This inventory (Fig. 13.2) was developed by Pradhan [83], based on the five-factor model of any human experience created by the mind. This comprehensive inventory serves as a main tool in the Y-MBCT-pain psychotherapy and is used to generate data on the content as well as the sequence of the five components as they come up during expression of the pain experience in client’s daily life or in therapist’s office during the trial practice of meditation. Also, this inventory helps to delineate the cognitive distortions, to identify maladaptive feelings, memories, or life experiences including the client’s maladaptive urges/impulses, safety behaviors, and avoidance behavior that maintained the symptoms and dysfunctions in a vicious cycle. This helps people identify and develop skills to change all the five key components that form the core of the pain experience, that is, negative thoughts, feelings, memories, and behaviors. Based on the scriptural concepts on human mind and any human experience, this model emphasizes that individuals—not outside situations and events—create their own experiences, pain included. And by changing their negative thoughts and behaviors, people can change their awareness of pain and develop better coping skills, even if the actual level of pain stays the same. This pain symptom inventory provides rich and personalized information on the pain experience of the patient and helps the therapist to target the individual components of this experience using the brief CBT interventions in an individualized yet symptom-specific and structured way. Pain symptom inventory and interventions in the Y-MBCT-pain module help the individual getting detached from all components of the pain and then to reappraise them in less emotional if not entirely neutral way. This provides a new perspective on pain experience and subsequently these individual components (the thoughts, emotions, and behaviors related to pain) are changed using brief CBT and also improve coping strategies, and thus put the discomfort in a better context to be able to be reappraised. This helps individuals recognize that the pain interferes less with their quality of life, and therefore can function better.

All experiences are representations which can be changed by promoting new learning. Mindfulness philosophies assert that all of the information derived by the mind based on the five components of human experience are just representations in the mind [83]. These representations, as the name suggests, are symbolic (akin to map rather than territory) and dependent on the quality/state of the mind and brain during their acquisition and subsequent expressions. Also, they change with change of the conditions that invoked these representations and thus are amenable to new learnings that result in new memories. This is true for the pain experience as well, which is amenable to new learning that provides new meanings or new associations to the existing information. Recent research from cognitive neuroscience upholds this view and asserts that memory is state dependent and changeable [78, 79] and thus experience is prone to change as well. Meditative wisdom informs us that amelioration of stress and healthy reappraisal of situations are possible by modification of the internal representations: this is done by achieving the meditative insight about the nature of these representations so that premature actions or cognitions (judgments, conclusions or biases, etc.) are prevented. Y-MBCT-pain model utilizes these principles for the treatment of chronic pain. Thus, breaking down the individual pain experience, which is a composite of the five basic components as mentioned above, and eliciting the details of their sequence, form, and contents by using the quantitative five-factor inventory, paves the way for modifying them further with mindfulness tool and the brief CBT interventions. The targeted and specific Y-MBCT-pain tools help in de-escalation of arousal or avoidance symptoms in response to the pain experiences and also help to deconstruct the pain experience by inducing the detached observation and reappraisal of the five components of pain. This detached observation helps the individual to move from the reactive state to a responsive state and also prevents the client from acting on the pain experience. This provides the insight (Pali. nanna) into the pain experience and thus provides new learnings and new meanings which eventually becomes no longer distressing or dysfunctional.

Y-MBCT-pain interventions are applied for the patients in five steps in a sequence and perfected initially by six to eight therapist-assisted individual sessions (30-min duration each) followed by home practice daily. These five steps are as follows:

These above interventions are done in two stages, and over six to eight individual therapy sessions (30 min each) as described below:

Y-MBCT pain can be distinguished from other approaches within CBT or other mindfulness treatment approaches in the philosophical assumptions and the scientific strategies it adopts. Y-MBCT pain has roots in learning theory and in the learning and memory processes (extinction and reconsolidation processes) that influences the multilayered experience of chronic pain and in laboratory studies of basic behavioral processes. It includes an emphasis on cognitive processes and affective-behavioral experiences, just as in other CBT approaches but in more inclusive ways. Y-MBCT-pain module uses extensively the five-factor inventory and tends to “normalize” human suffering to a certain extent by seeing the pain experience as a continuum from the normal day-to-day pain experience to grossly dysfunctional pain experience. As one can see in the five-factor inventory and the Y-MBCT-pain model, pain and suffering as inherent in the human condition are built into the design of human experience and behavior. In this approach, the therapist practices meditation with the client in-session, thus establishes better empathic connection with the client and his/her pain and suffering. These approaches reflect an emphasis on qualities in the behavior of the treatment provider and on the experiential methods rather than on didactic ones (which are mere verbal jargons). Also, it focuses on changing the responses to the pain and its associated symptoms rather than focusing on the symptoms themselves (care, not cure approach). It tends to focus more on the process rather than just on contents. The pain symptom inventory based on the five-factor model is akin to the thought record of traditional CBT but is more inclusive. The triadic model of thought record used in traditional CBT focuses primarily on one’s thoughts, feelings, and behavior, whereas the pain symptom inventory touches upon all five components.

The experiential data obtained from the trial-breathing meditation during eliciting the five-factor response to pain and from the use of the ASMI (Assessment Scale for Mindfulness Interventions) [83] emphasize on the patient’s psychological flexibility (or inflexibility) aspects and attempts to enhance the flexibility in non-judgmental and empathic ways. Psychological flexibility is the capacity to continue with or change behavior, guided by one’s goals, in a context of the various interacting psychological processes [63].

The psychosomatic adaptations for therapeutic use of the Y-MBCT pain are based on two major themes in Yoga: Yoga as a profound psychosomatic science and meditation as a science of attention. Y-MBCT pain relies on the fact that pain is the ultimate psychosomatic phenomenon. Pain is composed of both somatic signal (something wrong with the body) and interpretation of the meaning of that signal (this meaning is learning dependent and can be changed by the five-factor model). Pradhan’s model uses the five-factor model and ASMI scale to use brief CBT to decrease and alter the meaning of pain by new learning. Pain experience = tissue damage/pain sensitization of the body combined with the emotional reaction to it that is brought by the five factors in one’s mind: Mindfulness interventions change emotional reaction to it (via five-factor inventory), FA and detachment from pain experience. Of note, detachment (disassociation) is different from dissociation and should not be confused with it [83]. Dissociation is a rather primitive defense mechanism of mind, whereas detachment is a higher-order psychological function that can be cultivated through mindfulness interventions.

Thus, the Y-MBCT for pain model, beginning with the physical body, eventually influences all aspects of the person: physical, mental, emotional, and spiritual. It offers various levels and approaches to relax, energize, remodel, and strengthen body and mind. The postures (Sanskrit: asanas) and meditative breathing (Sanskrit: pranayama) harmonize the physiological system and initiate a relaxation response in the neurohumoral system by effecting a reduction in the existing metabolism, establishing a quieter breathing, stabilizing the blood pressure, reducing muscle tension, lowering heart rate, and slowing and synchronizing the brain wave pattern, all of which contribute to one’s stress arousal pattern in response to pain. As these pain response patterns get modulated, hyperarousal of the nervous system and the static load on postural muscles get reduced and the function of viscera improves with the sense of relaxation and sleep gets deeper and sustained, fatigue diminishes. Also, when somebody gets established in a regular schedule of meditation, the personalized meanings of pain and suffering change and the preexisting conditioning and identification with chronic pain reduces: all of these change the context and meanings of the pain and its associated dysfunctions in the sufferer’s daily life. Meditation and pranayama, along with relaxing and physically nondemanding postures can help individuals deal with the emotional aspects of chronic pain, reduce anxiety and depression effectively, and improve the perceived and actual quality of life.

In pain management, considering the low resources and difficulties in the implementation of multidimensional treatment, it is important to develop treatment models that are easy to implement, that can be combined with other treatment modalities, and most importantly can be done via self-help. Y-MBCT pain is a self-help module and this model can be used alone or in combination with pain medications or other therapies as well depending upon the severity of pain, and the need of the individuals. It relieves a burden from clinicians as well. Yoga and mindfulness have been shown to increase one’s level of control by enhancing the self-efficacy [60]. Self-efficacy is defined as the individual’s perceived capacity to exercise self-control over their cognitive, behavioral, and affective responses to stressful events, and is considered as an important psychological resource buffering the impact of stress on the individual. Also, mindfulness changes one’s perception of pain and the meanings attached with these perceptions. The combination of pain and the perceived uncontrollability of pain mutually influence each other and serve to amplify the pain experience. The element of the ability to control is a critical component of pain management, and mindfulness provides an excellent opportunity for many to modulate or even eliminate the pain.

Compared to the often nonstandardized and piecemeal use of Yoga, as just a physical exercise or as a breathing technique or as an isolated meditation technique, as typically seen in the Western world, Y-MBCT pain uses standardized and sequential use of all eight steps of Yoga in flexible, personalized, and pain experience-specific manner. These interventions in the Y-MBCT pain combine all three aspects of Yoga, that is, philosophy, technique, and practice. These include the Yogic lifestyle (Middle Way), the physical aspects of Yoga such as postures and physical exercises (Sanskrit. asanas and kriya respectively), and standardized breathing techniques, meditation techniques (both FA meditation and mindfulness meditation, which belong to the fifth and sixth steps of Yoga) targeted toward individual symptoms and accompanying dysfunctions, and most importantly includes personalized counseling of the clients about the mindfulness philosophy that elucidates the workings of the human mind in normal and pathological states, as described in the scriptural traditions of Yoga. This model is holistic and translational in its development, targeted and standardized in its use, and can be flexibly combined with other evidence-based treatments including medications and psychotherapeutic or cognitive–behavioral interventions for the management of pain. In near future, as an extension of our research work in population with chronic PTSD to those with chronic pain [87], we intend to use the Y-MBCT-pain model in a randomized control trial, which will compare the efficacy of this treatment with other treatments (e.g., pain medications like NSAIDs, opiates or ketamine, and other therapies like CBT for pain). Of note, ketamine is a glutamate (NMDA) receptor antagonist and is a novel analgesic. In pain conditions, it works through two main mechanisms: analgesia (by mu receptor agonism) and also by the alteration of pain perception and pain memory (by glutamate antagonism) [1]. Also as a pharmacological agent, ketamine is being increasingly used in stress-related conditions like depression, PTSD, which are often comorbid in patients with chronic pain. Thus in future we also intend to develop ways in which Y-MBCT pain can be used alone or in combination with beneficial elements of other treatment modalities in a “tiered approach” depending on the severity and complexity of the pain and of course preference of the individuals with pain.