I was in a session with my physical therapist recently, and she was talking about chronic pain.  She explained how when we have an injury or some type of condition that causes chronic pain, we begin to move in ways that protect us from triggering this pain.  For instance, if we have a back injury, we may begin to walk in ways that help us avoid placing ourselves in any physical position that somehow makes us more vulnerable to that pain.  Consequently, we begin to strengthen muscles that ordinarily would not be activated when we are moving more naturally.  She said that this is called “guarding.”

Guarding.  Of course that is what we do when we are trying to protect our bodies from activating a painful injury or condition.  She continued to explain that guarding eventually becomes an unconscious way we move in order to avoid pain.  And the muscles we strengthen and physical positions we assume become implicit ways we protect our bodies from pain.  The problem with this, she went on, is that by guarding; by holding our bodies in certain positions to avoid pain, or by strengthening unrelated muscle groups to compensate in order to avoid pain, we actually, inadvertently, begin to limit our movement and range of motion.  Slowly but surely, we aren’t able to do the things we used to do.  Our movements become more limited.  And as a result, we feel more and more debilitated.

The Origin of Pain

Marla was 35 years old and came to see me because of an extensive history of loss.  Both of her parents died when she was in grade school.  As a result, she was raised by an older sister who lived quite a distance from their parents.  Living with her sister meant leaving her family home, her friends, and the community she had been living in her entire life.  She remembers her first day in her new school.  “I was outgoing and had so many friends before I moved,” she said as she looked down at her hands twisting in her lap.  “And that first day in my new school, I couldn’t stop crying.  I cried almost every day for almost that entire year.  I went from being outgoing and well-liked, to being alone and scared.  I’d made my mark with these new people, and when I started middle school, I was the object of ridicule and teasing.”

As I learned more about her growing up, Marla shared that the teasing lessened before she graduated from high school, when she found a small group of friends.  Still, she carried the pain from so many years of loss and rejection.  “I came to you,” she said one day, “because I want to be in a relationship and I see myself in a relationship, but I’m scared and feel uncomfortable in large groups of people.  In fact, I’m even uncomfortable in small groups---I just shut down and stop talking.  How will I ever be in a relationship if I can’t even talk to people?” 

As we got to know one another, and as we talked more about Marla’s relationship history, she told me that she had dated off and on in college and in early adulthood.  None of these relationships lasted more than a few months, and all of them ended as a result of a decision made by the other person.  For Marla, this confirmed what she already knew was true:  there was something so wrong with her that rejection and loss were inevitable. 

We began to explore this further, and fortunately, while we were working together, Marla met someone and began dating.  She came to a session after her fourth date filled with excitement, but as we talked further, she shared she was thinking about ending the relationship before her next date.  This had become a pattern for her over the past few years.  She would occasionally meet someone to whom she was attracted, but very early on in the relationship, she would stop returning phone calls, stop returning e-mails, and stop returning text messages. 

Guarding Against Emotional Pain

Because this latest possible relationship began while she was in therapy, we had the opportunity to examine her pattern of ending relationships---hopefully before she guarded against the current one.  “I can already hear the voices in my head telling me I’m going to be rejected unless I act fast,” she said one day.  “We have plans to get together this next weekend, but I’ve already thought about cancelling.”  Gently, I asked if we could slow down and more closely examine her urges to end the relationship before it went further. 

Marla agreed to more discussion and also agreed to a truce with the part of herself that was determined to stop this relationship from going further.  Some of what helped her slow down was my reassurance that she could end the relationship at any time; that giving it a little more time she wouldn't be trapped.  Since she was in therapy to learn to do things differently, this was an opportunity to experiment with new strategies.  Hopefully, she might develop ways of taking care of herself that allowed her to connect more intimately with another human being, without prematurely foreclosing this possibility. 

Marla was guarding.  She had endured such chronic pain that she had developed a system for moving through the world that helped avoid situations that would trigger feelings of loss and rejection.  She had strengthened different “muscle groups” to compensate for this pain.  As a result, she was becoming more and more relationally limited and more and more relationally debilitated.  At any inkling of pain, she was convinced this was indicative of more intense, and perhaps unmanageable, pain. 

Guarding aka “Survival Strategies”

Expert trauma therapist and social worker Babette Rothschild has written several books and many articles on the effects of trauma.  Much of what she writes is useful in almost all psychotherapy.  One principle she has written about that continues to stand out for me is her approach to “survival strategies.”  Similar to how we guard to protect ourselves from chronic pain, Rothschild uses the term “survival strategies” instead of “guarding,” though in a practical sense, they are identical.

She cautions that we should try, as much as possible, not to strip people of the survival strategies they have learned to manage pain; that stripping old and dependable survival strategies before we have offered replacement strategies may leave us feeling naked, vulnerable, and exposed.  Instead, she advocates for adding new survival strategies as alternatives.  Always add, she cautions, rather than take away.  The idea is that once we have alternative ways of managing emotional pain, we will be more able to let go of the strategies that have developed over time.  At the first inkling of potential pain, we can access other ways of coping that enhance our emotional flexibility. 

Triggering Pain

I’ve had chronic back pain for a number of years and have tried all sorts of treatment including medication, injections, and physical therapy.  Thankfully, I have found a physical therapist who spends an entire hour with me, individually, and in a private room with the door closed.  She palpates my back and when she finds an area that is carrying tension, she gently puts more and more pressure until there is some sense of release.  She has explained that she is finding my “trigger points.”  In the safety of this room, with her full attention on almost every possible physical reaction I might have, she releases points of tension.  She then explains exercises I can do to restore my core so that I won’t need to rely on muscles not intended for walking, lifting, gardening, and dog walking.

I called my physical therapist the other day in a panic.  I had done some of the exercises she had suggested and I awakened with pain in my back reminiscent of times when the pain has been severe and unrelenting.  I told her I was afraid to do any more of the exercises.  I knew my progress was over and that I would soon feel limited and debilitated by pain.  I’d once again feel hopeless that I could do anything to live without such pain. 

Almost immediately she returned my call.  While acknowledging my pain and my fear, with a sense of calm and reassurance, she reminded me that because I felt some pain, it did not mean I would have the pain that I used to have.  “Keep doing the exercises,” she suggested.  “But maybe do them less frequently, and don’t be afraid to take an over the counter pain reliever.  Don’t panic,” she said.  “You’re learning new ways of moving so that you don’t have to guard against pain the way you used to.”

A Little Pain, A Lot of Gain

I felt myself relax.  My panic eased.  I reminded myself that I am in the process of changing the way I move in almost every aspect of my life.  And I did as she suggested.  I continued with my exercises and also sat and slept in ways that took pressure off the sensitive areas of my back. I reminded myself that I’ll need to be conscious of how I’ve guarded for years.  Ultimately, with enough exercise and practice, new patterns of muscle groups will be strengthened and eventually, I can let go of guarding.

How interesting it is that making physical changes to manage physical pain is really no different than making emotional changes to manage emotional pain.  Pain is pain.  Most of us don’t like to feel it, so it comes as no surprise that chronic and intense pain activates our system of guarding.  When we strengthen new muscle systems or survival strategies, we are more apt to let go of old habits we’ve depended on for protection.

Several days after I called my physical therapist in a panic, I got an e-mail from her.  “How are you doing?” she wrote.  “Just remember a little pain doesn’t mean you’re bound to return to chronic pain.”  A part of me knows this, but her support and reassurance let me breathe more deeply. 

And then I thought of Marla and the ways she has been guarding for many years.  Our work involves teaching her new ways to move in the world and new muscle groups to exercise.  And as my physical therapist has done with me, when she feels pain that is reminiscent of older wounds, I’ll remind her that a little pain doesn’t mean she is bound to return to chronic pain.  I hope with reassurance, she too, will breathe more deeply.

Even when pain is chronic and nasty, it hurts because the brain has concluded, for some reason or another, that you are threatened and in danger and need protecting.  The trick is finding out why the brain has come to this conclusion.

—David Butler and Lorimer Mosely, “Explain Pain”