Serenity and Adaptation.
Throughout the generations, the place the Aleuts called ‘The Great Land’ has faithfully taught its peoples existential truths that can’t be learned vicariously. Living at the mercy of a much larger and untamed world presents precious opportunities for self-awareness that are an increasingly rare privilege in the affluent and artificial West.
I’ve been asked by my Academy to provide a frontier perspective on pain management, and in my initial article I led off with our Alaskan proclivity for the pragmatic and our low threshold for modification or abandonment of what doesn't work. Applying that mindset to pain management, I argued that the consensus mandate for a biopsychosocial-spiritual approach, a preventive mindset and a self-management focus (all components advised in the National Pain Strategy) are things that work - and have worked for millenia. These threads of wisdom and responsibility have been handed down for centuries in societies around the globe, and our own Alaska Native traditions are no exception. After all, these are people who adapted to the harshest environment on the planet, and you don't do that without respect for and commitment to personal and community health, and resilience.
In this entry I’d like to talk just a little bit about how the lessons of wilderness can translate across zip code and culture, and inform how we approach rheumatoid arthritis or degenerative disc disease in Albany or Albuquerque, Boise or Boca Raton.
Wilderness is the absence of human control. Living in tundra means accepting the certainty of temperature and daylight extremes, resource scarcity, and our own fragility. In most ways really, no matter where or how we live, our lives are beyond our control. Epigenetics notwithstanding, our DNA is fairly immutable. Entropy and decay don’t negotiate. The economy and world events (or even our own municipal ones) don't generally take our opinion under consideration. “Pain is inevitable…” say the neo-Buddhists, and the null hypothesis hasn’t been rejected yet.
Pain is a subjective experience markedly influenced and modulated both positively and negatively by cognitive and emotional state. Recent research (1) is validating what we’ve known all along: anxiety may be the single greatest contributor to chronic pain. And I’d argue that acceptance-commitment therapy (ACT) offers some of the greatest antidote to anxiety and chronic pain in our psychological toolbox (2,3). From a frontier perspective though, we’ve found that talking with patients about their specific pain-related anxieties directly is fairly unfruitful. Putting things in a larger context, e.g., using an example from nature to illustrate the inadvisability of expending needless energy against the tide, a glacier, or the seasons seems to resonate more – at least with our crowd.
“God, grant me the serenity to accept the things I cannot change…”
We’re careful though to lead them away from the precipice of misconception that acceptance comprises abandonment of hope; on the contrary, relinquishing pursuit of the impossible makes room for appreciation and cultivation of the best possible.
“…Courage to change the things I can…”
That introduces the other great lesson of wilderness: alignment. Like many up here, a good friend of mine (a DoD computer network contractor) spent some time on Bristol Bay in his younger days. He learned quickly that the rhythm of commercial fishing by necessity parallels the run of the salmon; when they’re entering the bay from the ocean, you work 24, 48, 72 hours straight - whatever it takes. And when they’re gone, you rest. We don’t alter the laws of nature – we conform to them.
As AA has focused the second part of Reinhold Niebuhr’s Serenity Prayer on personal change, so too I’m applying the ‘change’ part not to the wilderness environment (for that is generally fruitless) nor the pain condition, but to us. It’s not that we don’t offer dorsal column stimulation for refractory and severe postlaminectomy syndrome, and we push curcumin on just about everyone. Really though, we focus more on changing underlying health deficits (of body, mind and relationships) that empower if not cause pain. If we don’t come into alignment with the natural order of things in the Last Frontier or in Los Angeles, things will ultimately not go well for us. That which we can control ought to be prioritized if we are to survive, let alone live well.
Modern stress, sleep deprivation, pro-inflammatory diet, failure to exercise regularly – it’s quite clear that these factors cause and increase pain. What makes us think we can bend these natural laws? Flexibility is what ACT is all about, and really what alignment is about too. Adapt or die, we sometimes say to the hardheaded (and here in the frontier that isn’t politically incorrect.)
Wilderness is a disappearing resource on our planet. It’s increasingly recognized as a fragile and crucial ecological commodity and we tend to think of it in terms of conservation. It’s also increasingly recognized as vitally important for the wellbeing of communities and individuals. Besides the obvious beauty and grandeur aspects, we desire wilderness for: A glimpse of continuity… An awareness of something larger than us…
An invitation to transcendence… I’d like to conclude this entry with some thoughts that at best may seem a bit out of place with a pain management blog at first glance, and at worst may seem terribly insensitive or even cruel. But in the greater context of human coexistence with pain around the world for the past several thousand years at least, they may make a bit more sense.
Pain is something we need, as many of us tell our patients. Congenital insensitivity generally confers a lifespan of less than two decades, and leprosy or diabetic neuropathy (as Dr. Paul Brand taught us) generally leads to significant body part attrition. Accepting and aligning with The Gift of Pain, as he calls it in his peerless book by that title is something rather foreign to our modern Western haste and urgency to avoid it.
And yet in those processes of acceptance and alignment – perhaps only through those processes – do we find our place in a bigger world and universe.
(1) Burke AL, Mathias JL, Denson LA. Psychological functioning of people living with chronic pain: a meta-analytic review. Br J Clin Psychol. 2015; 54:345-60.
(2) McCracken LM, Vowles KE. Acceptance and commitment therapy and mindfulness for chronic pain: model, process, and progress. Am Psychol. 2014;69:178-87
(3) Hughes LS, Clark J, Colclough JA, Dale E, McMillan D. Acceptance and
Commitment Therapy (ACT) for Chronic Pain: A Systematic Review and Meta-Analysis. Clin J Pain. 2017; 33:552-568.
-Heath McAnally, MD, MSPH
6 Sep 2018
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