Some people like to use end of year journalling as part of reflecting on the year as it draws to a close.  Journalling can be helpful as part of reflecting on the year and see what’s gone well, what’s not been easy or challenging and what helped navigate these times, what’s been meaningful and other aspects too.   Some people like to reflect on the year and journal and others don’t, either way is ok.

As we reflect it is important that we notice what has been helpful, supportive or ‘positive’ as well as the more tricky and challenging times.  Our brains have a ‘negativity’ bias, this means that we will naturally remember the challenges and focus here if we don’t intentionally explore the ‘positives’ too.

This time of year is often a reflective time and when we align with nature seasons it’s a time for slowing down.  Our society and the commercialisation around Christmas tends to make people busier which can take us away for our natural need to slow down, turn a little inward, to rest and restore.

Before we look at different types of journaling and some tips I feel that it’s important to mention a few things:

• We all struggle and suffer sometimes and these will be part of everyone’s years to varying degrees, this is part of being human.  There will also be joy, connection, love, wonder and other nurturing emotions and feelings to varying degrees too
• There isn’t a right or wrong way to reflect or journal
• It can feel too much to reflect on the year, this is normal and it’s ok not to do it.  We can reflect and journal if it feels ok to do so and like it might be helpful for us and if not we don’t have to do it.

Types of Journalling

There are many types of journalling I have listed some of them below along with examples of how they can be used as part of end of year reflections:

• Free flow journalling/stream of consciousness journalling – this basically means writing whatever comes into your head even if it doesn’t seem to make sense.  Instead of choosing one focus like gratitude or feelings as journal prompts free flow journalling doesn’t have a focus and it is writing without editing
• Gratitude journalling – this is basically noticing and focusing on what you are grateful for.   For end of year journalling you could notice a few things that you are grateful for each month of the year as you explore the year that’s gone by and simply list them and/or use one, or a few of them as journalling prompts
• Art journalling – this type of journalling uses visual representations of things like your thoughts and feelings.  You could draw or find illustrations/visuals that you feel reflect your year as you review it
• Nature journalling – this type of journalling relates to what you are noticing in nature.  It can be combined with other types of journalling like art journaling.  One way this can be used is to gather nature pictures that you have from throughout the year and then journal with what arises through connecting with the picture memories, this may also lead into other types of journalling like what you are grateful for within the year
• Yoga journalling – this type of journalling is where people write in their journal after a yoga practice.  An example for end of year reflections could be to hold the intention to reflect and review the year, take this onto the yoga mat and then journal with any thoughts, feelings and insights that may have come up
• Strength based journalling – this journalling focuses on your strengths and exploring these through journalling.  For example, see if you can notice something that has helped you to thrive and/or manage the challenges this year and journal about this
• Values based journalling – this uses your values as a prompt for your writing.  One way to do this is to note down your core values and then journal with each value and how you brought it to life this year.  If you’re unsure of your values do a values exploration exercise first, there are some in my book, linked at the end of this blog
• Bullet journalling – this can be any sort of bullet point list.  For an end of year review you could list the things that you are grateful for, the values in your year, the strengths that helped you navigate challenges and helped you to thrive, and/or inspirational quotes that reflect your year.

There are many more types and you can blend different ones together and of course create your own journalling style

Questions for journalling:

 Questions can be used as journal prompts, some examples for end of year reflections/journalling:

• What has gone well the last month/last few months/this year and why?
• What are 1-5 things that I am most proud of this year and why?
• What has been tricky or challenging & what have I learnt from this/what am I taking from it?
• What helped me navigate the challenges?
• What strengths helped me this year?
• What’s been supportive for me this year?
• What 1-5 things am I grateful for right now/over the last few months/this year?
• Did I set boundaries, did I stick to them and were they helpful?
• What’s created some balance, some ease, some stability this year?
• How have I related to myself most often this year? (For example, with self-criticism or self-compassion)
• Is my daily routine supportive of my wellbeing?
• What 1-2 things could I keep doing or start doing regularly that would make a difference to my wellbeing?
• What are my core values (3-5 values) and how have they been part of this year?
• What is most important to me & why?
• What do I want to take into the new year?  What feels welcome to have more of? (This ties in with word of the year if you do this)
• What would I like to explore more of, what qualities do I want to embody next year?
• What could it be helpful to let go of?

Journalling tips

Some people like to reflect prior to journalling and then deepen the reflection through journalling and other people prefer to journal first and then reflect more in some way, for example through a yoga or other somatic movement practice, and others prefer to do something like a yoga practice first and then journal.  There isn’t a right or a wrong with journalling or reflecting, it is simply what feels ok for you and what’s helpful.

Before starting reflection and/or journalling I suggest people do a somatic (body) check-in and notice how they are.  The way I guide a somatic check-in is by encouraging connection to the body with compassion and curiosity to notice what’s present, for example noticing sensations, energy levels, the breath (if it’s ok to notice this), what thoughts are present and how they show up in the body.  I also encourage people to reflect and journal in a somatic way, this basically means noticing the bodies reactions, the body’s wisdom as you reflect, for example, what sensations do you notice, what’s your breath like, is there a temperature change, how are you feeling, what do you notice where in your body?  Without doing this we are only reflecting on a head level and this means we are missing important information and the body’s wisdom.   It is important to slow down and pause regularly, this can help us to notice what’s present in the body and increases our awareness and understanding

I encourage people to journal and reflect with compassion and curiosity, holding the intention to be curious and compassionate can be part of this.  As well as holding this intention you can connect to your compassionate self to support with journalling in a compassionate way, there are various exercise available that can guide with this.  There are a few in my book and there are some audios freely available like this one by Dr Shelley Kerr: https://on.soundcloud.com/kSyVQUZu923v9HYz7

It can also be helpful to use soothing rhythm breathing from compassionate mind training, this can be used as part of connecting to your compassionate self or simply to connect to your body, settle and slow down.  I have an audio freely available for this here: https://on.soundcloud.com/kqJdxtjerKGMUHBq6  There are a number of other soothing rhythm breathing practices freely available, you can find a few of them here: https://www.compassionatemind.co.uk/resource/audio

If reflecting on the whole year feels overwhelming consider what feels ok, perhaps exploring the last month or last few months, or something else that feels better to you.  If nothing feels ok and it feels too much don’t do it and perhaps reach out for some support instead.

One way you can reflect using end of year journalling is by reflecting back on the year by moving back through time from now and noticing what events/memories come to mind and what is present in your body, noting feelings or something else down in your journal.  Once you have reviewed the whole year you could choose a common feeling to journal with, or use some things that you are grateful for that have come to mind.  If journalling on the whole year feels too much you can split it into chunks, maybe quarters.

When you have finished your reflection one of the things you may wish to explore may be what would it be helpful to have more of in the following year, what would support you and what may you wish to let go of.   You can journal with these as prompts as well.  What you wish to have more of can be used as a word of the year (or words) for the following year, something I see as a kind of gentle guide.

Summary

• There are many types of journalling and you can blend different types together
• You don’t have to use a specific journalling type you can create your own approach 
• You can review the whole year working backwards from now or split it into chunks, for example review each quarter
• Do a somatic check-in before beginning and during the journalling 
• Slow down, this helps you to notice what’s present in the body
• Go at your own pace and take breaks as needed
• Use the body’s wisdom along with the minds understanding in your journalling
• Hold the intention to be curious and compassionate
• Connect to your compassionate self and use soothing rhythm breathing if these feel helpful for you
• Journalling can be combined with yoga and other somatic practices
• You could explore what it would be helpful to invite more of in the following year, what would build on your strengths & resources and support your wellbeing 
• There isn’t a right or wrong way to journal or reflect.

In this blog I mentioned that there are some values exercises in my book you can find the book here: https://www.amazon.co.uk/Dancing-through-Life-Guide-Living/ dp/B08P1CFDNW/ref=mp_s_a_1_4? crid=3EHSYPASVND90&keywords=ann+parkinson+book&gid=1671047573&sprefix=ann+patkinson+ %2Caps%2C65&sr=8-4

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Aligning mind, body & heart

Terms like aligning mind, body and heart can seem a bit abstract so I’m going to define this in the way I see it before we explore connectedness more.  To me aligning mind, body and heart means living in a loving and embodied way aligned with our purpose and what’s meaningful, living from a place of love, compassion & connectedness.  By living in a loving and embodied way I mean noticing how, for example, our thoughts and feelings, are showing up in the body in a compassionate and non-judgemental way.  Part of healing is awakening our senses and being able to fully be in the present moment in an embodied and loving way.  We can’t do this if we are stuck in hyperarousal or hypoarousal, where we are stuck in our heads or rushing around all the time, disconnected from ourselves and the world around us, and not feeling safe/settled and secure.  Aligning body, mind and heart helps us regulate our nervous system, awaken to a deeper way of being and reconnect to the connectedness of everything.

Living in an embodied and open hearted way can also help us see that the obstacles and challenges that appear as part of life can help us awaken and grow.  We can ask questions that support with this like how can this help me grow? How can this help me serve myself and others?  How might this help serve my heartfelt intentions or aspirations?  Sometimes things are overwhelming, these times we won’t know the answers to these questions and we will struggle to connect to our bodies, these times we may need to find a suitable therapist to support us.

Love & connectedness in healing 

One of the things that is really important in healing is that our suffering is witnessed and acknowledged in a compassionate and non-judgemental way.  Suffering that is not witnessed and acknowledged, or done so in a critical way, often causes more trauma.   Love, compassion & connection are needed here because when we aren’t fully present and connected we can’t truly notice our suffering, or that of another, and without love and compassion there is judgement and criticism.

Acceptance is important in healing, it isn’t a one off thing, instead it’s ongoing and it can be said to be a moment by moment process.   Acceptance isn’t passive, it doesn’t mean putting up with something, or that things won’t change (things are always changing right down to each moment).  A great strength or courage is needed to be able to let go and trust in our inner wisdom and the process.  With curiosity, openness, courage and a compassionate loving presence (a heartfelt presence) we can notice and allow what’s present in the moment to be exactly as it is, even if it’s not how we would ideally choose it to be.  Being present with love & compassion helps us accept and allow what’s present to be without, for example, self-blame or self-criticism, and when these do appear they can be met with compassion and love too.   Allowing what’s present to be needs a sense of safety, or feeling safe enough in the present moment.  This means that we need the nervous system to be balanced or close to balance (where we are within our window of tolerance/ventral vagal system).

From a place of noticing what’s present in the body we can increase our understanding, connect to our inner wisdom and discern what’s supportive for us.  Any action comes from our inner wisdom rather than from a threat based reaction, for example a pushing away, trying to get rid of something, or avoiding.  It’s important for us to stop over controlling and resisting, this is part of being in a regulated nervous system (resistance & over control are part of our threat system and protection mechanisms), as it calms our nervous system and allows new possibilities to begin to surface.  Allowing what’s present to be with an acceptance or openness is a place where fear softens and we can start to see what’s resting underneath.  Holding whatever is present, in love compassion isn’t always easy and this is part of the practice and the healing.  Things can reappear that we thought we had dealt with once, that we had healed, new layers surface for healing, here again we practice acceptance and compassion.

We need trust to allow the healing process to unfold in its own time without wanting it to be a certain way or create a certain outcome, without pushing or resisting, easier said than done I know (that’s part of the practice too).  We naturally push away or resist what causes suffering and grasp what creates joy and the things we want more of.  Part of suffering is in the pushing away and grasping, we can learn to allow things to flow through (an ever ongoing practice).  We can, for example, notice that pain is present and allow it to be in the background as best we can, rather than trying to get rid of it and getting frustrated, angry or self-critical when nothing works.  This doesn’t mean we don’t take action to try and alleviate the suffering, instead it comes from a different place and we take wise action.  This may be no action sometimes, or something simple like after noticing what’s present and allowing it to be, offering ourselves some soothing words or soothing touch (this could be part of Tara Brach’s R.A.I.N practice or Kritsin Neff’s self-compassion break, for example).  We also need to learn to hold the outcome lightly, we cannot control this as there are many variable (some we don’t see) we can influence the outcome and control how we relate to it.

Often when we are suffering we lose trust in ourselves, I have seen this time and time again working with people with persistent pain, other long-term conditions and felt it myself.  The decreased trust, or the loss of trust, brings an opportunity to connect more deeply to it and develop more of a kind of unshakeable trust.  Part of trust is trusting that we have the skills, knowledge, resources/practices to manage, or if we don’t then believing that with support we can develop them.  Learning to trust the healing process is important and it means we need to trust in uncertainty too.  Trusting in uncertainty isn’t easy, it’s important because so much is uncertain in life, this means we need to let go of over control.  Being safely grounded in compassion and love links with trust in holding us steady enough within the uncertainty, within what feels like a vulnerable place.

Reconnecting to our inner wisdom is so important in healing, it supports and guides us.  Terms like inner wisdom and our true nature or essence, can seem a bit abstract, they aren’t tangible things we can see.  Our inner wisdom and true nature both hold love & compassion and connecting to them is important in healing.  Connecting to our inner wisdom through our body guides us in many ways, for example it can guide us when to explore something to deepen understanding and when to allow something to be in the background for the time being.  Sometimes we need help to access our inner wisdom especially if there is unprocessed trauma, the light of compassion and love can be hidden under layers.

Feeling the connectedness to love, nature and the wider whole is also important in healing and our overall wellbeing.  Research is showing us that it is not necessarily the amount of time that we spend in nature that is significant for our wellbeing, except in terms of physical wellbeing, there needs to be a sense of connectedness too (physical wellbeing needs this too, so again it’s not just the time in nature that’s important).  Sometimes we have disconnected from the interconnectedness of nature, reconnecting to this is part of our healing and it’s needed for natures healing.  Nature’s wisdom combines with our inner wisdom and can guide us when we listen.  If we haven’t lost the connection to the connectedness with nature then the sense of connectedness with this tends to deepen as part of healing.  Nature is part of us and we are part of nature, our wellbeing and natures wellbeing are inextricably interlinked, connecting to this helps our healing and also the healing that nature is desperately calling out for.

The interconnectedness with nature and something bigger than us may resonate with you or it may not, either way is ok.  If these things are of interest one of the books that I would recommend is called ‘Reconnection: Fixing Our Broken Relationship With Nature’ by Miles Richardson.

Common Humanity & Healing

As human beings we all experience joys and sorrows, love and loss, easier times and tough times, suffering and healing.  This is the common humanity we all share, we share many things as part of being human and connecting to this is important in healing.  Connection to others is important in healing, we are social animals.  We self-regulate and we co-regulate, our nervous system talks to other nervous systems.

Adapting to and processing many losses is part of being human and is often part of healing too  This can be for many reason, for example, from the multiple losses related to living with a chronic health condition, from life being different from the way you wished it to be, and/or from the loss of a loved one.  There isn’t a right or wrong way to grieve.  I wrote a grief and loss in persistent pain & other long term health conditions blog which you can find this here:

Part one https://unityphysio.co.uk/grief-loss-in-persistent-pain-other-health-conditions-part-one/

Part two https://unityphysio.co.uk/grief-loss-in-persistent-pain-other-health-conditions-part-two/

It is the tough times that we learn the most from and these times that we need a toolbox of practices to draw on, these can also be referred to as strategies or resources.  The tough times strengthen our heart and allow our heart to open more fully, to be present with love, compassion and courage, connect to the depth of our strength and to connect more deeply to the connectedness of everything with a sense of spaciousness.  We cannot heal until we learn what supports our nervous system regulation and have some resources/practices to support this and healing, we create more resources along our healing journey too.

What supports healing?

There are many things that can support us each day, that can become part of a way of being and part of healing, including: embodied self-awareness practices (awareness in the body), meditation, mindfulness, breath practices, self-compassion, yoga, exercise and movement, walking, time in nature, journaling, distraction (sometimes this is needed, for example when things are over whelming) and many more things.

When I had a really tough couple of years due to some health conditions I leaned deeply into my yoga and compassion practices and drew on many other resources that I had, my gratitude for these deepened and I developed many more resources through this time too.  I also reached out for additional support, remember we can’t heal on our own.

What practices and resources/strategies do you use to support you day to day?

Summary

To heal we need many things including: to restore balance and retrain our nervous system, a sense of safety and trust, an embodied loving awareness, acceptance, a variety of resources/practices along with a daily commitment to practice, belongingness, support of others, connection and connectedness, and of course compassion and love.  Healing takes time and a toolbox of strategies and practices, it’s not one thing that helps us heal it’s many things.  We can’t heal on our own, we need the co-regulation and support of others which can take many forms.  Sometimes support needs to be in the form of a therapist, other times it could be a coach or mentor, friends, or a wider community group that we are part of.

As we heal the confusion that we had in our suffering evolves into clarity and we awaken a little more to our true selves and the interconnectedness in everything too.  There are times that we think we have healed and everything is going smoothly and then something happens that opens up new layers that are ready to be healed.   Healing is something I have come to see as being ongoing, maybe you can relate to this too.  I don’t think there is a destination unless it is to return to our true selves and wholeness, to the alignment of mind body and heart and live from this place, and return again and again.  Each time there is a challenge or an obstacle it gives us an opportunity to grow and connect to our true selves, our inner wisdom, and more deeply to the connectedness within and around us.

We all already have what’s needed for healing within us, to access and nurture this we need to be able to safely connect to our bodies and we often need to change how we are relating to ourselves, from being critical, for example, to being more compassionate.  Sometimes we need help from a psychologist, or another psychological clinician to do this, for example when there is unresolved or unprocessed trauma.  We all have within us a core essence of compassion and love, this light never goes out, sometimes it’s under layers and we need help to be able to start to see it, and the more we connect to this place the more brightly it shines.

Healing has many aspects and perhaps we could see it as being rooted in connectedness and love, and aligning mind, body and heart.  I have come to understand that our healing rests within the love that is within and around us all and the connection to the interconnectedness of everything.  Healing is a place where enougness, okness, compassion, love, trust and freedom all rest.  Connecting to the wisdom of our body, heart, inner trust, compassion and love over and over again helps us to heal & develop an unshakeable inner core, or at least a less shakeable one.  The inner wisdom that is within us all, our core of love and compassion, is a place that we can come to know more deeply with time and once we have an embodied knowing (a felt sense in our body) we can return again and again to our true selves and a balanced state (our ventral vagal system/window of tolerance) that supports healing.  As we heal we can live more fully in an open hearted presence, developing a new way to be, relating to ourselves in a more loving and compassionate way and extending this love and compassion to others and the world around us.

To finish this blog I’m sharing a poem that I wrote called ‘Healing Within’:

Many things were unknown

Couldn’t be seen

In the darkness there was always some light

Flickering gently

Leading the way

Slowly, step by step

Pauses scattered through

Compassionate awareness enveloping

Body wisdom guiding to explore

What’s resting inside, to be seen, accepted and loved

Slowly, never to be rushed

Each footstep exploring

Heart trusting

A loving presence guiding

Exploring and listening

Natures wisdom shining

Deepening a knowing

Harmony evolving

Learning a new way to be

Compassion, love and trust united

Deeply embedded within

Shining brightly

Holding the steadiness

Resting in aliveness

Connected to the unity

Being & healing

You may also like to check out the poem I wrote called The Body Remembers The Trust

https://m.youtube.com/watch?v=2pgR3COJLPk

I would love to hear your thoughts on healing and this blog, do drop me an email if you would like to (info@unityphysio.co.uk) or share some thoughts in the comments on social media where I’ve shared this blog.

The post Healing Within Connectedness & Love (part two) appeared first on Unity Physiotherapy and Wellbeing.

I’ve especially been considering healing in relation to trauma, persistent pain, ME/CFS, long covid, PoTS and other long-term conditions, which is probably because these are the areas I work within and have lived experience of some too.   Many people are healing from trauma and/or a long-term health conditions in our modern world.  Last week I read in a new report by The Health Foundation it has suggested that 9.1 million people in England are expected to live with a major illness by 2040 and that a significant proportion of this will be related to certain conditions, including anxiety, depression, chronic pain and diabetes.   In my opinion there are many factors that need consideration here including healing and the innate connectedness that we need to reconnect to and nurture.

What does healing mean?

There is no agreed definition of healing, healing in acute terms means repairing damaged tissues, or fixing an injury, for example.  Things get complex when it’s not a simple acute injury and there isn’t a specific time frame to heal or repair the wound/injury.  When there are, for example, layers of trauma, or many symptoms from fibromyalgia, or someone is living with persistent pain healing becomes trickier to define.

Before reading on I invite you to consider what healing means to you?

I think we could say that healing is always an individual experience that involves reducing or transforming suffering.   However, if we were to say healing is only a change in suffering this would be a simplistic view, especially as suffering is complex and it is always changing, everything is always changing, and because healing is about more than the suffering or struggle that is part of the picture.

Another thing to consider with what healing means is that it may or may not mean full resolution of pain, anxiety, or other symptoms.  Often people have shared with me themes around alignment with their heart and what’s meaningful, connectedness and wholeness as part of what healing means to them, and these are things I can relate to from my own healing journey too.   Some people may say that not feeling whole implies that something is broken and needs fixing.  I don’t see it this way and instead see it as a disconnection from our true selves, disconnection from nature and a disconnection from the wider whole/universe (there are different terms for this, it can essentially be seen as something bigger than ourselves).  Although we may at times feel broken we never really are, our true self is like the sky in that it is always there and can never be broken and the weathers come and go.

A journey to wholeness is something I see as a heart based connection, a connection to meaning and purpose, to a sense of belonging, and to the love, trust and compassion that’s within us all.  We could maybe say that healing is a coming home to ourselves, reconnecting to our inner wisdom and connecting to the interconnectedness of everything.  I would say healing is also an alignment of mind, body and heart, a place where we can live fully connected from an open hearted presence with a gentle strength and love.  We will explore this a little more in part two of the blog.

I think that it is helpful to consider what nervous system regulation means in the context of healing, especially because we can’t heal with a nervous system that is dysregulated too often/too much.

What is nervous system regulation?

Nervous system regulation includes the whole nervous system and is often discussed in terms of the autonomic nervous system.  Everyone’s nervous system dysregulates many times a day and then re-regulates, the problems come when the nervous system is dysregulating too often or too much relative to the context and not re-regulating well.  A well regulated nervous systems helps us to feel safe or safe enough to be fully present and to engage with others and the world in general, and it helps all of our systems to function optimally.

There isn’t an agreed definition of nervous system regulation, this is one that I created for my Creating A Healing Path workshop series:

‘Nervous system regulation can be thought of as when our nervous system is flexibly able to move between different states in response to stressors & the level of arousal matches the context/what you are required to do.  It is where it is working in a balanced way that supports optimal function & healing.’

A quick summary of the autonomic nervous system (ANS) could be helpful here.  The ANS unconsciously controls and regulates our organs and unconscious body functions, including heart rate, breathing (which we also have conscious control over), blood pressure, and temperature.  It is split into two branches, the sympathetic nervous system (SNS), fight or flight, and the parasympathetic nervous system (PNS), rest and digest.  These work together to maintain a state of balance in the body (homeostasis) and we need both branches of the ANS, neither is good or bad.  The levels of activation of the SNS and PNS are always fluctuating, our central nervous system CNS) and autonomic nervous system are constantly adjusting, along with all other systems, to try and maintain homeostasis.  Our ANS and the CNS (mainly the amygdala and hypothalamus in the limbic system in the brain) are constantly monitoring for threat/danger or safety.  The ANS and CNS are constantly surveying our internal environment (information from all systems), along with our immediate and wider external environment, including how the interactions with others feel.  Our nervous system takes a better safe than sorry approach and our previous experiences and modern society mean it is often dysregulated by things that aren’t actual threats.  Once the threat, or potential threat, has gone we need to be able to return to regulation to function optimally and feel safe and settled again.  When this doesn’t happen automatically or takes sometime we can assist this process and there are many ways in which we can do this, this is part of healing.

It is important to mention that changes in ANS activation are associated with different chemical messengers which of course impact all of our systems.  Our thoughts feelings and emotions are also in themselves associated with different chemical messengers, they are part of our biology too.

There are different models that can help us to understand the ANS and nervous system regulation, the ones I use most often are Dan Siegel’s window of tolerance and Stephen Porge’s polyvagal theory, combined with the 3 circles model by Paul Gilbert (part of Compassion Focused Therapy).  For this blog I’m going to touch on the window of tolerance model and polyvagal theory.

The window of tolerance model was developed by Dan Siegel to describe the optimal level of arousal, it has three parts:

• Hyperarousal (too much SNS – fight or flight)
• Window of tolerance – optimal zone of arousal (balanced ANS)
• Hypoarousal (not enough SNS & PNS without the vagal brake)

In this model a dysregulated nervous system is one that is too often, or too much for the context, in hyperarousal or hypoarousal, and/or takes longer to regulate from these states back to regulation, and sometimes gets stuck for a while in one of these threat/protection based states.  When the nervous system is dysregulated in the direction of hyperarousal a variety of things associated with this can be present including: fear, panic, initial freeze (deer in headlights) emotional overwhelm, anxiety, irritability, anger, over-activity, lack of clarity, worry, gut issues, increased muscle tension, pain, insomnia, a tired and wired feeling.  When the nervous system is dysregulated in the direction of hypoarousal a variety of things associated with this can be present including: disconnection, dissociation, low mood, depression, decreased muscle tone, shame, guilt, feeling numb, fatigue, shut down.

(infographic by Dr Sarah Davies, the link to the blog that this is in is below)

Through the lens of the polyvagal theory by Stephen Porges we see the ANS protection responses as:

• SNS (fight or flight, includes the initial freeze response)
• Shut down or collapse (PNS minus vagal brake, termed dorsal vagal in this model)

Porges suggests that there are three pathways in the ANS, being the sympathetic nervous system (SNS) (mobilised/activated, protect/survival mode, unsafe), the ventral vagal circuit (safe, regulated, sympathetic and parasympathetic activity balanced with the vagal brake, and able to be socially engaged) and the dorsal vagal circuit (unsafe, protect/survival mode, shut down).   These three systems/states are also included on the above infographic).  The SNS part is where there is increased SNS activation (hyperarousal in window of tolerance).  The initial freeze response (deer in headlight type response) is SNS dominant, this is where we freeze whilst a decision is automatically made as to whether we can fight or flee, if neither are possible and this response continues eventually the SNS is overwhelmed by the PNS (we lose the ventral vagal regulation, the vagal brake – the rest and digest part of the PNS).  Here we go into a primitive survival response of shutdown or collapse, this is termed dorsal vagal in this model (it’s where there is increased hypoarousal in the window of tolerance model).  The ventral vagal system is where we are said to be safely activated, in other words the SNS is balanced by the PNS with the vagal brake.  Here all systems can function optimally, the ANS is in balance, the limbic system in the brain is settled and the frontal lobe is online.  When we are in the ventral vagal system we feel safe and secure, this supports social connection and full engagement in a heartfelt presence with ourselves and the world.

The wider our window of tolerance, the more frequently we can be in the ventral vagal system and the more easily we can return to this place again and again.  This helps systems function optimally and we can, for example, find ease within challenges.  Being in our ventral vagal system or window of tolerance helps create the conditions that support healing.  Also with a wider window of tolerance we can more often be in a full heart felt presence and have a greater tolerance to be with our own and others suffering, along with being able to access the wisdom to discern what may be helpful in alleviating or decreasing the suffering.

There is a lot of information on the window of tolerance model and polyvagal theory available, like this blog on the window of tolerance model:

https://www.drsarahdavies.com/post/what-is-window-of-tolerance-emotional-regulation-model-explained

You can find a free beginners guide to polyvagal theory on Deb Dana’s website here:

https://www.rhythmofregulation.com/resources

Considering nervous system regulation alone would be a reductionist way of looking at things, it needs to be considered as part of the whole picture.  This includes considering all systems, what is happening in our body, the thoughts and memories that are present, our behaviour, previous experiences, essentially the whole of our experience and the connectedness of everything.

Summary

Healing doesn’t have an agreed definition except in acute injury.  Healing involves changing or transforming suffering and creates a new way of being through reconnection to our true self and living aligned with our mind, body and heart.

When our nervous system is not well regulated, we don’t feel safe, we can’t see the bigger picture and are disconnected from ourselves, others and the wider whole, and we can’t heal from this place.  It is important we remember that we don’t control any of our nervous systems threat/protection responses (hyperarousal/hypoarousal), they are quickly automatically activated when protection is deemed as needed.  When we are within our window of tolerance or ventral vagal system enough (a regulated and balanced nervous system state) we are safely able to fully connect to ourselves and others, have a more expansive view, and conditions are optimised for healing.  A healing state is one that rests in safety and connection, a place where strength & gentleness are balanced, a place where the seeds of change can be planted, begin to grow and later flourish and these are all part of having a well-balanced regulated nervous system.

Perhaps we could see healing as a return to wholeness, or an alignment of mind, body & heart.  An alignment and wholeness that means that we can live a life full of meaning, with a sense of purpose, fully connected to ourselves, others & to something bigger than ourselves (the wider whole) in an open hearted and grounded way.  These will be explored a little in  part two of this blog.

What do you think, does this way of seeing healing resonate with you?

Link to part two of the blog https://unityphysio.co.uk/healing-within-connectedness-love-part-two/

(brain in hands image with this blog is from Shutterstock by Sergey Nivens, all others are owned by Ann Parkinson at Unity Physiotherapy & Wellbeing)

The post Healing Within Connectedness & Love (part one) appeared first on Unity Physiotherapy and Wellbeing.

What Can Help

We need resources to help us in the grief process, resources help balance the challenges & vulnerabilities that arise.  A really important inner resource is compassion which I think this is foundational in many things including in grief & loss.  Other resources include the process of learning itself, the support of others, perspective taking, being able to connect to safety and trust, and mindfulness.  If someone is under-resourced they are more likely to need some support from a counsellor or psychologist.  Also this can be needed, for example, if the grief triggers into previous traumatic experiences, which I think it often does, especially if someone is under-resourced and it’s still needed sometimes even if someone is well resourced too.  It’s important to recognise when help is needed and also remember that there is no right or wrong way to grieve.

One way to identify what could be supportive for you to nurture is to ask yourself:

What’s challenging for you?

What would help if it was more present in your mind? (for example, compassion, love)

What would it help to connect to in your body? (for example, love, kindness)

You can then nurture what you identify would be helpful, the more we practice and work with something the easier to is to access as it becomes more hard wired.  There may be a time when growing what’s nurturing creates more sadness, it’s important we listen to the not yet and reassure ourselves it’s ok to feel these things and see if it feels ok to continue the practice.  A practice where you can nurture what you identify as supportive could be one like this one, to nurture what’s supportive in the body:

https://soundcloud.com/user-103516027/nurturing-whats-supportive?si=2ef7028b5d334d2e8f6860c9cbfcfebf&utm_source=clipboard&utm_medium=text&utm_campaign=social_sharing

Our self-talk matters, as mentioned in part one of the blog our self-critic can get over active and we take the losses and grief and turn them into a big stick to beat ourselves up with, when this happens the compassionate self can help.  Let’s look at a couple of examples and some compassionate reframes: “I need to stop wallowing and get on with living life”, perhaps you could notice how this statement lands in your body and what state of mind it’s associated with?  The self-critic’s view is not very helpful and doesn’t acknowledge the impact, that it’s normal to not feel ok and settled after a loss/losses for a while (how ever long that while is).  Here’s a compassionate reframe example, “my grief reminds me of how much I’ve lost, it’s completely understandable that I’ve been struggling and how I’m feeling is normal, everyone grieves and experiences losses and it’s not easy to navigate this.”  How does that land with you?  Here’s an example that combines guilt with the self-critic, “if I had worked harder to get rid of this pain I wouldn’t have lost my ability to walk further than I can, do the garden and the housework, I really should have stopped it happening, I just wasn’t strong enough to do it.”  Wow that’s harsh isn’t it, how does this land with you?  Let’s look at a compassionate reframe here, “this has been really hard to manage and I did my best to maintain my function and do what I needed to.  I had no control over how things have turned out and I’m doing my best to find what’s helpful for me.”  How does this land in your body, what about your mind?

Being aware of where our attention is automatically resting is helpful, pain and losses take our attention automatically and become a default until we become aware and start to change this habit (it doesn’t mean ignoring the pain and losses).  We have tricky brains in that they are wired for protection and survival and so have a bias towards things that are perceived as a threat.  If, for example, we rest in anger, anxiety or pain all the time it becomes a habit and what we are growing.  Also, when we do this we are functioning from our sympathetic nervous system way too much which impacts us in many ways.  Being mindful of where our attention is, acknowledging what is present and learning about it, then unhooking from this and choosing a more helpful place for our attention is part of creating space around pain and loss.  In this way we can learn from what’s showing up and deepen our awareness without being hijacked by it.

When I did Rick Hanson’s Grief and Loss course recently (linked at the end of this blog) he mentioned that Peter Levine talks about being like a pendulum swinging into the intensity and discomfort and back out.  The rhythm of the pendulum and how long it stays with the discomfort can be whatever is right for you, perhaps this could be helpful in being with the losses and grief and how it’s showing up without feeling overwhelmed.  Over time we can swing into the grief and discomfort and stay a little longer if it’s helpful.  If someone can’t create space in their pain and time and time again they get pulled into it, or maybe even are stuck in it, reaching out for help may be needed.

Dr Rick Hanson also talks about even as the storm passes through the mind for your own grieving there is a place inside, a knowing that a small part isn’t swept away and is alright, even if it’s a tenth of 1%.  Can you notice this?  This basic alrightness as he calls it can be a place of refuge, a soothing place to rest and grow.  Keeping returning to it and building this indestructible, trustworthy, reliable, unshakable core, as Rick says, is helpful.

It’s important to acknowledge the losses through pain or other health conditions, honour them and when we are ready create something meaningful, something that’s helpful for the self and others.  A ritual can be part of this, for example, drawing something, creating a memory scrapbox or memory box, lighting a candle, planting a tree or other plant, writing a letter, getting a group of people together to acknowledge & honour the person that once was with compassion and love.

Here’s a list of other things that help, I’m not talking about them all else this blog will be way too long (this is not an exhaustive list, there are many more things):

The post Grief & Loss in Persistent Pain & Other Health Conditions (Part Two) appeared first on Unity Physiotherapy and Wellbeing.

The suffering associated with losses and grief affects us all many times throughout our lives, losses and grief are part of the human experience and living with love and an open heart.  One thing that I feel is important to mention at the start is that grief has no right or wrong way, no specific length of time, it’s individual.

I am writing this blog as I’m passionate about helping people with persistent pain and other health conditions and I feel that the associated grief and loss isn’t talked about enough.  I am not writing this a psychological clinician instead as a coach and physiotherapist who has done additional related trainings, supported people with losses and grief through persistent pain, and through my lived experience of many losses related to health and other losses.  I’ve supported people by holding space for the grief, acknowledging it and allowing people to process it in whatever way they needed to (alongside a psychological clinician when needed).

There are many losses in life, including deaths, losses of relationships, losses of role, physical and mental losses, climate related losses, societal losses, loss of trust and confidence in ourselves, loss of hopes and dreams, right down to the loss of each moment as we never get the same moment back.  Losses through living with pain and other health conditions can be sudden, or they can appear gradually, they commonly affect many domains of life and can be completely life changing.  Many things need consideration in living with losses and grief related to health conditions, non-finite losses or living losses as they are also called, I will mention some of the important aspects in this blog.

Grief & Our Assumptive World

We all create what is known as our assumptive world, a lot of this develops when we are very young, which is part of our attachment system.  The assumptive world includes how we see ourselves and others, how we feel safe in the world, how we feel that we fit into social systems and how we think the world should work.  It forms a foundation of how we navigate the world feeling safe and ok.  Sometimes things bump up against the assumptive world and we adjust it, other times it’s more affected and it can be shattered.  When this happens we often no longer know who we are, we struggle to know how to be in the world as our old way of being no longer works/is no longer possible and the world no longer makes sense to us.  I think this happens more than is recognised in persistent pain and other health conditions when losses impact multiple domains of life.

When multiple losses wipe out the world we once knew it results in a state of disequilibrium.  This often feels a very vulnerable place to be and we can feel out of control, so a sense of agency is important.  Here’s an analogy I developed, maybe you can relate: A small rowing boat was out at sea, it had been impacted by the many storms, it couldn’t orientate to where it was anymore and it had lost its trust in navigating the sea’s ever changing environment.   It had taken on too much water, this happened so quickly it was overwhelming, consequently it started to sink.  After a while it was possible to work out how to offload some of the water and some dolphins came to help support the boat whilst it brought itself to a state of floating once more.

Once floating it had no idea how to get to shore again even though it could see the glimmer of the lighthouse.  The dolphins were still present providing a sense of safety and comfort whilst the boat rested and floated a while.  It had decided to simply float whilst it reflected on its journey, learning more about the current, the changing waters and the storms.  It began to feel bigger and a little more spacious and ready to start to travel the tricky waters to the shore.  The boat turned towards the direction that the lighthouse glimmer appeared to be arising from, slowly rowing and pausing, rowing and pausing, checking in on the water and the changing tide.  From time to time it let go of a little more water that came on board, the dolphins accompanied the boat as it travelled which was soothing and provided a sense of safety as it learned to trust and navigate again.  The boat had the choice of when pausing was needed and when to change its speed and it kept checking in with what felt right for it.  It became aware of the importance of spaciousness as it travelled and being able to see the wider view once more,  it became aware of distant islands and much more that it could see on the horizon and closer by.  It felt connected to all around and the wider parts of the sea and sky that it couldn’t see, it was soothing to feel connected to all of this.  This was the start of re-learning about the world and the journey towards creating something meaningful for the boat.

Some of the aspects for consideration with grief and loss in persistent pain & other health conditions

There are tangible losses, things that can be more easily seen, and intangible losses that are not so easily seen and expressed.  Intangible losses include: a change in identity, loss of purpose, loss of trust and loss of safe connection to the self and others.  Losses when struggling with persistent pain commonly include: loss of independence, loss of physical function, loss of joy and play, loss of finances/financial stability, loss of relationships, losses of role, loss of identity, loss of trust (in the self and others), loss of self-confidence, loss of belonging and feeling isolated, loss of ability to do what’s needed, loss of work, loss of being able to engage in hobbies and activities once enjoyed.  Often there are commonly many layers with losses and things are complex.

The intangibility of some losses can make grief feel isolating and links into a sense of feeling helpless and hopeless, these are linked to suicide risk which is one reason why keeping connected to a sense of community is important.  People also often feel isolated when living with pain and pain itself lacks tangibility, so it can be a bit of a double whammy with the isolation aspect.  It’s important to connect to the bigger picture view, that pain, grief, loss and suffering are part of being part of being human and many people feel isolated sometimes.  Acknowledging others feel like this too and having a community to connect to is important and can bring a sense of relief, it can be soothing and a sense of connection can feel healing.  Also holding our losses in the bigger container of common humanity rather than in a small container can help things feel less overwhelming.

As with pain itself there is primary and secondary suffering.  With pain, for example, the primary suffering is the pain and then we have the secondary suffering which commonly incudes anxiety, frustration, anger, guilt, self-criticism, and grief.  With losses the primary suffering is the loss and grief, the secondary is, for example, guilt, anxiety, rumination, anger and frustration.  Tara Brach talks about this as first and second arrows, Dr Rick Hanson as first and second darts.

Those close to the person living with persistent pain, or another health condition, are also grieving the loss of the person that once was.  This can be forgotten, it’s important it is acknowledged that the people close to the person living with pain are also grieving the person they knew.

Grief is commonly influenced by unhelpful social messages, it’s important we do what feels right to us with grief and not what societal expectations and norms might dictate.  In society there are many harmful messages for example: pick yourself up and get on with it, you need to try harder, that it’s strong to suppress and strictly manage emotions, and that being self-reliant and fiercely independent is the ideal.  None of these are true!  There are also deep rooted, messages in society around expectations of a fix or cure which puts pressure on people to be ok and on others try and fix things, rather than simply being with the grief and allowing it to be present exactly as it is.

Loss triggers our threat system, the sympathetic nervous system, many different emotions and feelings and parts of ourselves associated with our threat system show up and some stay a while, and our protection mechanisms are generally heightened.  There can be numbness, a lack of emotions, and an emptiness too.  Two of the protective parts that show up are the critical self and the anxious self, it is completely understandable that these parts of us show up, especially as uncertainty can be tricky at the best of times and the unpredictability of pain and other health conditions add into this.  Anxiety may also have been present before the grief and losses too and it can be a strong undercurrent sometimes in grief, it can be woven through the grief too.

It can feel like we have no control and as a result we end up over controlling things to try and manage the uncertainty.  There are common questions I have been asked, and I’ve asked myself too, including: what if I don’t get better?  What if I get worse?  Will I be able to handle it?  These questions are coming from fear of uncertainty usually, and often the anxious self has all sorts of responses that aren’t particularly supportive in the long-term.  We need to acknowledge this part of ourselves and any others showing up that are needing to be seen, heard and understood and bring in our compassionate self to calm the protective parts down and create more helpful guidance and support.

Through unhelpful self-talk, perhaps combined with previous experiences and beliefs, we may also have attached unhelpful meanings to some of the losses, for example that we are not good enough, or we are weak, or we may be carrying unnecessary guilt.  It can be helpful to explore what meanings we have attached to things, seeing if they are true or helpful (likely neither) and creating a compassionate reframe.

Also there can be worry and rumination linked to the losses, this is usually serving a protective function, like the anxious self and critical self do.  When we look under rumination there may be a lot of fear, anxiety, sadness, anger, shame or other protective feelings and emotions.   It’s really common for people who have a lot of losses due to pain and other health conditions to have a fear of if they will manage in the future, and even if they will get worse and the potential impacts of this happening.  In my experience of working with people with pain and fatigue it is commonly fear, anxiety and shame that lie underneath the rumination.  Sometimes we need to work with a therapist to explore this, partly depending on our previous experiences and internal resources.

When someone dies we have a ritual, a few of the various important things about this include recognising and honouring the loss and bringing a community together, people united in loss with love and care for each other usually.  In non-death losses we don’t have a ritual and this is something that can be helpful.

We need to make sense of things, acknowledge and honour what’s been lost and what we miss.  Sometimes we need to let go of things and old ways of being, to then move into re-learning and compassionately rebuilding a new assumptive world that maintains safety.  Rebuilding creates meaning, this is different to making sense of everything, it’s the what now?  It could be seen as building and growing something that’s helpful for the self and others from what’s been lost.  It’s said to be deep work that goes right to our core, maybe you have been there and can relate to the depth, I can.

It’s not about coming to an end of dealing with the loss, although we can make peace with it and create something meaningful it often gets retriggered.  For example, say for a few years it’s not at the forefront of our minds, then it gets triggered & there’s more that we maybe need to acknowledge, notice & allow to flow through as we deepen awareness and perhaps make some changes.  What arises is an opportunity to understand things even more deeply, let go of anything that’s not serving us and develop more resources for navigating the tricky times.

Here’s the link to part two which covers some of the things that can help, there is also a short summary and some resources that may be helpful https://unityphysio.co.uk/grief-loss-in-persistent-pain-other-health-conditions-part-two/.  Please remember grief has no right or wrong way and to ask for support if you need it.

(Some images are the authors own, others are as follows from shutterstock: heart in hands by SewCream , dandelion by JanBusson; from stock.adobe.com: man in boat by fran_kie, words on clipboard by Syahrir ).

The post Grief & Loss in Persistent Pain & Other Health Conditions (Part One) appeared first on Unity Physiotherapy and Wellbeing.

An increase in pain or fatigue that significantly disrupts your daily function and/or sleep for a few days or more is commonly referred to as a flare-up, some people use other terminology, for example a set-back.  Some things commonly go along with this including increased self-criticism, frustration, low mood, and loss of tolerance for some activities.

What is a compassionate flare-up plan:

A flexible plan, developed and implemented through a compassionate lens, of what you can do to self-manage what is happening, to calm things down and build things back up again.  It draws on previous experience of managing your pain and what is helpful for your wellbeing.

Why is compassion important?

Compassion is important in a flare-up plan as often people blame themselves, self-criticism and frustration commonly increase, which in turn turns up the pain volume and has other draw-backs like the impact on your mood.  Having a compassionate focus also encourages kindness, gentleness, courage and strength.  Compassion helps you support yourself and do what’s wise for you at that time, for example, asking for a little more help and support for a few days or weeks (there is both strength & vulnerability in asking for help).  Compassion has also been shown to help in many ways including decreasing self-criticism, rumination and stress, along with improving resilience & overall wellbeing.

Compassion encourages you to step back rather than pushing on regardless or stopping everything (neither of which are recommended) and ask yourself questions like ‘what can I do for myself out of kindness today’ (this is a question I love that I heard on a course with Dr Mary Welford).

‘Our compassionate self brings wisdom that illuminates the available choices & the possibilities flowing alongside them, along with what could be most helpful right now.’

What causes a flare-up?  There are many reasons and commonly it is a combination of things, including:

• Doing too much (this could be the boom-bust cycle if it happens regularly)
• Working to build tolerance and fitness levels up
• Choosing to do an activity outside of tolerance levels (some activities are worth this)
• A virus
• Increased stress
• Decreased sleep

It isn’t always easy to work out what has caused a flare-up, sometimes it helps to explore what had led up to it and other times it isn’t.  If you find you are having repeated flare-ups without any obvious contributors the best thing to do is usually to focus on actioning your compassionate plan.

Why do we need a flare-up plan?  Here are a few reasons:

• It helps you stay in control and feel confident with self-management.
• There are always flare-ups when living with pain and sometimes these are really difficult to deal with and sometimes feels like a million steps backwards have just happened at great speed.  A compassionate flare-up plan helps us remember the things that are helpful, what we can do to manage things, calm things down and build tolerance back up.  It’s not always easy when pain increases to think clearly, having a plan helps us take action away from getting caught up in things like self-criticism, rumination and anxiety.
• If we don’t have a plan we can end up getting stuck n a cycle of doing less and less, as a result we end up maintaining a new lower level as systems adapt to this and we lose fitness and tolerance for the activities we need and want to do.  This also affects confidence for doing daily activities amongst other things.
• Flare-ups can make people withdraw further from others, themselves and the world around them.  Retreat is a natural protection mechanism, this may be a helpful short-term strategy, however it is not helpful when it is repeated regularly in the long-term.  Retreat and disconnection are also things that turn up the pain volume and sensitivity, connection to others and ourselves is an important part of managing pain and overall wellbeing.
• Some things are worth the flare-up, these are the things that matter most to us.  You can make a mindful choice to do an activity, even though pain is likely to increase, because you feel the activity is worth it and knowing you have a compassionate plan to help you over the following days to find some ease can be reassuring.  So, a compassionate flare-up plan can help you take steps forwards towards your values and what matters most to you.

What to put in a compassionate flare-up plan?

This is individual to you and requires some exploration and reflection.  Grab a notebook and make some notes, if you are having a flare-up now use this experience and previous ones as you read to make notes, otherwise remember the last time or times you had a pain or fatigue flare-up that affected your function and sleep for a few days or more.

• Consider what may have contributed to the flare-up, if this is helpful (sometimes it’s not, notice if you get stuck in a look of self-criticism and guilt).  Compassionately acknowledge (a gentle tone, a helpful acknowledgement without criticism) this and what could be done differently next time, if anything.
• What helped you calm things down and build things up before?  What didn’t help before?
• Set yourself some easy short-term goals based on meaningful activities (what’s important to you, what do you most enjoy doing).
• Plan to gradually build things up to rebuild tolerance and fitness.  Align this with your goals and allow yourself flexibility to adjust things if needed along the way.
•  Moving little and often is usually helpful.  Remember to include movement in your plan.
• Prioritise what needs to be done and leave the rest or ask for help (it’s not a weakness to ask for help it’s a strength).  It can be frustrating leaving things, there are strategies that can help you manage this.
• Having flexibility & support from your employer is important, having open and honest discussions with them about what support could be helpful during a flare-up (for example, frequent short breaks) to helps things settle down again.
• Remember to change how you usually pace things for a short-time, you will have lower tolerance as the need for protection has be deemed to have increased (things are on high alert), pacing differently can help calm things down.  It is important to have a flexible plan for building things back up as you will otherwise adapt to the new lower level.
• Don’t stop everything and rest for more than a few hours at a time, it is usually better to do a small amount regularly with short rests.
• Notice self-criticism with self-compassion and unhook from unhelpful thoughts.  One way to do this is to say, for example, ‘I notice that I am thinking the thought that…’  Another is to write a compassionate letter to yourself to acknowledge how things are and that it’s not your fault, it is understandable & part of being human and living with pain.  There was a post on this on Unity Physiotherapy & Wellbeing’s Facebook page in September 2019 as part of Pain Awareness Month.  There is also guidance in The Compassionate Mind Workbook & Compassion Focused Therapy for dummies.  If you are unsure, or struggle with this, please get help from a suitably trained therapist.
• Practice self-compassion.  There is guidance in both books mentioned above, The Compassionate Mind by Professor Paul Gilbert and on Kristien Neffs website https://www.self-compassion.org
• Increase relaxation based activities, for example meditation, gentle stretching or anything you find calming.

• Integrate more things that stimulate the soothing system (this is part of the 3 circles model in compassionate mind training/compassion focused therapy).  I go through this in clinic with people, there is also guidance in the above books and this video by Chris Winson https://m.youtube.com/watch?v=peC-bB4DqXQ&fbclid=IwAR3b10RyukjKxkukeByQB4XQVeo0bMkVfjo1uvwggpamb09iTc0r-vpc07M
• Consider if you need medication in a bad flare-up or can you manage things effectively with other strategies.  If you need medication discuss this with your Doctor, Pharmacist or Non-Medical Prescriber, such as a Physiotherapist who has done additional training, how to optimize this.
• Focus on the present moment and the small steps rather than the set back and where you were.

Need further help?

Ask your physiotherapist or other healthcare provider for help if you are unsure of how to create your flare-up plan.  Creating individual compassionate flare-up plans is something I help people with at Unity Physiotherapy & Wellbeing.

‘A compassionate flare-up plan helps you keep returning to a life full of meaning & purpose with pain in the background’

The post A Compassionate Plan for Persistent Pain Flare-Ups appeared first on Unity Physiotherapy and Wellbeing.

Living well with pain means being able to do the things: that are important to you and that matter most; the things you need to do; and doing the things that look after your health & wellbeing daily (including practices that help change pain, such as nervous system calming activities, with pain in the background.

There are many aspects involved in living well with pain, these need exploring and tailoring to what is most helpful for each individual.  Living well with pain and full resolution of pain (in reality the latter doesn’t happen for many people) takes time, flexible persistence, practice and compassion, to name a few of the important things.

Living well with pain needs an understanding of the changes that happen when pain persists along with an individual toolkit of things that help look after your health & wellbeing.  This blog will look at some of the aspects of living well with pain (whilst it changes in the background), and how we can do what matters most.  All of the aspects covered in this blog are either already blogs and resources on the Unity Physiotherapy & Wellbeing website or they will be in the future.  At the end of this blog you will find a link to a pdf resource document that has a few tips for the different aspects mentioned in this blog, along with a list of resources that are I feel are helpful and use with people in clinic.  This resource list is not exhaustive and there are many more (you can also find a longer list of resources on the Unity Physiotherapy website).

Tina, who lives with pain and runs livingwellpain.net created the helpful 25 elements of living well with pain diagram below (used here with her kind permission), and she has written about 10 of these in a blogs here http://livingwellpain.net/category/25-ways-to-manage-pain, you will find some of these woven into this blog.

Understanding Pain

Ok, this is complex! I am not going to go into the complexities of pain or the neuroscience in this blog, although understanding this and how this relates to you can be helpful.  Many books delve into this in varying levels like Explain Pain & Explain Pain Supercharged (the latter is more technical read) and there are many great articles and blogs too (some are listed at the end of this blog).

Understanding the different aspects of pain can help you understand that pain is a protection mechanism and systems can become overprotective, how different systems adapt when pain persists and that they can adapt again in a helpful way.  Understanding pain includes understanding why, for example, things like hurt doesn’t necessarily equal harm, pain cannot be found on scans (we are much more than a sum of our parts), pain is a protection mechanism and a poor reflection of what is going on in the tissues, movements and activities become associated with pain and are not necessarily causing harm.  It’s helpful for your friends and relatives to also have an evidenced based understanding of pain and how this relates to you.  An evidenced based understanding means having an awareness or a more in-depth understanding of what the research tells us about pain, and knowing what myths exist in society (there are many myths!).

(image edited, Nivens, Shutterstock)

Everything that contributes to us being human can contribute to pain, so that’s a lot of things!  I would be here forever if I listed them all, to give you an idea here are some of the factors that can contribute to pain: biological factors (everything including thoughts are part of our biology), a sensitive nervous system and body (includes the immune system), not feeling safe to move, not trusting your body, beliefs, values, how we interact with the world, attention, opinions of others, previous experiences, myths about pain, expectation, self-criticism, thoughts, feelings and emotions, stress, lack of connection, avoidance, nutrition, overdoing and underdoing things, lack of purpose, feeling no-one understands, and much more.

Pacing

There is no agreed definition or set way to do this.  In my mind pacing is essentially a flexible daily structure of what’s helpful for you.  There are no set rules, no-one paces the same way because no-one walks in the same shoes, even though we create similar footprints.  What we learn from what the evidence tells us can help, as well as from each other’s paths and footsteps.  Learning how to pace and manage pain is a journey of exploration that takes many directions.

When pain persists people commonly either stop doing what matters most to them, lose purpose, or push on through things (boom-bust cycle) which commonly further sensitises things (creates more protection).  I have heard it said for pacing ‘stop before you think you need a rest’, as a general rule this is not needed, although it can be part of a strategy to calm things down when you are having a flare-up or with, such as, neuropathic pain.

Have a compassionate & flexible plan as a guide when things get challenging

Life is always changing there is no constant, things are in a constant state of flux and this includes pain.  Sometimes that flux changes significantly, sleep quality and function are affected, this is often referred to  as a pain set-back or flare-up.  It is important to know what helps when things flare-up, to help calm things back down, and approach things in a flexible and compassionate way.

Be compassionate with yourself, flare-ups are common and not a fault of anyone.   Self-compassion helps in many ways including: quietening self-criticism, modulating feelings like guilt, anger and frustration, and decreasing rumination (all of these turn up the pain volume and can contribute to anxiety).  Self-compassion can also help with pacing and knowing what’s helpful, as well as making wise choices that can help nurture overall health & wellbeing.  It’s important to not stay at the reduced level for too long, as you will accommodate to this; this is one reason a flexible plan, that incorporates building things back up gradually, helps.

Sleep

Getting enough good quality sleep is essential for our health and wellbeing, usually this is around 7-9 hours.  When living with pain, lack of sleep commonly means we notice more pain, are more sensitive to stimuli (eg react to less movement) and more easily feel stressed.  There are a number of things you can do to help give yourself the best opportunity of good sleep.  There are some tips in the resource accompanying this blog.

 Exercise

Exercise is essential for our health and wellbeing and is helpful in living well with pain, yet there are differences in how our nervous systems and bodies react to exercise when we live with pain.  Some people find exercising daunting due to significant increases in pain as a result.  It is important that the exercise you do is something that you enjoy doing and you explore what is the right level to start with.  Exercise is important for many reasons, even if it doesn’t modulate pain (it does for some), it helps you keep strength and tolerance to keep doing what matters.

There are a number of aspects you can modulate with exercise, like frequency, repetitions, speed, and intensity.    This is a link to a blog I wrote on exercising with persistent pain, it gives some more information and general guidance https://www.unityphysio.co.uk/exercising-with-persistent-pain/.  My blog and the following blog (written by physiotherapist Thomas Jesson) provide general guidance and are not intended to replace individual medical advice https://medium.com/@thomas_jesson/exercising-when-it-hurts-a8b70f7b1ebf?_referrer=twitter&fbclid=IwAR3ohbyxL7QSRzfkg1jmtHNRnxJW_ouHYD8Tm_Ql_8_88EtLBNGlPiS2pcQ

Language

What we say to ourselves (our self-talk) matters.  How we talk to ourselves is a habit that we can change.  Part of being human is we are wired to focus on the negative and to compare ourselves with others.  We can train our language and how we relate to ourselves to be more helpful.  Commonly when living with pain self-talk is often self-critical, this is part of our threat system and can contribute to systems staying on high alert which increases pain.  There are some tips about language in the resource associated with this blog and more information and exercises in my pending book. 

Acceptance

Acceptance is important for us all, life is tricky and we all have things to deal with that are challenging.  There is a common misconception that acceptance is passive and that it means giving in or that we are happy to leave something as is, it doesn’t.  It’s important to know that all any of us can do is accept things as they are in the moment, not as they will be tomorrow or next week, it’s an ongoing process not something we only do once!

Acceptance means being able to allow things to be present, with compassion, awareness and understanding, without pushing things away (avoiding), dropping the struggle and living well despite pain being present.   This doesn’t mean pain won’t change, it will, instead it means pain is no longer the focus, and we are not putting life on hold waiting for the next thing that someone says will get rid of it (this commonly increases the pain and affects our mood).  Instead of pain being the driver we can learn to put it in the back seat and let it be there, acceptance is one part of doing this without trying to push it out of the car (this uses so much energy and focus!).  Who knows one day it may move further away and we can move it to sit on the car roof!

It’s important to remember pain can, and does, change even though for many it doesn’t fully go away it can.  Acceptance helps us steer in the direction of what’s meaningful.  Accepting you have persistent pain helps you take pain out of the driving seat, take back control again and steer in the direction of the things that matter to you in life even if pain is in the background.

Meaning, Purpose & Connection

One of the things, ok three things, that are particularly important are meaning, purpose and connection, these are inextricably interlinked.  I have lost count of the number of times that someone has said ‘I feel like I have no purpose.’  This relates to not being connected to oneself and others, not living aligned with what’s most important (this is usually aligned to our values).  By knowing what your values are and setting goals alongside these you can start to reconnect to what’s most meaningful to you.  Our work can be part of our purpose and its helpful if it is, my work is connected to my purpose in life and my values.

When we stop doing what’s meaningful we lack connection to ourselves and others which is important for our wellbeing.  When we do what’s meaningful to us, and when we feel connected to others, helpful neurotransmitters are released (chemical messengers) too that help modulate pain and help us feel happy, content or relaxed.  Connection and compassion are both important for our wellbeing.

There is opportunity within the pain to steer towards what matters, to be guided by your values and let go of some things that don’t serve you and those around you.  A lot of people say to me they are grateful in some ways as they come to see what’s most important, living with pain I can relate to this.

*This blog is intended as general information and guidance and is not intended to be individual medical advice*

Link to tips for aspects discussed in this blog 

Resource alongside living well blog

Resources

Books:

• Explain Pain by David Butler & Lorimer Moseley
• Painful Yarns by Lorimer Moseley
• Pain Heros by Alison Sim
• Understand Pain Live Well Again by Neil Pearson
• The Compassionate Mind Workbook by Chris Irons & Elaine Beaumont
• Compassion focused Therapy for Dummies by Mary Welford
• The Mindful Self-Compassion Workbook by Kristin Neff & Christopher Germer.

Blogs:

• Livingwellpain http://livingwellpain.net
• My Cuppa Jo blogs https://www.mycuppajo.com
• Pain Chats https://painchats.com

Other resources:

• Pain Toolkit https://www.paintoolkit.org

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