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Introduction
Body awareness is a complex construct at the inter-
face of mind and body. Depending where it is dis-
cussed, whether in primar y care medicine, behavioral
science, health psychology, cognitive neuroscience,
anthropology, massage therapy, physical therapy,
body-oriented psychotherapy, martial arts, or in vari-
ous mind-body approaches, we hear quite divergent
views about it. Historically, it has commonly been
associated with hypervigilance and hypochondria-
sis and thereby been viewed as a proxy for anxiety
(Porges 1993; Cio 1991); however, conversely, it
can be associated with mindfulness and discrimi-
native attunement to subtle bodily cues and then it
becomes a powerful tool in self-regulation. As one
view describes it as maladaptive and the other as
benecial, there may still remain substantial confu-
sion despite recent attempts at a more dierentiated
understanding of the body awareness construct
(Mehling et al. 2009).We dene body awareness
as sensory awareness that originates from the
body’sphysiological state, involving interactive pro-
cesses (including pain and emotion), actions (includ-
ing movement), and appraisal (as well as complex
bottom-up and top-down neural activities) shaped
by the person’s attitudes, beliefs, and experience in
their social and cultural context (Mehling et al. 2009).
These top-down activities determine whether body
awareness is maladaptive or benecial.
Neurophysiology of Pain as it Relates to
Body Awareness
From a neurophysiological viewpoint, body aware-
ness includes both proprioception and intero-
ception. Proprioception is the perception of joint
angles and muscle tensions, of movement, posture,
and balance. Interoception is the perception of all
sensations from inside the body and includes the
perception of physical sensations related to internal
organ function such as heart beat, respiration, sati-
ety, and the autonomic nervous system symptoms
related to emotions (Cameron 2001; Craig 2002;
Vaitl 1996; Barrett et al. 2004). Much of these per-
ceptions remains unconscious; what becomes
conscious enters proprioceptive and interoceptive
awareness, which involves higher mental processes
such as emotions, memories, attitudes, beliefs,
and behavior (Cameron 2001). Neuroscience has
revealed how and in which areas of the brain inter-
oception is processed and how it relates to emotion
and pain (Critchley et al. 2004; Wiens 2005; Bechara
and Naqvi 2004; Naqvi et al. 2006).In this chapter,
however, we will emphasize the rst-person phe-
nomenology of massage and body therapy experi-
ences, an area that is of yet not within the purview
of current brain science.
Pain, particularly chronic pain, is a highly complex
subjective experience with sensory discriminative,
aective, and behavioral aspects, and distinguish-
able neural pathways for each. The last decades
have provided important new insight into pain
and the ways it is neurologically processed. Both
pain in its aective component and interoception
use identical neural pathways (Craig 2003a; Craig
2003b) and converge in a cortex region of the brain
that processes the physical and sensory aspects of
emotions and their autonomic nervous system cor-
relates (Craig 2003a). Pain as a bodily sensation is
part of interoception and has intriguing parallels to
emotions. As both pain and emotions have sensory,
aective, and motivational-behavioral aspects and
common neurological pathways, some neurosci-
entists now view pain as a “homeostatic emotion”:
pain is a signal from the body that motivates behav-
ior to maintain or restore the system’s energetic bal-
ance and integrity, e.g., protect a wound or avoid
potentially damaging situations. Pain—often quite
dramatically—demands our attention, enters con-
sciousness and, thereby, emerges as an experience
we access through interoceptive body awareness.
Cynthia J. PRICE Wolf MEHLING chapter 16
Body awareness and pain
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Handspring Publishing (2016)
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Developmental Phenomenology of Body
Awareness
How pain and body awareness interact and unfold
for our patients has been beautifully described
by Sally Gadow as a dialectic of self and body
(Gadow 1980). In a rst level or stage of that dia-
lectic labeled by her “the lived body,” the body is
taken for granted: we are unaware of it. The philos-
opher Drew Leder described the body in that rst
stage simply as “absent” (Leder 1990). We and our
patients might live in this state before pain occurs
and demands our attention. In a second level labe-
led “the objective body” by Sally Gadow, the body
is experienced as opposed to the self. We are forced
to pay attention to the pain in our body. Body and
self are in tension with each other or in a state of dis-
unity, the body as the new object of our attention
is “symptomatic” and patients experience func-
tional constraints from pain. This state is the situ-
ation that brings patients into therapy, either with
the medical system or with practitioners who use
the approaches described in this book. None of us
likes to pay attention to our pain; we experience it
as an aversive stimulus that preferably is dealt with
through distraction. When we seek to give pain our
attention, often by asking another person, a loved
one, or a professional to do so, the helping per-
son or a practitioner is tasked to look at our body
where it hurts, as we have a hard time focusing our
attention on it ourselves. In a third developmental
stage, if reached, labeled as “cultivated immedia-
cy”(Gadow 1980), we then may experience a new
relationship to the body characterized by accept-
ance and immediacy. We now accept that the body
may have had its good “reasons” to start hurting,
for example, when we had ignored our physical
limits, believing we can do whatever we want. In
a fourth state labeled “the subjective body,” the
body may be experienced without objectica-
tion as a source of learning and meaning. In focus
groups we have conducted with practitioners, they
described the body experienced in that stage as
endowed with “intelligence” and having an “innate
tendency towards embodiment” (Mehling et al.
2011). The body then is no longer (a) just the means
by which the self carries out its projects, or (b) the
source of pain, constraints, and limits to the self’s
goals, but rather an integral and equal part of the
self and the locus of consciousness and subjectivity
with its own perspective (Hudak et al. 2007).
Relevance of Body Awareness for Body
Therapy Approaches to Pain Management
Because everyday body awareness—in the way
we understand it and dened it above—includes
the lters and modications from our deep beliefs,
Sidebar 16.1 Patient Interviews
In response to the question, “Have your condition
or symptoms or ability to function changed since
receiving care?” replies included:
• “I am far more knowledgeable about my
health issues since I am aorded more time,
expertise, guidance, and overall sensitivity
as compared to most available practitioners
within traditional UCMC medical
environment. I also am alerted to less
invasive and eective approaches outside of
the realm of healthcare oerings. [Regarding
how I feel about myself or my pain since
receiving care:] I feel I am more in control of
my health condition since I am more aware of
my health issues. I am more proactive, have
greater options as a result.”
• “I am in less pain and can resume many of my
normal activities. In past years I have dealt with
the pain as it was just part of what I had to do. I
needed additional help and not shots for pain
and spine. [Regarding how I feel about myself
or my pain since receiving care:] I can function
in day-to-day life without as much pain. I have
slowly started to add activities back in my
life—spin, hiking within moderation. I feel like
I am getting my life back.”
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Body awareness and pain
biases, expectations, and attitudes, it might play
an important role in our perception of pain (Cio
and Holloway 1993; Zeidan et al. 2011). Pain is inti-
mately entwined with emotions (Wade et al. 1990;
Cauda et al. 2012), and pain management has much
in common with emotion regulation. Attention,
how we direct and focus it, plays a key role in both
emotion and pain regulation.
A pain patient can focus attention, e.g., on low
back pain, in quite dierent ways: (a) ignore the
pain (distraction, endurance; rst stage in the
developmental model above) (Hasenbring and
Verbunt 2010) (b) focus on it with worry and anxi-
ety-driven hypervigilance (fear-avoidance; the sec-
ond stage) (Vlaeyen and Linton 2012), or (c) focus
on it with mindful attention (the third or fourth
stage) (McCracken and Keogh 2009). These dier-
ent styles of attention versus distraction have a
major impact on the perceived intensity of chronic
pain (see Sidebar 16.2) (Hasenbring et al. 2009; Flink
et al. 2009; Hasenbring 2000; Eccleston et al. 1997;
Eccleston and Crombez 2005; Gard et al. 2011; John-
ston et al. 2012).
Most of the therapeutic approaches discussed in
this book have developed outside of medical and
behavioral science. When the ecacy or eective-
ness of these methods is investigated in research,
the mechanisms of action are generally unknown.
However, when taking a broader perspective,
we argue that the development of body aware-
ness, moving along the stages described above,
might be a common denominator of these thera-
pies’ mechanism of action for their various bene-
ts (Shusterman 2008; Fogel 2009; Mehling et al.
2011). Indeed, body-based approaches can provide
patients with a unique opportunity to learn intero-
ceptive awareness as a tool for pain management.
History of Body Awareness: Applications
in Related Modalities
While the majority of body-based approaches claim
to enhance body awareness, the explicit focus
on body awareness varies greatly (Daubenmier
2005; Sherman et al. 2005; Price 2005; Smith et al.
1999; Kahn 2007; Ives 2003; Ernst and Canter 2003;
Mehling 2001; Lazar et al. 2005; Holzel et al. 2011;
Recent research ndings suggest that focusing on
sensory/discriminative aspects of acute experimen -
tal pain may be useful pain-regulation strategies
when severe pain is expected (Johnston et al. 2012).
It implies that directing attention in specic ways
towards sensations of pain may be a promising way
of coping with chronic pain. Thus, attention reg-
ulation appears to be a critical element of intero-
ception for pain management and may determine
whether body awareness is benecial or mala-
daptive in a given situation. This has been known
by healers and clinicians over the ages, including
many practitioners of the approaches presented
in this book, expressed in Nietzsche’s remarks that
great pain may be the ultimate teacher (Nietzsche
1882), but medical and behavioral science may still
have to catch up.
Sidebar 16.2 Research (Cont.)
Sidebar 16.2 Research
Psychologists stud ying the eect of mindfulness—
mostly in the form of mindfulness-based stress
reduction (MBSR)—on emotions and pain found
that “one problem in chronic pain is not only the
pain itself, but the ‘tur ning away’ from, the averting
of attention from, the re gions that give rise to pain-
ful sensations, either through deliberate distrac-
tion, or by thinking about the pain (conceptually)
rather than experiencing the sensations directly”
(Williams 2010). Intriguingly, this psychologist
describes two ways of distraction from pain: rst,
the common mechanisms of the deliberative diver-
sion of attention, for example, by watching a movie
or cracking jokes with friends; but second, an often
unrealized mechanism of distraction, that of think-
ing about the pain rather than directly feeling it, a
distinction that we will see is of major importance.
(Cont.)
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Mehling et al. 2005). In Feldenkrais and Alexander
Technique and Mindful Awareness in Body-oriented
Therapy, there is an explicit and active focus on
teaching and developing interoceptive awareness
as an integral aspect of each therapeutic approach.
For practices such as yoga, tai-chi, qi-gong, and
mindfulness meditation, body awareness is funda-
mental to the practice and the degree to which this
is explicitly taught and developed varies by teacher
and practice style. Approaches in which the patient
is more receptive (vs. active) such as in massage,
structural work, energy work, and Asian modali-
ties, body awareness is considered important yet is
often implicit versus an integral educational focus.
It is important to touch on the role of culture.
Many of the approaches in this book originated
in the East (e.g. tai-chi, yoga, acupressure, tui na,
shiatsu, qi-gong), where there was not the Carte-
sian split between mind and body. As these tradi-
tions came to the West, the need to address body
awareness for health and healing was more clearly
identied (Benson 1985), and was picked up in
experiential psychology (Gendlin 2012), mind-body
practices to treat medical conditions (Kabat-Zinn
1982), and lead to the development of new body
therapy approaches, many of which are highlighted
in this book.
As indicated above, the use of focused attention
to the body to attend to sensory experience is criti-
cal to pain management. Touch, either from a practi-
tioner or self-touch, can be used to increase attention
to an area of the body and to increase interoceptive
awareness of sensations. For patients in pain, it is
much easier for them to focus on their pain when
supported by a therapist who can meet them with
touch right where it hurts. In massage, patients can
gain this awareness if they attend to their bodily
sensations in response to the activity of the mas-
sage practitioner. More direct guidance from the
practitioner aids this process by bringing increased
intention and conscious attention to bodily experi-
ence. This can require that the practitioner have/use
a psycho-educational approach, particularly if the
patient is not able to easily attend to bodily expe-
rience. Diculty attending to bodily experience is
common among patients who have habits of dis-
connection or dissociation from the body—due to
chronic pain, trauma, or other mental health chal-
lenges. The dimensions of body awareness that we
think are integral from a theoretical/educational per-
spective are outlined in the next section.
Body Awareness for the Treatment of
Pain: Theory and Research
Theoretical Framework
Body awareness can be understood in theory as a
construct of multiple dimensions (Mehling et al. 2009):
• Noticing body sensations includes bodily
sensations that are viewed as negative,
positive, and neutral (e.g., from breathing).
• Emotional reaction and attentional response
to these sensations include: (a) suppressing,
ignoring, or avoiding perceptions of
sensations such as by distracting oneself;
(b) worrying that something is wrong;
and (c) present-moment awareness with
nonjudgmental awareness of sensations, i.e., a
mindful presence.
• Capacity to regulate attention pertains to
various ways of controlling one’s attention
as an active regulatory process. These
include the ability to (a) sustain awareness,
(b) actively direct attention to various parts
of the body, (c) narrow or widen the focus of
attention, and (d) allow sensations without
trying to change them.
• Mind-body integration is viewed as the
goal of mind-body therapies and includes:
(a) emotional awareness, the awareness
that certain physical sensations are the
sensory aspect of emotions; (b) self-
regulation of emotions, sensations, and
behavior; and (c) ability to feel a sense of an
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Body awareness and pain
embodied self, representing a sense of the
interconnectedness of mental, emotional,
and physical processes as opposed to a
disembodied sense of alienation and of being
disconnected from one’s body.
• Trusting body sensations reects beliefs about
the importance of sensations and the extent
to which one views awareness of bodily
sensations as helpful for decision making or
health.
All of these dimensions of body awareness can
be useful in pain management. We may better
understand how by rst starting with a brief over-
view of well-known key psychological factors for
the trajectory of pain, including research on low
back pain as an example and then, second, relating
the elements of body awareness to the psychology
of pain.
• Depression, although preferably viewed more
as a consequence rather than an antecedent
of chronic pain, distress (complaining
of physical symptoms associated with
depression and anxiety), depressive mood,
and somatization are all implicated in the
transition from acute to chronic low back
pain. Longitudinal studies have yielded
somewhat contradictory results, and some
researchers postulate that this is because
people with chronic pain can be divided into
two groups that appear quite dierent. In
one group, pain symptoms are associated
with other somatic symptoms and symptoms
of depression and anxiety, heightened stress
reactivity, and a sense of overwhelm. In the
second group, individuals tend to stoically
ignore symptoms of discomfort and pain and
make a “happy face” in response to stress or
pain, thereby appearing quite the opposite
of depressed. Persons with this latter
endurance coping style have been found
to be equally at risk of longer pain duration
(Hasenbring 2000).
• Pain catastrophizing is conceptualized
with three components: magnication or
amplication of pain, ruminating thoughts
about pain, and perceived helplessness
in the face of pain. It appears to be the
strongest and most consistent psychosocial
factor associated with persistence of pain
and poor function in persons with chronic
pain, even after controlling for depression.
Catastrophizing is modiable, and, if
addressed in therapy, pain has been shown to
improve when catastrophizing decreases.
• Fear-avoidance is the behavior of avoiding
work, movement, or other activities due to
fearful beliefs that they may damage the body
or worsen pain. Fear-avoidance is associated
with catastrophic misinterpretations of
pain, increased escape and avoidance
behaviors, and increased pain intensity and
functional disability, and increases the risk
for developing new-onset back pain, for its
chronication, and for its persistence. The
value of changing beliefs about pain early in
its course has been shown in studies involving
patient education in physician and physical
therapy oces, and even over the public radio
(Buchbinder 2008; Buchbinder et al. 2001).
• Distraction is a coping style that generally
is favored by many patients, which is most
consistently advantageous with acute pain.
Its opposite, a hypervigilant attention style
towards pain, is related to anxiety and clearly
maladaptive. In research studies of chronic
pain, however, distraction appears to have
no consistent proven benets (Goubert
et al. 2004), although music, providing
distraction combined with positive aect
and relaxation, appears to diminish pain.
Whether an attention focus towards pain is
benecial or maladaptive may be mediated
by the attention style. An anxiety-driven
and hypervigilant attention style is likely
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240
maladaptive, while accepting and mindful
attention may be benecial (Mehling et al.
2013). Research on this question is underway.
• Ignoring pain is generally considered an
adaptive coping style, particularly with
the use of cognitive distraction, a focused
approach to diverting attention from pain
used by cognitive behavioral therapy (CBT).
Yet, suppressing the perception of pain
to avoid interruptions in daily activities, a
more disorganized and nonfocused search
for distraction that often fails and causes
feelings of emotional distress, is a form of
distressed endurance behavior and task
persistence that has been shown to lead to
chronic pain, possibly via physical overload
(Hasenbring and Verbunt 2010). There are,
however, studies indicating that the opposite
of ignoring and suppression, an in-vivo
exposure approach such as acceptance and
mindfulness training, may be eective in pain
patients (Flink et al. 2009; Linton et al. 2008;
Johnston et al. 2012).
• Recovery expectation is one of the strongest
predictors of chronic pain. Expectation itself is
strongly inuenced by concerns and worries
about pain exacerbations, recurrent pain,
nancial security, support at work, and self-
condence.
• Maladaptive body perception: A 2012
review of current behavioral pain research
and treatments showed, that “important
contributors to chronic pain may be disturbed
processing of the body image, impaired
multisensory integration and faulty feedback
from interoceptive processes,” which has
led to new treatment approaches, such as
sensory discrimination training, that focus
on a restoration of the body image and “the
alteration of maladaptive changes in body
perception” (Flor 2012).
We can now theorize how various therapeutic
approaches discussed above and in previous chap-
ters of this book may aid pain management by
modifying these key psychological factors through
improving various dimensions of body awareness.
A mindful focus on pain with nonjudgmental
present-moment awareness would diminish ignor-
ing, distraction, and catastrophizing. Dierentiating
variations in pain intensity and the felt experience
helps the patient gain insight into how these varia-
tions correlate to activity and movement, and allows
for ne-tuning of personal activities and modica-
tion of any fear-avoidance beliefs and behavior. If
pain is acknowledged as real but impermanent and
uctuating, like every emotion, the pain patient
learns that emotion and pain regulation skills can
change the intensity or bothersomeness of pain and
expectations about the pain duration. The sense
of overwhelm and helplessness (catastrophizing)
can then improve. If patients learn to listen to their
body, if they ultimately learn to trust that the body
can be a source of insight rather than merely a mean
adversary, then negative emotions (anxiety-fear,
depression) and catastrophizing can improve. If
present-moment awareness and direct immediate
felt experience can be learned, and if the patient
can learn to choose between thinking about pain
and sensing pain, a tendency for rumination (part of
catastrophizing) can be positively inuenced. These
are some theoretical ways in which body awareness
skills might benet pain management.
Research
Our research group compared a group of primary
care patients with current or past low back pain
with a group of individuals with professional clinical
experience in mind-body therapies on levels of
self-reported body awareness using the Multidi-
mensional Assessment of Interoceptive Awareness
(MAIA) scales (see Figure 16.1) (Mehling et al. 2013).
The therapies were the ones described in this book,
e.g., meditation, yoga, and bodywork therapy. We
found that “mind-body trained individuals scored
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Body awareness and pain
Below you will find a list of statements.
Please indicate how often each statement applies to you generally in daily life
Circle one number on each line
Never Always
When I am tense I notice where the tension is located in my body
0 1 2 3 4 5
1
I know when I am uncomfortable in my body 0 1 2 3 4 5
2
I notice where in my body I am comfortable 0 1 2 3 4 5
3
I notice changes in my breathing, such as whether it slows down or speeds up 0 1 2 3 4 5
4
I do not notice (I ignore) physical tension or discomfort until they become more severe 0 1 2 3 4 5
5
I distract myself from sensations of discomfort 0 1 2 3 4 5
6
When I feel pain or discomfort, I try to power through it 0 1 2 3 4 5
7
When I feel physical pain, I become upset. 0 1 2 3 4 5
8
I start to worry that something is wrong if I feel any discomfort. 0 1 2 3 4 5
9
I can notice an unpleasant body sensation without worrying about it
0 1 2 3 4 5
10
Attention regulation Ability to sustain and control attention to body sensations
Q11 + Q12 + Q13 + Q14 + Q15 + Q16 + Q17 / 7 =
4
Emotional awareness Awareness of the connection between body sensations and emotional states
Q18 + Q19 + Q20 + Q21 + Q22 / 5 =
5
Self regulation Ability to regulate distress by attention to body sensations
Q23 + Q24 + Q25 + Q26 / 4 =
6
Body listening Active listening to the body for insight
Q27 + Q28 + Q29 / 3 =
7
Trusting Experience of one’s body as safe and trustworthy
Q30 + Q31 + Q32 / 3 =
8
Noticing Awareness of uncomfortable, comfortable, and neutral body sensations
Q1 + Q2 + Q3 + Q4 / 4 =
1
Not-distracting Tendency not to ignore or distract oneself from sensations of pain or discomfort
Q5 (reverse) + Q6 (reverse) + Q7 (reverse) / 3 =
2
Not-worrying Tendency not to worry or experience emotional distress with sensations of pain or discomfort
Q8 (reverse) + Q9 (reverse) + Q10 / 3 =
3
Scoring instructions Take the average of the terms on each scale
Note: reverse-score items 5, 6, and 7 on Non-distracting, and items 8 and 9 on Not-worrying
Figu re 16 .1 (Continued)
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242
I can pay attention tomy breath without being distracted by things happening around me. 0 1 2 3 4 5
11
I can maintain awareness of my inner bodily sensations even when there is a lot going on around me 0 1 2 3 4 5
12
When I am in conversation with someone, I can payattention to my posture 0 1 2 3 4 5
13
I can return awareness to my body if I am distracted. 0 1 2 3 4 5
14
I can refocus my attention from thinking to sensing my body. 0 1 2 3 4 5
15
I can maintain awareness of my whole body even when a part of me is in pain or discomfort. 0 1 2 3 4 5
16
I am able to consciously focus on my body as a whole 0 1 2 3 4 5
17
I notice how my body changes when I am angry 0 1 2 3 4 5
18
When something is wrong in my life I can feel it in my body 0 1 2 3 4 5
19
I notice that my body feels dierent after a peaceful experience 0 1 2 3 4 5
20
I notice that my breathing becomes free and easy when I feel comfortable 0 1 2 3 4 5
21
When I am tense I notice where the tension is located in my body
0 1 2 3 4 5
22
I know when I am uncomfortable in my body 0 1 2 3 4 5
23
I notice where in my body I am comfortable 0 1 2 3 4 5
24
I notice changes in my breathing, such as whether it slows down or speeds up 0 1 2 3 4 5
25
I do not notice (I ignore) physical tension or discomfort until they become more severe 0 1 2 3 4 5
26
I distract myself from sensations of discomfort 0 1 2 3 4 5
27
When I feel pain or discomfort, I try to power through it 0 1 2 3 4 5
28
When I feel physical pain, I become upset. 0 1 2 3 4 5
29
I start to worry that something is wrong if I feel any discomfort. 0 1 2 3 4 5
30
I can notice an unpleasant body sensation without worrying about it 0 1 2 3 4 5
31
I can pay attention tomy breath without being distracted by things happening around me. 0 1 2 3 4 5
32
Figu re 16 .1
MAIA scale: Sample questions from the Multidimensional Assessment of Interoceptive Awareness scale.
For the complete document, permissions and copyright, please go to ww w.osher.ucsf.edu/maia/.
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Body awareness and pain
signicantly higher on all eight scales, suggest-
ing they may be more often aware of body sen-
sations, tend to ignore or distract themselves less
often from pain or discomfort, tend to worry less
often with sensations of pain and discomfort, are
more often able to sustain and control attention to
body sensation, are more often aware of the con-
nection between body sensations and emotional
states, listen more often to the body for insight,
and experience their body more often as safe and
trustworthy.” The dierence was particularly large
for the scale assessing distraction habits, which is
in line with Gadow’s developmental stage model
of body awareness and the dierence between the
second and third stages.
Neuroimaging studies have shown that mind-
fulness meditators might be able to downregulate
painful stimuli by increased sensory processing of
the pain sensation itself, rather than by distraction
away from it, and by replacing attempts to exert
more cognitive control over the pain with a distinct
brain state of cognitive disengagement (Gard et al.
2011).This is consistent with the view that “turning
away” from pain can be a problematic coping style,
particularly with chronic pain, and that body aware-
ness approaches might facilitate direct experience
of pain, thereby introducing an advantageous cop-
ing style for pain and discomfort (see Sidebar 16.3.).
Clinical Trials
As researchers, we use the MAIA (Mehling et al.
2012) or the Scale of Body Connection (SBC) (Price
and Thompson 2007) to assess body awareness (see
Sidebar 16.3 Research
Until now, few research studies have addressed the
topic of a mindful attention focus on pain versus
distraction as a coping mechanism for pain, and
how these two modes of attention might modify
the experience of pain. A group of Swedish pain
behavior scientists used a technique intended to
help people suering from chronic back pain and
low pain acceptance to alter the aversiveness or
threat value of their persisting pain. A small pilot
study compared a form of “interoceptive expo-
sure” to a relaxation/distraction breathing-based
technique, both over 3 weeks, in the presence of
their chronic pain (Flink et al. 2009). Additionally,
a larger study compared interoceptive exposure
to waitlist control (Linton et al. 2008). Both stud-
ies showed benets for function and fear in these
chronic pain patients. A few studies have addressed
this question with experimentally induced pain.
Another group showed that attention to the body
reduced pain, partially suppressing the eects of
high-pain expectancy, which commonly increases
pain and pain-related brain activity, and thereby
creates a vicious cycle of psychologically main-
tained pain (Johnston et al. 2012). An increased
body-focus had larger pain-reducing eects when
pain expectancy was high, suggesting that a focus
on external distractors can be counterproductive.
Overall, the results of that study show that focus-
ing on sensory/discriminative aspects of pain might
be a useful pain-regulation strategy when severe
pain is expected. A Belgian group investigated the
eects of distraction from pain during and after a
pain-inducing lifting task in patients with chronic
low back pain (Goubert et al. 2004). Distraction
was associated with more pain immediately after
the lifting task. Catastrophizing about pain wors-
ened pain through hypervigilance to pain. A 2012
review of current behavioral pain research and
treatments showed that “important contributors
to chronic pain may be disturbed processing of the
body image, impaired multisensory integration
and faulty feedback from interoceptive processes,”
which has led to new treatment approaches that
focus, among other things, on a restoration of the
body image and “the alteration of maladaptive
changes in body perception” (Flor 2012).
Sidebar 16.3 Research (Cont.)
(Cont.)
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Figure 16.1). The SBC has two scales: body aware-
ness and bodily dissociation. The SBC was devel-
oped prior to the MAIA and the majority of the SBC
body awareness items have been incorporated into
the MAIA. The body dissociation scale is relevant to
pain because disconnection or dissociation from
the body can be understood as avoidance/distrac-
tion strategies for coping with pain, involving a level
of separation from bodily sense-of-self (Price and
Thompson 2007). There has been a number of body
therapy clinical trials that have used the SBC and
have examined pain outcomes (see Sidebar 16.4).
Summary
Based on the research (see sidebars), we can
argue: (1) undergoing and learning the methods
presented in this book are associated with higher
body awareness in those aspects that are cap-
tured by self-report with the MAIA, at least cross-
sectionally (longitudinal studies of mind-body ther-
apies that used the MAIA, (Bornemann et al. 2015))
and with the SBC longitudinally; (2) increases in
body awareness through experimental behavior
modications can reduce pain; and (3) mindfulness
training appears to reduce pain in association with
increased activity in brain areas related to intero-
ceptive awareness and decreased activity in areas
related to rumination.
Methodology
Our work is intimately involved in the assessment
and treatment of pain using body awareness. As
researchers, we use the MAIA or the SBC to assess
patient self-reported change in body awareness. As
clinicians, we teach body or interoceptive aware-
ness to our patients to help them address their
pain. Patients are guided into a relaxed state and
learn to maintain attention on the subtle sensations
in the body despite constant distracting sensory
stimuli from the outside and their untamed, freely-
For example, one participant wrote, “I became
aware of what I’m feeling, where I’m holding ten-
sion, and to mentally loosen that area to reduce
pain. The pain had been the big thing for so long,
I feared it. It had all the power. I now have ways to
get around it and through it, and live with it.”
Sidebar 16.4 Research (Cont.)
Sidebar 16.4 Research
In a study of body therapy for women in recovery
from childhood sexual abuse, the majority of whom
reported signicant body pain (back pain or head-
ache were most frequent), body awareness and
bodily dissociation (on the SBC) and physical symp-
toms (i.e., pain and discomfort) were signicantly
improved after eight weekly 90-minute sessions
and maintained at the 3-month follow-up (Price
2005). Improved body connection indicators of
awareness and dissociation were highly associated
with fewer physical symptoms (such as back pain
and headache) and reduced levels of symptom dis-
comfort across time (Price 2007). In a study of Mind-
ful Awareness in Body-oriented Therapy (MABT), a
mind-body approach that combines touch-based
and mindfulness approaches to teach interocep-
tive awareness and self-care skills, pain and body
awareness/bodily dissociation were some of the
outcomes examined in the sample, women in
treatment for substance use disorders. Pain and
bodily dissociation were decreased from base-
line to 9-month follow-up among the participants
who received MABT as an adjunct to substance
use disorder treatment, but pain and bodily dis-
sociation were not decreased among participants
who received substance use disorder treatment
only (Price et al. 2012). Last, the qualitative results
from a study of MABT for female veterans with
co-morbid chronic pain and post-traumatic stress
disorder (PTSD) highlights the dimensions of body
awareness mentioned above and the ways in which
body awareness can facilitate self-understanding
and the development of new coping skills
to manage chronic pain (Price et al. 2007).
(Cont.)
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Body awareness and pain
associating thoughts. With this mindful attention, an
important goal is to learn to distinguish between (a)
experiencing the sensations from within the body and
(b) thoughts, beliefs, emotions, stories, and reactions
about these sensations. A primary goal is to allow
and be aware of body sensations as they come into
awareness at any given moment without controlling
or manipulating them. The advanced mode of aware-
ness is to become non-dual: instead of a mental self
as a subject attending to the body as an object, the
goal is to learn to be present and “collected” within
the body, fully experientially embodied, which is a
transition from the stage of disunity between body
and mind to become a conscious unity, the spiritual
meaning of “yoga.” Below is a brief outline of how we
address body awareness in practice:
• Intake Assessment: At the rst session,
in addition to an interview to learn the
patient’s history (injuries, diagnoses, previous
treatments, symptoms, and treatment
goals), we also ask a series of questions to
assess how easily the patient can engage in
body awareness activities and self-care. At
subsequent visits, we ask about their use of
body awareness practices in daily life since
the previous session.
• Treatment Methods: At the table, we engage
the patient in body awareness activities.
• Patient Education: If a patient is new to this
work or nds body awareness challenging,
we educate about the purpose of body
awareness and engage in educational
strategies to facilitate the ability to access and
incrementally increase body awareness.
• Patient Self-care: Integral to learning body
awareness practices, we encourage the
patient to use these practices in daily life for
self-care. Building on what the patient learns
and on changes that occur during the session,
we encourage the practice of simple body
awareness exercises during daily life.
• Monitoring Patient Outcomes and Safety: We
constantly assess the patient’s ability to
engage in body awareness activities during
the session through the patient’s use of
language, ability to bring mindful attention
to the body, and presence in the body which
we can monitor through touch. During our
sessions we pay close attention to imagery,
memories, and emotions our patient may
experience, and the arousal level that may
be associated with these in order to gauge
the patient’s ability to process these without
being overwhelmed.
To understand the process involved in body aware-
ness during bodywork practice, several aspects
of clinical practice are presented below in further
detail:
• Intake Assessment: It is important early on to
know how easily our patient can engage in
body awareness activities and self-care. In the
intake, questions related to body awareness
are helpful. For example, we might ask the
following questions to better understand the
patient’s awareness of his or her body:
• How would you describe your pain or the
discomfort you feel in your body?
• Where are you aware of holding tension in
your body?
• What do you do in your daily life to relieve
physical discomfort?
• Are you aware of anything that makes your
pain or discomfort increase?
• Do you feel connected to your body—in
other words, do you listen to your body for
cues about how you are feeling?
• Treatment (On the Table): To facilitate body
awareness in pain patients, we ask the
patient to attend to their bodily experience,
particularly in areas in which they experience
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physical discomfort. As we both use touch in
our clinical work, we typically place our hands
on the patient’s body to facilitate patient’s
ability to focus attention on his or her inner
body experience in the symptomatic area. We
might begin by asking the patient to describe
what she/he feels in the area (or space) of
pain. Finding words to describe sensation
requires the ability to access the internal
experience of discomfort, or the “felt-sense”
(Gendlin 2012) of an area within the body.
This can take practice and guidance, as it can
be dicult to bring awareness inside and to
know how an area feels. We listen for the use
of present-moment descriptive words that
identify sensation.
We then guide the patient to attend to
inner experience using mindful presence—a
nonjudgmental and compassionate attitude
of present-moment awareness. We guide
the patient in observation of his or her inner
body experience—sometimes using breath,
and sometimes asking about awareness
of various aspects of sensory awareness.
For example, in MABT, we ask the patient
to attend to interoceptive awareness by:
(a) bringing awareness to a specic area
within the body, (b) sustaining mindful
present-moment awareness in the body,
and (c) noticing specic aspects of sensory
awareness (sensation, image, emotion, and
form). This attention to inner experience
involves accessing multiple sensory modes
of sensory awareness (visual, kinaesthetic,
auditory, and emotional). Again, this can
take a lot of guidance and practice. However,
with successful practice, the capacity to
attend with mindful awareness to internal
experience expands, and with this can come
the ability to notice increasing specicity or
depth (sometimes referred to as granularity)
of awareness, a sense of the body as a trusted
resource, and associations between physical
sensation, emotion, memory, and behavior.
• Patient Education: It is not uncommon that
patients need to understand the concepts
behind therapeutic strategies, particularly
when they are experienced as challenging
and/or include a psycho-educational
component. We spend time talking with
the patient prior to and after sessions to
provide a conceptual framework, to discuss
the experiences on the table, and to answer
questions the patient may have. In small
case series study, this aspect of the work
was identied as important for trust and
motivation to engage (Price et al. 2011).
Similarly, patients often nd this work
challenging as they are being asked to be
active participants in a therapeutic process
and to engage with their pain in a way that
is often unfamiliar. Moving toward pain in
openness and self-compassion can be a
scary endeavor for those who typically avoid
sensations to cope with discomfort. We must
then facilitate the patient’s development of
this capacity with tremendous sensitivity,
creativity, and patience. Each patient is
dierent, and there are multiple strategies to
engage and deepen interoceptive awareness.
• Patient Self-care: Interoceptive or body
awareness is like anything else: practice helps
to develop capacity and integration into daily
life. We ask our patients to spend time every
day engaged in a body awareness practice.
It works best if they choose a process that
appeals to them the most—something that
they can easily achieve. For example, one
person may choose to attend to an area of
discomfort by placing a hand on this area
and breathing into the area while attending
to what she notices internally just before
going to bed each night. Another person
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Body awareness and pain
might choose to stop all activities for a few
minutes every hour or two throughout the
day and massage or stretch the tissue in an
area of discomfort—tuning into the sensation
adjusting posture and activities accordingly.
• Monitoring Patient Outcomes: We attend to
ourpatient’s ability to access and engage
in interoceptive or body awareness to help
facilitate this engagement, to guide the
therapeutic process, and to monitor change
over time. Our work involves a mindful
approach in which presence is a key factor.
Presence is what allows for awareness of
inner body sensation. As practitioners, we can
monitor presence in multiple ways including
body language, voice quality, word choice/
language, energy, and touch.
Practitioner skills are needed to teach and facilitate
patient body awareness. With skilful assessment,
the practitioner can learn to distinguish the
patient’s presence from a lack of presence. When
a patient is in presence, the practitioner should
notice a change of tonus in the bodily tissue. To the
practitioner this may feel like increased vitality in
the tissue, and is typically accompanied by a shift
in the patient’s overall demeanor toward a state of
deep inner attention. The patient’s ability to main-
tain presence activity is also something that can
be ‘‘felt’’ through the practitioner’s hands. When
the patient ‘‘leaves’’—(i.e., awareness absences
the inner body), this can often be sensed imme-
diately by the practitioner: there is a reduction in
the élan vital in the tissue. In addition, the prac-
titioner’s ability to maintain presence during the
session can enhance patient presence (Blackburn
and Price 2007).
Case Study
A 45-year-old single woman named Carol has a
fteen-year history of chronic pain. She has not
been employed for ten years due to debilitating
back pain and is prescribed opiates to manage
the pain. She no longer nds the medication to be
ecacious and has reduced her opioid use signi-
cantly over time. She now uses opioids occasionally
and gets by with over-the-counter analgesics on
most days. Carol is fairly inactive; she gets around
her house to accomplish simple household tasks
and will take an occasional walk around the block.
When her pain is severe, she stays on the couch and
watches TV or reads.
On her rst appointment, Carol reports that
she has had a couple of massages in her life but
is seeking body-oriented therapy on the basis of a
friend’s referral. She doesn’t know what to expect
but she is willing to try something new, almost
out of a sense of desperation. She is dreaming of
having movement back in her life, to have the pos-
sibility of travel and more fun times. Carol can’t
remember an event that explains the onset of her
symptoms; rather, increasing spasms in her back
over the course of a year to the point that she was
unable to continue normal daily activities. She
receives disability benets. Carol also reports a
history of depression and has taken anti-depres-
sants for six years.
In response to Intake questions, Carol indicates
that she took a course on pain management many
years ago and that she learned distraction tech-
niques, which she nds useful and continues to
practice. She said that she ignores her body when
she can, and that she doesn’t engage in many
body self-care activities. She is, however, able to
describe her back pain. She says that it is a con-
stant ache and that she experiences sharp twinges
that cause her to double over. She says she never
feels relaxed in her body, except for an occasional
moment when she rst wakes up in the morning
and before she moves. I administer the SBC, and
her scores are moderate (score of 3 on a 5-point
scale) for body awareness and high (score of 4)
for bodily dissociation, indicating that although
she has some body awareness she feels separated
from or not very connected to her body.
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On the table, I begin with massage to get a sense
of where she holds tension, asking her about what
she senses as we go along. She is able to describe
sensation in some areas and not in others. She
holds her body tight and every muscle group feels
tense. She is so habitually tense that, at times, she
has trouble noticing my touch. When working on
her back, I simply hold my hands on the areas that
cause her the most pain. After many minutes her
breathing relaxes and I notice the smallest hint of
give in her tissue. I ask her how she would describe
this area and she says, “It is like having two boul-
ders in there.” I ask her to bring her attention to the
space underneath my hands. Carol concentrates on
bringing her attention into the space in her back.
When she has connected in a bit, I ask how she
would describe the space—would she still say that
it feels like two boulders? She slowly replies, “No …
actually it feels more dark and thick with spiky
things nearby.” Carol’s response lets me know that
she is both visual and kinaesthetic in her sensory
orientation. She is also able to access interoceptive
awareness, even if for just a brief moment at a time.
Carol and I work together for many months;
each session, she seems to relax a bit more and to
feel/sense a bit more into her body. Her muscles
become more pliable. She is increasingly able to
follow along with her attention to various parts
of her body, and to describe what she feels. In our
work on her back she learns to bring her awareness
deeply into the areas where she has pain. At rst,
she can only come to the edges of it; but with time,
patience, and persistence, she is able to bring her
awareness inside the areas where she experiences
the most pain (or perhaps it is more accurate to say
that these areas of her back open to her). She devel-
ops the capacity to sustain her mindful attention
in these areas of her body and to notice sensation
within. She practices at home on a regular basis,
and more when the pain is severe. She notices that
when she brings her attention inside to her back,
that the sensations shift and the pain lessens. She
begins to have thoughts and memories associated
with her childhood come forth, sometimes during
her body awareness practice and sometimes at
any time during the day. They are uncomfortable
memories of her angry father, of being punished,
or feeling bad. She begins to paint, to use water-
colors: abstract paintings that are dark and intense.
She starts psychotherapy and begins to explore her
memories, her art, her emotions.
Carol is now engaged in a journey that leads her
to a new sense of self. Her back becomes a place in
her body that she goes to; a place that helps her to
unfold from. She has shifted from relating to her
body as dangerous to a place of resource. Her back
doesn’t always hurt and, although it often aches,
it no longer spasms. She can move and begins to
explore stretching and dancing on her own. She can
take long walks. She does not use opioids at all and
only occasionally over-the-counter analgesics. She
is thinking about working again. A year after our rst
session, her body awareness score on the 5-point
SBC is increased (from 3 to 4.5) and her bodily dis-
sociation score is reduced (from 4 to 2), indicating a
meaningful change that conrms my observations
and her reports. Carol has developed a daily body
awareness practice that has become second-nature
to her. She no longer needs my assistance although
she still comes in for the occasional session.
Conclusion
In this chapter we have outlined the positive role
of body/interoceptive awareness for pain manage-
ment. With practitioner guidance, a patient can
learn to shift from thinking to sensing, from atten-
tion that is directed outwards to attention directed
inwards on to subtle body sensations (from extero-
ception to interoception). Body-based approaches
can play a unique role in teaching body awareness
and can facilitate our patient’s engagement with
dimensions of body awareness that are linked to
regulation, self-care, and stages of acceptance and
change in relationship to both the experience of
pain and the experience of self.
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Additional Resources
To obtain the complete Multidimensional Assessment of
Interoceptive Awareness (MAIA) scale and for permission
and copyright, please go to PLoS-ONE 2012, and www.osher.
ucsf,edu/maia/
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Chapter 16.indd 252 11/30/2015 6:21:57 PM