Das, M., 2014. CAT and the Mind-Body Conundrum of Chronic Pain. Reformulation, Summer, pp.29-32.
There is no doubt about it: Chronic Pain has the power to ravage lives.
Imagine being in non-stop, unremitting pain. Medication may provide temporary relief but chronic pain can be relentless. Would your life be worth living if you were unable to engage in activities which make it meaningful? How would you retain confidence in your body? Realign your sense of self? Sustain your relationships with friends and family?
One in eight people develop chronic non-malignant pain (CNMP) in Britain. CNMP can be musculoskeletal, visceral, neuropathic or idiopathic in nature and is indiscriminate about which part of the body it affects. Occurring suddenly, after injury or failed surgery, or developing insidiously over years, as with fibromyalgia, it strikes all ages and races but is reported more by women than men. The figures are horrifying (Johnson, 2013): whilst back pain alone costs the NHS over £1 billion a year (Phillips, 2011), the cost to each individual person in pain is incalculable.
Avoiding pain is an evolutionary instinct. At a personal, cultural and evolutionary level, we battle to keep pain at bay. Imagine how confusing it is for people to be told they need to practice acceptance and that medical science has no solution for this biological process. While exploring the dialogic relationship we have with ourselves and our bodies as the repository of experience, learning and emotion, I feel a deep sense of gratitude to my clients who have very patiently taught me about pain over the years. This paper is not an academic treatise – it's about the men and women who battle chronic pain and tells their story.
The Mind-Body Conundrum
The balance we weave within our mind-body and self-other systems is fluid (Ryle, 1975) and depending, on the state of each of these dimensions, individually and relative to each other, our 'shock absorbers' vary in their ability to cushion us from the burden of illness. As pain becomes chronic, it engulfs us, often smothering our sense of who we are. Pain takes centre stage while other people are pushed to the periphery as each day becomes a battle for survival.
From the CAT perspective, how we react to pain depends on the building blocks of our life. In a perfect world, nurturing parental/primal interaction would lead to robust self-worth, allowing us to cope with adversity –including pain and disability – in autonomous ways. We would be able to seek help from others when needed without feeling weak and inadequate, holding on to our sense of self and knowing what we can offer in a spirit of reciprocity. Being merely human, reality is often at variance with this ideal and the lack of secure attachment may create an unsteady foundation from which the challenges of life may appear insurmountable.
Let's start with the obvious: early patterns of abandonment, neglect and illness in childhood make it harder for us to care for ourselves later in life. Paradoxically, because pain is so untenable and people 'shop around' for help, they may be unable to accept it when offered. Advice regarding pain management, such as pacing to prevent a recurrent boom-bust cycle, the concept of activity/rest cycles, are simply not heard or understood if people have had insufficient experience of receiving love and nurturing or, indeed, if they want to prove that they can cope without it anyway. On the other hand, if they suddenly find themselves receiving more concern and compassion because of their pain, fulfilling a lifetime's unmet need an implicit dilemma is created: – to remain ill and be cared for or get better but be alone again.
Progress may be implicitly sabotaged as one's only defence against burdensome commands is to proclaim how restrictive illness is. CAT is excellent at helping people find their voice so that they can say 'No!' in a safe and manageable manner. The power of reformulation enables people to start defining boundaries instead of limits and proactively cease clinging to their condition as a safe haven from an endlessly exacting world.
Similarly, when we had demanding parents offering only conditional care, we are often unable to give ourselves permission to look after ourselves or seek help from others. Inner dissonance results when we recognise but cannot attend to our needs, feeling responsible for putting other people first. Classically, people with fibromyalgia, where people have pain in multiple regions of the body, often learn that not attending to others' needs can have painful consequences, such as the potential withdrawal of affection, punishment, abuse (Clarke et al, 1994). Selecting partners and friends who replicate these patterns perpetuates the martyr role that involves submitting to and caring for others at cost to oneself whilst suppressing resentment and anger because it is dangerous to protest.
In individual therapy, there is potential for clients to become doubly trapped – wanting to appease loved ones in the world outside by continuing to meet their needs while simultaneously wanting to appease the therapist by attempting greater autonomy. The reader may be wondering what the possible exits are in this situation? We can start by helping people to ask and answer two invaluable questions: How old is my inner child feeling in the moment? What do I really need and want?
When our bodies have been abused by others, pain can exist in 'wounded' areas, as living proof of hurt and damage, hard to capture on an x-ray but tangible in therapy. People who can access and connect memories with bodily symptoms have a degree of psychological availability which – facilitates making connections in therapy. On the other hand, repression of trauma makes it harder for people to link their emotional experiences with their bodily pain, often causing them to cast around for a medical cure. Allowing staff to carry out physical examinations can make us all feel vulnerable at times, but this is amplified if prior learning indicates that the invasion of our personal space is fraught with peril. And what of situations where deliberate self-harm co-exists with chronic pain? Where either feels like deserved punishment for the other? Disentangling these patterns within the matrix of abuse is all-important, often reducing the chaos of 'revolving door' attendance at mental and physical health clinics (Pickvance et al, 2004).
To varying degrees, we all need defences for our psychological and social well-being. However. a lifetime's accumulation of defences can be rendered useless as pain tears them apart: Overcompensation by striving, appeasing others and keeping busy are not easy options when activity causes pain. As successive layers are stripped away, we come face to face with our inner self, our core pain. Unmet needs burst forth and unmanageable emotions take centre-stage. Girard (1966) said, 'underground man is a human rag soaked in shame and servitude'; as our disavowed self becomes suddenly and unwillingly exposed, we pursue avoidance, scrabbling for ways to hide and isolate ourselves from the world or scour the world frantically for a miracle cure.
The relief participants experience in pain management groups when meeting others with similar issues is indescribable! Learning from peers helps navigate the zone of proximal development more easily and anxieties attributed to damage and deterioration is revisited. People discover that slowing down is not failure, accepting help does not mean we are 'needy' and self-care does not equal selfishness; guilt and self-blame are challenged and it is absolutely wonderful to witness the birth of new 'exits', as people give themselves permission to change, no longer remaining cathexed with old roles and procedures.
Living with pain is a constant battle as its effects can spiral out of control like a bushfire, creating losses on so many fronts. As people struggle to hold down jobs and roles change within families, the need for self-reliance conflicts with the need for dependence on others. Sleep, energy levels, sex and eating patterns become skewed when homeostatic processes are destabilised. Life is timed by doses of medication which, whilst offering a modicum of control, can be double-edged when side effects compete with pain relief. When health care professionals struggle to offer solutions and 'Learn to live with it' becomes a catchphrase, hope plummets as helplessness and desperation soar.
While the 'ideal' patient can seemingly absorb pain management messages at an educational level and behave 'sensibly' – some clinicians' favourite word – by modifying their lives to accommodate pain, a polarised part of themselves which is screaming against the injustice of pain or the desolation of not being understood, is split off. On the other hand, people may present in complete emotional disregulation, absolutely out of touch with their integrated and coping selves. Out of control, they rage at their powerlessness.
So what do we do in the face of this tyrannical yoke? We exert rigid control over the parts we have power over, at the cost of becoming fused with these mechanisms. People cling to medication and treatments; we either engage in fewer activities by narrowing our world and cutting off anything that threatens the escalation of pain or rebelliously do too much, testing our limits, challenging pain.
In order to explore this further, consider the SDR in Figure 1 of a hypothetical person, 'Lisa', who had had chronic pain and fibromyalgia for over 10 years. Her story is sadly typical of many we hear about.
Lisa was brought up by older parents who were alternately neglectful, leaving her feeling unwanted, like a nuisance, or inordinately punitive and controlling of her role as their daughter, of her daily routine, her friends. Her mother suffered from depression and frequently took to her bed, leaving her to the care of her father, who hit her despite her efforts to be a 'good girl', making her feel powerless and unsafe. This was exaggerated when Lisa was enjoying herself, making her think it was unacceptable to feel happy.
Searching for care and acceptance, Lisa developed friends who often took advantage of her willingness to 'give'. She became pregnant at 19 years and was forced by her parents to marry her boyfriend; he was continually contemptuous of her desire to study while she brought up their two young children. While Lisa strove hard to be a model wife, mother and daughter, she was resentful that despite her best efforts, they continued to be demanding, handing out morsels of affection when she pleased them by looking after them. Lisa often worked at several part time jobs but a back injury at work as a carer took its toll. After the death of her father, the pain spread to other parts of the body. By the time of her referral, Lisa had stopped working, had unremitting pain in her back and neck, arms and legs, had low mood and generally felt out of control of her life and body.
Transference works in a multitude of ways (Hughes et al, 2000) and clinicians working with chronic pain experience a wide spectrum of countertransferential feelingss: I feel frustrated and deskilled on difficult days, humbled by my clients' strengths when things work well. People unable to witness the reality of another's pain take cover behind problem solving, 'I've heard it all before' and other distancing techniques. Projective identification leads to emotional as well as somatic transference. Psychological therapists without a working model of physical illness may typically perform the binocular trick - ignore its existence or feel flooded by it to the extent they are unable to proceed in therapy 'until it is resolved', often paralleling the client's process.
Whilst Pollard et al (2005) postulate that external dialogues are more conclusive than internal ones, in pain management, a world with very few answers, external dialogues may be equally indefinite and unsatisfactory at both ends of the table (Diamond, 2003). Patients are referred on endlessly - the 'medical merry-goround'- which is easier than risking a rupture by acknowledging they may not have a cure to offer. It is so easy to replicate people's early life experiences, making people feel disbelieved, powerless and blamed. Holding the reflexive perspective, staying present and compassionate in the face of suffering, is hard when both client and clinician struggle to hold between them the truth that some types of pain are here to stay.
So, when medication, injections and other interventions fail to work, what purchase does therapy have? Affirming our willingness to stay with another while they make sense of their suffering can be remarkably potent. Bearing witness to unresolvable pain and staying steady while our clients find their balance can help them find ways of accepting this burden. Therapists' acceptance of difference allows clients to accept theirs while mourning the fact that life may never be 'normal' again. Finding a way of feeling benevolent towards their pain frees people, making them less submerged as compassion is reborn. For each of us, integrating our pain with our sense of who we are implies finding a way of not fighting a part of yourselves, no matter how unwelcome it may be. And, it is far easier to write this than to practice it.
At its best, therapy can empower us, freeing us to attend to our own needs and those of others we care about, from a loving, relaxed place. As we regain belief in ourselves and the world, our confidence in handling the vagaries of our body returns. We handle flare-ups calmly and with flexibility, secure in the awareness that as we have handled adversity in the past, we can handle it again. Hope has potential, we dare to dream in tune with the motto of our service, 'Soaring above Pain'. Feeling autonomous, we can embrace the world from a position of connectedness, defining ourselves as human beings of infinite worth and possibility.
I owe a deep debt of gratitude to all my patients, who have taught me most of what I know about using CAT for Chronic Pain, to Sue Yabsley for her generous support and to my supervisor Val Fretten for always being there.
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Meherzin Das, Consultant Clinical Psychologist, Clinical Lead of the Dorset Community Pain Service, Dorset HealthCare University NHS Foundation Trust, is passionate about empowering people in pain to lead fulfilling lives. Her teamâ€™s model of Early Intervention for the Prevention of Chronic Pain won The Health Foundation Shine 2011 Award for Innovation in HealthCare. As Visiting Fellow, Bournemouth University, she enjoys helping future generations of psychologists further their training in what she believes to be one of the best carers in the world!
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