Chronic Pain

My research in chronic pain treatment has led me to work from several premises:

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  1. A psychoanalytically informed therapeutic perspective.
  2. “Accepting” (rather than “coping with”) pain allows chronic pain sufferers to minimize pain by defining and realizing life values (Acceptance and Commitment Therapy)
  3. Creating a community with other people who have chronic pain using the 12 step program, Chronic Pain Anonymous, which also emphasizes acceptance
  4. Alleviating fear through an accessible understanding of the neurophysiology of pain.

Although chronic pain creates anguish and despair, we’ll see that chronic pain can be the beginning of healing.

A Relational Approach

If you suffer from chronic pain, you are most likely feeling enormous anguish, fear, disbelief, and anger. Going from doctor to doctor, trying to find a way to alleviate your pain, you may be overcome with feelings of depression and futility. Because pain often prevents activities that you have been used to doing, you may find yourself becoming more and more isolated. And because pain is not visible to others, you may feel that there no one understands the painful prison you live in. When facing the inevitability of a radical change in the way you have been living your life, being told by doctor after doctor that there is no cure for your suffering and often that your suffering is “only in your head,” hopelessness can take over.

Chronic pain can be debilitating in every way. However, recent developments in the treatment of chronic pain are introducing hope and the possibility of building a new life for chronic pain sufferers. Research has shown that a majority of people who develop chronic pain have experienced early childhood trauma. I address this through a psychoanalytic approach to chronic pain treatment because it addresses early childhood trauma through the therapeutic relationship, and it has helped many people to become either pain-free or able to live productive lives with a minimum of suffering (Gabriel Burloux, 2004).

Trauma weakens the psyche, both physically and psychologically. If trauma is inflicted upon a young child who is in the process of forming a sense of self, difficulties will be created, such as the inability to form attachments or to develop resilience in dealing with life experiences. Furthermore, the stress that results from traumatic experiences compromises a child’s nervous system.

A particular finding has been that these traumas and the accompanying defenses will often be hidden. Although they affect an individual’s life, they are buried and therefore not dealt with. Chronic pain may develop as a way of signaling these early traumas.

Psychoanalysis was founded on the belief that uncovering early traumatic experiences can make it possible to overcome difficulties and live a fulfilling life. Psychoanalysis is generally thought to be too expensive to be an accessible form of therapy. But while this treatment typically means meeting 4-5 times a week, this is not essential; I have found that weekly meetings can be equally effective. What is crucial is that the relationship between doctor and patient allows early trauma to surface. The body no longer has to bear the burden of the initial suffering.

Cognitive Behavioral Approaches and Chronic Pain Anonymous

The traditional treatment for chronic pain is cognitive behavioral therapy. This form of treatment is most often offered in a multi-disciplinary treatment center and focuses on coping with chronic pain through changing patterns of thinking and behaving. Cognitive behavioral therapy is a useful tool for learning how to cope with chronic pain.

Recently, a new cognitive behavioral approach called Acceptance Commitment Therapy (ACT) has moved in the direction of the acceptance of pain rather than coping. One way to describe the difference between acceptance and coping is that coping with pain is like trying to fight off a fierce and attacking animal that is trying to run one’s life. Acceptance of pain means that pain no longer sits in the driver’s seat. What drives one’s life, then, becomes the values that one defines for leading a fulfilling life. When pain is accepted, it then becomes the background, not the foreground; the freedom is found to care more about living a personally fulfilling life rather than devoting hours on end to taming anguish.

Along with therapeutic treatment, my philosophy for chronic pain treatment is also based on the principle of acceptance. I use an approach outlined by Dr. Richard Reilly’s article, A 12-Step Program Approach to Chronic Pain [link to article sent by Enid]. Dr. Reilly argues for the importance of 12-step programs for chronic pain sufferers. Recently this idea has lead to the creation of Chronic Pain Anonymous (CPA). This program offers the 12 steps as a spiritual path toward living a life free of the suffering of chronic pain. CPA provides a community and understanding, as well as a way to develop spiritual resilience rather than hopeless despair. It is not a religious program, but rather a pragmatic and effective path toward letting go of control over what cannot be controlled and turning to something beyond oneself – whether it be the program or however one conceives of a “higher power.”

Because these groups provide tools for recovery from negative chronic pain behavior in a spiritual context, an approach which has been so successful for alcoholics, they are particularly helpful for the very difficult reality of living with pain. And because the 12-step programs do not have a fee, but are self-supporting through voluntary contributions, this is an option that chronic pain people are free to take advantage of without any worry of a health insurance veto.

Dr. Reilly argues that the similarity between those suffering from addiction and chronic, benign, intractable pain is striking. Just as chronic pain means your pain is carried as a life sentence, an addiction of any kind carries exactly the same life prognosis. “Addicts must acknowledge and face their addiction or they will die. A person with chronic pain either makes the best of the condition or the pain destroys any semblance of a normal life.” (Reilly, 1994, p. 40)

Martha Cleveland, Ph.D., offers a clear, concise description of how the 12-step approach can help the chronic pain sufferer in her book “Chronic Illness and the 12 Steps: A Practical Approach to Spiritual Resilience.” (Cleveland, 1999) This book is being used in the CPA groups that are springing up around the country.

Dr. Cleveland’s thesis is that most people with chronic physical illness or disability also suffer from intense, chronic emotional pain. Fear, anger, depression and hopelessness characterize chronic emotional pain. These emotions lead to negative chronic pain behavior which spirals into, as described above, feelings of isolation and despair that begin to set the boundaries of life.

While the reality of chronic illness or disability cannot be controlled, the emotional and spiritual response to that reality can. By spiritual response, Dr. Cleveland means “spiritual resiliency,” which she defines as the capacity to use one’s energy in a positive way, so that the lives of those afflicted with chronic pain, as well as the lives of those around them, are enriched. Using the 12 steps in a lifelong process, one can choose to commit to personal growth rather than allow one’s life to revolve increasingly around the pain. The 12-step program is a path for the individual to move past pain and towards healing.

Another group approach that I use is to work with people who suffer from chronic pain in a collective setting. This group gives people an opportunity to talk about their life before and after chronic pain in a mutually supportive environment. Sharing childhood and adult experiences with others gives members an opportunity to develop their personal history. In doing so, beliefs that people have been telling themselves about their life experiences become clearer. For example, an individual might realize that he/she has been blaming themselves for their parent’s divorce. But in understanding the beliefs that they have been living with, it becomes possible for people to reformulate their personal narratives and to open up possibilities for new life experiences.

The Neurophysiology of Chronic Pain

Another breakthrough in the treatment of chronic pain has been described by two doctors from Australia. Butler and Moseley, in their book, "Explain Pain," have shown that educating chronic pain patients in the neurophysiology that causes their suffering lessens fear and, therefore, pain. They use terms such as "neurotag" and "neuromatrix" to show that chronic pain is an illness in the nervous system in which the brain has become scrambled in its signaling of pain, sending pain signals when they are not necessary; that is, they are not an indication of an actual present injury. Instead, in some people, this erroneous signaling develops after an injury. This understanding, explained in simple language that is easily comprehensible, is bringing alleviation of suffering to many chronic pain patients.