Mindfulness-based approaches for managing chronic pain: Applications to vocational rehabilitation and employment

Abstract

BACKGROUND:

This article examines the American chronic pain epidemic and its implications for vocational rehabilitation (VR) research and practice.

OBJECTIVE:

The incidence and prevalence of health conditions that result in or are characterized by chronic pain are presented, followed by a description of how mindfulness approaches in counseling can be used to help VR consumers with chronic pain cope with the effects of their conditions.

CONCLUSION:

Emphasis is placed on mindfulness strategies that can be applied in VR practice settings to help workers with chronic pain achieve job satisfaction, job satisfactoriness, job retention, and high levels of quality of life.

Keywords

Chronic pain mindfulness mindfulness-based approaches vocational rehabilitation employment reasonable accommodations

1 Introduction

Chronic pain affects approximately 100 million adults in the United States, a prevalence that exceeds the total combined number of Americans living with diabetes, heart disease, and cancer (Gatchel, McGeary, McGeary, & Lippe, 2014). The Institute of Medicine (IOM, 2011) indicated that the number of Americans with chronic pain will continue to increase in the foreseeable future due to the rapid aging of the US population and subsequent increases in disabilities associated with both aging and chronic pain (e.g., diabetes, cardiovascular diseases, arthritis, cancer); increasing rates of obesity that predispose large numbers of Americans to chronic pain conditions such as diabetes-associated neuropathy and orthopedic problems; advances in medicine that have increased survival rates for individuals with catastrophic injuries and increased the lifespans of individuals with serious illnesses who must often contend with lifelong chronic pain; the performance of the majority of surgical procedures on an outpatient basis, thus increasing the risk of unmanaged acute postsurgical pain that could evolve into chronic pain; greater public awareness of chronic pain conditions; and the Affordable Care Act with its potential to increase access to diagnosis and treatment for those with chronic pain.

Chronic pain, not to be confused with temporary severe pain, lasts at least three months in duration and can inexplicably develop after tissue damage or sudden onset from an injury (Burch & Penman, 2013). Chronic pain is “ongoing or recurrent pain, lasting beyond the usual course of acute illness or injury healing ... which adversely affects the individual’s well-being” (American Chronic Pain Association [ACPA], 2015, p.10). The IOM (2011). identified sources of chronic pain such as underlying diseases or medical conditions that can result in pain that persists after the disease has been cured (e.g., shingles) or worsens as the disease progresses (e.g., cancer). Chronic pain may result after surgery when immediate acute pain following the surgery becomes chronic or when nerve damage occurred during the surgery. It can also result from inflammation as occurs in conditions such as rheumatoid arthritis and gout. Another type of chronic pain, central pain syndrome, is a neurological condition that results from dysfunction in the central nervous system (CNS; i.e., brain, brainstem, spinal cord). Central pain syndrome can develop with chronic illnesses and disabilities such as stroke, multiple sclerosis, Parkinson’s disease, brain tumors, limb amputations, brain injuries, and spinal cord injuries (ACPA, 2014). It may be months or years after the damage to the CNS before central pain syndrome develops. Examples of other conditions that result in chronic pain include headaches, arthritis, fibromyalgia, musculoskeletal disorders, trauma, heart disease (angina), complex regional pain syndrome, repetitive stress injuries, and irritable bowel syndrome (IOM, 2011).

Chronic pain can range from mild to severe and fluctuate from day to day or even throughout a single day. For example, individuals with diseases or medical conditions such as low back pain, arthritis, and fibromyalgia experience both persistent pain and flare-ups of worsening pain. The intensity of pain may be worse at certain times of the day (e.g., morning or evening). Currently, no objective medical tests are available to diagnose chronic pain. Instead, physicians take a pain history that relies on patients’ description of the type of pain (e.g., stabbing, throbbing, sharp, dull, piercing); its location(s); whether the pain is constant or episodic; how pain impacts their abilities to perform activities of daily living; and other symptoms (e.g., fatigue, insomnia, cognitive disruptions; NIH, 2011) that may co-occur with chronic pain. Physicians may also perform diagnostics to rule out conditions that could be the source of pain.

The treatment and management of chronic pain typically includes a combination of both nonpharmacological and pharmacological approaches, with the goal of returning patients to a pain level that is less disruptive to their daily lives (ACPA, 2014). Pharmacological approaches include medications to minimize pain and improve functionality. Cognitive behavioral therapy (CBT) has been described as the “gold standard” for treating the maladaptive thoughts (e.g., pain catastrophizing) that often accompany chronic pain (Day, Thorn, & Burns, 2012).

For many individuals, chronic pain is a severely debilitating condition that affects all areas of life and persists even after a full night of rest and the maximum dose of medication. No cure is available for chronic pain–it does not abate if one bathes in Epsom salts or ice water. Numerous treatments, in addition to pharmacological approaches and CBT, such as surgery, physical therapy, acupuncture, massage therapy, and spinal manipulations are available that can help ease the pain, but these do not completely resolve it, and, for many, they do not have any impact at all on minimizing pain. For individuals who receive minimal to no relief after pursuing multiple courses of treatment, it can seem as if there is no escaping the galling agony of chronic pain that encompasses the body, mind, and soul. When individuals exhaust all of their emotional, physical, and financial resources trying to find some relief without positive results, feelings of hopelessness, depression, and anxiety can emerge. Other negative outcomes of chronic pain include somatic symptoms, sleep deprivation, diminished emotional and physical well-being, and difficulties with psychosocial and vocational functioning (Koch & Rumrill, 2017; Omidi & Zargar, 2014). Because there is no cure, individuals themselves must take personal responsibility for learning how to manage their pain to the best of their ability and to live their lives as fully as possible despite being in constant pain.

Relatedly, in response to the nationwide opioid abuse epidemic, regulations for prescribing opioid analgesics for pain management have become so restrictive that people who are unable to function without these medications are denied access to them, a drastic consequence that pain advocates refer to as a violation of human rights (Brennan et al., 2007; IOM, 2011; Thernstrom, 2010). Brennan et al. (2007, p.212) further stated, “Unreasonable failure to provide adequate pain relief constitutes negligence.” The enactment of the Comprehensive Addiction and Recovery Act of 2016 could lead to further violation of individuals’ rights to effective treatment of their pain. For those individuals, denied the very medications that provide them with enough relief to experience an acceptable quality of life, their only recourse may be to illegally obtain these medications or to self-medicate with other substances. It is, therefore, imperative that (a) strategies directed at ameliorating the abuse of these opioid analgesics be balanced with the needs of individuals with chronic pain to have access to these medications and (b) effective pain management alternatives are provided to these individuals.

Described as the “third wave” of CBT, mindfulness approaches are increasing in value and popularity to manage chronic pain (Day et al., 2012). Mindfulness instructs the individual to progressively reduce suffering, which allows the individual to experience the richness of a full, uninhibited life (Burch & Penman, 2013). This practice places control in the hands of the person who performs it, thereby creating pathways that eliminate suffering and ensure peace in the face of pain. Mindfulness approaches are often recommended by practitioners and used by individuals to reduce pain suffering and the degree to which it interferes with their daily functioning. A substantial and expanding base of research literature indicates that mindfulness approaches are at least as effective as traditional CBT. Given that vocational rehabilitation (VR) practitioners can expect to provide services to increasing numbers of individuals with chronic pain, the purpose of this article is to (a) explore the vocational implications of chronic pain; (b) describe contemporary mindfulness approaches; and (c) examine the application of mindfulness approaches to managing pain at work so that employees with chronic pain can experience job satisfaction, job satisfactoriness, quality of work life, and job retention.

2 Vocational implications of chronic pain

Chronic pain is a commonly misunderstood, stigmatizing, and debilitating condition that can impair one’s ability to enter, re-enter, or maintain employment. Individuals with chronic pain experience high rates of unemployment and underemployment. Data from the Functioning and Disability Supplement of the 2012 National Health Interview Survey indicated that 36.7% of the survey respondents who reported experiencing a lot of pain most or every day in the last three months were unable to work (Nahin, 2015). Another 17.8% who reported some days of mild to severe pain over the last 3 months stated that they were unable to work. A variety of factors contribute to these unsatisfactory employment outcomes including fears that working will increase pain discomfort, medical advice that employment may not be feasible, uncertainty about the capacity to work, depression, sleep disruptions, and stigmatization and discrimination (Koch & Rumrill, 2017).

In addition to high rates of unemployment, adults with chronic pain who do work are absent from work more often than those without chronic pain. They also have higher rates of presenteeism (i.e., reduced performance while at work; Fine, 2011), and the highest rates of both absenteeism and presenteeism are among those with severe chronic pain. In 2012, the IOM estimated the annual value of lost productivity due to chronic pain at approximately $300 billion, and chronic pain has been cited as the most common reason for disability leave from work (Grodman et al., 2011).

Employed individuals with chronic pain experience numerous limitations that interfere with their ability to carry out the essential functions of their jobs. Among the most disruptive symptoms of chronic pain are excessive fatigue, reduced stamina, and exhaustion. Fatigue and related symptoms can cause difficulty with memory, concentration, completing tasks, and meeting deadlines. These symptoms can also lead to making careless mistakes and forgetting to finish assigned tasks. Fatigue is exacerbated by sleep disruptions, loss of appetite, depression, and anxiety- all of which commonly co-occur with chronic pain. Furthermore, chronic pain can cause irritability that impairs relationships with supervisors, co-workers, and customers. Other functional limitations can include muscle weakness, reduced mobility, and motor impairments (Grodman et al., 2011; IOM, 2011). Working in extreme heat or cold can exacerbate pain and other symptoms. For consumers with chronic pain who use opioid analgesics or medical cannabis, employment options may be restricted. For example, individuals who use medical cannabis may be precluded from working for companies that have drug-free office policies (Lusk et al., 2015).

In addition to the functional limitations associated with chronic pain, the pervasiveness of myths and stereotypes about chronic pain in contemporary society has resulted in the stigmatization of affected individuals. Chronic pain is frequently ambiguous, hidden, episodic, and diagnosed based on patient self-report of symptoms rather than evidence of specific biomarkers. Because of these characteristics of chronic pain, employers and co-workers may attribute symptoms of chronic pain to attention seeking, lack of motivation to work, malingering for secondary gain (e.g., disability compensation), weakness of character, and psychosomatic conditions. Consequently, employers who are uneducated about chronic pain can be reluctant to hire and accommodate these individuals, and those with chronic pain who are employed are often socially ostracized from their co-workers. These experiences can create hostile work environments and unnecessary job stress that exacerbate chronic pain and make it difficult for affected employees to continue working. Indeed, as previously mentioned, individuals with chronic pain who avoid working are often characterized as lacking motivation to work, even by VR professionals (Koch & Rumrill, 2017). However, what may appear to be a lack of motivation could be better explained by factors we previously mentioned that contribute to high unemployment rates (e.g., depression, anxiety about reinjuring oneself or experiencing increased pain, concerns about one’s ability to satisfactorily perform the functions of one’s job, misinformation from medical providers about one’s capacity to work). Additionally, individuals may be described as being unmotivated or uncooperative clients when in reality they may lack confidence that VR services will lead to positive outcomes or feel that their pain is invalidated by the VR professional (Koch & Rumrill, 2017).

Even with the many functional limitations and pervasive stigma that can accompany chronic pain, many individuals with pain disorders desire to work or continue to work. For these individuals, employment is beneficial to both their physical and psychological well-being. In addition to providing a source of income and health care benefits, work provides distraction from one’s pain, physical activity, social interaction, personal meaning and a sense of self-worth, and structure to one’s day (Koch & Rumrill, 2017). Conversely, unemployment often results in negative outcomes such as loss of income and health care benefits, worsening of symptoms, loss of identity, social isolation, depression, and substance use disorders (Strauser, 2013). The challenge for individuals with chronic pain is to identify employment opportunities and workplaces wherein the disruptions to job performance caused by chronic pain are minimized. In many cases, these individuals must make substantial changes to how they perform the essential functions of their jobs (Rakovski, Zettel-Watson, & Rutledge, 2012; Skaer, 2014). Others must change to different positions or occupations to maintain employment. Still others may need to reduce the number of hours they work (Skaer, 2014).

3 Overview of mindfulness-based approaches

Mindfulness is the practice of focusing attention on one’s moment-to-moment experiences with curiosity, lack of judgment, and openness to experiences (Hayes, Strosahl, & Wilson, 2012; Gu, Strauss, Bond, & Cavanaugh; Kabat-Zinn, 2013; Marchand, 2012; Rosenweig, Greeson, Reibel, Green, Jassen, & Beasley, 2010). Mindfulness approaches couple Eastern traditions such as Zen meditation and Hatha yoga with Western psychological approaches such as stress management and CBT (e.g., psychoeducation about stress, coping skills training, assertiveness training, cognitive therapy). Formal group formats to teach individuals mindfulness exercises and applications are typically offered in eight- week group sessions. In these groups, participants learn a variety of mindfulness techniques that can be widely applied to improving all aspects of life. Group participants receive homework assignments to practice mindfulness on a daily basis. Although group formats are widely used to teach mindfulness, with the proliferation of books, workbooks, e-books, and CD ROMs that provide instruction in mindfulness practices, these techniques can be self- taught as well.

When using mindfulness as a practice in the treatment and management of chronic pain, attention is given to uncomfortable bodily sensations (e.g., pain), thoughts, and emotions, but without attempts to change these experiences. Rather, the intent is to develop complete acceptance of the self and compassion toward positive and aversive experiences (Marchand, 2012). With this acknowledgement of pain as a part of their life experiences, individuals can then move forward toward making changes to improve their quality of life and pursue valued goals. Four variations of mindfulness practices used in the treatment and management of chronic pain include mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), acceptance and commitment therapy (ACT), and dialectical behavior therapy (DBT).

3.1 Mindfulness-based stress reduction and mindfulness-based cognitive therapy

Developed by Jon Kabat-Zinn in 1979, mindfulness-based stress reduction (MBSR) combines meditation with yoga. An eight week intensive group instruction in meditation aims to cultivate awareness of mind-body unity and behaviors that trigger unhealthy responses to problematic emotions, bodily sensations, and events (Omidi & Zargar, 2014). The three major exercises that are taught in MBSR are the sitting meditation, hatha yoga postures, and the body scan (Hyland, Lee, & Mills, 2015). Whereas meditation works at the autonomic physiological level to create a state of relaxation, yoga and body scans activate the muscles that chronic pain and disease could otherwise cause to atrophy. Body scans are exercises intended to bring awareness in a slow and deliberate approach to different parts of the body. A full body scan is usually done lying down and requires about 25 to 45 minutes to bring awareness to each part of the body-from the toes to the top of the head. MBSR synthesizes a method for teaching individuals in pain to mindfully take agency in their healing and strengthening process in order to promote muscle relaxation and pain reduction.

Mindfulness-based cognitive therapy (MBCT) extends MBSR by combining instruction and practice of mindfulness with CBT to teach individuals to release negative self-beliefs through recognition and assessment of negative thought patterns and replacement of these with positive, judgment-free thoughts (Segal, Teasdale, & Williams, 2002). Like MBSR, the three major mindfulness practices taught in MBCT are the sitting meditation, hatha yoga, and the body scan (Hyland et al., 2015). Early practices of CBT and new approaches to mindfulness both share the assumption that individuals have the potential for continued growth (Kumar, 2002). CBT consistently has the goal of encouraging awareness and acceptance of experiences for individuals with chronic pain conditions (Follette, Palm, & Pearson, 2006). MBCT teaches individuals to embrace thoughts and feelings with increased awareness, with the overall goal that increased awareness and openness to their experiences will lead to changing thoughts and feelings to improve individuals’ wellness (Segal et al., 2002).

3.2 Acceptance and commitment therapy

Acceptance and commitment therapy (ACT) is a psychological approach to pain management that involves two concepts: an acceptance of the aspects of pain that cannot be changed and a commitment to actions that are life-affirming and energizing (Dahl & Lundgren, 2006). ACT incorporates mindfulness strategies with behavioral interventions to assist individuals to develop psychological flexibility (Hayes, Strosahl, & Wilson, 2012). Psychological flexibility is the opposite of psychological rigidity, which is believed to be a major contributor to problems such as depression, anxiety, and pain. Psychological flexibility enables individuals to approach life from a more centered, engaged, and open stance. Psychological flexibility involves six core processes: acceptance, defusion, the self-as-context, flexible attention to the present moment, chosen values, and committed action.

The acronym ACT also stands for “accept, choose, and take action” which encourages individuals to remain in contact with painful events without succumbing to their control over their livelihoods (Hayes, Strosahl, & Wilson, 1999). Acceptance involves allowing a willing engagement of pain and letting go of the fight against it (Dahl & Lundgren, 2006). The choice to live with, not against, pain enables individuals the freedom of how to choose to live the rest of their lives and establish a plan of action to pursue values-based goals for a fulfilling life, defined by achievements not pain-induced limitations. ACT posits that the more an individual tries to fix suffering by limiting one’s experiences (i.e. “I cannot go for a walk today because of my arthritis”), the more that person’s life diminishes by lost opportunities (Dahl & Lundgren, 2006). ACT differs from traditional CBT in its assumption that “attempts to change certain aversive internal experiences, such as chronic pain, are likely to be futile at best, and at worst may contribute to increased distress and interference” (Wetherell et al., 2011, p. 2098).

Learning to carry one’s pain while pursuing values-based goals is a prominent pillar that upholds the practice of ACT. Acceptance can additionally be defined as the act by which individuals allow themselves to willingly engage their pain in order to move forward in pursuing their life goals (Dahl & Lundgren, 2006). Everything in their experience may be telling them that there are aspects of their lives that they cannot change, and that pain is one of them. Individuals may consider it unfair, compare themselves to other people, or fight the pain, but, in the end, it does not matter. The pain will remain with its unrelenting force. What option remains? The timeless adage comes to mind: if you can’t beat ‘em, join ‘em. Every time people tell themselves that they cannot accept their pain, they call their pain to mind – this action is called “experiential avoidance” – it reinforces the pain itself and the power pain has over individuals’ lives” (Dahl & Lundgren, 2006, p. 113). The basic tenets of ACT include contacting the present moment, defusing of emotions from thoughts, and unpacking the acceptance of emotions (Harris, 2009).

In order to practice ACT mindfulness, awareness is shifted from problem solving and anxiety about the future to appreciation of the present moment. This focus can be accomplished with exercises that focus on mindfulness of the breath as it fluctuates through the nose and travels through the rib cage and abdomen, gently rising and falling as thoughts drift with the flutter of breath (Harris, 2009). Other techniques used in ACT include exposure, instruction, behavioral activation, skills training, mindfulness, use of metaphors, visualization exercises, behavioral homework assignments, and techniques for building a strong therapeutic alliance (McCracken & Vowles, 2014).

3.3 Dialectical behavioral therapy

Dialectical behavioral therapy (DBT) is a type of CBT that aids in the management of overwhelming emotions and sensations through distress tolerance, mindfulness, emotion regulation, and interpersonal effectiveness (McKay, Wood, & Brantley, 2007). DBT advocates for individuals to practice distress tolerance skills that control suffering in a healthy way–distract, relax, cope (McKay, Wood, & Brantley, 2007). Distraction skills differ from avoidance because the individual is prepared to deal with the distressing event when emotions calm down; The DBT tenet of self-soothing teaches individuals to regulate their emotions when confronted with painful events (McKay, Wood, & Brantley, 2007). In a state of relaxation – as opposed to heightened panic - the body functions at a higher level of focus, thereby permitting the brain to devise healthy coping mechanisms (McKay, Wood, & Brantley, 2007). Self-soothing practices can include burning scented candles, constantly keeping in one’s possession the photographs of loved ones, or listening to gentle music.

Individuals in chronic pain are vulnerable to anxieties about worsening pain and their ability to keep functioning in valued life roles. They may have frequent disruptive thoughts about how life could have been different if they were not in so much pain. They may also predict that treatments will fail before even trying them or anticipate a day full of pain before getting out of bed. DBT refers to these thoughts as “time-travel” into the past and future, which creates tension and fortifies pain rather than releasing it into the present moment (McKay, Wood, & Brantley, 2007, p. 45). In DBT, individuals learn to focus on one thing at a time in the present moment to soothe overwhelming emotions. They also learn to identify and separate judgmental thoughts from their experiences to develop a wise mind – a collection of intuitive gut feelings from which people make sensible decisions about their lives (McKay, Wood, & Brantley, 2007). To combat distressing times in life, self-encouraging coping thoughts serve as a reminder of the stressful times they have conquered before and what key words gave them the most strength in those difficult times (McKay, Wood, & Brantley, 2007). A few examples of coping thoughts include, “I am strong and I can deal with this,” or “This situation will not last forever,” and “I’ve already been through many other painful experiences, and I’ve survived” (McKay, Davis, & Fanning, 1997, p.47).

4 Applications of mindfulness approaches to managing chronic pain at work

Mindfulness at work is a practice that is being encouraged by a growing number of employers, and an expanding number of research studies are being implemented to examine the impact of mindfulness on employment-related behaviors and outcomes. In fact, companies such as Monsanto, General Mills, Google, Aetna, Goldman Sachs, Bank of America, and Adobe Systems offer mindfulness-based classes and workshops to their employees to facilitate their health and well-being and improve job performance and employment stability (Hyland, Lee, & Mills, 2015). Although research on the impact of mindfulness interventions on employment outcomes (e.g., job satisfaction, job satisfactoriness, job tenure, turnover intentions) of employees with chronic pain is less prominent in the literature, we propose that the use of on-the-job mindfulness strategies by these individuals holds promise for improving these employment outcomes and warrants further investigation, especially considering the large and growing numbers of individuals with chronic pain in contemporary society. Mindfulness practices can be used by individuals with chronic pain to prepare for the workday, identify and implement reasonable accommodations, reduce job stress, improve work relationships, and, consequently, decrease the risk of premature departure from the workforce.

4.1 Preparing for the work day

Because chronic pain is a prominent part of individuals’ lives (Cowan, 2011), the first thought that they may have when they wake up in the morning is “How much pain am I in, and how will it interfere with my day?” Management of one’s pain requires a 24- hour a day commitment, and this commitment is imperative for those who work or who desire to work. Because the goal of mindfulness approaches is to equip individuals with the skills to practice being in the present moment on a daily and ongoing basis, the practice of mindfulness also requires a 24-hour a day commitment, and for employed individuals with chronic pain this begins with making preparations for the workday. Mindfulness practices can empower individuals to initiate important changes in their daily routines in preparation for a satisfying day at work. These changes include getting adequate sleep, beginning the day with a focus on the here and now as opposed to worrying about what the day may bring, delegating chores to others so that individuals have adequate physical and mental reserves to work, and/or giving up activities to free up time and energy to devote to work.

Mindfulness techniques can also be incorporated into the morning routine. Strategies such as meditation, stretching, yoga postures, body scans, breathing exercises, and the use of DBT coping thoughts can assist individuals to begin the day with a positive attitude, “seeing each moment as new, each day as an adventure” (Kabat-Zinn, 2013, p. 505). Even simple techniques such as slowing down instead of rushing through the morning routine, mindful tooth brushing (i.e., being aware of the actions involved in brushing your teeth, the sensations you experience in your mouth, the taste of the toothpaste, and the environment surrounding you); and mindful eating (i.e., putting aside any other activities you would typically do while eating so that you can focus exclusively on the taste, smells, and texture of food as well as the act of eating itself; Watt, 2012) can be helpful in keeping individuals calm and centered as they approach the workday.

When individuals must knowingly prepare for a particularly stressful work day (e.g., a scheduled work meeting with a difficult co-worker, supervisor, or customer; an impending deadline; a presentation to co-workers or customers), mindfulness exercises can be instrumental in defusing anticipatory anxiety and engaging in thoughtful reflection and activation of techniques that can be employed to mitigate, minimize, or successfully manage the stressful event. Again, allowing time in the morning for meditation, yoga, deep breathing exercises, and/ or writing down coping thoughts can reduce anticipatory stress and prepare individuals to enter stressful situations in a calm and centered manner.

4.2 Identifying and implementing reasonable accommodations

Although not traditionally incorporated into the accommodation planning process, mindfulness exercises can be used as (a) self-initiated accommodations for individuals with chronic pain or (b) strategies to identify and implement formally requested on-the-job accommodations. Practicing mindfulness on the job can be an accommodation, in and of itself, that individuals can implement on their own without going through the formal process of requesting accommodations, a process that is stressful and can exacerbate pain. Examples of self-implemented mindful accommodations include periodic breaks to practice seated meditation, body scans, mindful walking (i.e., bringing full awareness to the act of walking) deep breathing, stretching, and progressive relaxation. Self-implemented mindfulness accommodations are likely to be most feasible when employees have flexibility in their work schedules, the ability to work from home, or their own private office spaces in quiet locations or can access a quiet space without disruptions in which to practice mindfulness exercises. Practicing mindfulness strategies such as those described above may involve making accommodations such as taking shorter breaks rather than one long break during the workday or adjusting work hours to engage in these activities. If a private, quiet space is not readily available, the employee may need to consult with the employer to locate or create such a space.

Mindfulness exercises can also be used to identify formal accommodations that can be implemented to reduce stress and manage pain. Being mindful of bodily sensations as employees with chronic pain perform various job functions brings to awareness the presence or absence of pain along with the severity and location of the pain, coupled with attention to what one is correspondingly doing, thinking, and feeling. This enhanced awareness of moment-by-moment experiences can be instrumental to identifying needed changes to body mechanics, one’s workstation, and how essential functions are performed. Furthermore, awareness of one’s thoughts, feelings, bodily sensations, and actions when one is in the least amount of pain can lead to exploration of (a) individual and environmental factors that contribute to reduced pain and (b) how these factors can be translated into reasonable accommodation strategies to implement in other situations in which pain is greater. CBT techniques can be coupled with mindfulness practices for problem-solving and identifying specific accommodations such as breaking down work assignments into manageable tasks, performing the most demanding tasks when one is in the least amount of pain, alternating between demanding and less demanding tasks, performing some assignments from home, and seeking help from co-workers in completing tasks that increase pain.

Many individuals with chronic pain fear that disclosing their disability status or requesting formal accommodations might invoke an environment of hostility from their employers and coworkers who may perceive them as lazy or resent them for receiving reasonable accommodations (Gold, Oire, Fabian, & Wewiorski, 2012). Similarly, some employees fear that, once they have made formal accommodation requests, they will be deemed illegitimate by co-workers who do not have disabilities (Gold, Oire, Fabian, & Wewiorski, 2012). Mindfulness-based practices can be an effective tool for navigating stressful situations in the workplace, such as disclosing one’s disability status and making formal accommodation requests. Vance, Campbell, and Dong (2016) studied the role of mindfulness in the accommodation request process for 150 workers with disabilities. The researchers found that mindfulness did indeed have an interactive relationship with intentions to request accommodations. The authors interpreted their results as providing evidence that mindfulness encourages individuals to fully engage in the task at hand (e.g., requesting an accommodation) rather than ruminating over the potential negative outcomes of requesting accommodations (Vance et al., 2016).

VR professionals can incorporate mindfulness approaches into counseling, guidance, and job development and placement to address issues such as fears that work will cause re-injury or exacerbation of pain and concerns about disability disclosure (especially how to make formal accommodation requests). For example, before discussing whether to pursue employment, to return to work, or to disclose one’s disability status and need for accommodations, clients can use practices such as mindful meditation, deep breathing, and relaxation exercises to increase awareness of their thoughts, feelings, and bodily sensations in response to the prospect of taking these actions. This practice can lead to an enhanced ability to describe their concerns to the VR professional and to then engage in problem-solving to address their concerns. The VR professional can then weigh with the client the risks and benefits of working or making accommodation requests. If clients decide they want to pursue employment or to disclose their disability status to their employers to receive reasonable accommodations, guided meditations or relaxation techniques to reduce anxiety can be coupled with career exploration and job search activities, education about the accommodation planning process, the development of written scripts for disclosing one’s disability status and need for accommodations, and/or role plays to practice interviewing or making formal requests for reasonable accommodations. These practices have the potential to increase clients’ self-efficacy in making informed decisions about work and effectively communicating their accommodation needs to employers. Immediately before they approach their employers, they can practice deep breathing, meditation, and/or relaxation exercises so that they embark on the difficult task of making a formal accommodation request with calmness and composure (Dong et al., 2016).

4.3 Managing job stress

Anxiety and stress create muscle tension and constriction of blood vessels that then cause muscles to become fatigued and inefficient. Recently, researchers have also discovered that individuals with chronic low back pain have higher levels of cortisol than control subjects, which are associated with smaller hippocampal volume and stronger pain-evoked activity in the region of the hippocampus that are related with anticipatory anxiety and associative learning (Vachon-Pressau et al., 2013). Therefore, the capacity to manage on the job stress is imperative for employees with chronic pain. One of the most common applications of mindfulness approaches is to the management of stress, and as Kabat-Zinn (2013, p. 506) pointed out:

Work stress can be greatly reduced in many cases simply by an intentional commitment to cultivated calmness and awareness in the domain of work and by letting mindfulness guide our actions and our responses to all stressors we have to deal with or tolerate.

Kabat-Zinn (2013) also indicated that bringing mindfulness practices into the employment arena can vastly improve one’s quality of work life, regardless of one’s job. Mindfulness on the job requires a change in perspective from work as a stressful or undesirable activity to work as a challenge and opportunity for growth. Stressors are then re-conceptualized as opportunities for individuals to practice patience, compassion, and assertiveness. The practice of mindfulness increases awareness of factors that contribute to job stress and enables individuals to take a problem-solving approach to coping more effectively with these stressors. For example, awareness that large work projects increase both stress and pain can prompt individuals to couple mindfulness with strategies such as breaking down these projects into smaller manageable components. Kabat-Zin (2013) offered additional strategies for managing job stress such as breathing exercises to keep oneself calm and centered, sitting in the car or outside the job site and breathing for a few minutes before going into work, completing one task at a time instead of multi-tasking, and stopping what one is doing every hour to briefly focus on one’s breathing and practice body scan meditation. Another exercise that can be used to manage job stress and better connect with oneself and one’s surroundings is Drop Anchor. It can be useful in situations in which individuals feel overwhelmed by stress, Drop Anchor requires five simple steps:

Plant your feet into the floor.

Push them down – notice the floor beneath you, supporting you.

Notice the muscle tension in your legs as you push your feet down.

Notice your entire body – and the feeling of gravity flowing down through your head, spine and legs into your feet.

Now look around and notice what you can see and hear around you. Notice where you are and what you’re doing (Harris, 2009, p. 170).

If individuals find the Drop Anchor exercise to be helpful, they can be encouraged by VR professionals to post the written steps of this exercise in their workstations as a constant reminder of how to reduce stress.

Body scans can also be effective in stressful work situations and teach individuals to ‘be with’ their anxiety, stress, and painful sensations rather than impulsively reacting, lashing out, or escaping stressful situations (Watt, 2012). Experiences at approaching stressful situations in this way empower individuals with the knowledge that they are capable of responding to stress in a manner that does not, or minimally, exacerbates their pain. Again, employees with chronic pain who know before beginning the work day that they must contend with a stressful situation can practice mindfulness exercises such as meditation, yoga stretches, or body scans when they wake up in the morning or in a quiet location at work before entering into the stressful situation.

Finally, the DBT Mindfulness FLAME is a useful stress reduction tool that reminds individuals to incorporate mindfulness practices into their work lives. The steps in FLAME are:

F ocus and shift your attention to be mindful of the present moment

L et go of distracting thoughts and judgments by allowing them to float past without getting stuck on them

Use radical A cceptance to remain nonjudgmental

Use wise M ind to make healthy decisions about your life

Do what’s E ffective in order to accomplish your goals

(McKay, Wood, & Brantley, 2007, p. 109).

The FLAME steps can, like the Drop Anchor steps, be posted in the workstations of individuals who find this strategy to be helpful in reducing job stress.

4.4 Improving interactions with supervisors, Co-workers, and customers

When individuals with chronic pain become proficient with mindfulness techniques, they also become proficient at navigating relationships with coworkers and employers and managing conflict. In fact, Kabat-Zinn (2013) emphasized that the ongoing practice of mindfulness techniques can cultivate positive and supportive relationships with co-workers, supervisors, and customers. As Kabat-Zinn (2013, p. 273) also noted,

the more centered you are within yourself, the easier it will be for you to be centered in your relationships with others, to appreciate the various threads of connection that give meaning to your world, and to fine-tune them as things change and life unfolds.

Mindful presence in the here-and-now improves listening skills and increases empathy for both oneself and others (Kabat-Zinn, 2013). When one has greater empathy for self and others, misunderstandings in communications can be reduced. Nonjudgmental awareness of how one is communicating, how one’s communications are being received by others, and what one can do to improve communications can lead to more genuine interactions that benefit all parties. In this respect, mindfulness increases awareness of how to be more sensitive to the feelings and needs of others. Mindful awareness of communications also involves being attentive to nonverbal messages communicated by oneself and others through tone of voice and body language.

One mindfulness practice that can be used to improve on-the-job communications is the lovingkindness meditation, the purpose of which is to facilitate positive feelings for oneself and others, greater nonjudgementalness in relationships, and increased patience and acceptance of others (Kabat-Zinn, 2013; Kang, Gray, & Dovidio, 2014). In lovingkindness meditation, individuals begin the meditation by focusing on warm feelings they have for the person they most care about. Then, they extend these feelings to themselves and next to a growing circle of other people in their lives, and finally to all of humankind (Kang et al., 2014). Simply practicing lovingkindness meditation for seven minutes before interacting with others on the job has great potential for improving communications and eliciting needed support from co-workers. Watt (2012) outlined all the steps in the lovingkindness meditation (as well as many other mindfulness exercises). Workers with chronic pain can audio- record the steps and use the recording to guide them in the meditation before their encounters with co-workers or supervisors that they anticipate will be difficult.

The practice of ACT exercises can also facilitate improved relationships on the job. When individuals accept their chronic pain, the pain becomes defused, less catastrophic, and more manageable. Through acceptance and defusion, individuals are then better able to communicate about their pain to supervisors and co-workers in a manner that is more likely to elicit understanding, support, and accommodations instead of invalidation, rejection, and hostility. Rather than hiding their pain from others and reacting irritably when their pain is exacerbated (which is almost always counter-productive), individuals who recognize that the impact of chronic pain on their lives is not as catastrophic as they originally believed and that they can still pursue valued goals (such as employment) are able to (a) communicate more effectively with others about how pain affects their job performance and (b) request accommodations that they may need.

4.5 Preventing premature departure from employment

Given the substantial research literature base providing evidence of the positive effects of mindfulness practices on (a) clinical outcomes for individuals with chronic pain and (b) employment outcomes for employees in general, we propose that mindfulness practices implemented on the job are also likely to enhance job performance, satisfaction, and retention – and to prevent premature departure from the workforce for individuals with chronic pain. Numerous randomized clinical trials have demonstrated the positive effects of mindfulness approaches, including reduced chronic pain and anxiety, decreased risk of relapse of depression, improvement in current depressive symptoms, reduced stress, and improved quality of life (Gu, Strauss, Bond, & Cavanaugh, 2015). Clinical trials show mindfulness meditation techniques to be as effective as medications or counseling for relief of anxiety, stress, and depression. Mindfulness improves working memory and attention span while reducing pain, thus, enhancing physical resilience (Burch & Penman, 2013).

Several investigators have discovered that Zen meditation reduces stress and blood pressure and decreases pain sensitivity. For example, in a study that tested pain sensitivity and cortical thickness during exposure to moderate pain, researchers discovered that participants who received a mindful attention intervention were better able to modulate both the unpleasantness and intensity of the stimulation than participants in a control group, and this effect was positively associated with their use of mindful attention (Grant, Courtemanche, Duerdan, Duncan, & Rainville, 2010, p. 44). This study suggests that Zen mindfulness leads to cognitive, affective, and autonomic self-regulation and influences the structures of pain-pathways to the brain (Grant et al., 2010, p.44). Through heightened control, Zen meditation strengthens brain processes that mitigate pain and regulate emotions.

Other researchers have found that MBSR reduces stress, decreases pain, increases pain coping, and may improve sleep. In research conducted by Omidi and Zargar (2014), MBSR was found to have a significant effect on mitigating the impact of chronic pain on medical illnesses such as fibromyalgia, multiple sclerosis, and chronic back pain. MBCT has also been demonstrated to be effective in treating depression and reducing fatigue. MBCT is believed to cause changes in the part of the brain that produces stress hormones and to improve the immune system (Marchand, 2012). Research to date has demonstrated that ACT has positive effects on physical and social functioning and reduces pain-related medical visits. Overall, ACT has been found to be as effective as traditional CBT in the treatment of chronic pain (McCracken & Vowles, 2014; Wetherell, 2011).

DBT is associated with reduced blood pressure and steady heart beat (McKay, Wood, & Brantley, 2007). As individuals in chronic pain learn to mindfully observe their feelings, the realization will occur that – although pain may not be temporary – the emotional pain associated with feelings is fleeting (McKay, Wood, & Brantley, 2007). Secondly, the act of describing the feeling of being in pain to others grants the individual a sense of control that may not exist for people coping with chronic pain who have no outlets to express their feelings.

Hyland, Lee, and Mills (2015) provided a comprehensive overview of mindfulness training implemented at worksites. They noted that a growing number of employers are offering programs that are typically adapted from MBSR with shorter classes to reduce the amount of time that employees are taken away from performing job tasks. Several formats are offered including 5 to 12 week workshops, multiday employee retreats, and on-line training that employees can complete at their desks or workstations. Hyland et al. cautioned that, as these interventions become increasingly prominent in workplaces, the likelihood of untrained facilitators providing these trainings also increases. They further noted the need to compare the effectiveness of adapted, shorter versions of mindfulness training to that of longer versions.

Hyland et al. also summarized the outcomes of a multitude of research studies on mindfulness training for employees and noted many positive effects of these interventions on employee attitudes, work behaviors, and relationship skills. Among the positive outcomes they identified in the research were increased problem-solving skills, reduced job stress, improved relationships with others, enhanced performance on job tasks requiring sustained attention, improved mood and affect, increased subjective well-being, improved decision-making, reduced emotional reactivity that could lead to impulsive decision-making, greater openness to constructive criticism or negative feedback, increased creativity and innovation, reduced absenteeism and job turnover, increased productivity, increased task endurance, increased positive attitudes and accompanying behaviors, reduced emotional exhaustion, and greater job satisfaction.

5 Conclusion

The effectiveness of mindfulness practices in managing chronic pain and promoting psychological well-being are well documented in a growing body of research studies involving numerous consumer populations. Although the applications of mindfulness in the workplace and in vocational rehabilitation services for workers with chronic pain have been less thoroughly examined, early evidence indicates considerable promise that mindfulness training may be helpful for people who seek to continue their employment even while coping with the often-debilitating effects of pain disorders. As a means of improving workers’ proficiency in the Americans with Disabilities Act’s reasonable accommodation process, facilitating effective communication with supervisors and co-workers, managing pain-related symptoms at work, retaining employment over time, and reducing the likelihood of premature departure from the labor force, mindfulness approaches have the potential to increase the consumer’s control over his or her pain experience and, thereby, over his or her career path. However, research is needed to substantiate this proposition. In particular, the effects of these practices on employment-related outcomes such as job satisfaction, satisfactoriness, and retention; availability and use of workplace accommodations; turnover intentions; and quality of work life should be investigated.

Conflict of interest

None to report.

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