Using The Mind, Not Drugs, To Fight Pain

Guest lecturer Jim Carson stood in front of the undergraduate health psychology class of nearly 120 students and held up raisins.

Forget everything you know about raisins, the former yogic monk told the students. Just look closely at this little wrinkled thing, feel it, know the texture, look at the colors, observe.

"When you're ready, put the raisin in your mouth, but don't chew and swallow right away. Be mindful of its texture in your mouth, the details of the taste, the feeling of puncturing the skin."

Within minutes, with raisins as his only teaching tool, Carson had the full attention of the students.

Fitting, actually, for a man who uses the mind, not modern drugs, to fight psychological distress and chronic pain.

After 12 years as a swami in the yoga tradition, Carson arrived at Duke in September to pursue research in clinical psychology and to advance meditation as a relevant coping technique for stress and pain in medicine. His arrival coincided neatly with the growing interest in alternative therapies within Duke's psychology and psychiatry departments.

"He had interest in two of the major topics we are working on now," said Dr. Frank Keefe, professor of clinical psychology. "One of the two topics is meditation-based approaches, so he is a real benefit to our group."

Carson decided to pursue research in clinical psychology when he realized that potential beneficiaries from his meditation expertise found it hard to relate to a monk. "I had been keeping up with psychology for all those years, and finally it made sense to get clinical training and help a wider segment of people," he said.

Born and raised Episcopalian, Carson developed his interest in the Eastern tradition of meditation at age 12, several years before he attended the University of North Carolina as an undergraduate.

"I read lots of meditation and yoga books," said Carson. "But it wasn't as much the intellectual pursuit as an experiential one that I wanted, and I thought, 'Why do anything less?'"

Carson eventually moved to a small village in western India, where he studied meditation and yoga under the guidance of his mentor Swami Muktananda. After seven years of study, he was initiated into the Saraswati order in the yoga tradition.

"It wasn't Hindu or Buddhist, per se," Carson said. "There were no vows of beliefs. Rather, it was a dedication to a set of principles seeking to know truth through meditative practices and teaching others."

Another key requirement was celibacy, said Carson, who is now happily married.

He and the other monks in the community, dressed in traditional dark orange monastic robes, arose most mornings at 4 to meditate.

"But people have this idea of monastic life being quiet and isolated, and it wasn't really like that," he said. As part of his duty to the order, Carson traveled to a network of meditation centers throughout the United States, Europe, South America, New Zealand and Australia to teach meditation and yoga.

"I was living in big cities and meeting all sorts of people from all walks of life," said Carson. "I met so many wonderful people in beautiful places, but over time I began to feel ready for a transition in my life."

Carson wanted to expose a larger population to meditation, but people often could not get beyond his appearance and status as a monk. "I had been reading about Jon Kabat-Zinn and his work inspired me to try a new approach," said Carson.

Kabat-Zinn, a Boston native who studied meditation with a Korean Zen master for several years, started in 1979 the Stress Reduction Program at the University of Massachusetts, the first university clinic in the United States to use meditation and mindfulness therapy for chronic pain patients.

In a 1982 study, Kabat-Zinn found that 65 percent of the patients who spent 10 weeks in his outpatient mindfulness program reported a significant reduction of pain.

Kabat-Zinn's initiative was a catalyst for similar meditation-based programs in the U.S. Over the past decade, mindfulness research has gained interest in the United Kingdom and Canada as well, with several recent studies focusing on applications of mindfulness for clinical anxiety and depression.

Carson's current work follows Kabat-Zinn's lead: bring meditation into the mainstream as a treatment for the suffering.

Carson, who holds a Ph.D and is a clinical associate in medical psychology, is concentrating his efforts on two research projects. The first, under Keefe's leadership, is an emotional-coping intervention for people with chronic low back pain.

"In chronic back-pain patients, anger is a strong predictor of daily functioning," said Carson. "If we can help them let go of some of the anger with therapy, we can help them regain function."

The intervention uses a technique called "loving-kindness" meditation, which asks patients to focus their thoughts on individuals in their lives who they love in order to generate positive emotions.

As participants become more skilled at holding this focus, they are encouraged to use the positive direction of their emotions to forgive individuals in their life that they feel have harmed them.

"Our rationale is that the anger we all hold toward wrong-doers and ourselves negatively affects physical pain and psychological well-being," said Ann Aspnes, a graduate student in health psychology who is collaborating with Carson and Dr. Steven Thorp, research associate in medical psychology, on this project. "[In this study] we are working with a population that modern medicine cannot offer anything besides more drugs, and while their pain medications are extremely helpful, the medicines have their own limits and side effects and expense."

Carson, who meditates daily, said meditation must be practiced in order to teach. Through his extensive experience with meditation, Carson has been able to effectively promote well-being and calm during sessions with the study's patients, said his associates.

"That puts a lot more control in the hands of the patients who had been totally reliant on doctors to solve their problems," said Aspnes. Carson is also involved in a randomized trial looking at augmenting antidepressant medication with mindfulness meditation to treat depressed lung cancer patients. Principal investigator Dr. Thomas Lynch, director of the Duke Cognitive Behavioral Research and Treatment Program and a former student of Kabat-Zinn, said the study developed from the group's interest in helping hard-to-treat populations. "I'm interested in mindfulness and acceptance-based therapies primarily because change-oriented coping does not always work," said Lynch. "There are many things in life that one cannot change, and it is certainly effective to maintain a focus on the present moment without judgment and without clinging to the past or future." Some researchers in the pain field, however, question the accuracy of clinical studies on meditation, noting that indirect factors could contribute to the improvements seen with meditation. "It is very hard to do a placebo-controlled study of meditation," said Dr. James Campbell, vice chairman of the neurosurgery department at Johns Hopkins University. "One of the principles of placebo use is that the placebo should simulate the conditions of the actual treatment, and this kind of testing so far as I know has not been done in meditation work." Nonetheless, the practical benefits of meditation are gaining acceptance in departments outside the behavioral sciences. "People in our department as well as in neurology and anesthesiology have accepted relaxation and meditation techniques as important in the treatment of chronic pain," said Dr. Richard Surwit, professor and vice chairman of the psychiatry and behavioral sciences department. "Meditation and relaxation are used fairly widely at Duke and at other major medical centers."