Dr Melanie L Davis, 2017. “Never-ending hurt”: How CAT can help inform the management of chronic pain. Reformulation, Summer, pp.16-21.
I cannot imagine what it must be like living with pain that does not go away. A constant reminder of hurt that appears never-ending. As a clinical psychologist working within a multi-disciplinary Pain Management Service, I am drawn to therapeutic approaches which offer hope and give clients living with chronic pain the opportunity for deep understanding and therefore the potential for a more manageable life.
Chronic physical pain; that is any continuous, long-term pain that lasts more than 12 weeks (British Pain Society; BPS, 2014), is estimated to affect 14 million people in England alone with 31% of men and 37% of women reporting persistent pain as part of a National Health Survey for England (Bridges, 2011). The severe suffering that can accompany a chronic pain condition is well-recognised, with 41% of people who attend pain clinics reporting that their pain has prevented them from working (National Pain Audit, 2012) and 16% of sufferers experiencing their pain as so bad that they sometimes want to die (Donaldson, 2008).
Traditionally, psychological therapy within pain management services has taken the form of Cognitive Behavioural Therapy (CBT) based group programmes (BPS, 2009) which focus on optimising patients’ self-management of their pain, with the increasingly popular addition of concepts from the ‘third wave’ CBT therapies such as Acceptance and Commitment Therapy (ACT; Dahl & Lundgren, 2006) and Compassion-Focused Therapy (CFT; Gilbert, 2009). However, until the recent contributions of Das (2014; 2015), little has been written about the potential offerings of Cognitive Analytic Therapy (CAT) theory and practice to this population, although clinical outcomes have emerged for other such health difficulties including medically unexplained symptoms (Jenaway, 2011), obesity (Hill, 2015) and diabetes (Fosbury, Bosley, Ryle, Sonksen & Judd, 1997).
Through reflections on the experience of CAT Practitioner Training, I will propose in this article that CAT can offer a specific contribution to the therapeutic management of chronic pain. Three connected routes stand out to me: (a) the relational focus, (b) the role of integration and (c) the time-limited nature of the work. I have converted these ideas into three prompts which I now use clinically with this population group.
(a) who or what can the pain represent relationally?
(b) how can we keep attending to the meaning of the pain through integration of mind and body?
(c) offer permission to grieve losses (including the loss of the ideal, ‘pain-free living’) by naming the ending.
“Amy” (name changed) is a 42-year old woman who has agreed to my sharing elements of her clinical material from a 24-session CAT in order to illustrate the use of the three prompt approach in CAT with chronic pain. Amy came to therapy to focus on her difficulties with depression and anxiety in the context of chronic, widespread pain, significant fatigue and a diagnosis of Fibromyalgia. For many clinicians working within Pain Management Services, the end goal of therapeutic work is to promote someone’s ‘acceptance’ of their pain. However, why would anyone ever wish to accept such on-going hurt? In attending closely to the relational self, CAT offers, I believe, a way to integrate understanding of the interplay between emotional and physical hurt and pain, put simply but beautifully by Amy in a note she wrote to me, following our final follow-up session, “I am me and it is OK to be me”.
A Relational Focus from the Beginning: Who or what can the pain represent relationally?
For many people presenting to a pain management clinic, referral for psychological assessment can be experienced as a threat, especially if this referral is perceived as a suggestion that physical sensations are not entirely real, or have a mental component. Although client expectations are often, and understandably, geared towards total pain relief, or, at the very least some reduction to their painful bodily sensations, the task of the multidisciplinary team is to work towards client self-management of their pain. This involves achieving a balance between Ryle and Kerr’s (2002) concepts of ‘doing to’ clients, for example, via further invasive injections, or ‘being with’ in a supportive, but often non-directive manner. Here, the CAT model’s “doing with” philosophy offers an alternative approach in helping patients understand that their reactions to pain are often based on the very building blocks of their lives. For example, from the assessment stage, the therapist can be listening out for examples of how childhood physical and emotional pain experiences were responded to by parents, and bring this into the dialogue to aid client understanding.
Despite the therapist’s understanding of the connection between early life experiences and the concept that one’s ability to cope and manage pain may be influenced by these historical patterns, as described by reciprocal roles (Ryle & Kerr, 2002), this can be a novel idea to many clients. I have found a very useful clinical tool at this stage is Potter’s (2010) ‘mapping the moment’.
Such visual representation of key emotional states, and the process through which these are triggered by interaction with others, can draw attention to emerging reciprocal roles enactments, often in the therapy room, or in relation to the experience of the team, or other health professionals so far. My experience is that clients can relate fairly quickly to these concepts when seen on paper.
By definition, successful self-management of pain requires individuals to have an awareness of self. Through its explicitly relational focus, CAT offers a radical social model of self by drawing on understandings about the inter-subjectivity of the infant (Stern, 1985); the idea that from birth, we are born with an intrinsic motivation to actively engage in social interaction and communication with our caregivers, and not be mere recipients. As such, CAT is well-placed to help patients recognise how their view of themselves has developed and how it therefore impacts on their relationship with their pain. In his extensive work on psychological trauma, Van der Kolk (2015, p.97) emphasises this further asserting that “self-regulation depends on having a friendly relationship with your body” and given this, we therefore get our “first lessons in care from the way we are cared for” (2015, p110).
Focusing on the historical origins of client’s here-and-now behaviours when managing pain, in the reformulation stage of therapy, helps not only in identifying how someone may have experienced receiving care, or lack of it, from others throughout their life, but also how this translates into their own patterns of self-care. As chronic pain is an ever-present ‘other’, whose presence is more or less visible in the therapy room, how an individual relates to this ‘other’ can help or hinder their pain management. I argue here that to know oneself is to be in touch with one’s pain, and that this is a necessary step in being able to later accept that pain.
For example, Amy’s physical discomfort in the therapy room was palpable, and often served as a real cognitive barrier when, in the middle of a sentence, she would have to stop, stand up and move around the room, due to her pain sensations, often closing her eyes to block out any further stimuli. As well as demonstrating well the ‘interruption’ phenomenon, of Morley’s (2008) ‘three I’s’ of his psychology of pain model (pain interferes, interrupts and changes one’s identity), Amy and I began to find it containing to name this experience as the reciprocal role; ‘overwhelming to overwhelmed’, and went on to include her pain and fatigue on her CAT Map (see Figure 1 on previous page) as part of the symptomatic procedure (Ryle, 1997).
Similar to Hill’s (2015) observations about clients with obesity, a common theme I have witnessed with individuals with chronic pain, especially widespread pain, are personal histories which include clients’ needs being put secondary to others, often a parent. For example, when Amy and I were able to name the enactment of such ‘blaming to blamed’ role, which originated from Amy’s experience of her mother (other to self) in relation to her treatment of her own body when in pain (self-to-self), this proved pivotal for her understanding. The manner in which Amy spoke about her bodily sensations;“even relaxing is exhausting” offered further insight into her ‘self-to-self’ reciprocal roles, which then led to shared descriptions on the CAT map, such as Amy’s guilt-ridden “defective self”. Similarly, by identifying the ‘criticising to criticised’ roles, which we generated from Amy’s early memories of the pressure upon her to provide care for the family, particularly when her mother was incapacitated through illness, Amy was able to recognise how she had internalised these ‘other-to-self’ roles as ‘self-to-self’ (Ryle & Bennett, 1997) expressed as harsh self-blame, and a sense of ‘greediness’ should she turn compassionate self-care upon herself.
Once the reformulation phase is underway, I have found that other pain management team members working with the client in different specialties such as occupational therapy or physiotherapy often benefit from this shared understanding, with the client’s consent. It has helped to emphasise to the team the core therapeutic aim of remaining ‘non-collusive’ with the client’s reciprocal roles (Ryle & Kerr, 2002) with the initial task of recognition, before any sustainable review of repeating patterns and procedures is possible.
To help the team recognise potential reciprocal roles from the different ways patients communicated about their pain, I developed a table (see Figure 2 opposite) adapted from Ryle and Kerr’s (2002) summary of parent- and child-derived roles from a pain perspective. This attempted to offer greater insight into the possible specific meanings of pain to each individual, and so encourage further exploration and dialogue whenever possible.
A Dialogue with Core Pain: How can we keep attending to the meaning of the pain through integration of mind and body?
Pain is such an abhorrent sensation that there is an overriding, evolutionary urge to push it away and avoid wherever possible as it is seen as a core threat to self-regulation (Gibert, 2009). Therefore to keep attending to pain in the room, even when seemingly intolerable by both client and therapist, can be a core part of the therapy as it allows for the generation of alternatives RRs such as ‘attending to attended to’, or ‘tolerating to tolerated’.
This brings to mind Mann’s (1973) writings and his concept of ‘chronically endured core pain’; as if ‘core pain’ can be understood as unmanageable feeling, then this concept can be usefully introduced in therapy. For example, the notion that pain can be experienced as having both physical and mental components even though it is often through deeply unpleasant bodily sensations that we may first become aware of it. Das (2014) asserts that a person’s ‘core pain’, which in this sense, we might think of as emotional in nature, can rise to the fore in the presence of physical pain. This is consistent with the perception of any pain sensation being a threat to the integration of a healthy, whole self as it can so drastically alter the way in which we view ourselves and our core identity (Morley, 2008). So, similar to Sellix’s (2002, p.29) description of his own personal study of core pain, it appears that only when this pain is touched upon and the contributing reciprocal roles explored can this become the “true agent of change”.
By reformulating someone’s pain through a relational approach, I propose that an individual’s ‘self-to-self’ relationship with their pain, as internalised from previous experience of ‘other-to-self’ and ‘self-to-other’ relating, can be explored and re-negotiated in a way that promotes acceptance and an understanding of embodied distress, as opposed to the pain being seen as an ongoing, intrusive irritant that must be eliminated (enacting, for example, a ‘dismissing to dismissed’ role). Here, the integration of the analytic with cognitive understandings allows the CAT therapist to name the current cognitive barriers to progress in the context of the relational history.
With clients experiencing chronic pain, it has been possible to name ‘pain-specific’ procedures which, without revision, maintain dysfunctional patterns and symptoms. This process can be a helpful way of helping patients recognise why they have not been able to put into practice recognised pain management strategies: pacing, planning and prioritising, as described in the popular ‘Pain Management Plan’ self-help resource (Lewin, 2010). For example, a common procedure I have experienced with pain management clients is the ‘underserving snag’ where prioritising self does not fit with a lifelong view of self as being subservient to others, as in Amy’s case. Another example was Amy’s ‘pacing dilemma’where either she pushed herself to feel in ‘perfect control’ (her idealised place) of her life by over-doing household tasks and being left utterly exhausted, or she acknowledged her fatigue and felt forced to rest but then this inactivity only reinforced her deep feelings of inadequacy leaving her guilt-ridden for letting down herself and others, driving her to push hard again in a self-reinforcing cycle.
Given that CAT draws on a dialogic perspective (Bakhtin, 1984; Leiman, 1997), the model encourages the naming and giving voice to previously unrecognised emotions. Whilst this is usually attended to via language primarily, Dower (2014) describes the value in bringing the body into the room relationally through the embodiment of reciprocal roles and focused attention on bodily transferences. This seems of particular relevance when working with someone living with chronic pain bearing in mind that growing understandings about the physiological implications of psychological trauma now increasingly recognise that we can experience intense physical sensations in the face of threat, through which healthy, ‘good enough’ attachments to others can help mediate pain (Gerhardt, 2015; Van der Kolk, 2015).
To illustrate the importance of attending to embodied reciprocal roles, my own experience of headaches, back or neck pain, prompted by the therapeutic encounter, has opened up dialogue with clients around experiences of relational stress; voiced through comments such as others in their lives being experienced as “a pain in the neck”, or putting “too much pressure on my shoulders”. With Amy, through supervision, I was encouraged to attend to her repeated expression of how “utterly exhausted” she felt, no matter what she did. Through practice of a mindful breathing exercise, as described by Burch and Penman (2013), focusing on her fatigued self-state, Amy spoke of a memory of her mother being similarly fatigued which led to the identification of a feeling of intense guilt regarding the way that she had treated her mother at the time; a feeling which she appeared to have suppressed.
Over the following few weeks, Amy spoke of increasing expressions of the grief and sadness she felt as she processed these feelings of guilt, which had previously seemed outside of her emotional capacity. Had we not focused on being with her deep sense of physical exhaustion we would not have extended her ZPD (Zone of Proximal Development; Vygotsky, 1978). In addition, through further integration of mindfulness with CAT (Finch, 2013) the reformulation of Amy’s pain and fatigue seemed to encourage the development of self-awareness and compassion for her body and mind in-between sessions as well as within the therapy. This was evidenced by reduced self-critical responses, better behavioural pacing (including more rest periods), less guilt and better toleration of further breathing practices, finding them more “calming” now than “hurting”, as before.
Time-Limited Working: Offering permission to grieve losses (including loss of the ideal) by naming the ending
When it comes to the ending, to have such an open dialogue about the time limits of the therapeutic work has proved very helpful in pain management for a number of reasons. Initially, it helps the facing of multiple losses, so common with this client group. Given the long-term, chronic nature of pain, many people will be discharged from services still experiencing significant levels of physical distress. Therefore, addressing the ending directly in a contained, thought-through way, can help not only the therapist but the also the wider team to discuss how and when to speak of discharge, and how to manage the transference and counter-transference feelings, or enactment of reciprocal roles, that can result.
Clinicians can choose to work within pain management for a variety of reasons, and noting the ‘rescuer’ within ourselves and the huge pull to step into the idealised place can be deeply containing for our clients. For example, I have found it hugely freeing within a service that provides care for clients with long-term conditions to routinely now name the ‘idealised place’ (Potter, 2010) on the client’s CAT map as early as possible. For Amy, to be able to discuss individual understandings of ‘perfect care’ has allowed for important mobilisation of self-acceptance. For example, Amy’s development of an ‘exit’ to this idealised placed, revising the role by ‘letting go of striving for perfection’ seemed to prompt the permission for her to grieve the losses of what has not been, and cannot now be, due to the impact of her pain; the grieving of which is deemed to be an important stage in the acceptance and adjustment cycle (Hammond & Hirst-Winthrop, 2016). As Mann (1973) discusses, to work through such feelings of loss, and also anger and disappointment can be a transformative experience as the end of the therapeutic work can offer a new experience of a contained ending and a manageable loss so as not to repeat older patterns of possible avoidance, rejection or abandonment.
I have not distinguished here between different forms of pain presentation, for example whether the pain is musculoskeletal, neuropathic or widespread in nature, but similar to Bell’s (1999) suggestion of the distinctive psychological profiles of different eating disorder presentations, it may be possible to offer specific treatments for different presentations within pain management. For example, in her initial reformulation of Fibromyalgia presentations within a group setting, Das (2015) suggests that ‘swallowing anger, exploding with pain’ offers a useful shorthand description from which to start exploring key reciprocal roles. Given that group programmes have been key to therapeutic interventions in pain management historically, especially in terms of peer validation and a sense of common belonging (Das, 2014), one next step I am keen to explore is the development of CAT groups (Hepple & Bowdrey, 2015; Mulhall, 2013) to complement emerging CFT group approaches, but with relational issues as the primary focus. I would be interested in connecting with other practitioners grappling with similar issues in order to inform future client care and treatment pathways with pain management, and related areas. It has been a humbling experience to see meaningful change through CAT in the presence of such a disabling, long-term condition.
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Thanks to Lawrence Welch and Caroline Dower for their comments on earlier drafts of this article
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