INSPIRE Program

Welcome to Week 1 of the UCSF INSPIRE pain management program. We are grateful that you've chosen to join us on this journey. We understand that your time is valuable, so we want to make the most of the time we spend together. Over the past couple of years, we have worked closely with your community to create this mobile app. This app provides mind-body interventions and connects you with a pain management coach who will support you each week. In addition to the weekly program, you can also access the library, your personal materials, and a full list of mind and body exercises through the buttons on the home page. For this week, Week 1 of 12, we will begin by setting the stage and discussing how we can have the right mindset to make the most of the program. We will then explore three short "Lessons" that show the connections between the mind and body in relation to pain. We'll include patient stories and a video featuring a patient's experience. To help you try out the skills, we will provide suggestions for practicing these exercises on your own. Remember, you'll have your first telehealth appointment with your personal coach in the upcoming week. If you haven't scheduled it yet, we'll reach out to you to find a convenient time. So let's roll up our sleeves and dive into Week 1. Together, let's find inspiration and embark on your journey of healing and growth.

It is likely that you have been coping with chronic pain for a long time. It's also likely that you have multiple different types of pain. You may have tried a lot of different treatments and have probably seen a lot of doctors and other pain specialists. You know there is not any "magic solution" but you also might have found a few things that help -- at least a little. We are hoping you are willing to roll up your sleeves with us and try out some mind-body exercises like meditation, breathing, looking at thoughts, stretching, and movement. It's okay to have doubts about what will work but we hope you will first try things out and see how they work for you this time -- even if you have tried them before. Some of the exercises might bring up negative feelings or painful memories, but we encourage you to work through these with us. You just might find relief on the other side. We can't predict exactly what will work best for you, so we will have to try a lot of different things out before we land on just the right thing. If something doesn't work, don't get discouraged. We will try something else out. We are grateful you are joining us and look forward to helping you find a better tomorrow.

Your pain is real, and it affects many parts of your life. We understand because we've been through chronic pain too and talked to many people like you. Our goal is to give you tools to manage your pain and live your best life.

In this program, we will teach you techniques for both your mind and body. The "mind" is how you think, feel, and believe, including your spirit or "heart." The "body" means your muscles, joints, flexibility, and endurance. Your mind and body are connected and affect each other. Pain in your body also affects your mind, and pain in your mind affects your body. This program will help both your mind and body feel better. Practices like meditation, deep breathing, and cognitive behavioral therapy (CBT) can help calm your mind, reduce stress, and manage pain.

Movement, when you find the right program for you, can increase flexibility, strength, and stamina. When your body feels better, your mind finds peace.

Everyone has felt pain, but not everyone understands chronic pain. Chronic pain can trap you in a negative cycle. Many people with chronic pain fear that moving will make it worse, so they move less, which can make their pain worse. This cycle also creates negative thoughts and emotions like depression and frustration, making us avoid activities and people. When our body feels bad and we have negative emotions, it becomes very stressful, which makes our pain worse.

But it doesn't have to be this way! We can break the cycle by staying active. It's okay to have doubts, but work with us for the next 12 weeks and see what happens. Let's hear stories of real people with chronic pain and see how this program can help you.

Hi, I'm Benjamin. I'm a teacher at Lincoln High School here in San Francisco -- mostly history and social studies. I just turned 44 but I've been dealing with chronic low back pain for almost 10 years now. Luckily, I can now work full-time and do most of the activities that are meaningful to me but that wasn't always the case. I started having this intense pain in my lower back that would shoot down my left leg. I had no idea what was going on until I got an MRI and they said the bones in my lower spine were collapsing and crushing my nerves. Some days, I couldn't even get out of bed. I remember literally having to crawl on my hands and knees to get to the bathroom. I was 35 at the time and felt like I was an invalid. I went out on temporary disability, started medications, and got referred to a surgeon who was injected steroids into my spine. All this helped but only a little. I went back to work but was using a walker on bad days -- 35 years old and using a walker. Man, I was depressed and getting pretty hopeless.

It totally killed my social life and dating was completely out -- and I'm still single to prove it. My friends and family -- who are locals -- were supportive but they didn't really get it. They thought I complained too much so I just stopped talking about it. My frustration with this disease led me to spend hundreds of hours learning as much as I could about chronic pain and strategies that might work to cope with it. I kept coming across meditation as something that has helped people deal with pain but I was pretty skeptical at first. After a few false starts, about three years ago I decided to give it a serious try by taking a class and listening to some guided meditations online. I have been meditating almost daily since then, and it has become my most important coping strategy. It's hard to explain but I just feel the stress leaving my body, like I settle into it and can just let go.

Meditation and mindfulness have taught me that, while the physical sensation may be unavoidable, the feelings and thoughts that flow from the sensation -- and all that extra tension and stress - are under my control. It's like I worry less about things I can't change and I'm able to better accept my limitations without being bitter or angry about them. Now, after three years of using meditation for pain management, I believe that it truly helps. I didn't realize the extent to which my mind, like my body, can improve, expand, and even heal with 20-30 minutes a day of meditation. It has been a fascinating and worthwhile path and I am grateful that I found it.

Next we want to introduce you to Sophia. Sophia used to work as a nurse's aide at San Francisco General Hospital. She's married, has 3 adult children ranging in age from 26 to 32, and she celebrated her 58th birthday last month. She initially reduced her work hours to care for her family then quit work entirely when her mother developed dementia and needed a caregiver. After her mother passed away and her kids left home, she finally started paying attention to her own health. She noticed she hurt all the time all over and even the slightest activity could trigger a fl are-up. After many medical workups, she was diagnosed with fibromyalgia and arthritis. She is suffering from chronic pain throughout her body. She is going to tell us why movement was her best coping tool and how it helps her physically and mentally.

Hi I'm Sophia and I'm 58 years old. I've had chronic pain for about 18 years now. It's hard to remember life before chronic pain but I guess this is what I have to deal with. I got diagnosed with fibromyalgia and arthritis and neither are really curable. At first, the doctors gave me a lot of pain pills but they made me pretty loopy and too tired to really do anything -- and besides, I was still in pain even with all those pills. I've tried acupuncture, herbal remedies, meditation, and massage. They helped a little but they were kind of expensive and not covered by my insurance. My husband was really sweet at first but then he sort of withdrew. He has his own issues with back pain and headaches but doesn't talk about it. I used to work as a nurse's aide but after several years of suffering, I just wasn't really able to work anymore. It was up to my husband to pay all the bills which put a lot more stress on both of us. My kids were pretty young when this all started and there wasn't much they could do so it was up to me to figure it out.

My real breakthrough came from joining an online fibromyalgia group. It was all women who understood what I was going through and many of them had some really good advice. I learned that any movement is better than nothing even if it's just walking around the block or doing the laundry. I learned about pacing myself and spreading activities over several days so I wouldn't get so wiped out. I found some really good gentle yoga videos on YouTube and learned some good tips about deep breathing and stretches to loosen up my joints to stay limber and less prone to get injured.

The thing that really surprised me is that taking better care of my body really affected the way I was feeling. I was less depressed. I was less stressed. I felt more hopeful. I was doing something that was making a difference and it was as simple as finding a movement and exercise program that worked for me. I still have chronic pain and I still get discouraged sometimes but movement works -- at least it did for me. Just keep looking and trying out new things. Something will be right for you.

So far, we have been learning about the connections between the mind and body and how they relate to pain. We also started following the stories of two patients who we will see throughout the course. Benjamin used mindfulness, while Sophia used movement exercises to cope with her chronic pain. But you don\'t have to take our word for it. There is a lot of research that shows how techniques like meditation, stretching, and movement can really help you manage your pain. If you click on the library icon on the home screen, you can find articles, websites, and summaries that describe the effectiveness of these approaches. Now, let\'s hear from another patient who actively used these techniques and learn about their experience.

Now that we've heard from people living with and managing their chronic pain, let's talk about mindfulness and meditation. Mindfulness is about paying purposeful attention to what is happening in the present moment without judgment. Mindfulness acknowledges and accepts that there may be worrying about the future, stressing about the past, or getting tied up with daily distractions. When that happens, we learn to observe, accept, and react with kindness. 9 When it comes to chronic pain, mindfulness can help us feel grounded, more focused, and more able to do the work that needs to be done. There's a great deal of research that has shown that mindfulness meditation can reduce pain and improve the overall quality of life for people experiencing chronic pain.

For example, studies have found that mindfulness meditation can not only decrease pain intensity and make pain feel less bothersome, but also reduce feelings of stress and anxiety. By practicing mindfulness, we can learn to observe pain without getting caught up in negative thoughts or emotions. This can create a sense of distance from the pain and allow for a more peaceful and accepting relationship with it. Instead of "giving up", mindfulness helps us step out of the downward spiral of chronic pain.

But how does mindfulness work? One theory is that mindfulness changes the way our brains process pain signals. It activates certain brain regions involved in attention and emotion regulation, reducing the experience of pain. Mindfulness can also bring about relaxation, lowering heart rate and promoting a sense of calm. It's sort of like the opposite of a stress response.

In summary, mindfulness is a practice of being fully present in the moment, and can be a valuable tool for managing chronic pain. Through mindfulness meditation, people can have a reduction in pain intensity and an improvement in their well-being. The practice helps to change the brain's response to pain and promotes a sense of relaxation. Embracing mindfulness can lead to a more peaceful and accepting relationship with chronic pain, ultimately enhancing your quality of life.

Let's go back to our patient, Benjamin, and see how this worked for him.

Hi, It's me Benjamin again. Last time, I talked about how I decided to give meditation a serious try and how it really helped my chronic pain. Through meditation and mindfulness, I discovered that although I can't make the physical sensations go away, I do have power over how I feel and think about them. With practice, I am better at making sure I don't let my thoughts and emotions that arise from the pain to determine my behaviors Since I've been practicing for a while now, I have found specific meditation techniques that can help me change, or even reduce, my physical sensation of pain. For example, when I'm in pain, I try closing my eyes and concentrating on a part of my body that feels good -- even if it is just feeling the breeze on my face or the sensation of a comfortable shirt on my arm. Each time, I found that the feeling of pain goes down. I can also do the opposite and focus intently on my pain but with a sense of curiosity. Asking questions like: What exactly does my pain feel like? Where exactly is it located? What is the shape of the pain? How does it change from minute to minute? I notice that it does change, and this realization itself can make the pain easier to bear. I have found around a dozen approaches like this that can help with pain and I now use them routinely when my pain is at its worst.

These days, I've found that meditation is more accessible than ever. There are many apps, videos, and classes that can help people start mindfulness practice right away, anywhere, and anytime. I was skeptical at first because it didn't seem like it could possibly work for something like back pain. But after a serious try, meditation has definitely become my best way to manage pain. Give it a try and see what happens. It worked for me and it might work for you!

Now that we've heard an example of how meditation was helpful for a patient with chronic pain, let's get in a little practice ourselves. There are lots of different types of meditation and you might have tried some before. Keep in mind that it takes most people -- even Zen meditation masters -- several tries before it really clicks. To keep it easy, we are going to start with what's called the 3-minute breathing space. It is literally only 3 minutes so you don't have to invest a lot of time. When we get to some suggested practices later, we will give you a selection of different, slightly longer meditations to choose from.

The 3-minute breathing space is a simple yet powerful practice taken from mindfulness-based cognitive therapy. This exercise is designed to help you bring your attention to the present moment and create a sense of calm and clarity. By taking just a few minutes for yourself, you can cultivate a greater awareness of your thoughts, emotions, and bodily sensations. It involves 3 simple steps -- settling into mindful awareness, focusing on your breath, then expanding your awareness to include your whole body. Remember, this exercise can be practiced anytime, anywhere. Whenever you need a moment of pause and inner stillness, come back to this 3-Minute Breathing Space. It is a valuable tool for grounding yourself in the present moment and nurturing your well-being.

Things to remember 💡

• New skills take time and practice to learn
• You don't have to be perfect. Only have 1 minute? Try the recommended exercise for one minute. That's ok!
• Were your thoughts still racing? That's ok too. We will try longer, more relaxing meditations later this week.

💡The 3 Min Breathing Space is a quick and easy exercise you can do almost anywhere, at any time. It is simple but powerful. Follow along with the video to try it.

Congratulations on completing the 3-minute breathing space exercise! Taking time for yourself and engaging in mindfulness practice is a wonderful way to nurture your well-being and address your chronic pain. Let's discuss what you might have experienced during this meditation and address any common struggles that can arise.

First, it's important to know that meditation is a skill that develops over time with practice. So, if you found it challenging to maintain focus or stillness during the exercise, know that it is completely normal. Our minds naturally wander, and it takes time and patience to cultivate a greater sense of focus and presence.

Secondly, this was only 3 minutes so you might not have been able to really settle down into the practice or you may not have noticed much of a change in your mind or bodily sensations. This is totally ok. The more you practice, the quicker you'll get into it and the better your results will be. There are other meditations out there but remember this 3-minute quickie is one you can take out and use any time.

During the meditation, you might have noticed a range of experiences. Some individuals fi nd that their thoughts were active, with a lot of ideas, worries, or plans popping up. Others may have experienced physical sensations, such as restlessness or discomfort. Remember, there is no right or wrong experience during meditation. The goal is simply to observe these experiences with a non-judgmental attitude.

Positive reinforcement and self-compassion are key. If you found moments of peace, even if they were brief, celebrate them as reminders that you are capable of fi nding calm amidst the business of life. If you encountered challenges or distractions, instead of feeling discouraged, view them as opportunities for growth. By cultivating awareness, you are developing a valuable skill that can bring balance and resilience into your daily routine.

What we particularly like about this exercise is that you can really do it just about anywhere. As soon as you start to feel tensed up or feel a pain fl are coming, move to 14 your breath. Use your breath to get yourself back on track. Once you feel more settled, your mind will be more clear to decide what you have to do next. Ok, take a deep breath, and let's keep going. Up next, we're going to talk about how movement and activities can help in your journey of managing chronic pain.

Congratulations again on making it this far in our first week. Next, we want to introduce the idea of practicing these new skills at home. It's important to practice new skills at home because that's where the real magic happens! When we learn something new, like the skills we're working on, practicing at home, or wherever is comfortable, helps us get better and make those skills a part of our everyday lives. Here's why it's so important:

1\. Becoming Really Good: When we practice at home, we get to become really good at the skills we're learning. Just like when we practice playing a musical instrument or playing a sport, practicing new skills helps our brains remember them and do them automatically. The more we practice, the better we get!

2\. Using Skills in Real Life: By practicing at home, we can use these skills in real-life situations. Think about it like using a tool from your toolbox when you need it. Practicing at home helps us know when and how to use these skills to handle tough or challenging situations in our lives.

3\. Dealing with Challenges: Sometimes it can be tough to practice at home because we're busy, we forget, or we lose motivation. But guess what? That's totally normal! Lots of people feel the same way. The good news is we will work to identify people in your life who can support you when you face challenges. You don't have to go through this alone.

Every week, we will give you skills to practice for your mind and for your body. Sometimes, we'll ask you to repeat a skill you've already learned. Other times, we will ask you to practice something entirely new. You can always go back to a previous chapter to find your practice assignments. For both meditation and movement, it's best to practice every day but any practice is better than nothing at all, so do the best you can.

Remember, we're all on this journey together. Practicing new skills at home is an exciting adventure that helps us become better versions of ourselves. Keep up the great work and keep practicing!

Meditation is a special way to find peace and calmness in our busy lives. When we practice meditation regularly, it helps us feel better and be more present in the moment. There are two types of meditation: formal and informal. Formal meditation is when we set aside specific time to sit quietly and focus on our breath or a chosen object. Informal meditation is when we bring mindfulness into our daily activities, like eating or walking. Sometimes, meditation can be challenging. Our minds wander, and it's hard to stay focused. But remember, this is normal! Be patient and kind to yourself. If one type of meditation doesn't feel right, try another. There are many ways to meditate, and it may take a few tries to find what works best for you. We will be offering you both informal and formal mindfulness skills to practice every week as part of your pain management program. The more you practice, the better your results will be. So, keep exploring, keep practicing, and don't give up. You're on a wonderful journey toward inner peace.

Transcript coming soon.

Pain can have a big impact on how our bodies feel and what we can do. When we experience pain, it can make our muscles feel tense and stiff, limiting our ability to move freely. It can also make it hard to do activities that we enjoy or need to do every day. But there is hope! Movement, stretching, and exercise can play an important role in reducing chronic pain. When we move our bodies, it helps to loosen up those tense muscles, increasing flexibility. Stretching can make our muscles more relaxed and less likely to feel tight. In addition to lifting our mood, regular exercise strengthens our muscles and improves our overall fitness, which can help us better manage pain. It's important to start slowly and choose activities that you enjoy and that feel comfortable for your body. Remember, movement, stretching, and exercise are powerful tools that can bring relief and improve your quality of life.

Let's take a minute to hear more about how movement was used by one of our patients, Sophia.

Hi, it's Sophia again. I was telling you a little bit about my story earlier in this session. I've been living with chronic pain for about 18 years. One of the only things that helped me manage my pain was finding a movement and exercise program that worked for me. At fi rst, the idea of exercising seemed ridiculous. How could I possibly move my body when every step felt like a struggle? But I knew I had to try something different, so I started a journey to explore the right movements for me.

I was getting a lot of advice from different people but in the end, I needed to fi nd the right thing that worked for me. I decided to begin with walking. It was something I could do at my own pace, and I didn't need any fancy equipment. I started with short walks, just a few minutes each day, and increased the time little by little as my body let 18 me. Over time, I realized that the key to finding the right movement program for me was to listen to my body's signals. I started to figure out the difference between normal discomfort and pain that was harmful. I paid attention to how different activities affected me and found myself doing activities that were good for me.

Now, I'm going for walks with my friends 3 days a week, doing a few stretches here and there, doing some gentle yoga videos, and keeping my garden. It was hard to get started and I did need to learn how to pace myself. I also learned that I don't have to do it all at once -- it's ok to spread things out so I don't get overly tired or too sore the next day."

Of course, there were setbacks along the way. Some days, my pain would fl are up, but I didn't give up. I reminded myself of my own progress the relief I was feeling. I held onto the hope that even on difficult days, movement would be a source of healing.

Today, as I reflect on my journey, I can't help but feel a sense of gratitude. Exercise and movement have become my allies in managing chronic pain. They have given me a renewed sense of hope and empowerment. While I still have pain, I now have exercise and movement to remind me that I am stronger than my pain.

Next up is your first suggested skills practice for your body or ways to start moving more to feel better. As you begin your new program to increase movement and exercise, it's important to set some expectations. First, choose activities that you enjoy and that make you feel good. The activities should be nourishing to your mind or your body. It could be walking, dancing, or even playing a sport. Remember, the goal is to have fun while moving your body. Pace yourself by starting with shorter sessions and gradually increasing the time and intensity. Take breaks when needed, and don't push yourself too hard. It's also helpful to space out your practice throughout the day. You can take short movement breaks every hour or divide your exercise into smaller sessions. Regular practice is key, so try to incorporate movement into your daily routine. Remember, progress happens one step at a time. Each day is a new opportunity to do your best, so focus on the present moment and do your best. Believe in yourself, stay committed, and enjoy the journey of becoming stronger and healthier. You've got this!

Take a look at this list of movement activities and pick one that appeals to you. You are also welcome to choose something that's not on this list. It's up to you.

List of activities:

Walking Yoga Strengthening Tai chi Sports Something else!

When starting a new movement or exercise program, safety should always come fi rst. It's important to listen to your body and be mindful of any pain or discomfort that you may feel during and after exercise. Some muscle soreness and fatigue are normal, especially when starting a new routine, but sharp or shooting pain should be avoided. Here are some basic safety tips to keep in mind:

1\. Start slow and gradually increase intensity: This will help your body adjust to the demands of increased movement or exercise and reduce your risk for injury.

2\. Warm up and cool down: Before and after any extended movement activity or exercise, take some time to properly warm up and cool down your body. This can include some light stretching and low-intensity movements.

3\. Use proper form: When performing stretches or exercises, make sure you're using proper form to avoid unnecessary strain on your joints and muscles.

4\. Stay hydrated: Drink plenty of water before, during, and after exercise to stay hydrated and avoid muscle cramps.

5\. Don't push through pain: If you experience sharp or shooting pain during any movement, stop immediately and seek medical attention if necessary.

Remember, movement and exercise can be an important tool for managing chronic pain, but it's important to take things slow and listen to your body to avoid injury.

Our last suggested skills practice for this week is called "self-monitoring" or simply keeping track of things you are doing or feeling that might aff ect your health or your experience of pain -- kind of like keeping a pain diary or an exercise log.

Self-monitoring can be a powerful tool that helps us understand ourselves better and make positive changes in our lives. By paying attention to what's going on inside our minds and bodies, we can understand how certain situations aff ect us. This awareness helps us identify patterns, triggers, and areas where we might need some extra support. Self-monitoring can also help us track our progress over time. By recording our thoughts, feelings, and behaviors, we can see the positive changes we've made. It's a way to celebrate our successes, no matter how small they may seem. This can boost our motivation and confi dence, encouraging us to keep moving forward.

Remember, self-monitoring is not about judgment or criticism. It's about learning and growth. By paying attention to ourselves, we can discover insights and make positive changes. So, let's embrace self-monitoring as a valuable tool on our journey towards well-being and personal growth.

So here's the assignment:

At the end of each day, we'd like you to write down two things. First, jot down some notes on how active you have been that day. Include what you did and how much or long you did it. The activities could be nourishing or they might have been depleting and stressful.

Examples include going for a walk, doing laundry, shopping, or even just talking with a neighbor.

Second, at the end of each day, rate your mood on a scale of 1-10 where 1 is the worst mood possible and 10 is the best mood possible.

There's no right or wrong answer. You are just creating a record of your activity level and your average mood for the day.

Good luck and get moving!

Great job! You completed week 1 of the program!

In this session, we discussed how you can create the right mindset to make this program work for you. We know that you've probably tried a lot of diff erent things and been to many medical appointments to manage your pain. Our goal is to provide you with evidence-based tools that have helped others like you take control of pain and live their best life.

Throughout the program, we'll focus on both your mind and body. Your mind includes your thoughts, feelings, and your spirit, while your body consists of muscles, joints, flexibility, strength, and your activities. We started to talk this week about how chronic pain aff ects both your body and mind, and why our program emphasizes strengthening your body and off ering relief for your mind.

We also talked about how diff erent strategies that have helped patients like you gain control over their chronic pain, such as mindfulness, breathing activities, movement, and exercise can break the cycle of pain, be healing while improving your well-being.

We would encourage you to practice these activities to help you even more. This practice will improve your ability to use the skills when you need them most and fi gure out what approaches work best for you. We're excited to continue this journey with you and help improve your pain over the next 12 weeks!

# Week 2

Welcome back to the UCSF INSPIRE chronic pain management program! We are a group of doctors, organizations, and community members working together to help you learn evidence-

based strategies to manage chronic pain. Over the past few years, we have collaborated with your community to create a mobile app and health coaching program. This app provides mind-

body exercises and connects you with a pain management coach who will support you every week. The program lasts for 12 weeks, during which we will go through lessons and exercises that have been proven to help with chronic pain. It may seem like a lot, but remember that you will have a coach by your side every week. You can also take things at your own pace. Feel free to take breaks and pick up where you left off later. We encourage you to try everything at least once or twice before deciding what works best for you and your pain. In addition to your weekly program, you can also access a pain management library, a community forum, and a list of mind and body exercises and videos.

Let's start Week 2 together! You can go forward or backward as you like, but we recommend following the flow we have set up for you. Last week, we talked about having the right mindset and being willing to try things out, even if they don't work at first. We also discussed the connection between the mind and body, the chronic pain cycle, and introduced two patient stories. We encouraged you to practice skills like the 3-minute breathing space, choose a movement activity, and keep track of your activity levels and mood. Hopefully, you had a telehealth visit with your coach to talk about your first week and set some goals. In Week 2, we will focus on mindfulness in two main lessons. We will learn foundational mindfulness skills and do some awareness-raising exercises together. After that, we will explore how to be more aware of our thoughts and how they can affect how we feel physically. We call it "Thinking about thinking." We'll start exploring some strategies to think in ways that help you feel more in control and more hopeful even though you might be in pain. We will end the week with more practice and patient stories.

Let's get inspired with Week 2!

Starting a new program to manage chronic pain is a lot like planting seeds in a garden. First, you have to prepare the soil. Last week we talked about cultivating the right attitude -- our soil - to help you constructively explore and try new pain management skills. Once the soil is ready, it's time to plant the seeds -- the new mind-body skills. Just as seeds need time to sprout and grow into healthy plants, we need time to explore and try out these new skills. And as we use these new skills, our bodies may need time to adapt and heal. It's important to have patience throughout this process.

At first, it may feel discouraging when progress seems slow or when we face setbacks. But remember, just like tending to a garden, consistent effort and care will yield results. Each small step, whether it's gentle exercises, mindfulness practices, or seeking professional guidance, is like planting another seed in the soil of our well-being. And just like seeds hidden beneath the surface, changes are occurring beneath the surface of our bodies. Muscles are strengthening, flexibility is increasing, and our overall well-being is improving, even if we can't see it yet.

Remember that growth takes time, and the journey itself is valuable.

So, be patient, dear gardener. Trust the process, have faith in yourself, and know that with time and perseverance, you will witness the growth and transformation of the beautiful garden you seek and deserve.

Congratulations! You've made to the end of Week #2. There are only 10 weeks left before you finish the program. Remember that you will meet with your coach every week so be sure to check for your next appointment.

In Week 2, we took a deeper dive into Mind-based interventions including mindfulness skills and some "brain training" where we practiced rethinking thoughts that affect your reaction to pain. Remember that strengthening your mind doesn't mean your pain isn't real. It's just another set of tools to help you get closer to the life you want to have. Throughout our course, we will come back to mind-skills like different types of meditation and different types of brain training. And just like going to the gym or workout out, it sometimes takes a while before you notice a difference.

This week, we heard from Dr. Sibel Demir -- a doctor that specializes in back pain. Dr. Demir was so impressed with how much mindfulness meditation helped her personally, she went back to school to learn how to be a mindfulness teacher. In fact, she helped us design many of the mindfulness exercises you'll see throughout the course. From there, we started expanding what we mean to be mindful. You can be mindful of your breath, of your body, of sensation, or just about anything. We did a brief mindfulness practice and you'll get to practice more later this week. We then moved to thinking about thinking. We started training our brains to capture what we're thinking, evaluate how it makes us feel, then rethink it if it isn't very helpful. In fact, there's a lot of research that shows that challenging these negative thoughts and relaxing your body are probably the two best things that you can do for your pain. Be sure to try some of these on your own and practice with your coach. Throughout the rest of this course, you'll see that our Mind-based skills are either mindfulness meditation based or brain training skills. We think both will be important additions to your toolbox.

We also shared a list of things you can practice in your own time. Give them a try and see how they feel to you. Remember too, that you can click the icons at the bottom of the screen at any time. The books icon takes you to the library. The person icon takes you to a full list of the body intervention. The mind icon takes you to a full list of meditations and brain training. The file box takes you to the "My Stuff" sections where you can see your favorites, your survey scores, and review your pain flare-up plan. If you don't have a flare-up plan just yet, be sure to discuss this with your coach so you can create one together.

Next week, we'll take a deep dive into body-based interventions and see if we can find movement that works for you. Get going and be INSPIRED.

Hi, I'm Dr. Sibel Demir a full Professor in the Department of Orthopedic Surgery at UCSF. I specialize in non-surgical treatments for spinal disorders and work with patients who have chronic pain nearly every day. I wanted to share a little bit about my medical journey and how I became convinced that mindfulness meditation is a powerful tool to reduce suffering and pain.

Ten years ago, I was a miserable person. I wasn't happy at work. I wasn't happy at home either. One day I was in the kitchen at home and I heard my inner voice said "Now what? Is this the way we would live? Are you planning to do anything about it?\" Then I remembered the conversation I had with my dad. My dad reads a lot. He told me we should all practice mindfulness since it is possible to make happiness from suffering. When I remembered this conversation, I purchased books written by Jack Kornfield, books written by Thich Nhat Hanh, books written by Dalai Lama, and Pema Chodron. I started to read the books. Amazingly they work. I started to do the meditations in the books. They also work. While I was reading the books, I realized I would like to build happiness and peace in me, independent from the external environment. I would like to spread happiness and peace to people around me, I would like to live with an open and peaceful heart, and I would like to teach people how to make happiness from suffering. Then I searched for possible trainings I could do. I really liked the two-year mindfulness meditation teacher certification program founded by Jack Kornfield and Tara Brach. Then I did this training and graduated from this program.

Mindfulness has multiple positive effects on me and indirectly on people around me.

What I love the most about mindfulness is increasing my ability to use the space between stimulus and response. As Viktor Frankl said \"There is a space between stimulus and response. In that space is our power to choose our response. In our response lies our growth, our freedom, and our happiness\".

It has been shown that mindfulness meditation is able to down-regulate pain pathways, and also deactivate and activate some of the centers in our brain and reduce pain. After finishing my mindfulness meditation training, I have decided to combine my mindfulness meditation knowledge with medicine and help our patients with chronic pain.

\'If you know how to make good use of the mud, you can grow beautiful lotuses. If you know how to make good use of suffering, you can produce happiness. No mud, no lotus\" - Thich Nhat Hanh

Now that we've covered what mindfulness is and heard from Dr. Demir, let's dig into mindfulness of body breathing, sensations, and feelings. It sounds simple but it takes some practice if you're not used to tuning into yourself this closely.

Now, most people with chronic pain have spent a lot of time being very aware of how much it hurts. You can't exactly forget something that causes so much suffering. But there's a lot of other things going on in your body that might be worth tuning into.

We will cover different tools of mindfulness so that you have several options to use. You don't have to do them all, but we do recommend keep trying different ones until you find couple that you find helpful!

Let's start with breathing. The concept of "mindfulness of breath" is a transformative practice that lies at the heart of mindfulness meditation. It's the most common focus of many different types of meditation. By directing our attention to the simple and natural rhythm of our breath, we open a gateway to profound insights and inner calm. Paying attention to our breathing is not just an exercise in relaxation; it is a doorway to a deeper understanding of ourselves and the world around us. By bringing mindful awareness to our breath, we invite ourselves into the present moment, nurturing a sense of groundedness and stability. Our breath becomes our anchor.

Over time, we become more attuned to the subtleties of our breath, discovering its ever-

changing nature and its ability to anchor us in the present moment. As our awareness deepens, we may explore different techniques, such as counting the breath or following its pathway through the body. With consistent practice, the mindfulness of breath becomes a powerful tool, always available to us, supporting our well-being and inviting us to live with greater intention and clarity. You had a chance to practice a mindfulness of breath exercise last week. Be sure to repeat that exercise if you found it helpful. Remember that you can mark you favorites by pressing the heart shape on the screen.

Another mindfulness skill we wanted to introduce today is mindfulness of sensations within your body -- above and beyond the pain you might regularly feel. The concept of "mindfulness of body" invites us to cultivate an intimate relationship with the sensations that arise within us.

By bringing a gentle, non-judgmental awareness to our bodily experiences, we can uncover deep insights and nurture our health and well-being. This practice invites us to pay attention to our bodies as a source of wisdom, guiding us towards greater self-understanding and inner harmony.

Learning to direct our attention to bodily sensations is a gradual process that unfolds with patience and practice. We start by simply turning our awareness inward and scanning our bodies, noticing any areas of tension, comfort, warmth, or coolness. We observe the ebb and flow of sensations without seeking to change them or clinging to them. This gentle curiosity and open-mindedness create a space of acceptance and presence.

One common concern that arises when attending to painful or unpleasant sensations is the fear that it will intensify the discomfort. However, in mindfulness practice, we approach these sensations with a different perspective. Rather than trying to avoid or suppress them, we acknowledge their presence and hold them with kindness and understanding. This compassionate attention can actually help us develop a new relationship with pain or discomfort, reducing our resistance and offering a sense of relief. May we embrace this journey with open hearts, recognizing that our bodies are remarkable vessels of awareness, deserving of our attentive presence and care.

Now, it's time for a little practice. If you need to stand up or stretch or take a break, please feel free to do so. If you are ready for some practice, just click to the next screen. You will be guided through an 8min experience called "Connecting with our bodies." Give it a try and see what it's like. At the end of this week's lessons, you will have more links to longer exercises where you can continue to develop these skills. Ready, set, let's be mindful!

Our next practice will be connecting with our bodies. Find yourself a way of sitting, a posture that allows you to feel that you're both comfortable and alert. If you are unable to sit, you can do this exercise standing or lying down. Once you are positioned, I want you to take a few deep breaths.

Just let yourself settle into this posture.

[Pause] When we start to relax, we start to feel our body. We start coming home. There's a relaxed attentiveness that allows us to be here.

[Pause] And as a way of beginning a little bit of exploring, I'd like to invite you to take your hand and put it in front of you. Take a look at your hand. Turn it around, and for these next few moments, just notice what it looks like visually to you and whatever thoughts come up about your hand's functions, whatever history you have with your hand, feelings about your hands.

You might even mentally whisper the word "hand."

And then close your eyes.

And keep the arm up.

And just begin to gently move the hand back and forth in front of you, moving slowly enough that you can really feel the sensations of moving through space.

Feel the sensations within the sensations, and just be aware of the aliveness that's here. And you might even pause the movement, and just feeling from the inside out, sensing is there any shape or boundary to the aliveness, sensing the difference between any idea of hand and these direct sensations, this immediacy of experience that's right here.

Allow yourself to gently lower the hand.

Just rest.

[Pause] You can bring the same quality of inside-out attention to the whole body. We'll scan through the body, relaxing, waking up the awareness inside the body.

[Pause] You might begin at the brow.

Let the eyes be soft.

Let the brow be smooth, relaxing the eyes, and feeling the tingling and vibrating, perhaps the light and darkness, the lids.

[Pause] Sometimes, if you imagine smiling into the eyes, the corners of the eyes up a bit, you can sense even more relaxing and ease, and even more sensation and aliveness.

With the jaw, be relaxed.

You might sense that half-smile at the mouth, perhaps the inside of the mouth smiling.

And again, with that relaxed attentiveness, feeling the sensations, the tongue, gums, inside the lips, filling the mouth.

[Pause] You might let the awareness fill the shoulder area, relaxing, perhaps letting the shoulders relax back and down a bit, and feeling the shoulders from the inside out.

Perhaps there's a natural dissolving, like ice to water, water to gas.

With interest sensing the aliveness and space inside the shoulders, the movement of sensation.

[Pause] You might feel the hands from inside out again, letting them rest in a very easy and effortless way, perhaps softening a little, and then bringing that intimate attention to feel the life of the hands, tingling, perhaps vibrating, pulsing, maybe.

You might notice that if you soften even more, there's more of an experience of aliveness.

[Pause] You can bring the same intimate attention throughout the whole body, letting the chest be open, and feeling the chest from the inside out, feeling the heart, feeling the movement of sensation throughout the whole chest area, relaxed and present, bringing a curious, gentle attention to what's here.

[Pause] Relaxing the area of the belly, letting this next breath be received in a softening belly, this breath, and now this one, and again, sensing how you can experience awareness deep into the torso.

[Pause] Just as a cup can be filled with water, this body can be filled with awareness, sensing the aliveness, sensation through the whole pelvic area, and down through the legs and the feet.

[Pause] You might be aware of the pressure and warmth where your feet are, and feeling them from the inside out.

[Pause] And widening the lens of attention to include the whole body now, simultaneously, sensing this body as a field of sensation.

Letting everything be just as it is.

[Pause] Sensing the possibility of resting in a vast, open awareness, experiencing this play of life, this changing dance of sensation.

\[Pause, followed by ringing the bell\]

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If you liked the last exercise, we invite you to practice with a more advanced meditation called the Body Scan. If not, you can skip this video. Press "Next" to continue.\ \ The Body Scan is a 30-minute core mindfulness exercise. Try it using the video below. The more you do it, the more you improve. Mark it as a favorite to find it easily.

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Transcript coming soon.

In our journey to manage pain, we introduced body-based activities like walking and doing things that bring us joy and we talked about mind-based skills like meditation or mindfulness.

Now, we're going to turn to what might be one of the most powerful mind skills -- Thinking about thinking. We're going to look at how our thoughts can impact our pain and how changing our thoughts can help us feel more in control of our lives and our pain.

When you're in pain, what thoughts come to mind? Usually, as pain increases, our thoughts become more negative. Surprisingly, research shows that negative thoughts can actually make the pain worse by speeding up pain signals and affecting the pain centers of our brains. These negative thoughts can also prevent us from doing things that we know can make the pain better.

Unhelpful thoughts lead to unhelpful behaviors.

Don't worry though, everyone has negative thoughts! Sometimes, these thoughts pop up automatically. For instance, you might think, "My pain will never go away," or "I can't do anything with this pain" or you may have the sometimes terrifying belief that feeling pain means you are doing further damage to your body. Believing these thoughts can lead to avoiding activities and people, and it becomes less likely that we'll use the pain management skills we have. It's like a chain reaction of negative thoughts, feeling upset, avoiding others, and not using the helpful skills we already know. But here's the good news - we can break this cycle!

But let's get this out of the way first. Your pain is real. Period. Your pain is valid and you deserve compassionate support from others and from yourself. Looking at ways to challenge negative thoughts doesn't invalidate your experience in any way. It's a tool -- an important, research-based tool -- to help you manage your pain more effectively while improving your mood.

In general, there are 3 key steps to challenging negative, hurtful thoughts and finding your way to more helpful solutions.

1\. Be aware of your thoughts. This is the mindfulness of thoughts skill.

2\. Think about your thinking. Remember that thoughts are not facts. They are opinions and opinions should be questioned if they aren't helpful or fair.

3\. Rethink your thoughts. Rethink the hurtful thoughts so they are fair and balanced. The thoughts should lift you up and motivate you to do things you know will help your pain or our mood. If it's too hard to rethink the thought, use a mantra or positive coping statement to give yourself encouragement and hope.

So that's 3 things: Aware, Think, and Rethink. Aware, Think, Rethink. Let's dive into each one of these steps.

The first part is to raise your present moment AWARENESS of what you are thinking -- or being mindful of your thoughts. The sooner you can catch your thoughts, the better chance you have of stopping that negative downward spiral. We all have many many thoughts throughout the day -- some positive, some negative, and many that are somewhere in between. Thoughts include memories, fantasies, predictions about the future, or just a running commentary on things happening in the present moment -- like noticing how much your body hurts. As you learn this skill, it is sometimes helpful just to write down your thoughts so you don't have to remember them. This will also make it easier in the next step where you question the thoughts.

A good clue that you may be thinking negative thoughts is a sudden dip in your mood or increased tension in your body. Negative thoughts are stressful, so it makes sense if your body starts tensing up with a stress response. When you notice those sensations, ask yourself, "What was I just thinking? Was it about my pain?" Don't critique or judge. You are just raising your awareness of your thoughts. Your thoughts might be something like, "I can't stand another day of this...Will this pain ever go away...why can't other people be more supportive...or I should just give up because nothing will help." Jot down the thought if you can.

Now since your body has probably tensed up, a good next step is to take a few calming breaths.

You don't have to do a full relaxation exercise, but you can if that's what works best for you. So, take a few breaths, slow down your heart rate, and see if you can relax any muscles that have tensed up.

Now you are ready for step 2 where you THINK ABOUT YOUR THINKING. First you might ask yourself, is this thought helpful or hurtful? Notice I didn't say is it true or false because that's often too difficult to prove. Just ask, is this thought helping me or hurting me? If it is helping then great, leave that one alone. In fact, you might want to bookmark it so you can use it later when you need it. If the thought isn't helping -- and negative thoughts almost never do -- then it's time to question it. Remember that thoughts are not facts. A thought is just a mental event.

Thoughts are opinions that are often based on incomplete information, and they may be greatly affected by your mood.

You might ask yourself:

• Is this thought fair and balanced? When we hurt, it is usually pretty easy to remember

everything negative and to forget the positives -- like the times you were able to manage your pain or enjoy time with others. Take a step back and make sure you are remembering both sides of the coin.

• Look for evidence. Have you had experiences that might suggest this thought isn't

accurate? For example, if the thought is "I give up. This pain will never change. I'll never get better" -- think back to times when your pain has gone up or down, in other words, a time when it HAS changed. Think back to days that were maybe better than others --

days when your pain DID get better. You most likely have a lot of inner strength and resilience that you've temporarily forgotten.

• Is this thought the "right size"? When we hurt it is easy to magnify what we are feeling

and how bad it's going to get. Yes, what is happening is bad and it's unfair but are you imagining the right-sized outcomes?

Once you've questioned your thoughts, it is time to move to step 3 -- RETHINK YOUR THINKING.

If you are feeling tense in your body again, take some of those deep breaths to help you settle back down. Now it's time to rethink those thoughts. Here you rewrite your thoughts, so they are fair, balanced, and right-sized. This can be tough because we may have a deeply held habit of thinking negatively.

You might try some of these strategies:

• If someone you loved shared these negative thoughts with you, what would you say to

them? How would you support them and help them have more hope? This strategy is all about helping us have the same compassion for ourselves as we have for others.

• Try "Yes-But" -- If you thought "This pain is horrible and it will never get better" rethink it

to say, "Yes, this pain is horrible, but I have good days and bad." Or YES, this pain has been part of my life for many years and there's no cure in sight BUT there are things I can do to help reduce my suffering." This strategy acknowledges that part of the original thought is true but overall, it is too negative and unhelpful.

• Imagine you are a judge looking at the evidence for and again a particular thought. If

the original thought is "If I get out of bed and start moving, I will be in horrible pain so I should just lie here all day" -- the judge would love for evidence for and against. Yes, you have had days with horrible pain. Yes, exerting yourself physically can sometimes trigger a pain flare-up. But the judge would also see that lying in bed has weakened your muscles, reduced stamina, and reduced flexibility. The judge would see that you've been ok doing some light activities in the past and sometimes even felt good afterward. So the judge might rewrite that thought to "When I get out of bed and start moving, I'm often sore and ache more at first, but if I pace myself and don't overdo it, I can sometimes feel better. Lying in bed all day doesn't really help and it isolates me from the people and things I love. If I'm going to be in pain regardless, I might as well do something."

After you've rewritten those thoughts, you are well on your way to finding a solution to your pain flare-up. Just as negative thoughts push us down, more positive thoughts can lift us up.

Repeat the more positive thoughts to yourself and see how they make you feel.

If you can't come up with a way to rewrite the thought, try replacing it with something else entirely like a mantra or what is sometimes called a coping statement. These are simple, pre-

written statements that help you feel encouraged and more in control. Some people even write these out on index cards or put them on sticky notes around their house. You can say them to yourself over and over until you feel better. Your coping statement might be something like --

I've gotten through this before and I can do it again; This too shall pass; or I'm a strong resilient person just having a bad day. Later, we will do an exercise and help you come up with our own statements. Your coach can help you with this too.

Now think about what other things -- maybe movement, activities, or other behaviors you can do that might help solve or at least reduce the problem of your ongoing chronic pain. How can you nurture yourself? What brings you some relief? Engage in activities that bring you joy, relaxation, and a sense of connection. Embrace practices such as gentle movement, mindfulness, and self-expression to discover what resonates with you. There's no guarantee it will work but your chances are far better than doing nothing at all.

So, there you have it -- Thinking about Thinking. Be AWARE of your thoughts, THINK about your thoughts, and RETHINK your thinking. And don't forget to mix in some deep breathing or other relaxation exercises. Create your own space and your own mindset for healing. It'll take practice and you might get stuck, but remember, you have your coach to help you.

You've got this!

Hi Again, It's me Benjamin -- the high school teacher with a bad back. We met last week when you were learning about how the mind relates to pain. Lucky for me, I found mindfulness meditation -- it relaxes my body and my mind and just helps me feel more settled and in control. I don't react as much or get as hopeless. When I meditate, I focus on my breath and just observe things like my thoughts -- good thoughts, bad thoughts, neutral thoughts. Whatever comes up, comes up, and do my best not to judge myself or react.

Today, I wanted to share something else I've found in the mind category that works for me. I've learned to think about my thinking and how it can either help me or hurt me. The way I'm thinking about my pain can lift me up and help me see ways to cope or sometimes thoughts can really ramp up my worries and fears and just make me feel more terrible. And when I'm feeling terrible emotionally, I feel worse physically. That's just the way it works for me.

I've learned to pay more attention to what I'm thinking -- and most of us are thinking something pretty much all the time. You might be thinking of something else right now. It might be big or little or helpful or hurtful or just random noise in the background. It's all good until those thoughts start ramping up our worries or fears. Like today, I was getting out of bed and reached for my slippers. I somehow overreached and hurt my back -- like I somehow injured myself just by doing an everyday thing. It's really frustrating and kind of humiliating. Like, really? Well, once my back gets tweaked, I sometimes panic and I can go downhill fast. My mind just starts racing. I was thinking "Oh God, here we go again. Look at me, a fragile invalid at the ripe old age of 44. Now I can't go to work. Now I'm going to be miserable all day." Well, as you can see my mind was racing off into some pretty unhelpful directions. My pain was real for sure but now I know that the way I was thinking about it only made matters worse -- and on top of that, the thoughts I was having weren't particularly fair or true. I was feeling angry, sad, frustrated, and defeated -- none of these helped me figure out how to help myself and get on with my day.

So what did I do? I caught myself thinking and said, "Hold up, Ben. Take a few breaths." And I started doing some deep breathing just to help myself get settled and to relax a little. This helped with the panic feeling. Then I started thinking about my thinking. I reminded myself that sometimes these little flareups don't last very long -- sometimes they do but often they don't. I can stretch a little, try a little massage, or put a little ice on it to give me a little boost. I reminded myself I've lived with this pain for over 10 years. My spine isn't ever going to fix itself but that doesn't mean I can't live. I love being a teacher and I've managed to make it to work nearly all the time. I pace myself. I make sure I sit when I have to. I have learned to lean, move, and stretch in ways that help. Some of my students have been really sweet about it and some of them are hilarious. They named my back pain, Mary, and if they see me wince a little or slow down they say, "Hold on, Mary! Nobody invited you to the party!" I know it's goofy but it makes me laugh. So there I was, sitting on my bed, holding my slippers still with a stabbing pain in my back but I was smiling. My thoughts had changed and so had my feelings. I pushed myself up, then I walked to the kitchen so I could get on with my day.

So now that we've learned how to think about thinking and we've heard from Benjamin about his experiences, let's apply these ideas to you and to your situation.

Remember there are just a few simple steps:

1\. Be aware of your thoughts and how they make you feel. If your thoughts aren't helping, first take a few breaths and try to help your body and mind relax.

2\. Think about your thinking. Once you feel settled, start questioning the thoughts and determine if the thoughts are fair or balanced. Often our thoughts are hijacked by the panic feelings that might follow a pain flare-up.

3\. Rethink your thoughts. If your thoughts weren't fair or balanced or were just too negative, try to change them so that they are more fair, more balanced, and more helpful. If it's too hard to come up with a new thought, just use a mantra or coping statements that you've found and have meaning for you. Repeat the more helpful thought or the coping statement over and over again. Now, it's time to get on with your day. Is there anything else you can do to feel better?

Any movement or activities? Maybe a mindfulness exercise? Think of something constructive that might help.

Ok, so let's start this exercise with being aware of your thoughts. You might ask yourself questions like:

• What was going through my mind just before or just after I started to feel this way?
• What is the thing I am most afraid might happen?
• What is the worst thing that could happen?
• What memories does this lead me to experience?
• What does this mean about my future, my life, my health?

Go ahead and close your eyes and think back to the last time you felt upset, anxious, depressed, or just stressed out. Take your mind back to that time and try to remember what was going on.

What time of day was it? What were you doing? Was anyone else around? Think about any details that might help you remember. Now, try to remember the thought or at least the kinds of thoughts that were going through your mind. Now open your eyes and click to the next page.

You'll see a list of thought examples. Click on the one that most closely matches what you were thinking.

Look at the below list and select the thought that best matches what you were thinking during that negative event. These are just examples so you can also just come up with your own. I'll give you a few seconds to capture the thought. Once you've grabbed the thought, it's time for some relaxation. Let's practice just a few deep breaths. Remember we want to sit up or stand up as straight as we can so we can fully open our lungs. Remember that want to breathe from our bellies and not our shoulders. Breathe in through your nose \[inhale\] and out through your mouth \[exhale\]. Breathe in through your nose \[inhale\] and out through your mouth.

Negative Thoughts:

\- Oh, great. Here we go again. I can't stand this.

\- This is horrible. My life is horrible.

\- This is never going to get better.

\- I can't do anything anymore.

\- This is what I deserve.

\- I hate every healthy person around me

Now let's THINK about your thinking and wrestle with those thoughts. Let's try to silence that inner saboteur. The idea is not to generate happy, unrealistic thoughts but to create a more balanced and fair way of looking at experiences. You might challenge the negative thought by trying to collect the facts.

Ask questions such as:

• Is this 100% true?
• Is there a different way to look at this issue?
• What would I tell a close friend if they had this thought?
• Is this thought helpful to me?
• Is there evidence that I am not taking into account?

When you answer these questions, you have a more balanced and realistic view of the situation.

Replacing unhealthy thoughts with more helpful ones will help you cope better with your pain and reduce those feelings of panic or helplessness. Let's look at a few examples on the next screen. Once you've reviewed the examples, see if you can Rethink your own thoughts.

Ok -- so let's tune into our brains and get in some practice for Thinking about Thinking.

Remember that there are 3 simple steps to help you break free from thoughts that hurt you and make coping more difficult.

The steps are 1\) Be aware of your thoughts -- capture them when they come up 2\) Think about your thinking -- is it balance, fair, or too one-sided? Does it make you feel better or worse?

3\) Rethink your thinking. Try using "Yes..but" or imagine you are talking to a friend that might be having the same thought.

To practice this skills, it's easiest to get a piece of paper and just write things down. This will help you see the thoughts so you can wrestle with them more effectively. It's also something that you can share with your coach later. And don't worry if you get stuck. Everybody gets stuck at some point. In Week 5, we will take a more detailed look at this technique but for now, just do the best you.

So here's the goal:

\- Write down thoughts you have captured on at least two different occasions in the next week. Remember that a drop in mood or an increase in tension often signal that your thoughts are active and might need to be examined.

\- After you've written down the thoughts, take a careful look. Ask questions such as:

• Is this 100% true?
• Is there a different way to look at this issue?
• What would I tell a close friend if they had this thought?
• Is this thought helpful to me?
• Is there evidence that I am not taking into account?

\- After you've looked at your thoughts and see how they might not be all that fair, try rethinking them. What would you say to a friend? How can your thought be more fair?

You might also want to try just writing out some encouraging and supportive coping statements.

Can you come up with at least two that you can use this next week? Don't forget your coach can help!

Another technique that can also be helpful in managing pain flare-ups or negative mood is to use positive coping statements. Think about things you could say to yourself that might help you feel better. You are your own best support. Pick a few from the following list or write your own.

Consider putting them on an index card or piece of paper so you can see them and read them over and over. You can think of these as daily affirmations that you can use anytime you start to feel bad. Look over this list and pick your favorites.

This last skill practice will be a continuation for a skill you started last week. It's called self-

monitoring or really just keeping a record of what you do and how it affects you. At the end of each day, we'd like you to write down two things. First, jot down some notes on how active you have been that day. Include what you did and how much or long you did it. Second, at the end of each day, rate your mood on a scale of 1-10 where 1 is the worst mood possible and 10 is the best mood possible. There's no right or wrong answer. You are just creating a record of your activity level and your mood. This is the same as last week.

This week, we'd like you to also pick one movement activity you'd like to try this week (or keep the same one as last week) and pick one pleasant or fun activity from the list on the next screen (or make up your own). Be sure to write down these activities on your activity record and be sure to practice your mindfulness skills while you are doing these activities. Reflect on how it goes so you can discuss with your coach.

One last thing, we want to revisit sensations you might feel when you are exercising. Remember, its normal to feel sore, tired, or have muscle tightness during or after exercise. Think about the other sensations that you are having during and after exercise. If you are experiencing PAIN during or after exercise, think about changing the activity. If you want to do the same activity, how could you do it with less pain?

You can find more tips about safely starting an exercise and movement program in the library or under the movement icon below. Click on the next button to see the list of activities you can choose from. Have fun!

Congratulations! You've made to the end of Week #2. There are only 10 weeks left before you finish the program. Remember that you will meet with your coach every week so be sure to check for your next appointment.

In Week 2, we took a deeper dive into Mind-based interventions including mindfulness skills and some "brain training" where we practiced rethinking thoughts that affect your reaction to pain. Remember that strengthening your mind doesn't mean your pain isn't real. It's just another set of tools to help you get closer to the life you want to have. Throughout our course, we will come back to mind-skills like different types of meditation and different types of brain training. And just like going to the gym or workout out, it sometimes takes a while before you notice a difference.

This week, we heard from Dr. Sibel Demir -- a doctor that specializes in back pain. Dr. Demir was so impressed with how much mindfulness meditation helped her personally, she went back to school to learn how to be a mindfulness teacher. In fact, she helped us design many of the mindfulness exercises you'll see throughout the course. From there, we started expanding what we mean to be mindful. You can be mindful of your breath, of your body, of sensation, or just about anything. We did a brief mindfulness practice and you'll get to practice more later this week. We then moved to thinking about thinking. We started training our brains to capture what we're thinking, evaluate how it makes us feel, then rethink it if it isn't very helpful. In fact, there's a lot of research that shows that challenging these negative thoughts and relaxing your body are probably the two best things that you can do for your pain. Be sure to try some of these on your own and practice with your coach. Throughout the rest of this course, you'll see that our Mind-based skills are either mindfulness meditation based or brain training skills. We think both will be important additions to your toolbox.

We also shared a list of things you can practice in your own time. Give them a try and see how they feel to you. Remember too, that you can click the icons at the bottom of the screen at any time. The books icon takes you to the library. The person icon takes you to a full list of the body intervention. The mind icon takes you to a full list of meditations and brain training. The file box takes you to the "My Stuff" sections where you can see your favorites, your survey scores, and review your pain flare-up plan. If you don't have a flare-up plan just yet, be sure to discuss this with your coach so you can create one together.

Next week, we'll take a deep dive into body-based interventions and see if we can find movement that works for you. Get going and be INSPIRED.

# Week 3

Welcome to Week 3 of the INSPIRE program -- you're doing great! Last week, we introduced "thinking about thinking" and more about mindfulness and meditation. Both can be super powerful tools to help you manage your pain. We hope you were able to try at least one meditation activity and one movement activity last week -- but if not, no worries, just let your coach know and you can work through this together.

This week, you'll start with a video where a Physical Therapist (PT) will talk about what movement is, why it's important, and how it relates to pain. You'll also hear stories about real patients and how they got better with the help of movement.

After the videos, you'll think about your experiences with different types of movement and exercise. This will help make your movement program just right for you.

Before we talk about exercise specifics, let's go over some important safety tips. It's important to warm up before exercising by doing easy activities to get your body ready. We can also prevent pain by doing exercises correctly and listening to our bodies. We'll talk more about staying safe as you make progress with your exercise program.

In the first lesson on movement, we'll talk about why exercise or just movement in general is good for you. You'll learn that although your pain may discourage movement, not moving enough can make actually make your pain worse. We'll discuss how we can break this pain cycle using gentle movement programs that fit your needs.

We'll talk about the health benefits of increasing your physical activity and movement. Ideally, everyone should aim for at least 150 minutes of physical activity each week and do strengthening exercises at least three times a week. But don't worry if you can't do this much right now, any movement is better than none and any increase in movement is a step in the right direction. Importantly, remember that you don't have to do all this movement all at once. I like to think about "exercise snacks" -- where you do maybe 5 minutes of movement here and there throughout the day -- snacking on movement. It all adds up but in a good way.

Finally, we'll discuss frequency, intensity, type, and time -- FITT for short. These are tools you can use to track and increase your exercise activities. After that, we'll show you some simple movements and have you pay attention to how they feel in your body to help you practice outside of the INSPIRE app.

Okay -- let's continue our journey toward managing chronic pain and learn about movement from a Physical Therapist!

Hi everyone, I'm Doctor Matthew Miller, and I'm a physical therapist researcher at UCSF. As a physical therapist, my job is to help minimize the effects of disability on how people live their lives and many of them are living with chronic pain.

Did you know that movement can be like medicine for chronic pain? It's true! When we engage in daily activities and exercise, it can actually help improve our mood, reduce feelings of depression, and improve our quality of life.

You see, our bodies are made to move. When we stay active, it sends signals to our brain that make us feel happier and more positive. Moving our bodies releases special chemicals called endorphins, which act like natural painkillers and boost our mood.

But here's the exciting part: exercise doesn't have to mean just going to the gym or doing intense workouts. Everyday activities like walking, dancing, playing outside, or even cleaning the house can count as exercise too! That means we have a lot of opportunities throughout the day to make our bodies feel good.

When we make movement a regular part of our lives, it can bring big benefits. It can help us manage our chronic pain better, improve our flexibility and strength, and even increase our energy levels. Plus, it can help us sleep better at night, which is important for our overall well-

being.

So, let's think beyond just "exercise" and see our daily activities as opportunities to take care of our bodies and minds. Let's find joy in moving and being active. Whether it's taking a stroll with friends, playing a game, or dancing to our favorite music, each movement can be like a dose of medicine for our chronic pain.

Remember, movement is not just good for our physical health but also our emotional well-

being. So let's start moving your body, have fun, and enjoy the benefits of movement as our very own form of medicine.

We know you might have done exercises before, but we want to keep you safe. Here are some tips to help you exercise safely:

1\. **Warm-Up**: Start with easy activities, like stretching or walking. This gets your body ready and helps prevent injuries.

2\. **Exercise Form**: Doing exercises the right way helps prevent pain. If your form gets bad, take a break or try an easier exercise.

3\. **Exercise Progression**: Increase your workouts little by little. This makes your muscles stronger and reduces pain. Take small steps!

4\. **Listen to Your Body**: It's normal to feel sore and tired after exercise, but avoid pain. If you feel pain, stop and rest. Try a different exercise if needed.

5\. **Know Your Limits**: Learn how much exercise is enough for you. Sometimes you might do too much, and that's okay! You will learn your limits over time.

6\. **Prevent Injury**: Use the right equipment, wear the right shoes, and follow advice for your condition. Staying safe makes exercise more fun!

Remember, everyone is different, and so are the injuries and conditions that cause pain. Pay attention to your own body's needs and talk to your coach if you have any questions. Any movement is better than no movement at all. Stay active, stay safe, and enjoy exercising!

We've talked about exercise and movement activities, but there are a few more things to know. It's important to understand how movement can help manage and reduce some of your pain.

First, pain is a signal from our body that something isn't right. It can be caused by injuries, illnesses, or other things. When we feel pain, we often move less because we're afraid it will hurt more. But guess what? When we move less, our muscles get weaker, our range of motion gets smaller, and the pain can get worse or last longer.

The good news is that when we start moving again, we can break this bad cycle! Exercise and movement build strength and flexibility, which help you reach your goals. Whether it's playing sports, dancing, or moving without pain, exercise can help you.

Different activities are better for different people and their goals. For example, if you want to get stronger, activities like lifting weights or doing push-ups can help. If you want more flexibility, activities like stretching or yoga are great. It's important to find activities that match your goals and body because these can help you feel better and achieve your goals.

So, let's get moving and see the power of exercise together!

We just talked about how the right exercise can help with chronic pain. Now, let's talk about different parts of exercise you can change to make it work for you!

These parts are frequency, intensity, time, and type -- FITT for short. Frequency means how often you exercise each week. Intensity is how hard the exercise is. For example, moderate-intensity activities make your heart pump faster and make you breathe harder. Time is how many minutes you exercise. Type is the kind of exercise you choose, like walking, swimming, or dancing.

When changing exercises to help with your pain, listen to your body. Here are some tips to help you:

1. **Frequency and Time**: Start slow with short and frequent exercises. Take breaks when needed. Maybe start with 10 minutes of activity (or two 5-minute sessions) for 5 days a week.
2. **Intensity**: Begin with low-intensity exercises that feel comfortable.
3. **Type**: Choose low-impact activities that are easy on your joints, like walking, swimming, or cycling. You can also do flexibility exercises like stretching or yoga to improve movement and reduce muscle tension.

Changing and improving your exercise over time will help you feel better. To do this, you can:

• Increase the duration by 2-3 minutes each session.
• Move slowly from low to moderate-intensity exercises. The goal is to challenge yourself without making your pain worse.
• Add different fun activities.
• Aim for 30 minutes of exercise 5 days a week.

Everyone's experience with chronic pain is different, so make an exercise plan that works for you. As you find the right plan, you'll start to see the health benefits of movement and exercise.

Now we are going to try an exercise! Each week, we will show you a new movement to help with your pain.

This week, you have two options. One exercise helps make your muscles stronger, and the other is a stretching exercise. We recommend watching the video first, then playing it again while you try it yourself.

Before starting, remember to go at your own speed! If any part of the exercise hurts, keep watching the video and try the next activity. After you've done one of these activities, we'll talk about how the mind and body are connected.

Now we are going to try an exercise! Each week, we will show you a new movement to help with your pain.

This week, you have two options. One exercise helps make your muscles stronger, and the other is a stretching exercise. We recommend watching the video first, then playing it again while you try it yourself.

Before starting, remember to go at your own speed! If any part of the exercise hurts, keep watching the video and try the next activity. After you've done one of these activities, we'll talk about how the mind and body are connected.

We talked about the importance of exercise and movement. Now, let's connect this with what we learned about the mind. Being present during movement means paying full attention to how your body moves right now. It's about noticing every feeling, every breath, and every move you make. This is important for living with chronic pain because it helps us understand our bodies and pain better.

When we are present while moving, we notice how our bodies feel and what they need. We can find areas of tension or discomfort and use gentle movements or stretches to help. By focusing on each movement, we can learn to move in ways that support our health and reduce pain.

Chronic pain can sometimes make us feel disconnected from our bodies or overwhelmed. By being present during movement, we can gain control and understand our bodies better. We can listen to our bodies with kindness and respond to their signals to promote healing and self-care.

It's important to approach movement with curiosity and compassion, without pushing ourselves too hard. Each movement is a chance to connect with our bodies, be aware of our pain, and find what feels right. By being present during movement, we can feel more empowered and strong in dealing with chronic pain.

To illustrate this idea, let's do a quick exercise.

You can do the following practice seated or even lying down. You can have your eyes closed or eyes open. Feel free to customize this technique so it works best for you.

Your hands are your primary anchor, or point of focus, for this practice. Be as mindful as you can of the movement and all the accompanying sensations. This moving meditation will begin with conscious breathing with the movement. Feel free to explore the movement with your breathing free and unrestricted.

Let your hands rest comfortably on the tops of your thighs. Close your eyes, or let them be open with a relaxed, soft gaze. Relax. Open your awareness to the sounds around you, the sense of smell, taste, and touch.

How intimately can you feel your hands from the inside right now?

Feel the backs of the hands.

Feel the volume of the palms, fingers, and thumbs.

Feel the space between the fingers.

You may be able to sense the pulse, tingling, or subtle sensations.

Bring your attention to your right hand, palm against your thigh.\ Gently turn the palm facing up.\ As you inhale, gently lift your right hand about five or six inches off your thigh.

You might inwardly whisper to yourself, "Lifting."

Turn the palm facing down, and exhaling slowly, lower the palm to your thigh.

You might inwardly whisper, "Placing."

Bring your attention to your left hand, palm against your thigh. Gently turn the palm facing up.

As you inhale, gently lift your left hand about five or six inches off your thigh.

You might inwardly whisper to yourself, "Lifting."

Turn the palm facing down, and exhaling slowly, lower the palm to your thigh.

You might inwardly whisper, "Placing."

Alternating now, lift and place your hands, consciously breathing with the movement and labeling "lifting" or "placing."

Let the movement be smooth and as natural as possible.

Notice how intimately you can time the breath with the movement of the hands.

The breath should feel easy, with no strain.

As you continue, you might release control of the breath.

Focus on the movement, noting what is happening as it's happening.

Feel free to experiment. It might be helpful to vary the pace, slowing down or speeding up slightly as you feel the movement of the hands.

Experiment with the practice of labeling.

You might concentrate on naming "lifting" and "placing" precisely as the movement is happening, but also feel free to drop the technique of labeling and focus more on the flow of movement.

Just as with breath-based meditation, your attention will wander again and again.

When you notice your mind has drifted, acknowledge this moment of wakefulness and guide your attention back to the practice.

Continue for as long as it feels helpful.

\*\*\* Use this practice anytime to gather your attention and cultivate a more embodied sense of presence and mindful movement.

We also wanted to talk about mindfulness in everyday activities. This means paying full attention to what we do every day, like brushing our teeth, eating, or walking. It involves being present and fully engaged, rather than doing things automatically or with a distracted mind. This is important for chronic pain because it can help us find moments of relief and peace in our daily challenges.

When we practice mindfulness in routine activities, we focus on the sensations, movements, and experiences. For example, when we eat mindfully, we enjoy the taste, texture, and smell of our food. We notice the act of chewing and swallowing and appreciate the nourishment it gives us.

By paying attention to these simple activities, we can find moments of calm and joy even with pain.

Chronic pain can often take over our thoughts. By practicing mindfulness in routine activities, we can create a break from the pain, shifting our focus to the present moment. This can bring relief, even if it's just for a short time.

By being mindful of everyday activities, we learn to appreciate small joys, even with pain. It helps us feel grateful for simple things and find peace despite challenges. So, as you go through your day, remember to be mindful of even the most ordinary activities. Let them become moments of rest and renewal in your journey with chronic pain.

Now, let's try a mindfulness activity to practice these ideas. This video is a guided meditation in sitting that will help you focus on breathing and listening to your body. Take a few minutes to try the activity, even if you don't finish the whole thing.

For the next few minutes, I'm going to guide some seated postures.

And there are three things to keep in mind.

The first one is the breath.

As best you can, let your breath be long, slow, deep, and full.

You'll be forgetting the breath from time to time, but the more you can remember the breath and keep it at the center of your practice, the more it will guide your attention inside.

The second is not to push\-- as best you can\-- to not extend beyond 75% of your capacity in any time.

And the third is if there's anything I lead that doesn't feel right for you, trust your body.

Listen to your body.

And respond to what feels best for you.

So when you're ready, you can close your eyes and we'll begin with a seated centering.

With your eyes closed, begin to slow down the breath.

And a particular form of breath you might explore would be to inhale slowly to the count of five.

And exhale slowly to the count of five.

Inhale slowly to the count of five.

And exhale slowly to the count of five.

And sense, if possible, through this whole sequence to let your breath be this slow and this full.

In particular, to sense if you can smooth out your breath as best as you can.

And as we prepare for some movement and meditation, you might turn your palms so they're facing up.

And you can turn the palms out to the side or bring the palms forward.

And as you're ready, slowly inhale to the count of five.

Bring the fingertips and palms together.

And then exhale, the hands right down to the midline of the body.

And again, turn the palms either out to the side or facing them forward.

Inhale, the arms, you bring them up overhead. Fingertips and palms together.

Exhale, down through the midline As you continue, notice as you draw the arms up overhead\-- you might be able to draw the breath all the way up under the collarbone.

So inflating the upper lobes of the lungs.

And again\-- as you exhale, just sense, and relax, and feel.

And as you breathe, drawing the breath into the upper lobes of the lungs\-- you might lift the chin slightly, as if you're looking up into the light.

And continuing on your own\-- feel the breath.

Feel the movement.

And feel the effect on the mind.

On the exhalation, let the hands come to rest on the tops of your thighs.

Close your eyes for a moment and just relax, and feel, and sense what's present.

And then as you're ready\-- taking your right hand, bring it to the outside of your chair.

Begin to deepen the breath\-- again, as best you can.

Breathing in slow to the count of five.

Exhaling to the count of five.

Turn the left palm out of the side or in front, depending on how much space you have.

And as you're ready, breathe that arm up, pressing down through the floor of the pelvis.

Down through the sit bones.

You might draw the navel in toward the spine.

And as you breathe, sense what can lengthen on the inhalation.

Notice everything you can feel on the exhalation.

And as you're ready, you might very gently let your torso begin to drift over toward the right side careful not to extend beyond 75% of your capacity.

And again, what could lengthen on the inhalation?

What can you feel on the exhalation?

Notice what happens if you draw that left shoulder blade back just slightly.

And in your own time, very gently let that hand drift down.

Track the hand as it moves through space, letting the left hand come down slowly to the outside of the chair.

Relax and feel.

And then as you're ready, turning the right palm out to the side or facing forward, depending on what space you have around you.

And as you're ready, gently inhale.

The breath slow, full, deep, and particularly smooth.

And again, as you're pressing down to the floor of the pelvis, pressing down through the seat bones\--

draw the navel in toward the spine slightly.

Sensing what could lengthen on the inhalation.

How much can you feel on the exhalation?

Inviting your torso now to drift gently over toward the left side.

Not to extend beyond 75% of your capacity, just to this place where you're engaged without any strain.

Where is the breath?

How much can you feel right now?

And what happens if you draw the right shoulder blade back, just slightly?

And as you're ready now, very gently release that hand down.

Track that hand as it flows through space.

Let the hand drift forward, bringing the right hand to the outside of the left knee.

Preparing for the spinal twist.

In this position, you can either bring your hand to your waist, or if you like, you can reach the left hand and hook it behind your chair if that's comfortable for you.

And facing forward, establish the breath\-- again, slow, deep, and smooth.

And press down to the floor the pelvis, down through the seat bones.

You might draw the navel in toward the spine.

And notice if it's possible\-- to both slightly lengthen through the back of the neck and at the same time to relax.

And as you're ready, moving with the breath as if you're tracing the horizon with your eyes.

Begin to draw the chin over to the left side.

Again, fully engage with the breath\-- full, deep, and smooth.

What could lengthen on the in breath?

How much can you feel and sense on the out breath?

Notice the quality of the breath and how the quality of the breath is directly related to the quality of your attention and to the quality of your experience.

And gently now, as you begin to release\-- let the torso begin to glide forward.

Taking the left hand, bringing it to the outside the right knee.

And facing forward.

Draw the right elbow or either the hand to the waist.

Or if you like, you can bring the elbow behind the chair.

Facing forward\-- again, center in the breath.

Slow, deep, full, and smooth.

And pressing down through the floor of the pelvis, pressing down through the seat bones\-- you might draw the navel in toward the spine just slightly.

And as you're ready, moving with the breath as if you're tracing the horizon with your fingertips.

Begin to guide the chin over toward the right shoulder.

And sense if you can keep the breath flowing\-- smooth, and full, and deep.

Inquiring what could lengthen on the in breath.

And noticing everything you can feel on the out breath.

One more full, slow, deep breath in.

And very gently now, beginning to return.

You might take a moment to rest your palms on the tops of your thighs and close the eyes.

And just sense, for these moments, the quality of presence.

And then as you're ready, you might either bring your hands to your waist.

Or if you like, you can take your palms and bring them to your lower back and press down into your lower back.

Once again, establish the breath.

Press down into the sit bones, down through the floor of the pelvis.

Draw the navel in toward the spine slightly.

Sense if you can both relax and lengthen to the back of the neck.

Then as you're ready, begin to draw the shoulder blades close together.

As you draw the shoulder blades close together, you might sense if you can draw the shoulders down just slightly.

And imagine that you are breathing your heart forward.

Fully engage with the breath now, as you enter into the posture.

And if it's comfortable for you, you might lift the chin slightly as if you're looking up into the light.

What could lengthen, what could open as you inhale?

How much can you feel on the exhalation?

Scanning for any new sensations.

Shoulder blades drawn close together, shoulders down slightly.

Feel the contraction through the back of the body.

And feel the sense of opening as you breathe the heart forward.

Very gently now, release\-- releasing the contraction.

Draw your palms to the tops of your thighs.

Take a moment to fully relax the breath. Relax through the back of the neck, along the base of the skull.

And then as you're ready, let the torso begin to come forward as you, in your own time\-- if it's comfortable for you\-- bring the torso right over the tops of the thighs and relax forward.

You might relax along the back of the neck.

Relax the muscles of the face.

You might relax the tongue and the lips.

And before you begin the return, you might imagine that you could stack each vertebra as you begin to roll the spine up to a seated position.

Very slowly, in your own time, stacking one vertebra on top of the other.

Letting your head come up last.

Very gently, begin to roll the spine up. In your own time, finding this sense of balancing the skull on the top of the spinal column.

Eyes closed, breath now fully released and free flowing.

Relax and feel this natural shift from movement to stillness.

Things we covered this week:

• Physical Therapist perspective about movement as medicine for chronic pain
• Different exercises for you to try and adapt to your needs
• Connecting movement and mind activities for chronic pain management

Great job! You've finished week 3. Remember, you are not alone on this journey. You have weekly meetings with your coach to talk about pain challenges while you're in the program.

This week, we focused on how exercise and movement can help your pain. Chronic pain can make everyday activities hard, leaving you less active and feeling down. It creates a bad cycle where less activity leads to more pain. Dr. Matthew Miller, a physical therapist, shared how movement and exercise can break this cycle by increasing your strength, range of motion, and mood.

We also talked about different exercises you can try, like walking, stretching, yoga, Tai chi, and strengthening exercises. We mentioned different things because everyone has different needs and goals. Try a few of them this week!

If you don't love the activities we talked about, don't worry. It might take time to find what works best for you. There are other options in the movement library. When you're done here, take a minute to explore them!

Finally, we connected mindfulness and movement with a seated meditation activity. There are other meditation activities for standing, walking, and more in the Mind section of the app. Try them out this week too.

Keep up the great work, and take notes of things to discuss with your coach. I look forward to seeing you next week!

Welcome to Week 4 of INSPIRE! Congratulations on completing one-third of the course! We hope that you've learned some useful skills so far and are ready to dive in this week.

In today's lesson, we'll start with a quick refresher on the different features of the app to make sure you can get the most out of this program. Then, we will explore how stress affects pain and how managing stress can help you better manage your pain.

Get ready to discover the incredible '1-2-3' stress coping skills! These three practical techniques will empower you to take control and feel more confident in handling the stress in your daily life. As you learn about the connection between stress and pain, you'll understand how managing stress can help you to reduce and better control your pain while improving your ability to function in your everyday life.

As always, we'll end with some practical suggestions for exercises you can practice on your own this week. These exercises will be part of your toolkit for managing stress and pain more effectively.

As always, your pain coach is available to support you and can help you practice and polish up these new skills.

We want to remind you that you're on a journey of growth, and each step you take brings you closer to a better understanding of yourself and your well-being. Let's get started!

In the face of chronic pain, a person can be compared to the lotus flower, which grows and blossoms in muddy waters. Just like the lotus, individuals with chronic pain face challenging circumstances and difficult experiences. However, in spite of these struggles they have the potential to grow stronger, wiser, and more beautiful.

The lotus begins its journey as a seed buried deep in the mud, surrounded by darkness.

Similarly, a person with chronic pain may initially feel overwhelmed by their condition, trapped in a cycle of discomfort and limitation. But just as the lotus seed perseveres, individuals can find inner strength and resilience within themselves.

As the lotus reaches for the light, its stem grows through the murky waters, defying the odds and pushing past adversity. Likewise, those with chronic pain can find the strength to rise above their challenges. Through their perseverance and determination, they continue to strive for a better quality of life, seeking relief and exploring different strategies for managing their pain.

Finally, the lotus flower emerges from the water, unfolding its petals in all their splendor and beauty. Similarly, individuals with chronic pain can find growth, transformation, and even moments of profound beauty in their journey. They develop resilience, compassion, and wisdom that can inspire others and bring hope to those facing similar struggles.

Just as the lotus flower is admired for its ability to thrive in unfavorable conditions, individuals with chronic pain can also inspire others by showing that it is possible to find strength and beauty even amidst difficulties. Through their experiences, they cultivate empathy and understanding, becoming a source of support and inspiration for others who face similar challenges So, remember that like the lotus, you too have the potential to grow stronger and more beautiful in spite of the difficult experiences you have been through. Embrace your journey and trust in your own resilience. You have the power to bloom and radiate your own unique beauty in the world.

You aren't in this alone - the INSPIRE team is with you to help you find the tools you need to build your own resilience. So let's get to it!

Have you noticed how pain and stress often go together? When you're in pain, you feel stressed. And when you're stressed, your pain gets worse. It's a tough cycle.

Today, we'll learn about stress and how it affects us. Don't worry! There are ways to manage stress and feel better. Let's dive in!

So, what is stress? Stress is our body's response to tough situations. It's like an alarm system, getting us ready to face challenges, including pain. It says, "Hey, this is tough. Let's get ready!"

When stressed, we feel overwhelmed or anxious.

But what if that stress alarm never shuts off? Then stress becomes a problem. If we're always stressed and see everything as a threat, the alarm keeps going off, even when it shouldn't. If we feel helpless, the alarm is on all the time, making us feel really stressed.

Stress affects our emotions, thoughts, bodies, and relationships. Our bodies might respond with tense muscles, headaches, or trouble sleeping. Long-term stress can weaken our immune system, making us more likely to get sick. Stress can also hurt our relationships, making it hard to connect with others, or making us want to avoid them and suffer alone.

Coping is how we deal with stress. It means finding healthy ways to manage and reduce stress.

Coping can be directly addressing a problem, like getting a massage for sore muscles, or doing something that lifts your mood, like talking to a friend.

Building resilience is about bouncing back from tough times and adapting to changes. To be resilient, we need to fine-tune that "stress alarm" so it only goes off when needed. This means thinking about our thinking, like we discussed before.

Being resilient also means not getting tangled up in worries. Mindfulness and meditation can help us focus on the present moment. Lastly, resilience means having different coping tools --

ways to solve problems and lift your mood.

The good news is you can learn to manage stress better. By reducing stress, you'll think more clearly, have more energy, and improve your health. You'll be better at focusing, making decisions, and facing challenges, including managing your chronic pain. Lowering stress also helps you find better ways to cope with pain and stops stress from hurting your body more.

We'll share 3 core coping strategies. The first helps you tackle stressful thoughts. The second uses movement as medicine to reduce stress. The third strategy takes us back to mindfulness skills to fight stress. Next, we'll explore how stress links with chronic pain and demonstrate these new skills.

You might wonder how stress affects your pain and why it's important to know this connection.

Let's look at what research says.

One theory is that your spinal cord acts like a gatekeeper for pain signals. If the gate opens wide, you feel more pain. But stress reduction techniques can close the gate, letting fewer pain signals through.

Remember, pain isn't just a simple nerve signal. It's a mix of nerve signals, mood, thoughts, stress, fitness, and more. The good news is, there are many ways to reduce pain, and one way is by managing stress.

So, what opens the gate and makes pain worse? Research shows that depression, anxiety, and stress can make us more sensitive to pain. Relaxation, joy, and positive distractions can close the gate and help us feel less pain.

Another theory is about our thoughts and beliefs. When we feel pain, it's natural to focus on it and think negatively. These thoughts can make pain feel worse and stress us out more, creating a downward spiral and opening that gate further.

Stress also takes us away from the present moment. When we're stressed, we worry about the future and disconnect from now. This raises stress levels and makes pain feel worse. We become very "un-mindful," which is the opposite of what we've been trying to do by focusing on the present without judgment.

And lastly, pain affects our movements too. It can make us afraid to move, but avoiding movement can decrease mobility and increase pain. Research shows that not moving can make things worse by making us lose strength and flexibility. With movement, you use it or lose it.

Understanding how stress affects pain helps us manage it better. In the next lessons, we'll cover the "1-2-3s" of coping with stress: tackling thoughts, increasing movement safely, and building mindfulness. Let's start by hearing from a patient who managed to turn things around despite being overwhelmed with stress.

Living with chronic back pain has been a struggle for me for years now. It affects my daily life, my activities, and even my ability to enjoy the things I love. Some days are better than others and initially this felt like it was out of my control. But what I've come to realize is that my thoughts and behaviors -- and how they relate to stress - play a crucial role in how I feel and how I manage my chronic pain.

Now, don't get me wrong. I didn't give up on the medical stuff. I'm still taking medications that help a little. But I've learned that reducing my stress is an important addition to my pain management plan and it just generally improves my quality of life.

At times, I catch myself constantly worrying about worst-case scenarios. "This pain will never end, I'm going to lose the ability to walk, I'm going to fall apart if this continues" - these unhelpful thoughts make my pain worse and put me in a bad mood. It's as if my mind becomes a battleground, filled with negativity and fear. And the more I dwell on these thoughts, the more intense the pain feels and the more hopeless I get.

But it's not just the pain itself that holds me back. It's also how it limits my daily activities. I become hesitant, fearful even, of movements that might trigger more pain. And in my attempt to avoid that pain, I sometimes end up avoiding those movements altogether. Unfortunately, this almost total avoidance only leads to more problems. I became out of shape, lost my flexibility, and actually made my muscle soreness and stiffness worse. I was trying to protect myself from the pain, but I ended up making things worse. It's a vicious cycle that I'm determined to break.

Stress has a way of pulling us away from the present moment. When I'm consumed by stress, my mind is filled with worries, anxieties, and uncertainties about the future. It's like I'm living in a state of chaos, disconnected from the here and now.

But I've learned that by managing my stress, I can lower the intensity of my pain. My pain doctor taught me ways to quiet my mind and be present in the moment. When I use these skills, the weight of my stress begins to lift, and my pain feels more manageable.

I wanted to share my story with you because I believe that there's nothing really special about my story and that and that we as patients with chronic pain can find relief. By understanding how our thoughts can make pain worse and the power of reducing stress, we can regain control over our lives. You're not helpless in your journey. You can learn new skills, shift your mindset, and embrace techniques that empower you to manage your pain and stress more effectively. If I can do it, then so can you!

The inspiring story you just heard is a powerful reminder that we have tools to help us overcome the challenges of chronic pain when we effectively manage our stress. Now, let's delve into the coping skills that will empower you to take control of your stress and better manage your pain. When we say "coping skills" we are referring to things that you can do to either directly address the things that are stressing you out or things you can do to change your thoughts, change your mood, and relax your body. Recognizing stress is important to both cope with the problem and cope with its effects on your mind, mood, and body.

In the upcoming lessons, we will guide you through the "1-2-3s" of coping with stress. These practical coping skills will empower you to face stress head-on and find relief. Let's take a quick look at each of these skills.

\[1\] The first skill is all about getting out of your head. We'll help you address negative thoughts and develop healthier ways to cope with them. By reframing your thinking and developing a more positive mindset, you can reduce the impact of stress on your pain levels.

\[2\] Second, we'll explore using your body to combat stress. Through simple movements and exercises, we'll show you how to release tension, increase relaxation, and restore balance. You'll discover the power of physical activity in managing stress and improving your overall well-being.

\[3\] Lastly, we'll delve into the practice of mindfulness by introducing a new meditation exercise called RAIN, which give you 4 simple steps to take to address your stress.

In the next lesson, we'll dive deeper into the first coping skill---getting out of your head. Are you ready to take the next step on your journey toward managing stress and pain? Let's get started!

Let's dive into the first coping skill: "Getting out of your head." Our thoughts affect how we feel, behave, and stress levels. Let's see how we can stop unhelpful thoughts from taking over and regain control over our minds.

Have you ever been stuck in a cycle of worry or negative thinking? Your thoughts keep looping, making you more stressed, even if you can't change things. This worrying can become a habit and make things feel worse. But remember, thoughts are not facts---they are just opinions in our heads influenced by pain and mood.

In Week 2, we talked about "thinking about thinking," where you catch a thought, think about it, and then try to think about it in a more helpful way. Now, we'll show you something different that might help you let go of those thoughts without a struggle.

A powerful idea to keep in mind is that you are not your thoughts. Just because you think something doesn't mean it's true or important. We have all sorts of thoughts that are just distractions inside our heads. Thoughts about pain or stress do not define who you are or how you live your life.

We can practice separating ourselves from our thoughts and creating some distance. This is called De-Fusion. It means keeping your identity and self-worth separate from your thoughts.

This allows us to observe our thoughts without getting caught up in them. Just notice the thought as if it were something floating by. Thoughts come and go.

So, how do we break free from our thoughts and be more present in the moment? Try a simple exercise called "Name 3 Things."

Here's how it works: When you get caught up in negative thoughts, notice three things around you---a sound, an object, or a sensation. For example, you might hear a truck driving by---that's one. You might see a pile of dirty clothes---that's two. You might smell your neighbor barbecuing---that's three. This exercise helps you connect with what's happening now, bringing your focus to the present moment. It takes you out of your head and away from stressful thoughts.

Ready to try it? Take a deep breath and start by naming three things you can see, hear, or sense around you. By "sense" we mean anything you can smell, taste, or touch. Look around and start naming those three things. So, what did you come up with? Did you find this easy or challenging?

Remember, this skill takes time and patience. Keep practicing it to embrace the present moment. It will help you get out of your head, interrupt your worries, and feel less stressed. Be sure to talk about this skill with your coach because it definitely takes practice!

As we go through our weekly lessons, you'll learn and practice different techniques to help you develop a healthier relationship with your thoughts.

Before we start the practice, let's review the key elements of "Naming 3 Things".

First, you have to catch when you are stuck in a loop of worrying. This loop can make you feel tense and anxious. When that happens, it's time to break out this coping skill.

Second, remind yourself that Thoughts Are Not Facts and they don't define your identity.

Thoughts are just like passing clouds in the sky---they come and go.

Now, let's practice taking a step back from your thoughts. Imagine you're observing them from a distance, rather than getting caught up in them. You can say to yourself, "Oh, there's a thought...and another one...and another one. I can just sit here and breathe."

Lastly, use something to focus on the Present Moment. You can always use mindfulness techniques you're learned, like focusing on your breath. Or you can do a simple but powerful exercise called "Name 3 Things."

This means taking a moment to notice and name three things around you---a sound, an object, or a sensation. If needed, just keep naming things over and over to keep yourself out of your head. This shifts your attention away from stressful thoughts and into the present moment.

As you practice, remember\...

1\. Be Patient: It takes time and practice to break out of unhelpful thought patterns. Don't worry if it feels a bit challenging at first---it will get easier with time.

2\. Stay Consistent: Make it a habit to regularly notice your surroundings. The more you practice, the more natural it will become.

3\. Let the thoughts pass: If focusing is hard or stressful thoughts return, remember that thoughts are like passing clouds---they don't have to control your mood or stress levels. Take a deep breath and gently bring your attention back to the present moment.

Let's practice together. Take a moment now to think of three things you can see around you, three things you can hear, and three things you can feel. Ready? Take a deep breath and begin by naming three things you can see, hear, or feel around you. Let this exercise guide you toward being fully present in the moment. Bringing your attention to what is happening right now helps to calm your mind and reduce stress.

Great job! You may also extend this practice beyond the "Name 3 Things" exercise. Throughout your day, try to be fully present and engaged in whatever you're doing---whether it's eating, walking, or talking to someone. These everyday mindfulness skills can help you stay present and out of your head.

In our next exercise, we'll move on to coping skill #2: "Using your body to combat stress." Get ready to discover how physical activity and movement can be powerful allies in managing stress and promoting well-being.

You're making fantastic progress on your journey toward managing stress and finding relief from pain. Keep up the excellent work, and I'll see you in the next exercise!

Welcome to the second skill in our "1-2-3s of Stress Coping" journey---Using Your Body to Combat Stress. In this lesson, we'll learn how physical activity can help deal with stress and improve well-being.

First, let's talk about what happens when we feel stressed. Stress shows up as tension in our bodies from things like work pressure, personal conflicts, or chronic pain. When stressed, our body releases hormones like cortisol and adrenaline.

Cortisol, the "stress hormone," helps our body respond to stress by giving us more energy and focus. But too much cortisol for too long isn't good and can make us more sensitive to pain.

Adrenaline, the "fight-or-flight" hormone, speeds up our heart rate and boosts energy during stress. But too much adrenaline for too long can also harm our health.

We can lower body tension and reduce pain by practicing things like breathing exercises, meditation, or progressive muscle relaxation. For now, focus on taking slow, deep breaths. You can also try the Body Scan or 3-minute breathing space techniques.

Using movement as medicine is the second skill in the 1-2-3 stress management package. Being active helps "burn off" stress, releases tension, and promotes relaxation. Physical activity can also distract you from worrying if you focus on your movements.

One simple way to be active is by walking outside. Walking moves your body and lets you enjoy nature. Movement, fresh air, and the outdoors can lower stress and improve well-being. Even in a city, you can walk around your neighborhood and notice trees, clouds, or kids laughing.

Another great option is walking with a friend. This adds social interaction and support, making the walk more enjoyable and helping lower stress. It's a powerful way to keep worries in check.

Whether you walk alone or with a friend, remember that physical activity is a valuable tool in your stress management toolbox. Reducing stress is key to relieving pain symptoms.

Let's practice Using Our Bodies to Combat Stress!

Congratulations on your progress in mastering the "1-2-3s" of coping with stress! You've already learned two out of three of these valuable skills.

This week, we will focus on Yoga to help with Coping Skill #2: Using Your Body to Fight Stress. Yoga combines gentle movements, deep breathing, and relaxation, which can calm you down, reduce stress, and improve flexibility and strength.

Here's why moving helps with stress: It releases tension and reduces stress hormones, making you feel better. Choose exercises you like, such as walking outside, which can help you enjoy nature and get fresh air. Walking with a friend can make it even more fun.

To keep exercise stress-free, try these tips:

1\. Start Small: Begin with short, easy activities. Gradually make them longer and harder.

This helps you build strength and makes exercise more enjoyable.

2\. Listen to Your Body: Feeling sore is normal, but avoid pain. Stop and rest if needed.

Try a different exercise if something hurts.

3\. Find Motivation: Pick activities you enjoy. Trying new things might be challenging, but you might find something that helps with pain and makes you happy.

4\. Overcome Challenges: If you're busy, try shorter exercise sessions. If you have doubts, remember the benefits. If you're too sore, take it easy and lower the intensity next time.

Pick one of these yoga videos, and do as much as you can. When you're done, click next to keep moving through this week.

Pick one of these yoga videos, and do as much as you can. When you're done, click next to keep moving through this week.

So let's get back to the 1-2-3s of stress reduction by looking at coping skill #3 where we use a meditation technique called RAIN to reduce stress. But first, let's take a quick detour and talk about mindfulness and stress more generally. At this point, we know that mindfulness works. Multiple research studies have shown us that mindfulness works to alleviate stress, reduce pain and improve functioning. There is no literal, paint-by-numbers prescription for coping with pain; however, there are several important teachings and skillful mindfulness practices to consider when working with pain and unpleasant sensations. We are going to share just a few here and remember that all of the strategies are available to you at any time in the INSPIRE library.

One important take home from the mindfulness world is that although the experience of pain may be inevitable, we can still manage our suffering. There are things we can do, strategies we can use to reduce the amount of suffering we feel even if the pain stays the same. So let's unpack that a little and see what that means. First, it acknowledges that we all will feel pain at some point whether it is physical pain, emotional pain or some other kind of pain. Life can be painful – sometimes chronically painful. Secondly, it doesn't mean that we choose to make ourselves suffer but it does suggest that the ways we react to pain can increase our sense of suffering. Remember that although pain and suffering often go hand in hand, you can have intense pain with low suffering – like maybe a woman having a baby – that's high pain but it's also high joy. On the other hand, you can have low pain but high suffering. A depressed person many have low physical pain but they may be suffering a great deal. Mindfulness tells us that bringing our awareness to the present with non-judgement and acceptance can help us avoid the trap of increasing our suffering.

Here are a few important take homes we have taken from our mindfulness teachers and authors like Tara Brach and John Kabat-Zinn: First, anything we bring awareness to deepens our presence and freedom. Because pain is an inevitable and frequent visitor, the intention to let this be a gateway to awakening will powerfully energize your path. Relating to pain with curiosity and kindness directly transforms your experience into a pathway of freedom and possibility. In a way, you are rewriting the story of what the pain means. It doesn't mean you are broken. It doesn't mean there is ongoing damage to your body. It is a sensation – an unpleasant sensation – that could possibly open new doors for you.

Second, when we resist pain – by physical tensing, emotional reactivity, mental judgment or behavioral avoidance – we give it power. It becomes our enemy and we become its victim. In a way our identity, becomes linked with the pain. The pain becomes our focus. It becomes central to who we are and where our energy goes. Resisting or fighting the pain turns unpleasantness into suffering. Although it may not seem this way, letting go or simply bringing your non-judgmental awareness to the sensation of pain can be the best strategy to reduce your suffering. Awareness and mindfulness are the antidote to suffering. By purposefully bringing a kind and mindful attention to pain and the resistance to pain, the identification and victimhood that creates suffering is dissolved. We aren't giving up. We are not allowing ourselves to be pulled into a downward spiral where our lack of awareness and our negative thinking make us suffer more.

So if we want to use mindfulness to manage stress and reduce suffering, what can we do? Click on the next page to learn about a meditation called RAIN.

We'll now practice a guided meditation called RAIN. In this meditation, we'll recognize a sensation and allow ourselves to experience it. I invite you to sit quietly and sit in a way that's comfortable but feels alert. You might close your eyes and take a few deep breaths.

[Pause] Scanning your life, bring to mind something that's going on that brings up an emotional reaction.

And it may be something that has to do with world events, finances.

It may be the well-being of another or of many others.

Maybe something to do with a personal relationship that's difficult.

It may have to do with your health.

So sensing something that brings up an emotional reaction like anger or fear, dislike or hatred, shame.

As you choose something to work with, it's best to choose something that's bothering you but not a traumatic experience.

[Pause] With whatever you choose, visualize a scene or situation that brings up this emotion, this place of emotional stuckness.

The room that you're in, if another person's involved, the look on their face or what might be being said. Sense what's the worst part of this for you, what's most getting under your skin.

[Pause] The R of RAIN is to recognize what's happening.

You might sense whatever feeling is most intense.

Is it fear? Worry? Anger? Agitation?

If there's more than one feeling, just choose whatever most caught your attention, and you might name it in your mind.

[Pause] The A of RAIN, allow the life that's here to be just as it is.

So sending a message to yourself to accept this entire experience and let it be.

Find that willingness to pause and accept that in these moments, this is what's here.

And you might even try whispering "yes" or "this belongs".

[Pause] Allowing creates a little space so you can begin to investigate.

Let your investigation be gentle, kind, and with curiosity.

Begin to explore what you're experiencing more closely.

You might again sense what the worst part of this is for you.

Maybe what you're most afraid of.

Maybe you can notice your beliefs behind these feelings.

Are you believing that something's wrong with you, that you're failing in some way, that you're unlovable, unworthy?

Or that you can't be close to another person, that if they're acting that way, they couldn't care about you?

Are you believing that you're unsafe or danger is near? Something bad's about to happen?

[Pause] And most importantly, sense where you're feeling the experience in your body.

If the belief is that you're falling short, what does that feel like in your body? Check your throat, your chest, and your belly.

And wherever you feel the most vulnerability or feelings, you might experiment and try putting your hand there, especially if you've never done this before, to keep the attention there.

Perhaps breathe with it and notice, what's it like?

Is there heat or tightness? Squeezing? Pressure?

You might let your face express what you're feeling. Again, experiment.

Bring the brows together, tightening in the jaw.

[Pause] And also your posture. You might find that you wanna hunch over a little bit, or whatever your posture does, it expresses the feeling.

Maybe your hands are in fists.

[Pause] Again, feel the throat, the chest, and the belly to sense the feelings inside you.

And with courage, feel right where the feelings are strongest.

[Pause] Now, I - investigating by asking the place where you feel the emotions the strongest.

What do you need?

Or how do you want me to be with you?

Does this fearful part of you want understanding?

Forgiveness? Company?

Does it want acceptance?

Compassion? Love? Feeling of protection?

[Pause] Imagine that you're listening from the most awake and wise part of your being so that you can begin to offer nurturing to the vulnerability inside you so you can begin to offer what is needed.

[Pause] Again, place your hand on the part of your body where you feel the emotions the strongest, if it's not there already, and let the touch of your hand communicate care and tenderness.

You might even vary the pressure so that it shows your intention to offer kindness to yourself.

You might offer yourself a wise message right now such as, "It's okay," or, "I'm here, and I'm not leaving." Or if there's fear, "Thank you for trying to protect me, but I'm okay right now." Or maybe, "Trust your goodness." Whatever message feels right for you.

[Pause] And lastly -- N for nurturing. Let nurturing be a sincere experiment.

And if it's hard to offer nurturing to yourself, you might imagine receiving love from another person or source.

The love and wisdom that flows through someone you trust, a dear friend or teacher or healer or spiritual figure or formless presence.

Perhaps you're imagining someone who loves you, their caring gaze.

And just try to sense their pure love flowing in through your hand, into the most vulnerable part of your being.

[Pause] Most of us have a hard time letting in love, so you might really set your intention.

Whether you're offering love from your own heart or receiving from another source, let it in. Let that vulnerability be bathed in love.

Let it into the cells, in the spaces between the cells, washing through your entire being.

[Pause] After going through RAIN, imagine the possibility of relaxing back into a state of loving awareness.

Letting go and allowing yourself into that light and that love. Sense the presence that's right here right now.

You might notice the difference between when you started, the sense of a small self, an angry self, an anxious self, and where you are now, a self that's aware, a self that's present.

And you might know this natural awareness and presence as the innermost truth of what you are.

[Pause] Expand your attention to sense others, wishing for them the same intention to wake up their hearts and minds and sense this heart space, the shared heart space that really is edgeless, that includes the earth our mother and all beings.

That all beings everywhere realize their very essence as loving awareness, that all beings live from that loving awareness, expressing their creativity, expressing their clarity, expressing their compassion and wisdom.

That all beings experience great, natural peace.

That there be peace on earth and peace everywhere.

[Pause] As we come to the end of this meditation, let yourself slowly embody this loving awareness.

\[Pause, followed by ringing the bell\]

Congratulations! You have completed the fourth week of INSPIRE, which was all about stress and how it relates to pain. As you learned, we all have stress and now we are familiar with how it affects our mood, our energy, our sleep, and our general well-being. This week, we took a closer look at how stress specifically affects our experience of chronic pain.

We learned about several pathways that explain why high stress can lead to more pain. Stress can literally open a gate that makes pain signals to our brain stronger and faster. It can also affect our thoughts, making them more negative, which in turn makes us feel even more stressed, tense, and tired. We learned how stress can push us away from the people we love and discourage us from doing things that might help with our pain, like gentle movements or activities that boost our mood.

But the good news is, there's a lot we can do to reduce our stress. In previous weeks, you learned about the 3-minute breathing space and different types of meditation that can ease our bodies and minds. You also learned how to manage thoughts that might be making you feel worse. This week, we added 3 new coping skills:

First, you learned how to get out of your head by focusing on the present moment. We did an exercise called "Name 3 Things" where you called out three things around you in the present moment. They could be objects, sounds, smells, colors -- just about anything. The point is that it helps us get out of our head so that we can focus on the present.

Our second skill was using movement to reduce stress. Learning this skill reminds us that it's important to spend time with people we love, and if we add some gentle movement by taking a walk or doing yoga together, it's even better. Even if you're alone, a walk in nature or simply somewhere outdoors can often bring some peace.

Our third skill was RAIN, where we Recognize what we are feeling, Allow the feeling to be what it is and how it is, Investigate the feeling and what it means, and Nurture ourselves with kindness and self-compassion. Learning meditation, just like the other skills, takes practice, so give it a try on your own or discuss it with your coach.

And remember, if you are ever in a pinch and need some quick stress relief, you can always come to the app and click on the Quick Relief Now button to immediately open up some helpful exercises.

Thank you again for completing Week 4. We look forward to seeing you for week 5, where we will explore more exercises to train your brain.

Be well!

With love and gratitude, The INSPIRE Team # Week 5

Hello and welcome to week 5! We're so glad you're back. The INSPIRE team really appreciates how hard you've been working, especially if you're in pain. It's not easy, but you're doing great, and we're thankful for that!

This week, we're going back to a topic from week 2 called "Thinking about Thinking." We learned to notice our thoughts, think about them, and then think differently about them. We figured out that thoughts are just things our minds do - they're not always true. In week 2, we thought of new, helpful ways to think or remembered some good things to tell ourselves when things get tough. Now, we want to understand where these thoughts come from, how they connect with our feelings, and what we do or don't do because of them.

We're going to show you something called the CBT triangle. It helps you see how thoughts, feelings, and what we do are all connected. We'll also talk about the "ABC" model. This simple idea helps you see how an activating event (A), what we believe about it (B), and the consequences that follow (C) are all linked. This helps us see how our thoughts can really change our feelings and actions.

We'll show you these ideas with a video and a fun exercise where you can try out the ABC's yourself.

After that, we'll talk about "behavior." We'll discuss what we mean by "behaviors" and look at physical activities -- including movement - that might help with your pain. We'll explore activities you enjoy, things that make you feel good, and see how they can affect your pain. Just like eating a healthy diet, you need a variety of activities to stay in good shape. We'll also plan specific times for activities and think about how they make us feel. We'll even think of some backup plans. Remember, staying active can help improve your mood and thoughts, even if you have chronic pain. Every little activity counts!

This journey is tough but very rewarding. The more you put into it, the more you'll get out of it. Let's get started!

Hello, everyone! Today we're going to explore what's called the CBT triangle. CBT stands for Cognitive Behavioral Therapy. It looks at cognitions -- or thoughts -- and behaviors which is how this type of therapy got its name -- Cognitive Behavioral Therapy. It's a way of understanding how our thoughts, behaviors, and feelings are connected and affect each other.

Let's take a look at this simple triangle.

The arrows show that each corner of this triangle affects the other two. What we think can change how we behave and feel. How we behave can affect our feelings and thoughts.

And our feelings can influence our thoughts and behaviors. Notice that the arrows are two-way arrows so these relationships go both ways. It's complicated but the good news is that if you want to change the way you feel or how you think or what you do, you can really jump in at any point to start making changes. But first, let's give some examples of what we mean by thoughts, feelings, and behaviors.

Thoughts are often the easiest to capture and write down because they are usually in words.

Thoughts might be things you say to yourself in your head or commentary you make to yourself about other people or situations. But thoughts aren't just things that happen on the surface, they are also beliefs we have about ourselves, our pain, and what sorts of treatments we believe will work. Thoughts can be memories of our past, thoughts about our present, or fantasies about the future. Thoughts can also be pictures or even musical lyrics. Thoughts are really the sum total of our mental activity.

Feelings are a little harder to capture. A feeling might be a sensation like pain or a grumbling stomach but usually we are referring to emotions like sad, mad, anxious, or happy. We can't just tell ourselves to feel something so if we want to change how we feel, we will probably need to change our thoughts or change our behaviors -- the other two corners on the triangle.

Remember, though, that the arrows are two way. When you feel depressed, your thoughts will be pushed in a negative direction and you will be more likely to be inactive in terms of your behaviors. It's all connected.

The last category is behavior and it's a pretty big one too. It could be something as simple as taking a shower or something a lot more challenging like running a marathon. It includes physical activity but also social activity like talking on the phone, texting, or going on social media. Behaviors can include healthy habits like eating a nutritious meal and also unhealthy behaviors like smoking or drinking too much. Some behaviors nourish us while other deplete us.

Some behaviors are pleasant while others give us a sense of accomplishment -- most people don't find cleaning the bathroom pleasant but at least you got something done! Our motivation to do behaviors can be influenced by our feelings -- our emotions -- and by our thoughts. How many times have you talked yourself out of doing something? And with these two-way arrows, remember that behaviors can affect our mood and our thoughts too. Going for a gentle walk in the woods (a behavior) can shift our thoughts to the beauty around us and lift our spirits.

So there you have it -- our CBT Triangle linking thoughts, feelings, and behaviors. Knowing this system can help you figure out why something's happening and it can also point to strategies to help you make changes. Can't find the motivation to go to physical therapy? Well, you might be thinking that it won't help or it's too much of a hassle. You might also just be feeling down or sad which further saps your motivation. Are you feeling especially good after a call with your pain coach? Well, the behavior of talking with your coach and sharing your progress most likely lifted your mood. And your thought of "Wow, finally someone listens to me" probably helped boost your mood too. It's all connected.

Next, let's look at something called the ABC model so we can get you set up for some interactive exercises. Just click Next to move on. If you want to save this clip, be sure to click on the heart button to save it a favorite.

We're going talk through the ABC model using scenarios with someone who has been dealing with back pain for a while -- Bob. Bob's pain disrupts his daily life, and because of it, he's not very active and tends to be irritable most of the time. Using the ABC model helps us see how events can trigger thoughts which can then cause feelings and behaviors to occur.

The 'A' stands for activating event, 'B' is for belief (really your thoughts), and 'C' is for consequence which could refer to your feelings or your behaviors.

Let's look at an example. Bob's 'A', the activating event, is waking up with back pain.

Bob thinks, 'I can't do anything today because of this pain.' That's his 'B', his belief or what he's thinking.

Because of his belief, Bob decides to stay in bed and skip his morning walk. He feels upset and frustrated. That's 'C', the consequence." It includes emotions and a behavior -- staying in bed.

Now, notice that there's a B in the middle. It's not just the activating event that makes Bob feel upset and frustrated, it's the activating event PLUS the way he thinks about the activating event. The ABC model makes sure we don't forget the B -- the beliefs. This will be especially important if we decide we want different consequences -- our C.

Let's rewind a bit. What if Bob changes his belief when he wakes up with the pain?

It's the same Activating event -- he wakes up with pain -- but a different belief.

This time, Bob thinks, 'I should take it easy, but I can still try to do my morning walk.'

That's a new 'B', a new belief.

Because of this helpful belief, Bob takes his time but still goes for his morning walk.

He feels better and less frustrated. That's a positive 'C', a positive consequence.

And that's the power of the ABC model. It helps us zoom in on that middle step -- the beliefs that are driving the consequences. By changing our beliefs, we can influence our behaviors and feelings (the consequences), even when dealing with an unpleasant activating event like chronic pain.

We can shift the ways we think about things that happen. It's all about knowing your ABCs -- or developing a more present-moment awareness of events that trigger you, what you think about the event, and the consequences it has for your emotions and your behaviors. A-B-C.

Let's now hear from another patient -- much like Bob -- who figured out how to improve his consequences using the ABC model.

Hi again, friends! Alex here. I'm back to share how changing my behaviors impacted my journey with chronic pain.

For a long time, my behaviors were directly linked to my pain. When I hurt, I'd shut down. I'd skip outings with friends, avoid tasks, even simple ones. The pain felt like an unscalable wall.

The more I allowed my pain to control my actions, the more my mood plummeted. I started suffering not just physically, but emotionally too. I felt isolated, disconnected from my life and the people in it.

But then I started learning about what is called behavioral activation in pain management. By activation, it just means you get more active doing more activities. It's about doing more but also finding a balance in what we do, just like a balanced diet.

I started by taking out my calendar and just writing in things that I intended to do. I began with modest goals. A five-minute stretch routine in the morning. Then, I added a hobby that I enjoy, painting. I broke down tasks into manageable bits. Instead of cleaning the entire house, I'd start with just one room. It helped to write my plans down on a calendar in advance and it felt really good to see that I was doing at least some of them.

Over time, I started reconnecting with my friends. A quick chat over the phone, a short visit to a nearby park. It wasn't easy, but planning ahead and taking small, manageable steps made it possible.

Being more active and finding the right activities had a profound effect. It lifted my mood and reduced my overall suffering. It brought a sense of purpose and meaning and even enjoyment back into my life.

I hope my story inspires you. Remember, with chronic pain, small, manageable changes in your behaviors can have a big impact on your life. Start small and write a few ideas down on a calendar. It's not just about managing the physical pain, but also about taking care of your emotional well-being.

Until next time, take care of yourselves and remember, you're not alone in this journey.

Now it's your turn to try the ABCD exercise. Before you start this exercise, we want you to find a piece of paper, divide it into a grid with four boxes, kind of like this. Label them A for activating event, B for beliefs or thoughts, and C for consequences, and the bottom right hand box is the D box for dispute. Push pause now and come back when you have your paper grid and you're ready to do the exercise.

Now that you have your ABCD grid, it's time to start filling things in.

First you want to start up with the a box in the top left corner, the activating event. It might have been a pain flare up, or it might have been a friend not calling you back. It's really anything that triggers beliefs and consequences, positive or negative. It's what gets this whole process started.

Next, you'll think about your beliefs, the thoughts that popped to mind when that activating event occurred. So for the first example, it might be, "Oh man, here we go again. This pain has ruined my life." Or it could be, "I might as well give up.

What's the point?" For the friend example, it could be, "I guess I'm just not that important to them," or' "That's the last time I call them. I'm sick of reaching out all the time." There's no right or wrong answer. Don't worry about if it's true or false.

We just want to decide, does it create helpful or hurtful consequences? And that's the next box that you'll do in the top right-hand corner for consequences.

Remember, consequences can be behaviors. They can also be emotions or feelings. So again, with that first example of a pain flare up, you might stay in bed all day as a behavior, or you may have the emotions of being angry, of feeling depressed, or your body might feel really tense. With our second example, you may have the emotions of feeling angry or really spiteful against that particular friend. You may have the impulse to ignore them the next time that they call you or text you and you just don't want to respond because you want to get even.

Now, if you decide that those consequences are not the ones that you want, then it's time to think about ways to try to change them, and the first place you would go is to think about the activating event. Now, we can't control everything in our environment, but we do have some control over what we are exposed to. For instance, if you know being around your brother-in-law is always going to trigger a bout of anger, well maybe don't be around him so much. If you know that having alcohol in that house will cause you to have a craving to drink, then make sure that you don't have alcohol in the house. You're exerting some control to remove as many triggers as possible.

The other thing you can do is to directly address those body-based responses. So if you're feeling stressed, if you're feeling really tense in your muscles, then what you could do is to do a relaxation exercise, like the meditation, like yoga, or even just some simple deep breathing or some relaxing music, so you can work on the activating event or the consequences. The last and biggest and probably most difficult category is to work on those beliefs, and that's the bottom right-hand corner in the dispute box. By dispute, we just mean to rethink those thoughts. We know that thoughts aren't facts. Their opinions and opinions change all the time.

So let's look at those initial thoughts and see if there's a way that we can rethink those thoughts so that they have better consequences.

So for the first example, you might say instead, "Yes, this stinks, but the flare up is temporary."

You've used the "Yes, but" technique that we talked about in week two: Yes, part of this is true, but there's more to it that's maybe not so negative. You might also think there are things I can do that help me feel better, like ice or massage. You're thinking about past experiences, past evidence, and you're also reminding yourself that you do have some control, even when it feels like you might not.

Let's look at our second example of a friend not calling you back. Well, you might think, "Well maybe they're having a hard time too. They've been depressed, and depression is no joke." Here, you're feeling some empathy towards your friend.

You're putting yourself in those shoes and imagining maybe alternate explanations other than them just ignoring you. You might also think, "Well, someone has to take the lead, and I'm able to do that right now. They did set up our last lunch date."

So again, you're changing your perspective. You're thinking about past events and coming up with a thought that hopefully has better consequences.

Now it's okay to have a hard time with the D box. In fact, nearly everyone gets stuck there, but that's okay, just let your coach know about it, and they can help you practice more. Once you've practiced a bit, you'll get better at it.

We suggest you do this ABCD exercise at least two to three times this week, then share it with your coach. And remember this is just one tool in your toolbox. All you need to do is find a few tools that work for you. Good luck.

We want you to practice the ABCD exercise at least 3 times this week. Through this activity, you'll identify:

• Activating event (something that happened that set off a strong emotion)
• Belief in what you were thinking
• Consequences of the event
• Dispute — a more helpful way to think about the activating event

Don't forget, your beliefs are your thoughts that went through your head, memories, or if you evaluated the scenario at the time of the event. The consequences were feelings, emotions, actions, or other things that happened after the event - whether good or bad feelings. The D is how you will dispute or rewrite your original beliefs that weren't so fair or helpful. Remember that while your thoughts are real, they may not be true! This is your opportunity to step back and see what you were thinking, and if it wasn't helpful, rethink it! What would you say to a friend if they had this thought? What's the other side of the coin? Are you being fair and balanced? Don't worry, the Dispute is the hardest part and you'll get more practice later. Make sure you work on your disputes with your coach.

Let's go back to what you learned about the CBT triangle. This is the triangle that shows us how you think affects how you feel and your behaviors also affect how you feel and even how you think.

Let's explore and better understand behaviors and activities that are especially important when you're managing chronic pain. Behaviors and activities include the things we do like hobbies, house chores, or social events, and are important because we tend to value them and they give us a sense of meaning. I want to emphasize up front that when we talk about behaviors, we aren't necessarily talking about big events or things that take a lot of time, effort, or money. We want to look at all behaviors big and small then see which ones we'd like to keep or change.

Ok. So first let's talk about types of activities. Some activities bring us a sense of accomplishment, like completing a gentle exercise routine or getting the kitchen cleaned. Others off er pleasure, like listening to your favorite music, or a comforting phone call with a friend. One isn't necessarily better than the other because you probably need both a sense of accomplishment and some pleasure in your life. You need a mix of things you have to do and things you want to do. It's similar to a balanced diet - we need a well-rounded mix of these activities supports our well-being. When you refl ect on your daily activities, do you have a healthy mix of things you want to do and things you have to do? A good place to start is to think of things you love to do. Do you like nature? Plan a walk in the park or time outside. Has a house project been making you anxious? Try taking just one small step toward getting it done.

Secondly, let's talk about pacing. We live in a fast-paced world where we are expected to do too much. But don't fall for it. Do what you can at your own speed. It's crucial not to overdo things, especially when dealing with chronic pain. Start with modest, manageable goals. Maybe you begin with a 5-minute gentle stretch routine and gradually extend it over time walking half a block and increasing it a few feet every day. So, be sure to pick your best time of day and respect how much you can do.

Lastly, if the activity or behavior seems really big and complicated, try breaking it down into smaller, manageable parts. Instead of cleaning the whole house, start with one room. If that one room is too much, just pick one corner or maybe just clear off the table. Once you've done that one piece, give yourself credit for the progress you've made. If you can, do the next step, and then the next. You can stop whenever you run out of time, energy, or if you start hurting too much. Before you know it, you will have made some progress or completed the task.

So remember, while managing chronic pain, a balanced variety of activities is as crucial as a balanced diet for physical health. Do things you want to do and things you have to do. Start small, pace yourself, and break things down if you need to. Remember that behavior and activities can have a strong effect on how you feel and even how you think. Every journey begins with one step -- and we are here to take that step with you!

Hi again, friends! Alex here. I'm back to share how changing my behaviors impacted my journey with chronic pain.

For a long time, my behaviors were directly linked to my pain. When I hurt, I'd shut down. I'd skip outings with friends, avoid tasks, even simple ones. The pain felt like an unscalable wall.

The more I allowed my pain to control my actions, the more my mood plummeted. I started suffering not just physically, but emotionally too. I felt isolated, disconnected from my life and the people in it.

But then I started learning about what is called behavioral activation in pain management. By activation, it just means you get more active doing more activities. It's about doing more but also finding a balance in what we do, just like a balanced diet.

I started by taking out my calendar and just writing in things that I intended to do. I began with modest goals. A five-minute stretch routine in the morning. Then, I added a hobby that I enjoy, painting. I broke down tasks into manageable bits. Instead of cleaning the entire house, I'd start with just one room. It helped to write my plans down on a calendar in advance and it felt really good to see that I was doing at least some of them.

Over time, I started reconnecting with my friends. A quick chat over the phone, a short visit to a nearby park. It wasn't easy, but planning ahead and taking small, manageable steps made it possible.

Being more active and finding the right activities had a profound effect. It lifted my mood and reduced my overall suffering. It brought a sense of purpose and meaning and even enjoyment back into my life.

I hope my story inspires you. Remember, with chronic pain, small, manageable changes in your behaviors can have a big impact on your life. Start small and write a few ideas down on a calendar. It's not just about managing the physical pain, but also about taking care of your emotional well-being.

Until next time, take care of yourselves and remember, you're not alone in this journey.

Congratulations on finishing Week 5! You're almost halfway through! We focused a lot on behaviors and activities this week.

We learned about the CBT triangle, showing how thoughts, feelings, and behaviors are interconnected. Each one influences the others. We also explored the ABC model, which helps us understand our reactions in different situations:

• A stands for the activating event, the thing that starts it all.
• B is the beliefs or thoughts that come up.
• C represents the consequences, how the event and your thoughts affect your

feelings and actions.

We added a D for dispute, which is when you challenge unhelpful thoughts. Don't be discouraged if this doesn't make sense to you, we know this is one of the toughest parts of the whole program. That's why you'll be meeting with your coach. They can help offer tips, clear up any confusing parts, and guide problem solving for other challenges too.

Next, we took a closer look at behaviors, a key part of the CBT triangle. You learned about different types of behaviors---things you want to do versus things you have to do---and the importance of balancing them. Every behavior counts, even simple ones like taking a shower, eating, or walking, because they all affect our mood and thoughts.

We discussed pacing ourselves with activities and exercise and breaking them into smaller, manageable parts.

We also talked about activity scheduling for the next week. Scheduling, even smaller activities, makes us more likely to do the activities we know will help us in the long run.

Give it a try this week!

Just like the past few weeks, we also hope you keep practicing your mind and body skills, like walking, stretching, or trying new activities like yoga or Tai Chi. Continue with the meditation type that suits you best.

Remember the ABCs, and try to apply them in real life. Your coach is eager to see how you do. Keep up the great work, and see you next week!

# Week 6

Welcome to Week 6 of the UCSF INSPIRE chronic pain management program! You're halfway through this journey. Be proud!

Take a moment to think about your progress. Over the past weeks, you've learned valuable skills to manage your chronic pain including mindfulness, meditation, movement, and ways to think about your thinking. Hopefully, you've found some favorite tools to add to your toolbox -- just be sure to mark them with the heart button as you move through the app.

Remember, the app also has extra resources like the library and videos. Just click the library button at the bottom of the screen. Explore the library to learn more and find new ways to manage pain.

If you haven't been able to keep up fully, don't worry. You can still make a positive change, no matter where you are in your journey. Remember that every step matters.

This week, we'll start bringing all the lessons together. We'll look at how thoughts about movement can affect your motivation and your chances of better managing your chronic pain.

We'll also introduce new mindfulness exercises that you might want to add to your favorites.

Keep going, stay motivated, and trust in your ability to create positive change. Your efforts to manage your chronic pain are inspiring, and we're here to support you.

Let's dive into Week 6! We will keep building resilience and well-being in the face of chronic pain. Are you ready for this next step in your journey?

Meet Sarah, a busy mom who has lived with chronic low back pain for years. Like many of you, she faced daily challenges.

With help from her pain coach, Sarah learned skills that changed her life. The UCSF INSPIRE program is here to teach you these skills too.

Sarah used to think, "I can't handle this pain." It affected her mood, her relationships, and her enjoyment of life.

But then she found out she could cope. The program taught her to spot and challenge unhelpful thoughts. At first, it was hard, but with practice, it made a huge difference.

Thought records became her best friend. They helped her see negative thoughts as just thoughts, not truths. She learned to change them into positive thoughts.

This made a big difference. She started doing activities she loves, spending quality time with her family, and being more present at work.

Today, Sarah says, "I am in control of my thoughts and my life." There are still tough days, but she has the skills to get through them with resilience and hope.

As you start Week 6, take it from Sarah and dive in. The UCSF INSPIRE program will teach you these important skills. It may take work, but it's worth it. You'll find new ways to manage your chronic pain and improve your life.

You've got this! Join us in Week 6 and let's take the next steps together.

Welcome back to our pain management journey. In Week 5, we learned about the ABCD grid and how to challenge negative thoughts. Today, we'll learn about "Habits of Mind." Remember: Thoughts are not facts; they are like clouds passing through the sky. We can observe them, but they don't define reality. It's crucial to recognize our thoughts as either helpful or hurtful. Habits of Mind are our usual ways of thinking. These habits can sometimes lead to biased thinking. They influence how we see and respond to different situations. Here are some examples of habits of mind:

• **Personalization**: Blaming yourself for things beyond your control. For instance, "My chronic pain is all my fault; I must have caused it with my bad habits."
• **Magnification**: Making a situation seem worse than it is. For example, "My pain is unbearable; it will never get better, and I can't handle it."
• **Fortune Telling**: Predicting the future negatively without evidence. For example, "I know my pain will never improve, and I'll always be limited by it."
• **All-or-Nothing Thinking**: Seeing things in black and white. For instance, "If I can't attend the entire family gathering due to pain, it's pointless to go at all."
• **Overgeneralization**: Drawing broad conclusions from one event. For example, "I tried one pain management technique, and it didn't work, so none of them will ever work for me." Have you experienced these habits? Being aware of them helps you catch them. When you notice these patterns, ask if they are helpful or hurtful in managing your pain. Just like with negative thoughts, you can challenge these habits of mind. Cognitive restructuring helps you reframe these thoughts. Here are some tips:
• **Show compassion to yourself**, like you would to a loved one. What would you say to support someone you loved?
• **Use the "Yes-But" strategy** to create a balanced view. Yes, something bad happened BUT there's another side to it.
• **Be a fair judge**, evaluating the evidence for and against these thoughts. Let's re-write some examples:

**Personalization**: "My chronic pain is all my fault."

**Re-Written Thought**: "Chronic pain can have many causes. I'll focus on managing my pain with my coach's help."

**Magnification**: "My pain is unbearable; it will never get better."

**Re-Written Thought**: "My pain can be intense, but I've handled tough days before. I'll use my strategies and stay hopeful."

**Fortune Telling**: "I know my pain will never improve."

**Re-Written Thought**: "I can't predict the future. I'll take one step at a time and stay open to improvement."

**All-or-Nothing Thinking**: "If I can't attend the entire family gathering, it's pointless to go."

**Re-Written Thought**: "I may not stay the whole time, but I can still enjoy some moments with my family."

**Overgeneralization**: "One technique didn't work, so none will."

**Re-Written Thought**: "One technique didn't work, but I'll try others to find what helps."

Changing these habits takes practice and patience. Be gentle with yourself. If it's challenging, ask your pain coach for support. In the next lesson, we'll continue building on these skills. Keep up the good work! Small steps can lead to big progress in managing your pain. You've got this!

After learning about ABC, where we explored the connections between activating events, beliefs, and consequences, we will now dive deeper into a powerful technique called "Thought Records." Thought Records help us understand our thoughts and emotions better. They let us challenge negative thinking and develop more balanced ways of thinking. ABC+D stands for Activating Event, Belief, Consequences, and Dispute. Notice how one can identify the activating events, their beliefs, the consequences they experienced, and how they disputed their negative thoughts. By understanding their thoughts and disputing them, they created more positive outcomes.

Now, let's learn how to create our own Thought Records using the mobile app's helpful tips. To start, think of a recent event that triggered negative thoughts related to your chronic pain. Identify the Activating Event, the situation that led to these thoughts. Next, write down your Beliefs - what thoughts went through your mind at that moment. Be honest and specific. Now, examine the Consequences - what emotions or behaviors resulted from those thoughts? Understanding the impact of these thoughts on your feelings and actions is crucial. Here's where the Dispute comes in - a powerful step in challenging negative thoughts. We'll teach you two ways to dispute your thoughts.

**Method 1: What would you say to a friend who had this thought?** Imagine your best friend or a loved one had the same thought you wrote down. What would you say to them? Use the same kindness and compassion towards yourself.

**Method 2: Yes\...But** Use the "Yes\...But" strategy. Acknowledge the truth in your original thought, and then reframe it in a more balanced way. This helps you create a more realistic perspective.

Now it's your turn! Let's practice filling out two Thought Records on your own using the ABC+D format. This exercise will help you become more aware of your thought patterns and enable you to dispute negative thoughts effectively. Great job! You've completed two Thought Records. By practicing this exercise regularly, you'll get better at challenging negative thoughts and developing a more positive mindset. Lastly, as an option, you may choose to ask your Pain Coach to review your Thought Records and provide feedback. Our coaches are here to support you in managing chronic pain. Remember, each step you take in disputing negative thoughts brings you closer to building resilience and improving your well-being. Keep up the fantastic work, and we'll see you in the next lesson!

Let's dive in with our first skill practice. Here, we want to apply the ABCD tool that you learned last week. It is a structured way to help you to better understand and address negative consequences you might be having in your life. Let's keep our focus on thoughts about movement and how those thoughts might cause us to be inactive or even hopeless and depressed -- the negative consequences.

Recall that for ABCD -- you divide a piece of paper into 4 squares. The A for Activating event goes in the top left corner. The B for beliefs (or thoughts) goes in the bottom left corner.

Remember that the beliefs are under the surface just like they are under the horizontal line on your page. The C for consequences is in the top right -- they are above the line where you can see them. They might be emotions or behaviors or something else. Consequences can be good or bad. The D for dispute goes in the bottom right corner. The dispute is where you re-write your thoughts after you have analyzed them for fairness or balance or helpfulness.

Now that you have your ABCD grid, it's time to start filling things in.

First, you want to write down an activating event that is related to movement. It might be listening to this lesson about movement that stirred up some thoughts. It could be your significant other asking you if you'd like to go for a walk. Really anything that starts off this process of thinking and reacting.

After you have your activating event, see if you can capture what you were thinking -- your 'B'

for belief. It's easy to notice the feelings that came up later but the thoughts can be a bit trickier. What went through your head? Did it bring a memory to mind? Did you evaluate the situation? Maybe blame yourself or someone else? Did you have any thoughts about things not being fair? Just jot down the beliefs.

Now it's time to write down the consequence. Remember that consequences can be emotions or behaviors and they can be good or bad, pleasant or unpleasant. Did you feel angry, hurt, sad, or lonely? Did you raise your voice, slam the door, or go hide in your bedroom? Do you feel motivated or unmotivated to be active? If the consequences aren't what you wanted, then it's time to do the D box -- your dispute.

Now, the D box is the hardest since it is tough to step back and see our own thoughts. Refer back to Week 2 Thinking about Thinking if you need to. Remember these tips:

• If someone you loved shared these negative thoughts with you, what would you say to

them? How would you support them and help them have more hope? This strategy is all about helping us have the same compassion for ourselves as we have for others.

• Try "Yes-But" -- If you thought is "I can't be active or I'll injure myself" you could rethink

it to "Yes, injury is possible but I can start small and listen to my body. Inactivity is its own kind of injury." This strategy acknowledges that part of the original thought is true but overall it is too negative and unhelpful.

• Imagine you are a judge looking at the evidence for and again a particular thought. If

the original thought is "If I get out of bed and start moving, I will be in horrible pain so I should just lie here all day" -- the judge would want evidence for and against. Yes, you have had days with horrible pain. Yes, exerting yourself physically can sometimes trigger a pain flare-up. But the judge would also see that lying in bed has weakened your muscles, reduced stamina, and reduced flexibility. The judge would see that you've been ok doing some light activities in the past and sometimes even felt good afterwards. So the judge might rewrite that thought to "When I get out of bed and start moving, I'm often sore and ache more at first. But if I pace myself and don't over do it, I can sometimes feel better. Lying in bed all day doesn't really help and it isolates me from the people and things I love. If I'm going to be in pain regardless, I might as well do something."

It's ok to have a hard time with the D box. In fact, nearly everyone gets stuck here. But that's ok. Just let your coach know about it and they can help you practice more. Once you've practiced a bit, you'll get faster and better at it.

And remember that this is just one tool in your toolbox. All you need to do is find a few tools that work for you and help you get moving.

In this lesson, we'll look at how our thoughts affect our actions, especially with movement and exercise.

Thoughts can either get us moving or make us want to give up. Imagine thinking about going for a walk or starting a new exercise. What comes to mind? Do you think about your energy, pain, or how nice it is outside? These thoughts can motivate or discourage you. We've learned ways to make our thoughts more helpful, like the ABCD or thought record exercises.

First, recognize your thoughts about movement. Are they helping or hurting you? Are they fair?

Can you just observe them, or do you need to rethink them?

Let's try an exercise. Think about a movement activity, like stretching or walking. Notice your thoughts, both positive and negative. Now, evaluate those thoughts. Are any negative ones holding you back? Reframe them in a more helpful way.

For example, if you think, "I can't do this; it's too hard," reframe it to, "I can start small and build up. Every effort counts."

If you think, "It won't make a difference," rethink it to, "Movement might help. I won't know until I try."

It's normal to have both positive and negative thoughts about movement. Challenge the unhelpful ones and embrace positive thoughts to help with pain management.

On the mobile app, there's an exercise to explore your thoughts about movement. Keep practicing and challenging unhelpful beliefs. Your journey towards managing pain is full of growth and self-discovery.

In this lesson, we'll explore how our habits of mind can influence our approach to movement and physical activities. Our habits, shaped by past experiences and thought patterns, can either support or hinder our journey towards effective pain management.

Just like some people tend to be optimists, while others are more pessimistic, we all have unique habits of mind. These habits influence how we think and act in various situations.

Remember, it's not about being right or wrong, but about recognizing whether these habits are helpful or hurtful.

Life experiences can also shape our habits. For example, if you've experienced an injury, you might become overly worried about certain activities that involve using your back, even when your back is feeling okay. It's natural to develop these cautionary habits as a protective response.

Now, let's take a moment to reflect on our own habits of mind. Think about your approach to movement and physical activities. Are there any habitual patterns that either support or hinder your progress?

It's essential to recognize these habits and assess whether they are serving you well or holding you back. Some habits might be helpful in keeping you safe, while others might limit your ability to engage in activities you enjoy.

We want to encourage you to start examining these habits. Ask yourself which ones should stay because they protect your well-being, and which ones might need to be challenged or let go to create space for growth and progress.

Embrace the opportunity to cultivate habits of mind that support your journey towards better chronic pain management. Cultivate habits of positive thinking, self-compassion, and mindful movement.

On the mobile app, you'll find a helpful exercise to explore your habits of mind and movement further. Take this opportunity to reflect and refine your habits, making way for positive change.

Remember, you've made it through two-thirds of this week's lessons, and you are making good progress. Keep going, and trust in your ability to embrace positive change in your pain management journey. You've got this!

This week, we talked about aerobic activities and how they help manage chronic pain. We also discussed how our thoughts affect how active we are.

We hope you started an aerobic program, like walking. To progress this idea, we want you to try other forms of aerobic exercise by adding in 2 days of a new activity like swimming, biking, or hiking. Find activities you enjoy to add more tools to your toolbox.

Pay attention to your thoughts about these activities. What did you think before, during, and after the activity? Notice any negative habits of mind, like blaming yourself or predicting the worst. How did these thoughts affect your motivation and experience? Use the strategies you've learned to break these habits and negative thoughts to reach your exercise goals.

This journey can be tough, but you can do it! Remember, your coach and others in your life can help you. Keep up the good work!

For this week's movement spotlight, let's talk about aerobic exercise, also known as "cardio." We'll review what it is, its benefits, and ideas to help you get moving!

**What is Aerobic Activity?** Aerobic exercise makes your heart beat faster and helps your body use oxygen better. It involves moving your body in ways that keep your heart rate up for at least 10 minutes. This type of exercise strengthens your heart, helps you breathe better, and boosts your energy.

**Benefits of Aerobic Exercise:** Aerobic exercise is great for your heart and breathing, but it also improves your mood, reduces stress, and helps you sleep better. It can even reduce pain over time by releasing natural painkillers called endorphins.

**Ideas to Get Moving:** We've already talked about walking, which is a simple aerobic activity. Other activities to consider are swimming, dancing, biking, and jogging. These activities get your whole body moving and your heart pumping. Some might seem challenging, but think about which ones you might enjoy. Start slowly with small steps. You can also break up your exercise into shorter sessions throughout the day. Low-impact activities like swimming or using a stationary bike are great alternatives. If you haven't tried these, think about who you could talk to for help -- starting something new is easier with a friend.

**Final Tips:** Listen to your body, review the safety tips, and talk to your coach if you have questions about exercise and movement.

This week, our movement spotlight described aerobic activities and how they can be beneficial for managing chronic pain. We also talked about how thoughts can be related to how active we are in our daily lives. We hope you feel like you've been able to get started on an aerobic program like walking, but we want you to explore other forms of aerobic exercise this week. Just like other parts of this program, exploring new tools is important, because you may find that you enjoy this new strategy, and it might work well for you. In addition to the program you've already started on, add in two days where you try a new aerobic activity. These can be things like swimming, stationary biking, hiking, or any other activity that is sustained for 10 minutes. The goal is to find activities that you enjoy that can give you more strategies to be active. Think of these strategies as tools in your toolbox that can be used for different purposes. In addition to trying these new activities, we want you to pay special attention to the automatic thoughts that come up about the activity. What are the things you thought about when you decided to do the activity? What were you thinking about when you were doing the activity. What about after the activity? Also think about any habits of the mind that come up for you. Did you blame yourself focusing on negative events, predict future events with a negative lens, or take an all or nothing approach this week? How did these thoughts or habits of the mind influence your motivation or experience? Consider strategies that you can use to break your habits of the mind and negative thoughts so that you can achieve your movement and exercise goals. We know this journey can be tough, but we believe in you. You're not alone in this journey, too. Don't forget that your coach or other people in your life can also help you work through some of these challenges too. Keep up the good work!

Our Plan:

1\. Sleep, Insomnia, and Pain Education 2\. Thoughts, Behaviors, Activity, and Insomnia 3\. Treatments for Sleep 4\. Behaviors to Improve Sleep Welcome to week 7! Congratulations! You are now halfway through this program. You've come a long way in exploring mindfulness, working with thoughts, and adding movement into your daily routines. It's ok if you've had a few setbacks or still have some doubts. This is totally normal.

Now for this week's content where we will focus on something most don't get enough of -- Sleep. Are you interested in getting a good night's rest? Tired of being tired? This week we will look at some proven mind-body strategies to help you get a good night's rest. We will first do a little education about sleep and more specifically about insomnia and the major things that cause us to lose sleep -- like having chronic pain or high levels of stress. Then we will turn to proven strategies to help us sleep better and sleep longer. You'll see that some of the tools you have already learned - like relaxation and not getting tangled up in thoughts - can come in handy here too. So let's get started and see what we can do to improve your sleep.

Sleep is something we all need to stay healthy and feel our best. It helps our bodies and minds rest, heal, and recharge. For some people, though, falling asleep or staying asleep can be really tough. This is called insomnia, and it's more common than you might think.

Insomnia can affect anyone, but it can be especially challenging for someone living with chronic pain. Chronic pain is when a person has long-lasting pain that doesn't go away easily. This kind of pain can make it really hard to get comfortable and relax enough to fall asleep. It's like having a constant ache or discomfort that keeps your mind racing and tense even when you're tired.

The relationship between pain and sleep is really like a cycle. When someone is in pain, it can be tough to fall asleep or stay asleep. Lack of sleep, in turn, can make the pain feel worse and more intense. Your body and mind just can't recover without sleep. It becomes a vicious cycle that's hard to break. That's why it's so important to find ways to manage both pain and sleep to break the cycle and feel better.

Beyond chronic pain, there are other reasons why people experience insomnia. Sometimes, stress or worries can make it difficult to sleep. Imagine having a medical procedure tomorrow or worrying about a sick child at home -- it's hard to shut off your thoughts and drift into dreamland. Depression and anxiety are other common causes of insomnia as are medical conditions like sleep apnea or snoring and restless legs. Other times, certain medications, caffeine, alcohol, unhealthy sleep habits, or changes in routine can throw off your sleep pattern and really affect sleep quality.

Getting enough sleep is vital for everyone, especially those living with chronic pain. It helps the body and mind heal, boosts energy levels, improves mood, and improves overall well-being. If you are struggling with insomnia, it's important to assess and address the issue. We recommend following this program but also talking to your doctor or healthcare provider who can help find ways to improve sleep and manage pain. Everyone deserves a good night's rest!

Sometimes, a person's thoughts, behaviors, and emotions can cause insomnia. This means trouble falling asleep, waking up in the middle of the night, or waking up too early. As the last lesson mentioned, sleep problems can be caused by many things. Let's use the CBT triangle to understand how our thoughts, emotions, and behaviors affect sleep.

Our thoughts can play a big role in insomnia. Worries or fears that keep replaying in our minds can make it hard to relax and fall asleep. We might worry about money, family, health, or anything else. Sometimes we worry about things that haven't happened yet or replay bad memories, like fights or losses. Thoughts like "Oh no, another sleepless night" or "I must sleep because tomorrow is a big day" can also keep us awake. These thoughts activate our brains and bodies so much that we can't sleep, even if we're tired. As we learned with the CBT triangle, thoughts affect our emotions. How we think affects how we feel, and both can affect our sleep.

Emotions like sadness, anxiety, anger, or frustration can cause insomnia. They make us stressed and tense, which interferes with sleep. As we learned in earlier lessons, emotions are linked to thoughts. You feel sad because of sad thoughts, or anxious because you're thinking about a threat. It's hard to just change an emotion. Telling yourself to "snap out of it" doesn't work. But changing our thoughts or behaviors can help.

Our behaviors, or the things we do, also affect our sleep. Spending too much time in front of screens, like watching TV or using electronic devices, can make it harder to sleep. The bright lights from screens can trick our brains into thinking it's daytime. Also, too much excitement before bed, like playing video games or having loud noises around, can make it hard to relax. Drinking coffee or alcohol or taking long naps during the day can cause insomnia. Doing too much physical activity or exercising right before bedtime can make our chronic pain worse or make us too active to fall asleep.

So our thoughts, feelings, and behaviors can all affect our sleep. The first step is to understand this connection and see how it works in real life. Can you think of any thoughts, feelings, or behaviors that might be interfering with your sleep? Next, we will do a sleep assessment and then move on to strategies to help you get some rest.

Let's do a brief reflection exercise to explore how your thoughts, feelings, and behaviors might be affecting your sleep. Here's some step by step instructions:

1. Think About Your Day: Take a moment to recall your day from morning to bedtime. Try to recall what you did, how you felt, and what you spent time thinking about.
2. List Down: On a piece of paper, make three columns:

Thoughts: Were you anxious about a job interview, thereby making it hard to fall asleep? Or perhaps you felt grateful for a well-spent day, leading to a peaceful night? Feelings: Were you stressed or anxious? Maybe sad or down about something that happened?

Behaviors: Did you have caffeine late in the day? Maybe you watched TV or used your phone right before bed? Perhaps you had a late-night heavy metal?

1. Connections: Try to connect these examples to nights when you felt you had good sleep and nights when you didn't. Are there patterns? Maybe on days you feel accomplished, you sleep better. Or perhaps on days you skip your evening walk, you find it hard to doze off .
2. Plan for Better Sleep: Now that you've identifi ed potential influencers of your sleep, think about small changes you can make. For instance, if screen time before bed disrupts your sleep, can you read a book instead?

Wrap-up: Understanding how your daily thoughts, behaviors, and activities influence sleep is a step towards healthier sleep patterns. Regularly reflecting can help you identify patterns and make meaningful changes to improve your sleep over time.

Insomnia can often be exacerbated by negative thought patterns and worries about sleep. Cognitive restructuring is a technique that can help you challenge and change these unhelpful thoughts. We used the ABCD technique in weeks 5 and 6. Here, we will focus on the B -- the beliefs and the D -- the dispute or how we might rethink the thoughts that are keeping us awake.

Step 1: Identifying Negative Thoughts and Beliefs: Begin by identifying the thoughts and beliefs that contribute to your insomnia. These could be concerns about not being able to fall asleep, fear of being tired the next day, or frustration about past sleepless nights. Write down these thoughts.

Step 2: Dispute the Negative Thoughts: Now, dispute these negative thoughts. Ask yourself:

• Is this thought based on facts or assumptions?
• What evidence do I have that contradicts this thought?
• Am I catastrophizing the situation?
• How likely is the worst-case scenario to happen? For example, if your thought is, "I'll never be able to function tomorrow without enough sleep tonight," challenge it by considering past instances where you managed well despite lack of sleep.

Step 3: Rewrite the Negative Thoughts: Rewrite your negative thoughts into more balanced and realistic statements. For instance:

• From: "I must get eight hours of sleep; otherwise, I can't function."
• To: "While it's ideal to get eight hours, I can function reasonably well with a bit less sleep. One night of poor sleep doesn't ruin my ability to cope."

-Remember to use some of the more general techniques we shared in weeks 5 and 6 like "What would you say to a good friend having this thought?" or you could use the "Yes...But" technique -- "Yes, I'll be tired if I don't sleep well but I've managed to function MANY times before with very little sleep."

Step 4: Creating a coping statement. You might also try to create a new positive coping statement to replace negative thoughts. For example:

• "I am resilient; I can handle the day even with less sleep."
• "My body knows how to rest, and tomorrow is a new day." We suggest just taking out a piece of paper and giving this a whirl.

When someone is experiencing insomnia, there are several evidence-based interventions that can help improve their sleep. These interventions include medications, behavior changes, mindfulness, movement and exercise, and relaxation techniques. One highly effective intervention, known as Cognitive Behavioral Therapy for Insomnia (or CBT-i), is considered the gold standard for treating insomnia.

Medications can be prescribed by doctors to help improve sleep in some cases. However, it's important to use them under the guidance of a healthcare professional, as they can have side effects and should not be relied upon as the only solution. There are over-the-counter sleep aids like melatonin or Benadryl but we advise first talking with your doctor about these. They may interact with your other medications and will most likely have side effects.

Behavior changes can also make a big difference in improving sleep. Establishing a regular sleep schedule, with consistent bedtimes and wake-up times, can help train the body to know when it's time to sleep. Avoiding stimulating activities, like watching TV or using electronic devices, close to bedtime can also be helpful. Instead, engaging in relaxing activities such as reading a book or listening to calming music can prepare the mind for sleep. Having a set wind-down routine -- like taking a bath, brushing your teeth, and turning out the lights - can also help train your brain and body that it's time for sleep.

Mindfulness techniques, like deep breathing and meditation, can calm the mind and promote relaxation before bedtime. These practices help redirect attention away from racing thoughts and worries, allowing for a more peaceful state of mind conducive to sleep. As you focus on your breathing, your body usually relaxes, your heart rate slows, and you might start to feel drowsy.

Movement and exercise can play a role in improving sleep as well. Engaging in regular physical activity during the day can tire the body, making it easier to fall asleep at night. However, it's important to avoid exercising too close to bedtime, as it can make the body feel too alert and awake. And remember that we've learned about "Pacing and Spacing". Be sure to pace yourself and not do too much activity too quickly. And make sure you space your movement activities far enough apart that you don't injure yourself or get too sore or depleted.

Among these interventions, CBT-i stands out as the gold standard for treating insomnia. It combines various techniques, including addressing negative thoughts and worries about sleep, establishing healthy sleep habits, and using relaxation techniques. CBT-i helps people develop long-term skills and strategies to improve their sleep patterns, leading to lasting improvements in their quality of sleep. We encourage you to look online for the many free CBT-i offerings or you might even considering downloading the free mobile app called Insomnia Coach that walks you through 5 weeks of CBT-I.

Remember, everyone's journey to better sleep is unique, and what works for one person may not work for another. It's important to work with a healthcare professional who can guide and tailor the interventions to individual needs. With the right approach and support, it's possible to achieve restful and rejuvenating sleep.

Research shows that movement and exercise can help you sleep better. When you exercise, it can make it easier to fall asleep and stay asleep. Aerobic activities like walking, swimming, and dancing are really good for sleep! They use up extra energy and make your body feel tired and relaxed. But try to avoid intense exercise close to bedtime because it might make you feel too awake to sleep well.

Since we talked about aerobic exercise last week, let's learn about another type of exercise that helps with chronic pain and sleep: Tai Chi. Tai Chi is a gentle exercise from China. It involves slow, flowing movements that help calm your mind and relax your body. Because of this, doing Tai Chi can help improve your sleep. It's like a mix of exercise and meditation that can help you get a good night's rest. To try Tai Chi, you can follow the Youtube videos below.

Transcript coming soon.

Transcript coming soon.

"I used to struggle with sleep every night due to my chronic pain. It felt like a never-ending cycle of pain keeping me awake, and lack of sleep making the pain worse. But then, my doctor introduced me to something called Cognitive Behavioral Therapy for Insomnia (CBT-i), and it changed my life.

CBT-i taught me so many helpful techniques to improve my sleep and manage my chronic pain. The first thing we worked on was my thoughts and worries about sleep. I used to get anxious and frustrated when I couldn't fall asleep, but CBT-i helped me understand that these negative thoughts were only making things worse. By learning to challenge those thoughts and replace them with positive ones, I started feeling more relaxed and confident about my sleep.

One of the best things about CBT-i was the focus on establishing healthy sleep habits. My therapist helped me create a consistent sleep schedule, with regular bedtimes and wake-up times. This routine helped train my body to recognize when it was time to sleep, and I found myself falling asleep more easily. We also worked on creating a relaxing bedtime routine, like reading a book or taking a warm bath, which signaled to my body that it was time to unwind and prepare for sleep.

CBT-i also taught me relaxation techniques that I could use when I felt my pain levels rising. Deep breathing exercises and guided imagery helped me calm my mind and body, reducing the intensity of my pain. I learned to focus on the present moment and let go of worries that would keep me awake at night.

Since starting CBT-i, my sleep quality has improved significantly. I now sleep more soundly and wake up feeling refreshed. And the best part is, the improvements in my sleep have had a positive impact on my overall quality of life. I have more energy during the day, which allows me to engage in activities that I enjoy. I can spend quality time with my family and friends without feeling constantly tired or irritable.

CBT-i has been a game-changer for me. It has given me the tools and strategies to break the cycle of pain and poor sleep. While chronic pain is still a part of my life, I now have a better understanding of how sleep and pain interact, and I can manage them more effectively. I am so grateful to my healthcare provider for introducing me to CBT-i and helping me regain control of my sleep and my life.

If you're struggling with both chronic pain and insomnia, I highly recommend exploring CBT-i. It may take some time and eff ort, but the benefits are truly worth it. CBT-i has transformed my nights from restless and painful to peaceful and rejuvenating. Don't give up hope -- better sleep is possible, even with chronic pain!"

When it comes to improving sleep, there are several behavioral strategies that can make a big difference. These strategies focus on changing behaviors and habits to create a more conducive environment for sleep. Let's explore some of these strategies.

One helpful tool is keeping a sleep record. This involves writing down important details about your sleep, such as the time you go to bed and wake up, how long it takes to fall asleep, and any disruptions or awakenings during the night. By tracking your sleep patterns, you can identify patterns or triggers that may be affecting your sleep. This information can then be used to make adjustments and improve your sleep routine.

Another important strategy is practicing good sleep hygiene. Sleep hygiene refers to creating a sleep-friendly environment and adopting healthy habits that promote better sleep. This includes having a comfortable and quiet sleep environment, ensuring a cool and dark room, and using a supportive mattress and pillow. Establishing a relaxing bedtime routine, such as reading a book or taking a warm bath, can signal to your body that it's time to wind down and prepare for sleep. It's also helpful to avoid stimulating activities close to bedtime, like using electronic devices or watching exciting TV shows.

In addition to sleep record-keeping and sleep hygiene, there are other behavioral strategies that can improve sleep. Setting a consistent sleep schedule, with regular bedtimes and wake-up times, can help regulate your body's internal clock and promote better sleep. It's important to avoid napping during the day, as it can interfere with your ability to fall asleep at night. Engaging in regular physical activity, like moderate exercise during the day, can also contribute to better sleep. However, it's best to avoid intense exercise close to bedtime, as it can make you feel more alert and awake.

By implementing these behavioral strategies, you can create a sleep routine and environment that supports restful and rejuvenating sleep. Remember, everyone's sleep needs are different, so it may take some trial and error to fi nd what works best for you. If you continue to experience difficulties with sleep, it's important to consult with a healthcare professional who can provide further guidance and support. Restful sleep is within your reach, and with the right behavioral strategies, you can improve the quality of your sleep and wake up feeling refreshed and ready for the day.

So far we've learned how thoughts, feelings, and behaviors can aff ect your sleep. You did some self refl ection about a typical day and started looking for causes of your insomnia. You learned about treatments including behavioral interventions and something called sleep hygiene. This next exercise will help you better assess how you measure up with the sleep hygiene recommendations. Circle the items that fi t for you. The items you checked are signs of good sleep hygiene. The ones you don't check are things you might want to try out.

Based on recent research and our more than 20 years of working with people who have sleep difficulties, we've created a short-list of things you might try to sleep better:

• Only go to bed when you feel sleepy
• Get up at the same time every day even if you didn't sleep well
• Get out of bed and do something mellow if you can't sleep fall asleep after 20-30 min
• Do not nap or limit to 30 min before 2pm
• Limit caffeine and alcohol
• Improve your sleep environment
• Keep a worry list next to your bed to jot down items that wake you up
• Be kind to yourself. Insomnia is very common so you are in good company!

Welcome to this guided sleep meditation for deep relaxation and restful sleep. Find a comfortable position in your bed, allowing your body to sink into the mattress. Close your eyes gently, and let go of any tension in your muscles.

Begin by bringing your awareness to your breath. Feel the natural fl ow of your breath, the gentle rise, and fall of your chest and abdomen. Breathe in slowly and deeply through your nose, allowing your lungs to fi ll with fresh, calming air. Hold it for a moment, and then exhale gently through your mouth, releasing any tension or stress.

With each breath, imagine inhaling relaxation and exhaling any worries or thoughts. Let go of the events of the day; they no longer serve you in this moment. This is your time to rest and rejuvenate.

Now, shift your awareness to your body. Starting from your toes, imagine a warm, soft light gently relaxing every muscle it touches. Feel this soothing light slowly moving up through your feet, ankles, and calves, melting away any tension. Allow this warm light to travel up through your knees, thighs, and hips, easing any discomfort or restlessness.

Feel the relaxation spreading to your lower back, your abdomen, and your chest. Let the warmth and calmness fi ll your body, releasing any tightness or heaviness. Let it travel through your fi ngers, hands, and arms, all the way to your shoulders. Sense the tension dissolving away, leaving you feeling light and tranquil.

Imagine this comforting light now bathing your neck and throat, relaxing all the muscles. Let it fl ow into your face, softening your jaw, your cheeks, and your forehead. Feel the space between your eyebrows smooth out, and your eyelids becoming heavy and warm.

Now, visualize yourself in a serene place, a place where you feel completely safe and at peace. It could be a beach, a forest, a meadow, or any place that brings you tranquility.

Picture the details---the colors, the textures, the sounds, and the smells. Feel the gentle breeze against your skin and the softness beneath you.

As you continue to breathe deeply, sense the connection between your body and the ground beneath you. Feel supported and secure. Allow any remaining thoughts to drift away like leaves on a gentle stream, leaving your mind clear and calm.

Now, bring your awareness back to your breath. With each inhale, imagine drawing in the pure essence of relaxation, and with each exhale, release any tension, allowing it to dissolve into the peaceful atmosphere around you.

As you begin to drift into sleep, know that you are safe, you are at peace, and you are deserving of this rest. Embrace the stillness and surrender to the quietude of the night.

Sweet dreams. Goodnight.

Congratulations! You have now completed the materials for week 7 where we focused on sleep and how to treat insomnia. We learned about how pain and insomnia create a vicious cycle -- you can't sleep because you hurt but then you hurt more the next day because you don't sleep. This is all made worse by thoughts, feelings, and behaviors that might further push us away from the restorative rest our body and minds need to recover. You did some quick self-assessments for yourself then learned about all the different evidence-based strategies that might help you sleep better -- including this week's movement spotlight on Tai Chi. We introduced you to the idea of sleep hygiene and helped you do some more self-assessments with a sleep hygiene checklist. We then pulled forward our previous skill of Thinking about Thinking where we used the ABCD technique to rewrite our thoughts to be more helpful. Lastly, we introduced a relaxing new sleep meditation that we hope you'll try. As always, we hope you can review and practice these skills over the course of the next week and beyond. Best of luck and may you sleep well this week.

# Week 8

Welcome to Week 8 of the INSPIRE program! You're now two-thirds of the way through-- great job! We've shared many strategies to help you manage your chronic pain. Different tools work for different people.

Let's do a quick review of the strategies we've covered so far: managing chronic pain with movement and exercise, doing more activities, mindfulness, and thinking about thinking. This review will help you remember these strategies and build your toolbox.

This week's new material is about building confidence in managing your chronic pain.

Confidence is important because it makes you feel like you can achieve your goals and motivates you to put in the eff ort. We know building confidence can be tough, so we'll talk about what it is and how to build it.

Take a deep breath, and let's get ready to build more skills to manage your chronic pain. I'm confident that you've got this!

All right, let's first review "movement as medicine." In Week 3, you learned that movement can generally be described using the FITT criteria which stands for frequency, intensity, type, and time. When we think about frequency, that means how many days a week you are doing physical activity. Remember that even little activities count so be sure to give yourself credit. Try to have movement activities every day if you can. The I stands for intensity or how difficult or challenging the activity might be. It's always important to respect your body and start with an intensity level that matches your ability. It might be at a beginner level -- like walking short distances with no hills or it could be a moderate or high intensity exercise that makes you breathe harder and increases your heart rate -- like biking or swimming. The first T is for type of exercise or movement and it is exactly what you might think -- it just specifies what the activity is. It might be something like walking, cycling, or swimming but it can also mean things like gardening or housework or other everyday activities. Remember that all activities 147 count! The last T - time -- is the time that you take to be active added up over the course of the day. So you may find that you do 5 minutes of walking in the morning, 10 minutes of house chores before lunch, 15 minutes of walking in the afternoon and then you may fi nd that you do gardening in the evening for 10 minutes. This means that you've done 40 minutes of activity in the day even though each time you were doing activity it was maybe anywhere between 5 and 15 minutes. So remember to think about FITT -- F, I, T, T -- frequency, intensity, type, and time. By applying FITT to your activities, you'll get a better idea of where you are today and things you might do in the future to help yourself move more.

The last thing I wanted to remind you about today is called pacing and spacing. Think of your daily activities as a race -- just like marathon runners carefully pace themselves, you need to do the same. It's essential to consider not only the time but also the intensity, type, and frequency of your activities. Pacing helps reduce the likelihood that an activity will worsen your pain or cause a new injury. Additionally, spacing out your activities throughout the day helps prevent you from getting over-tired or sore and will gradually build stamina, allowing you to accomplish all your desired tasks without being overwhelmed.

By adhering to these guidelines and being mindful of how you structure your movement routine, you can harness the power of movement as medicine to enhance your physical well-being and more effectively manage your chronic pain. Remember, every small step counts toward your larger goal of a healthier and more active lifestyle.

Our next review topic is about a concept called behavioral activation -- which is really just finding ways to be more active and get more things done. Behavioral activation means doing things that you enjoy, make you feel good, or that are important to you. These activities can help you feel happier and less stressed, even if you're dealing with chronic pain. We asked you to start keeping a record of your activities all the way back in Week 2. We asked you to start scheduling more activities starting in Week 5 -- when you also learned about the CBT triangle and how our activities affect our mood and our thoughts.

When we talk about activities we are including things that you NEED to do and WANT to do -- the key is that these activities are important to you! There are things you need to do, like going to work, doing chores, or going to school. Things you want to do might include reading, drawing, spending time with family. Both kinds of activities are important and give you a sense of purpose and responsibility. It's like having a balanced diet -- you don't want all of one activity. You want a healthy mix of diff erent types of activities. Remember, it's okay if you can't do a lot of big activities. All your activities, even the small ones, add up throughout the day! Things like watering plants, listening to music, talking with friends, going for a walk, or reading are all activities that add up and can help your mood. Even if you can't do a lot at once, doing a little bit here and there still counts.

In Week 5, you learned about activity scheduling. An activity schedule is when you make a plan, decide on activities that you want to do each day, and fi gure out what time you want to do each activity. You might put these into a calendar on your phone or write them down each morning. The important part is that you decide when you will do which activity. Make sure they are realistic but don't let negative thoughts talk you out of doing something new or different.

You also learned about self-monitoring or activity recording. With this strategy, you keep track of the activities that you did by writing them down. Include how long you did each activity, and how it made you feel. By keeping this record, you'll get a better idea of what the best activities you can schedule to improve your mood. This is Activity scheduling and Activity recording.

Alright, so that's the refresher about behavioral activation. It's a helpful way to become and stay active, doing things that matter to you! Hopefully, you can keep track of your activities -- old and new -- and figure out what works for you. And don't forget: every little activity counts!

Next up is our review of mindfulness. Mindfulness means being fully present and aware of where we are, what we feel, and what we're doing without judgment. It helps us respond thoughtfully instead of reacting quickly. So far, we've practiced mindfulness of breath, body sensations, thoughts, emotions, movement, and everyday activities. To develop mindfulness skills, practice both formally with special time for activities like guided meditation and informally by incorporating mindfulness into daily life, like eating or walking.

Let's review key mindfulness concepts:

Presence and Awareness:

Mindfulness involves being fully engaged in the present moment. For chronic pain, this means accepting the pain without judgment and seeing it as a sensation, not a defining feature. Awareness helps you understand pain patterns and triggers, allowing better choices about activities and self-care.

Non-Judgment and Acceptance:

Mindfulness encourages observing experiences, including pain, without labeling them as good or bad. This non-judgmental approach reduces emotional suffering. Acceptance means acknowledging pain without resigning to it. It frees mental and emotional energy for constructive actions.

Responding vs. Reacting:

Mindfulness teaches responding with intention instead of reacting impulsively. Instead of frustration or despair, you can pause, breathe, and choose a deliberate response, like gentle movement or breathing exercises. This breaks negative reaction patterns, reduces stress, and promotes control.

In conclusion, mindfulness changes how you relate to chronic pain. Through presence, awareness, non-judgment, and intentional response, it offers hope and healing. Mindfulness empowers you to transform your relationship with pain, reclaiming control and purpose. Remember, you are not just your pain but a resilient being capable of facing life's challenges with grace and strength.

The last topic we'd like to review is what we called "Thinking about Thinking" all the way back in Week 2. We took a deeper dive into Thinking about Thinking with the ABCD exercises in Weeks 5 and 6. Remember that you can always go back and review prior weeks or you can fi nd all the exercises about thinking.

So what is thinking about thinking or what is more formally called cognitive restructuring? Thinking about Thinking is a step-by-step tool to reshape our thoughts turning the unhelpful ones into more positive and benefi cial ones.

First, it's important to remember how thoughts shape our world. Ever notice when you think positively, you feel good, and then you act confi dently? That's because your thoughts set off a chain reaction. They're like sunlight breaking through the clouds, making us feel great about ourselves and everything around us. These thoughts can be as simple as, "I did a good job today!" or "The world has so many beautiful things." But unhelpful thoughts are the cloudy days. They can make everything look gray. They add challenges to our day, and can even make our pain feel more intense. For example, thinking "I'll never get this right" or "My pain will never get better" can really bring us down. When you do thinking about thinking, you fi rst become aware of the thought, then you really examine it -- you think about your thinking -- to decide if it is helpful or hurtful. If it is fair or balanced or accurate. If the thought is hurtful then you Rethink the thought -- you rewrite it so that it is more fair, more balanced, and more constructive.

So, again, those 3 steps are 1\. Be Aware of the Thought: "I always mess things up."

2\. Think about your Thinking: Is this always true? Have I succeeded before?

3\. Rethink the Thought: "I might have made a mistake today, but I've done well before, and I can learn from this."

If you'd like to practice this some more, go back to the ABCD exercise. Thinking about thinking is a powerful tool that we've seen transform people's lives. We hope you'll give it a try too!

Alright, now that we've reviewed a few topics that are familiar to you, let's shift gears and learn something new. We're going to talk about the concept of "self-efficacy."

Self-efficacy is a belief that we have control over situations in our life. It's like having confidence and trust in our own abilities to do things to improve our situation. When we believe we can do something, and do it well, it can help us overcome challenges and achieve our goals.

Self-efficacy is important for many parts of our lives, especially for our health. When we feel confident about taking care of ourselves, it can make a big difference in how we feel and how well we do, especially with managing chronic pain. Let's look at three important areas where self-efficacy matters:

1\. Chronic pain: Living with chronic pain is tough. Having self-efficacy can help you cope and better manage living with the pain. When we have a positive belief that we can manage our pain, and not let it control our lives, we can find better ways to deal with it and improve our overall well-being.

2\. Exercise and movement activities: Self-efficacy plays a big role in exercise. We've talked about how exercise and movement can help manage pain, but we also know that regularly exercising can be hard! If you have better self-efficacy and confidence, you feel good about doing exercise and movement activities, helping to grow your motivated to keep them going and try new activities.

3\. Health: When we believe we can make healthy choices, like eating nutritious foods, getting enough sleep, and manage medications, we are more likely to do those things. Engaging in these healthier activities and choices can lead to better health, like feeling stronger, having more energy, better mood and improved quality of life.

Summary:

● Remember past successes ● Watch others succeed ● Take small steps first ● Have a plan, resources, and tools So far we've learned that your self-confidence affects your ability to manage your chronic pain. Feeling like you CAN do something really boosts your motivation to take action. Believing you can manage your pain also helps you get through any setbacks you might experience. People who are confident are better at problem solving. They are more hopeful and generally more successful. But how do you build more self-confidence?

Research has shown there are a few proven ways that you can improve, build, and cultivate your self-confidence.

First, you can recognize your past successes. When you are feeling down, it's easy to remember failures but harder to remember successes. Take a moment to reflect on your past achievements, no matter how small they may seem. Remind yourself of times when you faced challenges and succeeded. Write them down or say them out loud so they are harder to forget. How do you feel when you think of those successes? Hopefully, recognizing these successes proves from your own experiences that you CAN make things happen. You CAN overcome challenges.

The second way you can build self-confidence is through watching other people succeed. Observing others or just hearing about other people who have successfully managed chronic pain can be really helpful. Learning from their experiences can provide inspiration and ideas for coping strategies. This is why we've included lots of patient stories throughout the program. These inspiring stories show that people can and do succeed at managing their pain. You can also seek out support groups or connect with other people who share similar experiences to gain their insights and encouragement.

Third, break a big task into small steps so that you can experience success at each step of the way. Recognize and celebrate every time you take a step forward even if it is just a baby step. Let others know about your progress. Positive feedback from yourself and others reinforces your belief in your abilities and motivates you to keep moving forward.

Lastly, having solid plans, resources, tools, and support can help build your self-confidence. If you take time to develop specific plans, it will be easier to handle challenges and manage your pain. Looking for and using helpful resources and tools, like relaxation activities, exercise and movement activities, and the ABCD, can also help to make things easier, increase your chances of success, and help build your confidence. It's also helpful to build a support network of friends, family, or healthcare professionals who can encourage and help you on your journey - especially when the going gets tough!

Remember, building self-confidence is a gradual process, and it's okay to face setbacks. Remember those past successes, think about others like you that have succeeded, be sure to break things into small steps that you can recognize and celebrate. We believe in you -- now it's time to believe in yourself! Be inspired!

Hi there! I'm Sonia, and I want to share my story with you. Living with chronic pain for the past few years has been tough, but what made it even harder, especially in the beginning, was my low confi dence and lack of control. Every time the pain fl ared up, I'd feel defeated, thinking I couldn't handle it, and it held me back from living the life I wanted.

I used to avoid going out with my friends because I was afraid the pain would ruin everything. Even small tasks, like doing the dishes, or taking out the trash, felt like giant obstacles. I couldn't see a way out of this cycle.

But then, something changed. I learned about the power of building self-confi dence to make positive changes. First, I recognized that I wasn't always helpless. I dug deep into my memories and reminded myself of past successes, even the little ones. Like, one day I woke up and was having a really bad pain fl are, but I got up anyway. Because I got up and got out of bed that day, I was able to meet with a friend, which helped me not focus on my pain. It felt good to remember how I overcame that challenge and had something good happen because of it.

Then, I started observing others who were living with chronic pain and managing it better than I was. I saw how they coped and lived. Watching and talking to them at a local support group gave me hope and inspiration. I realized that if they could do it, I could too!

The other thing that really helped me build confi dence was to plan out my day. I would come up with a plan, and in the plan I would write out a few diff erent pain management techniques, relaxation exercises, and other strategies that I would use if I was having a pain fl are in the middle of the day. And I always had a Plan B so if my original plan didn't work, I knew what to try next. Having a pain management plan made me feel more in control.

As I continued on this journey, I found myself becoming more capable, resilient, and CONFIDENT! With my newfound confi dence for managing my pain, I started painting again and doing more with my loved ones. Getting back to these things after chronic pain had such a hold of my life gave me a strong sense of joy and accomplishment!

Building self-confi dence about my pain management didn't happen overnight, but it has transformed my life. I'm not letting chronic pain defi ne me anymore, and I've learned that recognizing past successes, observing others, making solid plans, and taking small steps with positive feedback can truly make a diff erence.

If I can do it, so can you! Take that fi rst step and believe in yourself. You've got this!

Over the past few weeks, we've covered many topics! We've talked about mindfulness, thinking about thinking, exercise, and movement. Now, we want to talk about compassion, self-compassion, and loving-kindness. These are powerful tools that can help you feel better about yourself.

First, let's talk about compassion. Compassion is about showing kindness and understanding to others who are going through tough times. You've probably shown compassion to your family, friends, and loved ones. It means you care about their feelings and try to help them. Compassion makes our relationships stronger and more meaningful.

Next, let's move on to self-compassion. Self-compassion is like the compassion we talked about, but directed toward yourself! It means being kind to yourself, especially during tough moments. Having chronic pain can be frustrating, sad, or even make you angry. It's okay to feel these emotions and not be too hard on yourself. Treat yourself with the same care and love you'd give to someone you care about.

Living with chronic pain might make you feel like you're missing out on things you used to enjoy. That's where loving-kindness comes in. Loving-kindness is about sending good wishes and positive energy to yourself and others. It's like off ering a warm hug to your soul. It helps you feel positive despite the challenges you face.

These three tools come from mindfulness. Mindfulness is about being present and aware of your thoughts and feelings without judgment. When you're mindful, you can observe your emotions and reactions to pain without being critical. This allows you to respond to yourself with compassion, self-compassion, and loving-kindness.

By using compassion, self-compassion, and loving-kindness, you'll become more resilient. Despite the challenges of chronic pain, you'll start to feel better about yourself and develop inner strength and peace. It's a journey of self-discovery, and with these tools, you can face it with courage and grace.

This week, we want to talk about exercises that make your muscles stronger. We hope you can try some of these strengthening exercises this week!

Strengthening exercises make your muscles stronger -- exercises like doing 3 sets of 10 repetitions of lifting weights, doing push-ups or squats, and using resistance bands.

Strengthening is important because it helps your muscles support your body better, making everyday activities like carrying groceries or walking upstairs easier. It can also improve your posture, make you feel better, and reduce pain over time. For people with chronic pain, strength training can be a tool to help you make progress!

To start strength training, be careful and follow the safety tips we've shared before -- listen to your body, start small, and go slow with your progress. For example, you can start with light weights or bands and slowly increase them as you get stronger. You can also start with fewer repetitions or sets to avoid overworking your muscles and give your body time to adjust to the new routine.

Since we know strengthening exercises can help with pain, we want you to try doing them two days this week. We've shared some exercises with you this week, but you can choose any kind of strengthening exercise.

This week, we want to talk about exercises that make your muscles stronger. We hope you can try some of these strengthening exercises this week!

Strengthening exercises make your muscles stronger -- exercises like doing 3 sets of 10 repetitions of lifting weights, doing push-ups or squats, and using resistance bands.

Strengthening is important because it helps your muscles support your body better, making everyday activities like carrying groceries or walking upstairs easier. It can also improve your posture, make you feel better, and reduce pain over time. For people with chronic pain, strength training can be a tool to help you make progress!

To start strength training, be careful and follow the safety tips we've shared before -- listen to your body, start small, and go slow with your progress. For example, you can start with light weights or bands and slowly increase them as you get stronger. You can also start with fewer repetitions or sets to avoid overworking your muscles and give your body time to adjust to the new routine.

Since we know strengthening exercises can help with pain, we want you to try doing them two days this week. We've shared some exercises with you this week, but you can choose any kind of strengthening exercise.

This week, we want to talk about exercises that make your muscles stronger. We hope you can try some of these strengthening exercises this week!

Strengthening exercises make your muscles stronger -- exercises like doing 3 sets of 10 repetitions of lifting weights, doing push-ups or squats, and using resistance bands.

Strengthening is important because it helps your muscles support your body better, making everyday activities like carrying groceries or walking upstairs easier. It can also improve your posture, make you feel better, and reduce pain over time. For people with chronic pain, strength training can be a tool to help you make progress!

To start strength training, be careful and follow the safety tips we've shared before -- listen to your body, start small, and go slow with your progress. For example, you can start with light weights or bands and slowly increase them as you get stronger. You can also start with fewer repetitions or sets to avoid overworking your muscles and give your body time to adjust to the new routine.

Since we know strengthening exercises can help with pain, we want you to try doing them two days this week. We've shared some exercises with you this week, but you can choose any kind of strengthening exercise.

Transcript coming soon.

Transcript coming soon.

You did it! Another week is done. We know it's hard to keep coming back, so we really appreciate your eff ort. Give yourself credit. You are doing this!

This week, we reviewed key concepts. First, we talked about "Movement as Medicine." We want you to fi nd a way to move that works for you -- any movement in any amount. Start low, go slow, and build when you are able. Movement should be fun and healing. Think about strength, fl exibility, balance, and endurance.

Next, we reviewed behavioral activation. This helps you be more active despite any constraints. Find a balance between things you want to do and things you have to do. Look back at week 5 to review activity scheduling if you need to.

We also talked about mindfulness. We don't expect you to become a mindfulness expert, but core ideas of mindfulness are useful. Work on being present and aware. Practice non-judgment and acceptance. Learn to respond instead of react. A response is more thoughtful and helps you feel more in control.

We introduced two new things this week -- building self-confi dence and a new type of meditation called Loving Kindness. For self-confi dence, remember your past successes and break big tasks into small parts. Loving Kindness helps us have more compassion for ourselves and others. It's a gentle and uplifting form of meditation.

That's a wrap on week 8. You are two-thirds of the way through. Keep going!

# Week 9

You've made it to week 9! Congrats on making it this far! Last week, we talked about how self- confi dence that you can achieve your goals is related to your chronic pain, movement and exercise, and your overall health. In short, self-confi dence makes it so that you have more power to take charge of your life. We also talked about how you can build self-confi dence with some specifi c strategies like recognizing past successes, observing others, and using baby steps with positive feedback. The other way to build self-confi dence is to have and use solid plans, resources, and support -- this is important because it sets you up for success! We also talked about how change is hard and that practicing self-compassion and loving kindness are important strategies to help manage your chronic pain.

As we guide you on your journey for managing your chronic pain, we need to revisit movement, exercise, and mind strategies like meditation and Thinking about Thinking. By revisiting these topics, we hope that you can gain a deeper understanding of how these strategies are related to your pain. We also think reviewing these topics again will give you a few more potential tools that work for you.

First, we will go into more depth on mindfulness and how present-moment awareness can help you manage your chronic pain. Mindfulness is particularly relevant because it counters the eff ects of suff ering caused by chronic pain. We will talk about how mindfulness strategies like awareness of sensations, awareness of attitudes, taking it moment to moment, resource of space, titrating and pendulating, and loving kindness can help to minimize suff ering and be powerful tools for your toolbox. We will also revisit the strategy of Thinking about Thinking. While this isn't classic mindfulness or meditation, it is a mind strategy that helps you capture your thoughts, examine them, and change them if they aren't helpful.

After mindfulness and meditation, we will take a deeper dive into advanced ideas about movement. We will talk about how to change and initiate behaviors, especially pertaining to movement and exercise. We will talk about how you can use things like behavioral substitution (or switching) contingency management (or earning rewards), social accountability, and decisional balance to help you be more active. We will also spend some time talking about how you can use baby steps, spacing and pacing to help build stamina and endurance -- which you may have found to be worse with your chronic pain.

So let's roll up our sleeves and keep building that toolbox AND your confi dence to use it. Time to jump into this week's fi rst topic -- Mindfulness and meditation! Let's go!

Mindfulness is our fi rst stop in today's session. We wanted to review, a little deeper, how mindfulness can help you manage your chronic pain and diff erent mindfulness strategies that have helped other people in similar situations as your own.

We know that everyone's experience is diff erent, but there are a few things that can really make chronic pain worse. Those things are stress, anxiety, suff ering, and resistance. We talked about suff ering and resistance in week 2 when Dr. Deverin shared about how mindfulness helped change her clinical practice. During that session, we talked about how pain is inevitable, but whether or not we're suff ering depends on how we're relating to what's going on. If your pain sneaks up on you, you may feel down on yourself and that's suff ering. It's suff ering when our identity gets contracted, and a common reaction is to resist, which commonly makes it worse, increasing stress and anxiety. With the rise in stress and anxiety, you may also have increased muscular tension too. So, you can see that all of these thoughts, emotions, and feelings are all connected. That's where mindfulness can be really helpful - we can start making meanings out of what's really going on.

Mindfulness is when you pay attention on purpose and stay in the present moment without judgment -- in essence you are being fully aware of what is happening right now in the present moment. Mindfulness acknowledges and accepts that there may be worrying about the future, stressing about the past, or getting tied up with daily distractions. When that happens, we learn to observe, accept, and react with kindness. When it comes to chronic pain, mindfulness can be a useful tool that helps us feel grounded, more focused, and more able to roll up our sleeves and do the work that needs to be done.

More specifi cally, studies have found that mindfulness meditation can decrease the intensity of pain sensations and make them feel less bothersome. It can also reduce feelings of stress and anxiety that often accompany chronic pain. By practicing mindfulness, individuals can learn to observe their pain without getting caught up in negative thoughts or emotions. This can create a sense of distance from the pain and allow for a more peaceful and accepting relationship with it. It's not giving up. It's stepping outside of the chronic pain cycle that often puts us on a downward spiral.

To practice mindfulness, choose one of these 3 strategies to practice: 3 minute breathing space, Body Scan meditation, or RAIN meditation.

To practice mindfulness, choose one of these 3 strategies to practice: 3 minute breathing space, Body Scan meditation, or RAIN meditation.

To practice mindfulness, choose one of these 3 strategies to practice: 3 minute breathing space, Body Scan meditation, or RAIN meditation.

We've learned about two very diff erent tools to respond to our thoughts -- we can capture them then challenge them or we can use the principles of mindfulness where we just observe the thought without judgment. So we either wrestle with our thoughts -- which is known to work -- or we sit back and observe the thoughts without reacting. Thoughts are just like clouds blowing by -- also a strategy proven to work. Which one you use is really up to you and may depend on the situation. Let's walk through a quick example where we use both strategies. Let's say you weren't feeling well one afternoon so you laid down to take what you thought would be a quick nap. Unfortunately, you slept right through your doctor's appointment where you were going to get some prescriptions refi lled. You feel upset, worried, and guilty. You think, "Now I'm really in a mess. Why didn't I set an alarm? I'll run out of meds and I'll be really miserable. " If you decide to wrestle with those thoughts -- what we called Thinking about Thinking -- you would fi rst write down those thoughts then you'd start to ask yourself a series of questions: · Are these thoughts fair and balanced? · Can I think of any counter examples? · What's the other side to this situation? · Is this reaction the right size given the situation?

• What would I say to a friend that made this same mistake? Next, you'd try re-writing those thoughts so they helpfully push you into taking steps to solve the problem and boost your mood in the process. You might write "Yes, I slept through my appointment but I can call or go to the clinic now, explain what happened and get the next appointment" or "Yes, I made a mistake but if I slept that long, I must have needed it. I rarely miss appointments and I'm almost always on time. It's ok not to be perfect." Are there other counter thoughts you might come up with? Let's go back to that scenario and those negative thoughts- "Now I'm really in a mess. Why didn't I set an alarm? I'll run out of meds and I'll be really miserable." If you were to try the mindfulness route of coping with these unhelpful thoughts you would notice them but not react. You'd just let them run their course and blow on by. When you feel those negative emotions -- which is a good clue to start turning into your thoughts -- you would settle down, take some deep breaths and just practice being in the present moment. You don't run from your thoughts and you don't wrestle with them. They are just mental events that pop up then fade away. If you feel yourself getting hooked by a thought, remind yourself that thoughts are just clouds going by. Thoughts are just opinions that are often based on incomplete information. Don't judge the thought. Don't judge yourself. Practice self-compassion and stay present. Eventually, the thoughts fade and so do the negative feelings. See the diff erence? Try them both out -- Thinking about thinking and mindfulness. Add them both to your toolbox!

Now that we've talked about mindfulness, let's dive into how exercise and movement can help manage your pain. Exercise can make you stronger, more fl exible, and break the pain cycle, improving your health and quality of life. We know that changing habits, like starting to exercise, can be tough! It can feel new, progress might be slow, and you might face challenges or setbacks. It's important to know that these feelings are normal. We're here to share two strategies that can help:

Baby Steps: Imagine climbing a big mountain. Instead of trying to reach the top all at once, you take small steps. That's what baby steps are---breaking a big goal into smaller, manageable parts. By taking smaller steps, you learn, have success, and gain momentum in changing your habits! Pacing/Spacing: Imagine you're in a race. If you sprint at the start, you might get tired and not fi nish. But if you pace yourself, spread out your energy, and take breaks, you have a better chance of fi nishing strong. That's what pacing/spacing is---fi nding the right rhythm for you. When you use baby steps and pacing/spacing over time, it helps us build the stamina to do activities longer without getting tired. Using these strategies also means you can do activities without "grinding our gears", or pushing your body too hard. It's a mismatch like trying to pedal really fast while being in a diffi cult gear on a bike. Its too hard, you get tired fast, and eventually you stop riding because it didn't feel good. So, instead of "grinding gears," let's talk about how we can use baby steps and pacing spacing to fi nd the right balance to build stamina and manage setbacks during your exercise behavior change journey!

Baby steps are a great way to build stamina. The best way to start is to fi nd exercises that match your current abilities and gradually increase the diffi culty over time, like fi nding the right gear on a bike. Using baby steps, you can slowly add small changes, such as walking a bit more each day or adding a slight hill to your path. The key is to start small and gradually make things harder as you get stronger. This approach not only improves your stamina and endurance but also helps you stay in tune with your body. Pacing and spacing are important because your body needs breaks! When you exercise, pace yourself to fi nish your planned activity. This might mean starting slower or taking more breaks. For example, on a 20-minute walk, you could rest for 2 minutes every 5 minutes. This approach helps you build stamina and endurance while avoiding burnout. You can also spread your exercise throughout the day, like taking a 15-minute walk in the morning and another in the evening. This way, you can reach your goals without getting too tired, giving your body time to catch its breath and get ready for more.

Setbacks with Chronic Pain are common and frustrating. Setbacks are like curveballs, throwing us off our game. Let's think about it when we are using the baby steps and spacing/pacing approach. Taking baby steps when you're dealing with a setback can help you reset your progress. We recommend focusing on what you can do now, given your current challenges. You might not be able to do the same activities as before, so start small! Think about what has helped in the past and use those activities to get through this tough time. Listen to your body and don't push too hard. If walking hurts, try going a shorter distance or at a slower pace. It's like taking gentle steps to allow your body to heal and get stronger over time. Spacing and pacing your activities during a setback is key to giving your body time to heal and recover. It's okay to take more breaks and spread out your exercise more than usual. This helps your body recover without feeling overwhelmed. Think of it like an adventure -- you want to enjoy it, not rush through it. Taking your time with spacing and pacing also lets you use the mindfulness strategies we discussed earlier.

Hey there! It's nice to meet you. My name is Marcus, and I've been living with chronic pain for years. I want to share a story with you about how exercise helped me in my pain management journey.

Before I started exercising, I felt like my mood was always low, and the pain I felt was just dragging me down. I wasn't able to do the things I loved because of that pain. I couldn't play with my children and grandchildren, I couldn't work, and it was really tough.

At fi rst, I was a bit nervous about starting to exercise. I didn't know if I could do it, especially with my back pain. I thought exercise would make the pain in my back worse, but I decided to take it slow and listen to my body. I started with short walks around my neighborhood. And you know what? After a while, my mood started to lift - I felt happier and more positive.

As I kept going, I started to go for longer walks, and I started challenging myself by adding in some hillier paths. I started noticing another change over time: my pain was getting better! It wasn't gone completely, but it was more manageable. With better pain, I started adding in yoga to mix things up a bit. I started to feel stronger, and that gave me a real boost of confi dence. I also felt like I was on the right track.

If you're feeling stuck with chronic pain like I was, I want you to know that there's hope. Starting a regular exercise program helped me and it might help you too. Today, I have more energy, I can do things I haven't done in a long time, I sleep better, and have fewer visits to the doctor. It was like a snowball eff ect -- one positive change led to another. Remember, start small, listen to your body, and don't be afraid to ask for help from your doctor. You've got this, and you might just fi nd yourself feeling better than you ever thought possible.

Nice work! You've learned more about movement, exercise, meditation, thinking about thinking and other mind strategies for chronic pain. We think this knowledge is a powerful tool as you continue on your journey!

We are hopeful that you can use mindfulness and present-moment awareness to help counter the eff ects of suff ering that you may experience because of chronic pain. As you explore the mindfulness strategies, take note of which ones work best for you. For some, awareness of sensations and awareness of attitudes might work best. But for others, taking it moment to moment, titrating and pendulating, and loving kindness work better. No one way is the right way, but we want you to fi nd what works best for you. Some of you may also fi nd that Thinking about Thinking works best for you -- that's okay too!

We also took time this week to acknowledge that changing your movement and exercise patterns can be hard work! It's common to encounter challenges, experience slow progress, and have setbacks -- this is a normal part of change. Some strategies that you can counteract these challenges with are substituting a habit for something that is healthier, contingency management (aka: rewarding ourselves for a job well done), social accountability, and decisional balance. We also took time to describe changing exercise and movement in baby steps, using spacing and pacing to help build stamina and endurance. Just like the mind strategies, we know all of these don't work for everyone, but we want you to try some of these tools to see which ones work for you! Finding the right balance of change will maximize the chances of having better management of your chronic pain.

So that's week 9! We hope you take time to practice mind strategies, movement, and exercise to see which tools work best for you!

# Week 10

Congratulations on making it this far! Over the past weeks, we've explored how mindfulness, thoughts, movement, and self-confi dence can help you manage chronic pain and live your best life.

This week, we'll focus on something just as important: social connections and community. Social support isn't just helpful in daily life; it's also a key part of managing chronic pain. Unfortunately, chronic pain can sometimes isolate us from others, leading to feelings of loneliness or disconnection. This week, we'll explore ways to strengthen your social support network.

We'll talk about who's in your network, the types of support they can off er, and the challenges you might face. We'll also look at how chronic pain can aff ect communication and problem-solving within your support network. Additionally, we'll discuss isolation and loneliness---two related but distinct issues that can impact your well-being.

Building supportive relationships can be challenging, especially when others don't fully understand what you're going through. But with the right strategies, you can create connections that help you manage your pain more eff ectively.

Remember, your medical team is also part of your support system. Doctors, nurses, and therapists are all here to help. Don't hesitate to reach out if you need support.

Ready to dive in? Let's talk about social connections and community!

Let's talk about social support. Social support means giving and receiving care and help among friends, family, or others. It's like having a team of people who understand you, stand by you, and whom you can support in various ways. We all need to feel connected, loved, and safe.

For those living with chronic pain, social support is even more important. Coping with daily challenges can be tough, but having people who listen, off er a shoulder to lean on, or help with tasks can make a big diff erence. Social support may seem complicated, but we'll break it down into types of support and discuss the importance of knowing what kind you need and who can best provide it.

Types of Social Support:

● Emotional Support: When people off er comfort, understanding, and empathy. They listen to your feelings, show they care, and help you manage emotions. Some people are better at this than others, so it's important to know who in your life is good at providing emotional support.

● Practical Support: Help with tasks or daily activities like cooking, cleaning, or running errands. These "acts of service" show love and support and can be very helpful when dealing with chronic pain.

● Financial Support: Assistance with money or resources such as paying bills or providing essential items. Chronic pain can lead to fi nancial challenges, so this type of support might be an important part of your plan.

● Intellectual Support: Sharing knowledge, advice, or guidance. Friends who off er suggestions or information to help you manage your pain provide intellectual support. Don't hesitate to ask those knowledgeable about your condition for help.

Having a mix of these types of support can make managing chronic pain easier and put you in a better position to off er support in return. It's your job to know what kind of support you need and who in your network can provide it. We'll map out your support network and fi gure out what each person can off er. If your network is small or non-existent, we'll work on how to add new people.

Building and maintaining a support system can be hard. Chronic pain is not always visible, so others might not fully understand your situation, which can lead to feelings of isolation. Cancelling plans or avoiding events because of pain can create guilt or disappointment for both you and those in your support network. Chronic pain can also increase stress and sadness, making it harder for others to know how to support you. This week we'll off er strategies to help build and use your support network eff ectively.

Lastly, don't forget that support can come from your medical team including doctors, nurses, and therapists. They provide emotional and intellectual support even if they can't assist with practical tasks. Let your medical providers know what kind of support you need and don't hesitate to speak up if you feel unsupported.

You may be wondering how social support is related to things we've been talking about in the INSPIRE program, but you should know that social support is really important when it comes to exercise! Having friends, family, or workout buddies can make exercising more fun and help you stick with it. Here's how:

1\. Encouragement and Motivation: When you exercise with others, you feel more connected and motivated. It makes the activity more enjoyable and helps you stay committed.

2\. Accountability: Friends and family can help you stay on track. Knowing others are counting on you can push you to keep up with your routine.

3\. Sharing the Journey: Exercising together means you can cheer each other on, celebrate wins, support each other through challenges, and makes the whole experience less lonely.

4\. Practical Help: Exercising with someone can also help with things like transportation, costs, equipment, and planning. You might also help your friend get more active, so it's a win-win!

In short, moving with someone you care about makes the experience better and helps you both stay active!

Transcript coming soon.

Now that we've covered the basics of social support, let's talk about isolation and loneliness -- two other ideas that are related, but diff erent.

Social isolation is a condition where an individual has limited contact or interaction with others. It occurs when a person has very few social engagements, few social connections, and limited participation in social activities. Social isolation can result from various factors, such as living alone, lack of social support, physical disabilities, chronic pain, or geographic isolation. Socially isolated individuals may have limited access to companionship, emotional support, or practical assistance, leading to a reduced sense of belonging and community.

On the other hand, we feel lonely when the social relationships we desire don't match the actual social relationships that we have. It is the feeling of being alone, disconnected, or lacking meaningful social connections, even when surrounded by others. Loneliness is not solely determined by the number of social interactions a person has; it is about the quality and depth of those interactions. One can feel lonely even in a crowded room if they lack meaningful connections with others. Loneliness often involves a sense of emptiness, sadness, or longing for companionship.

Reducing social isolation and loneliness is crucial to improve the management of your chronic pain -- feeling better emotionally means feeling better physically and suff ering less. One way to do this is by communicating openly with friends, family, healthcare providers, and others in your support network about your needs and challenges. Letting them know what you're going through can help them understand your challenges and encourage them to provide the right kind of support. Engaging in support groups for chronic pain is another way to connect you with people who understand your struggles, making you feel less alone. Also, joining local clubs, spiritual groups, or classes based on your interests, not just related to chronic pain, can also help you meet new people and build connections. Lastly - connecting through technology with video or phone calls, can also combat feelings of isolation.

In a nutshell, isolation and loneliness stem from feeling disconnected, while social support involves having a network of caring people. There's no right number of people for your network or correct level of relationship quality to make this work, so just try adding people and/or improving your relationships until you notice a diff erence. Let most things, it may take a while but every journey starts with one step.

Let's take a closer look at what we called your social support network. The most obvious characteristic is its size -- how many people are in it. But there's also density or distance.

Are all your friends gathered locally in the same area, or are they scattered around the country or even the world? What is the diversity of individuals? Are they all the same age, same gender, and same background---or is there a wider range? Another characteristic is the level of reciprocity. Do you always give more support than you receive? Do you get more support than you give? And the last feature we'll mention is the level of intimacy or emotional closeness. Some people are in your inner circle but others are really more of an acquaintance than a close friend. 179 We're going to do a quick exercise that will help you visually see the characteristics of your social support network. It's called the Circles Exercise. First, you just draw several concentric circles so it looks kind of like a bullseye or a dart board. The smallest circle is in the center and there are bigger and bigger rings around that center as you move out to the edges.

So here, you get to be the center of the universe, so you're right in the middle. You would write your name in the middle of the smallest circle. Then for the other rings, you can think of them as the rings of orbit. Rings closer to the center are closer to you. Think of the closest ring as your inner circle where you keep your closest friends and family and the outer ring as where you might put your acquaintances. For this exercise, you put a person's name, anyone that you would consider a social support or even a potential social support, somewhere on this diagram. And if they're close to you, they're going to be in your inner orbits. So they're going to be in your inner circle. If they're a little further out, you place them a little further out on the circle. And if they are just a potential friend or social support just write their name on the edge of the circle. So go ahead and start thinking of those names and what circle you might put them in. Go ahead, grab a piece of paper then come right back so we can guide you through the results.

Excellent. Thank you for coming back. I hope you were able to draw your circles and write down some names. Even if you just did it in your head, let's take what you have and see how we can use it to help you improve your social support network.

There are a few things you can look at. How many names did you write down? Is your diagram crowded or is it too empty? There's no right number of names but quality does matter. How many people are in your inner circle? It may only be one or two or it might even be no one at all. That's ok. This just tells us that maybe its time to start looking who might be a good candidate for building a closer relationship with. Are there any names further out on your circles that you might want to pull in closer? If you don't have many names anywhere or if your diagram is completely empty, that's ok too. This is just a starting place. It tells us that it will be really important for you to start meeting new people so that you don't have to feel so isolated, alone, and unsupported.

The last thing you might want to do is to look at the names on your circle and think about what kind of support each person is good at. Remember there's emotional support, practical support, fi nancial support, and intellectual support. Knowing who's good at what and what kind of support you need, will help you decide who to ask for support.

Ok -- you did it. Another exercise down! You got this!

Let's now turn to one of our core skill sets, Mindfulness and look at how it might aff ect our relationships and social supports. Mindfulness, with its emphasis on being fully present in the moment, off ers insights and techniques that can signifi cantly enhance communication skills, foster empathy, and promote active listening.

Mindful listening goes beyond just hearing words; it involves being fully present and attentive to the speaker. In relationships, especially in moments of confl ict or emotional distress, mindful listening can be transformative. When you listen mindfully, you are not formulating your response while the other person speaks; you are fully absorbing their words, tone, and emotions. This depth of presence allows you to understand not just the content but also the underlying feelings and needs.

For instance, imagine your partner expressing frustration about a long day at work. Instead of planning what to say next, you focus entirely on their words and body language. Through mindful listening, you might sense their exhaustion, stress, or perhaps a need for validation. Responding with empathy and understanding can create a safe space for them to express themselves more openly.

Mindfulness can also improve how we express ourselves. Before speaking, taking a moment of mindfulness can help in articulating thoughts clearly and with kindness. Mindful speech involves choosing words deliberately, considering their impact on the listener. It's about expressing yourself authentically while being aware of the emotional tone and potential reactions your words might evoke.

Consider a situation where you need to discuss a sensitive topic with a friend. Mindful speaking involves expressing your feelings and thoughts honestly but in a way that promotes understanding rather than defensiveness. Mindful communication encourages "I" statements, such as "I feel" or "I need," which emphasize personal emotions and needs without sounding like you are blaming someone.

Mindfulness in relationships also includes attention to non-verbal cues. Being mindful of body language, facial expressions, and gestures enhances understanding. For example, if your colleague looks tense during a conversation, mindful observation allows you to notice their discomfort. This awareness can prompt you to pause and inquire if they are okay, demonstrating your attentiveness and care.

Mindfulness can also help with relationship confl ict. When confl icts arise, being mindful helps in managing emotional reactions. It allows you to observe your own feelings of anger or frustration without being consumed by them. Mindfulness provides the mental space to choose responses consciously instead of reacting impulsively. During disagreements, couples can practice mindful breathing to calm their minds before discussing the issue, promoting a more constructive dialogue.

In essence, mindfulness nurtures a sense of presence, deepening connections by fostering genuine understanding and empathy. By being fully engaged in both listening and speaking, individuals in relationships can create an atmosphere of mutual respect and openness, laying the foundation for healthier, more meaningful connections.

Transcript coming soon.

Chronic pain can often feel like a heavy burden, aff ecting not only the body but also the mind and spirit. Yet, in the journey of chronic pain, the support of friends, family, and community can be a beacon of hope and healing. Social support, the comfort and assistance we get from others, plays a vital role in how we experience chronic pain and the strategies we might use to manage our pain.

Social support is like having a circle of caring hands around you. It's the understanding smile of a friend, the encouraging words of a family member, and the helpful gestures of neighbors. When you have chronic pain, these connections become even more crucial. They provide emotional warmth, showing you that you're not alone in your struggles. And when we talk about social support, it doesn't have to be one-on-one. It can include your community, your church, your co-workers, or even your pets. Feeling connected and supported is really the key.

In this week's materials, we defi ned the diff erent types of support you might need -- emotional, practical, fi nancial, and intellectual. You also did a circles exercise to identify all of your potential support people and how close they are to you. Were your circles full? Did your inner circle have enough people in it?

You also learned about how mindfulness can boost our ability to communicate eff ectively with others. Being fully present without judgement is really a key ingredient for being a good listener. Being mindfully aware of what you need and when you need it is a huge step forward in being able to communicate your needs eff ectively. Be sure to practice some of the mindfulness listening and talking exercises if you haven't done them already.

We should also remember what we've learned about our thoughts and how they aff ect our behaviors. Thoughts can directly infl uence your behaviors and how you relate to others. If you believe people won't understand your pain, you might withdraw, missing out on the support waiting for you. However, if you open your heart to the possibility of connection, you invite kindness and understanding. It won't always work out but worth trying. Identify someone you'd like to invite into your inner circle. What sorts of thoughts might help you take that step? What would that step look like?

In the tapestry of chronic pain, social connections are threads of vibrant colors. They weave through the fabric of your life, creating a support network strong enough to bear any challenge. Remember, reaching out is not a sign of weakness but a gesture of courage. Your community, your friends, and your family are like stars guiding you through the darkest nights. Together, with movement, mindfulness, helpful thoughts, and open communication, you can transform your experience of chronic pain. It's a journey where every step, every smile, and every shared moment becomes a testament to the power of human connection, reminding you that you are never alone.

# Week 11

Welcome to week 11, only one week left! Remember that you are encouraged to go back and review prior weeks. . If you've learned a lot so far that is terrifi c! But it's even better if you learn then put that knowledge into use. What new behaviors or activities have you adopted? There's still time!

Last week we talked about social connectedness and how that relates to pain. Hopefully you had a chance to practice your mindfulness activities and that you found someone you could do some movement and exercise with. It's okay if you weren't able to do all the practicing you want, but hopefully you are on the right track.

This week we are going to help you pull it all together by building and improving your pain management toolbox in our fi rst section. Your toolbox will be your own personal collection of strategies you have found helpful. The more tools you have the better as long as you know how and when to use them. We review the diff erence between reacting and responding to a negative or stressful situation. Our goal is to constructively respond which usually means pulling one of our tools out of our toolbox.

In the second section, we will introduce some new material about positive emotions. We've been pretty focused on things like depression, stress, or anxiety but there's more to life than the negative. We're going to look at the fl ip side using examples of gratitude and something called savoring -- or a way to extend the enjoyment of a positive experience so the positive mood can last even longer.

And as always, we will have some practical tips and suggestions for practice. We want to make sure you get these skills locked in so you can be your own pain management expert, your own source of inspiration. Ready? Set? Let's go!

Once in a lush garden, there stood a majestic tree, the Tree of Harmony. This tree was renowned for its vibrant and diverse branches, each bearing its own fruit, each with its unique healing properties.

One day, a weary traveler arrived, burdened by the weight of chronic pain. Seeking relief, they approached the Tree of Harmony. The traveler noticed the branches loaded with fruits: Movement, Mindfulness, Medication, Social Support, and Helpful Thoughts.

The traveler picked one fruit, Movement, and consumed it. They felt a surge of strength, but the pain remained. Puzzled, the traveler then picked the fruit of Mindfulness. As they savored its essence, they felt a wave of calm wash over them. Yet, the pain still lingered.

Realizing that they must try a diff erent approach, the traveler plucked the fruit of Medication. This fruit brought them a measure of relief, but it was not a complete remedy. They continued to taste each fruit individually: Social Support and Helpful Thoughts, and each provided valuable relief, but the pain persisted.

Frustrated, the traveler sat beneath the Tree of Harmony, refl ecting upon their journey. Suddenly, it dawned on them: the power lay not in choosing just one fruit but in 186 combining them. They reached out and gathered a handful of fruits from each branch and blended them together.

As the traveler consumed this mixture of healing fruits, a remarkable transformation occurred. The pain slowly dissipated, replaced by a sense of wholeness and well-being. The traveler felt strong, calm, supported, and optimistic, all at once.

Under the shade of the Tree of Harmony, the traveler realized the profound lesson it held. In managing chronic pain, it is not the single intervention that brings relief, but the harmonious blending of multiple complementary approaches. Each fruit, while helpful on its own, becomes more potent when combined with others. It is the symphony of these interventions, working together in unity, that brings the sweetest relief, reminding us that in the garden of healing, harmony is the key.

Now let's start blending those "fruits" and build your toolbox!

Before we start building your toolbox, let us explain what we mean. Over the course of the past 11 weeks, we've covered a lot of material. You've learned many many skills from mindfulness, thinking about thinking, movement spotlights, and practical ways to manage stress and build social supports. You may have found some of the skills interesting and helpful and you may have decided some of the skills we demonstrated just don't work for you. That is fi ne! In fact, we expect each person to walk away with something diff erent and hopefully something helpful.

We've tried to encourage you along the way to explore your favorite skills or exercises. We're hoping this made it quicker for you to fi nd those skills and keep practicing them. We hope for you to create your own collection of diff erent strategies to help you manage your chronic pain.

You may remember you create your pain management plan including what to do if you get a bad fl are-up. That plan includes many of your tools but it also includes your doctor, other health care professionals, your medications, and the names and contact information for your social supports. It's kind of like a user's manual for your pain management program. The toolbox is related but it's more of a collection of all of the strategies rather than a plan of when and how to use them. Think of the pain management plan as the fi nal dish and the toolbox strategies as all the ingredients and spices you have in your kitchen.

So once you have your toolbox, how do you use it? The fi rst step is to understand the problem or the situation you are in followed by fi nding the right tool to do the job. If that tool doesn't work or only partly fi xes the problem, reach back into the toolbox and pick another tool. For example, if you get tangled up in negative thoughts or worries that go around and around in your head, reach into your toolbox and pull out the ABCD exercise. If that doesn't work then you can pull out the mindfulness exercise where you simply observe thoughts. Thoughts are just like clouds blowing by in the sky. You learn not to react. Your response is acceptance and non-judgement.

Now that we've reviewed some basics about your toolbox and where to fi nd it, let's expand that idea of learning to respond rather than reacting. Why be blown around by bad weather when you can prepare and respond in a way that keeps you safe, warm, and dry.

Let's explore the diff erence between reacting and responding when managing chronic pain. Our goal is to help you respond constructively to pain, rather than simply react.

Reacting is often an automatic, emotional response triggered by pain. It's usually driven by fear, frustration, or desperation. For example, consider Benjamin, whom we met in Week 1. When his chronic back pain fl ared up, Benjamin used to react by clenching his fi sts, yelling, or complaining out of frustration. These reactions often made his pain and stress worse.

Responding, on the other hand, is a more thoughtful, deliberate approach. It takes into account the situation, emotions, and long-term well-being. After practicing mindfulness, Benjamin learned to respond to his pain diff erently. Now, when his pain intensifi es, he pauses, takes a deep breath, and uses his relaxation exercises. He acknowledges the pain without letting it control his emotions and chooses actions like gentle stretching or applying heat---strategies from his pain management toolbox---that bring relief.

It's important to note that everyone reacts sometimes. It's human! The key is to learn to shift from reacting to responding. Over time, with practice, responding thoughtfully to pain becomes more automatic. Your toolbox of coping skills will help you fi nd ways to respond constructively, making pain easier to manage.

Over the past 11 weeks, you've learned many tools and strategies for managing chronic pain and improving your quality of life. Each person's experience with pain is unique, so we've included a wide variety of approaches for you to try and practice. By now, you've likely found strategies that work best for you, and we hope they've been helpful on your journey.

We've divided these tools into two major categories: mind and body. On the mind side, we introduced mindfulness and meditation. You've learned about formal practices like the Body Scan, Mindfulness of Breath, and Loving Kindness meditations. There are also informal practices, like the 3-Minute Breathing Space, which you can integrate into everyday activities. All of these practices, and many more, can be found in the Mind section of the app.

We also explored brain training exercises like Thinking about Thinking and the ABCD model. This helps you examine how an Activating Event leads to automatic Beliefs that trigger emotional or behavioral Consequences. If the consequences aren't helpful, you can learn to Dispute the belief -- really rethink the thought - and reframe it in a more constructive way.

On the body side, we introduced various movement exercises like stretching, walking, and more specialized practices like yoga and Tai Chi. Movement helps break the cycle of pain, boosts mood, and increases energy. In addition, we covered relaxation techniques like progressive muscle relaxation and massage---helpful tools to calm the body and ease the mind.

We also explored self-monitoring where you keep track of activities and how they made you feel. Using an activity record can help identify which activities boost your mood or reduce pain. We then encouraged you to practice activity scheduling by planning helpful activities ahead of time.

In many sessions, we blended mind and body techniques. For example, you practiced mindful walking and focused on being present with body sensations. Remember, mind and body are closely linked, and using both types of tools can enhance your overall well-being.

Throughout the program, we also covered special topics like sleep (Week 7), self-confidence (Week 8), and social support (Week 10). Each of these weeks introduced tools you can add to your pain management toolbox. Remember: for any problem you face, there's a tool to help!

Transcript coming soon.

Transcript coming soon.

Let's face it. Life can be full of heartache and pain. You don't have to look too far to fi nd something that's disturbing or distressing. We know that anxiety and depression are increasingly common - and particularly if you have something like chronic pain. Throughout this course, we've focused on empowering you to use tools to address these sorts of problems. But there's one big area we need to bring forward. One key part of life that often gets ignored - positive experiences and positive emotions. Even in the darkest of times there can still be a spark of hope, a smile, a kind gesture, something that reminds us that there's good in the world still. Medicine tends to focus only on the negative. It's all about fi nding and treating disease. Mental health is often mistakenly seen as the absence of mental illness. But mental health isn't just the absence of suff ering or disease. It's also the presence of hope, enjoyment, curiosity, love, commitment, gratitude, faith, and joy. There's another half to life that we would be mistaken to ignore. In fact, most recently psychologists have created a new fi eld called "positive psychology" that look at just those things - what they are, what they do to our health and quality of life, and most importantly, how can we cultivate more of those positive states. We're going to talk about a few diff erent aspects of these positive states now.

The fi rst positive state that we want to cover is GRATITUDE! Recently, there's been a great deal of research on gratitude, or what has been called an "attitude of gratitude." Now, gratitude has been linked to better health, sounder sleep, less anxiety and depression, higher long-term satisfaction with life, and kinder behavior toward others, including romantic partners. Another study shows that feeling grateful makes people less likely to turn aggressive when provoked. A good example of some of the seminal work was done by Robert Emmons at the University of California and Davis. He started with a program that he called Gratitude Light. In this program, people were asked to complete a gratitude journal where they list 5 things once per week that they are grateful for. Each item can only be one sentence long. After two months, participants were more optimistic, happier, exercised more, AND had fewer physical complaints.

We've also found that positive emotions can build new relationships. But how? When an individual is in a negative mood state, they circle their social wagons. They're more closed to outside social contacts or to building new relationships. The opposite is true for positive emotions. When we're in a positive emotional state, we're more likely to reach out to others, to meet new people, or to deepen existing relationships. So positive emotions may be there to broaden our cognitive repertoire and to build important social relationships that will sustain us in the negative times ahead.

But are there things to be grateful for when you have chronic pain? Yes! We think so and so do many others. Remember that gratitude has no limits or bounds placed on it. We can be grateful for something in the past, present, or even something in the future like a dream that gives us comfort or hope. We can be grateful about people - those we know or even those we don't know. We can be grateful for simple things like feeling the warmth of the sun or the cool, refreshing relief you get from a glass of water when you're thirsty. We can be grateful for worldly things or spiritual things - and, well, I think you get the point. If we try, we can nearly always fi nd something to be grateful about. The challenge is remembering to look for something, then once you've found something, holding onto it so you can continue to feel its healing eff ects.

Let's take this concept and see how you can build your own gratitude!

The next positive state we want to explore is savoring. Savoring is a core concept in positive psychology that focuses on fully experiencing and appreciating positive moments. It's about slowing down, being present, and letting the positive aspects of life deeply uplift and touch us.

Imagine sitting down to enjoy a delicious meal. Instead of quickly eating, savoring involves paying attention to the aroma, noticing the fl avors with each bite, and fully appreciating the experience. It's about immersing yourself in the present moment and allowing the positivity of that experience to resonate deeply within you.

Savoring is similar to mindfulness, but with a specifi c focus on being mindful of positive experiences. While mindfulness encourages us to observe the present moment, savoring helps us to extend and amplify the joy and positivity that come from those moments.

Here's how to Practice Savoring:

Slow Down: When you encounter something positive, take a moment to slow down and fully immerse yourself in the experience.

Engage Your Senses: Focus on what you see, hear, taste, smell, or feel. This sensory engagement deepens the experience and makes it more vivid.

Refl ect on the Moment: Think about why this moment brings you joy and what makes it meaningful.

Extend the Experience: After the moment has passed, revisit it mentally to allow the positive emotions to linger. Refl ect on the joy or contentment you felt and let it carry forward.

By practicing savoring, you can make positive moments "stickier," allowing them to last longer and have a greater impact on your emotional well-being. Savoring helps us hold onto the good, even when life feels challenging.

Now that we've explored coping mechanisms, let's shift our focus to happiness and joy---two important concepts from mindfulness that can help you manage chronic pain.

Happiness is a feeling of contentment and satisfaction with life. It's about appreciating the good things around you and feeling at peace. Joy, on the other hand, is a burst of positive emotions like excitement, delight, or pleasure. While happiness is more of a steady state, joy is often more intense but short-lived. Both happiness and joy are about experiencing positive emotions and being present in the moment.

Practicing mindfulness helps you cope with pain by focusing on the positive aspects of life and reducing the negative impact of pain on your happiness. When you stay present in joyful moments, you create a mental space where the intensity of pain may lessen, allowing joy to shine through.

We know that fi nding happiness and joy can be challenging when you're managing chronic pain, but it is possible. You can build these emotions into your life through social connections, gratitude, and savoring.

Social connectedness: Spending time with friends and family, talking, and sharing feelings can increase happiness. Strong social connections make you feel less alone and more supported. If you're unsure how to build social support, consider joining clubs, volunteering, or participating in group activities. These actions can help you connect with others and boost your mood.

Gratitude: Being thankful for the good things in your life helps build happiness. You can express your gratitude in a journal or tell others how much you appreciate them. Practicing gratitude regularly makes you more aware of the positive things around you, even on diffi cult days.

Savoring: Taking time to fully enjoy and appreciate positive experiences builds joy. This might mean slowing down to enjoy a beautiful sunset, savor a meal, or share a moment of laughter with a friend. Savoring allows you to prolong the positive eff ects of these experiences and bring more joy into your life.

You can use happiness and joy as tools to help manage your chronic pain. With strategies like social connection, gratitude, and savoring, you can build more positive experiences into your daily life and improve your overall well-being.

Congratulations on completing Week 11! This week, we reviewed how you can integrate everything you've learned over the past 10 weeks into your pain management plan. Remember that although each pain management strategy can work well on its own, they often work even better when combined into a cohesive plan.

We hope you also gained new insights into how happiness and joy can be added to your overall approach to managing chronic pain. Positive emotions are powerful tools that, when cultivated, can improve your emotional and physical well-being.

Finally, we took time to reflect on your journey within the INSPIRE program. Think about how far you've come---doesn't it feel like you've made progress? We know you have! If you're feeling stuck or need extra guidance, don't hesitate to talk to your pain coach---they are here to support you every step of the way.

As we close out this week, take time to review the tools in your personal toolbox and think about how you can use them together to achieve your pain management goals. You've got the knowledge, the tools, and the support system---now it's time to put it all into action!

What You Learned This Week:

How to combine the tools you've learned into a comprehensive pain management plan.

The importance of using positive emotions like happiness and joy to enhance your well-being.

Strategies for reviewing and refining your toolbox to ensure you have the right tools for any situation.

# Week 12

Welcome to Week 12, the fi nal chapter of our chronic pain management program! Congratulations on your dedication and perseverance in this journey. As we close this chapter, take some time to refl ect, review, and plan for the future. This is just the beginning of your journey, and now you have more tools to help you live the life you want.

This week, we'll revisit your pain management plan step by step. It's an opportunity to evaluate what has worked well for you and what might need adjustments. Remember that your plan is dynamic---it can evolve as your needs change. You don't need to worry about remembering everything when you're in pain if you've prepared in advance.

Next, we'll review the key mind-body pain management skills you've learned over the past 11 weeks. From mindfulness to movement to thinking about thinking, you've acquired a toolbox of techniques that empower you in your pain management journey.

We will also re-emphasize the importance of self-care and self-compassion. Chronic pain adds a heavy burden to your life, but you deserve kindness and understanding. Self-care is like the gentle embrace you off er yourself during challenging times. We'll explore how to nurture your well-being through these concepts.

In addition, you'll refl ect on your progress. What have you learned along the way? Which tools have become your favorites? Recognize the growth you've made and how mindfulness, movement, or thought exercises have impacted your daily life. We want these tools to become positive habits that are woven into your everyday routine.

Lastly, you'll envision your future. What will life be like one month, two months, or six months from now? How will you continue to manage your pain? You'll also consider the importance of community. Whether it's family, friends, or groups with shared interests, your community can be a powerful source of support.

Managing chronic pain is an ongoing journey, and while challenges may arise, so will opportunities for growth and resilience. You've put in the work, and now it's time to continue nurturing your well-being with self-compassion and support from your community.

Now that you've made it to our final week, we thought it would be important to review your comprehensive pain management package. This should include all the tools, strategies, and people that comprise your pain management team. In your last coaching visit, your coach will help go over this and make sure everyone is on board.

Remember that you have two categories in your pain management program. One focuses on the management of everyday pain and the other focuses on really bad periods when the pain flares up and the usual tools aren't working so well. Let's think about what might go into each of these.

Thinking about thinking is one strategy to manage your chronic pain. You may still need medical treatments, such as medications or procedures like nerve blocks or injections. You may need behavioral interventions, such as physical therapy or more simply, movement as medicine. You might also work in integrative medicine treatments, such as yoga, tai chi, mindfulness meditation, or acupuncture. Remember that you have your toolbox where you've marked all of your favorites. You might want to take a look at it now and see what elements you want to put into your pain management plan.

Your daily plan will include strategies and tools that we've covered but might also include tips and reminders like the following:

o Get a change of scenery. Even though you might be in a lot of pain and don't want to go anywhere, sometimes getting out of the house is just the enjoyment you need.

o Use distraction. Whether you're at home or out of the house, take your mind elsewhere---otherwise known as attentional deployment.

o Join support groups. Talking to people who understand what you're going through---either in person or online---can be really helpful.

o Know your limits and don't overdo it. It's important to stay active but also to know how active is the right amount.

For your pain flare-up plan, you'll need to consult your doctor about what you should or shouldn't do in terms of adjusting your medication. Your doctor can also give you a better sense of when chronic pain is an emergency that requires an ER visit versus something you can maybe power through on your own or with your family. Can you take extra pain pills? Maybe.

Should you use massage? Or ice or heat? Be sure to list out all your strategies and have them handy when you need them. You can print out your pain flare-up plan and include your doctors'

numbers on it so that family members can stay oriented, too.

Whew -- that's a lot but remember that you'll have one more visit with your coach after this week to go over your plan and you'll have two booster sessions several months down the road. You can also print out your plan and share it with your doctor. You've put a lot of work into this so be proud!

Now that you've almost completed the weekly program, this is a great time to review the core skills that have the most impact. Last week, we discussed the major categories of mind-body skills, including mindfulness, movement, and thinking about thinking. This week, we'll highlight some of the most eff ective mindfulness strategies for managing chronic pain, as identifi ed by patients and supported by research.

Here are some key practices that can have a profound eff ect on your pain management:

Mindfulness in Everyday Life: Practicing mindfulness can dramatically change your attitude, improve your focus, and help you let go of things beyond your control. Being present in the moment can reduce stress and tension, making it easier to handle daily challenges. Remember to focus on your breath and be aware of your body's sensations---this can help alleviate stress before it becomes overwhelming.

Formal Mindfulness Practices: The body scan is one of the most researched and eff ective tools for pain management. During a body scan, you bring attention to diff erent parts of your body, observing sensations without judgment. This practice can help you develop a healthier relationship with pain by approaching it with curiosity and openness rather than resistance. We recommend doing the body scan several times a week to see its full benefi ts. You can fi nd the guided body scan exercise in the Mind section of the app.

Mindful Movement: Movement is medicine. Be sure to develop the skills that help you stay in touch with your body. Walking meditation, Yoga, and Tai Chi, when combined with mindfulness, can break the cycle of pain by reducing tension and increasing fl exibility. They also off er mental benefi ts by improving mood and helping you stay present in the moment. The key is to pace yourself and stay mindful of how your body feels during movement, even small steps add up.

By consistently practicing these skills, you'll become more adept at managing pain, and over time, they will become second nature.

As you continue your journey of managing your pain using your new tools, we wanted to remind you of an important but often overlooked concept - the importance of self care and self compassion and how they fi t into your Lets take one last time to review self-care, self-compassion, and how they can be used in your chronic pain journey. First, we want to remind you that managing your pain will have ups and downs, ebbs and fl ows, and that self-care and self-compassion are tools that you can use to make it through the tough times. We also have introduced you to other topics that can help build your pain management toolbox. Hopefully you feel like you are ready for anything and can take what you've learned in this program. You are not to blame for your chronic pain. You are not to blame for your fl are-ups. You are not to blame for how medical professionals might have treated or mistreated you because of your pain. You deserve respect, compassion and acceptance - remind yourself of that daily even if no one else is there to do it. In fact, let me say that again -- You deserve respect, compassion, and acceptance. Period.

Just as a quick refresher, let's review how our program fi ts with the idea of self-compassion.

From mindfulness, we have been practicing presence, acceptance, and non-judgment. More specifi cally, we introduced a type of meditation called Loving Kindness which has been proven to build compassion for yourself and for others.

From movement, we've encouraged you to respect your body. To love your body with all its imperfections or injuries. Pain creates fear of movement. Pain creates a distrust or even dislike of your body. Use your breathing to get settled, then see what movements you can do. Try some of the special movement programs -- like gentle yoga or Tai Chi.

And last, let's remember some of the lessons from the thinking about thinking exercises. This was things like the ABCD Exercise or learning more balanced and fair or helpful thoughts. We encourage you to jot down some positive coping statements and repeat those to yourself every day.

This next exercise is something we call "Looking Ahead." No one can predict the future but we can imagine what we think the future will bring and then try to prepare for it. Do you see good things on the horizon? Or maybe some big challenges you aren't sure you can meet? Let's look ahead and see what we can do.

I want you to close your eyes -- if you feel comfortable doing so -- and take a few deep, centering breaths. Just let yourself settle then turn your attention to your mind's eye. I want you to picture yourself and your life one month from now. Where will you be? What will you be doing? How will you be feeling? Just make the best prediction you can. What sorts of things will be going on? Do you think you will still be using the skills you learned as part of INSPIRE?

Now let's fi rst imagine that things are really good. You feel better, happier, more in control of your pain. You have a higher quality of life. You are more hopeful than you've been in a long time. What got you here? What things or people or activities got you into this good place? See them, name them, and think about how you can make sure you use them.

Now imagine that you've had a hard time. You aren't practicing your new skills as much as you'd like and you feel yourself slipping backwards. What was it that knocked you off track? Was it about time? Money? Social support? Competing demands? Think about the most likely roadblocks then think about ways you might be able to prepare for them. Life will always have ups and downs that are beyond our control but are there any things you can do now, in advance, that might help you have a softer landing?

We will end our exercise here but encourage you to repeat it imagining where you will be in 6 months, a year, or even 5 years. What will be helping you? What resources can you tap into? What might be holding you back? How might you prepare for that?

Let's look ahead and move forward!

While refl ecting on your personal growth and future plans is important, it's equally crucial to think about the role of community in your health and well-being. Whether you're part of a family, have close friends, or belong to a larger group, your community plays a signifi cant role in supporting your health.

In Week 10, we explored how social connections contribute to better health. Now, as you approach the end of this program, it's time to strengthen those connections. Social support off ers emotional encouragement, a sense of belonging, and practical help when needed---all of which are vital to your well-being.

What communities do you belong to? It could be your family, neighborhood, workplace, or a group of people coping with chronic pain. If you feel like your community connections are lacking, think about the type of communities you'd like to join. How can you take steps to get involved?

Here are some ideas for engaging with your community:

Shared activities: Organize or join activities with your community, such as fi tness classes, neighborhood events, or volunteer opportunities. These activities can deepen your connections and create a shared sense of purpose.

Local events: Attend local fairs, festivals, or workshops. Participating in community events allows you to meet new people and strengthen your ties.

Join clubs or groups: Whether it's a hobby, a social cause, or a support group, joining a club or group can help you build relationships and fi nd shared interests.

Volunteer: Volunteering is a powerful way to give back to your community while also building connections.

Remember that your community can also support your health goals. Fitness groups, health education programs, or sharing health information within your community can enhance your well-being. You might also fi nd that you can off er valuable insights and support to others in your community who are managing health challenges.

Congratulations on completing the 12-week INSPIRE chronic pain management program! Over these weeks, you've embarked on a journey of self-discovery, resilience, and empowerment. Let's take a moment to refl ect on the incredible progress and valuable insights you've gained.

Movement and Exercise:

You've explored the transformative power of movement as medicine. From gentle stretches to more dynamic activities, you've discovered how physical activity can enhance not only your physical well-being but also uplift your mood and contribute to an overall sense of vitality.

Mindfulness and Meditation:

Delving into the realms of mindfulness and meditation, you've cultivated a deeper connection between your mind and body. Through the practice of being present in the moment, you've harnessed a powerful tool for managing stress, reducing anxiety, and fostering a sense of calm amidst life's challenges. You are more present, more aware, and more accepting.

Understanding Thoughts and Pain:

Examining the intricate relationship between thoughts and pain, you've gained valuable insights into the impact of your mental landscape on your pain experience. Your pain is not all in your head but how you think can either help you or hurt you. Recognizing and challenging negative thought patterns has empowered you to take control of your narrative and foster a more positive mindset.

Throughout this journey, you've demonstrated remarkable resilience. Every lesson, exercise, and moment of self-refl ection has contributed to your growth. You've embraced challenges, acknowledged your strengths, and learned to adapt in the face of adversity. You've earned this!

As you stand at the culmination of this course, remember that your journey doesn't end here; it transforms. You've laid a solid foundation for continued growth and well-being. The skills and insights you've acquired are lifelong companions, ready to support you in your ongoing pursuit of a fulfi lling and meaningful life.

Take a moment to acknowledge your achievements, both big and small. Celebrate the dedication you've shown to your well-being. As you move forward, know that you carry within you the wisdom and strength to navigate the path ahead. Your commitment to self-care and personal growth is a testament to your resilience and determination. The journey continues, and you're well-prepared to face whatever comes your way. Keep moving forward with confi dence, compassion for yourself, and the knowledge that you possess the tools to lead a life of purpose and joy. And most of all, BE INSPIRED!

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Now that we've talked about mindfulness, let's dive into how exercise and movement can help manage your pain. Exercise can make you stronger, more fl exible, and break the pain cycle, improving your health and quality of life. We know that changing habits, like starting to exercise, can be tough! It can feel new, progress might be slow, and you might face challenges or setbacks. It's important to know that these feelings are normal. We're here to share two strategies that can help:

Baby Steps: Imagine climbing a big mountain. Instead of trying to reach the top all at once, you take small steps. That's what baby steps are---breaking a big goal into smaller, manageable parts. By taking smaller steps, you learn, have success, and gain momentum in changing your habits! Pacing/Spacing: Imagine you're in a race. If you sprint at the start, you might get tired and not fi nish. But if you pace yourself, spread out your energy, and take breaks, you have a better chance of fi nishing strong. That's what pacing/spacing is---fi nding the right rhythm for you. When you use baby steps and pacing/spacing over time, it helps us build the stamina to do activities longer without getting tired. Using these strategies also means you can do activities without "grinding our gears", or pushing your body too hard. It's a mismatch like trying to pedal really fast while being in a diffi cult gear on a bike. Its too hard, you get tired fast, and eventually you stop riding because it didn't feel good. So, instead of "grinding gears," let's talk about how we can use baby steps and pacing spacing to fi nd the right balance to build stamina and manage setbacks during your exercise behavior change journey!

Baby steps are a great way to build stamina. The best way to start is to fi nd exercises that match your current abilities and gradually increase the diffi culty over time, like fi nding the right gear on a bike. Using baby steps, you can slowly add small changes, such as walking a bit more each day or adding a slight hill to your path. The key is to start small and gradually make things harder as you get stronger. This approach not only improves your stamina and endurance but also helps you stay in tune with your body. Pacing and spacing are important because your body needs breaks! When you exercise, pace yourself to fi nish your planned activity. This might mean starting slower or taking more breaks. For example, on a 20-minute walk, you could rest for 2 minutes every 5 minutes. This approach helps you build stamina and endurance while avoiding burnout. You can also spread your exercise throughout the day, like taking a 15-minute walk in the morning and another in the evening. This way, you can reach your goals without getting too tired, giving your body time to catch its breath and get ready for more.

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You may be wondering how social support is related to things we've been talking about in the INSPIRE program, but you should know that social support is really important when it comes to exercise! Having friends, family, or workout buddies can make exercising more fun and help you stick with it. Here's how:

1\. Encouragement and Motivation: When you exercise with others, you feel more connected and motivated. It makes the activity more enjoyable and helps you stay committed.

2\. Accountability: Friends and family can help you stay on track. Knowing others are counting on you can push you to keep up with your routine.

3\. Sharing the Journey: Exercising together means you can cheer each other on, celebrate wins, support each other through challenges, and makes the whole experience less lonely.

4\. Practical Help: Exercising with someone can also help with things like transportation, costs, equipment, and planning. You might also help your friend get more active, so it's a win-win!

In short, moving with someone you care about makes the experience better and helps you both stay active!

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Let's do a brief reflection exercise to explore how your thoughts, feelings, and behaviors might be affecting your sleep. Here's some step by step instructions:

1. Think About Your Day: Take a moment to recall your day from morning to bedtime. Try to recall what you did, how you felt, and what you spent time thinking about.
2. List Down: On a piece of paper, make three columns:

Thoughts: Were you anxious about a job interview, thereby making it hard to fall asleep? Or perhaps you felt grateful for a well-spent day, leading to a peaceful night? Feelings: Were you stressed or anxious? Maybe sad or down about something that happened?

Behaviors: Did you have caffeine late in the day? Maybe you watched TV or used your phone right before bed? Perhaps you had a late-night heavy metal?

1. Connections: Try to connect these examples to nights when you felt you had good sleep and nights when you didn't. Are there patterns? Maybe on days you feel accomplished, you sleep better. Or perhaps on days you skip your evening walk, you find it hard to doze off .
2. Plan for Better Sleep: Now that you've identifi ed potential influencers of your sleep, think about small changes you can make. For instance, if screen time before bed disrupts your sleep, can you read a book instead?

Wrap-up: Understanding how your daily thoughts, behaviors, and activities influence sleep is a step towards healthier sleep patterns. Regularly reflecting can help you identify patterns and make meaningful changes to improve your sleep over time.

Insomnia can often be exacerbated by negative thought patterns and worries about sleep. Cognitive restructuring is a technique that can help you challenge and change these unhelpful thoughts. We used the ABCD technique in weeks 5 and 6. Here, we will focus on the B -- the beliefs and the D -- the dispute or how we might rethink the thoughts that are keeping us awake.

Step 1: Identifying Negative Thoughts and Beliefs: Begin by identifying the thoughts and beliefs that contribute to your insomnia. These could be concerns about not being able to fall asleep, fear of being tired the next day, or frustration about past sleepless nights. Write down these thoughts.

Step 2: Dispute the Negative Thoughts: Now, dispute these negative thoughts. Ask yourself:

• Is this thought based on facts or assumptions?
• What evidence do I have that contradicts this thought?
• Am I catastrophizing the situation?
• How likely is the worst-case scenario to happen? For example, if your thought is, "I'll never be able to function tomorrow without enough sleep tonight," challenge it by considering past instances where you managed well despite lack of sleep.

Step 3: Rewrite the Negative Thoughts: Rewrite your negative thoughts into more balanced and realistic statements. For instance:

• From: "I must get eight hours of sleep; otherwise, I can't function."
• To: "While it's ideal to get eight hours, I can function reasonably well with a bit less sleep. One night of poor sleep doesn't ruin my ability to cope."

-Remember to use some of the more general techniques we shared in weeks 5 and 6 like "What would you say to a good friend having this thought?" or you could use the "Yes...But" technique -- "Yes, I'll be tired if I don't sleep well but I've managed to function MANY times before with very little sleep."

Step 4: Creating a coping statement. You might also try to create a new positive coping statement to replace negative thoughts. For example:

• "I am resilient; I can handle the day even with less sleep."
• "My body knows how to rest, and tomorrow is a new day." We suggest just taking out a piece of paper and giving this a whirl.

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The fi rst positive state that we want to cover is GRATITUDE! Recently, there's been a great deal of research on gratitude, or what has been called an "attitude of gratitude." Now, gratitude has been linked to better health, sounder sleep, less anxiety and depression, higher long-term satisfaction with life, and kinder behavior toward others, including romantic partners. Another study shows that feeling grateful makes people less likely to turn aggressive when provoked. A good example of some of the seminal work was done by Robert Emmons at the University of California and Davis. He started with a program that he called Gratitude Light. In this program, people were asked to complete a gratitude journal where they list 5 things once per week that they are grateful for. Each item can only be one sentence long. After two months, participants were more optimistic, happier, exercised more, AND had fewer physical complaints.

We've also found that positive emotions can build new relationships. But how? When an individual is in a negative mood state, they circle their social wagons. They're more closed to outside social contacts or to building new relationships. The opposite is true for positive emotions. When we're in a positive emotional state, we're more likely to reach out to others, to meet new people, or to deepen existing relationships. So positive emotions may be there to broaden our cognitive repertoire and to build important social relationships that will sustain us in the negative times ahead.

But are there things to be grateful for when you have chronic pain? Yes! We think so and so do many others. Remember that gratitude has no limits or bounds placed on it. We can be grateful for something in the past, present, or even something in the future like a dream that gives us comfort or hope. We can be grateful about people - those we know or even those we don't know. We can be grateful for simple things like feeling the warmth of the sun or the cool, refreshing relief you get from a glass of water when you're thirsty. We can be grateful for worldly things or spiritual things - and, well, I think you get the point. If we try, we can nearly always fi nd something to be grateful about. The challenge is remembering to look for something, then once you've found something, holding onto it so you can continue to feel its healing eff ects.

Let's take this concept and see how you can build your own gratitude!

The next positive state we want to explore is savoring. Savoring is a core concept in positive psychology that focuses on fully experiencing and appreciating positive moments. It's about slowing down, being present, and letting the positive aspects of life deeply uplift and touch us.

Imagine sitting down to enjoy a delicious meal. Instead of quickly eating, savoring involves paying attention to the aroma, noticing the fl avors with each bite, and fully appreciating the experience. It's about immersing yourself in the present moment and allowing the positivity of that experience to resonate deeply within you.

Savoring is similar to mindfulness, but with a specifi c focus on being mindful of positive experiences. While mindfulness encourages us to observe the present moment, savoring helps us to extend and amplify the joy and positivity that come from those moments.

Here's how to Practice Savoring:

Slow Down: When you encounter something positive, take a moment to slow down and fully immerse yourself in the experience.

Engage Your Senses: Focus on what you see, hear, taste, smell, or feel. This sensory engagement deepens the experience and makes it more vivid.

Refl ect on the Moment: Think about why this moment brings you joy and what makes it meaningful.

Extend the Experience: After the moment has passed, revisit it mentally to allow the positive emotions to linger. Refl ect on the joy or contentment you felt and let it carry forward.

By practicing savoring, you can make positive moments "stickier," allowing them to last longer and have a greater impact on your emotional well-being. Savoring helps us hold onto the good, even when life feels challenging.

Now that we've explored coping mechanisms, let's shift our focus to happiness and joy---two important concepts from mindfulness that can help you manage chronic pain.

Happiness is a feeling of contentment and satisfaction with life. It's about appreciating the good things around you and feeling at peace. Joy, on the other hand, is a burst of positive emotions like excitement, delight, or pleasure. While happiness is more of a steady state, joy is often more intense but short-lived. Both happiness and joy are about experiencing positive emotions and being present in the moment.

Practicing mindfulness helps you cope with pain by focusing on the positive aspects of life and reducing the negative impact of pain on your happiness. When you stay present in joyful moments, you create a mental space where the intensity of pain may lessen, allowing joy to shine through.

We know that fi nding happiness and joy can be challenging when you're managing chronic pain, but it is possible. You can build these emotions into your life through social connections, gratitude, and savoring.

Social connectedness: Spending time with friends and family, talking, and sharing feelings can increase happiness. Strong social connections make you feel less alone and more supported. If you're unsure how to build social support, consider joining clubs, volunteering, or participating in group activities. These actions can help you connect with others and boost your mood.

Gratitude: Being thankful for the good things in your life helps build happiness. You can express your gratitude in a journal or tell others how much you appreciate them. Practicing gratitude regularly makes you more aware of the positive things around you, even on diffi cult days.

Savoring: Taking time to fully enjoy and appreciate positive experiences builds joy. This might mean slowing down to enjoy a beautiful sunset, savor a meal, or share a moment of laughter with a friend. Savoring allows you to prolong the positive eff ects of these experiences and bring more joy into your life.

You can use happiness and joy as tools to help manage your chronic pain. With strategies like social connection, gratitude, and savoring, you can build more positive experiences into your daily life and improve your overall well-being.