From the latest issue of AmSAT News: The Alexander Technique and Chronic Pain

Chronic pain can devastate your entire life. It can destroy careers and relationships, and rob you of the enjoyment of everyday life. Even if it does not prevent normal activity, just experiencing pain saps both energy and the ability to be fully present.

Students who come to an Alexander Technique teacher because of pain are likely to be suffering the effects not only of the pain itself, but also of months or years of unsatisfactory conventional treatment.

For example, most doctors have two ideas about how to help: surgery and medication. Surgery does not address many causes of chronic pain. Medication does not always help, either. If it does help, it may have debilitating side effects; and it may be difficult to get because of cost or narcotics control laws. In addition, pain patients sometimes deal with physicians who think they are malingerers or drug addicts. Doctors may tire of patients who do not get better and begin to resent, even dislike them. While this history increases the challenges of teaching students with chronic pain, it also increases the students’ motivation to learn.

This article offers suggestions to Alexander Technique teachers working with students suffering from chronic pain, based on my own experience as a chronic pain patient studying the Technique. I do not wish to suggest that what I have to say holds true in every case. I have found that the truth about my own state of being evolves as I continue to question and explore. What follows is an effort to set forth my beliefs and thoughts, from my own experience, at this moment.

Introduction: My Experiences with Chronic Pain and the Alexander Technique

I first took lessons in the Alexander Technique to help me deal with severe, chronic headaches that were making it impossible for me to continue working as a partner at a large New York law firm. I found the Technique after years of struggling, without success, to solve my problem through conventional medical approaches.

I believe my chronic headaches began as a result of what I did to myself while pursuing a career as a lawyer, in the course of many years of working at a desk and computer for 60–80 hours a week, under conditions of almost constant stress and sleep deprivation. At first the headaches occurred several times a year. Gradually, they became more frequent and increasingly severe, until I was having them several times a month. The pain was so severe that even sitting up produced violent nausea, and movement and conversation were intolerable. These attacks, which struck without warning, lasted anywhere from twelve hours to five days. Eventually, I was in almost constant pain.

I first sought medical help for the headaches when they began to occur every few months. I saw four different neurologists and a pain management specialist, all highly recommended, prominent physicians at major medical centers in New York City. The five doctors gave me three different diagnoses. Some said I had migraines; others said I had tension headaches; later, after the headaches became almost constant, some doctors called them “chronic daily headaches.”

Each doctor made a diagnosis during my first visit and proceeded to prescribe medication according to the established protocol for that diagnosis. When one medication proved ineffective, each doctor had me try another, then another, and then various combinations. Not one doctor was willing to reconsider the initial diagnosis or therapeutic approach when the medications failed. When I questioned this approach, I was told that it was just a matter of finding through experimentation which medications worked. In order to get a fresh perspective, I had to move on to the next doctor. In most cases, the new doctor would tell me the old doctor was completely wrong about the diagnosis, the treatment plan, or both.

I tried dozens of drugs of two types: 1) to stop pain when a headache began and 2) to prevent headaches from occurring. None of the drugs provided lasting relief. In fact, I believe the prophylactic medications may have caused the pain to shift from episodic to nearly constant. The prophylactic medications also caused a wide array of unpleasant and frightening side effects.

After several difficult years of physician-prescribed experimentation, I was in constant pain and unable to work. I was forced to take a disability leave from my job.

Just before my leave, I changed doctors for the fourth time. My new doctor was a pain management specialist who told me that the previous diagnoses––migraines and chronic daily headache––were all wrong. According to him, I had chronic tension headaches with trigger points in my sub-occipital region, and the treatment course that I had been pursuing had actually caused the problem. This seemed reasonable to me, because of a simple demonstration: I went to him when I had a headache, he injected my trigger points with a lidocaine (anesthetic) solution, and the headache went away.

He prescribed a muscle relaxant, a non-steroidal anti-inflammatory drug, and physical therapy. In addition, on my own initiative, I pursued massage, meditation, yoga, and swimming, and I did not use a computer at all. This regimen provided some relief: after several months, I was not in constant pain. But my life still revolved around my attempts to prevent headaches. I was always on the verge of pain, and the severe episodes continued to occur regularly.

During my disability leave, I realized that I had many habits that were either causing the pain or making it worse. However, neither my doctor nor my physical therapists could tell me how to change these habits. I strengthened and stretched my muscles, I arched my back and tucked my chin, I exercised, I “relaxed,” I had my vision checked, I tried to sit up straight, and so forth. But the minute I resumed the type of activities required by my job––even under non-stressful circumstances––the habits kicked back in and triggered the pain. At this point in my journey, I heard about the Alexander Technique from a friend who had taken lessons years before. She lent me Michael Gelb's Body Learning.1 After reading a few chapters, I knew that I had to try this. The book makes clear that the Alexander Technique teaches how to change the way we habitually react to stress and other stimuli: the very thing I believed I needed to master in order to get better. And it identifies the head-neck-back relationship––the very part of my body that I believed was causing all my problems––as the key to good coordination and easeful movement.

Within a month, I had begun weekly lessons with Jessica Wolf. The learning process that unfolded over the next 15 months was fascinating and much farther-reaching than I had imagined. Unlike everything else I had tried, instead of providing immediate relief that soon diminished or vanished altogether, it resulted in slow, lasting improvements. Instead of requiring me to take time out from everyday activities to undo the damage those activities were causing, I could use it all the time so that normal life was less damaging in the first place. And instead of having debilitating side effects, it was fun and even sometimes exhilarating. Eventually I realized that I wanted to be an Alexander Technique teacher in my post-law life, and enrolled at the American Center for the Alexander Technique (ACAT) in New York.

I wish I could say that my story is like the one we sometimes hear in the Alexander community: a student comes to the Technique with severe pain and, after a course of lessons, is free from pain forever. I do not doubt that this does happen, but it has not happened to me. I still have episodes of severe pain from time to time. However, much has changed:

First, the episodes have become less frequent. My improved use means that I can engage in normal activities, like sitting for a few hours at a time, with much less likelihood of triggering the pain. I am much more aware of my whole self, so that I avoid pushing myself to the point of pain. The episodes that I now experience are not always related to any use issue that I can identify; often, they start when I wake up in the middle of the night with pain.

Second, I no longer react to pain or the threat of pain by bracing, which used to cause radiating pain throughout my head, neck, and back. By inhibiting this reaction and using my directions, I can counteract that pulling in, so that I do not perpetuate and exacerbate the pain through my own instinctive, subconscious reactions. When the pain ends, I feel much better, instead of compressed and shaky for hours.

Third, the pain is now much more localized. I have been on a journey deeper and deeper into my neck and head, shedding outer layers as I go. Now the pain occurs in one specific place near my occiput.

In addition to the dramatic improvement in the frequency and duration of these episodes, I have finally found a doctor who prescribed a migraine medication that eliminates pain when I have a severe attack. Even that is something I found through the Alexander Technique; I sought out this doctor because he is a neurologist who actually recommends the Alexander Technique to his patients and who understands why it helps me.

This doctor saw a pattern that no one else had perceived: he suggested that I do have migraines and that the nausea and vomiting that usually accompany severe pain episodes are a vagal reaction to pain, so that oral medication does not get into my system. He gave me a prescription for an injectable migraine medication. For the first time in the 20 years that I have been suffering headaches, I have something that actually takes away the pain. It is an indescribable relief not to be afraid that at any moment I may be forced to stop all activities and undergo hours or days of suffering.

I was also greatly relieved to be told that there is a component to my pain that is not the result of faulty use. I had reached that conclusion on my own, because it seemed to me that, after all my Alexander Technique training, my use had become much better and I did not know why I could not avoid the disabling pain. My new doctor explained that, like my grandmother, I probably have a genetic condition that causes migraines: nerve signals that are not experienced as pain by most people are interpreted by my brain as pain. I felt validated to know that the pain was not entirely my fault.

I continue to explore ways to improve my condition. The Alexander Technique is invaluable in this process as well. Because of my training, I am able to consider what might help, then try it out, understand whether it is helping or not, use my thinking to enhance what works, and trust that I have real insight into my own condition while still being open to insights from others.

Implications for Teaching the Alexander Technique: Information for and Advice to Teachers

The experiences described above have led me to some general observations about common effects of living with chronic pain and some suggestions for Alexander Technique teachers about how to work with students with chronic pain. While I believe these suggestions are relevant for others who have had experiences like mine, I also believe that nothing in our work is true for everyone or at all times. Please take what I have to say as provisional ideas to consider and use if appropriate.

Effects of Chronic Pain on the Psycho-Physical Self

The results of living with chronic pain included, for me:

  • Diminished ability to perceive proprioceptive information;
  • Reflexive bracing of my entire body;
  • Difficulty letting my teacher move the parts of me that hurt (my head and neck);
  • Deep emotional wounds, including fear, guilt, and anger;
  • Strong motivation to learn the Alexander Technique to address habits that I believed were contributing to my pain.

A blunted proprioceptive sense is both a cause of and a defense against pain. I spent years sitting at a desk in a fixed position for long hours, responding to conflicting urgent demands on my time. During the first seven years of this lifestyle, I did not feel any pain at all; I only remembered that I had a body when it demanded food or sleep. Then I started to feel pain periodically and, eventually, continually. Even then, it seemed to me that the pain came out of nowhere.

It was years before I was able to understand the connection between my use and the pain. In the meantime, without perceiving what I was doing, I held my whole body, especially my head, neck, and back, rigid in an attempt not to feel the pain. Thus, my lack of awareness of my body led to my pain, and my pain led me to try to block out awareness of my body: truly a vicious cycle.

This vicious cycle creates special challenges for the Alexander Technique teacher and student. Unconsciously tensing muscles as a defense against pain is not an unreasonable strategy, in the short run. Movement can hurt and can exacerbate a recent injury. The nerves that convey sensory feedback from muscles to the brain do not work as well when the muscle tissue is contracted, so that pain can, in fact, be deadened by tensing. But, over the long term, bracing must be undone in order to restore better functioning.

Lessons become a delicate dance between letting go in order to feel more and feeling that there is more to let go––all the while dealing with the very real fear that letting go will be painful. The closer you get to the parts of the body that hurt, the harder this becomes.

The emotional wounds of chronic pain go beyond fear. For years, I was told by a series of experts that I would feel better if I followed their advice; each surge of hope was followed by bitter disappointment and anger when the pain returned. These feelings were often compounded when the experts reacted to these failures by showing impatience with me, or even hostility, as if I were malingering or deliberately not getting better.

I became used to having my accounts of my own experience dismissed by physicians. For example, once when I explained to a pain management specialist what I thought was happening in my own body, he replied, “When did you graduate from medical school?” I lost confidence in my doctors, one by one, when they would not reconsider their initial diagnoses, but persisted in advocating approaches that were not working or even making me feel worse. Such experiences can lead to anger, guilt, and difficulty trusting others. I feel lucky that I am not vulnerable to depression; without my in-born happy temperament, I might well have become severely depressed.

For me, the Alexander Technique represented a radically different experience that gradually undid the damage from years of pain. Alexander Technique teachers offer the following rare skills:

  • The ability to truly listen to and observe their students;
  • A willingness not to know, to continue to question and explore;
  • A practical way to unlearn harmful habits that contribute to pain;
  • Their own example of poise and competence in the face of life’s difficulties.

Suggestions for the Teacher

Here are a few suggestions for Alexander Technique teachers working with students with chronic pain. Although I express them as do’s and don’ts, I emphasize again that these are suggestions rather than prescriptions. If I have learned anything in my training, it is that each person is a unique individual and must be treated as such.

Use Inhibition In the Face of Blunted Kinesthesia and Bracing

I have explained above that chronic pain results in a blunted kinesthetic sense and reflexive bracing of the entire body. These can make it extremely difficult for a student to notice and let go of tension patterns in any given moment. Help your student to cultivate awareness, teach inhibition and direction, and do not worry about whether the results are immediately discernible by the teacher or the student. Trust in the powerful benefits of the Alexander Technique over time.

Putting hands on a part of the student’s body that hurts or has a history of hurting can provoke strong reactions, even when the touch is as gentle and non-intrusive as it can be; when the touch is made with an intention to bring about change, it may trigger reflexive bracing, or elicit change so quickly that the student feels unsafe or experiences pain.

The indirect approach of the Alexander Technique is ideally suited to help in such a situation. You know from your training and experience that you can help your student bring about change without ever talking about or putting your hands on the part that the student wants to “fix.” Lulie Westfeldt gives a good example of this in recalling her first series of lessons with F.M. Alexander, which brought about marked improvements in her damaged foot and leg without his ever seeming to pay any attention to that part of her.2 This advice may be harder to follow with a student whose problem, like mine, originates in the head and neck: I found it very trying at first to be reminded constantly to “free my neck,” which was the very thing I was longing to do but couldn’t. I had to free my breathing, my hip joints, my shoulders, my legs, and every other part of me as part of the process of learning to free my neck.

When long-held tension does release, it may be an overwhelming experience. The student may react positively or negatively, but in any case is likely to be disoriented. When I have had such experiences, my teachers have recognized what happened and made sure I was aware that I needed to regain my equilibrium, and that the effects might continue for several hours or days. With this guidance, I have been able to learn a great deal from the occasional sudden changes I have experienced.

Respect the Student's Suffering

If you have yourself suffered from chronic pain or suffer from it now, your student may like to know that. However, it is more important to listen carefully to your student’s experience and to treat it as real and valid than to recount your own story.

Be respectful of your student’s self-imposed limits on what he is willing to do in a lesson. You may feel that the student is capable of doing something, if only he would trust the Alexander Technique principles. However, if the student thinks the activity is impossible, or will cause pain or injury, it may not be helpful to insist. Consider instead a very mild version of the same activity, to allow the student to work on the principles while feeling safe. For example, a student who fears that going into a squat will cause knee pain may be willing to explore monkey.

Be careful about how you bring up the possibility that the student is causing her own pain. Of course, the student probably already believes this on some level, having chosen to take lessons with you. It may be a relief to her, since it means she has the power to bring about her own remedy. On the other hand, no matter how carefully you choose your words, she may feel that you are blaming her, or she may blame herself. This is clearly counterproductive, especially if the student is not yet able to change the habits that are causing the problem. Rather than expressly making the link between the habits and the pain, I suggest working with awareness, inhibition, and direction to bring about change, allowing the student to discover for herself how this relieves pain.

Don't Promise A Cure, But Offer Help

Individuals who come to the Technique because of chronic pain are likely to have been repeatedly disappointed by experts who promised to end their pain but failed to do so. I believe it is best for our profession not to join the ranks of the over-promising experts.

Lulie Westfeldt wrote that F.M. Alexander told her, at their first meeting, “I cannot tell you yet how much improvement you can expect.... It will depend upon the extent to which your condition is caused by mal-coordination. I think a great deal of it is, but we can only find out about this as we go along.”3

Follow F.M.’s example: Don’t assure your student in absolute terms that the Alexander Technique will relieve the pain. It may not. Pain relief from medication, acupuncture, or other methods may be effective and necessary. That does not invalidate the Alexander Technique as a method to help with use-related pain, nor does it mean that the student is failing to learn and use the Technique. And there are conditions that worsen or remain the same, despite the best efforts of all concerned. In all these cases, the Alexander Technique can be immensely valuable. For example, the Technique may enable the student to decrease his reliance on pain medication over time or slow the progression of distressing symptoms.

If the Alexander Technique is not presented as a cure-all, its true benefits can emerge more freely.

Understand Primary vs. Secondary Pain

Judy Stern, one of my trainers at ACAT, is a physical therapist as well as an Alexander Technique teacher; she has many students with back pain and other chronic pain conditions. She makes a distinction between what she calls “primary pain” and “secondary pain.” Primary pain is pain from an injury; for this kind of pain to end, healing must occur. Secondary pain is what can be eliminated in an Alexander Technique lesson. It may be the body’s immediate reaction to poor use––the lower back pain that disappears as soon as a person changes the way he or she is sitting. Or it may result from the body’s reaction to primary pain––for example, the pain I used to feel in the large muscles of my back when I had a headache, but which I now can prevent using the Alexander Technique.

The fact that pain results from poor use does not mean that it is purely secondary. Poor use over many months or years can itself result in injury. Repetitive strain injuries (RSI) are an
example: good use may help prevent RSI, and over time improved use may help RSI to heal, but Alexander Technique lessons may not necessarily provide quick relief.

Consider the Role of Attention in the Experience of Pain

I have been encouraged by various Alexander Technique teachers to deal with pain by “not avoiding it.” This advice is helpful during migraines, because fighting the pain does not relieve it, but instead causes the parts of me that do not hurt to be compressed and start to hurt as well. However, it took extensive experimentation during pain episodes for me to understand the benefits and limitations of this strategy. At first, I misinterpreted the advice as advocating that I give my attention to the pain. This often increased the pain, and never alleviated it.

Instead, I find it helpful to use an approach suggested to me by another of my trainers at ACAT, Cynthia Reynolds: I keep renewing my awareness of my whole self and the environment around me, and “use what I know” (Cynthia’s words), in particular directing my shoulders to release away from one another, because pulling my shoulders in is a big part of my pattern of bracing against the pain. This thought process allows me to give my attention to something that is helpful in the long run.

Now that I have a medication that does alleviate my pain, I have found it extremely beneficial to give myself the injection, then apply my thought process as I lie in bed, waiting for it to take effect. I also continue with my thinking after the pain subsides, to help prevent a recurrence.

My advice to teachers, based on this experience, is not to tell a student simply to adopt a new attitude with the promise that it will help; if it does not help, the student may become disillusioned with you or the Technique or blame herself for being unable to carry out your suggestions. Rather, empower your student to examine the effects of her attention and attitude—as well as her muscular responses––on her experience of pain and her reactions to it.

Be Aware of your Student's Experiences with Physicians

The Alexander Technique can help your student become a better patient. As his kinesthetic sense improves and he practices nonjudgmental self-observation, he can provide more accurate information about what is actually happening in himself.

This improvement in self-understanding can be very helpful to a physician who values the patient’s insights and experiences. This is not true of all physicians, however. Pain is inherently a subjective experience, which cannot be measured by any external observer or instrument. A physician who does not trust patients’ reports of their subjective experiences will not take advantage of the improved awareness of Alexander Technique students.

More broadly, doctors whose patients seek out the Technique may react in any number of ways. A minority of doctors may have heard of the Alexander Technique and be interested in the benefits. Many will not have heard of it and will not want to hear about it: before they have any idea of what it is, they will classify it as an “alternative therapy” that is unproven and unscientific, and they will shut their minds to it.

Consider What Your Student is Hearing from Other Sources

Aside from physicians, your student may be getting advice about how to deal with pain from a variety of others, such as physical therapists, massage therapists, acupuncturists, chiropractors, personal trainers, and yoga teachers. These other forms of help can, of course, be compatible and even synergistic with the Alexander Technique. However, in some cases, you may believe that your student is getting advice that is wrong or even harmful. For example, a physical therapist may have prescribed exercises that the student is currently unable to do with good use, therefore making things worse.

This is a difficult situation to deal with if the student has trust in the other advisor. It can be devastating to hear two “experts” contradict one another. Rather than stating directly your belief that the other advice is wrong, I suggest you work with the student to test its validity and see if there is another way to approach the matter. In my example of physical therapy exercises, see if you can help the student do the exercises in a better way.

This is the approach Jessica Wolf took with me. I went to physical therapy for a year, including the first six months of my lessons with Jessica. I now believe that most of what my physical therapists were having me do was misguided. They kept telling me such things as “tuck your chin, arch your lower back, and press your shoulders back.” They had me doing exercises and stretches that provided little relief ––not surprisingly, since at that time my idea of exercise involved tightening my neck, and my idea of stretching involved forcibly “relaxing” my muscles like over-stretched rubber bands. Most of my physical therapists either did not notice or did not feel it necessary to correct these ideas. Those who did try to correct them were not successful: they sometimes told me not to tense my neck or not to overstretch my muscles, but I did not know how to put those instructions into practice without the kind of hands-on help that an Alexander Technique teacher would have provided.

I remember specifically asking Jessica about one particular neck stretch that every physical therapist I ever worked with tried to get me to do. I was to pull my head straight back, hold it there for ten counts, release, and repeat 20 times. I was told to do this once an hour, all day long. I always refused to do it, because it hurt and it did not seem to help in any way. When I asked Jessica if she thought it could be useful, she merely remarked: “Maybe, but I don’t see how!”

Over the course of many Alexander Technique lessons, I began to re-conceptualize the physical therapy activities and carry them out with better use. In the end, I realized that the way to improve my posture and movement was not simply to strengthen or stretch specific muscles, but to change my habits of use. Jessica wisely guided me to discover this gradually, rather than telling me up front that my physical therapists were wrong.

Draw on Your Special Skills

Alexander Technique teachers know how to listen to and observe their students’ whole selves in ways that few others do.
 
For the student, to be with someone who takes in what she says about her history and subjective experience, observes non-judgmentally, and then works with her in a way that reflects that understanding and observation, is in itself a powerful message about the Alexander Technique.

Your own poise and ability to inhibit are also invaluable. One of the most difficult things about my own situation has been dealing with other peoples’ reactions. Some people try to avoid hearing about my pain; others are overly urgent in expressing their sympathy. Either way, the message I receive is that hearing about my pain makes them feel bad, which I find difficult to deal with, especially when I am in pain. Equally difficult are those who react by telling the story of their own physical problems or asking me whether I have tried a long list of possible remedies and wanting to know why they did not work.

These reactions from other people have made me reluctant to talk about my pain and have reinforced my need to be by myself when I am in pain. Alexander Technique teachers, on the other hand, have always been able to express connection with me without imposing any burden on me to respond to their emotional reactions, and without offering unsolicited advice. I think that when listening to a student’s stories of pain, the best thing you can do to help is to keep your poise and sense of separateness, not assuming responsibility for making it better; instead, let your touch and your lessons in the fundamentals of the Technique communicate your caring and show your student how to help herself.

Recognize the Motivating Force of Pain

A student who believes that changing habits is vital to obtaining relief from pain can be powerfully motivated to learn the Alexander Technique. There is a possible pitfall in this strength of motivation. Many beginning students (certainly including me) tend to neglect inhibition and misinterpret the directions as a “doing.” A student with a strong desire to overcome pain may “do” the directions with extra vigor, which cannot be helpful and might even hurt. I therefore suggest that you be as explicit as possible with your student about the non-doing nature of the Technique. Find out, through discussion and observation, how he understands inhibition and direction, and guide him to a more sophisticated understanding on the nature of non-doing.

On the positive side, a student with chronic pain is likely to be one of your most dedicated students. It is not hard to remember to apply the Alexander Technique in everyday life between lessons––and to find the discipline to do so––if you hope it will decrease your pain.

Be Confident About What the Alexander Technique Can Do

The Alexander Technique has an important role to play in the treatment of chronic pain of all types. Regardless of the underlying cause, the Technique can help the student change her reaction to pain, minimizing the secondary pain and dysfunction that can result from bracing against pain. It also can create better conditions for healing by improving blood flow to the affected area and preventing re-injury through continued bad use.

Most importantly, the student can regain a sense of choice and control. For me, this has meant becoming friends with a part of myself that had come to seem like the enemy. This newfound wholeness is in itself a profound benefit.

Endnotes:

  1. Michael J. Gelb, Body Learning (New York: Henry Holt, 1995).
  2. Lulie Westfeldt, F. Matthias Alexander: The Man and His Work (London: Mouritz, 1998), 29.
  3. Ibid., 23.

I am very grateful to:

  • Maggi Heilweil; Jessica Wolf; Judy Stern; Brooke Lieb; Cynthia Reynolds; Mark Josefsberg;  Michael Hanko—each of whom has made an invaluable contribution to my recovery from pain.
  • All my wonderful teachers and classmates at ACAT—it has been a privilege and a joy to be with you every day.
  • And of course, F.M. Alexander—without him I don’t know where I would be!

Karen G. Krueger received an A.B. in Comparative Literature from Princeton University, a J.D. from Columbia Law School, and an L.L.M. in taxation from New York University Law School. She received her certification as a teacher of the Alexander Technique from ACAT in December 2010. She lives and teaches in New York City.

A version of this article was submitted by the author to ACAT as her final paper for the training program and was published in ACAT’s E-News.

© 2011 Karen G. Krueger. All rights reserved.

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