PART 1 – INTRODUCTION: PELVIC PAIN IS A PSYCHO-PHYSICAL EVENT
During the writing of the fourth edition of our book, a physical therapy colleague of ours reported an important story that occurred with one of her patients. The patient was a woman with pelvic pain who had experienced an intense flare-up of her symptoms, and she had started seeing our colleague in an attempt to reverse the flare-up. In one of their physical therapy sessions a remarkable event occurred. It was remarkable not because it was uncommon (indeed we see it often in our patients) but because the event was witnessed in a therapeutic setting and the relationship between cause and effect was so clear. While the therapist was pressing on trigger points inside the vagina of her patient, the patient began to talk about a politician she despised. As the woman shared her anger, the therapist felt her finger being crushed in a vise-like grip of the woman’s pelvic muscle contraction.
Emotional upset, anxiety and sympathetic nervous system arousal can trigger clenching, contraction, and spasm in the pelvic muscles
The patient was middle-aged and the physical therapist was amazed at the strength of contraction of the muscles of this woman’s pelvic floor while she shared her upset feelings. The vice-like pelvic contraction appeared suddenly in this patient and the strength of the contraction was intense. The physical therapist shared with us that it felt like her finger was about to be crushed and she felt frightened that she might be injured.
“Did you feel that?” the physical therapist asked her patient.
“Did I feel what?” replied the patient.
“Can’t you feel the spasm that your pelvis has gone into right now while you are talking about your hatred of this man?” asked the physical therapist.
The patient was dumbfounded. “Feel what? I don’t feel anything,” replied the patient.
Almost unbelievably, the patient had no sense of the relationship between her emotions and the reaction of her pelvic muscles. And while this particular example was striking given the setting and acute cause/effect detection of our colleague, we have seen this psycho-physical inner behavior in all of our patients over the last 21 years and believe it to be the primary causative and perpetuating factor in chronic pelvic pain syndromes.
Chronic pelvic pain syndromes represent a psycho-physical event
Indeed, the chronic pelvic pain that we treat is a psycho-physical event. Unfortunately, the historical treatment of pelvic pain has almost entirely been a misdirected physical treatment of the organs of the pelvis such as the prostate or bladder. Indeed, the conventional medical establishment unfortunately continues to place most of the blame for pelvic pain on the pelvic organs, and attempts to throw various pharmaceuticals at the condition, including antibiotics, anti-inflammatories, botox, and other classes of medications, as well as procedures such as nerve blocks and even surgery, all of which have had, at best, mixed results. And, when physical therapy for the pelvic muscles is prescribed, it is almost always prescribed alone, that is, with no accompanying psychological/cognitive support, relaxation training, or self-treatment training.
In our experience, a limited course of solitary physical therapy produces mediocre to poor results in the pelvic pain patient. In our FDA study that led to the approval of our internal trigger point wand, approximately ¼ of our patients had previously undergone some physical therapy and their baseline level of symptoms was no different than those who had received no previous physical therapy. It has been our strong collective experience over the years that simply treating pelvic pain as a physical event and trying to rehabilitate the pelvic muscles to a supple and pain-free state without addressing the psychological environment and inner behavior of the patient is ultimately not helpful and can often result in the patient abandoning his/her treatment regimen.
Of course, we are not saying that the physical therapy aspects of our protocol are not important in recovering from chronic pelvic pain and dysfunction. It is essential to understand, diagnose, evaluate and treat the myofascial trigger points and muscular restriction that has developed inside and around the pelvic floor in muscle based chronic pelvic pain syndromes. We consider ourselves disciples and champions of the work of Drs. Janet Travel and David Simon and their seminal medical textbook Myofascial Pain & Dysfunction. We comprehensively treat our patients for myofascial trigger points, conducting what we believe to be the gold standard evaluation and identification of trigger points, and then we treat them over multiple sessions in our immersion retreats with specific manual trigger point release, myofascial release, skin rolling, and other myofascial trigger techniques. We train our patients extensively in self-treatment of trigger points using our FDA-approved internal trigger point wand, the theracane, trigger point balls, and other tools, and teach specific yoga-type stretches following trigger point self-treatment. We have developed an unrivaled 300 plus page manual regarding physical therapy self-treatment that our patients take home with them, which includes our “Pressure Principle” concept that details how to determine the level of pressure to use in trigger point self-treatment. Thus, as one can see, we have a world class physical aspect of our protocol and continue to enhance and improve it. What sets us apart from most providers, however, is our deep understanding of chronic pelvic pain syndromes as a psycho-physical disorder and that we pair with our physical protocol with a comprehensive and continuing relaxation/behavioral protocol.
Ignoring the psychological environment of muscle based pelvic pain means that it typically sticks around
The psychological environment that perpetuates the physical contraction, irritability, pain and dysfunction of the pelvic floor has simply not been fully addressed in conventional medicine. When the psychological/anxiety environment that regularly tightens up the pelvis is ignored, pelvic pain typically remains a gnawing and ongoing problem. Even if the relationship between anxiety and pelvic floor pain is acknowledged, and drugs, psychotherapy, mindfulness, or breathing exercises are casually or partially suggested, these mechanisms still usually fail, in our opinion, because the practitioner fails in adequately advising and informing the patient of how significant the intervention needs to be in order to profoundly and reliably down-regulate the patient’s sympathetic nervous system and anxiety.
Over the last 20 years of enhancing the Wise-Anderson protocol, we have developed both a strong and substantial behavioral and psychological protocol of intervention to help patients stop their pain and dysfunction. In the psychological area, we have come to an understanding and treatment of anxiety and the nervous environment of the pelvic pain patient that we believe is remarkable and unparalleled. In this essay, we describe in more detail our method of teaching patients to reduce their anxiety and sympathetic nervous system arousal.
PART 2 – THE TENSION-ANXIETY-PAIN-PROTECTIVE GUARDING CYCLE AND THE METHOD OF EXTENDED PARADOXICAL RELAXATION TO BREAK IT
How anxiety keeps the pelvic muscles tight and painful
The typical etiology (the manner of causation) in chronic pelvic pain syndromes we treat is that the muscles of the pelvis in someone with a tendency toward anxiety tighten up in response to their daily anxiety over a long period of time, often months or even years and decades. During this extended period of anxiety-related pelvic muscle contraction, myofascial trigger points form in the chronically contracted muscle tissue and then, often with an intense period of acute stress, these tightened and restricted muscles get pushed over a certain threshold, become painful and produce a variety of physical dysfunctions and pain. When pelvic muscles remain in this chronically squeezed and contracted posture, they become very sore, painful (including all types of pain such as burning, stinging, aching, shooting, piercing, etc), and irritated. In this constricted state blood flow becomes inhibited, range of motion is restricted, and interference occurs with the neurological relationships that allow for normal and symptom-free life functions: urination, defecation, sexual activity, sitting, exercising, and any other movement or function that involves the pelvis.
The Tension-Anxiety-Pain-Protective Guarding Cycle is the heart of the self-feeding vicious cycle of chronic muscle based pelvic pain
The major concept we introduced in the early editions of our book, A Headache in the Pelvis, is the self-feeding vicious cycle of tension-anxiety-pain-protective guarding. This cycle is the causative and perpetuating heart of muscle based chronic pelvic pain disorders, and is the reason why the sore, irritated and painful pelvic muscles cannot achieve the environmental space to heal like other conditions the body heals on its own. The reason for this is the significant multitasking required by the pelvic floor and the normally inaccessible environment of the internal pelvic floor (vs. the shoulder, for example). Immediately below is a helpful graphic demonstrating this vicious cycle:
The pelvic floor muscles are like a hub of many highways
The pelvic floor is like a hub in which many freeways converge and the pelvic floor, like the heart, is almost always moving and called upon for different tasks including key life functions like urination, defecation, sexual function and structural support. Even breathing in and out moves the pelvic floor. Even the most basic full body movements involve the pelvic floor muscles because of their intimate support of the body’s core.
Once the pelvis becomes sore and painful, and normal life functions are disturbed, the pelvis becomes hyper-sensitive to anxiety and/or nervous system arousal, which we refer to herein interchangeably. Indeed, the onset of anxiety can immediately aggravate hyper-irritable pelvic tissue and directly result in the further tightening or “guarding” of the muscles. Beyond this initial reflexive protective clenching that occurs in response to anxiety and nervousness, an additional layer of reflexive tightening can occur in the pelvic pain patient in response to the actual pain, and all of this inner behavior usually occurs outside of a person’s awareness if the patient does not understand and comprehend this cycle.
Pelvic pain as a tail-pulled-between-the-legs phenomenon
We have discussed in several previous writings how pelvic pain can be understood biologically and psychologically as a tail-pulled-between-the-legs phenomenon where fear causes a contraction of the pelvic muscles that pull in the mammalian tail as an evolutionary reflexive response to stress and anxiety. There are a number of ways to comprehend the fact that the pelvic floor muscles, once they have become painful and dysfunctional, fail to heal in a way that normally occurs in other, less complex, more easily treatable parts of the body. Indeed, the reflexive and ongoing engagement and clenching in the pelvis interferes with and prevents the kind of rest, relaxation, blood flow and protection from stress that is required to restore the pelvic tissue back to a supple, relaxed, functional, pain-free state.
Anxiety is the fuel to the fire of chronic pelvic pain syndromes
Some level of anxiety or sympathetic nervous system up-regulation is what almost all patients with chronic pelvic pain syndromes live with day in and day out. Anxiety can trigger pelvic contraction and, as Gevirtz and Hubbard demonstrated in their 1995 experiments, electrical activity strongly increases in trigger points with increased anxiety. Anxiety regularly exacerbates the condition and this mental state is further fed by the patient’s catastrophic thinking, the isolation of often being unable to share the feelings and experiences of pelvic pain, and a conventional medical establishment unequipped to provide any significant help or relief to the sufferer. Most pelvic pain patients who have not been trained in our protocol have no way to reduce their level of nervous upset and anxiety other than with drugs, which of course, have their own significant side effects and problems.
In the presence of anxiety and reflexive protective guarding, the sore contracted pelvis cannot find the healing space and environment to restore to a normal, non-symptomatic state. Added to an individual’s anxiety is the puzzlement of the doctors. The doctor is often frustrated about his inability to help the problem and is not infrequently worried that perhaps he has missed something. Doctors are problem solvers. As we have discussed in our book and other essays, certain doctors do not respond well to their own helplessness to solve the problem of chronic pelvic pain syndromes. Any anxiety, uncertainty or helplessness felt by the doctor is almost always communicated to the patient – a communication whose impact can be overwhelmingly upsetting to the patient.
That pelvic pain is hugely affected and perpetuated by anxiety is why the placebo effect reduces the anxiety that helps fuel the condition. This is also why many people have a reduction in symptoms after they read our book. Many of our patients whose symptoms reduce after reading A Headache in the Pelvis report their emotional relief after finally finding something that makes sense about what is going on and offers some intuitively viable solution.
Anxiety, sympathetic nervous system arousal, and reflex guarding is the environment that keep the pelvis painful; the concept of a stopping anxiety and protective guarding to create a “healing environment” for pelvic pain and dysfunction
During our 21 years of treating muscle-based chronic pelvic pain syndromes with the Wise-Anderson Protocol, we have often said that the challenge of healing and rehabilitating the pelvis would be much easier if we could send the pelvis on a long island vacation where it had nothing to do but relax and heal its chronically tightened, sore, irritable and painful state. While meant comically, our saying this acknowledges a very important question in the understanding and treatment of pelvic pain, and one that is rarely discussed in the realm of conventional treatment for pelvic pain: namely, how can we create a healing environment that allows for the sore, contracted and painful pelvic muscles to heal? How can we interrupt the tension-anxiety-pain-protective guarding cycle in a profound enough way to fully permit the pelvic floor muscle irritability to heal, just like other muscle conditions heal?
The inner healing environment of Extended Paradoxical Relaxation
This idea of a “healing environment” to allow physical healing both in terms of an external environment and a “local or internal” environment, is intuitively understandable and practiced in a multitude of medical conditions and treatments, including the following very familiar ones –
- a cast for a broken bone to ensure bone immobilization and a reliable healing environment for the process of bone healing;
- a neck brace for the neck after certain types of neck injuries;
- band-aids and tourniquets along with antiseptic ointments for cuts and wounds to heal;
- stroke and brain rehabilitation centers for the regaining of function lost in stroke and brain damage disorders;
- in-patient addiction retreat centers for drug and alcohol users that remove the abuser from the aspects of his/her life that make it difficult to abstain from drugs or alcohol.
As one can see, these examples include both external, social-psychological healing environments (addiction retreat centers, stroke rehab centers, etc.) and local, body-focused healing environments (cast for a broken bone, wound healing, neck brace, etc.). Both of these aspects of the healing environment are crucial in chronic pelvic pain syndromes because the factors of the external, social-psychological healing environment (anxiety, work and family stresses) are so inextricably intertwined with the local function and state of the muscles in and around the pelvis. It is unfortunate that we could prepare an exhaustive and long list of healing environments like those listed above for myriad conditions in conventional medicine yet a similar concept for chronic pelvic pain syndromes has hardly ever been discussed.
When we get a cold, we don’t have to change our environment in order to recover; perhaps we get some extra sleep and stay home for a few days but otherwise we maintain our normal lifestyles of work and relationships. Healing from pelvic pain and other conditions similar to the above examples, however, requires a heightened and more intentional intervention to our normal schedule. Drug rehabilitation is an obvious and well known example where “time away” is almost universally accepted and supported by the entire medical community as well as a patient’s family and friends. This type of caregiver and social support is exactly what the pelvic pain patient needs in attending to his/her recovery as well.
The Wise-Anderson Protocol helps patients create a daily “healing environment”
In our view, when the symptoms of the pelvic pain patient get routinely better, like in the morning, on week-ends, on vacation or in a hot bath, they are in an “inner healing environment.” The muscle tension has eased, the nervous system is quieter. We are convinced that chronically contracted and dysfunctional pelvic muscles need a “healing environment” in order to optimize recovery potential in the patient. In this healing environment the pelvic muscles are not caught in the tension-anxiety-pain-protective guarding cycle. The Wise-Anderson Protocol is focused on helping the patient create this healing environment regularly in order to interrupt the self-feeding cycle that keeps the pelvic muscles sore, irritated and painful.
While we cannot place a literal “cast” on the pelvic muscles, like you can on a broken leg, or send it to a tropical island for an extended healing vacation free from the onslaught of a vigilant and aroused nervous system, we have developed a 2-4 hour daily practice that can help turn off the relentless self-feeling cycle of tension-anxiety-pain-protective guarding. We do this by using the practice of daily Extended Paradoxical Relaxation (EPR). The practice of EPR allows for a profound down-regulation of our sympathetic nervous systems, which in turns stops fueling the fire of pelvic pain and allows the pelvic muscles time to heal.
The concept of taking a significant and continuous 2-4 hour daily break from your normal life in order to heal from pelvic pain (which we mean to include the variety of diagnoses given to pelvic pain including prostatitis, pelvic floor dysfunction, interstitial cystitis, chronic proctalgia, levator ani syndrome, among others) is not something that is part of the current conversation among professionals who treat pelvic pain. While certain conditions like stroke and drug rehabilitation have been treated in month long immersive formats, it is rare for a patient of a functional somatic disorder to be encouraged to do this. In a recent essay we wrote for our blog comparing a locked up computer to the state of a dysfunctional, up-regulated nervous system, we stated:
With regard to people who have chronic pelvic pain, their bodies can be said to be experiencing a similar overwhelm to that of the frozen, locked-up computer. Too many tasks, stresses, demands, and pressures have accumulated over time and the body has found itself in a distant place from its homeostatic, healthy, default mode. In response to the demands of our hectic lives, the muscles of the pelvic region have engaged in a pattern of chronic, unyielding protective guarding as a method of coping with and getting through these stresses. These pelvic muscles, normally supple and pain-free and able to relax and contract easily, are rigid and chronically contracted and dysfunctional. In other words, the pelvis has become part of the body’s lock up, just like the locked up computer.
Using an Extended Paradoxical Relaxation retreat to train the patient in EPR and “Kick-Start” their recovery journey
What Extended Paradoxical Relaxation provides is a regular daily hiatus from the tasks, stresses, demands, and pressures that have played a causative and perpetuating role in a patient’s symptoms. When a soldier returns injured from war, or a patient survives a stroke, usually all of the caregivers and family support a comprehensive, immersive, long term treatment program. The physicians, physical therapists, psychologists/counselors, and loved ones of the patient are all on the same team and understand that a sustained, repetitive healing environment will be required for many months or years for the patient to reach his/her full potential of recovery.
We are studying a similar methodology for the functional somatic disorder of chronic pelvic pain where treatment begins with a multi-week, (9-30 days) immersion, in-patient clinic, in which the patient receives all of the training in the physical therapy aspects of our protocol and engages in 4-7 hours of our Extended Paradoxical Relaxation method in order to profoundly intervene in and break the vicious cycle causing and perpetuating their pelvic pain and dysfunction.
This extended, intensive immersion retreat sets the patient on the path to recovery by helping patients regularly turn off the ongoing mental narrative and regular experience of being ‘on’ in order to respond to personal and work demands, and by spending enough sustained hours in a state of Extended Paradoxical Relaxation in order to create the healing cast for the pelvic muscles to return to a supple, relaxed, functional pain free state. Indeed, our goal in conducting research into this extended EPR retreat is to place the patient into an almost permanent “airplane mode” for several weeks and essentially bring the ancient practice of the meditation retreat into the 21st Century as medical treatment for functional somatic disorders like chronic pelvic pain.
PART 3 – BRINING THE TRADITIONAL MEDITATION RETREAT INTO THE 21ST CENTURY TO DOWN-REGULATE THE NERVOUS SYSTEM AND HEAL THE PELVIC FLOOR
For thousands of years, in most spiritual or wisdom traditions, it has been common for those seeking deep inner understanding to spend long periods of time in meditation and contemplation. Innumerable books and texts over the centuries have extensively documented and profiled the concept of the meditation retreat in the Buddhist, Hindu, Judeo-Christian, and Muslim traditions.
Indeed, among other Biblical examples, Jesus was purported to have spent 40 days of contemplation in the desert, and all of the other religious traditions have similar stories in their sacred texts. From Buddha to St. Francis to Hindu sadhus to contemporary meditators like Thomas Merton, quieting the body and mind through meditation has been a lofty practice. Even today, the explosion in popularity in the practice of yoga, including its brief forms of meditation at the end of most hatha yoga classes, demonstrates a collective intuition that quieting down the nervous system through meditation is good for us.
Paradoxical Relaxation practice is a secular form of meditation
My teacher Edmund Jacobson went to great lengths to make a distinction between his protocol, which he called Progressive Relaxation, and many other practices including meditation. He wanted make a distinction between Progressive Relaxation and other practices and phenomena that produced relaxation like meditation, transference in psychoanalysis, spiritualism, yoga, and hypnosis, among others.
Jacobson wanted to identify Progressive Relaxation as a scientific and medical protocol aimed at reducing nervous system arousal that only relied on practitioners following the given instructions during a session. He did numerous scientific experiments with barium and fluoroscopy to demonstrate the scientific efficacy of his method. He worked with Bell labs in the 1940s to invent the electromyography that was able to measure electrical activity in muscles that he used to document the efficacy of his method.
Despite Jacobson’s protests and attempts at drawing clear distinctions between his relaxation method and other practices and phenomena that produced relaxation, contemporary methods of relaxation and ancient methods of meditation have more similarities than differences. Relaxation methods and meditation methods all aim at controlling attention to bring about the quieting of body and mind. While relaxation teachers don’t don robes, light candles or incense, or lecture students on spiritual subjects, the basic principles apply to both the directing attention away from discursive thought and cognitions and back to a focus that allows the reduction of thinking and mental activity. These instructions are the main ingredients in helping reducing sympathetic “fight or flight” nervous system arousal.
Meditation and relaxation methods, from the largest perspective, are essentially the same and both borrow from the universal principles that allow for the nervous system to quiet down. While psycho-physiologists may call the goal of relaxation “stress reduction” and “autonomic down-regulation,” while meditation teachers may call meditation the “practice of inner peace,” there is no essential difference to them on the inside if the practitioners gains entrance to the relaxation response and gains peace and equanimity; in short, it is a healing environment whether the practitioner calls what she did meditation or relaxation.
Brief periods of regular relaxation have been shown to help certain health difficulties and reduce anxiety but the effects of longer periods of relaxation have not been studied
Conventional wisdom in the 21st century easily understands the relationship between stress and illness. In the last few decades, stress reduction has become a subject of much interest not only because the relationship between stress and illness is often reported in the popular media, but many people feel the effects of stress with the increasing non-stop computer culture that routinely bombards one with stimuli, often disturbing, from numerous portals such as email, text, instant message, Twitter, Facebook, etc. The sources of our nervous system stimulation has become endless with the explosion of communication technologies.
Much has been written about the benefits of meditation for stress reduction. As with relaxation methods, such meditation interventions are prescribed in the form of relatively short periods of time – perhaps a ½ hour to an hour a day where one is asked to sit upright and quiet, and direct attention to the breath, a sound or a visual image. Indeed, meditation has been shown to help depression, anxiety disorders, chronic fatigue syndrome, and functional somatic disorders, including irritable bowel syndrome. It has also been shown in helping reduce the symptoms related to heart disease, and in our own work and previous studies, in the reduction of pelvic pain symptoms. These studies, however, typically do not include long, extended periods of relaxation/meditation. They tend to be confined to daily, ½ hr – 1 hour periods. Thus, to be sure, meditation does have the capacity to lower nervous system arousal to some modest degree or another when done regularly and reliably in short periods of time on a once a day basis.
Like these studies, for the past 21 years of our work with pelvic pain, we have asked patients to do short periods of Paradoxical Relaxation, typically between 30 minutes to 50 minutes, twice a day. We have had excellent results with a large number of our patients with this regimen. There are certain patients, however, who seem to require several hours to calm down enough to enter into the healing state of nervous system down-regulation. In recent times, for these patients, we have been recommending significantly longer periods of Extended Paradoxical Relaxation – between 2-4 hours, if not longer, on a daily basis for those whose symptoms continue to be at a plateau.
In the ways we live now, however, long periods of meditation/relxation that range from multiple hours to days (or even weeks or months) do exist but are very uncommon. Modern life, and its demands for real-time access and constant production of content, strongly discourages us from taking that unwired, unconnected sabbatical. Busy is good the society tells us. Taking a hiatius where one is “unwired” and off the communications grid is not on the radar screen of what people think about in the 21st century. Indeed, even a two or three week vacation can cause anxiety in many people for fear that their employer will consider such a break excessive. And while meditation retreats are offered at a few centers in the world, they typically are not done as part of a treatment for a specific medical disorder, as we use in the Wise-Anderson Protocol for chronic pelvic pain syndromes.
The Meditation Retreat as specific medical treatment in the Wise-Anderson Protocol
Little scientific research has been done in terms of documenting the real physiological healing potential of long relaxation retreat periods that give the nervous system a profound rest from the ongoing stimulation of the demands of life. Because meditation retreats are typically done for spiritual reasons and not for medical reasons, and because there appears to be no economic advantage to be gained by a company in investing time and research energy into the benefits of extended periods of nervous system quieting, little reliable data is available on the true, scientific healing potential of such a practice. It may be clear to some that if you were able to calm down and be peaceful for a long period of time it would have the potential to heal your medical condition; however, many people have little exposure to scenarios of recovery outside the conventional medical system and its drugs and procedures.
In the Wise-Anderson Protocol, we are now studying a modern-day, 21st-century version of the meditation retreat done at the same time and in combination with our medical, physical therapy, and psychological protocols. We believe an extended, intensive relaxation retreat combined with our Protocol has huge undiscovered potential in helping even the most refractory chronic pelvic pain patients.
From Spiritual Focused to Medical Focused: Bringing Meditation into the 21st Century
There is little difference between meditation instructions today and meditation instruction given centuries ago. Indeed, in meditation communities there tends to be a reverence toward ancient instructions. The concept exists that somehow ancient instructions have a certain power that should be adhered to up to the present day, and it is heretical to do otherwise. It is not uncommon for meditation instructions to be relatively brief and sparse, done at the beginning of someone’s interest in meditation, and infrequently reiterated or explored as someone continues meditation over their lifetime. One is expected to remember of their own accord the instructions on how to do meditation; for example, in many traditions one is often directed to attend to one’s breath and every time one’s attention wanders away from the sensation of the breath, one should return their attention to it. The meditator, however, is charged with being responsible for these self-instructions and self-motivation themselves.
In the most popular meditation traditions still active today, there are usually some instructions given about what to do when one’s attention is distracted by thinking, but again, the instructions for bringing attention back to focus is very uncommon. The meditator is expected to coach him or herself regarding directing attention on a moment-to-moment basis after the initial instructions are given and no one has truly researched what actually goes on in the mind of the meditator over time. When I first learned meditation, the instructions were given by a relative neophyte and I struggled for many years with the instructions to keep my posture straight and to focus my attention in the lower part of my abdomen. This was often difficult for me to do and at the end of meditations I would notice that, while some inner quieting had occurred, nothing really remarkable occurred in my nervous system.
Simply put, the ancient meditation instructions suffer from the problem of not having the necessary psychological insight to support the patient within the context of the stresses and demands the patient faces in modern times and its particular relation to the patient’s medical symptoms. To sit on a pillow in a cross legged position and keep a straight spine, among other ancient instructions, prove to be very difficult to a symptomatic pelvic pain patient in 2015 in facing the terms of his/her nervous system up-regulation. We do not put counseling and psychotherapy sessions on a recorded CD nor do we rely on ancient texts to determine how we counsel psychology patients in modern times. In Paradoxical Relaxation, we bring the instructions of relaxation practice, and the relationship between instructor and student, into a modern context where all of the nuances and subtleties of a reliable relaxation practice can be addressed and enhanced.
The Evolution of Extended Paradoxical Relaxation
In our experience of teaching Paradoxical Relaxation, instructions and how to focus attention usually can be held in the mind for about 10 to 30 seconds. After that the mind will tend to wander unless someone is very practiced in focusing attention and is good at self-coaching. Paradoxical Relaxation has been informed by the work of Edmond Jacobson and the number of meditation traditions that I have studied over the years. The relaxation method of Paradoxical Relaxation has mostly been informed by my attempt over the years to down-regulate my own sympathetic nervous system, and borrowing from different teachings I have experienced has been helpful to some degree.
Extended Paradoxical Relaxation that is done over a 2-5 hour period daily has evolved over the last 21 years as a relaxation/meditation method that very particularly and specifically bring meditation into the 21st-century. As someone becomes skillful in doing Paradoxical Relaxation over this long period of time daily, we have noticed that there is a qualitative shift in the effectiveness of the methodology.
Chronic pelvic pain is a problem that is fed by nervous system arousal. If someone were able to calm down mentally and emotionally and release the chronic contraction of their pelvic muscles and related areas, their pelvic pain would resolve relatively quickly. The main problem with pelvic pain recovery comes from the pelvis not being given a rest from the onslaught of nervous system stimulation that is relentlessly delivered throughout one’s day by anxiety and the common stresses of modern life.
The purpose of Extended Paradoxical Relaxation, in the form of an “off the grid” relaxation retreat, is to give a hiatus or sabbatical to the nervous system arousal over a period of two or three weeks (or possibly longer) that can initiate the healing of the pelvic muscles from their irritable, sore, dysfunctional and painful state. During the retreat we engage the patient in 4-7 hours of Paradoxical Relaxation sessions. Often times “opening the door” is the hardest process in recovery; once the body’s momentum gets started in a healing direction, the patient usually is easily able to stay reliably committed to the protocol and the healing journey. This is the goal of the intensive, multi-week Extended Paradoxical Relaxation retreat.
Here are some of the methodologies we are using in Extended Paradoxical Relaxation:
- Noise canceling headphones to help block out any distracting noise in the environment.
- A sophisticated, light stopping sleep mask to help keep the light out that can help calm down nervous arousal.
- We help the patient find the ideal position to rest in during the practice, not based on ancient traditions but what works best for the patient in light of their current physical symptoms.
- Importantly, we give detailed and optimized instructions to the real live person doing relaxation every 20 or 30 seconds to a minute and we address in our instructions the obstacles to relaxation, for example: (1) the desire to escape from discomfort that is inevitable when you sit down with a condition that involves pain; (2) the desire for pleasure and the avoidance of pain; (3) the desire to reach an ideal outcome instead of staying focused in the present moment which is paradoxically the essential ingredient in shifting a painful and uncomfortable physical state to one that is comfortably pleasurable and provides a healing environment for the pelvic tissues.
Finally, when someone goes home after their relaxation retreat with us we ask them to do what is rarely asked of any patient, which is to take 2 to 3 hours a day to create a hiatus for the nervous system. We ask them to get up early or to somehow create the time that they would take if their pain was some critical condition like a stroke recovery that demanded a certain amount of rehabilitation time. We do this for a very specific, medical reason: we have found in our 21 years of experience that this is the kind of commitment necessary to break the vicious tension-anxiety-pain-protective guarding cycle that forms the causative and perpetuating foundation of pelvic pain and dysfunction.
We have found that the length of the relaxation session is critical to the efficacy of the method in a certain sub-population of our patients. This is the same difference between taking a sub-minimal amount of a drug that doesn’t have enough traction to affect the disorder and increasing the dosage to a dosage that demonstrates efficacy. In a 14 day immersion program we just concluded we found a qualitative difference between a brief Paradoxical Relaxation session and the hours-long session. It is clear that there is a minimum dosage for the efficacy of certain drugs; likewise, we are seeing that for certain patients, there is a minimum “dosage” of relaxation in terms of the time allocated for it. For certain patients, the difference between doing Paradoxical Relaxation for ½ hr/ day and 3 hours per day makes the difference between remaining in pain and resolving the pain.
We are also excited to announce that in conjunction with our research into these longer, multi-week relaxation retreats where we do 4-7 hours a day of Extended Paradoxical Relaxation, we are developing a “take-home kit” that will include a comprehensive book, audio-visual materials, Paradoxical Relaxation recordings, and other support tools. Our goal with this kit is to provide as much environmental support as possible so that the patient can “re-create” the healing environment of the relaxation retreat at home as much as possible. Because of its personal nature with audio-visual recordings, the kit will also reinforce the teacher-student connection that occurred during the relaxation retreat. We will also be exploring the possibility of the kit as a stand-alone product for the treatment of a wide range of anxiety and functional somatic disorders.