Yoga Therapy in Practice: Assembling the Pain Puzzle

Originally published by IAYT in Yoga Therapy Today

Written by Robin Rothenberg

When I was a little girl, one of my favorite self-directed activities was assembling jigsaw puzzles. I'd spend hours playing on my own, thrilled by the mystery of how seemingly random puzzle pieces could fit together and make a whole. Organizing outliers that didn't seem to obviously fit into the gestalt gave rise to ambiguity, and it wasn't always clear how to proceed. Sometimes it required stepping back, giving my eyes and mind a rest, and then returning with a fresh perspective. One thing was certain, if I narrowed my focus and fixated on trying to find the perfect fit, I inevitably ended up frustrated and defeated. Back then, I had no idea that I was training myself for a career in yoga therapy! 

Every day in my yoga therapy practice I have a similar jigsaw puzzle experience. Typical scenario: a client enters asking for assistance in alleviating pain. Although pain can show up in a variety of places in the body, heart, or mind, objectively speaking “pain” is not a complete descriptor of the experience any particular person may be having at any particular time. Even if the client points to a specific area on her back and says the pain here averages a 7 on a 1–10 scale, this still doesn't provide enough information for me to assess how to begin our work together. It's rather like she arrived with the puzzle still in its box. My job as a yoga therapist is to open the box and begin a process of facilitation, supporting each client in putting the pieces of her own puzzle together. If I do my job well, the client comes to understand what this pain signifies in her life and defines her own individual path to healing. 

Where to Begin: Know the Questions

As my colleagues and I mentor yoga therapy trainees, one of the most commonly expressed concerns is, “What if I don't know what to do?” Our response is inevitably along the lines of “Keep asking questions, and listen for the answers from the client.” While clients may walk in looking to us for the answers, the truth is they are the ones who have been living with the pain, the duhkha (suffering and stress), the dis-ease. Regardless of what we have studied, they are the experts on their experience. In his Yoga Sutra 1:7, Patanjali states that pratyaksha pramana is “valid proof through the direct experience of an object via the mind and the senses.” Pain is perceived by the client and the interpretation of that pain requires input from the perceiver in order to understand the proper course of action.

Pain is usually accompanied by a story. There's a time before the pain, especially in the case of an accident or injury. Who was this person before the onset? How did she perceive herself? What activities were an integral part of identity? What does it mean to the client to no longer be able to do those activities because of the limitations imposed by pain? How has the chronicity of pain impacted selfesteem, relationships, and her sense of who she is and how she moves through the world?

Sometimes the onset itself is blurred because of all the subsequent chapters. By the time a client ends up at the yoga therapist there has usually been a large cast of characters giving input with their diagnoses, opinions, and treatment protocols. Some of these may have yielded temporary relief, but obviously not entirely or the client wouldn't be continuing to search for support. This part of the story is often confusing for the client and for us as well. How do we make sense of seemingly random pieces of the puzzle? For example: a 6-month stint in physical therapy (PT) that seemed to help, followed by a flare-up and then another 3 months of PT that didn't appear to make a difference; an MRI report that describes an anomaly, but which doesn't quite fit with the patient's experience of pain; contrary opinions from different medical professionals that the client may or may not be interpreting as intended. Although the client may be grasping and even desperate for “the answer,” this is precisely the time for us to step back and ask more questions to gain a larger perspective.

I view the intake form and process as a launch pad for a rich and revealing conversation. Questions like “How do you have fun?” or “How well do you nourish yourself?” may not seem to be directly linked to the resolution of pain; however, they help me better understand how this person is relating to life, not just to the pain. I watch the client's facial expressions and body language closely, noticing where there is levity amidst the expressed challenges and where there is deep sorrow that was not conveyed by the ink on the page. Each of these nuggets are pieces of the puzzle that's helping to fill in the picture of the person in front of me. 

What Gets in the Way—Beliefs and the Mind

Beliefs can drive pain. I've often heard clients state, “My back is just like my dad's” or “My friend had this same exact thing, and she had to have surgery.” Beliefs can foster a sense of impotence about the capacity to change the status quo, even more so than genetics or other contributing factors. I recently worked with a yoga teacher who believed her back pain was directly linked to the findings on an MRI report that showed disc degeneration and a possible tear. I observed that she had a highly flexible body, but not much stability in her pelvis. For years she had practiced a fairly vigorous asana style, one that has a strong association with sacroiliac joint (SIJ) dysfunction. When I queried her about the possibility of SIJ involvement, she shot back that she had a disc issue and not an SIJ problem, as “proven” by the report. 

Clients often come to my office armed with their MRI reports as if the reports hold the key to their quest. Truth be told, while I review all the reports carefully, I am still far more interested in the clients' own experiences and relationship to their condition than in the information on the pages. Overuse of medical interventions such as MRIs for conditions like nonspecific low-back pain has been identified as a considerable problem. The drive to screen is prompted in part by patients' expectations as well as physicians' concerns about legal issues. Studies have shown that there is low correlation between MRI findings and symptoms of pain experienced by patients in the lumbar area.1 In fact, depression has been shown to be a much more relevant predictor of low-back pain than findings on an MRI report.2 So, if the pain isn't on the screen, then where is it and what can we do about it?

Knowing our Tools: Working with the Whole Person

One of my teachers frequently taught that to be a yoga therapist requires that we are one part coach, one part counselor, and one part spiritual guide. It's true that the panchamaya model, the mutidimensional teaching that informs our work in yoga, reminds us that the physical, emotional, and spiritual dimensions are always interrelating and impacting one another. This perspective is in fact our greatest asset, and it's also the most demanding part of our practice. It would be far easier to lock in on one aspect—poor posture, a negative attitude, a lack of spiritual connection—to explain away the pain. However, I've rarely seen pain arising from just one of the mayas. Poor posture may in fact be linked to poor self-esteem or depression. I've had clients who are deeply connected to their church community and who radiate joy but are unable to sit or stand comfortably for any period of time. We have to be willing to play with the pieces: to observe, question, and support our clients in developing more interoceptive awareness. The more we can inspire them to be curious about their own pain puzzle and embark on an inward journey, the more we are truly practicing and teaching yoga.

The yoga teacher with the disc issues had been suffering for two years when I met her. She was depressed and frustrated that no one had figured out what to do about her pain. The worst time for her was the pain she felt upon waking in the morning. I listened to her story, noting “pieces” where the edges seemed to match up and where they diverged. At one point, I suggested that perhaps she might have more than one issue going on—SIJ dysfunction and the lumbar disc problem. While at first resistant to this idea, as we continued to explore together, through breath, movement, supportive relaxation positions, and core work, she gradually became more accepting of this as a possibility. Sometimes I made suggestions, but mostly I asked her again and again to to notice how the practices were affecting her and to describe her experience so that she could hear herself as “the one who knows.”

By the end of our time together she identified that the SIJ and lack of core stability were the bigger issues for her. She recognized that her twisted sleep position was particularly aggravating to her SIJ, and that by consciously propping her pelvis at night she awakened without the usual pinch and grab in her lower right quadrant. Most importantly, she realized that she had been externalizing her experience, looking for the “experts”—including me—to tell her what the problem was. She said that in the two years she'd been searching for the answer, she had never stopped and just felt into her body and explored what it wanted and needed. In the end, it wasn't so much that her back pain had been resolved but that, in her words, she “didn't feel lost any more.” 

We need to remember that our job isn't to fix anyone's pain, but rather it is to guide a process of discovery through which clients can come to know themselves better. Armed with self-awareness and clarity about the relationship between choice and consequence, pain ceases to have the same bewitching power over the mind. This is the unique gift of yoga therapy and a never-ending source of intrigue for the puzzlers among us.

1. Emery, D. J., Shojania, K. G., Forster, A. J., Mojaverian, N., & Feasby, T. E. (May 13, 2013). The overuse of magnetic resonance imaging, The Journal of the American Medical Association Internal Medicine, 173(9), 823–5. 2. Jarvik, J. G., Hollingsworth, P. J., Haynor, D. R., Boyko, E. J., & Deyo, R. A. (July 1, 2005). Three-year incident of low back pain in an initially asymptomatic cohort: Clinical and imaging risk factors. Spine, 30(13), 1541–8.

This article was originally published in Yoga Therapy Today. Yoga Therapy Today is published by the International Association of Yoga Therapists