Disentangling Self from Pain Transforming our relationship to pain through mindfulness. By Fadel Zeidan

I was in awe the first time I held Rage Against the Machine’s CD, The Ultimate Sacrifice. Featured on the cover was Malcolm Browne’s World Press Photo of the Year (1963) of the Venerable Thích Quảng Đức. Đức, a Vietnamese Mahayana Buddhist monk, was seated in a perfect lotus position, his body engulfed in flames. His act of self-immolation was in protest to the persecution of Buddhists by the South Vietnamese government. Subsumed in fire, he did not flinch. As Browne reported, “He never uttered a sound.” During Đức’s posthumous ceremonial cremation, it was said that his heart remained intact and did not burn. It was placed in Ho Chi Minh City’s Xa Loi Pagoda as an eternal symbol of compassion.

As a Palestinian refugee, the intertwining of non-violent resistance to oppression and mind-body transcendence was as compelling as it was haunting. Witnessing Đức’s ultimate sacrifice, I was transfixed by the empirical proof that we could use our minds to influence our bodies, and maybe even to understand the great mystery of our consciousness. This fascination with consciousness, with the very nature of self, had roots in my own experiences as a young person who moved to the United States from the Middle East. Existential questions related to ‘who am I?’ and ‘where do I belong?’ loomed large for me in those early days as someone who had been expelled from homes that my ancestors had lived in for countless generations.

Seven years later, slouching in my seat in the last row of my undergraduate Health Psychology course, I watched as my professor rolled a television into our classroom. She shared with us a video of an MIT-trained microbiologist named Jon Kabat-Zinn, who was offering raisins to individuals suffering from catastrophic chronic pain. Jon instructed the patients to “notice” and “be aware” of the sensations that arose as they ate just one raisin over the course of five minutes. By the end of this video, I learned that Mindfulness-Based Stress Reduction (MBSR)—the now standardized and highly popular mindfulness intervention and meditation—could produce profound improvements in chronic pain. Yet pain “itself” was not the primary target of the intervention. Instead, the relationship between one’s awareness of arising sensations and one’s response to them was being changed. I wondered, could this be how the Venerable Đức overcame his body’s reflexes?

As I later learned, ancient contemplative texts contain insights about pain that are remarkably aligned with empirical evidence gathered over decades of rigorous research. The Sallatha Sutta, a Theravadin Buddhist scripture from the Pali Canon (translated as The Arrow or The Dart), explicitly states that there is a key difference in the experience of pain between individuals trained in mindfulness and those who are not.1 The Sutta compares the reaction to pain to being struck by an arrow and, in the case of untrained individuals, being struck immediately after by a second arrow. The two arrows are described as representing physical and mental pain, respectively. The first arrow refers to the noxious sensation one initially feels (referred to as “intensity” in pain research). The second arrow could be described as the appraisals we make about the initial experience—catastrophizing, worry, distress, and emotional suffering (referred to as “unpleasantness” in pain research). Interestingly, although this is a 3,000-year-old text, the idea is remarkably consistent with our current understanding of pain physiology. The claim of Buddhist contemplatives is that mindfully trained individuals do not cling to sensory experiences, nor emotional appraisals such as those engaged during the experience of pain. The implication is that through mindfulness-based mental training, we can learn to accept negative or painful sensations, while at the same time modulating the resulting emotional suffering.

“…ancient contemplative texts contain insights about pain that are remarkably aligned with empirical evidence gathered over decades of rigorous research.”

Mindfulness and Pain

In 2000, I joined three different laboratories as an undergraduate student, and began running independent studies examining the effects of mindfulness meditation as relates to anxiety, depression, and pain. While my professors advised me that mindfulness research was “a career killer” and not to be taken seriously, I was motivated and inspired by my experiences at early Mind & Life Summer Research Institutes (SRI). Part meditation retreat, part science conference, part slumber party, the SRI took place in a serene setting on the Hudson River an hour north of New York City. There, I discovered a burgeoning community of like-minded researchers focused on upping the standards and rigor of our nascent field. I also found that there was a small group of us studying the effects of mindfulness on pain.

Pain is a great teacher of psychology, physiology, and mindfulness. I first was interested in pain not necessarily from a clinical perspective, but to more deeply understand consciousness. The subjective experience of pain is contingent on our prior history, memories, and expectations. The way we feel pain manifests through a constellation of interactions between the sensory, cognitive, and emotional dimensions of our moment-to-moment experience. And neuroscience research has shown that feeling pain is associated with a distributed network of activity across the brain. We study how nociception (the way the body processes pain) interacts with the cognitive and emotional aspects of pain to understand how our minds impact our experience.

A recent surge of rigorous clinical trials have repeatedly demonstrated that mindfulness-based interventions reduce chronic pain and opioid misuse.2 Rebecca Wells3 and David Seminowicz4 found that MBSR reliably reduces migraine frequency and intensity. Eric Garland created an intervention called Mindfulness-Oriented Recovery Enhancement that produces dramatic and durable improvements in chronic pain and opioid misuse.5 Dan Cherkin published a study showing that MBSR was just as effective as cognitive behavioral therapy—“the gold standard” psychological treatment for pain and depression—at reducing chronic low back pain.6

Across multiple studies, we and other groups found that mindfulness meditation can be used to immediately reduce pain produced in the lab. We use techniques like applying very hot or cold stimuli, electrical shocks, or capsaicin (think hot pepper) to different areas of the limbs. We’ve repeatedly found that directing your attention to the sensations of breathing in a non-reactive fashion (e.g., as used in shamatha vipassana, and insight practices) is a reliable way to immediately reduce acute pain.

It’s an exciting time to be a pain researcher. Now more than ever, we are seeing that physical pain can be dramatically shaped by our thoughts, expectations, and ruminations about impending events. These are all inherent targets of mindfulness practice. And while we still don’t fully understand how mindfulness meditation works to reduce pain, we’ve learned a lot about the process.

“…we are seeing that physical pain can be dramatically shaped by our thoughts, expectations, and ruminations about impending events.”

The Power of Belief

For many years, there was a huge elephant in the room for pain researchers. Was the pain relief from mindfulness meditation driven by placebo responses? That is, was pain relief happening simply because people believed meditation would help? The placebo effect—when an inert treatment (like a sugar pill) causes benefit simply due to expectations of benefit—is well known in science, and the effect is strong. Thus, all medical treatments and therapies must undergo multiple phases of placebo-controlled clinical trials before they are deemed effective and safe. Yet placebo-controlled mindfulness meditation trials are rarely performed.

In our early studies,7 we used a traditional placebo cream control (instructing patients that petroleum jelly was lidocaine). However, it’s likely that having a cream applied to the skin versus practicing mindfulness meditation would act through different neural, physiological, and psychological pathways, even if they both resulted in a placebo effect. To bridge this explanatory gap, we designed and tested a technique we labeled “sham-mindfulness meditation” that was to serve as a placebo control for mindfulness meditation. (We now call it “non-mindfulness meditation,” as we’ve learned it is certainly no sham.) This control group paralleled the genuine mindfulness meditation intervention in every way, including the way we introduced the interventions (e.g., meditation posture, eyes closed, and so on). However, the non-mindfulness group was simply instructed to “take deep breaths” every two to three minutes “as we sit here in mindfulness meditation.” The only difference between the two interventions was that the genuine mindfulness participants focused on the changing sensations of their ongoing breathing in a non-reactive manner. In this way, we were able to study a practice that is as close to mindfulness as possible, but without the part we thought was essential for mindfulness—the non-reactivity.

To date, we have published several papers comparing mindfulness meditation to the non-mindfulness meditation technique in healthy study volunteers.8 We’ve found similarities and differences. To our surprise, both techniques reliably and dramatically reduce experimentally-induced pain. Was mindfulness a placebo? Or was non-mindfulness meditation working the same way as mindfulness? This is where investigating the biological mechanisms of the two meditation techniques proved fruitful. Across these studies, we found that mindfulness meditation did not engage the same biological mechanisms evoked by placebo. In contrast, non-mindfulness meditation did share many of the mechanisms and effects exhibited by placebo, as described below.

^{In this podcast episode, Fadel expands on research showing that mindfulness induces pain relief and efforts to make mindfulness training more widely accessible.}

Pain Relief Without Opioids

While the pain-relieving effects of mindfulness and non-mindfulness meditation were similar, the biology underlying the two techniques couldn’t be more different. When we measured brain activity during these studies, we found that pain reduction from non-mindfulness meditation was associated with slower breathing rate, and also activated an area of the brain called the periaqueductal gray matter. This area controls the “endogenous opioid” system—our body’s own natural pain-relieving system.

This wasn’t too surprising, as pain relief from a spectrum of non-drug approaches is known to be driven by our body’s opioid system, including from placebo, distraction, hypnosis, and acupuncture. However, mindfulness didn’t seem to be activating the brain centers that control this system. Something else was driving the pain relief from mindfulness.

To dig even deeper, we decided to test this more directly. High dose naloxone—the powerful opioid receptor blocking drug—can reliably inhibit the body’s natural opioid system. In a series of experiments, we injected healthy study volunteers with intravenous naloxone during mindfulness and non-mindfulness meditation, and exposed them to painful heat. We were excited to find that mindfulness meditation still reduced pain, even when the body’s natural opioids were blocked with naloxone. This again suggested that mindfulness was not using the endogenous opioid system. By contrast, pain relief from our non-mindfulness meditation control was blocked with naloxone,9 suggesting that it was mediated by endogenous opiates. And around the same time, a study led by Lisa May and Elliott Berkman found that blocking endogenous opioids actually enhanced pain relief from heat during mindfulness meditation.10 So it seems that mindfulness is acting through a novel mechanism unrelated to opioids, and we think it has something to do with our sense of self.

Pain and Self

When we scanned the brains of our volunteers, we consistently found that mindfulness-induced reductions in pain were associated with deactivating the thalamus—a core part of the brain that acts as a gatekeeper, regulating all of the sensory information coming from the body into the brain. More recently, we discovered that greater reductions of activity in the default mode network—a neural network supporting self-narrative, mind-wandering, and self-referential value—also predicted pain relief.11 And the more dissociated, or uncoupled, the activity in the thalamus was from the activity in the default mode network, the more mindfulness meditation facilitated pain relief. While we can’t infer subjective experience directly from brain data, based on what we know about these areas, it’s possible that mindfulness works to disentangle self-related processing from pain-related processing. So the feeling that produces the feeling of pain may still be there, but it’s not as strongly incorporated into your sense of self. Could this mechanism reflect the diminishment of the Sullatta Suta’s second arrow?

It’s interesting to consider that across almost all mindfulness/pain–focused experiments, the unpleasantness dimension of pain has been reduced much more than pain intensity. For instance, the experience of chronic pain is dramatically influenced by the context in which it occurs. One example of this comes from studies assessing pain in patients and in women giving birth. Labor pain is rated higher on intensity compared to unpleasantness.12 In contrast, cancer pain was rated significantly higher on the unpleasantness vs. intensity dimension. The suggestion here is that the contextual evaluation of welcoming a new baby into the world when compared to facing one’s own death has profound implications for what might have otherwise been very similar experiences. Mindfulness, in a similar, albeit less profound manner than giving birth or dying, also modifies the second arrow of meaning, interpretation, and appraisals of self.

Joshua Grant and Pierre Rainville were the first to elegantly demonstrate that Zazen practitioners required significantly higher painful temperatures to report the same amount of pain as compared to age-matched non-meditators.13 They, too, showed a disentanglement between self-related and pain-related neural processing involving the thalamus and the prefrontal cortex.14 What makes these data so much more impressive was that these participants were explicitly instructed not to meditate during the study—these reductions in pain took place in the practitioners’ resting state. They also showed that more meditation experience was associated with less pain sensitivity and greater disengagement from self and pain-related processing. Together, this suggests that pain reductions we and others have measured during meditation could also transfer over into daily life.

The Bigger Picture

The United States is in the middle of an opioid epidemic, and things have only gotten worse since the global COVID-19 pandemic.15 A recent study found that around one fifth of adults experience chronic pain, which is more prevalent and more costly to society than ever before. I am, however, optimistic that mind-body approaches like mindfulness meditation will be used increasingly in clinical settings to treat the whole person rather than just the symptoms. Mindfulness appears to offer a reliable approach to pain relief that bypasses the body’s opioid system. Furthermore, it’s possible that this kind of training could avoid plateau effects that are often seen with pharmaceutical treatments.

Stepping back from the research, the most consistent theme we see is that mindfulness meditation can alter both the sensory experience of pain, and our emotional response to it, by modifying how we contextualize, evaluate, and appraise the experience of pain as it relates to our concept of self. Maybe we can’t cure chronic pain—but the data are clear—we can change the relationship between the self and arising pain to deny the second dart of suffering.

Notes

1. 1.

   Bohdi, B. (2005). In the Buddha’s Words: An Anthology of Discourses from the Pali Canon. Boston, MA: Wisdom Publications.

2. 2.

   Jacob, J.A. (2016). As Opioid Prescribing Guidelines Tighten, Mindfulness Meditation Holds Promise for Pain Relief. JAMA, 315(22), 2385-2387. https://doi.org/10.1001/jama.2016.4875

3. 3.

   Wells, R.E., O’Connell, N., Pierce, C.R., Estave, P., Penzien, D.B., Loder, E., Zeidan, F., & Houle, T.T. (2021). Effectiveness of Mindfulness Meditation vs Headache Education for Adults With Migraine: A Randomized Clinical Trial. JAMA Intern Med, 181(3), 317-328. https://doi.org/10.1001/jamainternmed.2020.7090

4. 4.

   Seminowicz, D.A., Burrowes, S.A.B., Kearson, A., Zhang, J., Krimmel, S.R., Samawi, L., Furman, A.J., Keaser, M.L., Gould, N.F., Magyari, T., White, L., Goloubeva, O., Goyal, M., Peterlin, B.L., & Haythornthwaite, J.A. (2020). Enhanced mindfulness-based stress reduction in episodic migraine: a randomized clinical trial with magnetic resonance imaging outcomes. Pain, 161(8), 1837-1846. https://doi.org/10.1097/j.pain.0000000000001860

5. 5.

   Garland, E.L., Hanley, A.W., Nakamura, Y., Barrett, J.W., Baker, A.K., Reese, S.E., Riquino, M.R., Froeliger, B., & Donaldson, G.W. (2022). Mindfulness-Oriented Recovery Enhancement vs Supportive Group Therapy for Co-occurring Opioid Misuse and Chronic Pain in Primary Care: A Randomized Clinical Trial. JAMA Intern Med, 182(4), 407-417. https://doi.org/10.1001/jamainternmed.2022.0033

6. 6.

   Cherkin, D.C., Sherman, K.J., Balderson, B.H., Cook, A.J., Anderson, M.L., Hawkes, R.J., Hansen, K.E., & Turner, J.A. (2016). Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA, 315(12), 1240-1249. https://doi.org/10.1001/jama.2016.2323

7. 7.

   Zeidan, F., Emerson, N.M., Farris, S.R., Ray, J.N., Jung, Y., McHaffie, J.G., & Coghill, R.C. (2015). Mindfulness Meditation-Based Pain Relief Employs Different Neural Mechanisms Than Placebo and Sham Mindfulness Meditation-Induced Analgesia. J Neurosci, 35(46), 15307-15325. https://doi.org/10.1523/JNEUROSCI.2542-15.2015

8. 8.

   Zeidan, F., Johnson, S.K., Gordon, N.S., & Goolkasian, P. (2010). Effects of brief and sham mindfulness meditation on mood and cardiovascular variables. J Altern Complement Med 16(8), 867-873. https://doi.org/10.1089/acm.2009.0321

9. 9.

   Wells, R.E., Collier, J., Posey, G., Morgan, F., Auman, T., Strittameter, B., Magalhaes, R., Adler-Neal, A., McHaffie, J.G., & Zeidan, F. (2020). Attention to breath sensations does not engage endogenous opioids to reduce pain. Pain, 161(8), 1884. https://doi.org/10.1097/j.pain.0000000000001865

10. 10.

    May, L.M., Kosek, P., Zeidan, F., & Berkman, E.T. (2018). Enhancement of Meditation Analgesia by Opioid Antagonist in Experienced Meditators. Psychosom Med, 80(9), 807. https://doi.org/10.1097/PSY.0000000000000580

11. 11.

    Riegner, G., Posey, G., Oliva, V., Jung, Y., Mobley, W., & Zeidan, F. (2022). Disentangling self from pain: mindfulness meditation-induced pain relief is driven by thalamic-default mode network decoupling. Pain, 10-1097. (epub ahead of print)

12. 12.

    Price, D.D., Harkins, S.W., & Baker, C. (1987). Sensory-affective relationships among different types of clinical and experimental pain. Pain, 28(3), 297-307. https://doi.org/10.1016/0304-3959(87)90065-0

13. 13.

    Grant, J.A., & Rainville, P. (2009). Pain sensitivity and analgesic effects of mindful states in Zen meditators: a cross-sectional study. Psychosomatic Medicine, 71(1), 106-114. https://doi.org/10.1097/PSY.0b013e31818f52ee

14. 14.

    Grant. J.A., Courtemanche, J., & Rainville, P. (2011). A non-elaborative mental stance and decoupling of executive and pain-related cortices predicts low pain sensitivity in Zen meditators. Pain, 152(1), 150-156. https://doi.org/10.1016/j.pain.2010.10.006

15. 15.

    Nahin, R.L. Feinberg, T., Kapos, F.P., & Terman, G.W. (2023). Estimated rates of incident and persistent chronic pain among US adults, 2019-2020. JAMA Netw Open, 6(5):e2313563. doi:10.1001/jamanetworkopen.2023.13563