When touched with a feeling of pain,

the ordinary uninstructed person

sorrows, grieves,

and laments, beats his breast,

becomes distraught.

So he feels two pains,

physical and mental. Just as if they were to shoot a man with an arrow and,

right afterward,

were to shoot him with another one,

so that he would feel

the pains of two arrows. –The Buddha

In the following section, four Buddhist teachers explore the benefits of daily practice for dealing with physical pain.

At home in our bodies

An Interview with Jon Kabat-Zinn

Can Buddhist practice liberate us from the prison of physical pain? How can meditation help when medicine falls short? Jon Kabat-Zinn, Ph.D., professor emeritus of medicine at the University of Massachusetts Medical School, speaks to these questions as a longtime practitioner of Buddhist meditation and hatha yoga, and as a pioneer in the use of mindfulness to treat chronic pain and illness. More than 13,000 people have visited the world-renowned Stress Reduction Clinic that Kabat-Zinn established in 1979 at the UMass Medical Center, and the eight-week Mindfulness-Based Stress Reduction (MBSR) program—described in Kabat-Zinn’s bestseller Full Catastrophe Living—is now also offered at some two hundred other medical facilities worldwide.

Tricycle editor-at-large Joan Duncan Oliver spoke with Kabat-Zinn in September 2002.

Let’s start with a basic question: What is pain?

Physical pain is the response of the body and the nervous system to a huge range of stimuli that are perceived as noxious, damaging, or dangerous. There are really three dimensions to pain: the physical, or sensory component; the emotional, or affective component— how we feel about the sensation; and the cognitive component—the meaning we attribute to our pain.

Let’s say you’ve got a pain in your back. You can’t lift your children; getting in and out of the car is difficult; you can’t sit in meditation. Maybe you can’t even work. That’s the physical component. But you’re having to give up a lot, and you’re going to have feelings about that—anger, probably—and you’re susceptible to depression. That’s the emotional response. And then you have thoughts about the pain—questions about what caused it, negative stories about what’s going to happen. Those expectations, projections, and fears compound the stress of the pain, eroding the quality of your life.

There is a way to work with all this, based on Buddhist meditative practices, that can liberate you, to a very large extent, from the experience of pain. Whether or not you can reduce the level of sensory pain, the affective and cognitive contributions to the pain—which make it much worse—usually can be lessened. And then, very often, the sensory component of the pain changes as well.

You mean that once you’ve changed your relationship to the pain, the physical discomfort may decrease?

That’s the key point: You change your relationship to the pain by opening up to it and paying attention to it. You “put out the welcome mat.” Not because you’re masochistic, but because the pain is there. So you need to understand the nature of the experience and the possibilities for, as the doctors might put it, “learning to live with it,” or, as the Buddhists might put it, “liberation from the suffering.” If you distinguish between pain and suffering, change is possible. As the saying goes, “Pain is inevitable; suffering is optional.”

There have been studies looking at how the mind processes acute pain at the sensory level. Subjects are randomized between two groups, then given the cold pressor test, where a tourniquet is placed around your bicep, then you stick your arm into ice water. There’s no more blood flow, so your arm gets very painful very fast. They measure how long you can keep your arm in the water as a function of whether you are given an attentional strategy, such as paying attention to the sensations and really moving into them and being with them as nonjudgmentally as you can—a mindfulness strategy, in other words—or a distraction strategy, where you just try to think about other things and tune out the pain. What they found was that in the early minutes of having your arm in the ice water, distraction works better than mindfulness: You’re less aware of the discomfort because you’re telling yourself a story, or remembering something, or having a fantasy.

But after the arm is in the cold water for a while, mindfulness becomes much more powerful than distraction for tolerating the pain. With distraction alone, once it breaks down and doesn’t work, you’ve got nothing.

The Mindfulness-Based Stress Reduction program uses the body scan as well as sitting meditation to manage pain. Can you explain how the body scan works?

The body scan is a variation on a traditional Burmese practice called sweeping, from the school of U Ba Khin, that S. N. Goenka teaches in his ten-day Vipassana retreats. The traditional method involves tuning in to sensation in a narrow horizontal band that is slowly brought down through the entire body, as if you were giving yourself a CAT scan. This is analogous to the way certain metals, such as zinc, are purified in a circular zone furnace. I thought it would be hard for people in chronic pain to sit for forty-five minutes, so I modified the practice. It is done lying down, starting at the toes and moving up through different regions of the body.

This practice is a way of getting out of the head and developing intimacy with the body. The challenge is, can you feel the toes of your left foot without wiggling them? You tune in to the toes, then gradually move your attention to the bottom of the foot and the heel, and feel the contact with the floor. Then you move to the ankle and slowly up the leg to the pelvis. Then you go to the toes of the right foot and move up the right leg. Very slowly you move up the torso, through the lower back and abdomen, then the upper back and chest, and the shoulders. Then you go to the fingers on both hands and move up the arms to the shoulders. Then you move through the neck and throat, the face and the back of the head, and then right on up through the top of the head.

And all the while, you’re in contact with the breath. I tend to have people feel the breath moving in and out of the body region they’re attending to, so that there’s a sort of dual awareness. As you move up the body, you’re learning how to focus on a particular region, then let go of it and move on. It’s like cultivating concentration and mindfulness simultaneously, because there is a continual flow. You’re not staying with one object of attention.

Does the body scan work like a relaxation practice?

The body scan is a meditation practice, not a relaxation exercise. Relaxation is done with a goal in mind. Meditation is about nonstriving and emptiness. If you get into thinking, “I’m doing this meditation to take away my pain,” you’re coming at it with the wrong motivation. Meditation doesn’t “work” or not “work”; it’s about being with things as they are.

What if your pain is so bad that it’s hard for you to concentrate on anything else?

You have a number of choices. Let’s say you have lower back pain. You can say, “I’m going to try to focus on my toes, even in the presence of back pain. The back’s always there; I’ll get to it sooner or later. Why don’t I see if I can really learn to focus my attention where it’s being asked to focus?” Often, when you do that, the felt sense of the pain in the back lessens.

But if the pain is too great, you can go to the region where the pain is and let the breath merge with it. Breathe in and feel the breath, or in your mind’s eye see the breath moving down into the lower back. Then on the out-breath, as the breath lets go, see if you can allow the mind to let go. You’re not trying to shut off the sensations from the lower back—just to experience the fullness of whatever happens as you let go.

Then in the next moment, the sensations and the feelings and the thoughts might all come flooding back, and you’ve got the next in-breath to work with. So it’s a practice.

You develop an observer’s attitude toward the pain?

Basically, you’re intentionally bearing witness to the pain rather than distancing yourself from it; we’re not teaching mindfulness as a dualistic practice. Nevertheless, there’s a sense that there’s the pain, and there’s the observing of the pain. It’s important to understand that as an intermediate step toward ultimate liberation. It means that I can rest in awareness, then ask myself, “Is the awareness in pain in this moment?” And the answer invariably is, “As I look at it right now, the awareness of the pain is not in pain.” When you realize you can rest in this awareness, the pain may be just as intense, but you’re now cultivating equanimity and clear comprehension. You’re seeing the pain as it is, as sensation. There is a knowing that it is not pleasant. But the interpretation that the pain is killing me, or ruining my life, and all the emotions and stories that go with that, are seen for what they are. In that seeing, they often go into abeyance.

What do you tell people who say, “My practice isn’t working: I’m still in pain”?

When you think that your practice should be working, then you’ve already fallen out of your practice and into expectations that the practice is going to achieve some kind of prefigured, desirable result. This need to get rid of is its own form of ignorance, and we need to look at our “I” statements. A worthy object of attention and inquiry is: Who is suffering? Who is in pain? We can ask that, but rather than coming up with an answer qua thought, we can drop into not-knowing and experience simply being aware.

Not that “simply being aware” is easy. When pain arises, the same challenge occurs as when the breath arises. That’s one reason to practice when we’re not in a lot of pain – to cultivate strong practice so we can rely on it when it becomes extremely difficult to practice.

You seem to be saying that pain is just like the rest of life, only more so.

If you pay attention to the little episodes of pain in your life, you can learn how to work with the bigger episodes because you learn about anicca, impermanence; anatta, no-self; and dukkha, suffering. The meditation orientation is not about fixing pain or making it better. It’s about looking deeply into the nature of pain – making use of it in certain ways that might allow us to grow. In that growing, things will change, and we have the potential to make choices that will move us toward greater wisdom and compassion, including self-compassion, and thus toward freedom from suffering.

Some forms of pain are harder to deal with than others, aren’t they? Lower back pain, for example.

Lower back pain tends to be more complex because every time you stand up or move in any way, you may be exacerbating the inflammation or instability. But over time, you can actually dramatically transform your relationship to your back. What we’re talking about is the deep structure of rehabilitation.

The deep meaning of “rehabilitation,” which is related to the word “habitation,” is “learning to live inside again.” And the deeper Indo-European root is ghabh-e, which means “giving and receiving,” like tonglen, the Tibetan Buddhist practice. So rehabilitation is an exchange, in which you’re willing to move into the interiority of your being and work at the boundary with what is, with full awareness and compassion. If you work that edge patiently, with perseverance, motivation, and kindness, if you give yourself over to it with mindfulness, there is the very real possibility of returning home to your body and learning to live inside again.

In my view, we all need to learn to live inside again. We don’t have to have pain to wake up to the fact that we might be happier if we inhabited the totality of our lives.

The Practice of Nonpreference

When pain becomes just one object among many in our awareness, it loses its power.

By Darlene Cohen

Nothing I had learned in my years of Zen sitting practice and innumerable retreats had prepared me for the ordeal of developing rheumatoid arthritis in my seventh year of practice. Overwhelmed by the power of pain, I could do little else but surrender to the pure physicality of my existence. I wouldn’t have chosen to explore consciousness on such a visceral level, but once I was forced to, I discovered that there were other experiences waiting to be noticed.

If, at any given moment, I was aware of ten different aspects of the present moment—say, the hum of the air conditioner, the thought of the laundry I had to do, my glasses sliding down my nose, and throbbing pain in my hips—that’s too much pain; it’s one object of awareness out of ten. But if, at that moment, I could become aware of a hundred aspects of the present moment—not only the ten things I noticed before but also more subtle aspects, like the shadow of the lamp against the wall, the brush of my hair against my ear, the pull of my clothes against my skin—then my pain was one among a hundred objects of consciousness, and it became a pain I could live with.

How do we develop this appreciation of things just as they are, especially if we are sick and in pain? We must treat our pain gently, respectfully, not resisting it but living with it. When we do resist it, we need to treat that with respect, too. My Zen meditation training turned out to be a great help to me. I simply focused my attention on my immediate experience – on my body sensations, my sense impressions, the stream of my consciousness. As in Zen practice, there is no goal involved. There is only the relentless, implacable present. And it is only in the present that we can cultivate the mental stability that is required to practice nonpreference for the conditions of our lives.

If we take such an attitude, no pain can commandeer our lives. We can begin to live with our suffering in such a way that frustrations and disappointments are part of the rich tapestry of living. To develop this attitude, we need to cultivate skills that enable us to be present for all of our life, not just the moments we prefer. We tend to overlook these everyday epiphanies, waiting for some Big Event. What cultivating attention to detail introduces is spaciousness, space around thoughts and activities, that allows us to live a rich and satisfying life right in the middle of misery.

Just as a clay Buddha cannot go through water and a wood Buddha cannot go through fire, a goal-oriented healing practice cannot permeate deeply enough. We must penetrate our pain so thoroughly that illness and health lose their distinction, allowing us just to live our lives. Our relief from pain and our healing have to be given up again and again to set us free of the desire to be well. Otherwise, getting well is just another hindrance to us, like any other achievement. Fortunately for our ultimate freedom, recurring illness is like a villain stomping on our fingertips as we cling desperately to our healthy, functioning bodies. Healing ourselves is like living our lives. It is not a preparation for anything else, nor a journey to another situation called wellness. It is its own self; it has its own value. It is each thing as it is.

Darlene Cohen is a Zen priest trained at San Francisco Zen Center and a teacher at Crystal Springs Sangha in Burlingame, California. She works with people in pain in Sonoma County, gives seminars at medical facilities and meditation centers throughout the country on living with chronic pain, and is the author of Turning Suffering Inside Out.

A Guided Meditation: Bringing Lovingkindness and Compassion into Areas of Pain

Allow your eyes to close gently.

Center attention on the breathing.

Move awareness now to a part of the body where there is pain and discomfort.

Rest there.

Be aware of any sensations that might be there.

Allow whatever you find to be okay.

No fight.

“No struggle.

Be with the truth, with acceptance.

Continue attending to the breath for a while. If possible, breathe into and through the pain, as if this were actually the place where the breath enters and leaves the body.

Direct the following phrases quietly to the area of pain (or use your own meaningful phrases). Allow the words to echo within you.

I welcome you into my heart.”

I accept you.”

I care about this pain.”

I hold you deep in my heart.”

I accept what is happening right now.”

May I be free from fear.”

May I be happy, just where I am.”

May I be peaceful with what is happening.”

“You may lay your hands gently on the area of discomfort.

Allow feelings of lovingkindness and compassion to flow through the body. If there are no feelings of compassion, that is okay, also.

Continue repeating the phrases.

End by returning to the breathing for a while.

Living with the mistaken notion that we should be free of pain, we make matters worse for ourselves.

By Ezra Bayda

This is a fact of life; we don’t like pain. We suffer because we marry our instinctive aversion to pain to the deep-seated belief that life should be free from pain. In resisting our pain by holding this belief, we strengthen just what we’re trying to avoid. When we make pain the enemy, we solidify it. This resistance is where our suffering begins.

Again, on experiencing pain, we almost always immediately resist. On top of the physical discomfort we quickly add a layer of negative judgments: “Why is this happening to me?” “I can’t bear this,” and so on. Regardless of whether we actually voice these judgments, we thoroughly believe them, which reinforces their devastating power. Rather than see them as a grafted-on filter, we accept them, unquestioned, as the truth. This blind belief in our thoughts further solidifies our physical experience of pain into the dense heaviness of suffering. And though we can intellectually accept the Buddha’s First Noble Truth that life entails suffering, when it happens to us, we rarely want anything to do with it.

How do we live the practice life when we’re in pain? To apply such phrases as “Be one with the pain” or “There is no self” (and therefore no one to suffer) is neither comforting nor helpful. We must first understand that both our pain and our suffering are truly our path, our teacher. While this understanding doesn’t necessarily entail liking our pain or our suffering, it does liberate us from regarding them as enemies we have to conquer. Once we have this understanding, which is a fundamental change in how we relate to life, we can begin to deal with the layers of pain and suffering that make up so much of our existence.

In early 1991 I had an acute and prolonged relapse of an immune system disease in which my muscles attack themselves. On the one hand, I had definite and objective physical symptoms with which to deal. On the other, I had layer upon layer of dark, emotion-based thoughts. These strongly believed thoughts not only exacerbated the physical symptoms but also had their own painful quality. My belief had been that I couldn’t practice because my life was so difficult. To accept these difficulties as my practice would mean I’d have to stop resisting and willingly let them in.

I began doing five different meditations a day and continued this for almost two years. Over time I learned to see the difference between the physical pain, the resistance to the pain, and the layers of emotion-based thoughts. I began to see the physical symptoms of discomfort as if they were in the center of a circle, with a concentric layer of resistance around it, and a concentric layer of emotions and thoughts around that. The very intensity of the emotional reaction “I can’t take this” is enough to tell us that we are caught in a belief system. Without awareness, these beliefs slip by so easily that we don’t even question their truth. With awareness, the thoughts can eventually be seen as thoughts and nothing more. In fact, we can begin to realize that they may not even be true! Thus the suffering is no longer fueled by our blind acceptance of our beliefs as the truth about reality.

Once I clarified these beliefs, it was easier to bring awareness to the resistance itself. Acknowledging the resistance as a physical, sensory experience is a big step. No longer seeing it as the enemy (“The Resistance”), we can begin the process of gradually softening into the sensations of resistance themselves. We bring awareness to wherever we experience tightness, pushing away, holding. We soften those energies with the light touch of awareness, opening the edges around the pain. No longer believing the thoughts, no longer fighting the resistance, left me with just the physical sensations. But now it was a physical experience without the suffering! I saw clearly how we hold our suffering in place with fear-based thoughts that arise in reaction to pain. These thoughts are further solidified by our resistance to letting the pain just be.

As often as I was able, I would breathe into the heartspace on the inbreath and then send lovingkindness to my body, to my immune system, via the outbreath. With this sense of spaciousness and heart, I found I could enter directly into the sensations. In the moments when I could experience them not as “pain” but as intense physical energy, I was struck by a sense of quiet joy. Sometimes I felt a depth of appreciation that, by ordinary standards, would simply not compute. Opening to pain itself may still not be possible if the pain is intense, but in most cases pain is not as unbearable as we think it is.

Certainly, we can’t always transform pain from meaningless suffering into a sense of spaciousness, but at least we can practice seeing into the layers of beliefs and resistance that hold our suffering in place, thereby coming closer to gently opening to what is.

Ezra Bayda has been a student of Zen since 1978. He currently leads a meditation group in Santa Rosa, California, while continuing his studies with Zen teacher Joko Beck. Excerpted from Being Zen, ï¿½ 2002 by Ezra Bayda. Reprinted by arrangement with Shambhala Publications, Inc.

Working with Pain

Diagnosed HIV-positive in 1989, Vipassana teacher Gavin Harrison offers some advice on how to confront physical pain.

Pain is an intrinsic part of being born in a physical body, as the Buddha has taught. In reality, aging and sickness begin the moment we enter the world. Yet we are conditioned to ward off all pain. We are unwilling to allow the pain simply to happen. There are some important and challenging questions relating to physical pain and our bodies:

Are we comfortable with the truth of our bodies? Do we feel a need to control the changes in our bodies? Do we need to change things in any way? Can our mind be sufficiently spacious and receptive to allow all that appears to arise without our resistance or aversion? Can we be okay with heat, pressure, tingling, cold, and throbbing in the body? Is it all okay? Can it be workable?

Paradoxically, once we are willing to work with pain, we feel that it is not all bad. Pain is a riveting object of attention; to paraphrase Samuel Johnson, it concentrates the mind wonderfully. If we leave the breath and direct attention to whatever physical sensation is in the body, allowing ourselves to be present with whatever has arisen, the mind doesn’t tend to wander very much. If we are truly aware of the sensations, we find that pain can focus and calm the mind. There can be a joy that arises with this concentration. We are not scattered. The mind is happily focused.

What else do we discover in our examination of painful sensations? With careful observation, we find that the sensations are dissolving all the time. What previously seemed like a solid mass of misery is in fact changing from moment to moment. We may also discover that it was our aversion that made the pain seem really intolerable. When the aversion dissolves, what is left is much simpler and much less intimidating.

Gavin Harrison ordained in 1983 and lived as a monk for a short time. From In the Lap of the Buddha by Gavin Harrison. ï¿½ 1994 by The Dharma Foundation. Reprinted with permission of Shambhala Publications, Inc., www.shambhala.com.