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A Life Larger than Pain

The Pathway from Resignation to Renewal

by Erv Hinds, M.D. (more about this book and author)

Chapter 6: Energizing the Spirit
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Your soul is not a passive or a theoretical entity that occupies a space in the vicinity of your chest cavity. It is a positive, purposeful force at the core of your being.

–GARY ZUKAV[42]

SPIRITUALITY HAS COME OF AGE in recent years. What used to be embarrassingly passé is now popular. For many, religion provides a helpful way to organize life around an inner center. It keeps us from becoming mired in the superficial and materialistic. It ritualizes our need to take time out and pay attention to the intangibles, to nurture the self we often neglect in our rush to do and achieve and consume. It is not easy to take time out from schedules and demands to practice the life of the spirit. It is a gift to be compelled to do so, and that is the blessing that accompanies the curse of pain. The very thing you've been putting off, which you said you would get around to someday, has become a necessity. You are catapulted into this need to move beyond the physical plane of life not just when you get to it, but now: this is the place where you will find the help you need to carry the burden of illness.

As with anything trendy, spirituality can be trivialized as little more than a pleasurable experiment on the path to self-enhancement. Those in pain do not have the luxury of pursuing self-enhancement hobbies. Their need is raw and immediate. The resources they turn to must hold up under pressure that would buckle anything inauthentic.
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I was once called in to manage the pain of a forty-four-year-old woman dying of adenocarcinoma of the lung, found in only about 7 percent of total lung cancer cases. Martha Conley's affluent family had been able to afford experimentation with a multitude of alternative treatment therapies. Following her lung biopsy they had pursued macrobiotic therapy in California and from there went to Mexico for even more non-traditional care. Martha's husband was a strong advocate of psychology-based approaches to defeating illnesses, especially meditation techniques and intentional thought processes. When they learned about the variety of alternative practices available in Santa Fe, he championed the family's move.

Sadly, before long Martha was admitted to the hospital emergency room in extreme pain. As soon as her husband left the room, Martha turned to the nurses and begged them for help. The nurses were able to get her admitted to our extended care wing, called El Cariño (for cariñoso, caring). When I arrived, discussions had been underway concerning pain medication. Martha was anxious, confused, and exhausted. Her husband disapproved of pharmacological methods for handling his wife's pain, but he began to relent. We started treatment with different kinds of oral narcotics, anti-emetics, and patches placed on the skin to act as long-acting narcotic reservoirs. Eventually, Martha required IV narcotics to control her pain.

When I first went in to meet Martha, I held her hand and listened to the person inside the wasting body. We talked about her pain and fear and her desire for a sense of peace. As the question arose of how to accomplish this, I felt compelled to discuss non-denominational, generalized spirituality and asked about her background. She had been raised as an Episcopalian, although she had not been in a Christian church for years. Over the years she had toyed with so-called New Age ideas, but she had jumped from one system to another with little depth or staying power.

After about three sessions Martha eventually identified that deep within her was a belief in a loving Father, in the person of Jesus who suffered for our sins. We discussed the suffering of the saints in every religion–the difficult, painful deaths of many of the apostles, of many well-known gurus in other traditions, and most assuredly the painful suffering of

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Jesus on the cross. It took several sessions for her to begin developing a sense of affirmation that she was in good company if people like this could suffer. We reflected on how our lives are brief and transient moments in the span of existence. Pain brings us to our knees, giving us the opportunity to look toward eternity.

Martha's intense anxiety began to drain away as peace welled up within her. We called a local Episcopal priest, a warm and loving man who helped her deepen this peace and gain some closure. Martha had been estranged from her mother for years, but they reestablished communication across the bridge of forgiveness. Two sons also arrived. Joy and sorrow intermingled as wonderful reunion moments took place in her room in the midst of suffering. Her husband had become much more accepting of the benefits of Western medicine, and her relatives approached the reality of her impending death with a sense of peace and purpose.

This upper-middle-class woman, lulled by material comfort, had ignored her spiritual search for years. When all else fell away, the spiritual was the only realm that held any hope for her. She was able to reach deep down within to the fragments of belief and come up with the recrudescence of what was true for her. She did this in a remarkably short time, and it gave her a powerful sense of peace and raison d'être. Just as anxiety markedly accentuates pain, so does peacefulness markedly inhibit its intensity. The pain still afflicted her, but only intermittently, and it was overridden by her quiet confidence.

Illness and pain compel patients to find their own authentic faith. For some, this spirituality is well-defined. For others, it is a misty, uncharted landscape. We have so many choices and listen to so many different voices, it can get in the way of staying with one set of beliefs long enough to practice them. Many of us were started off as children in some kind of religious tradition that we abandoned along the way or perhaps even came to resent. Yet at least a seed was planted that could later be revitalized. I have seen how this early influence can be harvested years later to bear fruit in a spiritual awakening that yields a new sense of meaning.
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Material comfort sometimes breeds the delicious illusion that we can skate comfortably along the surface of life from one pleasant destination to the next. When the ice cracked open for Martha, she had a lot of work to do. But even this eleventh-hour change opened up a larger world that gave new meaning to her life while she was preparing to leave it.

In the broadest sense, renewing the spirit means doing whatever helps you grow inwardly, to strengthen you for dealing with the physical pain. Spiritual practice is a profoundly effective way to be beyond the moment. When you're inside pain, you are trapped in the moment. When you can transcend the moment, you are moving into something bigger than the pain. Each time you acknowledge and act on whatever is spiritually authentic for you, you are building a life larger than your pain. It will not happen all at once. Just as physical exercise will help you build body strength and mental exercise will help keep your mind active, regular spiritual practice will nourish your inner life. As you keep taking steps forward in your journey of faith, the larger context in which you find meaning and purpose beyond the pain will become more real to you.

Until the fairly recent emergence of complementary medicine, conventional treatment and alternative health have been on opposite ends of the spectrum between evidence-based science and non-scientific metaphysics. Although the dichotomy is beginning to ease, there will be a need to inform physicians about your intent to seek spiritual resources while participating in concrete Western medicine. This hasn't always been the case, however.

spirituality: a stranger to the healthcare system

In Prayer: The Heart's True Home, Richard Foster observes that the distinction between priests, psychologists, and physicians is a relatively recent one.[43] In the past, the physician of the body, the physician of the mind, and the physician of the spirit were the same person. The ancient Hebrews, in particular, saw persons as a unity, and for them it would be unthinkable to minister to the body without ministering to the spirit. The Zohar, a thirteenth-century work of Jewish mysticism, advises the physician that if he "cannot give his patient medicine for his body, he should [at least] make sure that medicine is given him for his soul."[44]
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Treating pain patients forces healthcare professionals back to an earlier era in which doctors relied on the art of medicine, rather than on the science of medicine, to facilitate healing. The doctor's responsibility is not simply to alleviate pain, but to help patients reframe an illness discussion to a wellness belief. For most patients, what is wrong with the body is far outweighed by what is right with the body. Enlisting the strength of the healthy parts will help shore up the weak parts. The dispiriting thought, "I am not well," needs to be replaced with the affirmation, "I am a well person with a problem." Physicians can encourage their patients to participate actively in their own wellness–to recognize their gifts, including their unique spiritual strengths, as powerful catalysts to the healing process.

Our culture has traditionally drawn clear boundaries between religion and science, the invisible and the visible, the intuitive and the verifiable. If it is hard for pain patients to accept the mystery of healing, it may be even harder for physicians. They are trained to raise questions in order to find answers. A healthcare provider raised on lab tests will find it difficult to shift gears into the mystery of the spiritual. But these realms are not mutually exclusive. The reality of the broken or maimed part does not mean physician and patient cannot simultaneously explore the spiritual. Physicians are slow to take the lead here, because it is not concrete. They are used to dealing with identifiable cause and effect. Once they learn to respect mystery, however, they become more mature physicians. They can celebrate the journey of healing with their patients without having to understand it. If a patient improves inexplicably, they can embrace the progress instead of obsessing over why it occurred.

Sometimes it is necessary to leave the questions unasked in order to provide what the patient truly needs at a given moment. Why me? is not so much a question as a cry of suffering. When patients are grappling with why they are having pain, I have been known to launch into scientific explanations of neuropathways, dorsal horn of the spinal cord physiology, and neurotransmitter linguistics. If I notice that patient and relatives grow distracted and their eyes glaze over, I will ask solicitously, "Would you like me to explain that again?" "No, that's quite all right, doctor," they inevitably reply.
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There is a time for consolation, not explanation. When your best friend agonizes, "What did I do to deserve this?" you don't chronicle her personal weaknesses, trying to identify causal factors. You reassure her of your commitment to be there for her. Sometimes, what patients need most from doctors is simply a few minutes of human presence to buffer the delivery of information.

Americans spend billions of dollars each year on alternative therapies, in part because the traditional doctor-patient relationship has deteriorated. Alternative medicine more often meets the patient's need for a hands-on relationship rather than an impersonal transaction. It often does so with appropriate touch, something that technology-based care has insidiously abdicated. Physicians are far more effective when they not only care for patients but also about them. When people are sick, their functioning is reduced to a level akin to that of children and animals. They survive on intuition and instinct, and they can usually sense the other person's true level of interest or concern. Faith in the physician can help facilitate healing; distrust or feeling depersonalized can help thwart healing.

Most pain patients have already been failed by the promise of more sophisticated technology or a more efficient healthcare system. They need a doctor who will look at the whole person before assessing what is best for the hurting parts. Perhaps more than in any other area of conventional medicine, pain management is dependent upon the model of partnership between physician and patient. The hierarchical model, in which the patient passively submits to the authority of a professional who dictates treatment like a military superior assigning orders, simply does not work. The partnership model requires many changes in the way we currently practice medicine. For patients, it means an open exchange of information and insight, a willingness to learn and to put into practice the mind-body techniques that can alleviate the pain.

In the evolving world of managed care, sometimes called "care of the managers," I find myself in frenetic, chaotic, and time-squeezed circumstances. In addition to my work at the pain center, I am often called into surgery to perform as an anesthesiologist. Many years ago, anesthesiologists made preoperative visits. They got to know the patient, explained

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the surgical procedure, and addressed some of the pain from the anxiety and fear at the eleventh hour before surgery. Now, it is increasingly difficult to focus on patients' pain and anxiety. Many patients are admitted and released on the same day of surgery, and they see me for only a few minutes before their procedure.

In the past I would have held the patient's hand or taken the patient's pulse, sat down by the bedside, and listened. In this encounter, I would develop a sense of the patient as a person, beyond just the raw medical condition. We would discuss the operation. During the physical exam, I would thoroughly listen to the heart and lungs and examine the airway and appropriate anatomy, all the while attempting to be reassuring. This encounter with the patient took time.

Now, in the managed care system, I have less than two minutes to do a history, perform a physical, and project an authentic concern for the patient. Then, off we go to surgery. I usually give something intravenous to alleviate fear and anxiety. I catch myself saying the same thing to each patient. There is a sense of hurry I am sure the patients pick up. Some of them want to get this over with and move on, but most would like genuine interest and expertise from the anesthesiologist. Because of the speed at which the operation must be performed, all the professionals involved–the scrub nurse, the circulating nurse, the recovery nurse, the surgeon, and the anesthesiologist–develop what I call a "mode of automaticity."

In the moments right before an operation, I no longer have time to watch for cues, whether spiritual or psychological, for how a particular patient is approaching this intervention. If the patient wants prayer from a spouse or minister, it is almost impossible for me to notice it. In the past, as the patient was going to sleep, I would have tried to affirm or reinforce the spiritual beliefs manifested by the patient or by the family.

Healthcare workers will often intone, "Just relax," as if this were possible for someone who has spent a lifetime being anxious over intervention. This one-size-fits-all approach overlooks how complicated and individualized the pain experience is. The patient's perceptions of pain may be rooted in their belief systems, woven into their expectations, and intensified

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by fears from childhood. Pharmacology may or may not alleviate pain, but using it as the exclusive treatment ignores other pain generators–anxiety, fear, and loneliness.

In this day of less hands-on attention and more hands-off mechanisms, pain management centers become almost the first line of defense with many patients. It may be here that the patient is touched and fully examined for the first time. The pain center is the natural place to listen for clues of spirituality and the natural place for complementary medicine. This is often the first place where the patient is touched appropriately–physically, psychologically, or spiritually–by medical care professionals.

Our pain center blends left-brain and right-brain approaches–the search for concrete, empirically verifiable interventions as well as the Native American way of embracing mystery and seeking harmony. Since we are open to many alternatives, we can avoid the therapeutic tunnel vision of simply writing prescriptions or doing procedures. We are often fortunate to see direct results of specific interventions, but we don't have to attribute overall success to a specific modality alone. We respect the reality of our patients' suffering, honor their journey through it, and celebrate the mystery of healing in its many forms without demanding solutions.

When we learned that one of our patients was dealing with the death of his daughter, we called him as soon as we heard about it. The next time I saw him, I simply put my arms around him. As I felt his tears on my shoulder, I wondered if he had ever been hugged by another man. This man had endured many procedures when he came to us, most of them unsuccessful. We were able to modulate the pain with some appropriate adjuvant non-narcotic medication, but our greatest help, I think, has been a strengthening from within. He is a different person, emotionally and spiritually, than the man who first walked through our doors. He was catapulted into a dimension of life he had never known before, and he now has a strong sense of his own inner growth. He feels a certain accountability to us for this new development, and he no longer goes to a primary-care physician. He comes to the pain center twice a month not so much for the back pain, but because we're the only ones who have

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recognized that his grief is more significant than the pain from his back surgery.

Although physicians readily make referrals for psychological support or physical therapy, most tend to be uncomfortable with helping patients get spiritual support consistent with their patient's religious background or current beliefs. Many of them are now recognizing, however, that this factor has as much potential as any other aspect of medical care to meet patients' needs–not by taking the place of those other approaches, but by complementing them in laying a foundation of support for the healing process. Some healthcare workers may feel it is intrusive to listen for cues to a patient's spiritual beliefs, but more and more patients are asking to be treated as a whole person, including the request for spiritual support in times when their health is challenged.

To integrate the dimension of spirituality into the treatment of pain requires a partnership of healing between patient and physician, even more so than decision-making about procedural interventions, physical therapy, and mind-body techniques. If you are facing a surgical procedure without the spiritual support you need, ask friends, family, a chaplain, or a local church leader for help. Let your medical team know what you are doing and why, so they can cooperate as much as possible. Ask your physician about his or her comfort level with integrating spiritual resources in your treatment.

practicing renewal

When I set apart quiet time in the morning because I'm anxious about the potential land mines of the upcoming day, I practice Christian meditation to calm my spirit. Richard Foster, the Quaker author, has been my mentor.[45] One exercise he teaches involves sitting and in a rhythmical pattern breathing in the grace of God, breathing out fear, breathing in the Holy Spirit, breathing out anxiety. This practice is especially helpful with patients anticipating surgery.

The power of spiritual renewal, combined with appropriate pain treatment, was especially evident in a patient of mine suffering with complex regional pain syndrome (RSD), a sympathetic nervous system dysfunction

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causing agonizing neuropathic pain (of nerve origin). Jennifer Knott had RSD in two, possibly three, extremities. She was miserable and deactivated, with other health problems including bilateral mastectomies for breast cancer. A speech pathologist, Jennifer was running out of energy and spirit as she desperately sought a way to continue functioning effectively.

We tried numerous meditations, blocks, and methodologies to deal with Jennifer's neuropathic pain. She started warm water exercises, which began to make a difference. She progressed rapidly, acquired a swim coach, and started training for the Special Olympics.

Jennifer's hope for a future began to distance her from a life dominated by chronic pain and helped her revive a dormant spiritual seed. She had been raised traditional Catholic, and although she hadn't fallen away from the church it was hard for her to integrate her Catholicism effectively in managing pain. We helped her locate a Jungian psychologist, who was also a priest, to help her integrate her struggles with her spiritual growth. This, along with her swimming, enabled her to build a stronger sense of self, reasons for hope, and ways to celebrate her unique personhood.

Jennifer improved so significantly that she won several gold medals at the national Special Olympics and became a local hero in the Albuquerque newspapers. In the process of reactivation, she found a special place where she was acknowledged and applauded. She built a track record of accomplishment while continuing to deal with painful RSD. Physiologically, she progressed significantly, although intermittently she continued to need a wheelchair. She has helped other chronic pain patients reactivate themselves by finding and nurturing their spiritual center.

the transforming power of prayer

Although there are many components to the spiritual life, I believe prayer is foundational. It is the movement of your spirit, and it will move you beyond somatic (body-focused) preoccupation toward the larger life that is not dominated and defined by your illness or injury. It nurtures the

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spirit as it quiets mind and body, strengthening the inner life just as weight-lifting builds muscle. Prayer takes as many different forms and expressions as there are individuals and beliefs, but it has proven to be consistently effective in healing and maintaining health. No one can substantiate supernatural answers to prayer, but scientists have proven that it has top-down calming effects physiologically (see chapter four). However, you don't have to understand why prayer works in order to embrace it and practice it.

Prayer is perhaps the shortest route from our society's obsession with youth, superficial beauty, and perfect health to a grounded awareness of what is truly life-giving. In his book Living Our Dying, Joseph Sharp comments, "When we begin to look at our spiritual practices we begin to see that their purpose is not to inoculate us from pain but to provide us with the tools with which to process and transform seemingly meaningless pain into meaningful growth."[46] Prayer is a vital way of processing pain into growth and becoming spiritually prepared to face aging, suffering, and even death.

Our impulse is to beg God to take away the pain, because that seems the only solution to the problem. We cannot see any benefit from the pain, and all we want is an end to it. When we don't have enough insight to know how or what to pray, "Thy will be done" is perhaps the best plea. As we learn the mechanisms to modulate pain and understand how it controls our moods, prayer will begin to shift us from desperate pleading into reverence for God and thankfulness for moments of less pain. What we ask for in relief of discomfort may frequently change as we grow spiritually.

For those whose pain traps them excruciatingly inside their bodies in a hellish present that seems to have neither end nor exit, prayer can open the way to an interlude of timelessness–a merciful transcendence of suffering. This experience has been described by mystics across the world's great religious traditions–Christian, Jewish, Muslim, and Hindu. It is sometimes referred to as the "eternal now"–a state of being in which the boundaries of past, present, and future melt away in the perceived union of the soul with ultimate reality or infinite being. In their analysis of the relationship between the brain and religious experience,

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Eugene d'Aquili and Andrew Newberg refer to this altered state of consciousness as "absolute unitary being."[47]

Living prayerfully can help you integrate spirit, mind, and body in moving toward wholeness through the healing process. The spiritual disciplines of the ancient Christian tradition, such as fasting, meditation, silence and solitude, appointed hours for daily and nightly rites, and simple ritual petitions were developed to help weave prayer into the warp and weft of thought and action. Here is an example of praying the simple "Jesus prayer," an Eastern Orthodox practice. This quote is from Gregory of Sinai, a fourteenth-century monastic:

Sit down alone and in silence. Lower your head, shut your eyes, breathe out gently and imagine yourself looking into your own heart. Carry your mind, that is, your thoughts, from your head to your heart. As you breathe out, say, 'Lord Jesus Christ, have mercy on me.' Say it moving your lips gently, or simply say it in your mind. Try to put all other thoughts aside. Be calm, be patient and repeat the process very frequently.

Orthodox Christians who practice this prayer regularly attest to its transforming power to move the human spirit into communion with the Divine.

One of the most vivid examples of transformation I have been privileged to witness is manifested in the life of one of my patients, an ENT surgeon about my age, whom I have known for many years. Well over ten years ago, when I first met him, he was an aggressive professional with a strong and dominant ego, very much part of mainstream society. In our early years of working together I didn't know much about him except that he was a very good surgeon. Then he went through a very difficult divorce and somewhere in the process became a Buddhist. He pursued it quite seriously, often going away on retreat for as much as a month at a time to sit with different teachers.

Quietly and gradually, this man's personality has changed. At least from all outward appearances, he is now a peaceful, gentle, reflective soul. He no longer performs as many surgeries as he used to, and he

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regularly takes time out to be away from the office. Those of us who have known him before and after his major life change have witnessed a metamorphosis. His practice is small, his needs are simple, and his quiet contentment is clear. In the midst of great heartache, he has found a spiritual path that is true for him, and is far more valuable than his medical practice.

Many years ago, when he was just beginning his Buddhist practice, he and I had several conversations about his intense back pain. At that time I never saw him as a patient. He had learned to manage the pain without having to undergo surgery. Several years later, however, he developed significant neck pain that radiated into his upper extremities, causing weakness and numbness in his hands and fingers that threatened his surgical career. He came to me for a cervical epidural block, which entailed placing a needle in the epidural space just behind his spinal cord and injecting medication to decrease the swelling around the cervical nerve roots. The procedure was successful in reducing the swelling, giving the nerve roots some room, and consequently easing his pain. He was able to regain strength in his hands and continue surgery, but at a more gentle pace.

He seemed remarkably calm about the whole process, and he had cancelled surgery for several months. He was viewing this event from a deeper, spiritual perspective, rather than as simply an unwanted intrusion upon his productivity. After quiet reflection, he decided to come to our pain center. He was not exceedingly hopeful that the procedure–which entailed some serious risk–would completely eliminate the pain, and he was not anxious about jumping back onto the performance treadmill of medical life. Instead, he was willing to flow with whatever was going to happen, whether it would lead him into a reduced workload or even into early retirement. In meditation, he had learned to turn over the outcome by accepting whatever spiritual path this experience would take him on. The uncertainty of being on a path he could not control was even somewhat exhilarating for him.

What struck me most about this experience was not so much that he got better because of the procedure, but the content of our conversations immediately before and after. This man had been "sitting" for ten years

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in daily Zen Buddhist meditation, strengthening and deepening his beliefs. When he came to me he was, like most patients, both fearful and hopeful. He feared the pain and hoped that I would be able to alleviate it. He spoke a lot about the gulf between fear and hope, two sides of the same coin. Our society, is very wrapped up in these extremes, and tends to rush from one to the other. He practiced being comfortable with staying in the space between them. He cited the Buddhist concept of the dharmas, pairs of opposites. Pleasure/pain is one of the dharmas, and we discussed the necessity of living with both simultaneously. Another dharma is gain/loss, which was crucial in his situation because of his surgical profession. Rather than trying to eradicate the negative extreme, he chose to occupy the middle ground, refusing to cling to one extreme over the other.

Most surgeons have strong egos. This character quality is usually considered a gift of sorts, because it requires a certain inner strength to cut into people. My friend had found a new strength in the pursuit of "egolessness," a concept common to Buddhists and Christian mystics, which involves setting aside intense personal desires so that they no longer drive thought and behavior. Two other concepts he clung to, again key to both Buddhist and Christian thought, are the impermanence of everything and the recognition of the inevitability of suffering–and its value as a source of wisdom. If the procedure was not successful and he was forced onto a different professional track, then he would accept this change as part of the impermanence of all things, and he would learn from it.

He spoke to me in a quiet, unhurried manner about how he had handled the pain during his sitting times–"leaning into" the discomfort, trying to listen closely to it. He put aside the temptation to worry anxiously about his future as a surgeon and what would happen to his income. Instead, he focused on what message the pain might have for him in the long run, rather than rushing to jump back into the professional marketplace at the earliest opportunity. My friend and colleague had discovered that the way to inner peace leads not around our fears, but through them.
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when spiritual practice seems futile

The transforming power of prayer is at work even when peace seems elusive and unattainable. Times of seeming desertion, absence, and abandonment from God appear to be universal, especially for chronic pain sufferers. Theological niceties are of little help when one is entrenched in chronic pain while at the same time in a spiritual wasteland. Sixteenth-century mystic John of the Cross called it "the dark night of the soul"; an anonymous English author identified it as "the cloud of unknowing."

Saint John of the Cross described this wilderness experience as a profound reorientation of the self, inwardly and outwardly:

In the process of the forsaken prayer our feeling of God is hidden; there are two purifications which occur. The first strips us of dependence on exterior things. The second purification involved stripping us of dependence of the interior intelligence, pride, and charm. Our trust in all exterior and interior results is being shattered so that we learn faith in God alone. Through our barrenness of soul God is producing detachment, humility, patience, perseverance.

The Jewish and Christian scriptures are filled with stories of those who endured intense feelings of being forsaken by God: Abraham and Sarah waiting into old age for their promised offspring…Moses exiled from Egypt's splendor, waiting year after year in silence for God to show up and deliver the Israelites from slavery…the prophet Elijah, exhausted and hungry and marked for death, keeping a lonely vigil in a desolate cave…Jeremiah, lowered down into a dungeon well until he sank into the mire…Mary's vigil at her son's cross … Christ dying in agony, crying out, "My God, My God, why hast Thou forsaken me?" To feel godforsaken is a universal human experience. Pain makes us feel that this abandonment is the final truth about our lives. If we turn to God in prayer instead of turning away in despair, we will be able to see this desolation as a stage in the process of spiritual purification. The dross is being stripped away and the gold of our soul refined. However painful, it is also hopeful: we are moving toward a larger and better life. I am

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encouraged by this courageous prayer from the AIDS quilt: "Lead us, O God, to see a way where there is no path. Give us to hear music when our own song ceases. And when the warm touch of life forsakes us and our courage melts away, may we stumble in the darkness into Thee."[48]

In an address to the American Pain Society National meeting in 1996, Rabbi Harold S. Kushner said that in the beginning of a chronic pain experience, "our will is in struggle with God's will. We beg, we pout, we demand. We expect God to perform like a magician" to rid us of suffering.[49] After an arduous journey of pain and struggle, some people are finally able to give up begging and pleading in the relief of relinquishment. Paradoxically, this leads to freedom. The prison of pain becomes a school of surrender. Freed from desperate pleading for ourselves, we have capacity to care for others, to put their needs first, to give genuinely and joyfully. Little by little we are changed by what A. W. Tozer called a daily "crucifixion of the will."[50]

Sometimes we don't have the energy for prayer, or we're too discouraged to pray, or the circumstances aren't right and we're not ready, or we're in too much pain. But these are the times when we are most in need of prayer. Philosopher Diogenes Allen recounts the advice of Sister Basilea Schlink, the founder of a Protestant monastic order for women in the former West Germany: "When you are suffering say, 'Yes, Father,' and strength will flow into your heart." She offered this counsel "not as a theory, but as a description of what actually happens when we so yield."[51] It makes no difference how we feel about ourselves; when we draw near to God, even in wordless exhaustion, we open the way to experiencing how close God is to us.

Genuine healing is not always a physical change. In the divine mystery, sometimes it is a new thirst for spiritual things, a change of heart, or a peace that passes all understanding. Some miracles are visible only to the eyes of the spirit. Developing this inner vision is a form of renewing the spirit.
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prayer behavior versus pain behavior

One noticeable effect of spiritual renewal is the movement from pain behavior to prayer behavior. Margaret Mead accurately observed that our society has moved from being task-based to entertainment-based. This shift breeds passivity in many areas of life, and it shows up clearly in patients who are not used to being asked to contribute to their healing. Most of Western society looks to medicines, operations, and procedures for healing. Involvement in exercise, diet change, prayer, and methodical cognitive skills is seldom invoked as primary in the healing process.

Prayer behavior is virtually the opposite of pain behavior. In pain medicine, we refer to pain behavior as action that seeks help and sympathy. Limping, grimacing, and whining are manifestations of distress that exaggerate the pain.

We all have pain behavior. Mine often follows when I have been up all night in surgery. I can make my eyes look deeper within their sockets so I really look exhausted. I go around the hospital projecting an image of self-sacrifice, but inwardly seeking sympathy for my hard work and fatigue. We all do this to some degree, but chronic pain patients create an aura of pain behavior around their persona. If this can be pointed out in a humorous way, patients are less likely to assume the dependent posture that distances them from healthcare providers and their relatives. Occasionally we take videos of patients exhibiting pain behavior and play the tapes for them. They are often shocked, but the exercise helps them make adjustments to move beyond the pain.

Prayer focuses upward and outward, away from the body. Pain behavior focuses inward on the body. Prayer moves toward others, interceding on their behalf. It is often selfless rather than self-centered. Prayer is a way of turning over of control. Pain behavior is a way of seeking control. Prayer behavior is characterized by mature expressions of love and service. Pain behavior demands love and service from others. Prayer behavior seeks truth, clarity, and honesty. Pain behavior is mired in deception, dissolution, and disappointment.
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One of my beloved patients is Sister Mary Joaquin, a nun at a monastery in a very beautiful part of New Mexico on the Chama River, thirteen miles from paved roads. She suffers from a connective tissue disease, a very rare type of rheumatoid arthritis called CREST syndrome. She has many problems associated with it, including complications that have affected her heart rate, crippled her hands and her back, and left her in a great deal of pain. She has been through much adversity in her life, and she continues to teach me.

Sister often enters her prayer chamber by walking across a meadow to the primitive chapel of Christ in the Desert to meditate on the crucified Christ. If she has pain in her hip or back, she looks at the hip or back of the body on the huge crucifix and turns the pain over to Jesus. If her hands are especially painful, she gazes on the nailed hands of Jesus on the cross, meditating on the suffering he experienced. It seems to her as if Jesus is able to take some of the pain from her.

Sister practices a Catholic tradition of suffering for others: a spiritual acceptance of others' burdens while giving to them health. Sister once witnessed the miracle of an elderly woman giving her sight to an almost blind young person. She practices taking in other people's suffering, breathing in the pain and breathing out healing, much like the Buddhist practice of tonglen.

Because of her personal adversity, Sister can suffer more easily for others in prayer and meditation. She has known many people in chronic pain who are unable to get outside themselves, making it very difficult for others to take care of them. She has learned how to focus on Jesus in meditation in order to keep from being enveloped when the pain of the far-advanced CREST syndrome disease threatens to overwhelm her. This practice frees her from becoming lost in her own suffering, so that she can focus on others in need.

Sister recalled the story of Mother Teresa changing a dressing on a leper, while an interviewing journalist exclaimed that he wouldn't take that dressing off for a million dollars. Mother Teresa turned to him and said she wouldn't do it for a million dollars either–only for Jesus. Sister

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admired the way Mother Teresa's life was filled with Jesus. She did not want the world's attention–she seemed to have attained egolessness.

Sister Joaquin sees many parallels among the major religious traditions and believes there are universal truths present in all of them. The purifying effect of pain is one of them: "When I have less pain," she told me, "my meditation is less effective. The greater my pain, the more effective I am in meditation." She no longer asks for relief of her pain, because she views it as a gift enabling her to focus on others' suffering in prayer and meditation.

Sister endured a period of significant depression when she could not find a way in her elderly years to be productive. The only way she was able to get through it was by meditating on the sufferings of Christ. Eventually, her depression began to lift as she was able to turn her pain over to Jesus and allow it to become a vehicle through which healing love could flow to others. The life of the spirit does not yield steady upward progress, she feels. All of us have times when we feel far from God, and when prayer and meditation seem useless. In fact, the longer we live, the more these times of distance will characterize our experience. Interludes of feeling God's presence in a close and intimate way are precious and few.

Recently, Sister returned to the pain center with worsened arthritis. She had pain in her lower back and radiating down one leg. Under flouoroscopy (a dynamic x-ray process), her spine appeared profoundly arthritic. My job was to try to locate a specific nerve, block it, and put some medication around that area to decrease the nerve inflammation. It was an arduous process, and Sister, in her seventy-eight years, was peaceful and calm during the hour-long procedure. It was difficult for me to place needles accurately, even with the latest fluoroscopic technology. I was doubtful that this would be a long-term solution for her pain, but the surgeons were wary of performing any more operations on her because of her age and medical problems.

We were able to relieve the pain almost entirely for five days, and then it came lunging back. You might expect that temporary relief would be followed by despair in such a case; Sister viewed the five days as a

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wonderful gift. She wrote to me that she was able once again to be almost pain-free, and to take a much-needed breather from the severity of the physical suffering and the intensity of her meditative prayer. It was as if the field were able to lie fallow for a brief period of time, giving her strength to re-enter the strenuous process of enduring the pain and struggling in prayer for those who suffer. My colleagues and I are debating whether to do the procedure again, but I am struck by how she values both the pain and the respite from it.

recovering wholeness

In childhood we often experience a sense of wholeness that we later lose in adulthood. A child has not yet learned to ignore some parts of reality in order to pursue others; there is an unselfconscious unity. I find that when I ask people to allow their child to revisit their adult, it puts them in touch with the vulnerable and tender parts of themselves they have starved out or left behind. Recovering these lost parts is what helps them move toward a larger sense of what life is about, to reconnect with what is most important.

There may be some deep spiritual truth from childhood that has lain dormant for years. Perhaps letting the child revisit the adult will reawaken some authentic truths for you. Seeking ways to grow spiritually will strengthen you for growing through pain instead of being diminished and defeated by it. You may not recover the physical wholeness you had before the pain set in, but as you strengthen your spirit you will most likely recover a sense of what you thought had been lost to you forever.

In the healing process, most patients have a strong sense of "returning" to what they once believed but lost faith in, to a sense of self that had been neglected or buried by the pressures of life and the crisis of declining health, to a simple happiness and peace they have not experienced since the best moments of their childhood.

One of my patients was a very attractive woman in her late thirties with intellectual prowess to match her physical beauty. After graduating from Harvard Business School she went on to earn a doctorate in nuclear

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physics. Her regular workouts in the gym had sculpted her body to a physique that could grace magazine covers. She had all the gifts that our society prizes and she worked very hard to make sure she excelled in all of them. Her husband was an accomplished professional as well, and although their busy lives did not afford much time for nurturing the marriage, they had managed to add two children. Even their family unit seemed a mark of their achievement.

Her constant success-seeking began foundering, however, with severe migraine headaches. They had been her Achilles' heel all her adult life, but now they were steadily worsening, eroding her productivity. She'd been to clinics all over the country, especially in California, and tried virtually every new treatment known or proposed.

I faced my initial appointment with her with some trepidation, wondering if I would be expected to figure out some new pharmacological intervention that all of California had not been able to come up with. She was very intent upon finding a medication that would keep her on the path of productivity. Our initial discussions revealed that she had done virtually nothing in the area of mind-body work, because she did not believe it would be much help. She was extremely concrete in her thinking, and mind-body techniques did not seem very concrete to her.

She agreed to give this direction a try, however, when I explained to her how processes such as hypnosis, biofeedback, and relaxation exercises directly affect the interrelation of the brain and the nervous system in turning the volume of pain up or down. I also referred her to a behavioral psychologist from England, practicing in Albuquerque, who was especially gifted at working in concrete ways.

In a very short period of time she began to notice a positive difference. I was especially intrigued by her description of "feeling" her mental pathways. An inveterate perfectionist, she was given to fits of road rage with other drivers. After a few sessions of mind-body work, she became sensitized to what was happening in her thought patterns during these episodes. She began to notice other contexts in which these same brain pathways went on red alert: impatience with others when they did not perform, frustration with herself when she failed to attain her high

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standards. Her work on cognitive thought patterns gave her a new understanding of the mechanistic ways she was triggering or reinforcing her headaches. For the first time in her life, she began to feel hopeful about the possibility that she could do something to help reverse these headaches.

She had very few women friends; her image of perfection had kept others at a distance from her. She began to experience endearment directed toward her not-so-perfect self. There began to be a noticeable body-mind shift. After she acknowledged the body-mind connection, we began to explore the possibilities of the body-spirit connection, to consider moving from her left-brain physicist, business school mentality to her right-brain vulnerability and her childhood desire to be in touch with spiritual things.

I told her that just as it requires hard work at the health spa to change the way you look, it takes a lot of regular work to experience psychological and spiritual growth. She recognizes that if she is going to change that physiological response of headaches, she is going to have to be comfortable with the mystery that psychology and spirituality can definitely affect physical things. She has an enormous amount of energy–as she redirects some of it in acknowledging that spirituality is as important as concrete physical realities, she will make a big difference in her headaches.

She is being vulnerable in admitting that the spiritual realm is new to her–not only that, but she recognizes that she has missed so much in this area by focusing so exclusively on her professional accomplishments and her physical beauty. She has begun to realize that reconnecting with her spirituality can help her with the body-mind connection. She can actually visualize the shifting of the intensity of her headaches and her responses to life. Her needs for affection, for people to like her for who she is rather than for what she does, are now being met. She practices showing vulnerability and has been rewarded with warmer reactions from people than she has ever received before–strokes she has really needed.
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However you select your spiritual path, learn to acknowledge and reinforce it throughout the day. The ordinary, everyday moments of life offer us numerous opportunities to work on our spirits–waiting at the red light, in the doctor's office, in line at the grocery store. This is the ground God meets you on: where your pain meets you.
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STEPS FOR THE PATH:

energizing the power of the spirit

1.

Today, I would rate my general pain level as:

0

1

2

3

4

5

6

7

8

9

10

pain free

excruciating pain

2.

Do you have any experience with practicing a daily spiritual discipline such as prayer, quiet reflection, or meditative reading? How has it helped you deal with your pain?

3.

Scientific advances in Western medicine have increased exponentially the options for treatment. But these advances have also tended to exclude any appreciation for the mystery of healing. Consider the difference between "cure" and "healing."

4.

One way to re-energize the spirit is to change how you think of yourself. You are no longer an injured person, but a well person with a problem. Take an inventory of your mental, physical, and spiritual health. You will find that what is right with your body is far greater than what is wrong with it.

5.

In what ways can you practice your own authentic spirituality in the "little whiles" of life–waiting in the doctor's office, stalled in traffic, starting or ending your day, embarking on a difficult task?



[42] Gary Zukav. The Seat of the Soul. New York: Fireside/Simon & Schuster, 1989, p. 31.

[43] Richard Foster. Prayer: The Heart's True Home. San Francisco/ Harper, 1964.

[44] Zohar, I, 229b.

[45] Richard Foster. Celebration of Discipline. San Francisco/Harper, 1978.

[46] Sharp. Living Our Dying. New York: Hyperion, 1996.

[47] Eugene G. d'Aquili and Andrew B. Newberg. The Mystical Mind: Probing the Biology of Religious Experience. Minneapolis: Fortress Press, 1999, p. 14.

[48] AIDs quilt prayer. Atlanta, GA. www.Aidsquilt.org.

[49] Rabbi Harold S. Kushner. American Pain Society Meeting, 1996.

[50] A.W. Tozer in Celebration of Discipline by Richard Foster. San Francisco/Harper, 1978, pg 54.

[51] Allen Diogenes. The Traces of God. n.p.:Cowley, 1981, p. 50.

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