Ask Dr. Rick About:


Do you have any suggestions for people who commonly experience episodes of extreme pain?

First of all, I’m very sorry that you’re experiencing this. I am not a specialist in this area, so I offer these ideas modestly. What I have experienced myself and seen helpful for others is:

  • Know that you are not dying. The pain is terrible, awful, and yet your core of being is still intact. Try to locate yourself in this center, this core, as a place of refuge. Try to be aware of what is also true about yourself and the world: the things that are not in pain, the things that are working, the things that are good.
  • Have compassion for yourself. Bring a softness and sweetness to yourself, much as you would to a dear friend in extreme pain.
  • Accept the pain. Resisting it just makes it worse. It is here, it is true, even though it is not your preference.
  • See if you can explore it mindfully. Step back from it and observe the different aspects of the pain from a place of open spacious awareness. Try to see it more impersonally, as an intensely unpleasant collection of mental phenomena that are arising due to many causes and not created or owned by a “self.” Notice that awareness itself is untroubled by the pain it holds.
  • If you can, notice the universal characteristics of any experience in the pain: made up of many parts, continually vibrating/pulsing/changing, arising and passing away due to causes, and insubstantial. In effect, any experience, including extreme pain is “empty” of absolute independent existence, and the recognition of this can bring relief and freedom.
  • If you can, try to sense, intuit, or imagine the larger mystery, the unconditioned, the divine that is the ultimate space and basis of mind and matter. In this is our ultimate refuge, no matter how terrible the pain.

Can you offer any advice for managing chronic pain? Especially for handling pain mentally.

You’re right, the hardest thing about managing pain is our mental attitude towards it. If we resist anything, including our chronic pain, it puts us in the “red zone”, where our brains are in fight-or-flight mode and constantly agitated. I offer some ways out of this dilemma my essays Accept It and Minimize Painful Experiences.

I also recommend the work of Vidyamala Burch and Toni Bernhard; both offer excellent books and programs on how to free your mind even when your body is hurting.

Can you strengthen certain circuits in the brain to get more resilient? How can these stronger circuits help you in a crisis situation? For example, when you’ve experienced a lot of stress or mental pain?

Much research shows that we can definitely change the brain for the better. As the “hardware” of the brain improves in key regions such as the prefrontal cortex (PFC) behind your forehead, that part of the brain becomes more effective. For example, if a person is being challenged by stressors, improved regulation of the amygdala – sort of the alarm bell of the brain – by the PFC can help a person feel calmer under pressure. Just because there is a stressor does not mean we need to feel stressed, and improved brain function is like a shock absorber between us and the world.

You say that the brain has evolved to keep us alert and therefore there is an undercurrent of unease at all/most times. You also say that without pain or fear, the brain defaults to a setting of calm and contentment. How do I mesh these two different things?

Basically, I think the evidence is that both are true: there is an ongoing trickle of background anxiety to keep us vigilant, and there is also a strong inclination to default to the “responsive mode” of being peaceful, happy, and loving when we are not disturbed. Putting these two apparent facts together, I think the trickle of anxiety prompts us to scan for threat, but if we find that all is well for now, then we default to the responsive mode, and then this cycle repeats itself a moment later. For me the pragmatic point is to discern real threats and address them, while also recognizing the strong bias from evolution to look for threats behind every bush and thus appreciating the importance of exerting compensatory influences in a variety of ways, from inner practices such as I focus on to social support and (hopefully) decent health insurance.

What are the different ways we can work with our mind during experiences of intense pain?

Fundamentally, in my view, there are just three kinds of ways to engage the mind, to practice with it productively:

  1. Be with it – Observe the mind, experience the experience, feel the feelings, etc. without trying to change anything in the stream of consciousness. Hopefully one does this with an attitude of curiosity, kindness toward oneself, and a certain stepping back – “dis-identification” – from whatever one is experiencing. One could also explore more vulnerable, fundamental, or younger material “beneath” the surface of experience, such as the hurt underneath anger or the old pain from childhood that amplifies or distorts one’s reactions. Through being with one’s experience it may change, but one is not directly making efforts to change it.
  2. Decrease the negative – Here is where we make efforts in the mind to relax tension from the body, vent or otherwise release emotions like sadness or anger, challenge and let go of wrongheaded thoughts, or resist or abandon problematic desires (e.g., wanting to get hammered or to yell at the kids).
  3. Increase the positive – Here is where we make efforts in the mind to take skillful actions (e.g., sitting up straighter to be assertive, calling the doctor for an overdue check-up), to encourage feelings like gratitude and compassion, to develop useful perspectives and other thoughts, and to strengthen and commit to beneficial desires such as exercising or not interrupting one’s partner.


In effect, if the mind is like a garden we can observe it, pull weeds, and plant flowers. In a nutshell: let be, let go, and let in.

The three ways to engage the mind work together. For example, we need to make efforts to grow capacities to be with the mind, such as self-acceptance, observing-ego functions, or distress tolerance. And we be with the results of our efforts to reduce the negative and grow the positive.

Of the three, the first one (which approximates the conventional definition of “mindfulness”) is primary. You can always be with the mind, but you can’t always reduce the negative or grow the positive.

What guidelines would you suggest to determine the moment when it feels like it’s time to move from letting be to letting go or letting in? And how do you differentiate releasing the negative or building positive resources from defensive avoidance?

I’ll try to respond to both of your questions together, since they are the two sides of one coin.

Your question is very important, how do we know when it is best to stay in “being with” (or “let be”) mode – simply witnessing our experience in open, spacious, accepting, curious awareness – and when is it best to shift into “working with” mode, either through releasing the negative (let go) or replacing it with something positive (let in).

I don’t think there is an ultimate right answer, it is more a matter of what is right for this person with these capacities with this pain at this time. For me, some guidelines:

  • Does the person tend toward being with or working with? So it could be good to lean the other way, or at least be skeptical of what is habitual. Personally, my strong suit was working with and I didn’t like being with my feelings. So I had to push the pendulum the other way for balance, and focus for a while on simply accepting and experiencing my experience without trying to shift it.
  • On the other hand, some people might be very good at observing their experience, but the garden of their mind is still full of weeds – some fear and anger, frustration and disappointment, envy and shame – that they haven’t pulled and plus it lacks some flowers – some self-compassion, determination, anxiety skills, gratitude, sense of accomplishment, lovingkindness, or self-worth – that they could have grown. Spiritual bypass. Or even, as you mentioned, they could be invested in their narrative or in the “secondary gain” from staying stuck in their pain. These people would benefit from more wise effort, as the Buddha put it long ago.
  • Second guideline: Are you learning and growing and changing for the better from simply being with your experience? If so, great. But if not, if it’s same ol’ same ol’, then it’s probably time to move on, to letting go and letting in.
  • On the other hand, are your efforts to release the negative and replace it with something positive not bearing fruit? Then probably you need to go back to being with your experience, and feel it more fully, in your whole body . . . and in particular investigate and open to its deeper layers, the more vulnerable, more fundamental, younger layers of this material.
  • Third guideline: Do you need to build resources inside in order to be able to be with your experience? Resources like self-compassion, observing ego, steady mindfulness, and understanding why it is actually good to open to your own pain. Without these resources, opening to your feelings can be like opening a trap door to hell. Therefore, how would it serve the first way to engage the mind – just being with it – by starting with the third way to engage the mind: growing inner strengths that would help you sustain accepting mindfulness of your difficult experiences?
  • In actual practice, often there is a little movement in the mind in which we accept our experience and open to it . . . and then quickly call up some resource inside (a mini working with the mind) and then go back to being with one’s experience, but now more able to stay with it.
  • Fourth guideline: What can you bear? A little pain can go a long way. Be kind to yourself. Sometimes what works is to touch the suffering lightly – simply being with it – and then move on to something else. And then come back to the negative material later.
  • Final guideline: As a person’s practice and well-being matures, as they increasingly internalize positive experiences of core needs met (safety, satisfaction, and connection), there is less and less underlying sense of deficits or disturbances – drive states – that lead to suffering. So there is less and less need to work with one’s mind, and there is a natural growing focus on simply being with it, opening into awareness itself and a sense of intertwining with allness. At this stage of practice, working with the mind becomes increasingly subtle and being with the mind increasingly becomes the central feature of practice.

Of course, this stage of practice is the result of a lot of working with the mind. And it would be unskillful to try to bypass it.

I understand the benefits in the effort to be happy and at peace, but how does one deal with the sadness in life. How do I reconcile awareness of suffering with a feeling of well-being?

First, I try to develop my capacity to sit in both compassion and equanimity, opening the heart to pain while also being undisturbed in my core about it. A long-term project in my case, to be sure!

Second, I try to see the whole mosaic of reality, which includes both beings that will be harmed and beings that will be loved. Recognizing the good (using that word loosely) does not mean not recognizing and feeling moved by the bad; and seeing the good can help us bear and sometimes improve the bad.

What can I do if I get flooded with thoughts or painful feelings, even traumatic ones, when I try to meditate?

It’s important to build up inner resources for meditating. Buddha’s Brain focuses on inner resources, especially the fourth chapter on taking in the good.

A quick suggestion would be to find something that is reliably comfortable and peaceful in your experience – such as the breath, or an object of beauty, or a saying – and use that as your meditation anchor. Maybe while standing or walking, to reduce the dissociation. And keep disengaging from painful thoughts; don’t fight them, ignore them. And from time to time look at them categorically; in other words, see their nature, the nature of all experience, all phenomenology: transient, made of parts, arising and passing away due to causes, insubstantial, an unreliable basis for lasting happiness; seeing them in this way, they have less weight.

I suffer from GAD (generalized anxiety disorder) from a trauma I sustained two and a half years ago. I have tried to be 'kind to my amygdala' as I have learned from extensive reading that this part of my brain is responsible for my tension and pain. I have several conditioned responses I'm working through but I am having difficulty forming new neural pathways. What can I do to calm my nervous system and activate the parasympathetic nervous system?

Overcoming trauma can be difficult and here are some options that may help (some of which you might already be pursuing):

  • Take good care of your body. When a person does mental interventions with limited results, that naturally suggests a focus on the “hardware.” Options include exercise, nutrition, “nutraceuticals” (e.g., 5-HTP), a general health check (e.g., thyroid, other hormones, anemia), and possibly medication.
  • Really really repeatedly “take in the good” of experiences of calming, relaxing, recognizing that you are alright right now, protection, safety, and support. Use the Foundations of Well-Being program resources, especially the Learning and Calm pillars, also my book Hardwiring Happiness. The brain needs repetition, but with repetition it really will learn and change for the better.
  • Emphasize self-compassion. Check out Kristen Neff and Christopher Germer.
  • Try biofeedback based devices/programs like Heartmath to train your body (e.g., heartrate variability, vagal tone) to be calmer.
  • Try mindfulness, including brief practices such as with Headspace.
  • Most of all, be reassured that you really can feel better. It will take work, but altogether what I have written here is less than half an hour a day (of course, you can give it more time if you want), plus the work itself is sweet: it feels good to do it, and you can know that you are really helping yourself along the way.

I do not understand how “the fabric of this suffering” is the underlying operating of the mind. If we feel worry, pressure, or pain, how could the underlying operating of the mind be fine?

Thank you for this question. You have zeroed in on a big matter that I tried to describe in one small sentence!

What I was trying to say is that the contents of mind – anger, worry, pleasure, thoughts, perceptions, sensations, desires, etc. – are a part of the mind that may be troubled (even horribly so), but mind as a whole – including the awareness aspects of mind – is usually operating just fine.

So shifting awareness from the contents of mind to mind itself (as a whole) – put differently, shifting awareness to experience as a whole, including its awareness elements – can disengage us from upsetting thoughts and feelings and ground us in a reassuring sense of mind as a whole.

Try this experientially and see what you find. The sense of mind as a whole can be hard to sustain, but keep at it and it will get more stable. Also note that as soon as we (naturally) create a concept of mind-as-a-whole, that conceptualizing is a part of mind-as-a-whole and draws us out of it as a whole. Conceptualizing is OK, but keep letting go of it to open into again and again mind-as-a-whole.

Dr. Ramani Durvasula is a licensed clinical psychologist, author, and expert on the impact of toxic narcissism. She is a Professor of Psychology at California State University, Los Angeles, and also a Visiting Professor at the University of Johannesburg.

The focus of Dr. Ramani’s clinical, academic, and consultative work is the etiology and impact of narcissism and high-conflict, entitled, antagonistic personality styles on human relationships, mental health, and societal expectations. She has spoken on these issues to clinicians, educators, and researchers around the world.

She is the author of Should I Stay or Should I Go: Surviving a Relationship With a Narcissist, and Don't You Know Who I Am? How to Stay Sane in an Era of Narcissism, Entitlement, and Incivility. Her work has been featured at SxSW, TEDx, and on a wide range of media platforms including Red Table Talk, the Today Show, Oxygen, Investigation Discovery, and Bravo, and she is a featured expert on the digital media mental health platform MedCircle. Dr. Durvasula’s research on personality disorders has been funded by the National Institutes of Health and she is a Consulting Editor of the scientific journal Behavioral Medicine.

Dr. Stephen Porges is a Distinguished University Scientist at Indiana University, Professor of Psychiatry at the University of North Carolina, and Professor Emeritus at both the University of Illinois at Chicago and the University of Maryland. He is a former president of the Society for Psychophysiological Research and has been president of the Federation of Behavioral, Psychological, and Cognitive Sciences, which represents approximately twenty-thousand biobehavioral scientists. He’s led a number of other organizations and received a wide variety of professional awards.

In 1994 he proposed the Polyvagal Theory, a theory that links the evolution of the mammalian autonomic nervous system to social behavior and emphasizes the importance of physiological states in the expression of behavioral problems and psychiatric disorders. The theory is leading to innovative treatments based on insights into the mechanisms mediating symptoms observed in several behavioral, psychiatric, and physical disorders, and has had a major impact on the field of psychology.

Dr. Porges has published more than 300 peer-reviewed papers across a wide array of disciplines. He’s also the author of several books including The Polyvagal Theory: Neurophysiological foundations of Emotions, Attachment, Communication, and Self-regulation.

Dr. Bruce Perry is the Principal of the Neurosequential Network, Senior Fellow of The ChildTrauma Academy, and a Professor (Adjunct) in the Departments of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine at Northwestern University in Chicago and the School of Allied Health at La Trobe University in Melbourne, Australia. From 1993 to 2001 he was the Thomas S. Trammell Research Professor of Psychiatry at Baylor College of Medicine and chief of psychiatry at Texas Children's Hospital.

He’s one of the world’s leading experts on the impact of trauma in childhood, and his work on the impact of abuse, neglect, and trauma on the developing brain has impacted clinical practice, programs, and policy across the world. His work has been instrumental in describing how traumatic events in childhood change the biology of the brain.

Dr. Perry's most recent book, What Happened to You? Conversations on Trauma, Resilience, and Healing, co-authored with Oprah Winfrey, was released earlier this year. Dr. Perry is also the author, with Maia Szalavitz, of The Boy Who Was Raised As A Dog, a bestselling book based on his work with maltreated children, and Born For Love: Why Empathy is Essential and Endangered. Additionally, he’s authored more than 300 journal articles and book chapters and has been the recipient of a variety of professional awards.

Dr. Allison Briscoe-Smith is a child clinical psychologist who specializes in trauma and issues of race. She earned her undergraduate degree from Harvard and then received her Ph.D. in clinical psychology from the University of California, Berkeley. She performed postdoctoral work at the University of California San Francisco/San Francisco General Hospital. She has combined her love of teaching and advocacy by serving as a professor and by directing mental health programs for children experiencing trauma, homelessness, or foster care.

Dr. Briscoe-Smith is also a senior fellow of Berkeley’s Greater Good Science Center and is both a professor and the Director of Diversity, Equity, and Inclusion at the Wright Institute. She provides consultation and training to nonprofits and schools on how to support trauma-informed practices and cultural accountability.

Sharon Salzberg is a world-renowned teacher and New York Times bestselling author. She is widely considered one of the most influential individuals in bringing mindfulness practices to the West, and co-founded the Insight Meditation Society in Barre, Massachusetts alongside Jack Kornfield and Joseph Goldstein. Sharon has been a student of Dipa Ma, Anagarika Munindra, and Sayadaw U Pandita alongside other masters.

Sharon has authored 10 books, and is the host of the fantastic Metta Hour podcast. She was a contributing editor of Oprah’s O Magazine, had her work featured in Time and on NPR, and contributed to panels alongside the Dalai Lama.

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