Access to the PPM Journal and newsletters is FREE for clinicians.
15 Articles in Volume 21, Issue #4
Advanced Practice Matters: Needs Assessment in Pain Management Training
Analgesics of the Future: Novel Capsaicin Formulation CNTX-4975
Ask the PharmD: How to Improve Medication Adherence in Chronic Pain Management
Behavioral Medicine: Applying Mindfulness-Based Stress Reduction for Comorbid Pain and PTSD
Case Report: Multimodal Management of Osteoarthritis
Commentary: The PCP's Role in Preventing Chronic Back Pain
Guest Editorial: Structural Racism in Pain Practice and How to Combat the “Hidden Curriculum”
Hypermobile Ehlers-Danlos Syndrome: An Update on Therapeutic Approaches for Pain Management
Male Clinicians as Allies in Women’s Leadership: What Your Female Peers Want You to Know
Meet the Women Changing Pain Medicine
Perspective: It’s Time to Advocate for Early Interventional Pain Management
Research Insights: Is Spinal Fusion Surgery Being Overused in Back Pain Care?
Tips from the Field: Treating Pain in an Under-Resourced State
Utilizing Music Therapy to Manage Chronic Pain
Woman to Woman: Leaders Share Advice for the Next Generation of Pain Medicine Clinicians

Behavioral Medicine: Applying Mindfulness-Based Stress Reduction for Comorbid Pain and PTSD

Using body awareness, mindfulness meditation, and movement, MSBR can raise a person’s distress tolerance and alter their pain response.

It’s easy to accept a pleasant experience. An unpleasant experience, however, such as pain or trauma-related distress, can trigger thoughts, feelings, and physical sensations. When this occurs, the body may employ defense mechanisms to repress, distract, and project – in other words, anything to avoid the unpleasantness of the moment.

A core aspect of “mindfulness” is acceptance of one’s experience in the present moment. Mindfulness is an exercise in just noticing, or nonjudgmental awareness, which has been shown to have numerous biopsychosocial benefits – including to reduce symptoms of chronic pain and post-traumatic stress disorder (PTSD).

What Are Mindfulness-Based Interventions?

There are several types of mindfulness-based interventions, described below:

  • mindfulness-based cognitive therapy (MBCT)1
  • primary care brief mindfulness training (PCBMT)2
  • mindfulness-based exposure therapy (MBET)3
  • other mantra-based meditation training programs4

MBCT combines ideas of traditional cognitive therapies with meditative practices aimed at cultivating mindfulness. PCBMT was developed for primary care when patients present with symptoms consistent with subthreshold or diagnostic-level PTSD. MBET is a non-trauma-focused intervention that incorporates mindfulness training and in-vivo exposure. Mindfulness-based stress reduction (MBSR) is considered one of the original mindfulness-based interventions. It has been modified to be offered virtually,5 which has been useful throughout the COVID pandemic, and more importantly, has served to inform other mindfulness approaches, such as trauma-focused therapy.6,7

Which Disorders Do Mindfulness-Based Interventions Treat?

Jon Kabat-Zinn developed MBSR in 1979 for patients with treatment-resistant, chronic pain.8,9 He adopted the Buddhist wisdom that was initially developed to help deal with the distress of long meditations, where the body experiences discomfort from being in one position for an extended period of time. Kabat-Zinn reported feeling somewhat “called to create” the intervention for patients with treatment-resistant, chronic pain. MBSR has been found to be effective at reducing the adverse impact of chronic pain from migraine,10,11 the lower back,12-17 and other mixed conditions.18,19 Specifically, MBSR can increase psychological distress tolerance20,21 (ie, the ability to tolerate or withstand distressing emotional or physical states such as pain) and selectively alter the unpleasantness of pain.22 The technique has also been found to be effective at reducing the adverse impact of psychological conditions, such as PTSD.23

The most widely used of the mindfulness-based interventions, MBSR uses an integrated mind-body approach that aims to increase mindful attention in order to help patients better recognize when coping and/or pain management skills are needed.

This paper reviews MBSR and its impact on distress tolerance for patients with chronic pain. See also, using CBT and ACT in primarey care as part of chronic pain management.

Mindfulness-based stress reduction can reduce distress tolerance for people living with chronic pain. (Image: iStock)


Top-Down versus Bottom-Up Interventions

Predominately, treatment as usual in a psychological setting is delivered through a didactic, cognitive/top-down approach such as with cognitive-behavioral therapy (CBT).24 Its credence is that when patients are anticipating or experiencing pain, maladaptive thinking (ie, catastrophizing), activates the sympathetic nervous system. This system is responsible for stimulating activities associated with the fight-or-flight response, which then inhibits access to coping mechanisms stored in the frontal cortex.

Essentially, patients with chronic pain do not lack coping skills but instead lack access to the skills during sympathetic nervous system activation.25 While MBSR does offer top-down, cognitive-based interventions, it uniquely also offers bottom-up interventions. These interventions start in the body and engage the parasympathetic nervous system, which is responsible for stimulation of activities that occur when the body is at rest. Its action is described as being complementary to that of the sympathetic nervous system.

How MBSR Works in Pain Management

Mindfulness-based stress reduction uses a combination of body awareness, mindfulness meditation, and movement/yoga to help people become more mindful and accepting of the present moment.

Body Awareness

Bottom-up treatment interventions, such as MBSR, have a somatic focus and are informed by mindfulness. Mindfulness is not only the practice of paying attention to the present moment, but also of noticing information through the senses without appraisal.26 Attending to the physical senses helps patients gain awareness of their body and its sensations. Increased somatic awareness helps the patient notice signals of distress earlier, making it easier to intervene with coping mechanisms before feelings overwhelm thinking. Furthermore, connecting with the body helps to desensitize catastrophic reactions to bodily sensations. This response can lead to better distress tolerance, a reduction in pain-related catastrophizing, and increases in wellness across several outcome variables.

Mindfulness Meditation

In addition to somatic awareness, MBSR has a cognitive component. Mindfulness training instructs attention toward thoughts/self-talk without appraisal. Mindfulness practices assert that the self is not comprised of impermanent thoughts, but rather the self is the curious observer of the thoughts. MBSR facilitates the curious, nonjudgmental observer, and challenges the often-enmeshed relationship between thoughts and the self by encouraging a detached observation.27 Through this awareness, patients report increased wellness and quality of life.19,21

Focused attention is an important component of mindfulness.28 Focused attention is the practice of concentrating attention on one thing and noticing when attention moves from the target. Focused attention is required to notice somatic sensations and patterns of thoughts. MBSR includes exercises and trainings that aim to increase focused attention. The breath is the usual, initial object of focus. Once mindful breathing has been introduced, mindfulness practices can be generalized to other behaviors and practices like walking, eating, and even washing dishes or mowing the lawn. Further, MBSR instructs a nonjudgmental observation. Together, focused attention and nonjudgmental awareness make up the very basic components of mindfulness.28,29


Research identifies the importance of movement and the breath-based yoga components in MBSR. A meta-analysis of 17 studies investigating MBSR in a sample of patients with chronic pain found that those studies including the yoga component had favorable outcomes compared to those that did not.12 Theoretically, yoga is a more accessible way to introduce one-mindedness through its use of the body with movement, pose cues, and practice focusing attention in the present moment using proprioception.

Movement can also facilitate distress tolerance through gradual exposure to poses that challenge the body. Increases in distress tolerance have been found to explain some of the effectiveness of MBSR.21, 30,31

Distress Tolerance and Pain Management Factor Models

Distress tolerance is comprised of two subtypes: physical and psychological. The subtypes from this two-factor model have been supported in the research as two separate constructs, and lower psychological distress tolerance has been found to be associated with lower physical distress tolerance.32-35 These findings suggest that psychological tolerance is an important precursor to physical distress tolerance.

The Role of Mindfulness in Pain Reduction

Mindfulness has been found to mediate distress tolerance,21,30 and has historically been conceptualized as two factors:29

  1. focused attention
  2. nonjudgmental awareness29

More recently, research has suggested an alternative four-factor model of mindfulness:36

  1. being accepting/non-reactive
  2. maintaining awareness of the present moment
  3. describing the experiences
  4. being open/non-avoidant

An investigation into the four-factor model found that both relativity of thought, which is the recognition of thoughts as ever changing, and the acceptance subscales of mindfulness, mediate distress tolerance.21 The recognition of the importance of relativity of thought is consistent with Kabat-Zinn’s description of detached observation,25,37 whereby the patient aims to watch thoughts wax and wane, seeing them as separate from the self, instead of misidentifying often negative thoughts as part of the self.37

Further, a study investigating the impact of MBSR on Type D (distressed) personality dimensions found that mindfulness mediated improvements in negative affect and social inhibition.30

Using MBSR in Distressed Patient Populations: A Veterans Model

There are limits on the generalizability of research findings in the literature to special populations. Select populations, such as Veterans, are considered to have undergone more distress than the general population. The Veteran population is unique regarding professional competencies, military ethos, high degrees of medical comorbidities of PTSD and chronic pain, and barriers to treatment.38

Thus, the demand for complementary and integrative health within the Department of Veterans Affairs (VA) exceeds supply,39 such as time, space, funding, and staff training. Traditionally, MBSR is very resource intensive, requiring certified instructors, 2.5-hour sessions, and a daylong retreat. Past research has also shown that when one group member fails to benefit from treatment or leaves prematurely due to dissatisfaction, others in the group are likely to follow.40 These behaviors could be due to issues with the therapeutic alliance but may also highlight issues with the flexibility of the intervention. Considering the needs and resources available and concerns about attrition, a clinician may implement an MBSR intervention similar to the sample below designed by the authors (see Table I). See also, how to manage a pain practice in under-resourced, under-served areas.



The Pain MBSR Group program outlined herein is 1.5 hours/week for 8 weeks and is co-led by a psychologist trained in MBSR and a trainee. Groups are comprised of six to eight Veterans who suffer from PTSD and chronic pain. Using a group format makes the intervention more time efficient for providers, provides a mechanism for patients to learn coping skills from others, helps patients realize they are not alone, and helps them gain valuable social support from others. There is no daylong retreat with this protocol, which is a deviation from the traditional model.

Limitations of MBSR

It is true that MBSR may be an alternative method of treatment for physicians to consider that may help their patients cope with diseases, such as PTSD and chronic pain.41 However, the effectiveness of MBSR and its follow-up data has been inconclusive at times.12,42 There are several explanations for these findings. First, problems with retention and time commitment have been identified as potential reasons.43 These two concerns can be addressed, as done by the protocol delineated above, through reducing the time by one hour/week and removing the daylong retreat.

Other researchers speculate that the inconsistency among MBSR instructors contributes to the discrepancies found in research.15 Kabat-Zinn also highlights the need for an MBSR instructor who does more than follow a manualized delivery, and who also embodies the “essence” of MBSR.25 It may be that mindfulness practice done by instructors is like physical fitness in that both need regular practice to be maintained. Evidence supports a dosage effect in that more practice is related to greater gains.19 Instructors who practice mindfulness may also serve as models for this behavior.

Longitudinal RCTs will result in a better understanding of the impact of MBSR on distress tolerance. They may also help to determine the impact of group versus individual delivery, instructor influence, and movement versus non-movement based MBSR interventions. More research is also needed using MBSR with more underserved populations, especially those who are low socioeconomic status, female, LGBTQIA+ and/or Black, Indigenous, and People of Color (BIPOC). Future studies should investigate the impact of longer-term interventions that help develop lasting lifestyle changes, while considering accessibility and ease of delivery within an often overburdened healthcare delivery system.

Practical Takeaways

  • MBSR increases distress tolerance through increased use of mindfulness, specifically changing how one relates to their thoughts and through an adopted attitude of present moment acceptance.
  • Movement is important! There is empirical support for yoga as a significant active ingredient in MBSR and should be retained in MBSR informed interventions.
  • Exercising the mindfulness muscle may be a lifelong practice similar to physical fitness.
  • Future research should not consider MBSR as a brief intervention but rather as the foundation and catalyst to a lifestyle change that needs to be supported over time.




Last updated on: July 7, 2021
Continue Reading:
How to Avoid Patient Alienation When Discussing Stress
close X