Body Language and Confidence

I love the first autumn classes of the year, as they are still infused with a sense of the holidays. It's a lovely atmosphere: the studio is warm from the natural sunlight pouring through the skylights, the windows are open and the farm animals in the field behind often serenade us!

Today we had a wonderful session centered around the theme of confidence and lifting your breast bone (sternum, the bone at the front of your rib cage, connecting both sides). If you'd like to try it, place a fingertip on the top or near the top of your sternum, feel a little light pressure where your finger is. Meanwhile place your other hand to the side of your waist, that is between the bottom of your rib cage and the top of your pelvis. Focusing on the spot under your finger lift your sternum. You will feel your ribcage lengthen away from your pelvis, your shoulder blades softly drop a little and ease apart and your head will feel as if it has been centered and placed on the top of your spinal column.

Have you ever felt under pressure or intensely purposeful, or watched someone with those traits? When this happens it's almost like your body follows your head. The head is forward and may even be tipped forward with the chin close to your chest, so your sternum sinks slightly, the body can give the impression of scuttling behind to keep up!

The social psychologist Amy Cuddy used five poses – all essentially lifting the sternum - to test her research hypothesis that 'opening' your breast bone can increase confidence. Her team's research concluded that these poses did increase confidence. She also concluded that the opposite movements - allowing the sternum to sink back and the head to drop slightly forward - induced a feeling of powerlessness and a lack of confidence.  Lifting the sternum enables you to easily project a poised, enthusiastic confidence. This self-assured enthusiasm is an impressively useful predictor of success according to Ref Lakshmi's research. Fearfully holding back activates the sympathetic nervous system, your fight or flight mechanism, or stress response. It indicates that you are not willing to be fully present in the moment, and people can tell.

We all respond to non-verbal communication all the time so when your sternum is lifted and you are present, that is attentive to what is happening around you, people respond. When the sternum is lifted and the head is sitting on top of your spinal column you inadvertently become compelling. To begin with you may find it a little odd, your body may not be used to this position, it will become more natural with repetition, little incremental changes. What we now know though is that you can self-induce presence by allowing the body to lead the mind.

It's liberating, I have changed so much from the subtle physical changes you've helped me make Mags. Increasingly I suffered from balance issues before coming to you, I always used to walk with my eyes lowered, with my mind in a whirl. Now, I make an effort to lift my breast bone and notice what's going on more, it helps me to feel in control both physically and mentally. As a consequence my life is more enjoyable, to me it's about having more confidence. -Catherine, July 2016

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Confidence and Chronic Pain

Presence stems from believing in and trusting yourself – your real honest feelings, values, and abilities.
— Amy Cuddy
 Amy Cuddy developed the 'power pose'

Amy Cuddy developed the 'power pose'

Do you sometimes think that the fear of not knowing how or when you might be better is the worst thing about experiencing chronic pain? It seems that chronic pain somehow diminishes our sense of Presence. The above quote is from a new book recently published by Amy Cuddy[ii].  Presence refers to paying attention in the moment, an enhanced self-awareness. When talking with members of Chronic Pain Ireland at a speaking engagement recently I noticed that sometimes we fold in on ourselves to be smaller, more accepted. In a recent study children identified the figures with limbs astride, arms and legs wide apart, taking up lots of space as boys, and the figures that held themselves neatly as girls. Perhaps this suggests we believe ourselves to be more acceptable if we take up less space? Many of us are parents, or will have held responsible jobs, or significant roles in our communities. Yet still the onslaught of long term pain can seriously affect our confidence and sense of self. A diagnosis of Neurophysiologic Disorder or TMS can help us to understand how the autonomic nervous system is out of balance. It's possible to find a practitioner to help identify what to do about that imbalance. This can help to address the pain. It is a slow but sure way to establish or re build our confidence. It will take time, be rewarding and so worthwhile, however, in the meantime we can give ourselves a quick confidence boost that will rewire our neural pathways over time.

This rewiring is easy, practical, quick to do, it requires a little bit of time and courage, but no equipment, no other people, no financial cost and it’s fun!

Too good to be true?

The 'power pose' developed by Amy Cuddy can transform how we feel about ourselves and how others feel about us. Let me explain - one of the reasons you might feel better after walking, a swim or Pilates, is that you have changed how you hold your body through exercise.

How we hold our body has an impact on our mind, the neural pathways stimulated by lifting our chest just a fraction can give us confidence.  If we are fearful, powerlessness can creep into us affecting what we believe, think, and feel.

The changes we encounter simply by searching for an explanation for our pain can stimulate a fearful response. If we are not informed, the changes are often unpredictable, it is disconcerting, our sense of who we are and our sense of being in control are challenged. These changes can even alienate us from ourselves. What we know is that everyone has an individual response to pain. In fact that is true of most things, invariably one size does not fit all. To invoke the relaxation response to balance the nervous system you may practice mindfulness, meditation or adult colouring. As you feel more in control so your body might need a nudge to improve your confidence. 

Confidence brings the opportunity to believe and trust in yourself, your true feelings, values and abilities. This is important because if we trust ourselves then others can trust us. It is a chance to find peace with being who we are.

Many studies suggest that non-verbal behaviour can signal something more powerful than words. Self-assurance, poise, enthusiasm and confidence, all project a presence that demands that we take notice. Likewise when we hold back, perhaps through fear, we stimulate the sympathetic nervous system, commonly known as the Stress response. It is not a permanent state of being. Stressful situations that make us feel powerless and distracted can be improved by feeling present. When we feel present our speech, facial expressions, postures and movements align. We are being ourselves.

Cuddy describes it as internal convergence, harmony. Palpable and resonant, it makes us compelling. It comes about with incremental change. We can induce a sense of presence by allowing the body to lead the mind.

If you want to try it, take yourself somewhere private, stand with your legs apart, and raise your arms to make an X. Hold this power pose for a while, up to 2 minutes if you like. As you stand in the power pose your brain is receiving a message that you are confident! Repeat this as often as you wish and gradually your brain will believe your body. It's amazing! It works. I have seen the evidence that this works, as has Amy Cuddy. Have a go, let me know how you get on, I'd love to hear from you.

Presence comes from believing and trusting your story – your feelings, beliefs, values, and abilities.

This post was originally published in My Second Spring. 

 

Mags Clark-Smith is a movement specialist trained to treat Neurophysiologic Disorders. Mags lectured in Dance and Psychology and is passionate about empowering women to move with confidence and fulfill their potential.

She runs a busy Pilates Studio and Resolving Chronic Pain programme.

You are very welcome to contact her:

Email: magsmcs@gmail.com

Telephone:  086 104 0955

References:

 Amy Cuddy 2012 TED Talk 

[ii] Presence Bringing your BOLDEST SELF to your BIGGEST CHALLENGES by Amy Cuddy.

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Five Reasons to keep your mobile phone out of your bedroom

Can your mobile phone really disrupt your sleep? Well, yes frankly it can. “But I can't live without it!” I hear you cry and there's this thing called 'Nomophobia' isn't that a good enough reason to keep our phones close at all times?

Nomophobia is the fear of being out of contact by phone. No wait, stop: this is a classified phobia really? Yes, it appears that it is.

Well actually that's quite helpful because we can treat it like other phobias. Arachnophobia is the fear of spiders and there is plenty of support available to help reduce fear and anxiety about spiders.

So maybe we can devise a plan to gradually wean ourselves off bringing the phone into our bedroom? First of all let's remind ourselves why we don't want to have a phone in the bedroom in the first place:

  • The bedroom is designed to be restful, without any sources of stress or stimulation as they can be disruptive
  • In general it is easiest to sleep in a quiet place, with no unexpected noise
  • A cosy, warm, carefully lit bedroom is conducive to a good night's sleep
  • The bedroom is an intimate space for sleeping and sex
  • Relaxation before you sleep is vital

Convincing a Senior Executive of a mobile phone company to give up his phone

Here's a story about how the Director of an Irish Mobile Phone company changed his habits recently; if he can do this I'm sure we can. My advice to him was to begin with trying a night with the phone present but on 'silent', then an evening or so later putting it outside the bedroom door, he then choose to leave his phone downstairs and has continued to do that ever since. Not only is he sleeping better but in general his long term low back pain has resolved itself, it occasionally returns when triggered by stress. There is lots of evidence that we need to rebalance our autonomic nervous system and relax more. This leads to better overall health as it allows the body's natural healing mechanisms to work properly.

Sleep is an investment to enable us to live well and enjoy ourselves, it also makes us feel and look better! To relax we need to empower ourselves and take control of our bedroom environment.  Actual or anticipated messages and calls can trigger a low grade stress response that may disrupt our sleep. 

So, in our Second Spring let's call time on 24/7 availability, with the exception of children and partners. Or maybe without exception, perhaps our children could learn't to knock on the bedroom door before bursting in? Speaking personally, that would be terrific!

This post was originally published in My Second Spring. 

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Body Mind or Mind Body Connection?

Mind Body

Mind Body Medicine (MBM), which is also be referred to as Stress Illness, is an emerging discipline with roots in Tension Myositis Syndrome (TMS) and Psychophysiologic Disorders (PPD). MBM refers to the power the mind has to affect physical changes in our body. Many examples can be drawn on to illustrate MBM, an obvious one is a red face or 'flush' when we are embarrassed or have feelings of arousal if we are attracted to someone.

Body Mind

What if we were to flip the way we see this and consider the sequence of what happens for a minute? It is true to say that sometimes we feel the heat on our face and realise that we are embarrassed or feel aroused and realise we find someone attractive. This is body mind connection.

Bonnie Bainbridge Cohen has developed a way of working called 'Body Mind Centering'. The premise of her work is to raise body awareness, to sense, feel and act, and her wonderful book is called 'Sensing, Feeling, Action'. Movement Therapists work on reconnecting their patients with their bodies. Somatic coaches do something similar. In each case body awareness is improved, and confidence in the body significantly enhanced. People experiencing chronic pain often feel disconnected to their bodies and sometimes, they feel let down by their bodies. It can be so liberating to feel flexible and confident physically.

Mind Body or Body Mind?

Does this mean that strictly Mind Body Medicine could also be called Body Mind Medicine? Yes, I suppose it does, but I think that would be quite confusing and possibly divisive. It is however, important to recognise that increased body awareness can play a significant role in a healthy life and help us to heal if we are experiencing chronic pain.

Neurophysiologic Disorder

Neurophysiologic Disorder (NPD) seems to me to offer recognition of the information exchange between body and mind. NPD recognises that thoughts can directly affect your nervous system creating a physiological response. If this response is pain then the body is telling the mind something is wrong. Equally, we can send a positive message from the body to the mind through neural pathways.

The experience of chronic pain often means that we leave the body and retreat into the mind described by Popova as 'that ever-calculating, seething cauldron of thoughts, predictions, anxieties, judgements, and incessant meta-experiences about experience itself.' Many patients I teach associate their recovery with a re-connection with their body, as if whilst they were experiencing chronic pain they were disconnected from their body.

Amy Cuddy has published research to confirm that this positive message can be sent from the body to the mind, she calls it allowing your body to lead your mind. The premise is body awareness, and in her TED talk (2012) and in her book 'Presence' (2016) she specifically refers to a power pose that can positively affect our mind and how we think. The power pose is essentially being open across the chest rather than closed or concave; a lifting of the breast bone, or puffing out of the chest if you will. It's like a shot of self-confidence, an injection of self-belief or self-worth. This message is sent from our body to mind and interestingly it can also send a non-verbal message to other people. What is seen by others is a self-confident stance and invariably an assumption is made that the person is self-confident as Amy Cuddy says in her TED talk, 'Don't fake it till you make it, fake it until you believe it'.

Information exchange between body and mind

To listen to the body or to develop body awareness actively through movement or Body Mind Centering, for example, opens up the opportunity to add another dimension to Mind Body Medicine. In my experience it appears that for some people the Body Mind connection is the key to their healing process and a healthy life.

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Illness Beliefs and Highly Sensitive People

 Image: Robert Pittman

Image: Robert Pittman

One of the most difficult hurdles for people experiencing chronic pain is recognising that the 'illness beliefs' we assume everyone shares may in fact be particular to just us or our own family.  Working with nurses recently, I became very aware of how difficult it is to come to terms with the fact that we don't all share the same beliefs about illness. It seems that our childhood family unit can play a big part in how we view illness when we are adults.

Our childhood family values about illness may also trigger a reaction in us as adults for another reason. We may be what the researcher Elaine Aron calls ''a highly sensitive person'' (HSP) and the more people I meet recovering from chronic conditions the more relevant Aron's work seems to be.

Highly Sensitive people notice the world in finer detail -  they notice faint smells, the feel of a fabric, the volume of voices, and pick up on other subtle nuances embedded in life that others may overlook. This is a good thing: every group can benefit from a HSP to notice subtle communication, or suggest adjustments to an environment that might make it more comfortable. HSP can think and act slightly differently to the majority in a group, which means they may sometimes feel uncomfortable or not sure if they belong. If the group has a strong identity that relies on conformity the HSP may feel out of place.

If the HSP is aware of their sensitivity then it may not be an issue, particularly if they value and take pleasure in having a slightly different perspective.

When it comes to beliefs about illness and other things, most of us,  including highly sensitive people, might assume that everyone shares the same beliefs. This is not the case, and now as adults our childhood illness beliefs may need a review, bearing in mind our sensitivity, as there can be a link between the attributes of a HSP and the personality trait of perfectionism.

A child with the perfectionist trait of wanting to 'get it right' would have paid close attention to the subtle nuances of family illness beliefs. These beliefs will be strongly held, often throughout adulthood as well. Hence, it might come as rather a shock when we discover different illness beliefs to the ones we grew up with, and face the challenge of re-evaluating  our convictions. 

What do you believe about health, happiness and self regulation?

Is it time to take a look at the beliefs that support you?

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You're never too old to move!

The other day a family friend’s legs buckled underneath him after walking only five metres. When I asked him what was wrong, he explained that his legs are so weak now that he can’t walk.

He has recently had to undergo an official business audit which had to be completed within six weeks, and so was exceptionally stressful. He risked losing his license to practise as an Estate Agent in France if it was not completed on time or to the required standard. His accountant worked alongside him, and together they managed to submit the audit on time.

Immediately, my friend took to his bed and stayed there for five days, exhausted and unable to move. When I saw him he seemed convinced that he would never be able to walk properly again. ‘’I’m 67 years old, I’m overweight, I have diabetes. This is it, I know I will be spending more and more time in bed.’’

We stopped, and I asked him to hold the wall beside him and lift one leg in order to rotate the ankle. I did it too, and showed him. He lifted his leg while telling me he would ‘’keel over’’. He didn’t. He told me his ankle was ‘’too old to rotate’’. It wasn’t. We did the same thing on the other side. I asked him to do that 3-5 times a day. He told me he was old and his knees couldn’t stand it and he would be in his bed tomorrow.

The next day I received an email:

‘’Oh Mags oh Mags, I went for a WALK this morning, amazing how much better my legs feel.’’

Now my friend knows he can effect positive change in his body. To celebrate his success, I went for a 24km hike up into the mountains. The view was breathtaking. It seems even the smallest exercise makes a difference to how we feel, and what I am increasingly amazed by is that what we think and believe has a part to play in our general health too.

 

 Such a beautiful view... definitely worth the hike!

Such a beautiful view... definitely worth the hike!

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Can how you breathe really affect your level of pain?

 Image: Shawn Rossi

Image: Shawn Rossi

When someone arrives in my studio with chronic pain, they are assessed to see what movement range they have. Part of my work as a movement specialist is to teach gentle Pilates-based movement, using adapted exercises to strengthen muscles that may have been neglected and free up the body where it has restrictions The intention is to improve confidence in moving and to extend the range of pain-free movement. At the same time, I introduce deep breathing techniques to stimulate the intercostal muscles in the ribcage. Significantly, most people experiencing chronic pain can breathe in for only two, or maybe three, seconds. Over time it becomes more normal for them to breathe in for up to five seconds. As each person is different, they set their breathing goal according to their preference, for any number of seconds up to eight. Apart from activating and strengthening the ribcage muscles, deep breathing can stimulate self-healing activity in the body through the parasympathetic nervous system. The 2009 NICE report  recommends deep breathing as a way of reducing chronic low back pain, referencing plenty of evidence.

It's important that clients are medically screened to rule out serious problems, but if no issues are found then it is possible there may be a neurophysiological explanation. This means that the autonomic nervous system is out of balance. In simple terms, the autonomic nervous system has two modes of operation, and if they are not in balance the body may not produce the right environment in which to heal itself. The balance of the autonomic nervous system can be affected by many things - in particular stress. As the nervous system is operated unconsciously, it may require a different approach from the conventional biomedical one to re-balance it, and deep breathing may play a part.

In order to rebalance the autonomic nervous system, we need to understand the neurophysiology of chronic pain and how to recognise triggers that might perpetuate symptoms associated with it. This will help with pain resolution as well as improving stress resilience, which can lead to life changing results. Pain cannot be seen; it is experienced. The medical definition of chronic pain is pain that has persisted within the body for over 3 months, as opposed to pain evident for less than 3 months which is referred to as 'acute'. We expect the body to heal itself naturally in the short term. Appropriate medical intervention such as painkillers, or in some cases, surgery may be required, but in every case a balanced autonomic nervous system will help the healing process. Deep breathing can actively assist the body to achieve that balance.

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Let's not focus on the pain, shall we?

                          Image: Vincent AF

                         Image: Vincent AF

Let's not focus on the pain, shall we?

So many patients are upset that they can't get a medical practitioner to give them a reason for their pain. The expectation is that every pain has a biomedical explanation. In fact this may be true, however, the biomedical function of the autonomic nervous system is often overlooked. The questions and answers below might help you to further explore this:

Might it help to change the way we look at chronic pain?

The premise behind Resolving Chronic Pain (in line with TMS / PPD*) is the neurophysiology of chronic pain. The aim is to recognise neural pathways that are not helpful to you and with the help of the Resolving Chronic Pain programme create new, more constructive neural pathways.

What is the neurophysiology of chronic pain?

The neurophysiology of chronic pain is about recognising the importance of the parasympathetic nervous system. It's ability to heal the body, and how this 'self healing' is obstructed by low grade stress. Stress activates the sympathetic nervous system stimulating adrenalin and cortisol to be produced and priming the body for 'fight or flight' synonymous with the stress response. When the body is in the stress response it cannot self heal and therefore the natural resolution of acute pain is delayed.

Stress and Fear

It turns out that the chronic pain may also be linked with fear, a close companion to stress. A key understanding of PPD is that issues the mind is reluctant to contemplate or might be deeply angry about, are expressed through pain in the body. 

Chronic Pain is difficult to pin down

“Pain has always been a bit of a puzzle” says Ben Seymour, a neuroscientist at the University of Cambridge. “Hearing or vision can be traced from sensory organs to distinct brain regions, but pain is more complex, and incorporates thoughts and emotions. For example, studies have linked depression and anxiety to the development of pain conditions, and volunteers put in bad moods have a lower tolerance for pain”.

Depression and Pain

The stress response can lead to depression in a cyclic way, negative thoughts activating the sympathetic nervous system. The chemical reaction of the stress response leading to too much cortisol, depleting noradrenaline and dopamine levels so energy is depressed, replaced by apathy and negative thoughts.

The autonomic nervous system is invisible

About a quarter of those with chronic pain who contact UK charity 'Action on Pain say that their doctors don't believe them. “The problem is that chronic pain is invisible,” says chairman Ian Semmons. It is understandable that someone in chronic pain might feel upset, and therefore have negative thoughts if they think their Doctor disbelieves them.

Biomedical Solution

A balanced nervous system may be the biomedical solution that both doctor and patient are looking for.

 

*Glossary of terms: TMS Tension Myositis Syndrome, PPD Psychophysiological Disorders

Reference: Brain signature of emotion-linked pain is uncovered Jessica Hamzelou, January 2015

Please see Mags Clark-Smith's CPI article explaining how the autonomic nervous system works

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Chronic Pain: To suppress, manage or cure?

One of the most exciting speaking engagements for me this year was organised by Georgie Oldfield with support from SIRPA's executive board: Chronic Pain – To Suppress, manage or Cure?

All the speakers were health practitioners – doctors, researchers, psychotherapists - interested in the work of Dr John Sarno, a spine surgeon who identified TMS (also known as PPD) as a condition responsible for many cases of chronic back pain. John Sarno's daughter Christina attended the research meeting and the conference. She felt that her father would be thrilled that the work he started over 40 years ago is gathering pace.

The outcomes of this conference include plans for another gathering  at the Royal Society of Medicine in November 2016, many more health professionals engaged in understanding the neurophysiology of chronic pain, a TMS research group formed by all the interested speakers and a hardship fund set up by SIRPA.

My personal guest was John Lindsay, chair of Chronic Pain Ireland. Here is what he wrote after the event:

“My congratulations on a great event.... I was really impressed by your speakers and as a result of attending the event I am going to re-evaluate our approach to Self Management of Chronic Pain. My sincere thanks for the 'guest' invitation.”

More information about what the speakers said in our forthcoming Blogs!

Glossary of terms:

SIRPA: Stress Illness Recovery Practitioners Association

TMS: Tension Myositis Syndrome

PPD: Psychophysiological Disorders

 The executive board of SIRPA at the conference on 26th April 2015

The executive board of SIRPA at the conference on 26th April 2015

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Does it matter what we believe?

Research suggests that 95% of the time our mind reverts to the beliefs we hold in our subconscious, laid down before we were seven.

Pain can be caused by the body expressing a disconnection between those beliefs and what we consciously believe now.

We particularly revert to these long held beliefs in times of stress or when we are under pressure. It appears that during childhood we learn our belief system from the 'significant' others around us - be it our parents, older siblings, other family members, neighbours, friends or teachers. We observe how they deal with adversity, joy, money, relationships, in fact every aspect of living and we adopt their beliefs almost by osmosis. These form our 'core' beliefs.

'Give me the child until he is seven, and I will give you the man'

St Frances Xavier

Jesuits recognised that a child learns without discrimination until the age of about seven, and neuroplasticity of the brain research supports this now.

Later in life as adults many of these 'core' beliefs are no longer part of our belief system on a conscious level. However, under stress or otherwise we might automatically revert to them as a gauge against which we measure ourselves and others. Joseph Pilates famously said it takes 10,000 repeats to change a movement pattern, and a similar number of repeats are required to change a 'core' belief. It is as if they are instilled within us, logically we can disown them but when under pressure they can come back into play.

Many people who have successfully resolved their chronic pain have addressed their beliefs and bravely 'reprogrammed' their core beliefs to suit their present lifestyle. Brave, because it might require digging deep, churning up a few things and then doggedly sticking with the repeats to establish fresh self selected beliefs. This may need expert support and the use of specific tools.

So it seems it does matter what we believe, as chronic pain can be the body's expression to the brain that our beliefs are not true to who we are now.

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Presentation in Westport, Ireland on Sunday 19th April

 

There was an enthusiastic audience of therapists at the TASK conference in Westport, Co Mayo in the beautiful west of Ireland this Sunday 19th April. Mags gave a presentation based on four case studies illustrating the nature of Tension Myositis Syndrome (TMS) within a Whole Health Medicine Institute (WHMI) framework.

Mags will also giving a presentation this forthcoming Sunday 26th April 2015 at The Royal Society of Medicine in London: The ‘Suppress, Manage or Cure’ SIRPA conference is the first TMS conference in Europe. It’s very exciting with several key speakers from USA – Dr. David Clarke, Dr. Howard Schubiner to name just two.

In Westport, there was also great excitement celebrating 20 years of TASK Ireland and a fabulous practical session covering elemental postural techniques and abdominal muscle work. Mags developed a physical social network and individuals, duets and groups discussed their ‘take away’ key points from the presentation. 

Here are some of the take away points:

·       Respecting individual perspectives.

·       Valuing Active Listening.

·       Nurturing gentle physical movement.

·       Therapeutic relationship potential.

·      Appreciation that each practitioner has a unique blend of skills to offer.

What skills do you think are important to resolving chronic pain? We would love to hear your views please comment below!

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Praise for RCP Virtual Programme

'A breath of fresh air' – the Virtual Programme from Mags and Siobhán

Chronic pain, defined as lasting more than three months, is not normal and it is not something that patients should have to bear. In these teleclasses, Mags and Siobhán will guide you through their approach to dealing with chronic pain in a warm and engaging way. The classes are an interactive opportunity to engage with your pain and to learn more about how to resolve it. 

A single purchase gives you unlimited access to all six teleclasses, meaning that you can pause, rewind and reply the class at your leisure. There is no pressure to advance through them quickly, giving you the time you need to absorb new information and reflect upon what has been said. 

Mags and Siobhán take the listener through a clear and logical six step process, inviting them to examine their limiting beliefs and attitude to pain. There are many exercises and extra resources suggested along the way, empowering you to chose how much or how little extra research you would like to do. 

The content has been praised by patients as it is 'positive and encouraging. But it is realistic and shows a deep and sympathetic understanding of the difficulties of patients suffering from, chronic pain. Patients are encouraged to help themselves in a practical way, and difficult issues such as past emotionally charged experiences are acknowledged but not dwelt on.'

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