This podcast is offered by the San Francisco Zen Center on the web at www.sfcc.org. Our public programs are made possible by donations from people like you. Good morning, everyone. Can you hear me? Just raise your hand if you can't. I speak in a very low voice, soft voice. Anyway, my name is Grace Step. Damon, and I'm so glad to be here. I'm grateful to you, Timo, and to the leadership at SENSEN for inviting me to speak today. I was a resident here at one point for about 30 years, so I'm both a Buddhist practitioner and a physician. I practice with chronic pain and have done so for the last 13 years. And also, I was in the head on the Golden Gate Bridge about 15 years ago, so much of my work has been dealing with the outcome of life-changing events, change body and mind.

[01:08]

So what I'm going to talk about today is the intersection of medicine and chronic pain, because they have a lot to feed each other in medicine, say in Buddhism. They are the two pillars that I always go to. Whenever I'm blumbed or whenever I'm slightly overwhelmed by the categories or what I see as the facts of existence, which I've been in the last couple of weeks, as I'm sure many of you have been also. So, and because I'm 77, I no longer feel that despair is an option. It's not an option. And for full disclosure, I must add that I have tremendous faith in Buddhism, but less so in Western medicine for ameliorating, relieving suffering and healing.

[02:16]

My go-to activities for when I feel overwhelmed are practice, connection, like today. learning and sanctuary. And this place here has for years been my sanctuary. And even though I don't live here today, I still hold it in my mind. So sitting here right now, it's feeling wonderful. Thank you. As many of you, I'm sure, have heard, pain is forgiven in life, but suffering is optional. In the last 50 years, brain scientists, particularly in the last decade, brain scientists have made terrific advances in understanding how fitting or ahead of its time Buddhism actually is, talking about pain and suffering. After all, the Buddha said at one point, he gave the parable of the two arrows, meaning if you're shot by one arrow,

[03:25]

That, of course, causes you pain. But only if you make up a story about that shot. You tell your mind, oh, I'm suffering. Does that then become suffering? And that's the second arrow. What we do to ourselves, what kind of stories we tell ourselves about the facts of existence. To look at the beauty and complexity of the pain pathway, let's think about boiling a pot of water that's boiling on the stove. I did this recently. So imagine you go, pick up that pot, and you forget to put on a potholder. What happens? Of course, your fingers and hands feel tremendous pain or noxious stimuli. that's capable of damaging the body.

[04:27]

Noceoceptors are those receptors that we have everywhere in our body that can pick up stimuli capable of causing us great injury, even death sometimes. We've got them in our skin, joints, bones, muscles, where else? Viscera, yeah, viscera. what they do. So what happens when the receptors are stimulated is they put out a chemical soup and that chemical soup in turn creates an impulse, an electrical impulse, which if it's strong enough, can activate an action potential. You all remember about action potentials somewhere in your past life, when you're in fourth grade, Anyway, that action potential in turn goes through the fibers, nerve fibers, and shoots up toward the spinal column to the brain where the perception of pain is understood.

[05:42]

This complex biosocial psychological phenomenon known as pain, occurs mostly in the subcortical regions of our brain. While in typical situations, the noxious stimulation of pain may precede the actual event, and sometimes they don't overlap at all. For example, as a physician, I've seen many people in trauma who were horribly wounded. and they had no perception of pain despite their massive injury. On the other hand, you also can have pain without any evidence of tissue damage. The brain is the region where we shoot that second arrow. So in my case, I said to myself, what, you forgot to use a potholder?

[06:45]

You're demented. You must be becoming demented. You've got to go see it. You've got to get neuropsych testing. That's the second arrow. And while we commonly experience pain phenomena as a single event, in fact, it's made up of multiple parts. There's both the sensation itself, what we call noxious stimuli, and the nociceptors that pick it up. And then there's the labeling that we do to that sensation. And that's the labeling is what causes suffering. And also, it's increasingly clear that our attitudes toward that initial stimuli can also change the way we experience it. There's a wonderful story about Ronald Siegel, who was a

[07:48]

psychologist practicing medicine at Harvard Medical School. He also happens to be a chronic back pain specialist. Anyway, he says that meditation can also alleviate our responses to that first sensation of pain. And he thinks that most back pain is caused by muscular tension. rather than structural problems in the back. So sorry you're going. And many pain disorders are caused by this loop of increasing muscle tension when we get a noxious stimulant. And once we experience a pain sensation that we're afraid of due to injury, we bring all of our attention. And simply stated that it increases the pain no end, Siegel said.

[08:55]

And he believes that not only suffering, but the amount of pain itself can be reduced by turning our attention to the pain, saying yes to the sensation. By doing so, the intensity of the sensation diminishes. Mindfulness, however, is not a panacea. Siegel was already a big Buddhist meditator when he was struck down by back pain. He said, I totally worked myself up so much. Despite the meditation practice, I was convinced that ever moving was going to cause me lasting injury in my back. So go to a doctor before you try to... turn all your attention, because we want to rule out that there's no physical cause. Anyway, the key figure in understanding pain is, doesn't matter what its name was, but it has a gate control theory, which explains how pain can be gated.

[10:04]

An open gate allows the pain impulses or the sensation impulse to travel to the brain. Close gate doesn't allow them to travel to the brain. And in the brain, they're categorized, referred to as pain, as something aversive. Now we talk about the pain matrix as being different regions of the brain that contribute to pain. Nerve fibers carry on. impulses up the spot to the thalamus. From there, the thalamus, they branch in two ways. One goes to the somatosensory cortex, a region of the brain that contains a map of our body. And that tells us where pain is located. And then another pathway goes to the cingulate cortex.

[11:12]

And this region tells us that the sensing is unpleasant. Amazingly, people in the singular cortex experience pain, but they don't feel it as pain, meaning they experience the sensation, but they don't label it as painful. And pain lacks that urgent question. quality that gets us to pay attention to it. And it seems like there are sub-regions in the singular cortex that serve as a neural alarm to our bodies. They tell us when active at physical pain and or emotional distress like the sting of rejection. They put us on alert. And they tell us to suffer. And once we start suffering, then we decide to flee.

[12:17]

This area prepares us, in other words, for flight or fight. And when alarmed, we tense our muscles. And if we keep tensing our muscles too much, this leads to additional pain. The good news is that we can downregulate that. We can stop. this secondary calling of the parts of our brain, like the prefrontal cortex, which tells us, no, this is not alarming. There's no reason to flee. You don't have to do it. Just stay. In other words, what's going on is acceptable. And we relax our muscles. Take a deep breath. Take a deep breath now, all of you. And we experience pain sensation without fear, without tension, and the sense of suffering falls off.

[13:27]

This is the physiological basis, foundation of the parable of the two arrows. The impact of the second arrow is due to our resistance. to the first arrow. When our resistance disappears, so it goes. And also there's a whole nerve descending network of nerves that tend to downregulate the initial sensation of pain. For example, light touch. How many of you, let's say when you're about to get a shot, Or when you've had sutures, how many of you have bit the inside of your lip? Anyway, that's another way to downregulate pain. We cause pain in another part of our body, and that reduces the initial pain. Pleasure also does that.

[14:30]

How many of you have beaten chocolate? How many of you love chocolate? Chocolate. does something in the thalamus, which also downregulates our sensation and increases our sensitivity to reward. Same too with music and good friends. Those operate at the amygdala to increase our sense of reward. Now we get to chronic. which is the most common symptom that I ever hear about. Now, even when I was in private practice, it was the most common symptom. People came to me saying, Doc, this hurts. And once I did away with the actual acute cause, then chronic pain is what persists for more than three months and or goes beyond the normal healing.

[15:38]

that we would think, and or we don't have any other word or reason for it, then it becomes chronic pain. And the CTC estimates that 50 million people in the U.S. suffer from chronic pain. About 10% of those, meaning about, doesn't matter how many million, 5 million, anyway, I can still do that. Suffer from high-impact pain or pain that disrupts our lives on a daily basis, either by making our social, physical, mental, or work-related activities go down the chute. There's a higher prevalence of this chronic pain, of course, among older adults, among those living in poverty, among Among adults who were once employed but aren't employed now.

[16:40]

Among adults with disabilities, chronic diseases, medical diseases. And also, there's an increase in chronic pain for separated, divorced, LGBTQ people. And, of course, people living in poverty. That was the one I was looking for. Finally, chronic pain is said to involve 50% of those of us who are older. I'm not going to specify where older starts. And about 80% of nursing home residents. So up against this. Oh, actually, let me talk a little bit about the opioid crisis. I'm sure you all know about the opioid crisis. You know somebody who's been involved in the opioid crisis, somebody who's attacked by it.

[17:43]

Anyway, this is because in 1990s, he came up with this idea of a fifth vital sign. Vital signs are what indicate you're alive to a doctor, meaning heart rate, respiration rate, blood pressure, pulse. And they added the fifth one of pain. And that, of course, increased the focus on pain and led to a huge increase in the prescribing of opiates because they're the most effective medication for acute pain. So against that, we saw a huge number of overdose deaths. Of course, prescribing patterns have changed, but we went from 20,000 OD deaths in 2000 to over 120,000 last year.

[18:45]

Most of those are caused by synthetic opiates like fentanyl or diverted opiates like heroin. This, of course, led to... backlash in society at large. So opiates are no longer considered useful for anything but cancer-related chronic pain. And so all of my clients are having to find some other way. Because once you start using opiates, I don't care who you are, how you are, you become quickly habituated with which means it takes more and more to get the same pain relief. And with habituation increasing usage, so overdose rates increase. So how is it that we can deal with pain? And is pain treatment possible?

[19:48]

And if so, at what cost to the human being or to the nation that it looks like? Now, at my hospital, which is a skilled nursing facility where everybody, of course, is in pain, we were charged to start a pain program. And most of the residents we dealt have chronic, multiple medical problems. Most of them are marginally half-housed, meaning they're likely to be homeless, drug-abusing, or addicted, and psychologically challenged. We were very fortunate to be able to begin our program using ancillary treatment or alternative forms of treatment, like acupuncture, acupressure, all kinds of energy work, breathing, meditation, Reiki, music therapy.

[20:50]

You name it, we did it. And because we're doctors, sometimes I walk down the hallway, I think I'm getting paid to crank my JBL speak up as loud as I can and dance to Aretha Franklin. I can't believe I'm so lucky. We used to have a large room where we could bring everybody together. We meditated together. We told stories together. We laughed a lot. We could listen to music. We sang together. Now we have to see each resident separately or individually. This won't be any surprise because of COVID. But we still crank the music up. We still open the patient's door because staff, everybody loves music. I mean, everybody loves music. Everybody loves to groove on music. We start by creating relationships.

[21:59]

asking basic questions like, how is the pain for you? How does it affect your life? How do you experience it? What does it feel like? Is it sharp? Is it dull? You can ask yourself these questions right now because all of you have experienced some kind of pain. So just ask yourself, how do I experience it? What does it mean to me? And all of our treatment modalities, Use either the bottom up, meaning we start at the periphery, like touch and progressive muscle relaxation, or start at the periphery and send signals up to the brain, or we start at the brain by meditating, for example, or by imagery. Go downward. We also, of course, are trying to get to know our patient by creating relationships to them, by touching them psychically, by touching them physically, by touching them spiritually.

[23:15]

And most of all, we rely on those relationships for healing. We create, nurture, and support relationships. So ask yourself, What relationships do you support? What relationships support you? Beside the parable of the arrow, what does Buddhism have to say about suffering, about pain? Actually, it's got a lot to say about both things. It's essentially a training in compassion. Buddha said in his earliest lecture, my purpose in the world is single of bold. My purpose in the world is to relieve suffering. The Four Noble Truths, which the Buddha expelled, were about suffering, its cause, what creates it, what undoes it, and the eightfold path, which, of course, we all know.

[24:18]

And at the end of this lecture, we're going to vow to save all sentient beings. Now, how does this help our pain, our human pain? How does vowing to safe ascension help us? I live at the Redwoods, which is a senior living facility. And I've got to say, the day after the debate, the tension it suffered was so thick, nobody could breathe. So I listened to a nearby table. A grandmother saying, let's talk to our grandchildren. We cannot let them fall into a pit of despair. And a woman in my meditation group that meets on Saturdays yesterday said, I feel like my job is to be a light to everybody here suffering, sin, and pain.

[25:23]

So we're not the first generation, nor will we be the last to live through catastrophe. And I'm going to talk right now about somebody probably none of you have heard about. His name is Matsu. Just because I wanted to find something talking about Buddhism during a time which the bottom dropped out of Sasak. And the Ansan Rebellion is that time. time. John Herzog wrote a wonderful book about Chan Buddhism, which of course is the precursor to Zen in Japan and consequently here. And the golden age of Chan was during the Chan dynasty in 600 to 900 BC. And It was a period when art flourished, when culture flourished, when everything seemed to be going great guns.

[26:33]

I'm sure the Dow Jones, if they had it at that time, was breaking all records. But unfortunately, they had a long order to defend, and they had an imperial policy, all of which means constant warfare. They had higher, worsening. because they ran out of their own citizenry to beat the armory. So it was a period in 755, and it was a period of great famine, disease, warfare, and death, poverty. The population went from something like over 50 million to just over 15 million in nine years. That's two out of every three. Chinese died during that period. And some of our great ancestors, Bodhidharma, the sixth ancestor, Shitu, Lingji, Matsu, they were all born and lived during this time of rebellion.

[27:44]

So I was really interested in seeing what they had to say. Little is known about Matsu. except that he was born at the western border of China, near Tibet, and began studying Chan when he was under 30, I think. Eventually, he moved into the center of China. And the attitude of Chan right at that point was kind of eclectic. I mean, it was... off the cuff, not really interested in precepts, ceremonies, rituals, and had kind of a dumbed-down attitude. But it was rustic and freewheeling. Matsu left the Board of Regents, started studying with Wei Long, who was his teacher. And there's a wonderful story about Matsu sitting in his hut meditating.

[28:51]

still doing that. And all of a sudden, he heard a noise. And eventually, it was grinding. It got so irritated. He came outside and saw his teacher and said, what are you doing? The teacher said, I'm polishing a tile. And he said, why are you polishing a tile? The teacher said, I want a mirror. Matsu said, don't you know you can't polish a tile and have it become a mirror? And the teacher said, don't you know you can't sit in meditation and become a Buddha? And Matsu said, oh. And he was really taken aback. And he said, what should I do now? And his teacher said, well, if the car doesn't go, Which do you hit? Yaksu, the cart.

[29:52]

Matsu started studying again in earnest with him. Now Matsu is described as remarkable in appearance. I think this is part of the reason that I loved him. I loved him as Shuso, and I love him now. Anyway, he was like a bull, the gaze of a tiger. And it's sad that when he stuck his tongue out, his tongue would... go over his nose and up to his forehead. And on his feet, he had two round circles. Another description is much more poetic, saying he was stalwart, standing like a mountain, and deep and clear, like still water. Doesn't that sound nice? So Matsu finally started walking during the Anshan Rebellion and finally ended up in Taiwan Monastery where he had thousands of disciples.

[31:08]

He had 139 transmitted disciples, which is like being a single parent, I think, to over 500 rambunctious children. And the teachings of him, because they were formed during this period of struggle, have an immediacy and of vibrancy to probably his best-known teaching is contained in Case 30 of the Mumalongka, and it's called, doesn't matter what it's called, but anyway, one of his disciples, Daimei, came to him and said, what is Buddha? Matsu answered, this very mind is Buddha. And Muman's comment, the commentator in the Blue Cliff Record, said, if you directly grasp Matsu's meaning, you wear Buddha's clothes, you eat Buddha's food, speak Buddha's words, do Buddha's deeds.

[32:16]

That is, you are Buddha himself, I would say herself. Against the backdrop of China's most trying period, this call to the present was no casual invitation to stop holding on to the past, stop ruminating about the future. It is a spiritual battle. It's aimed at bringing the population that's in shock to back into reality. The population had given up. They felt like there was nothing to be done. They couldn't make a difference. Does that sound familiar? Matsu's claim, everyday mind is Buddha, which effectively cuts off escapism either into selfish, self-absorption,

[33:28]

or mystical abstraction. I'm like, God will pull me out of this. Ordinary mind is the way. We don't reject any lines of thought or feelings, flashes of anger. We feel generosity in the moment. I feel generosity to you guys. I hope you do to me. And that's happening in the moment. And we just can experience and be with this very moment, not with any other moment, not with the future, not with the past. We really do feel and care about closeness, no matter what the circumstances are. We right now are here. You've got the treasure in you. We all have the treasure in us. When Buddha stated, my whole purpose is to end suffering, the Four Noble Truths were his first Dharma talk.

[34:37]

And in those truths, he said, yes to suffering, yes to its cause, yes to its cessation, yes to the full path. And he didn't say, with no pain. What Buddha did was to help create a path for all of us that could help us by practice. Avoid the second arrow. We spend a lot of time in the company of our feelings and thoughts. We practice together. We meditate together. We hear a bird song together. We're not hearing it now, but at the crack of dawn. We do and hear. In other words, each of us lives away. web of interconnected lives with both the invisible and the visible. And then, for no apparent reason, your neighbor coughs. Somebody besides you moves.

[35:40]

Somebody drops something. The birdsong or the coughing may put you in a place startlingly where you've never been before. That's what's waking up is. Once there was a questioner of Matsu's named Shi Lao, who asked him, what is the meaning of Chan, Buddhism? And Matsu kicked him, knocking him over. And Shi Lao just started laughing. And he said, later he said, I have not stopped laughing since Mak. Push me over. These. Your neighbor coughing. Can have the same impact. Somebody pushing you over. But one of Ma's heirs said. That his teacher taught him. Two crucial things.

[36:42]

First that each of us. Is already in doubt. With everything we need. You are in doubt. I am in doubt. Our enlightenment. Is already here. And second. that each of us is free to use that treasure, which is our endowment, to respond however we want to whatever it is that's around us. And Matsu was passionate about responding to the time as an essential part of realization. He was not interested in emptiness. He said, from the point of view of the bodhisattva, which is what all of us are trying to do, be bearing oneself in emptiness and not knowing how to get out is like suffering the dormants of hell. As our hearts and minds open in meditation, so too our hands want to open.

[37:49]

And it's actually painful for us not to be able to use our hands. For Matsu, hell wasn't the trouble that he saw all around him. He was trying to escape that trouble. We started talking about pain in the fingers and my hand on the hot pot. That heat and hand started a whole signal that traveled up to my brain, which finally said, Grace, you're stupid. Grace, you need a neuropsych exam now. Matsu's prescription is much kinder. He said, take that mental debris. You need a neuropsych exam. You're getting demented. And just recognize that that's part of the mind. The mind itself is Buddha. This very mind is Buddha. We don't need to suffer.

[38:56]

And like the physician, the adage that we were told when I graduated from medical school, physician healed by self. That healing is not isolated. It's not singular. It takes place within a web of interconnectedness with all of life's forms. It happens by meditating, most of all by practice, by forming intimate relationships. primarily with our own mind, and also with Sangha, which we'll point out where we don't get our own mind. Sangha is a great antidote to our own tendency to avoid. And out of this intimacy comes compassion, tenderness, that will in time allow us, I hope, to give the appropriate response to every situation we come into whatever life presents itself.

[40:03]

Thank you very much. Thank you for listening to this podcast offered by the San Francisco Zen Center. Our Dharma talks are offered at no cost and this is made possible by the donations we receive. Your financial support helps us to continue to offer the Dharma. For more information, visit sfcc.org and click Giving. May we fully enjoy the Dharma.

[40:29]

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