinating is that we have the ability to 
alter the concentration of endorphins and enkephalins in our 
system through our behavior and our thought patterns.  One
study looked at the concentration of endorphins in response to 
electric stimulation to the gums.  It was found that giving a 
person a placebo drug (a sugar pill or salt tablet that has no 
chemical effect) actually increased the concentration of 
endorphins in those individuals' central nervous systems.
Because the placebo medication had no direct effect on pain 
relief, it had to be *positive thinking* on the part of the 
individuals who received the placebo that made the difference!  
In other words, the individuals who *believed* that they were 
getting a pill that would relieve their pain actually produced 
within their nervous system endorphins which helped them to 
tolerate much better the pain from electric stimulation.  This 
was discovered because naloxone, which prevented endorphins from 
being formed, would result in these individuals having much 
higher levels of pain after taking this placebo medication.  The
naloxone blocked the placebo effect by blocking the endorphins 
produced by the expectation of relief.  So what this experiment 
implies is that positive thinking actually has an effect on the 
chemicals in the brain that help us to control pain -- another 
very interesting example of the interaction of the mind and body.

It is also known that activity, particularly strenuous activity, 
increases the concentration of some of these endorphins and 
enkephalins.  This may explain why jogging and running can 
produce a natural "high" for some individuals, and why some of 
these individuals seem to become "addicted" to exercise, often
feeling very irritable and distressed when they are prevented 
from carrying out their daily program.  Perhaps it is the 
presence of endorphins which partially explains why activity is 
so important for people with chronic pain conditions and why pain 
centers across the country emphasize the importance of increasing
and maintaining physical activity.

A number of other experiments have been done on the ability of 
our thinking and our beliefs and our emotions to make a 
difference in terms of the amount of pain we experience.  Most of 
these experiments have been done with volunteers who are exposed 
to a painful stimulus of a given intensity and asked to tolerate 
the painful stimulus as long as possible or rate its intensity.  
An example might be an electric shock that becomes more and more 
intense or keeping one's hands in circulating ice cold water.  
The following factors have been found to influence the amount of 
pain people have experienced in these experiments:

    1.  Expectancy and Control:  Subjects who are lead to expect 
stimulus would be very painful or who believed that they had no 
control over it, reported more pain than individuals who did not 
expect that it would be painful or who believed they had control 
over the stimulus. In fact, in some experiments subjects were led 
to believe that they could actually control the intensity of
the pain stimulus by engaging in a certain activity (e.g., 
pushing a button), but in reality they had no control over the 
painful stimulus.  Just the belief that they had control made a 
real difference in how much pain they experienced.  One of the 
goals of this program is to teach you that you are not a helpless
victim but that you can do some things that will help you control 
your pain.

    2.  Attention:  People who focus their attention on their 
pain experience have more pain than those who use distraction by 
diverting their attention elsewhere.  That's why talking a lot 
about your pain, sitting or lying quietly alone most of the day, 
thinking about the pain, and rearranging your whole life around 
your pain all serve to make the pain worse.  On the other hand, 
using relaxing and distracting imagery, increasing physical 
activity, re-establishing social contacts, and finding new 
activities that interest you are all good ways of reducing pain 
by focusing attention elsewhere.

    3.  Anxiety:  People who are made to be anxious or who are 
known to be anxious tolerate pain much more poorly than do 
individuals who are relaxed.  Anyone who has worked in an 
emergency room or a dentist's office becomes well aware of the 
relationship between anxiety and pain perception.

    4.  Perceived Meaning:  An understanding of the importance of 
the meaning we give to pain has not come from experiments with 
volunteers so much as from clinical experience.  For example, an 
anesthesiologist named Beecher found that soldiers on the beaches 
of Normandy during D-Day showed an incredible ability to tolerate 
pain involved in on-the-spot surgical procedures and pain which
resulted from gunshot wounds.  He followed those individuals 
subsequently and found that in other situations, they had no 
greater ability to control pain than anyone else.  He attributed 
their tremendous ability to tolerate pain as being related to the 
fact that it was honorable and "for a cause" and that it might 
also represent an opportunity to go home.  Certainly, it might 
also relate to the fact that the soldiers were so busy with all 
the activity going on around them that they did not pay very much 
attention to the pain.  We have found that the meaning patients 
give to their chronic pain makes a lot of difference.  Some 
patients come to view their pain as a disaster or catastrophe
which has ruined their lives.  On the other hand, some patients 
are able to develop a more positive point of view by focusing on 
what they can do and by viewing their pain as a challenge to 
overcome.


Lamaze training for natural childbirth is a good example of the 
practical application of many of the factors discussed in this 
handout. The philosophy which unerlies the entire program is that 
the woman can learn ways to develop control over her pain.  One 
part of Lamaze training involves teaching the woman and her 
husband what to expect at each phase of labor and delivery.  Many 
of the techniques involve distraction from pain, such as focusing 
on the time periods between contractions or focusing on a spot on 
the wall.  The training exercises are also very similar to some 
relaxation exercises that involve deep breathing.  In addition, 
the perceived meaning of the pain is addressed.  The worst pains 
during the transition phase of labor are presented as evidence 
that the process is almost over with and if the woman can control 
the pain for just a little bit longer, the delivery will occur 
and the pain will subside.  Thus, the woman is conditioned to 
interpret this most severe pain in a positive light rather than 
to say to herself something like, "I can't stand this pain any
longer."

We hope that after considering the material provided in this 
session you will be more up-to-date in your thinking about the 
relationship between mind and body.  We also trust that this will 
pave the way for you to begin to use your mind in ways that will 
benefit your body's functioning and your pain in particular.  
Remember that the mind is the brain, and the brain is an organ of
the body.  It is only natural that the contents of the brain 
(e.g., thoughts, feelings, emotions, images, ideas, etc.) will 
affect the functioning of the body.  We are on the brink of a new 
scientific era which is rapidly leading to further advances in 
the therapeutic utilization of the mind/body relationship.
The foundations have already been laid, and that knowledge is 
available to you now.



********** **********

ASSIGNMENT FOR SESSION #3


1.  Apply the information covered in today's topic by carefully
    describing three ways that you will personally use your mind
    to control your pain in the future.  List only those techniques
    that you actually plan to put into practice:

    A.

    B.

    C.


2.  The topic for our next meeting is "Managing Sleep Problems and
    Regulating Activity Level."  To prepare for this session, please
    fill out the Sleep Hygiene Awareness Scale and complete the 
    attached Daily Sleep Diary each morning of the week (starting
    tomorrow morning).  Bring these completed forms with you to
    the next session.



********** **********

This form may help you understand your sleeping habits and let you 
understand what stresses you have before going to bed.


DIAGNOSIS OF DISORDERS OF INITIATING AND MAINTAINING SLEEP (INSOMNIA)

                           DAILY SLEEP DIARY



Name ___________________________________ 

__________________________________________________________________________             |                |       |       |       |       |       |       |       |
| Date           |       |       |       |       |       |       |       |
|                |       |       |       |       |       |       |       |
| Days           |  SUN  |  MON  |  TUE  |  WED  |  THU  |  FRI  |  SAT  |
|                |       |       |       |       |       |       |       |
| Minutes it     |       |       |       |       |       |       |       |  
| took to Fall   |       |       |       |       |       |       |       |
| Asleep         |       |       |       |       |       |       |       |
| Times Awaken   |       |       |       |       |       |       |       | 
| During         |       |       |       |       |       |       |       |
| the night      |       |       |       |       |       |       |       |
| Minutes        |       |       |       |       |       |       |       |  
| Awake          |       |       |       |       |       |       |       |  
| For            |       |       |       |       |       |       |       |  
| Each           |       |       |       |       |       |       |       |  
| Occurrence     |       |       |       |       |       |       |       |  
| Listed         |       |       |       |       |       |       |       |  
| Above          |       |       |       |       |       |       |       |
| Total Hours    |       |       |       |       |       |       |       | 
| and Minutes    |       |       |       |       |       |       |       | 
| of Sleep       |       |       |       |       |       |       |       |
| Difficulty to  |       |       |       |       |       |       |       | 
| Fall Asleep    |       |       |       |       |       |       |       |    
| Not very-Very  |       |       |       |       |       |       |       |
| 1 2 3 4 5      |       |       |       |       |       |       |       |
| How Rested You |       |       |       |       |       |       |       |   
| Feel This Morn.|       |       |       |       |       |       |       | 
| Very - Poorly  |       |       |       |       |       |       |       |  
| 1 2 3 4 5      |       |       |       |       |       |       |       |
| Quality Sleep  |       |       |       |       |       |       |       | 
| Last Night     |       |       |       |       |       |       |       |  
| Excellent-Poor |       |       |       |       |       |       |       |    
| 1 2 3 4 5      |       |       |       |       |       |       |       |
| Physical       |       |       |       |       |       |       |       |  
| Tension/Bed    |       |       |       |       |       |       |       | 
| Relaxed-Tense  |       |       |       |       |       |       |       |   
| 1 2 3 4 5      |       |       |       |       |       |       |       |
| Mental activity|       |       |       |       |       |       |       | 
| Level @ Bedtime|       |       |       |       |       |       |       | 
| Quiet - Active |       |       |       |       |       |       |       |  
| 1 2 3 4 5      |       |       |       |       |       |       |       |
| Functioning    |       |       |       |       |       |       |       |  
| Level Yesterday|       |       |       |       |       |       |       |  
| Well-Poor      |       |       |       |       |       |       |       | 
| 1 2 3 4 5      |       |       |       |       |       |       |       |



********** **********



DIAGNOSIS OF DISORDERS OF INITIATING AND MAINTAINING SLEEP (INSOMNIA)

             SLEEP HYGIENE AWARENESS AND PRACTICE SCALE


"Sleep Hygiene Knowledge"

This is a survey of the effect of selected daytime behaviors upon sleep.
We are interested in knowing your opinion about whether any of these 
daytime behaviors influence the quality and/or quantity of sleep.  For the 
following list of behaviors, please indicate your opinion as to the extent 
of the general effect, if any, that each behavior may have on nightly 
sleep.  Please use the following scale and answer each item by writing the 
appropriate number in the space provided.  Note that numbers 1, 2, and 3 
indicate degress of "benefit" to sleep, number 4 indicates "no effect" on 
sleep, and numbers 5, 6, and 7 indicate degrees of "disruption" of sleep.


  Beneficial to Sleep        No effect      Disruptive to sleep
  
  1       2          3          4          5          6        7
very  moderately  mildly                 mildly  moderately  very


What effect do each of these behaviors have upon sleep?

 1.  Daytime napping ________
 2.  Going to bed hungry ________
 3.  Going to bed thirsty ________
 4.  Smoking more than one pack of cigarettes a day ________
 5.  Using sleep medication regularly (prescription or over-the-
     counter) ________
 6.  Exercising strenuously within 2 hours of bedtime ________
 7.  Sleeping approximately the same length of time each night ________
 8.  Setting aside time to relax before bedtime ________
 9.  Consuming food, beverages, or medications containing
     caffeine ________
10.  Exercising in the afternoon or early evening ________
11.  Waking up at the same time each day ________
12.  Going to bed at the same time each day ________
13.  Drinking 3 ounces of alcohol in the evening (e.g., 3 mixed
     drinks, 3 beers, 3 glasses of wine) ________


"Caffeine Knowledge"

For each item on the following list, indicate whether you believe it 
contains caffeine or another stimulate by placing a Y (yes) or an N (no) in 
the space provided.  If you are not sure, make your best guess.  If you 
have never heard of an item, please place an X in the space.

___7-Up soft drink          ___lemonade              ___Mountain Dew
___regular tea              ___root beer             ___cola soft drinks
___Dristan cold remedy      ___chocolate cake        ___Dexatrim diet pills
___aspirin                  ___regular coffee        ___Tylenol
___Dr. Pepper soft drink    ___Excedrin              ___Aqua Ban diuretic
___Midol menstrual relief   ___Sudafed decongestant  ___Sprite soft drink

===========================================================================

Items 1-6, 9, and 13 are disruptive of sleep.

If responses to these questions are:  1,2,3, or 4, score as incorrect
                                      5,6, or 7, score as correct

Items 7, 8, 10, 11, and 12 are beneficial to sleep

If responses to these questions are:  1,2, or 3, score as correct
                                      4,5,6, or 7, score as incorrect.

Note:  the response 4 is always incorrect.

Scores on this section may range from 13-39.  Higher scores indicate less 
sleep hygiene knowledge.


Caffeine Knowledge:

The following are the correct answers:

N 7-Up soft drink         N lemonade              Y Mountain Dew
Y regular tea             N root beer             Y cola soft drinks
Y Dristan cold remedy     Y chocolate cake        Y Dexatrim diet pills
N aspirin                 Y regular coffee        N Tylenol
Y Dr. Pepper soft drink   Y Excedrin              Y Aqua Ban diuretic
Y Midol menstrual relief  Y Sudafed decongestant  N Sprite soft drink




-----------------------------------------------------------------
Message date:  Fri 10 Apr 92 
Birmingham Pain Clinic Visit #6
-----------------------------------------------------------------

April 8, 1992

The physical therapist was first today because of a scheduling 
problem.  He took us through the following exercises:

1.  Either standing or sitting, bring your right knee up, 
clasping it with your hands and pull up as far as comfortable.  
Repeat with the left knee.  Do this several times.

2.  Standing, with feet slightly apart and your hands on your 
hips, close you eyes and slowly lean your head over on your left 
shoulder, and then over on your right shoulder.  Do this several 
times.

3.  With hands on your hips, (or, if needed, steady yourself by 
holding onto a chair) first roll back to your heels, then slowly 
rock with your feet until you're up on your toes.  Repeat several 
times.

4.  While standing, with your arms out in front of you, push your 
shoulders forward as far as you can.  Then put your arms out in 
back of you as far as possible and push your shoulders back as 
far as you can.  Repeat several times.

5.  While standing, put your arms out in front of you, then put 
your arms out to your sides, parallel with the floor, then put 
your arms above your head.  Come back down with your arms in 
front of you and make small circles inward and then outward.  Put 
your arms back out to your sides, parallel with the floor
again, and make small circles inward and then outward.  Let your 
arms relax by your sides and shake them out.  Repeat this once or 
twice.

6.  While standing, one foot slightly in front of the other, 
"swim."  Move your head from side to side while you are making 
the motion of "swimming."  Then, do the "backstroke."

7.  With your left foot out in front of you, put your left arm 
forward and put your right arm in back, up and as high as 
possible.  Then, switch to your right foot and put your right arm 
forward and your left arm in back, up and as high as possible.  
Repeat a few times.

8.  Walk in place for a minute or so (comfortably).



********** **********

In group, he explained to us how important it is to stretch, if 
possible.  It keeps your muscles toned.  If you do not keep 
toned, your muscles will atrophy and chronic pain will increase.

He told us to be realistic of yourself.  If you must, "modify" 
exercises to suit your individual needs.  If you fail to 
recognize your limits, the pain will intensify.  If you "push" 
yourself, the muscles will spasm to try to increase blood 
circulation and nutrients.  Example:  One person in the group
explained how he tried to ride his bicycle for longer and longer 
periods thinking that the more he did, the better off he would 
be.  He complained of muscle cramps.  The Physical Therapist said 
that this was the wrong approach.  Someone in chronic pain must 
realize their limits and not overdo with exercise.   The goal is 
to keep toned so that the body as a whole will benefit from the
oxygen and circulation rather than stress one or a set of 
muscles.  Since pain affects sensation, sometimes we tend to 
"overdo it" because we don't feel the increase in pain right 
away.  We must learn to pace ourselves.

Relaxation is very important for a chronic pain sufferer.  It is 
as important as trying to keep your body toned.  You must learn 
to pace yourself.  If you feel fatigued or start hurting more, 
stop whatever it is you are doing before the pain increases more.

Self image (the way you view yourself) is very important.  If you 
can do all that you are capable of doing, you will feel better 
about yourself.  Rather than concentrating on what you "can't" 
do, concentrate on what you "can" do.



********** **********

Dr. Frank Brotherton, psychologist, explained to us the overall 
view of the Pain Clinic.  There are several things that they do 
to try to help a person with chronic pain.  There are nerve 
blocks, of which they usually do a series.  The reason for this 
is that needles cannot be placed in the exact spot all of the 
time.  For best results, they do a series of blocks and see if it 
helps.

Sometimes, a patient will be given a TENS unit to see if that 
might help.  Medication is important, too.  Finding the right 
medication for the particular chronic pain problem may be a trial 
and error method, though.  They have found that anti-depressants 
help a lot of chronic pain sufferers with sleeping problems.  If 
you can't sleep, it will affect your pain.

Medication is also important.  Along with the medication, 
physical therapy is usually recommended.  This is called a "team 
approach."  Usually, psychologists are not trained for chronic 
pain problems.  At this particular clinic, they are.  So, with 
medication, physical therapy, relaxation techniques, and
psychological guidance, the "team approach" has been very 
successful...although not always successful.

Barbiturates (Nembutal, Seconal, Ivinal, Phenobarbital) and 
Tranquilizers (Centrax, Librax, Serax, Xanax, Halcion, Valium, 
Dalmane, Restoril, Librium) are habit forming and have been found 
to actually interfere with sleep.  These should not be prescribed 
for the chronic pain patient for long terms effects.  Anti-
depressants (Amitriptyline, Elavil, Desyrel, Sermontel, Sinequan, 
Pamelor) have been proven to be very effective relaxants and are 
non-habit forming.  Methodone is a narcotic and is addictive.  
However, some chronic pain patients receive methodone for a short 
period rather than giving them a stronger pain medication.

There are four stages of sleep.  (This will be discussed in 
another message from a handout received.)

Almost all forms of chronic pain increase with tranquilizers.  
Every drug is a poison and the body reacts to it.  It is abnormal 
in the body and the body will build a tolerance.  The body reacts 
adversely if it doesn't get the medication by increasing the 
chronic pain.

He told us that "Common Sense" backfires when you have chronic 
pain.  He said it was better to take your medication as 
prescribed by your doctor rather than when you absolutely have
to have it.  Your body "learns" to react to get what it wants.  
If you're hurting very badly before you take your pain 
medication, your body remembers this.  Then, when the body wants 
more of whatever made it feel good, it will hurt more than it 
should in order to make you take that medication.

By the way, he told us that the morphine pump is only effective
for 6-8 months before the body begins to get used to the medication.
It seems that doctors omit telling their patients this fact.  
Also, he said that 80% of the chronic pain patients on 
narcotics have less chronic pain when they stopped taking the 
narcotics!

How can you tell if you're "hooked" on something?  You may have 
anxiety, depression, rapid shallow breathing, dizziness, cold 
sweats, and increased pain.  By the way, he threw in the fact 
that "pot" is not addictive.

Chronic pain sufferers who follow their doctor's advice and take 
their medication as prescribed can have "Iatrogenic Dependency."  
This is very common.  But, people who absolutely have to have 
coffee everyday are addicted to caffeine.  People are addicted to 
reading the morning paper, too!  Almost everyone is addicted to 
*something!*

How can you tell if you're physically addicted versus mentally 
addicted?  If you're physically addicted, your body reacts 
abnormally and will crave more and more medication.  It seems as 
if the amount you're taking isn't enough.  With mental addiction, 
you just "want it!"

One important bit of information.  If you or anyone you know are 
taking a high dose of Valium.......DO NOT JUST STOP TAKING IT 
BECAUSE IT COULD KILL YOU!!! Be sure to have your doctor "wean" 
you off.  This can be true of most tranquilizers.

Some doctors are not aware of the fact that certain medications 
(such as anti-depressants) can do more than just keep you out of 
a depression.  It is not their fault, however.  With their 
schedules, they rely on the drug representatives to tell them 
what the drugs are used for and whether or not they're addictive.  
So, the doctor passes this information on to the patient.  Right 
now, for instance, it is not truly known whether or not Flexaril 
is addictive or not.  There has not been enough documentation.

In essence, a good night's sleep is important.  There will be 
further information about this in one of the handouts that I will 
copy in a later message.



********** **********

Karen Kramer asked us to pretend that we had a "Burden Basket" 
sitting beside us.  We were to put all of our burdens in this 
basket for the session.  At the end of the session, we could pick 
them up, if we wanted, and carry them out with us.  This was to 
show us that everyday, we needed to just put our burdens, 
worries, etc., aside and give ourselves some time just for 
ourselves.

She showed us a breathing exercise.  Place your hand on your 
upper chest and breathe normally.  Then, place your hand on your 
upper abdomen (above the navel) and breathe normally.  Then, 
place your hand on your lower abdomen (below the navel) and 
breathe normally.  Notice the difference.

She said that we were all born knowing how to breathe.  For 
instance, have you ever watched a kitten or puppy asleep?  What 
part of that animal is moving when they breathe?  That's 
right...their tummy.  We should breathe from deep within us, not 
from only the chest.  The best place to breathe from is the  
diaphragm.  By doing the deep breathing exercises from the 
diaphragm, you get quicker relaxation, and you get full 
relaxation.

It is very important for a chronic pain sufferer to take time out 
during the day just for themselves.  If you must, unplug the 
phone and tell the kids that you will not be disturbed for 30 
minutes.  Make people understand that this is *as important* for 
you as their needs are to them.  Are you less important than the 
people around you?  Of course not!  You must learn to pace 
yourself, and take the time to relax everyday.

More information about this in a few messages from a handout.



********** **********

The following handout was given to me at the Birmingham Pain 
Clinic:


IMPROVING YOUR SLEEP WITHOUT SLEEPING PILLS

If you have been in pain for very long, it is quite likely that 
you have difficulty sleeping.  In our experience, some 90% or 
more of chronic pain patients report one or more of the three 
most common forms of insomnia:  (1) difficulty falling asleep, 
(2) waking up frequently during the night with difficulty falling 
back asleep, and/or (3) waking up in the wee hours of the morning 
before sufficient sleep is obtained. In fact, chronic insomnia or
inability to sleep is quite common in the general population (15-
20 million Americans), most of whom do not have a chronic pain 
problem to contend with. On the other hand, research conducted in 
sleep laboratories has shown that many people who complain of 
insomnia really have no sleep problem at all and suffer only from 
some common misconceptions about sleep.  For example, there is 
the misconception that:

    1.  We all need 7-8 hours of sleep per night.  The amount of
        sleep needed varies widely from one individual to another
        and may be as little as 4-5 hours per night or as much as
        9-10 hours per night.  Babies need more sleep than young
        adults, who typically need more sleep than older adults.
        Active people need more sleep than inactive people.  Also
        keep in mind that if you nap during the day, this should
        be counted as part of your total sleep time.  Finally,
        research has shown that most people make very poor
        estimates of the amount of time they spend asleep, with
        underestimation very common among those who perceive they
        have a sleep problem.

    2.  Waking up during the night indicates a sleep problem.
        Research has shown that sleep is a complicated activity
        (the brain is quite active during sleep) consisting of
        several stages, each serving an important function.
        The *normal* pattern of sleep consists of 4-5 periods of
        very light sleep or wakefulness during the night, most of
        which are forgotten by the time we wake up in the 
        morning.  

        Just because you wake up several times a night does not
        mean that you have a sleep problem.  If you are able to
        return to sleep each time without great difficulty, and
        you feel rested in the morning, then you are probably
        getting adequate sleep.

    3.  Restlessness and movement during the night indicates poor
        sleep.  The normal sleep pattern consists of several
        periods of movement and position change, often associated
        with the 4-5 periods of light sleep or wakefulness
        discussed in (2) above.

    4.  Dreams indicate disturbed sleep.  Sleep studies have 
	   shown repeatedly that most people have 4-5 periods of  
	   dream activity every night!  People just don't usually
        remember their dreams from the night before.  In fact,
        you will not remember your dreams unless you awaken
        either during or immediately after the dream.  Even an
        occasional nightmare does not indicate disturbed sleep.
        Only if the nightmares are frequent and quite 
        distressing do they signal an anxiety problem that 
        might be interfering with sleep.

Assuming you do have a real sleep problem, if you are like most 
Americans you will likely seek help via a variety of readily 
available "sleeping pills."  By "sleeping pills" we are referring 
to an array of medications known as either hypnotic-sedatives or 
tranquilizers (e.g., Seconal, Nembutal, chloral hydrate, Doriden, 
Placidyl, Dalmane, Restoril, Halcion, Valium).  Such medications 
are intended for short-term use in helping the patient deal with 
temporary life crises or problems and have few undesirable side 
effects when used accordingly (2-3 days).  However, these same 
medications are counterproductive when used to try to cope with a 
long-term sleep problem (weeks and months). First, they all 
produce dependency with repeated use, leading to a dead end where 
the patient is taking a maximum dose but still can't sleep 
(because tolerance has developed).  But now, if the patient tries 
to cut out the medication, sleep problems become even more 
severe.  Before there was insomnia; now there is dependency *and* 
insomnia.  Secondly, these medications all actually *interfere* 
with the normal sleep pattern.  Patients tend to associate 
unconsciousness with sleep, and these pills certainly help make 
you unconscious, but that is a far cry from the complicated 
series of events we call the normal sleep pattern. Perhaps it 
should be mentioned that alcohol is likewise a poor solution to a 
sleep problem for the same reasons cited above -- it produces 
dependency and it actually interferes with normal sleep.  In 
short, we do not advocate the use of such sleeping pills or 
alcohol to deal with a
chronic sleep problem.  On the other hand, if you have been using 
these 
medications, IT IS VERY IMPORTANT THAT YOU DON'T DECIDE TO JUST 
STOP THEM ON YOUR OWN.  Always get the assistance of your 
physician in discontinuing or changing any medications.

There are some sleep-inducing medications which might be very 
appropriate for you and which are widely prescribed in pain 
centers. These are the so-called antidepressants (so called 
because they were first developed primarily for the treatment of 
depression).  They have since been found to induce sleep and help
relieve certain types of pain when used regularly at the  
appropriate dose. Such medications are not dependency-producing 
and they don't appear to interfere with normal sleep patterns in 
most people.  They include amitriptyline, doxepin, Sinequan, 
Elavil, Adapin, Surmontil, Pamelor, and Deseryl.



********** **********

The following handout was given to me at the Birmingham Pain 
Clinic:


ACTIVITIES

Inability to pace activities wisely is one of the greatest 
contributors to chronic pain.  Many people become quite inactive 
because of their pain problems, fearing that activity will make 
them worse.  Others become overly active, perhaps trying to over 
compensate for their pain problems or show themselves and others 
that they are the same person they always were.

With prolonged inactivity, muscles get weak and actually 
deteriorate. In addition, there is evidence that the brain does 
not produce as much natural pain-relieving chemicals (endorphins) 
when people are very inactive. Inactivity is also one of the 
surest ways of becoming depressed, allowing all of your attention 
to be focused on how miserable you feel.  In fact, almost anyone 
can make himself or herself depressed by staying in bed and doing 
nothing for a period of several days.

Overactivity, on the other hand, keeps the person from resting 
and recovering and creates problems on its own, including re-
injury and increased stress and tension.  Increased muscle strain 
and re-injury is especially likely if periods of inactivity 
alternate with periods of overactivity.

While no sure answers can be given about what a person's proper 
activity level is, the physicians and physical therapists can 
help guide each individual. Some of the following points should 
serve as guidelines as well:

    1.  Most chronic pain patients who have become very inactive
        as a result of their pain can benefit greatly from
        gradually increasing their participation in physical
        activities, if they do so in successive small steps.

    2.  It is generally helpful to gradually increase activity
        levels with day-to-day consistency rather than have one
        day of extreme activity and the next day of little
        activity.  Also, take frequent breaks for rest and
        relaxation when necessary.

    3.  A slight, temporary increase in pain may accompany
        increases in activity level, especially in the beginning.
        If an increase in pain level makes increasing activity
        level aversive, then make your increases more gradual,
        staying at each level for a longer period of time before
        the next increase.  Of course, major increases in pain
        should be reported to your physician before proceeding
        further.

    4.  In order to increase activity levels, there is a need for
        patience, persistence, determination and focusing on
        making slow, gradual changes.  It is very important to
        have a balance of activity and rest.  Difficult tasks
        (e.g., mowing the lawn) may have to be done in several
        segments with time for breaks and relaxation in between.

Many people in pain give up other activities such as social or 
religious activities when they hurt.  By withdrawing from the 
anxiety of such activities, they often cut themselves off from 
others and feel increasingly depressed and isolated.  Some of the 
important benefits from increased activities are:  an increased 
sense of self-esteem and competence, improved mood, improved 
physical health, more contact with people (less isolation and 
loneliness), and, of course, long-term reductions in pain



********** **********

ASSIGNMENT FOR SESSION #4

1.  As explained in today's session, it is appropriate for most of you
    to work on gradually increasing activity level, both physical and
    social.  Indicate below two of the goals you have set for yourself
    in these areas.  Be as specific as possible, indicating first how
    much and how often you engage in the activity now, then what your
    specific goals are for the future (end of the program):

    A.  Physical Activity (Describe)

        How much are you doing now (Be specific)?

        What is your goal?


    B.  Social Activity (Describe)

        How much are you doing now (Be specific)?

        What is your goal?


2.  The topic for the next session is "Stress Management."  In the
    preparation for this topic think about some of the major
    stressors that you have to cope with and briefly describe below
    three of the most stressful things in your life at the present time:

     A.

     B.

     C.


Complete the "Stressful Events Scale" by checking off all those events that 
have happened to you over the past 12 months, circling the scale value 
associated with each, and adding up your total Stress Score.  Also, 
complete the "Stress Symptom Checklist" following the directions given, 
adding up your totals in each category.  Bring these completed forms with 
you to the next session with your name and date at the top of each page.



********** **********


The following handout was given to me at the Birmingham Pain 
Clinic:


STRESSFUL EVENTS SCALE

Below are listed many of the events in life which have been found 
to produce individual stress reactions in a cross section study 
conducted by Dr. Thomas H. Holmes at the University of 
Washington.  The scale value of each event reflects the amount of 
stress and disruption it causes in the life of the average 
person.  More than 200 units accumulated during the period of one 
year can cause some individuals to exceed their stress tolerance 
with resulting physiological and psychological illness.  Of 
course, individuals do vary in their tolerance for stress so that 
these figures should only be taken as a rough guide.


CHECK EACH EVENT IN THE LAST 12 MONTHS    CIRCLE YOUR SCALE VALUE

Death of a spouse                           100
Divorce                                      73
Marital separation                           65
Jail term                                    63
Death of a close family member               63
Personal injury or illness                   53
Marriage                                     50
Fired at work                                47
Marital reconciliation                       45
Retirement                                   45
Change in health of a family member          44
Pregnancy                                    40
Sexual difficulties                          39
Gain of a new family member                  39
Business readjustment                        39
Change in financial state                    38
Death of a close friend                      37
Change to a different line of work           36
Increased arguing with spouse                35
Mortgage over $10,000                        31
Foreclosure of mortgage or loan              30
Change in responsibilities at work           29
Son or daughter leaving home                 29
Trouble with in-laws                         29
Outstanding personal achievement             28
Wife/husband begins or stops work            26
Beginning or end of school                   26
Change in living conditions                  25
Revision of personal habits                  24
Trouble with boss                            23
Change in work hours or conditions           20
Change in residence                          20
Change in schools                            20
Change in recreation                         19
Change in church activities                  19
Change in social activities                  18
Mortgage or loan less than $10,000           17
Change in sleeping habits                    16
Change in family reunions/get togethers      15
Change in eating habits                      15
Vacation                                     13
Christmas                                    12
Minor violations of the law                  11

            Total the scale values circled: ______



********** **********

The following handout was given to me at the Birmingham Pain 
Clinic:


STRESS SYMPTOM CHECKLIST

Each of us experiences stress in different ways.  It is useful to 
see if your stress symptoms are predominantly physical, emotional 
or behavioral.  This will help you understand yourself better, 
develop more awareness and make best use of the techniques you 
will be taught.

Circle the appropriate number after each item, then total up your 
score for each section to see if you have more stress with physical,
emotional, or behavioral.

        0 = never           2 = sometimes
        1 = rarely          3 = often

Physical Symptoms:

Headaches   0 1 2 3
Indigestion   0 1 2 3
Stomach aches   0 1 2 3
Back pain   0 1 2 3
Tight neck or shoulders   0 1 2 3
Racing heart  0 1 2 3
Sweaty palms   0 1 2 3
Trouble sleeping   0 1 2 3
Tiredness   0 1 2 3
Restlessness (hard to sit still)   0 1 2 3
Dizziness   0 1 2 3
Ringing in ears   0 1 2 3

Total =  _____

Emotional Symptoms:

Crying, sad   0 1 2 3
Overwhelmed with pressures   0 1 2 3
Nervous, anxious   0 1 2 3
Angry   0 1 2 3
Bored--can't find any meaning to things   0 1 2 3
Lonely   0 1 2 3
Can't stop worrying   0 1 2 3
On edge--feeling ready to "explode"   0 1 2 3
Can't laugh   0 1 2 3
Unhappy for no particular reason   0 1 2 3
Powerless to change things   0 1 2 3
Easily upset   0 1 2 3

Total =  _____

Behavioral Symptoms:

Smoke excessively   0 1 2 3
Grind teeth at night   0 1 2 3
Trouble thinking clearly   0 1 2 3
Drink alcohol excessively   0 1 2 3
Forgetful   0 1 2 3
Can't make decisions   0 1 2 3
Bossiness   0 1 2 3
Compulsive eating   0 1 2 3
Thoughts of running away   0 1 2 3
Critical of others   0 1 2 3
Compulsive gum chewing   0 1 2 3
Can't seem to get things done   0 1 2 3

Total = _____


Totals:  Physical    _____
         Emotional   _____
         Behavioral  _____




********** **********

The following handout was given to me at the Birmingham Pain 
Clinic:


WHAT TO USE INSTEAD OF SLEEPING PILLS

If you have chronic insomnia or inability to sleep, you are in 
the company of 15 to 20 million other Americans.  Though many 
people rely heavily on barbiturates, hypnotics and alcohol to 
help them sleep, these seldom are the answer for sleeping 
problems  Many of these drugs are highly habit forming and higher 
and higher doses have to be taken to maintain the same effect.  
May of these drugs effect the structure of sleep, and suppress 
"deep sleep" as well as rapid eye movement (REM) sleep.  
Irritability, anxiety and other psychological effects have been 
found to result from these disruptions of normal sleep. 
Withdrawing these medications can be difficult, and should be 
done only under medical supervision.

The purpose of sleep is to rest and "recharge" yourself for the 
next day.  Many people do not need to sleep soundly for eight 
hours to accomplish this, and can do so with some effectiveness 
through relaxation.

There are many things people can do to help increase their 
chances of sleeping well.  If you have problems sleeping, you 
should follow *all* of these suggestions:

1.  Be as physically active as your condition allows you to be 
during the day.

2.  Carry on activities in a relaxed frame of mind.  Worry and 
frantic activity often produce tension which prevents sleep.  If 
you are chronically tense, "nervous" or depressed, discuss these 
problems with the professional staff, because these can disrupt 
sleep.

3.  Allow a period of "winding down" for about one hour before 
bedtime. Do not engage in any strenuous activities during this 
hour.  Different people find different ways of relaxing before 
bedtime.  Some people can help themselves sleep by taking a warm 
bath shortly before bedtime while others relax with something 
warm to drink (not alcohol or caffeine).  Practicing with the
relaxation tape immediately before bedtime is essential.  If you 
go to sleep and then wake up again in the middle of the night, 
you may benefit from practicing this procedure again.

4.  Get your body into a good schedule.  It is wise to go to bed 
at the same time every night and get up at the same time every 
morning regardless.  If you do not sleep well during the night 
but still get up at the same time you will be much more likely to 
sleep better the following night.  In addition, do not take 
unscheduled naps to make up for lost sleeping time.  Some people 
like to take a nap during the day, but they should only do so if 
this is an everyday routine.  Do not "toss and turn" for long 
periods of time.  Tossing and turning is often associated with 
mental worry, and also is a way of conditioning your body not to 
sleep while you are lying in bed.  Therefore, if you find 
yourself tossing and turning for more than just a few minutes, it 
is wise to get up for a short period of time and engage in a 
*relaxing* activity until you feel drowsy again.  Do not return 
to bed until you feel drowsy.

5.  Use your bed only for sleeping and sexual activity.  
Activities such as reading in bed and watching television in bed 
condition your mind and body not to sleep while being in bed and 
should be avoided.

6.  Avoid foods and drinks with caffeine for at least four hours 
before bed.  Caffeine is found in coffee, tea, many cola drinks 
and chocolate.

If you follow all of these instructions and still cannot sleep 
well, you may need further assistance.  Let the physician know 
what kinds of problems you are having.


********** **********

The following handout was given to me at the Birmingham Pain 
Clinic:


BREATHING EXERCISE

1.  Lie down.......or sit.

2.  Breathe through the nose, equal time inhalation/exhalations:
    slow, regular.

3.  Count steadily (one thousand 1, one thousand 2, etc.) as you
    inhale and repeating equal counts as you exhale.

4.  Put one hand on chest to be sure it stays still; other hand
    on abdomen as it rises and falls.


This exercise stimulates the parasympathetic nervous system, the 
calming part of the nervous system.

Keeps body calm, promotes relaxation.

Mental arithmetic diverts "busy" thoughts.

Monitoring chest and stomach gives you something to do with your 
hands.


********** **********

THREE DIMENSIONAL BREATHING

Lie on your back.  Place your hands on your upper chest and send 
your breath there.  Focus your attention on the exhale; expel all 
the stale air and then allow the breath to enter.  Inhale into 
the upper chest and exhale, sending all the breath down the arms 
and out of the hands. As you breathe, feel yourself expand in all 
three dimensions:  top to bottom; that is (from head to mid-
chest), side to side (between the shoulders), and front to back 
(from the sternum to upper spine).

Next, place your hands on the lower rib cage, in the area of the 
diaphragm.  Visualize the diaphragm moving beneath your hands:  
as you inhale, see and feel it moving into the abdomen; as you 
exhale, see and feel it relaxing upward into the chest.  Feel 
the expansion and contraction of this part of your body in all 
three dimensions.  Feel your ribs lift up and away from your 
spine.  Feel how your rib case expands and contracts at your 
sides.  And, feel how your body lengthens and contracts here at 
your middle with each breath.

Now, place your hands on the lower abdomen.  As you inhale, feel
your breath move into your abdomen.  Then exhale, sending the 
breath down and out through the legs.  Feel your abdomen 
expanding from front to back (from the stomach  wall to the 
tailbone), from side to side (feel the movement at the sides of
your abdomen and pelvis), and top to bottom (feel your lower back 
release and lengthen with each breath).

Finally, place your hands where they are most comfortable.  Allow 
a complete exhalation, and let your inhalation be natural and 
full. Focus in turn on all three areas.  As you breathe, track 
your breath from top to bottom, feeling how you lengthen from 
head to toes.  Track your breath from side to side in your
lower abdomen and pelvis, upper abdomen, rib cage, and shoulders.  
Track your breath from front to back, noticing the changing space 
between your back and the front of your chest, at your diaphragm, 
and in your pelvis and lower abdomen.



********** **********


                            EXERCISES


1.  Either standing or sitting, bring your right knee up, clasping it with 
your hands and pull up as far as comfortable.  Repeat with the left knee.  
Do this several times.

2.  Standing, with feet slightly apart and your hands on your hips, close 
your eyes and slowly lean your head over on your left shoulder, and then 
over on your right shoulder.  Do this several times.

3.  With hands on your hips, first roll back to your heels, and then 
slowly rock with your feet until you're up on your toes.  Repeat several 
times.

4.  While standing, with your arms out in front of you, push your shoulders 
forward as far as you can.  Then put your arms out in back of you as far as 
possible and push your shoulders back as far as you can.  Repeat several 
times.

5.  While standing, put your arms out in front of you, then put your arms 
out to your side, parallel with the floor, then put your arms above your 
head.  Come back down with your arms in front of you and make small circles 
inward and then outward.  Put your arms back out to your sides, parallel 
with the floor again, and make small circles inward and then outward.  Let 
your arms relax by your sides and shake them out.  Repeat this once or 
twice.

6.  While standing, one foot slightly in front of the other, "swim."  Move 
your head from side to side while you are making the motion of "swimming."  
Then, do the "backstroke."

7.  With your left foot out in front of you, put your left arm forward and 
put your right arm in back, up and as high as possible.  Then, switch to 
your right foot and put your right arm forward and your left arm in back, 
up and as high as possible.  Repeat a few times.

8.  Walk in place for a minute or so (comfortably).



-----------------------------------------------------------------
Message date:  Fri 16 Apr 92    
Birmingham Pain Clinic Visit #7
-----------------------------------------------------------------

Group Session #4
April 15, 1992


I asked Dr. Brotherton about his statements last week concerning endorphins.  I asked if endorphins can deplete, is there a way to replenish 
them.  I also asked, if they can be diminished, what effect would that have 
on a person.  He said up front that, very little is really known about 
endorphins.  But, it would have an affect on a person if their endorphins 
were depleted by having a higher pain than normal.  And, by the way, when  
getting my acupuncture treatment, I made a statement to Dr. Xavier.  She 
asked me how the acupuncture did last week and I told her that I only 
received about 3 hours diminished pain level before it returned to normal.
I added that perhaps my endorphin level was so low it couldn't stimulate 
them and she laughed and said, "Could be."  Having a TENS unit or a SCS 
(Spinal Cord Stimulator) would use endorphins faster than normal.

Dr. Brotherton told us that it is important for a chronic pain sufferer to 
increase their activity.  Most pain clinics "push" their patients into some 
sort of program that increases their level of activity.  They're not doing 
it because they don't think that the patient has chronic pain...on the 
contrary; they do it because inactivity leads to muscle atrophy.  Increased 
activity, in the long run, makes the pain less intense.  Muscles start to 
deteriorate within 3-4 days from lack of use.  Muscle cells die.  Sore 
spots in muscles develop.  Now, acute pain patients are told to rest a 
maximum of 3 to 4 days at the most before increasing their activity level.

Now, doctors are learning that in some cases (say, back injuries), it is 
better for the patient NOT to wear a back brace.  There are exceptions, of 
course. The muscles deteriorate from wearing a back brace.  Without a back 
brace, and with proper physical therapy, the muscles are strengthened.

The health of the whole body suffers with inactivity.  The pain gets worse 
first with increased activity, but then levels out and actually gets better 
for most cases.  A person must determine the right schedule of the proper 
activity.  Patients and chronic pain sufferers must learn to pace 
themselves.  It's a trial and error situation.  A person does not have to 
suffer a lot to get better.  Increase in activity will produce more pain, 
but the pain increase should be mild.  If the pain level is increased 
drastically, then the activity is too much.

Everyone should be on an exercise program.  Chronic pain sufferers tend to 
want to use common sense, but this actually hurts them.  But, "no pain, no 
gain" is a myth, also.  A sensible exercise program is needed.  Actually, 
the best exercise for a chronic pain sufferer is performed in water where 
there is no pressure on the problem pain area and it takes the pressure 
off the joints.

As added information, Dr. Brotherton said that people have been under the 
wrong impression for years.  Some people say, "But, I can't walk today 
because it's raining and I'll catch my death."  In his words, "You can't 
catch a cold from being out in the rain."  "You can't catch a cold from 
being out in cold weather."  "You can't catch a cold from getting your feet 
wet."  "The only way you catch a cold is by human contact!"

We talked about stress and what causes stress.  For instance, if you're not 
able to continue your responsibilities, this causes guilt.  Pressure causes 
stress as does pain, and money (either the lack of it, or too much of it!)  
The more stress you have, the less immune fighting power you have.  Too 
much stress is bad, but just the right amount is actually good.  Your 
development and growth are dependant on stress.  And, stress is not always
all bad.

He gave us this formula:  <Bad Stress> = Distress = Stress - Coping ability

If someone has been able to handle the "bad" things happening to them all 
of their lives, even though someone else may look at their life and ask 
them how in the world they were able to do it, then that person can handle 
almost any stress.  On the other hand, if a person has really had no 
stress, and something comes along to interrupt their life, then their 
stress may be higher than the person who has always had to cope with 
stressful events.

Relaxation is a skill you learn through practice.  Relaxation is very 
important for chronic pain sufferers.  But, DO NOT try to learn the 
relaxation techniques during "really bad pain days."

Pacing yourself is a problem.  On really good days, people have a tendency 
to do all the things they don't usually feel like doing because of the 
pain.  This is wrong.  You should hold back!  On bad days, try doing just a 
little more than you would normally.  It shouldn't really increase the pain 
that much.

Here is what Dr. Brotherton told us to do to try to remind yourself that 
you should pace yourself.  He said to go and buy something (a bracelet, 
ring, etc.) about every 2 weeks.  The "newness" wears off about that time.  
That new "something" is worn to remind yourself that you shouldn't "push" 
yourself beyond your limits.  If you can't afford to go out and buy 
something new every two weeks, then use something else.  Get pieces of 
different colored tape and put it on your hand...or, tie a string around 
your wrist (the old tie a string around your finger to remind you that 
you're supposed to do something trick).  But, always differ the positions 
of the items every two weeks.  It's something strange that you will notice 
and say to yourself, "Oh yea...I'm supposed to pace myself!"



********** **********

Bernard Harris, the physical therapist, showed us a few new exercises.  The 
first one was...

Grab your left hand with your right hand.  Stretch your arms to your left 
and up as far as you can.  Then, reverse and stretch your arms to your 
right and up as far as you can.  Repeat several times.

While sitting down, grab your right knee and bring it up as far as possible 
toward your chest.  While pausing, move your foot up and down as far as 
possible.  Repeat with the left knee.  Repeat several times.

With your hands on your hips, bend as far to the right as far comfortable.  
Then, bend to the left as far as comfortable.  Repeat several times.

Holding onto a chair, kick your right leg back and up as far as you can 
without causing pain.  Repeat with your left leg.  Repeat several times.

With your right arm you in front of you, and your right leg in front of 
your left leg, lunge forward (as if in fencing).  Do the same with your 
left arm and leg.  Repeat several times.



********** **********

Karen Kramer took us through a relaxation technique.  She taught us the 
importance of "Imagery" (daydreaming,  visualizing)...getting away from the 
pain.

This aged old way has worked for centuries.....story telling to relax.  As 
a child, you were read stories to relax so that you would go to sleep 
faster.  It's no different now.  Children have "wonderful" imaginations.  
As we grow up, we tend to lose these imaginations.  Now, we must try to 
regain it to help us to relax.

She had us close our eyes and began "story telling."  Let's see if I can 
remember most of it for you. ...   Think what it was like to be young.  
Imagine yourself as a "little person."  You are in a school room.  You can 
see the teacher at the front of the room.  She is writing on the 
blackboard.  It amazes you that the chalk writes so smoothly on the 
blackboard.  She is writing slowly and effortlessly.  As she writes, she 
says to you what she is writing. "This is an A," she says.  You notice how 
smooth her writing is.  She continues with the B, and with the C.  She 
tells you that she is giving you a gift.  She is giving you letters that 
you will learn how to write and be able to write them for all time.  
Perhaps you can remember what she looked like and maybe even her name.  
Notice the desks and children around you.  Perhaps you remember a special 
friend.  Look down and see what you are wearing.  Do you remember a special 
shirt or dress?  Remember how you felt when you wore it.  She had you take 
out your paper and pencil.  How large the pencil felt in your small hand.
She asked you to copy what she wrote on the blackboard.  It was hard for
you to make your letters look like what she wrote.  You can feel how the 
pencil felt writing those letters.  As you wrote the letters, you can hear 
the children outside playing in the yard.  Perhaps your mind wandered and 
you imagined what it would be like to be outside playing with them.  (She 
went on describing scenes that were very non-descriptive so that your 
imagination could take over.)  Then, she slowly brought us to the 
surroundings in the room, the noises outside, and our own breathing.  She 
made us aware of the fact that we were no longer in the schoolroom, but in 
a room in our present day.  She told us to become aware in our own time, 
and that we could open our eyes when we were ready.  Self-hypnosis?  
Perhaps.  Were we relaxed?  Yes.

Karen told us that when we daydream, and if we happen upon a bad memory, 
that our body would respond badly.  So, we were to say to ourselves, "I 
remember you...but I'm picking (something pleasant) to think about right 
now."  It can even be something you've never experienced.  She said that 
we could use this as a sleep inducer by just daydreaming ourselves to sleep.

The handouts given to us at this session follows.



********** **********

Handouts

Assignment for Group Session #5

1.  List below three major stressors that you are now facing.  Directly 
below each stressor describe a coping skill that you might learn in order 
to improve your ability to manage that stressor:

    a)  Stressor:

        Coping skill:


    b)  Stressor:

        Coping skill:


    c)  Stressor:

        Coping skill:


2.  The topic for the next session is "Pain and Emotions."  List below some 
of the emotional reactions caused by pain:

        Emotions caused by pain:

        Are these emotions helpful or harmful?

        What do you think one should do in order to cope effectively with 
        these emotions elicited by pain?



********** **********


HOW TO USE GUIDED IMAGERY AND POSITIVE VISUALIZATION


Would you like to try an experiment on yourself?  Without looking, what is 
the total number of windows in your home or apartment?

The important question is not how many windows, but how you arrived at the 
number.  A natural way to do it is through imagery.  To accurately count 
the windows, you had to remember and imagine each of them.

Almost all of us use imagery.  We use it to solve a variety of our daily 
problems.  "The soul never thinks without a picture," Aristotle said.


How to improve your ability to use imagery

Each of us possesses the ability to use some sort of imagery, but we have 
varying degrees of skill.  Depending on our life experiences and 
environment, we may have used imagery a lot of a little.  Dr. Mike Samuels, 
and his wife, Nancy Samuels devised some exercises to develop better 
imagery.  Here is a variation of the exercises that can help you develop 
your imagery skills.

     1.  Gaze at one of the geometrical drawings - a square,
         a circle, a triangle, or some such figure.  Then
         shut your eyes and try to visualize it.

     2.  Examine for a few moments a three-dimensional
         object such as an orange, a glass of water, or a
         lamp.  Again, close your eyes and imagine the object.

     3.  Visualize a schoolroom from your childhood.

     4.  Visualize your home or apartment.  Move around in it,
         go from room to room.

     5.  Visualize a person you know.

     6.  Visualize your reflection in a mirror.

Practice these exercises every day for one month.  It will take just a 
little more time to do the practice than it takes to read these directions.  
You may be surprised when you realize how vivid and creative your imagery 
can become.


(Note:  on the paper was drawn a square, underneath a circle, and 
underneath that, a triangle.  Under these figures was written:  "An imagery 
and visualization exercise is to gaze at one of these figures, then shut 
your eyes and try visualizing it.)  Perhaps you could print out this 
message and draw a square, circle, and triangle so that it would be like 
what I received.




------------------------------------------------------------------------
Message date:  Fri 24 Apr 92 
Birmingham Pain Clinic Visit #8
------------------------------------------------------------------------

April 22, 1992
Group #5

Dr. Frank Brotherton explained to us the following:

Acute & Chronic Pain causes "Anger"
Acute & Chronic Pain causes "Fear" (anxiety)
Only Chronic Pain causes    "Depression"

All these "emotions" cause the pain to become worse.  When a person denies
their anger and saves up their emotions rather than venting them, this is
called "displacement."  Anger is almost always at yourself and it causes
depression.  Anger directed inward makes a person feel useless, listless, 
non-caring, and sometimes even suicidal (among other feelings).  You feel 
"fear" in such instances as fearing that you might not get the drugs needed 
to control your pain...fear that you will not find a doctor that can help 
you with your pain...fear that you will lose function...fear that you will 
go crazy...fear that you will not be able to cope.

Anger and fear increase muscle tension, thereby increasing pain!

Anger, is what they call the "Fight instinct."  Fear is what they call the
"Flight instinct."  If an animal doesn't think it can fly (flee), it can't
fight.  For example, if you hunt an animal and it runs away, but is 
cornered, usually that animal will fight.  It "fears" something, therefore, 
it wants to "fight" so it can "flee."

Think of emotions as "useful" rather than something that gets in the way.
Emotion *is* motivation!  Often, if not always, "determination" is 
channelled anger.

Fear can boomerang on you, if you let it control you, though.

Emotion = Arousal + Perception

Emotion = Bodily Arousal + Perception (or meaning, or interpretation)
                           of the Mind

Anger is the same as other emotions including fear.  Perception 
differentiates "arousal."

You can control your thoughts by "Self Talk."  You make yourself angry.  
Let me repeat this, because it's very important.  "YOU MAKE YOURSELF 
ANGRY."  You can unlearn your emotions and recognize them (notwithstanding 
the genetic factor).

Here's an example he used.  There is a society of people living somewhere 
away from "civilization."  They do not know fear because there is nothing 
to be fearful of where they live.  One of the people is brought to a city.  
Someone comes up to them and puts a gun to their head and says they're 
going to kill them.  How would that person react?  Answer:  they wouldn't 
know how to react because they do not know fear.  Fear is taught to us
from the time we are born.  Think about it.

With chronic pain, you must not stop all activities.  This is fear.  Just 
the opposite, you must find a happy medium where the activity causes no 
more pain than before (after it increases slightly while finding that 
area).

Pain -- it hurts, but pain is good.  It tells you when you are doing too 
much.

Pain -- it hurts, but pain increasing significantly indicates that the 
activity you are doing should be decreased until the pain level is back to 
where it was before you overdid that activity.

Activity -- with chronic pain sufferers, it's like a roller coaster.  
People try to do something for various reasons, but if the activity is 
beyond the limits of their body, it should be reduced.  However, a slight 
increase in pain is good for a few weeks until the body tells you if that 
particular activity can be continued with no drastic pain increase.  If
the increase is drastic, then a re-evaluation must be made between your
doctor and your physical therapist, for example.  If it increases slightly,
and then levels off and actually reduces a little, then the exercise is
right for you.

Use your imagination to unlearn "self-talk."  If you experience an 
unpleasant situation, then take the time to relax, close your eyes, imagine 
that unpleasant situation and when you get to the part where it starts to 
make you angry, stop.  Open your eyes, and think about why it made you 
angry.  Then, repeat this technique.  Close you eyes again, imagine the 
same unpleasant situation and see if you can't get past the part where it 
starts to make you angry.  If you can, you will probably encounter another 
situation where you get angry again.  Stop, open your eyes, and analyze why 
it made you angry.  Keep repeating this session until you've fully analyzed 
why something has made you angry.  Most of the time, remember, anger comes 
from within yourself.  NO ONE CAN MAKE YOU ANGRY IF YOU DO NOT CHOSE TO 
BECOME ANGRY!



********** **********

Handouts:

EMOTIONS AND CHRONIC PAIN

The experience of pain almost always carries with it an emotional 
component. Indeed, many experts in the field of pain hold that it is 
impossible to perceive pain without an emotional reaction.  The emotional 
component of pain is an important part of its unpleasantness, and by 
learning to control and deal effectively with the emotional component, one 
can lessen the impact of the pain itself.

I.   Pain-Emotion Interactions

     A.  Fight or Flight Reactions
     B.  Neurological Pathways
     C.  Emotion Modulates Pain


II.  Emotions Frequently Associated with Pain

     A.  Fear or Anxiety
     B.  Anger
     C.  Depression

III. Coming to Terms with Chronic Pain

     A.  Fear, Anxiety, and Denial
     B.  Anger, Envy, and Resentment
     C.  Guilt and Bargaining
     D.  Guilt, Hopelessness, and Depression
     E.  Acceptance and Coping

IV.  Coping with Emotions

     A.  Maladaptive Coping

         1.  Emotional Inhibition (Blocked Expression)
         2.  Displacement and Scapegoating

     B.  More Adaptive Coping Techniques

         1.  Relaxation
         2.  Modification of Self-Talk
         3.  Assertiveness
         4.  Catharsis
         5.  Exercise
         6.  Humor
         7.  Nutrition



********** **********

ASSIGNMENT FOR GROUP SESSION #6

1.  A.  Explain what happens to strong emotions that are just "held in"
        or suppressed:


    B.  Briefly describe three coping techniques for dealing with
        emotions in a healthy and effective way:




2.  The next and final regular group session deals with "Pain Behavior: 
Effects on Self and Others."  Pain behavior refers to what people actually 
do when they are in pain.  Pain behavior can be divided into verbal pain 
behavior (i.e., what people say or the sounds they make) and nonverbal pain 
behavior (i.e., communicating pain without words or sounds).  List below 
some examples of *nonverbal* pain behavior:






     Think about how the pain behavior of others affects you and describe
several of these effects below:





---------------------------------------------------------------------------



********** **********

Karen Kramer took us through a relaxation technique different from the ones
before.  She had us imagine that we were in a bright spotlight.  Very 
slowly, that spotlight became smaller and smaller.  We were able to control 
the light and shine it on the one tiny place that was hurting the most.  
Then, depending on which felt better, the tiny light felt warm or cool.  
She had us imagine that the brighter it became, the less we would feel the 
pain.  She said all we had to do when the pain increased in the future, was 
to close our eyes for a few moments and imagine that little light giving us 
relief.

(Unfortunately, for me, it made my pain increase.  She said this happens in
some people and next time, for me to take the light and have it transfer 
the pain to some other part of my body, like my finger.)

Karen explained that we all should think up a "symbol for health."  I 
haven't yet thought of a symbol for myself, though.  But, she said that if 
you can picture that "symbol," then you could make yourself feel less pain 
everytime you thought of the "symbol."  Of course, this takes quite a lot 
of practice, but she said it could be done.

She told us that soon, we would not need the tapes given to us at the Pain
Clinic.  She said we would be able to just close our eyes and "imagine"
something pleasant...real or imaginary...and it will relax us, thereby
decreasing our pain.

She also said for us to be "aware" of our bodies.  For instance, notice how 
you stand and sit.  See if there is anything you do that puts stress on one
particular part of your body.  Do you stand with your knees locked?  Do you
stand cocked with one hip thrown out?  Do you sit with your arms crossed?  
Do you walk swinging your arms?  Do not lock your knees.  Do not stand with 
one hip thrown out.  Crossing your arms when sitting takes pressure off 
your neck and shoulders.  Swinging your arms while walking is natural and 
should be done.  Always check your body for tenseness.  Notice if you are 
standing in a checkout line and frowning.  Smooth out your face.  You can 
take little "vacations" while waiting in that checkout line...even with 
your eyes open.  Just *imagine* something pleasant and relax your body.  
Hold onto the cart to steady yourself and take quick vacations closing your 
eyes for moments at a time.  This will help you handle the increase in pain 
if you are experiencing it.



********** **********

Handout:

HELPFUL HINTS


HELPFUL HINT NO. 1:  Always Break Up Tasks into Small, Manageable Bits

There is nothing more encouraging than success.  Whether we are talking 
about a five-hundred-piece jigsaw puzzle or the management of pain, there 
is nothing more satisfying than completing what you set out to do and 
nothing worse than being so overwhelmed that you become paralyzed.

A friend, a sufferer from chronic pain, was feeling somewhat better than 
usual one fall day.  Being ambitious and helpful, he decided that he would 
show his wife, out of town for a meeting, how much better he was doing by 
raking all the leaves around his home.  This friend, of course, had felt 
frustrated by not being able to help his wife with the household tasks and 
felt that here, finally, was a chance to help, to show that he was still 
capable.  Now, as anyone with a tree or two in his yard knows, raking 
leaves is one of these strange tasks which defy natural physical law.  That 
is, the more you rake, the more leaves appear.  My friend decided to rake 
the whole yard before his wife returned the next day.  What a splendid gift 
it would make for her.  It turned out to be a horror.  A naturally back-
breaking job under any circumstances, it was overwhelming for a man not 
used to using his back and arm muscles.  Needing to please his wife and 
show her that he was still able to do his part, he raked and raked, and by 
suppertime he found that fully half the leaves were still there.  Obsessed 
by his desire to finish in one day, he went back out, but was more 
frustrated and angry when by 9 p.m., fully one quarter of his leaves were
still there and he could not move for stiffness...pushing on, becoming more
overwhelmed.  Well, the end of the story is that he did finish - at 
midnight.  His wife was very pleased, the yard looked splendid, and my 
friend spent the next four weeks in traction, somewhere between agony and 
purgatory.  His need to reassert his competence in the eyes of his wife had 
overwhelmed him.  He took on too much.  He should have determined what his 
"manageable bit" was and stuck to it, doing a little each day.  His wife 
would still have been pleased, the leaves would have been raked, and he 
would have been in less pain and not in the hospital.  He could have 
controlled his pain and the next four weeks of his life by remembering this 
helpful hint.


HELPFUL HINT NO. 2:  Pain Enhancers and Pain Reducers

It is worth reinforcing a somewhat obvious equation:  If the things in your
life that increase your pain outweigh the things in your life that reduce 
your pain, you will experience pain.  And vice versa.  It is as obvious a 
statement as the financial adage, "Buy low, sell high."  Most investors, 
however, do just the opposite.  They run with the pack; that is, they sell 
low and buy high because they are lost and frightened and do not understand 
the dynamics of the stock market.  So, too, with pain.  People become 
frightened when they do not understand, for instance, that pain medication 
has stopped working.  They begin to imagine that their injury has worsened, 
rather than understanding that the medicine has stopped working because 
their body has become used to it.  The fright causes anxiety, which makes 
the pain worse, which then provokes the need for more medicine, which does 
not work anyway, and so on and so on.  Know what makes your pain worse and 
what makes your pain better.  In detail.  Make a list of both.  If 
vacuuming the drapes causes pain but washing the sink does not, avoid one 
and do the other.  Multiply this by the hundreds of pain reducers and
enhancers that occur in each day's activities and you stand a good chance 
of devising a daily plan that includes as many reducers and as few enhancers as possible.

Charles Dickens, in "David Copperfield," gives us a parallel definition of
poverty and wealth and thus a plan for achieving whichever of the two we 
want.  "Wealth," said Dickens, "is sixpence in and sixpence out.  Poverty, 
on the other hand, is fivepence in and sixpence out."

Multiply this by the hundreds of pain reducers and enhancers that occur in 
each day's activities and you stand a good chance of devising a daily plan 
that includes as many reducers and as few enhancers as possible.


HELPFUL HINT NO. 3:  Pain is Not Injury

There once was a football coach who earned great regard from his players 
with the following admonition:  "Fellows, to play football, one must be 
able to distinguish pain from injury."

This is no small distinction.  We are products of conditioning.  From 
childhood on, we learn that pain means injury.  Indeed, in acute pain our 
body is telling us that there is injury and that we had better take care of 
it immediately.  In chronic pain, though, the injury is over and only the 
pain lingers on.  If one confuses pain and injury, then, like football 
players who do not learn well, we step out of the game.  Chronic pain is 
not a signal to stop life.  It is not a warning that damage is increasing.  
It is a signal to the prudent:  ease up, but never stop playing.


HELPFUL HINT NO. 4:  There is No Unitary Cure for Chronic Pain

We are once again discovering that illness and disease do not pop up from a
single source.  Similarly, there is no one cure for any disease.  Illness 
is an amalgam, a mixture of the right germ at the right time plus a genetic
predisposition to get certain kinds of problems plus stress plus  
personality plus a whole host of other environmental, physical, and 
developmental events.  From a strep throat to cancer, we are products of 
our heritage, our environment, our development, and our personality.

We say that we are only rediscovering this fact, because Plato first 
enunciated it many thousands of years ago.  In the eighteenth century, the 
philosopher Rene Descartes proposed that mind and body were separate and 
isolated entities and unaffected by each other.  We are just now coming to 
understand that Plato was correct, not Descartes, and so we can no longer 
look for unitary cures for our illnesses.  Identify as many causes for your 
pain as you can...physical, emotional, and environmental...but do not 
expect a single cure or your disappointment may well be another cause of 
your pain.


HELPFUL HINT NO. 5:  Biological Clocks

Each person has several biological built-in clocks that control his 
internal cycles.  One cycle is through in minutes, another in hours, one in 
days, and some cycles take years.  If you can learn to read these clocks, 
you can determine when is the best time for certain activities.  For 
instance, if you know that you are strongest at night, save some tasks that 
require extra strength or concentration for the evening.  If you are 
depressed in the morning, do not attempt complicated or difficult tasks 
until after lunch.

Learning to read yourself and gearing your activity to biological rhythms 
is a difficult task.  Scientists are just beginning to understand these 
cycles.  In a recent experiment, a lethal dose of E. coli bacteria was 
given to a group of mice at their subjective noon.  Eighty-three percent of 
the mice died. However, when the same bacteria and the same dose were given 
to the mice at their subjective midnight, only 15 percent died.  Why?  Was 
there some immunological mechanism that was stronger at midnight than at 
noon?  We don't know.  We do know, however, that the rhythm was stronger at 
midnight than at noon.

We do know, however, that the rhythm that controls immunity can also 
control other functions, including pain.  At some time in the future, we 
may be able to control these rhythms.  At the present time, you can benefit 
by being aware of yours.




---------------------------------------------------------------------------
Message date:  Thu 30 Apr 92 
Birmingham Pain Clinic Visit #9
---------------------------------------------------------------------------

April 29, 1992
Group Session #6 (and final)

Bernard Harris, the Physical Therapist, was with us for the first hour 
today because of a scheduling problem.  He summarized our sessions for the 
last five weeks by saying that what we had learned was not meant to be a 
quick cure, but rather how to manage our chronic pain.  Attitude is the 
most important tool for us to use.  We must think of ourselves as useful, 
helpful, and having value.  Bernard said, "I *value* each of you."  He said 
how important it was for us to reduce each large task into small tasks.  He 
asked us to please continue doing our exercises twice a day, but if that 
was difficult, to at least do them once a day.

Then, Bernard started the slide presentation.  The following are notes I 
took during this slide presentation.  The subject was "Understanding your 
Back."

Eight out of ten people will experience back problems in their lifetime.  
There are an average of 400,000 every year who experience occupational back 
injuries.  70% - 90% of all back problems are from injuries.  The average 
cost for care for back injuries is $5,000.  There are approximately two 
billion people per year who experience back problems.  Approximately six 
billion people are presently under treatment for back problems.

When someone experiences back problems, the following is what can happen:

     . Pain
     . Lost time from work
     . Expense
     . Inconvenience
     . Disability

Even cavemen experienced back pain.  Presently, in modern times, we 
experience degenerative changes.  We should avoid straining our 
back.  We must learn to lift properly, and not lift more than we can 
handle.  Prevention is easier than treatment.  You must take responsibility 
for your back.

The slide presentation (with narration on tape) went into some detail 
about:  Bones, ligaments, joints, muscles, nerves, and blood supply.

*Bone - There are 33 bones in our spine called vertebrae.  The first 6 are
cervical; the next 12 are thoracic, and the last 5 are lumbar (which sit on 
top of the sacrum).  The last 5 are fused in adults and are sacral.  At the 
very base of the spine is the coccyx, 5 small vertebrae that are all that 
remains of the tail, a hangover from our revolutionary past.  Discs in 
between the vertebrae act as shock absorbers.

*Ligaments - surround the spinal column to help keep the back strong.  Think of the ligaments like one of those plastic rings that holds soda 
or beer cans together.  If you take the rings and pull very hard, it 
stretches.  When you stop pulling, they do not go back into shape.  
Ligaments can remain stretched. (By the way, this is what happened to 
me with my Sacroiliac Joint Dysfunction.)

*Articular (Facet) Joints - there is an oil-like fluid that guides and 
helps movement of joints.  They are close to the nerves.  Inflammation 
irritates the nerves.  A disc is considered a joint.  DJD (Degenerative 
Joint Disease), or Degenerative Disc Disease, is arthritis (normal wear 
and tear).

*Muscles - we have long, thin back muscles attached to the spine.  These
muscles are *not* meant for lifting.  Think of these muscles like rubber 
bands.  They will pull and stretch, but when pulled too far, can tear.  
Improper or heavy lifting causes injury.  Be sure to test the load before 
you lift and always remember to lift with your legs.  The muscles in your 
legs are there especially for lifting.

*Nerves - this is the body's connectors between thought and action.  Having
something press on the nerves causes pain and sometimes limited movement.
Nerves can be damaged and not receive the proper signals from the brain.

*Vascular (Blood Supply) - is carried by the arteries and veins.  A disc 
has no direct blood supply.  It needs movement to remain healthy.  Always 
move with smooth, non-straining motions.  A quick jerk or sudden turn (or 
sometimes, even a very big sneeze) can damage a disc.  There are cases 
where a damaged disc has no known cause (like me).

After the slide presentation, Bernard said that we all must learn how to 
relax!  That we should find even 30 minutes a day to be by ourselves 
(without phones, without kids, without spouses, without interruptions).  We 
must get away from people and from distractions.  He said for us to try not 
to think about our pain.  One of the best distractions we could do for 
ourselves, he said, was to take a vacation (if we could afford it).  "Life 
is too short to dwell on the pain," he said.  "Your pain is real!  Learn to 
deal with it so it hopefully becomes more bearable."

Bernard has a little saying that he passed on to us.  "Character is not
determined when a man is in the sunshine, but when he is in a storm!"
Perception is important.  You must feel you have value.  It helps you and
others around you.  You must, however, respond to your own limitations.  He
gave us the following example:  You have a long rope.  You cut it in the
middle.  Then, you tie it back together.  Is the rope as strong as it was
before you cut it?  No.  Are we as strong as we were before our injury?  No.

Bernard mentioned that if we could, we should read about something called
"Conflict Resolution."  (It just so happens that a gentleman by the name of 
Bob Johnstone, a Psychologist in California, has written me about Conflict
Resolution.  If I can get his permission, I will have a file available for
download on this subject.)



********** **********

Dr. Frank Brotherton mentioned that the pain clinic is now doing something
differently.  They have started having a follow-up group about three months
after the group sessions are finished.  He said for those interested, they
would send out a letter informing us when it would be held so we could 
attend.  At that follow-up group, we could report on our progress, and ask 
questions that we may not have had the opportunity to ask in the six week 
group sessions.

Dr. Brotherton talked about "Pain Behavior."  He said that pain is a 
private experience.  Only *you* have access to your pain.  Your pain cannot 
affect others.  What affects others is your behavior when you are around 
them.

There are two main characteristics that affect other people when you are in
pain:  (1) Verbal - what you say; and (2) Non-Verbal - what you do.

People basically don't want to know about your pain.  Moans, grunts and 
groans, and your tone of voice aren't really considered verbal or non-
verbal.  These are sort of an in between characteristic.  Verbal is very 
obvious and consists of you saying something like, "Gee, I sure am in a lot 
of pain today."  Non-verbal consists of your facial expressions, change in 
body language, faking a smile, apathy (blank look), etc.  An example of 
apathy is the look on the faces of the concentration people that we have 
all seen in movies.  Body language is shown to others as your gait, 
posture, gestures, etc.  These are habits.

Here's an example he gave us.  When a person breaks their leg, it's put in 
a cast and they walk on crutches for awhile.  When the leg is healed, and 
the cast is removed, more times than not, that person will still limp.  
Physical therapy is usually required to teach that person how to walk 
normally again.

All of these things affect others negatively, which, in turn, affects you. 
Say, you're walking down the street and you see someone you know. This 
person has his head hung low, and he's walking very slowly, and walks as if 
he's in a *lot* of pain.  More than likely, you won't say something to this 
person, but will try to avoid contact with this person.

He asked us a question.  He said, "If you could get up out of the chair and
leave your pain behind in the chair...would you?"  Of course, we all 
answered "Yes!"  He then said, "Well, what makes you think that other 
people wouldn't want to do the same thing?  They don't want to be around 
you if all you do is complain about the pain all of the time." Zap!  There 
went the lightbulb in our heads.  It finally made sense.

We *do* get quite different responses from different people when we are in
pain:

1.  Attention
2.  Assistance
3.  Sympathy
4.  Avoidance
5.  Anger

1.  Attention - it can be good and it can be bad.  Sometimes you should
    modify your behavior depending on the circumstances.  Regulate your
    pain behavior according to the consequences.  Sometimes you need to
    have the attention from others in order to feel like a part of life.
    However, too much attention can make you feel worse and increase your
    pain.

2.  Assistance - being dependent on someone can be negative.  If you are
    doing something, and someone says something like, "Now, you know you
    can't do that...here, let me do it for you."  This is wrong if you
    feel it is something you can do.  Just tell them politely, "No, thank
    you...I can manage (or I can learn to do it myself)."  Be assertive.

3.  Sympathy - people might give you sympathy because they don't know
    what else to do.  *Empathy* is what you need.  It's trying to
    put them in your shoes.  Society teaches us sympathy, when what we
    need is empathy.  Try to find some sameness - an experience where
    they can relate to us, or had a similar experience.  Empathy is
    being a good listener.

4.  Avoidance - if attention, assistance, or sympathy doesn't work,
    people might try to avoid you.  Isn't that what happens to a lot of
    us with doctors?  They give you the attention that you are asking
    for when you first see them; then they give you assistance.  If what
    they do doesn't work, they give you sympathy.  Then, they refer you
    to another doctor or tell you that they can't help you.  This is
    avoidance.  Now, some people (spouses and children) are stuck with
    you!  Then, since they can't avoid you, they get "angry" at you.
    This is called, "Blaming the victim."

5.  Anger - this is the last response anyone can give you.  Sometimes,
    spouses take up hobbies, start working later at the office, and in
    extreme cases, get a divorce.  Can this be avoided?  Probably, if
    it all came as a result of your pain behavior.

Pain behavior causes all of the above.  But, remember, you yourself are
affected by your own pain behavior, too.  If *you* holler in pain, *YOU* 
pay "attention."  You help yourself, (but not too much) and this is 
assistance.  Pain phobia is caused by constantly thinking about pain or 
pain phobia is caused from a dramatic injury.  You can feel sorry for 
yourself (sympathy).  Distract yourself (avoidance).  If you say, 
"This is not me...I'm just not myself today.  I hope to be *me* again,"
then you are directing anger at yourself.  Be angry at your pain, but not
at yourself.  Admit that "This is me!"  Have regret instead of guilt.  
Do a lot of "self-talking" to yourself in positive terms.



********* *********

Karen Kramer took us through another relaxation technique.  She had us 
close our eyes and find our pulse.  Then, as we breathed in, we counted our 
pulse beats.  We did the same as we breathed out.  She said that for some 
people (like me) who get distracted easily, this counting helps them relax.  
You can hold a necklace made out of beads, and just count them as you 
relax.  You can use anything to concentrate on, and it may help block out 
the distractions and keep your mind from wandering.

She said that even when walking, we can meditate (like some Monks do).
This is relaxation while active.  She said we need to relax 
everyday...little by little, it will improve.  She said we need to be 
kind to ourselves and  treat ourselves nice.  We need to take care of 
ourselves.

END OF GROUPS


I must say that although my chronic pain has not diminished, my attitude 
has improved 100%!



********** **********

Handouts


PAIN BEHAVIOR AND SOCIAL INTERACTION

The title of this topic may seem a little odd to you.  Until this point we 
have had a lot to say about pain, but now we are talking about *pain 
behavior.* Pain behavior refers to what people actually do when they are in 
pain.  It's what communicates to others that they are in pain.  As we have 
mentioned before, pain is actually a very private experience; no one can 
truly know the pain of someone else.  We can't see anothers pain, or hear 
it, or experience it.  But we can "know" another person's pain indirectly 
by observing what they do--their pain behavior.

People express pain in many different ways, partly determined by their pain 
and partly determined by their:

  1.  Culture (e.g., southern Europeans express more pain behavior
      than northern Europeans)

  2.  Personality (e.g., some have developed more pain tolerance
      than others)

  3.  Developmental history (e.g., some have been exposed to
      conditions which encourage pain expression, while others
      have been exposed to parental up-bringing which discourages
      pain expression)

Among the many ways that we express pain, perhaps the most obvious is 
through words and sounds (verbal pain behavior).  When we tell someone that 
we hurt and when we describe our pain to others, we are using verbal pain 
behavior to communicate about our pain.  More interesting and less obvious 
are the ways that we communicate pain without words (nonverbal pain 
behavior).  Some of these nonverbal pain behaviors include facial 
expressions, gait (the way we walk), posture, and gestures (body 
movements).  You may have discovered that others around you, especially 
those who know you well, can often tell when you're in pain even when you 
try to hide it.  Most likely they are judging your pain via nonverbal pain 
behaviors, many of which you yourself are unaware.

One of the many interesting things about pain behavior, especially 
nonverbal behavior, is that it is often unintentional.  That is, you may be 
in the habit of doing certain things when you're in pain, and you may not 
be aware of the things you do that let others know you're in pain.  
Moreover, pain behavior often becomes a habit that may communicate pain 
even when it's not present. For example, when someone breaks a leg and has 
to wear a cast for several months, the person learns to walk with a limp 
out of necessity.  But when the cast is removed after the injury has 
healed, the person still walks with a limp and often must learn to walk 
normally again with the assistance of a physical therapist.  Consider for a 
moment how many of your own pain behaviors may have become habitual, 
communicating pain to others even when you don't intend to and even when 
you're not in pain.

As noted above, pain behavior communicates pain to those around you, and
because we are human beings, other people respond to our pain in rather
predictable ways.  Here we will focus on some of the undesirable reactions 
of others to our pain.  *First, pain behavior attracts attention* from 
others.  If someone moans or cries out in pain, others will notice and 
perhaps look to see what's going on.  A person in a wheel chair attracts 
attention, as does a person with a limp.  Of course, at times, you may 
desire attention for your pain, but most patients who have been n pain for 
a long time report that they don't want or need much of the attention they 
get -- loved ones always looking for signs that you may be in pain, people 
noticing how you walk or sit, and others observing and wondering about the 
pained expression on your face.  One way to decrease this negative 
attention from others is to be aware of your pain behavior and eliminate 
unintentional pain behavior and control other forms of pain behavior.

*A second reaction of others to pain is to offer assistance.*  We have all 
been trained to try and relieve the suffering of those around us whenever 
we can. Of course, you may want and need some of the help you get because 
of your pain, but other forms of assistance become annoying and unpleasant.  
Handicapped people often report that it is difficult to learn to do things 
for themselves because others are always offering their assistance.  
Imagine a person in a wheel chair trying to learn to open doors 
independently.  If they are in public, someone will almost always offer 
their well-meaning help.  You may also find that it is difficult to do 
things for yourself because others are always offering to help.  "Don't do 
that, you'll hurt yourself."  "Here, let me do that for you."  "You know 
what will happen tomorrow if you do that today." "You just sit down and 
rest, and I'll take care of that."  As a matter of fact, many people who 
have been in pain for a while don't even know what they can and can't do 
anymore, because they've developed the habit of relying on others more
than necessary.  This is a case of too much of a good thing, and you may 
need to be assertive in stating your desire to learn to do certain things 
for yourself.  If you are receiving more assistance than you really want, 
or more than is good for you, you might want to take a look at your own 
pain behavior that is prompting this reaction from others.

*A related reaction from others is sympathy.*  At times you may think you 
want sympathy from others, but sympathy is one thing that is almost always 
bad for us in the long run.  Imagine for a moment that everyone feels sorry 
for you all the time.  Poor, pitiful you.  Everyone sees you and thinks 
immediately, "Oh, that pitiful human being; I feel so sorry for her (or 
him)."  Before long you would feel like nothing -- worthless, useless, 
somehow less than everyone else.  That's what sympathy does; it puts you 
"one down" in relation to the person giving it.  Pretty soon, you are 
robbed of any sense of self-worth or self-esteem.  Depression and self-
hatred may be the end results.  But you do probably want understanding from 
others, and that's *empathy*, not sympathy or pity.  Your pain is an 
important part of your being, and it is natural that you want others to 
appreciate how you feel at times, at least those who are especially close 
to you.  Don't confuse empathy with sympathy.  Frequent pain behavior is 
most likely to get sympathy from others; occasional open and honest 
communication with others is likely to result in empathy or understanding.  
If you are feeling useless and worthless, this may be due partly to 
misguided, or even unintentional, pain behavior that tends to elicit the 
sympathy of others.

*Another reaction of others is anger or annoyance.*  This reaction is 
almost never desired by the person in pain and it is a difficult reaction 
to understand when it comes from loved ones.  How is it that one who truly 
cares for you could be angry at you for your pain?  One reason, of course, 
is that the loved one suffers some of the same frustrations you suffer when 
in pain.  Their life is also changed and limitations are imposed.  But 
there are other more subtle reasons that the pain of one person can elicit 
anger and resentment in another.  These reasons stem from the fact that 
seeing a loved one suffer is also painful to the observer, and it is 
especially frustrating when there seems to be nothing they can do to ease 
your suffering.  Just as your pain elicits anger in you, the indirect pain 
experienced by the observer elicits anger in them, anger which may be 
unintentionally directed toward you.  Their anger and frustration is 
especially likely to be directed toward you, especially if they can find 
some reason to blame you for your pain.  They may accuse you of bringing it 
on yourself by not taking care of yourself, not following the doctor's 
orders, not following their advice, not doing what you can for yourself, or 
exaggerating your pain, etc.  Note how this tendency to "blame the victim" 
takes away some of their pain.  Now, when they see that you are suffering, 
they don't have to suffer so much with you since you are now somehow 
responsible for your pain.  Without realizing it, they have learned to 
reduce some of their own suffering by changing their attitude toward you, 
and that is a powerful source of motivation.



********** **********

PAIN BEHAVIOR AND SOCIAL INTERACTION (continued)

Related to anger and annoyance is the *reaction of rejection and 
avoidance.* If it is annoying to be around someone who exhibits pain 
behavior, if it creates suffering in the other as well as in the person 
with pain, then it is only natural that loved ones and friends will begin 
to avoid contact with the patient.  Others around you have choices which 
you do not have -- they can get away from the pain.  Rejection and 
avoidance takes many forms, among which are ignoring the pain behavior, 
staying away from home, developing outside interests which keep them 
involved, devoting themselves to their work, etc.  Sometimes even divorce 
is the final rejection or avoidance.  Or maybe they just withdraw 
psychologically into their own world of thoughts and activities, leaving 
the patient feeling deserted and more alone.  The main point here is that 
these are natural reactions of those constantly exposed to the pain 
behavior of others, reactions which are, ironically, motivated initially by
care and concern.  Think about it -- if they didn't care about you, then 
your pain would not bother them so much.

If the pain behavior continues over a long period of time; and if anger,
rejection, and avoidance are not successful coping patterns, then a *sense 
of frustration, helplessness, and eventually depression sets in.*  We often 
see spouses of pain patients who are equally or more depressed than the 
patient is.  The mental and emotional consequences to family and friends 
should not be ignored, for they too suffer the consequences of pain.  Many 
studies have shown that when one is exposed to aversive or painful events 
repeatedly without any means of control over these events, one eventually 
gives up and slips into hopeless despair.  In a way, you are more in 
control of your pain than those around you are, and though your suffering 
is greater, you know what will and will not help.  Those close to you often 
feel even more helpless, since there is often little or nothing they can do 
for you.  Your suffering may be greater, but their sense of helplessness is 
at least equal to yours.

*A final consequence of exposure to long-term pain and/or pain behavior is
resignation.*  By resignation, I mean a kind of giving up in which the 
people involved come to accept things the way they are not as unchangeable 
and begin to adapt their behavior to the way things are now and ever shall 
be.  Once family, friends, and acquaintances have resigned themselves to 
the way things are, they quit trying to change things and settle into a 
kind of uneasy complacency which can then make any kind of change for the 
better extremely difficult to achieve.  This kind of resignation should be 
distinguished from *healthy acceptance.*  In acceptance you accept things 
the way they are, quit denying reality, and set about actively coping with 
and trying to improve the situation.  In resignation you accept things the 
way they are and give up trying to change them.  Acceptance is full of 
realistic hope and motivation; resignation is giving up in despair and 
depression.

You are most likely very aware of at least some of the reactions of others
described above, for you have probably reacted in similar ways to others 
who have been chronically ill or in pain.  But you are probably not very 
aware that *you react to your own pain behavior* in some of the same 
unfortunate ways that others react to you.  We are all observers of our own 
behavior--we watch ourselves, we listen to ourselves, and we react to 
ourselves, but we often don't realize the extent to which we do it and the 
effect it has on us.  For example, we tend to *pay attention to our own 
pain behavior.*  If there is constant and dramatic pain behavior, then we 
end up becoming overly attentive to ourselves in that we become self-
centered.  Many people have noted that many of those who suffer tend to 
become selfish over time.  This is a very understandable and very human 
reaction, but nevertheless one that is to be avoided when possible.  *We 
may also try to help or offer assistance to ourselves,* and within reason 
this is a healthy reaction.  But, if we are constantly showing pain 
behavior and constantly focusing on helping ourselves, we can become 
preoccupied with self-pampering and pain-avoidance, so much so that we may 
try to arrange our whole environment (indeed, our whole lives) around the 
avoidance or lessening of pain.  Similarly, our own pain behavior can lead 
us to *sympathize with ourselves* to the point where we engage in "woe-is-
me" thinking and self-pity, and we thereby contribute to our own sense of 
worthlessness.  Many of you are already well-aware that your own pain can
make you *angry at yourself.*  Just as others become angry with you, you 
also at times tend to blame yourself for your pain, leading to even greater 
feelings of worthlessness, self-hatred, and eventually *depression.*  We 
have noted above that others may start rejecting or avoiding contact with 
us if our pain behavior is too discomforting to them, but it may seem 
impossible to *reject or avoid yourself.*  You can't run away from 
yourself, we say.  But some people will try to do just this by denying this 
is the way they really are.  For example, one may say or think, "This is 
just not me--the real me was five years ago, before all this started."  Or, 
"If I could just get rid of this pain, then I could be myself again."  What 
we fail to realize is that by denying that "this is me," we are denying our 
own existence, our own sense of personal identity.  If this is not you, 
then who is it?  Nothing.  A shell.  Emptiness.  And this is the way we 
begin to feel about ourselves.  A healthier and more productive attitude 
would be to accept yourself the way you now are without committing yourself 
to always being that way..  This is me, and I will have to cope with it for 
the time being.  It doesn't mean I will always be this way; there are 
things I can learn to do that will help change the situation.  The
alternative is, of course, the *resignation and adaptation* discussed above
that makes any further change so difficult.

To summarize the major points made thus far, it is first important to be 
aware that our pain is communicated to others (and ourselves) by the way we 
act or behave when in pain (pain behavior).  Secondly, in this way our pain 
affects others (and ourselves) in ways that are often undesirable.  It can 
lead to unwanted and excessive attention, assistance, sympathy, anger, 
rejection, depression, and adaptation or resignation.  We can exert some 
control over these adverse reactions by first being aware of, and then 
learning to control pain behavior.  This is not to imply that your pain 
will go away if you just pretend and act like it's not there.  Nobody is 
suggesting that.  What *is* suggested is that failure to regulate and be 
aware of pain behavior and its effects can lead to bewildering and 
distressing reactions from other people (even from ourselves) -- reactions 
that only serve to increase suffering.



********** **********

MINI-RELAXATION EXERCISES

Breathing is the touchstone for awareness and recognition of the choice to
relax.  Since breathing goes on 24 hours a day, it affords a constant
opportunity for bringing the relaxation response into every aspect of daily
life.  Try to cultivate the habit of noticing your breathing as frequently 
as possible during the day, using it as a cue to be aware of yourself while 
using the exhalation to "let go" and relax.

In addition to general breath awareness, you may choose any of the 
following mini-relaxation exercises to use as frequently as you need during 
the day. Some of the minis are mental exercises and some are physical, but 
all have breath awareness in common.

Mental Exercises

1.  Breathing exercises

    a.  10 to 1 countdown:  Center in the breathing, letting go of
        tension as completely as possible with each exhalation as you
        count backwards from ten to one, repeating each number on
        successive exhalations.  Feel that tension drain from head,
        arms, body, feet as you breathe out each time.

    b.  Diaphragmatic breathing:  Breathe in to the count of four,
        letting your abdomen expand like a balloon.  Hold for the
        court of four.  Breathe out to the count of eight, letting
        you abdomen gradually flatten.  You can concentrate on the
        experience of the air entering your body, following it to
        the area of the abdomen and watching it leave.  Repeat this
        breath ten times.

        Note:  If you have a problem with this breath exercise sitting
        up, practice it lying on your back, and as you master it,
        gradually try it leaning back in a chair and finally sitting
        up straight.

2.  Exercises of imagination

    Each of us imagines in a different way.  Some people visualize
    scenes, others recreate sounds or sensations.  Experience the
    exercises in whichever way is most comfortable for you.

    a.  Take three slow deep breaths.  Now imagine yourself lying on
        a beach.  Experience the warm sun shining from above and the
        warm sand below.  Take a few moments to remember the sensations
        that you feel when lying in the sun, the smells of the beach or
        the visual images it brings.  Now center your awareness in
        your breathing and repeat to yourself "warm" on the inhalation
        and "heavy" on the exhalation (while letting go of tension).

    b.  Imagine lying in a warm bath, letting go on each exhalation,
        while floating in the water.

    c.  Center your attention on the breathing, creating any relaxing
        image you like to help yourself let go.



*************************************************************************

SELF RELAXATION EXERCISES

1.  a)  Breathe in deeply and clench fists.

    b)  Breathe out, let go of fists, and go as limp as a rag doll.

    c)  Start yawning.


2.  Pulse and inhalation and exhalation or counting and breathing.

                           -                       -
        /\                / \                     / \
  1,2  /  \ 1,2   1,2,3  /    \ 1,2,3,4   1,2,3  /    \ 1,2,3,4,5,6
      /     \--         /       \----           /       \------


3.  Music -- selection is important.  Familiar, instrumental, quiet.


4.  Use tape only when necessary.  Modify the technique from memory.
    Make it your own relaxation.


5.  Check for tension in the body frequently throughout the day, e.g.,
    jaw, shoulders, neck.  Breathe and let go.


6.  Use red traffic light as a cue to take 2 or 3 long slow deep breaths.


7.  Elaborate on your own imagery (daydream), e.g., pool river, lake,
    mountains.  Tie it in with your breathing.


8.  Meditate on a word or phrase that appeals to you (can be religious).
    Tie it in with your breathing.


9.  Abdominal breathing, especially in bed.




********** **********

SUGGESTED READING


1.  The Path to Pain Control, Meg Bogin, Houghton Mifflin Co. (1981)

2.  Conquering Pain, Dr. Sampson Lipton

3.  Free Yourself from Pain, David E. Bresler with Richard Trubo.
    New York:  Simon & Schuster (1979)

4.  Power Over Your Pain without Drugs, Neal H. Olshan.  New York:
    Rawson, Wade Publishers, Inc.  (1980)

5.  Pain Control - The Bethesda Program, Bruce Smoller, M.D., and
    Brian Schulman, M.D.  New York:  Doubleday & Co, Inc.  (1982)

6.  Mastering Pain, Richard A. Sternbach, M.D.   G.P. Putnam's
    Sons, New York  (1987)

7.  Coping with Chronic Pain, Richard W. Hawson and Kenneth E.
    Gerber.  New York:  The Guliford Press  (1990)

8.  Relexation Response, Herbert Benson, Morrow  (1975)

9.  Anatomy of an Illness,  Norman Cousins

10. The Healing Heart, Norman Cousins

11. Beyond the Relaxation Response, Herbert Benson

12. Minding the Body, Mending the Mind, Joan Borysenko, Ph.D.
    Addison-Wesley Publishing Co.

13. Love, Medicine and Miracles, Bernie Siegels, M.D.

14. Asserting Yourself, S. Bower and G. Bower

15. Assert Yourself, M.D. Galassi and J.P. Galassi


*Most of these books are available at your local library or through your local bookstore.



-end-

