Hello, everyone. My name is Kevin Bells. I'm the presenter of this webinar today. I'm an associate professor at the University of New Mexico and work primarily in the area of pain rehabilitation, which means my role as a clinical psychologist in these treatments is primarily to aid individuals with chronic pain in restoring adaptive function, getting life back on track, getting back to activities, particularly those that bring meaning and vitality and value to this business of living. My role in providing this webinar today is to introduce you to two cornerstone techniques of pain rehabilitation. These techniques are related to stress and pain, and they include both relaxation techniques and mindfulness techniques. Before I move on with the presentation itself, I just wanted to mention that this presentation is another one in the pain curriculum offered by the PCSSO, and there's more information about this curriculum and the organization itself towards the end of this presentation. My overall goals for this webinar include providing you with an introduction to historic conceptualizations of stress and how those inform our modern understanding of how things like chronic stressors, such as chronic illness or chronic social stressors, can have an impact on physical functioning and health behavior. I also want to provide some useful tools for clinicians out there in the form of a rationale for practice of relaxation and mindfulness. How might we introduce these techniques to our patients? We're going to run through one relaxation technique and one mindfulness technique, and I've also provided some resources that may be of use in the clinic. I also want to at least briefly describe what the evidence base is on relaxation and mindfulness techniques in terms of clinical utility. That review of the literature is admittedly brief and is restricted to chronic pain, but it'll hopefully give you a sense of what the effectiveness data out there for these techniques look like. Overall, what I hope is that by the end of this webinar, everyone who's listened to it will at least have some introductory knowledge on why we might use these techniques in the clinic, and we'll have groundwork for actually applying them in everyday clinical settings. I'd like to start off with just a brief overview of stress and the stress response. Historically, stress as a term was originally referred to in the study of physics. It was used to refer to internal pressures that are somehow bending or allowing a physical structure to become misshapen. The gentleman who's linked on the slide right now, Walter Cannon, is the first individual who's documented as coining this term, the fight-or-flight response. He intended this response to refer to the activity that happens both physiologically and behaviorally in organisms when they're presented with some external threats. So in essence, what Cannon was saying was that the body has a cascade of physiological events that ready the organism to either fight the organism off effectively or escape, excuse me, fight the threat off effectively or escape from it. Cannon later also wrote about how stress in humans can be conceptualized as a disruption of the normal state of affairs within the body or a disruption of homeostatic balance. So he said that these are oftentimes in humans external pressures and they disrupt what's happening inside physiologically in the body, and that this disruption can have an effect on overall functioning and on health. About 40 years later, a physiologist by the name of Hans Bellier, who was the first to use this term stress response in relation to what happens inside organisms when they're presented with a threat, was doing a variety of exercises primarily in rats but also other animals in order to try and document whether or not there was any common stress response across stressors. Part of his most salient or famous work included injecting rats with tissue extracts from various body organs, which the body responds to as a threat. And what he found was that over time, the stress response in these rats was fairly similar across the different injections of organ extract. And over time, the long-term effects of these stressors included things like chronic inflammation, some hypertrophy or some shrinking of various organs, some ulceration of body tissue, and even extended into things like, in rare cases, death or a significant reduction in activity levels in the organisms themselves. So they started to look quite psychomotor. They were quite retarded in terms of their psychomotor activity. Based on these data as well as others, he hypothesized that the stress response is composed of three primary components. And he called the overall model of these three components the general adaptation syndrome. The first stage, which he called the alarm stage, is characterized by a marshalling of the body's resources in order to effectively respond to the stressor or to the threat. So this is a fairly short phase, and it involves the rapid mobilization of the body's resources. The second stage, which he called resistance, is the longest stage in the general adaptation syndrome. And this stage is characterized by the body effectively responding to the stressor. So the resources have been marshalled. The physiological activity is responding appropriately to the stressor. But if this contact with the stress is prolonged, the organism can come into the third stage of Celia's general adaptation syndrome, which he called the exhaustion stage. At this point, the body's resources have been depleted, and this is when a lot of those longer-term bodily impacts were observed in the rats that Celia was studying. So this is when organ damage started to occur, things like mortality occurred, or that significant reduction in organism activity. In humans, of course, modern stress is different than it has been historically or than it has been with animals. And in essence, many of the stressors that we encounter today are chronic in nature. They aren't in response to some kind of acute threat or danger. Stressors tend to include things like chronic physical health conditions in a patient or in loved ones, economic or social concerns that are long-term and for which there's no clear answer. And the adaptiveness of this fight-or-flight response system that Canon talked about begins to lose its utility as the motivation of the body's resources to fight or run away begin to be misplaced or ill-placed. So the issue with these chronic stressors is that the characteristics of Celia's exhaustion stage can start to become manifest. Physical health conditions or emotional sequelae can begin. These can include things like what's listed here in the slide, so some increases in pain or discomfort. We know that with high stress system activity or high sympathetic nervous system activity, the activity of the immune system tends to be reduced and can be compromised and open the door for things like opportunistic infection. We know that individuals who have chronic stressors in their life or who are chronically stressed tend to both adhere more poorly to treatment and also retain less information about adherence when this information is provided by health care providers. Problematic substance use can result in disruption in social functioning. In other words, this whole cascade of problematic physiological and behavioral activity can occur. One of the primary things that we are going to do in this webinar is begin to discuss some skills that patients can engage in to try and reduce the long-term problematic effects of stressors. Two examples are relaxation and mindfulness techniques. This webinar is going to provide an introduction to two techniques here. Under the relaxation therapies technique heading, we're going to do a breathing exercise called diaphragmatic breathing, and we're also going to apply these breathing techniques to beginning to breathe more mindfully. What will hopefully become clear over the course of the webinar itself is that both diaphragmatic breathing and breathing mindfully may look quite similar in terms of their structure. We are essentially asking patients to do a similar thing behaviorally, but the purpose of these two exercises are likely to be subtly different, where the diaphragmatic breathing is really about increasing relaxation or decreasing stress, and mindful breathing is about aiding people in paying more close attention to what's happening in the present in order to allow them to better respond to things happening in the present. So the difference here is a bit subtle and it has to do with purpose, and hopefully I will fill in the gaps on that as the webinar progresses. I also want to take a moment and just discuss some realistic expectations here for mindfulness and relaxation techniques. As I mentioned at the beginning of my talk, these techniques or these two families of techniques form the cornerstone of a number of different psychological interventions, including pain rehabilitation, but they are unlikely to be sufficient to fully mitigate all of the negative and problematic effects that patients might be experiencing in relation to chronic illness or other kinds of chronic stressors. That being said, the advantages of these approaches or of using these approaches include the following. They're fairly easy to teach and can be done even within a fairly constrained period of clinical contact, so something like diaphragmatic breathing can be introduced in five to ten minutes and can be practiced and individuals can be sent home with some tools to practice. It can be used in these primary care health settings that tend to be very busy, as I've mentioned. These techniques offer patients a tangible tool that can be taken home and used in real-world or real-life situations, including situations that may involve contact with these acute stressors. And finally, over the longer term, when these relaxation and mindfulness therapies are practiced regularly and are integrated into a patient's or a person's regular way of going throughout their day, they can have some long-term benefit by decreasing the impact of chronic stressors or perhaps decreasing the longer-term problematic impacts of the stressors themselves. If we change topics to relaxation therapies, I want to add in here one other piece of the history, and this is some work done by Edmund Jacobson in the 1930s and 40s. Jacobson wrote a book called The Relaxation Response, and he used that term relaxation response on purpose to attempt to contrast what is happening in a body when relaxation is occurring as opposed to what is happening when the stress response or the fight-or-flight response is occurring. And in many ways, this work of Jacobson was concordant with some early psychophysiological data, including the work of Volpe, which concerned the concept of reciprocal inhibition. In essence, it's impossible to be in two diametrically opposed states at one point in time. So Volpe said things like, one cannot be anxious and stressed or anxious and relaxed, excuse me, at the same time. In essence, what relaxation techniques are attempting to do is move people more into a relaxed state because that will naturally move them out of an anxious or a stressed state. Diaphragmatic breathing, the technique that we're going to discuss today, is simple. It is a technique that tends to form the foundation of a number of different relaxation and mindfulness-based techniques. And in essence, it is moving one's belly more when they are breathing than they are moving their chest. So the next few slides here concern clinical rationale and provide a framework of introducing this to patients as well as practicing it. Rather than going through it step by step, what I'm going to do is run everyone listening here through the rationale that I would provide to patients, and then we're going to do an abbreviated diaphragmatic breathing relaxation exercise to give you a sense of what this might look like in the clinic. So when I'm introducing this technique to patients, I say the following. Most of us, when we are feeling stressed or are anxious, tend to breathe up with our chest, so our ribcage tends to expand and contract more than our belly does. And while that's a natural event, it does send a signal to the body that there is a threat out here in the environment and that the body may want to activate the fight or flight or stress response system. So in essence, breathing up with our chest can move us more into a stress response continuum. And what we're going to do is just practice the opposite of that, which is breathing with our belly. The way to do this technique is simply to breathe normally and naturally and make your belly move more than your chest moves. And the reason why this works is that there's a bit of tissue of muscle that separates the lungs from the rest of the guts, which is called the diaphragm. When we're breathing with our chest or when our ribcage is moving more, the diaphragm gets stretched up into the cavity that is filled by the lungs and allows less room for the lungs to expand into their normal cavity. What that means is that less oxygen makes it into the lungs, less oxygen makes it into the bloodstream, and that, as I've said, is a signal for the body to move into a stress response. When we breathe with our belly, the diaphragm is stretched out, which allows larger space for the lungs to expand into, allows more oxygen into the lungs, allows more oxygen into the bloodstream, and this sends a signal to the body that it's time to relax, that we can move more into a relaxation response. So those of you who are out there listening to this right now, what I'll ask you to do is just, if you're sitting, sit back in your chair. If you're standing, just get yourself in a comfortable position. Put one hand over your ribcage, up high by your sternum, and put another hand over your belly, and just take a few breaths where you make your belly move more than your chest. And as you're taking these belly breaths, just notice anything that is happening in your body, notice any responses to this. Clinically, when I introduced this technique in this way, it's fairly easy for people to make their belly move more than their chest. After doing this, I'm going to ask you to take a few deep breaths, and I'm going to ask you to make their belly move more than their chest. After doing even a brief introduction like the one that I just did, I can ask people, what responses did you have or what happened? And they might start to say things like, I felt like I was slowing down a little bit, like I was relaxing a little bit. They might begin to describe some warmth or some tingling in the extremities, and all of that is a sign of the relaxation response. And so if they do say these things, I'm trying to emphasize that they are, at this point in time, moving their body into more of a relaxed state. If that introduction goes well, I then ask them to engage in a five minute, five to seven minute exercise with me where we just practice diaphragmatic breathing. So again, for those of you who are sitting out there listening to this right now, I'd ask you to get in a comfortable position. Go ahead and close your eyes. You can put your hand over your chest and belly again if you wish, or you can just let your hands rest comfortably in your lap. And then what I'd like you to do is to just begin to breathe in this diaphragmatic way to make your belly move more than your chest. And as you're breathing in this way, I'd like you to take time to just notice what else is happening in your body as you're doing it. You may feel like you're slowing down or relaxing. You may start to feel some warmth or heaviness. And all of that's just a sign of this relaxation response occurring. All right, and because this is an abbreviated exercise for the purpose of this webinar, I'll ask you just to bring yourself back to the sound of my voice, and if your eyes are still closed, go ahead and open them. But I'd like you to reflect for yourself what it was that you noticed about this exercise, and just to keep this in mind as you're talking about patients with diaphragmatic breathing. Moving forward in the slides, as I said, the next few slides are just a summary of the clinical rationale that I provided, and this rationale has worked very well for me for years and years. It is part of the documentation that's out there for standard ways of introducing diaphragmatic breathing. So we talk about the diaphragm, it's just this tissue that separates the lungs from the rest of the internal organs, movement of the diaphragm has some influence on how much space is allowed for the lungs, and then we just make a distinction between breathing with your chest, which can activate the stress response, and breathing down with your belly, which can activate the relaxation response. I find introducing this exercise in two parts. The first part, just having someone put a hand over their chest and their belly, and then the second part, having them close their eyes and spend about five minutes doing diaphragmatic breathing, works fairly well. Again, it doesn't take a lot of time, so it is hopefully compatible with busy clinics that are out there. And at the end of the exercise, at the end of the five-minute period, which is just what's summarized in this clinical rationale three, it's important to ask participants about their experiences. So to do things like, after you've asked them to return their attention or awareness to the present, ask them what they noticed, and some common responses are listed here. Patients can say things like, that was relaxing, or I felt like I was falling asleep, I felt some warmth. Is there feeling any tingliness or dizziness in their head? That is understood as a phenomenon that occurs when more oxygenated blood is making it out to the extremities or up into the brain. And the reason for asking patients what they noticed is really to be able to do the following, to characterize this as a relaxation response that is under volitional control, in order to provide these patients the sense that this is a skill that's being developed, and if they want to use this skill of activating the relaxation response, one of the things they can do is simply take time to breathe in a diaphragmatic manner. If they found that this was beneficial, we may then encourage daily practice. We may say things like, if individuals practice and become proficient in this, the amount of time required to achieve a fairly robust relaxation response can be constrained. So people might be able to even do some relaxation techniques while in the midst of contact with an acute stressor, in order to slow down a bit, take time to gain some perspective, and then decide how to respond effectively. In addition to that, it can be useful from time to time to engage in some behavioral experiments, both before and after doing relaxation exercises, as well as the mindfulness exercises that I will provide and that we'll go over in just a moment. So we can do things like take physiological indicators of the stress or relaxation response. Measure things like heart rate before doing relaxation and after, or blood pressure or respiration rate. The data out there suggests that it's easier to get a bigger response when one measures digit temperature, just using a simple hand thermometer or one of those colorful stress cards that are out there that change colors as one is becoming more relaxed, which in essence, as one's digit temperature is increasing. And it is not uncommon to see an increase of digit temperature of several degrees up to as high as maybe six, seven, or eight degrees. And this can provide a little bit of concrete evidence of what is happening in the body as one is engaging in this volitional relaxation exercise. If that's not available or if that's not of interest, one can also do things like ask patients to rate levels of pain or stress or anxiety, both before and after the exercise. You can use a simple 0 to 10 subjective units of distress or SUD scale, where 0 indicates the absence of the phenomenon, no stress or no pain, and 10 indicates maximal experience of this phenomenon, so maximal pain or maximal stress. And these things can then be used as time goes on to give both you as a clinician, if you're asking patients to practice relaxation daily and bring you back subjective units of distress ratings, can give you as a clinician evidence of effectiveness over time, but it can also give the patient effectiveness over time and give them some understanding of how they can have an active role in regulating overall stress responding. Moving on to mindful breathing, as I said from the outset, there is a lot of similarity between breathing mindfully and diaphragmatic breathing in terms of what they look like. But the purpose of these are different. So in essence, mindful techniques or mindful breathing in this sense simply involves the augmentation of noticing ongoing present experiences and also noticing as these experiences come into our awareness and then leave our awareness. The overall rationale for this is that people can spend an awful lot of time being caught up in the future or the past, and that can come at a cost of responding effectively to things that are happening in the present. It can make people behave unwisely as they are on track of social cues or subtle environmental cues that may be urging a certain course of action, or it can contribute to missed opportunities. So individuals may have an opportunity to engage in some important, meaningful event, but because they're so caught up in some recent traumatic experience or some recent problematic experience that they may miss the opportunity to engage in this important action. So mindfulness techniques don't place as much primacy on the achievement of relaxation. They achieve greater primacy on the facilitation of awareness of the present, on acceptance of present experiences, particularly as they are related to ongoing awareness and ongoing things that are happening in the environment. It is not uncommon for mindfulness techniques to focus initially on a particular sensation or a particular activity. So for the purpose of today's exercise, we're going to pay particular attention to breathing. And from that attention on a circumscribed experience, which is breathing, over time we can build on the number of things that a patient is working on being aware of in order to cultivate more purposeful and also a greater and gentler response to ongoing experience. So just like the diaphragmatic breathing exercise, the next few slides here include a clinical rationale. And what I'm going to do is just provide you with that rationale. We're going to go through an exercise. And then I will hit the highlights of the slides themselves, but they're available for reference in the future should you need to go back to them. The way that I typically introduce mindfulness to patients is by telling stories about the utility of awareness and the disutility of a lack of awareness. So I might say something like this. Have you ever come home from a stressful day of work or school or something like that and been met on a threshold of the place where you live by someone who just started saying to you things that you found to be incredibly irritating? Or this person said exactly the thing you didn't need to hear? You've shown up with all this stress, feeling a bit strung out, and then someone showed up and said just the wrong thing. Has that ever happened? For most people, it has. How about this? Have you then let something slip from your mouth? Have you ever said something that was hurtful, that was potentially unintended, and that if you had had a moment to really think about whether or not this is the thing that you wanted to say, you may have made another decision. You may have decided not to say it because it wasn't going to achieve the outcomes that you want. Again, if I'm presenting this to patients, there's a bit of a conversation here and a normalization of this old foot-in-the-mouth technique of saying things that we didn't intend to say that led to some aversive consequences. If that conversation goes okay, I then say, what we're going to practice today is something called a mindfulness technique, and the purpose of this technique is just to give us a bit of that, a bit of space to have that moment of clarity in order to decide if what we're about to do is the thing that is in our best interest or the thing that's going to lead us in a good direction. In addition to that, what these exercises can allow us to do is notice when there are important opportunities happening outside in life, and to take advantage of those opportunities if we choose to do so. For example, it is not uncommon for someone who's really profoundly depressed to turn down invitations for social engagements. So a friend might call them and say, hey, let's go grab a cup of coffee or a beer, and a person who is struggling with depression might say something like, no, I just don't feel like it, or I'm so low today, I just couldn't possibly get out of the house. And the short-term impact of that social invitation refusal can be more distress or more depression as the person can feel like they're now missing out on an important event, but the long-term consequences can be quite significant as well, as a continued refusal of social invitation generally leads to the complete cessation of social invitations. In other words, no more social invitations are forthcoming. And again, as I'm providing this rationale to patients, I want to check in with them and ensure that they're following and understanding, and that they are at some level comprehending that this mindfulness exercise serves these dual purposes of better attending to what's happening right now, to allow better responding now, and also to take note of important opportunities that are presented in the environment so that I can decide to do them or not do them. If that rationale has gone okay, I ask people to just get comfortable in a chair that they're sitting, and I tell them what we're going to do is just focus on breathing, and that they don't have to do anything different or breathe in any particular way, but that I just want them to notice what it feels like to breathe. So for those of you who are listening to this, just like we did for the breathing exercise, if you are willing, go ahead and get yourself comfortable in the position that you're in, either sitting or standing. Go ahead and close your eyes. And I'd like you to begin to notice what it feels like to breathe. Just notice that sensation of air coming in through your nose or your mouth, filling up your lungs, and then going back out again. And when your mind wanders off, just noticing what it feels like to breathe, gently bring it back to breathing. And again, if your mind has wandered. All right, just like for the diaphragmatic breathing exercise, this one is abbreviated in the interest of this setting and venue. So I'd like you to go ahead and bring your attention back to the sound of my voice, open your eyes if you haven't done so, and just reflect on what you noticed while you were doing this breathing exercise. Were you able to notice what it feels like to breathe? If so, you did exactly what I asked you to do. If you did get distracted in there while noticing your breathing, were you able to bring your attention back to just noticing what it feels like to breathe? If so, you did exactly what I asked you to do. And then if I'm doing this clinically with patients, and again, if five, seven, ten minutes have elapsed, depending on what time allows, I ask them to tell me about what they experienced. But overall, I try and emphasize the purpose of this exercise is simply to notice breathing and notice when attention's wandered off breathing and to bring it back. So that this is an exercise that involves paying attention to where our attention is located on breathing, which is the here and now, or on something else, which is not the here and now. And if it's not on the here and now, simply to bring it back. And I'll talk more about why that might be useful in a moment here. So moving ahead to our clinical rationale, as I've said, mindfulness can allow us opportunities to engage in important stuff and to avoid doing things that we might otherwise regret. As we're more attentive to the present, we might be able to respond more effectively to things that are happening. This next slide is quite a long rationale that just summarizes a typical script of this foot-in-the-mouth example that I discussed. In the second paragraph, it's about highlighting the specific purposes for mindfulness. So it's about paying better attention to the present. We don't need to expect anything magical. This just involves paying attention to where attention is. If patients feel comfortable in the clinic, you can do this sitting, have them close their eyes. You can also close your eyes if you're the clinician leading them through this exercise. For the exercise, what we're trying to do is just cue them from time to time to notice distraction and to bring attention back. We may also expand out attention from breathing to ask people to notice things like sounds that are occurring. You can notice those sounds. Or we might ask them to notice various, hopefully mundane bodily sensations, like what it feels like to sit or what it feels like to have one's feet resting on the ground. This exercise can be fairly brief. As I've said a few times already, somewhere around five minutes seems to be a sufficient amount of time to introduce this. Periodically, as the therapist leading them through the exercise, we ask them to bring their attention back to the present. I provided here a sample recording of an introductory mindfulness session. That is the sound of my voice on there. That is free for use if you want to send a patient home with a link to this recording. There's also a sample script that is linked on the PCSSO website, which is free for everyone to use and distribute. It's not copyrighted in any way, so use it if it's useful to you or if it's useful to another provider in your clinic. Just like after relaxation exercises, it can be useful, or the most useful part of this may be in the post-exercise discussion. So after the allowed time has passed, we might ask the patient to return their attention and awareness to the here and now, either by asking them to notice the sound of our voice or by opening their eyes and just looking around the room a bit. Many common experiences that are noted, what people notice, can be similar to what they notice following diaphragmatic breathing. I felt more relaxed, I felt like I was falling asleep, I feel a little bit warmer or heavier or a bit more tingly. And while those experiences are perfectly acceptable and are good, it can be useful for clinics to really highlight for patients what the purpose of mindfulness exercises are. And the purpose here really is to maintain an awareness on what's happening in the here and now so that we can more effectively respond to what's occurring in the here and now. So all of those beneficial relaxation response effects are certainly acceptable and are welcome as an effect. But there's another one here that we want to cue patients into, which is noticing what's happening in the here and now. In addition to that, the patient might notice that they noticed what it felt like to be relaxed. That can be a source of important clinical conversations. We may want to highlight that distraction was perfectly normal and appropriate to be expected. But the key in doing this exercise is to notice when one was distracted and then to bring their attention back to the here and now so that if they're able to notice breathing and to notice distraction and bring attention back to breathing, they did exactly what we wanted them to do or what we asked them to do. May also give rise to some discussion of the potential utility of being more present in the patient's life. And the exact course of this conversation is likely to be idiosyncratic based on patient circumstances. But if someone is profoundly anxious and tend to spend their time worrying about what might happen in the future, there may be the opportunity to have a very fruitful clinical discussion on the importance of attending to the here and now because that may allow them to gain a better quality of life, may allow them to better avoid certain threats in the environment or certain anxiety-provoking events. It may also allow them some space to interact with anxiety in a more mindful way, in a way where they are aware of the anxiety, but not necessarily letting it make decisions for them. That kind of a conversation is a conversation we have very frequently with the chronic pain patients who we see within our clinic that the utility of mindfulness is not really in the pain reduction it might afford, but in its ability to help folks be less distracted by pain and more plugged in to important things that are occurring in their life. I want to spend a bit of time also talking about contraindications for both relaxation and mindfulness therapies. These contraindications are fairly well described in the literature, and while they're uncommon, they can be uncomfortable. So from time to time, patients can have a so-called paradoxical effect where they experience more anxiety as a result of a relaxation technique, or they're more distracted by some anxiety-provoking memory or worry than they would otherwise be normally in practicing this mindfulness technique. If this does happen clinically, and again, it's pretty rare, the appropriate clinical response is to normalize it and to say that it happens from time to time, also to try and identify the cause of the paradoxical effect. Across the literature, the paradoxical effect most often occurs in individuals who are highly anxious and who are worried about losing control over their body, or who are so used to being teed up and anxious all the time that any change in what they feel can be viewed as a problem or a threat or a circumstance that one ought to become more anxious about. And so if in a clinical discussion of this paradoxical effect, what becomes clear is that someone has a significant anxiety disorder or is experiencing symptoms of post-traumatic stress disorder or something of that ilk, an onward referral to a mental health care provider is certainly appropriate, in addition to things like normalizing, trying to uncover why this paradoxical response occurred. Moving to the last part of my webinar, as I noted at the onset, I just wanted to very briefly go over the evidence base for relaxation and mindfulness as they're applied to chronic pain specifically. Most of the literature that's out there for relaxation is for chronic pain or anxiety, and the evidence is fairly concordant across these two literatures. In 2010, Emmett Dunford and Miles Thompson published a review of the effects of relaxation in pain, and essentially what they found was summarized here in this bullet point, that relaxation has reasonably good evidence of pain reduction over the shorter term, but that there was not strong evidence that this pain-reducing effect was maintained over time. About a decade before that, a committee from the NIH also made a statement about the utility of relaxation techniques for chronic pain and insomnia, and essentially said the same thing, that relaxation techniques have good evidence of at least short-term effect when it comes to things like pain reduction and aiding with sleep onsets. The evidence for mindfulness is, the evidence base, excuse me, for mindfulness is younger than the evidence base for relaxation, but there have been a number of recent studies and recent reviews that have synthesized the evidence base of mindfulness for chronic pain. In 2015, a narrative review was published in the British Journal of General Practice, which indicated that the mindfulness studies that were out there for chronic pain had a lot of heterogeneity. In other words, there were a lot of outcomes used, and the effect sizes were quite different across different studies. There was a call for better quality studies, and these investigators said, in general, controlled studies show weaker effects, weaker beneficial effects than non-controlled studies. In 2014, we performed a review of treatment studies for chronic pain, and in essence, what we thought the literature suggested was when mindfulness techniques are used in conjunction with other behavior change techniques, such as cognitive behavioral therapy or acceptance and commitment therapy, these techniques tended to have reasonable evidence of overall efficacy. So that mindfulness alone may not give you a large beneficial effect, but when it's combined with other behavior change therapies, there seems to be reasonable evidence. And that conclusion of that paper is concordant with a recent meta-analysis just published in March of this year, which continued to indicate large heterogeneity in effect sizes, but in general, what these researchers found in the meta-analysis was that behavior change therapies plus mindfulness seems to have a larger effect size than mindfulness alone. So as I said at the beginning, it's unlikely that the addition of relaxation or mindfulness therapy is going to be sufficient for all humans who are experiencing chronic illness or chronic stressors, but these therapies, again, are teachable, they're portable, and they can be used and can potentially provide a foundation upon which other more intensive behavior change therapies can be built. With that out of the way, I'll just provide my citations, which are numbered throughout this webinar, and I'll also highlight the final two informational slides here about the PCSSO organization. This first slide gives information on a colleague support program, which is a one-to-one support program that can be offered to members or interested parties. In addition, there's a Listserv where public input or public support can be garnered, quick questions can be answered over the Listserv, and it's quite active and supportive. If you're interested in being added onto the Listserv, there is an email address at the very bottom of this slide, PCSS-O at AAAP.org. If you email that address and request that you be added to the Listserv, you will be. Finally, this PCSSO training is supported by a large consortium of professional organizations. More information about these organizations can be found on the PCSSO website or by emailing the address there or by subscribing to their Twitter account. So with that, I'll thank you very much for your time and attention. I hope that this is a useful introduction to these two techniques and a useful introduction to how they might be used clinically. If questions do arise, I'm very happy to be contacted either through the PCSSO organization or through my email address. If you look up Kevin Vells at the University of New Mexico, I'm the only one, so feel free to email me. Thank you. And with that, I'll draw this webinar to a close.

pain rehabilitation

relaxation techniques

mindfulness techniques

chronic stressors

diaphragmatic breathing

present moment

evidence base

behavior change therapies