THE MYSTERY OF MISERY:

THE PSYCHOLOGICAL EFFECTS OF LIVING WITH CHRONIC PAIN

by

ANTHONY SCHEVING

A clinical case study

submitted in partial fulfillment

of the requirements for the degree of

DOCTOR OF PSYCHOLOGY IN CLINICAL PSYCHOLOGY

MERIDIAN UNIVERSITY

2013

Copyright by

ANTHONY SCHEVING

2013

THE MYSTERY OF MISERY:

THE PSYCHOLOGICAL EFFECTS OF LIVING WITH CHRONIC PAIN

by

ANTHONY SCHEVING

A clinical case study

submitted in partial fulfillment

of the requirements for the degree of

DOCTOR OF PSYCHOLOGY IN CLINICAL PSYCHOLOGY

MERIDIAN UNIVERSITY

2013

This clinical case study has been accepted for the faculty of

Meridian University by:

__________________________________________

Melissa Schwartz, Ph.D.

Clinical Case Study Advisor

___________________________________________

Justin Forman, Ph.D.

Doctoral Project Committee Member

Quiet friend who has come so far,

feel how your breathing makes more space around you.

Let this darkness be a bell tower

and you the bell. As you ring,

what batters you becomes your strength.

Move back and forth into the change.

What is it like, such intensity of pain?

If the drink is bitter, turn yourself to wine.

In this uncontainable night,

be the mystery at the crossroads of your senses,

the meaning discovered there.

And if the world has ceased to hear you,

say to the silent earth: I flow.

To the rushing water, speak: I am.

- Rainer Maria Rilke

(Sonnets to Orpheus, Part Two, XXIX)

v

ABSTRACT

THE MYSTERY OF MISERY:

THE PSYCHOLOGICAL EFFECTS OF LIVING WITH CHRONIC PAIN

by

Anthony Scheving

This Clinical Case Study explores the topic of the psychological effects of living

with chronic pain as experienced by a 50-year-old man who suffered a career ending

injury. The study considered the complications created by the conflicting approaches of

medical and psychological interventions in the treatment of chronic pain.

Literature reviewed within in this study discussed the topic of chronic pain within

the framework of five perspectives: biological, cognitive/behavioral, psychodynamic,

sociocultural, and imaginal approaches. From the biological perspective, the theories of

Gate Control and Neuromatrix Theory are examined, as well as chronic pain being

defined as a subjective experience. In the cognitive/behavioral section, concepts of the

“onion model” of pain, relaxation, and distraction techniques are discussed. Additionally,

the technique of systematic desensitization is reviewed. The psychodynamic section

reviewed developmental and personality characteristics involved in chronic pain patients.

The sociocultural section examines chronic pain in relation to social power structures,

and the disempowering of suffering groups. Finally, the section on the imaginal approach

considers chronic pain as a liminal state, which can be affected by personifying pain to

make it responsive, thus affecting the experience of pain.

vi

Over the course of a year and a half of therapy, the client was engaged in the

cognitive techniques of relaxation, distraction, systematic desensitization, and imagery.

Later in therapy, he experienced the acceptance of his chronic pain condition, and the

befriending of pain using imaginal approaches of focusing and reflexive dialogue.

The primary learning of this study has to do with realizing that the confusion and

contradiction that currently exists within the field of chronic pain study can be clarified

and unified by the imaginal approach. The key to this integration is the focus on the

client’s experience. The tools, techniques, methods, and theories of the various

perspectives are validated by how they affect experience and restore imagination.

The mythic lens of T.S. Eliot’s “The Waste Land” symbolically speaks to the

barrenness of imagination, and complexity inherent in the experience of chronic pain.

This study offers hope to chronic pain sufferers in restoring a future with imagination and

possibility.

vii

ACKNOWLEDGMENTS

I would like to personally thank many family, friends, and colleagues who have

supported me in completing this project. First to my wife Nadine, who has sacrificed

much time, and met me with an enduring commitment, I thank you for all of your care

and attention. To my mother and father, Anna and Henry, I thank you for your unending

support, your encouragement, and your instilling the values of lifelong learning in your

children and grandchildren. I owe a debt of gratitude to Dr. Susan Day, my clinical

supervisor. Susan has been a generous source of knowledge of the subject of chronic pain

and a true supporter in completing this paper. I would like to thank Dr. Rita Sullivan of

On-Track Inc. in Medford, Oregon. She provided me with a job and an inspiration for

helping those in need. I would also like to thank my fellow cohort members from

Meridian University. As both a fellow student and a teaching assistant, I have met many

individuals who have provided a deep sense of community and connection. Finally, I

thank Melissa Schwartz, for providing much consideration and guidance in the

completion of this Clinical Case Study, and to Aftab Omer who along with Melissa have

created a unique and rich educational experience in the service of transformational

learning.

viii

CONTENTS

ABSTRACT ........................................................................................................................ v

ACKNOWLEDGMENTS ................................................................................................ vii

1. INTRODUCTION ................................................................................................. 1

Clinical Topic

Personal Exploration of the Subject/Topic Choice

Framework of the Treatment

Confidentiality and Ethical Concerns

Client History and Life Circumstances

Progression of the Treatment

Learnings

Personal and Professional Challenges

2. LITERATURE REVIEW .................................................................................... 17

Introduction and Overview

Biological Perspectives on Chronic Pain

Cognitive / Behavioral Perspectives on Chronic Pain

Psychodynamic Perspectives on Chronic Pain

Sociocultural Perspectives on Chronic Pain

Imaginal Approaches to Chronic Pain

Conclusion

3. PROGRESSION OF THE TREATMENT .......................................................... 68

The Beginning

Treatment Planning

ix

The Therapy Journey

Legal and Ethical Issues

Outcomes

4. LEARNINGS ....................................................................................................... 95

Introduction

Key Concepts and Major Principles

What Happened

Imaginal Structures

Primary Myth

Personal and Professional Development

Applying Imaginal Approaches to Psychology

5. REFLECTIONS ................................................................................................. 118

Personal Development and Transformation

Impact of the Learnings on My Understanding of the Topic

Mythic Implications of the Learnings

Significance of the Learnings

The Application of Imaginal Psychology to Psychotherapy

Bridging Imaginal Psychology

Areas for Future Research

Appendix

1. CLIENT CONSENT FORM ............................................................................. 131

2. THE WASTE LAND BY T. S. ELIOT ............................................................. 134

NOTES ............................................................................................................................ 148

REFERENCES............................................................................................................... 158

1

CHAPTER 1

INTRODUCTION

Clinical Topic

As a basic human experience, pain captures our attention like nothing else. This

Clinical Case Study seeks to understand chronic pain from a psychological perspective

and is further narrowed by an emphasis on chronic pain evolving from an injury. There

are many different types, classifications, and varieties of pain. The focus of this study is

the psychological effects of living with chronic pain. Although some may disagree, all

pain has a psychological component.

The discourse on pain and suffering has existed for millennia. Throughout history

philosophers, religious scholars, physicians, psychologists, anthropologists, sociologists,

and those inflicted have struggled to understand the depth and breadth of the subject of

pain. As recounted by Melanie Thernstrom, some of the earliest known records for the

treatment of pain were inscribed in cuneiform text on Sumerian clay tablets from 3400

B.C.1 John Bonica recaptures some of the earliest recorded history of concepts of pain. In

approximately 2000 B.C., the Indian Book of Veda and The Yellow Emperors Book of

Internal Medicine discussed treatments for pain. The ancient Egyptians recorded medical

treatments for pain as early as 1550 B.C. in the Ebers Papyrus. They conceived of a

system of arteries called “metu” that sent pain sensations through the body to the heart.2

Briefly described, chronic pain is pain that continues after physical healing has

occurred, when pain becomes the predominant focus of clinical attention, and

psychological issues are believed to contribute to the origin, intensity, or persistence of

2

the pain.3 The word pain comes from Latin origins, as pæna, meaning punishment. It was

borrowed from the Greek word poini, denoting penalty, payment, or retribution.4

In the last two decades, changes to both the definition of pain, and pain theory

have called attention to the need for psychological interventions for chronic pain. The

International Association for the Study of Pain in defining pain notes, “Pain is always

subjective.” 5 Similarly, Ronald Melzack’s Neuromatrix theory of pain calls attention to

the subjective experience of pain.6

The study of chronic pain has many important implications. Pain Management has

become its own field with specialists from varying professions, dedicated clinics, and

professional organizations. The field has its own specialist credentialing, and even board

certification for qualified anesthesiologists. Navigating this field is difficult as there are

many treatment choices, conflicting treatment philosophies, and many claims offering a

cure from chronic pain. With conflicting treatment choices there is much confusion on

how best to care for people suffering from chronic pain. Much of the confusion

surrounding the subject of chronic pain is related to current methods only addressing

limited aspects of the experience of pain, such as only addressing the biological aspects,

the behavioral aspects, or the developmental issues related to pain.

Chronic pain sufferers make up an increasing percentage of the population. The

topic of chronic pain treatment is generating increased interest as the population ages, and

as wounded veterans are returning from war. Using imaginal approaches to address

chronic pain offers a treatment that dialogs with the subjective experience of pain.

Imaginal approaches can be effective in treating chronic pain, especially in terms of

integrating the wide variety of pain management knowledge that is currently available.

3

This Clinical Case Study examines four psychological perspectives and one

approach within the current literature on pain: biological, cognitive/behavioral,

psychodynamic, sociocultural, and an imaginal approach. The biological perspective

offers the current dominant view of chronic pain conditions. It seeks to treat chronic pain

by attending to an underlying physical cause of the pain. When no such physical cause

can be found then pain is considered pathological or psychosomatic pain. The

cognitive/behavioral perspective seeks to address chronic pain by changing thoughts,

beliefs, and behaviors related to pain. The psychodynamic perspective looks to

developmental causes and personality features that contribute the experience and

maintenance of chronic pain. The sociocultural perspective searches for ways that chronic

pain sufferers are oppressed or excluded from social structures. It might be said that each

of these perspectives dismisses certain aspects of an individual’s experience of pain.

However, an imaginal approach is aimed at using image and imagination to integrate

experience as a means to restore soul, and promote and evoke the individual’s unique and

innate abilities to heal.

The subject client of this Clinical Case Study initially presented with a myriad of

psychological issues including insomnia, depression, and anxiety. I chose to focus on

chronic pain as this was his chief complaint and it appeared to be the origin of many of

the symptoms he was experiencing. The literature finds that depression, anxiety,

irritability and chronic pain are biologically linked.

Personal Exploration of the Subject/Topic Choice

Five years before I started this study, I had gone out for a Tuesday evening

ecstatic dance class. About an hour into the session, another dancer was moving toward

4

me and tripped. I reached out to catch her and she grabbed my left arm, hyper-extending

my elbow. We both fell to the floor. I remember feeling a sensation like a bolt of

lightning shooting up my arm. I looked down and noticed a hollow spot on my upper

arm. The other dancers gathered around me as I sat shocked in disbelief. One of them

volunteered to drive me to the emergency room.

The injury was a complete sever of the bicep tendon. It required surgery to be

reconnected. My insurance delayed approving the surgery for over a month. During the

wait, my bicep muscle atrophied. I came to realize many months after the injury, the

sensation that I felt of the lightning bolt shooting up my arm was an experience of nerve

damage. The surgery was able to reconnect tendon to bone, and repair muscle, skin, and

connective tissue, however, the nerve damage was more difficult to repair. Following the

injury, pain was present most of the time.

I was out of work for nine months after the injury. The bicep tendon break was on

my dominant arm, which limited activities including driving, lifting, and writing. Prior to

the injury, I had been working writing psychological reports, and supplementing my

income doing construction work. I did 12 weeks of occupational therapy where I

recovered some of the movement of my arm and hand, but full movement was limited

and painful. With the limited range of movement, I began to realize how much I relied on

the use of my dominant left arm and hand.

There were complications following the surgery. Two incisions had been made to

my elbow during the surgical procedure. Both incision sites became infected within a

month of the operation. My forearm became swollen and a knot about the size of a golf

ball developed on my outer elbow. Pain was persistent and extended from my left

5

shoulder throughout my left arm. I took opiate pain meds for a couple of months but did

not tolerate them well, feeling nauseous most of the time I was taking them. I quit taking

the meds and instead worked towards tolerating the pain with meditation, deep breathing

exercises, and relaxation techniques.

As the months went by, I began to experience depression and anxiety. As a man

in my 50’s I began to wonder about my future for working. I had surrendered the idea of

being able to resume construction work, but I was now also wondering about my ability

to concentrate and be attentive in the presence of pain, something I would need as I

continued as a psychotherapist. My sense of masculinity suffered as well. I noticed how

much I associated my masculinity with having strong arms. My sense of self worth took a

nosedive as I struggled with being out of work and having a self-image that included a

damaged body. I remember many tear-filled days burdened by depression, anxiety, and a

dull achy pain.

About two years after the injury, I signed up for a ten-day meditation retreat. I

was still experiencing periodic pain in my arm, but I was determined to complete the

meditation retreat as a part of my spiritual practice. During the retreat we sat as long as

14 hours per day. The focus was to follow our breath as we scanned the body and

attempted equanimity, the balancing of the pull toward pleasurable sensations and the

avoidance of painful sensations. After the retreat, I became aware that less of my time

being consumed by the pain in my arm. I became curious about how the sensation and

perception of pain could be altered by a variety of practices.

I started working with a number of chronic pain patients in early 2011, a couple of

years before starting this study. During that time, I became aware of a number of tools

6

and techniques to help others with the perception of pain. However, perhaps the thing that

helped the most in treating these clients was the opening that was created for empathic

relationship by being able to share my own experience of chronic pain.

At the time of this writing, it has been over six years since my injury, and I still

occasionally experience pain in my arm, but it no longer captures all of my attention. I

have come to live with it.

Framework of the Treatment

I had been working with the subject client of this Clinical Case Study, “Michael

Pena” (pseudonym), since February 8, 2012 at the office of Susan Day, a private practice

psychotherapy office located in Sonora, CA. At the time of this writing, Susan was my

clinical supervisor and was licensed by the state of California as a clinical psychologist.

My work under Susan had been as a registered psychological assistant.

This office was comprised of Susan and three other therapists, including myself.

All four members of this office received degrees from Meridian University. There is a

strong emphasis on the practice of Imaginal Psychology at this office. As a group, we

saw approximately 80 clients per week.

Michael was seen for one-hour sessions every week. At the time of writing this

paper, he had been seen 42 times and his treatment was ongoing. The primary orientation

I used in working with this client was Imaginal Process. The primary methods of working

with this client had been though conversation, hypnosis, Reflexive Dialogue and

Imaginal Dialogue.

7

Confidentiality and Ethical Concerns

The location of our psychotherapy offices has been in a small town in the Sierra

foothills. It is common to run into acquaintances while walking down the street or

standing in line at the grocery store. Maintaining confidentiality in a small town can be

difficult. The client subject of this study has been given the pseudonym, Michael Pena, in

order to protect his anonymity. This name bears no resemblance to the name of my client.

The name Michael was chosen because of its commonness. In addition, Pena was chosen

because it is a Spanish translation of the word “pain”. Although this is a Spanish

translation, this in no way reflects the ethnicity of my client. Additionally, some of my

subject client’s history and personal descriptive details have been altered to protect his

anonymity. Whenever I have altered history or personal descriptive details, I have done

so with much consideration as to how these changes might alter overall judgments,

discernments, and interpretations.

Michael was asked to participate in this study in December of 2012,

approximately a year before the completion of this study. At the time of my inquiring into

his interest, Michael had already been seeing me for therapy for several months. We had

already established a good therapeutic relationship. He had previously voiced a trust in

my opinions and suggestions. Therefore, he was very willing to be a participant in this

study.

My work with Michael was supervised by Susan Day. Susan has been licensed as

a psychologist with the California Board of Psychology. At the time of this writing, I was

registered with the board as a psychological assistant under Susan’s supervision. Susan

was a fellow cohort member of mine while in coursework at Meridian University. The

8

Board of Psychology has ethical guidelines that prohibit dual relationships that could

compromise the effectiveness of a supervisor/trainee relationship.7 Susan was not an

intimate partner, nor a family member, nor of any other relationship which could

compromise her effectiveness as my supervisor. Our relationship had always been either

academic or professional. While Susan and I share a deep respect for one another, and

have a good knowledge of each other’s past from our cohort work together, we did not

interact socially. Professional boundaries were maintained. I have worked in several

psychological internships and had difficulty finding doctoral supervision for state

licensure. I had a strong desire to work in a private practice office were Imaginal

Psychology was practiced. This very much limited my choices for supervision. My prior

relationship with Susan as a fellow cohort member only enhances her role as supervisor

as she was aware of the specifics of Imaginal Psychology as it was taught at Meridian

University. Group clinical supervision sessions were held weekly on Friday mornings and

lasted two hours. Additional one-hour individual supervision sessions were held weekly.

At the time of this writing, Susan’s office was comprised of three psychological

assistants working under her supervision. All of the psychological assistants, including

myself, attended Meridian University. This workplace was special and unique as we all

shared a similar psychological philosophy. In group supervision, we continued to practice

forms that we learned at Meridian. Similarly, we focused on continuing to develop skills

and capacities that were first explored at Meridian.

Susan’s supervision has been helpful in my work with this client. Her previous

background as a Registered Nurse has helped me in understanding the complex nature of

the biological perspective of chronic pain as well as understanding that perspective’s

9

limitations. Her insight has helped me explore the deeper meaning of Michael’s physical

and emotional pain.

Working with Michael over many months presented a couple of ethical dilemmas.

The first was in seeing Michael on a partial pro bono basis. The second was the

possibility of being subpoenaed to testify in a court case involving Michael. Midway

through his treatment, Michael settled a legal dispute with California State Workers

Compensation system. His Workers Compensation insurance carrier agreed to fund

ongoing medical and psychological treatment as part of his settlement. His insurance had

approved payment for two visits per month for the first four months and once monthly

beyond that period. Michael attended weekly one hour therapy sessions. I agreed to see

Michael on a pro bono basis for the remaining visits per month, beyond the one visit per

month that his insurance settlement covered.

The risks of working on a pro bono basis include the possibility of the client

taking the therapy sessions for granted or under valuing the treatment. There is also the

potential of the client becoming dependent on the therapist and the frequency of

treatment visits. Michael presented with some dependency tendencies. As of this writing,

Michael had not presented with issues of undervaluing treatment or becoming overly

dependent.

As for the possibility of having to testify in a court case involving Michael, this

ethical concern now appears to have been resolved. The court case was related to Michael

suing his Worker’s Compensation insurance. He won a settlement with the insurance

carrier without the need for my testimony. Had I been called to testify, my ethical

concern would have been primarily in having to reveal confidential material in court.

10

While the legal concerns of such testimony relieve me of responsibility to maintain

confidentiality in a court proceeding, ethically such testimony might still damage the

therapeutic relationship.

Client History and Life Circumstances

At the time of this writing, Michael was a 50-year-old man. He lived with his

fiancée, “Danielle” (pseudonym) in the small historic gold mining town of Columbia.

They lived in a small home on several acres. The couple does not have any children.

Michael formerly worked as an EMT, volunteer firefighter, ski instructor, and river

rafting guide. He has not held a job in the past four years due to his injury.

In his early childhood, Michael lived in Los Gatos, CA. He lived with his mother,

father, an older brother and two younger sisters. His father was a mortgage broker and his

mother worked in real estate. When Michael was age six, his father sustained a head

injury in a multiple car freeway accident. Michael’s father was released from the hospital

to recover at home, but died two weeks later. His mother moved the family to Bear

Valley, a small ski resort town in the Sierra foothills. She continued to make a living as a

real estate agent. Michael’s mother remarried briefly while he was 11-13 years of age.

Michael attended elementary school in Bear Valley in a small two-room

schoolhouse. In grade school, he was diagnosed with dyslexia. Once a week he attended a

special reading program in a community two hours from where he lived. He did learn to

read but, to this day still struggles with lengthy reading assignments. For high school, he

was bused 45 minutes away to attend Angels Camp High School. This was a small high

school with only 200 students. He did not participate in high school athletics. However,

11

living in a ski resort town allowed him the opportunity to excel in skiing. As a teenager,

he was a member of the U.S. Ski Team and competed at local and state levels.

Michael graduated from Columbia Community College in 1985 with an Associate

of Science degree and a specialization in Fire Science. He furthered his education at

Amador College getting EMT and paramedic certificates. His EMT training led to jobs

with fire fighting and ambulance companies. Michael supplemented his income with

seasonal jobs in river rafting and ski instruction. Michael’s employment as a ski

instructor included starting a company to teach skiing to disabled and developmentally

disabled students. Michael’s training in firefighting, paramedics, and seasonal sport

activities has allowed him to travel the world to seek adventure.

It was as a river-rafting guide that Michael was injured in 2007, five years before

the start of this study. The injury occurred when Michael and other tour guides attempted

to free a raft that had become caught in the rocks. A rope broke and Michael fell

backwards against a boulder with the other river guides landing on top of him. Michael

suffered multiple rib fractures on his right side and a minor head injury. He has been

unable to work consistently since this incident because of chronic pain.

My client had already experienced close to five years of medical treatment before

he was referred to me for psychological treatment. In that time, he was prescribed many

different pain medications, had acupuncture and chiropractic treatments, yet nothing

seemed to relieve his pain. Michael’s overall health has been compromised in the last

several years. Because of his complaints of persistent pain, he has been operated on

several times including trials on a transcutaneous electrical nerve stimulation implant,

dorsal column stimulator implant, intrathecal morphine pumps implant, and two nerve

12

blocks, all with little success in relieving his pain. He has contracted pneumonia twice.

Three years after the injury he had his seventh and eighth ribs amputated on his right

side. He attempted suicide twice in 2008 and once in 2010. One of the suicide attempts

occurred while he was in the hospital. During this hospital visit, several of his

medications were discontinued simultaneously. Michael appeared to be going through

withdrawal symptoms were he became anxious, confused, disoriented, and delusional. It

was during this time that he attempted to jump out a hospital window. The two other

attempts were at home. One home attempt involved an effort to jump out a second story

window. The other home attempt involved throwing a noose over a tree branch in a try at

hanging. His fiancé intervened in all three attempts.

Michael’s daily activities include reading, watching TV, doing household chores,

and walking his dog. The number of household chores he can do is limited. He cannot lift

over ten pounds of weight. He also cannot rake leaves or use large pruning shears as the

motion involved in those activities threatens a possible re-break of his ribs. He relies on

his fiancé to drive him to his appointments as he cannot drive himself due to the great

number of pain medications he takes daily.

Michael’s initial presenting problems were his Major Depression and chronic

pain. The main clinical issues that have emerged through my course of work with this

client include chronic pain, depressive symptoms, issues of self-esteem related to loss of

work, dependency needs, and the fear of addiction to his pain and anxiety medications.

He struggled with stress and anxiety over his finances, medical expenses, and future

earning potential. He had difficulty with sleeping, obtaining only three to four hours of

sleep per night. Because of his chronic pain, he became sedentary, getting little exercise.

13

In addition, Michael suffered with periods of grief. Shortly before starting therapy with

me, Michael’s 22-year-old nephew died in a motorcycle accident. Michael also lost his

mother to lung cancer early in 2013, towards the end of this study. He was struggling

with tremendous loss and grief throughout treatment.

Progression of the Treatment

I worked with Michael a little over a year and a half, and continued to see him

weekly at the time of this writing. Michael originally sought treatment for depression and

anxiety related to his industrial injury. I was able to convince Michael that the focus of

therapy should be on chronic pain, as this would encompass all of the symptoms he was

experiencing, and not just the depression and anxiety. I introduced to Michael reflexive

dialogue early in treatment to address a number of anxiety issues he was having related to

his chronic pain condition. I also used relaxation and distraction techniques to help him

reduce his levels of pain. The majority of our work together involved assisting him with

crises that arose frequently, and addressing the anxiety these events would create. I began

to work with Michael on dialoging with his pain in the later stages of treatment. At first,

this idea was met with a lot of resistance. As Michael was able to have key experiences,

his orientation to his pain began to shift.

As of this writing, I continue to work with Michael. He has made some major

improvements in his condition. Near the end of this study, his pain medications were

reduced by 70 percent thru a worker’s compensation utilization review process. Despite

this reduction, he was able to learn to tolerate the increased pain using relaxation and

focusing techniques. He has returned, with caution and limitation, to activities of skiing,

camping, and biking. He has also made limited attempts at driving. He still experienced

14

quite a bit of pain, but he has learned to differentiate between acute and chronic pain. He

also continued to have interruptions to his sleep. Michael gained hope in his future, and is

no longer completely debilitated by his chronic pain. He still has a long way to go with

treatment but his prognosis is good.

Learnings

One of my first learnings within this clinical case study was that a psychosomatic

diagnosis has the potential to create confusion and resistance. Michael was already aware

that he had been given a psychosomatic diagnosis when he first came in for treatment.

His experience of pain was that it was completely physical. His doctors originally agreed

with this assessment but later denied that his pain was completely physical. This denial

created resistance and regression as it was inconsistent with Michael’s perception of his

pain.

In order to work with Michael’s resistance it was necessary to find a way to both

validate his experience of pain and challenge him to change the way he was holding the

experience of it. Understanding chronic pain as a liminal experience, happening between

mind and body, helped in setting a framework that Michael could use to expand his

beliefs about his pain. Michael was later able to have a therapeutic experience that

changed this perception of pain as not only physical but also psychological.

The examination of the wasteland myth as symbolic and metaphoric of chronic

pain created a deeper understanding of the complexity of the condition while also

reinforcing its use as a liminal passage. The myth emphasized the emptiness, and

barrenness of the landscape that parallels the experience of someone consumed by

chronic pain.

15

Rachel Remen asserts that in order to learn to live with chronic pain one needs to

come to an acceptance of the condition.8 Accepting that pain may never completely go

away is difficult to come to terms with. The experience of pain can change when it is

accepted. Michael was able to have an experience of accepting pain with Gendlin’s

Focusing technique. Dialoguing with the pain allowed Michael to shift his experience

from objectifying pain to one of subjectifying and personifying the sensation. Through

this experience, he was also able to reach an understanding of how pain could be

befriended. Befriending pain is an initial step on the road to making peace with it.

The final and most significant learning of this clinical case study has to do with

realizing that the confusion and contradiction that currently exists within the field of

chronic pain study can be clarified and unified by the imaginal approach. The focus of the

imaginal approach is in reclaiming soul. Reclaiming soul is facilitated through an

attention to experience. The tools, techniques, methods, and theories of the various

psychological perspectives are used and validated by how they affect experience.

Personal and Professional Challenges

The greatest personal challenge that I had during this clinical case study was in

developing patience and empathy. The progression of Michael’s treatment moved much

slower than I anticipated. I found myself helping him work through numerous crises, that

I felt were taking attention away from the underlying causes of his distress. In learning to

move at a pace that was comfortable for Michael, I gained deeper empathy,

understanding, and compassion. He taught me that everyone experiences pain differently.

The course of Michael’s treatment also created professional challenges.

Throughout his treatment, I found myself at odds with doctors and insurance adjusters

16

who were in control of dictating the direction of his physical benefits. Michael had long

lost any say over his treatment, and thus had lost control of his body’s care. Attempts that

I made to recommend treatment options were met with negation and denial of services.

Through this course of study, I have also been able to meet and interact with a few local

physicians assistants that refer chronic pain patients to our agency. While my new

professional connections did not help with Michael’s case, they have been willing to

collaborate on other cases.

17

CHAPTER 2

LITERATURE REVIEW

Introduction and Overview

The literature reviewed for this Clinical Case Study includes several different

perspectives on the psychological effects of chronic pain and one psychological

approach, the imaginal approach. The different perspectives covered here include

biological, cognitive/behavioral, psychodynamic, and sociocultural. Reviews of these

different perspectives are envisioned as different lenses in which to imagine the scope of

the subject. In the literature on chronic pain, there are many conflicting perspectives.

Each orientation offers valuable ways to know and understand pain. In addition, each

exists within professional, cultural, and theoretical biases. Reviewing theories as lenses

allows for not only distinguishing similarities and differences but also allows integration

of these theories in meaningful ways.1

The biological perspective is the current dominant orientation for the study of

chronic pain. It uses the western medical model as the primary way to know about

chronic pain conditions. As such, biological perspectives mainly seek to find physical

correlations to the experience of pain. Its concern is with physicality and the body.

Cognitive-behavioral perspectives are primarily aimed at seeking changes in either

thinking or behavior. Its concern is oriented towards the mind and mental states.

Psychodynamic perspectives focus on the developmental aspects of personality. It looks

for resistance and defensive strategies in unconscious motivations. The psychodynamic

orientation seeks changes in ego and identity through the development of insight. The

18

sociocultural perspective looks for social and cultural influences that contribute to the

origin and maintenance of social issues and their effect on the individual. The imaginal

approach seeks to know the soul’s telos through image and imagination. It focuses on an

individual’s experience and seeks to expand the expression of experience through

imagination.

A Cultural History of the Understanding of Pain

In order to study chronic pain it is necessary to know how past cultures have

conceptualized pain in general. It has been primarily viewed as being associated with

biological/medical causes throughout history. Bonica writes that Galen, in the 2nd

century A.D., theorized the existence of soft nerve fibers as a conduit of the senses and

pain, and that the brain was the central organ associated with the reception of pain. Galen

also asserted that pain was a result of an interruption of continuity, which many have

interpreted as physical injury. Galen’s writings divided pain into four types; pulsating,

lancinating, weight, and stretching.2

According to Osama Tashani and Mark Johnson, Avicenna in the 11th century,

challenged Galen’s theories arguing that pain was not directly caused by injury but rather

a change to the physical condition of the organ, whether there was an injury or not.

Avicenna’s ideas were based on the concept of the temperaments of the organs, which at

that time; temperaments were conceived as hot, cold, dry, or wet. Avicenna also

expanded Galen’s classification of pain from four to 15 types. While Avicenna forwarded

the concept of disconnecting the experience of pain from injury, he noted that pain often

persisted even when the original stimulus had vanished. He deemed this type of pain,

“not true pain”, stating that this type of pain “does not exist.” 3 This may have been the

19

start of a chronic pain controversy that would last for hundreds of years, persisting to the

present day.

In 1664, Rene Descartes produced a description of a specific pain mechanism. As

documented by Bonica, this description was of a straight pain perception channel from

the skin to the brain. Descartes compared this mechanism to a bell tower, where the pain

fibers in the skin are analogized as rope connected to a bell located in the brain. When

the rope is pulled the bell rings, sounding alarm. This conceptualization of a specific pain

mechanism, with the intensity of pain experienced directly related to the extent of tissue

injury, was later labeled Specificity Theory.4

Bonica chronicles modifications that were made to Descartes’ descriptions of a

pain mechanism in the 19th century. In 1842, Johannes Muller developed the doctrine of

specific nerve energies. Muller questioned whether the quality of sensation was due to

special properties of the peripheral nerves, or particular effects of the areas of the brain

where the nerves terminate. Prior to Muller, it was generally understood that all sensory

information was transmitted to a common area in the brain. Muller assumed there would

be separate structures in the brain to match the five classical senses: touch, hearing, taste,

smell, and sight. The location of visual and auditory cortexes appeared to validate this

assumption. However, locating a cortical area for pain was elusive.5

Ronald Melzack and Patrick Wall write that in 1895 Max Von Frey expanded on

Muller’s work by proposing four cutaneous senses: touch, warmth, cold, and pain. Von

Frey then was able to match anatomical discoveries of specific peripheral nerve structures

to the cutaneous senses. Therefore, Von Frey is credited with finding the peripheral nerve

structures that became associated with pain reception. He is also often credited with the

20

formulation of specificity theory, although it had evolved from Descartes time and was

continuing to evolve.6

Fernando Cervero describes that Charles Sherrington made several contributions

to the comprehension of pain in 1900. Sherrington offered a description of pain as “the

psychological adjunct of a protective reflex.” 7 This description brings to light the

separate nature of the psychological experience of pain from the physiological

mechanism of the protective reflex. Sherrington also developed the concept of

nociception, commonly thought of as pain reception. Sherrington saw the need to

separate the physiological mechanisms associated with pain and the experience of pain.8

After Sherrington’s implication of a separation of physiological and psychological

components of pain, it soon became evident to some researchers that specificity theory

was inadequate in its explanation of pain. According to Melzack and Wall, the main

problem with specificity theory was related to the difference between two key concepts,

specificity and specialization. Specificity assumes a qualitative psychological experience

of pain directly related to a peripheral injury, delivered through a specific neural system.

Specialization involves a neural system that is specialized to transmit energy that

generates distinctive patterns of neural signals that can be changed by other sensory or

cognitive processes to result in a variety of experience. Von Frey’s earlier experiments

seemed to show that peripheral receptors were physiologically specialized, but not

psychologically specific.9

In 1894, Alfred Goldschieder introduced concepts that attempted to solve the

controversy between physiological and psychological perceptions of pain. Around the

same period, Sherrington was postulating the ideas of neural excitation and inhibition,

21

Goldscheider contributed that central summation and stimulus intensity were significant

modifiers to the psychological experience of pain.10 In essence, Goldscheider’s ideas lead

to the development of Intensive Theory. Intensive theory held that there was no specific

system for transmitting pain, and that pain receptors were shared, producing multiple

possible sensations. This view put intensive theory in direct opposition against specificity

theory. The problem facing intensive theorists was it appeared that Von Frey had already

located specific structures in the skin that looked to be pain receptors.11

William Livingston adds to the history of pain in the 19th century detailing the

biases of Muller, Von Frey, and Goldschieder. Livingston submits that Muller’s tenth law

of specific nerve energies emphasized a psychological element of pain, declaring, “The

mind not only perceives the sensations and interprets them according to the ideas

previously obtained, but it has a direct influence upon them, imparting to them

intensity.” 12 Livingston asserts that Von Frey maintained a clear distinction between

“true pain” and “mere unpleasantness”, which he attributed to an “affective state of

mind”. Although Goldscheider had as early as 1885 been working on finding specific

sensory mechanisms in the skin, he later found fault in his early work. Livingston states

that Goldschieder doubted that “pain receptors” and “pain fibers” were the exclusive

source of pain sensation.13

In the last years of the 1800’s clinical experimentation and observation appeared

to support the concepts of specificity theory. Cervero notes specificity became the

reigning theory despite the fact that Von Frey got nearly all of the associations between

cutaneous senses and peripheral nerve ending structures wrong.14 Specificity theory

appeared to be an adequate explanation for many experiences of pain. However, there

22

were several examples of chronic pain that could not be accounted for by specificity

theory, in particular phantom limb pain.

The persistent nature of phantom limb pain had perplexed the best minds studying

pain from the earliest times in history. Phantom limb pain drove the evolution of pain

theory into the 20th century. Livingston was one of the first researchers to propose a

description of the central physiological system involved with chronic pain and phantom

limb pain. He theorized initial trauma of an injury creates abnormal neural signal patterns

in reverberatory circuits located in the dorsal horns of the spine. The patterns could

stimulate activity in nearby circuits and create self-sustaining irregular feedback loops

between central and peripheral systems further creating sensory motor disturbance,

emotional disturbance, and the ongoing perception of pain. The reverberatory circuits

were never physiologically located but the concept influenced later theoretical

development. 15

In 1959, William Noordenbos contributed a concept of pathological pain

involving a multi-synaptic afferent system affected by thick and thin nerve fibers.

Previous researchers observed different nerve fibers that later became known as A-Delta

and C nerve fibers. The C fibers had long been associated with nociception. They were

thin, slow transmitting, and unmyelenated. The A-Delta fibers were thicker, faster

transmitting, and myelinated. It was assumed that C fibers transmitted nerve patterns

producing nociception and that the A-Delta fibers transmitted inhibitory neural signals.

Noordenbos concluded that in chronic pain states the A-Delta fibers lose their ability to

inhibit summation over the more abundant C fibers resulting in a greater perception of

pain.16

23

Biological Perspectives on Chronic Pain

This section will consider pain, chronic pain, and its psychological effects from a

biological perspective. This section also discusses the function of pain, various types and

classifications of pain, major theories of pain, comorbidity of chronic pain and

psychological disorders, and treatments of chronic pain from the biological perspective.

In this Clinical Case Study, biological perspectives are considered more specifically as

the anatomical, physiological, neurological, neurophysiological, and neuropsychological

processes involved with chronic pain.

It is a common long held belief that the primary function of pain is as a protective

reflex. At first signs of pain, our reflexes quickly kick in, withdraw the injured body part

from the perceived source of injury, and immobilize it to protect against further injury.

Pain can, and often does, exist outside of the scope of this basic function as a protective

reflex. When it does, it challenges our understanding of pain. Chronic pain is a type of

pain that is an outlier to the long held beliefs about the function of pain.

Types and Classifications of Pain

Types of pain are often listed by associated diseases, physiological mechanisms,

physical locations, or duration. A complete discussion of all the different kinds of pain

would be prohibitive in this study. It is necessary, however, to discuss some of the

classifications, types, and varieties in order to know how to differentiate chronic pain.

There is no one system of classifying pain that is globally accepted. In addition,

classifications of pain are overlapping in their definitions.17 One widely accepted

classification of pain distinguishes between three types of pain; transient, acute, and

24

chronic pain. In this classification, the three types of pain are differentiated from one

another primarily by duration. Transient pain is of a brief duration with little or no actual

tissue damage. Acute pain is longer in duration, and by definition is associated by actual

tissue damage, and anxiety. Chronic pain is usually defined as either pain lasting longer

than a specified period time, or pain that persists after an expected recovery period.

Chronic pain is not necessarily associated with actual tissue damage.18

Another widely accepted classification pertains to the physiological mechanism

that is the source of the pain. This classification also differentiates between three types of

pain; nociceptive, neuropathic, and inflammatory. Nociceptive pain is often thought of as

direct physical pain. However, it technically refers to noxious stimulus activating

peripheral nerves sending a signal to the central nervous system. Neuropathic pain is a

term used to describe pain that is sourced from pathology of the nervous system.

Inflammatory pain is sourced from the pressure sensed by the nervous system when

tissue cells are inflamed. Inflammation is a natural part of the tissue healing process, but

can occur in pathological conditions.

Chronic pain is known by many names: persistent pain, psychogenic pain, and

psychosomatic pain, to name just a few. Persistent pain is a direct synonym for chronic

pain. Psychogenic pain is a term used to refer to pain that originates in the mind.

Psychosomatic pain is a psychological term used to describe the body-mind relation of

pain disorders.

There are many varieties of chronic pain, like fibromyalgia, chronic diabetic pain,

arthritic pain, cancer pain, etc., and while many of these types of pain share similar

25

physiologically, there are also many differences and it becomes necessary to narrow the

discussion.

Biological Pain Theories

Influenced by the previous contributions of Goldschieder, Livingston and

Noordenbos, Melzack and Wall proposed a new theory in 1965 called Gate Control

Theory. Melzack and Wall were concerned that the previous dominant theories,

specificity, intensive, and pattern theory, were not accounting for psychological effects

associated with pain. To explain why thought and emotion modify pain perception,

Melzack and Wall proposed that a gating system existed within a substrate called the

substantia gelatinosa located in the dorsal horn of the spine. They proposed that the gate

was affected by both afferent (peripheral to central) and efferent (central to peripheral)

nerve fibers. Afferent C fibers and A-Delta fibers would carry ongoing activity

communicating tactile and sensory input to the brain. Under injury or noxious stimulation

excitatory or inhibitory signals from both peripheral and central inputs converge at the

dorsal horn structures to either open or close the gate, leading to either increased or

decreased perception of pain.19

Melzack and Wall refuted the idea of a ‘pain center’ in the brain. They write,

“Indeed, the concept is pure fiction, unless virtually the whole brain is considered to be

the ‘pain center’, because the thalamus, the limbic system, the hypothalamus, the brain-

stem reticular formation, the parietal cortex, and the frontal cortex are all implicated in

pain perception.” 20 Additionally, they note that the stimulation of a single nerve can

activate multiple distinct brain-stem pathways. Their theory proposed a physiological

26

mechanism that supported the psychological influence of experience, attention, and

emotion on pain perception.21

The gate control theory of pain became widely accepted as the answer to the

anomalies of pain mechanisms, such as phantom limb pain, leading to new research.

However, Melzack was still puzzled by certain aspects of phantom limb pain. He had

observed that paraplegics with near complete spinal cord breaks were experiencing

phantom limb pain despite the absence of any realistic peripheral neural input below the

point of the spinal cord break. Additionally, he concluded that the qualities of felt

experiences such as pain, warmth, cold, stinging, itching, and tickling could not be

directly correlated to external events, and therefore these qualitative experiences must be

internally and centrally generated.22

In 1993, Melzack proposed a new theory called Neuromatrix Theory. In his new

theory, he proposed that within the brain there exists an anatomical network comprised of

neural loops between thalamocortical and limbic systems. The network contains systems

for parallel, cyclical, overlapping processing of neural input and output that creates a

representation of a body-self. The neuromatrix is in essence a template of the unitary

whole body-self, producing a neural pattern, the neurosignature, which is received as a

projection by a sentient neural hub, where it is converted into a constantly modified flow

of awareness. In other words, the neuromatrix is a central map of the body self that stays

complete even when peripheral neural input is lost through amputation or nerve

damage.23

Melzack’s neuromatrix theory incorporated previous learnings from the gate

control theory including what was labeled the three dimensions of pain. The three

27

dimensions were made up of sensory-discriminative, affective-motivational, and

cognitive-evaluative systems. In the neuromatrix theory, these three systems made up the

sentient neural hub or the body-self neuromatrix. The inputs to the sentient neural hub

include the cognitive aspects of memory, attention, and meaning; the sensory aspects of

cutaneous, visceral, and muscular; and the emotional aspects of homeostasis and stress

mechanisms. The outputs of the sentient neural hub include pain perception, motivational

action programs, and stress regulation programs.24

Melzack’s complex conceptualization of an anatomical, physiological structure

that incorporates qualitative experience and a stream of awareness captured the interest of

consciousness researchers. In 1999, Richard Chapman and Yoshio Nakamura reviewed

the Neuromatrix theory. While they find some fault in Melzack’s theory, primarily

around philosophical concerns, Chapman and Nakamura conclude that both the studies of

pain and consciousness could be advanced by interdisciplinary research.25

While the neuromatrix theory represents that latest major advancement in pain

theory, others have been advancing physiological discoveries regarding pain. In 2009,

Vania Apkarian, Marwan Baliki, and Paul Geha used fMRI imaging techniques to study

patients in acute and chronic pain conditions. They have proposed a working diagram of

parallel processes of acute and chronic pain based on an expansion of Melzack and

Wall’s diagram of the gate theory. They conclude that a shift from acute to chronic pain

involves neural reorganization that strengthens one processing pathway while weakening

the other. Apkarian et al. also found strong connections between extended periods of

chronic pain and brain atrophy primarily occurring in the dorsolateral prefrontal cortex,

which they claim is at least partially irreversible.26

28

Biological Links between Chronic Pain Depression and Anxiety

Another aspect of the Apkarian et al. study was interested in predictive factors of

chronic pain. They cite multiple studies linking depression with chronic pain suggesting

depression as a potential predictive factor. However, they conclude that depression and

other psychological disorders have not been shown to be accurate predictors of the

progression from acute and chronic pain.27

Despite the lack of evidence for depression being a predictor for the progression

from acute to chronic pain, there is ample evidence supporting the comorbidity of chronic

pain and depression. Oye Guryee and his associates, in a World Health Organization

(WHO) study, found a four-fold increase of depression and anxiety disorders among

those experiencing persistent pain. The study was conducted in 14 countries with close to

26,000 participants. The WHO study also found that the rate of comorbidity of persistent

pain with anxiety was nearly as high as the comorbidity of persistent pain with

depression.28

From the biological perspective it is somewhat expected that one would find high

correlations between depression, anxiety, and chronic pain. As previously mentioned,

neural transmission of nociception terminates within several areas of the brain, including

areas of the brain commonly associated with emotional processing.

Francis Dunne attempted to explain some possible biological factors linking

chronic pain to depression. He makes the case for a relation between chronic pain and

depression through the common neurotransmitters involved with both conditions. A

neurotransmitter commonly associated with pain is substance P. It is released from the

terminals of afferent nociceptive C nerve fibers, while glutamate is a primary

29

neurotransmitter associated with A-Delta fibers. Substance P is found throughout the

central nervous system, spinal cord, brain stem and brain. It is specifically found in brain

regions that regulate emotion. It is also closely associated with serotonin and

norepinephrine. Dunne believes serotonin and norepinephrine may be the common link

between depression and pain. He states, “Both serotoninergic and noradrenergic

pathways ascend from subcortical areas (brainstem, hypothalamus, and thalamus) to the

whole neocortex and mediate emotional and physiological responses. Their pathways

descend the spinal cord and suppress nociceptive inputs.” 29

Dunne’s article is partially based on an earlier study by Matthew Blair and his

associates. Blair et al. map out in detail the transmission and modulation of pain from the

peripheral site, thru the spinal cord, to the thalamus, hypothalamus, frontal cortex, and

somatosensory cortex. They state, “A common theory holds that depression and painful

symptoms follow the same descending pathways of the central nervous system.” 30 The

authors go on to reveal that suppressive effects of serotonin and norepinephrine on

nociceptive inputs are diminished as these two neurotransmitters are depleted in chronic

pain and depression conditions.31

Blair, et al. devote a portion of their article to highlighting the periaqueductal gray

matter area of the brain as a key structure in the modulation of pain. They state that the

periaqueductal gray matter area, along with other relay sites in the midbrain, medulla,

amygdala, and dorsal horns are abundant in receptors for endogenous opioids

(endorphins). Experiments with morphine and intrathecal applications of serotonin and

norepinephrine to these sites have successfully blocked pain signals.32

30

The role of endorphins in the modulation of pain may also provide some clues to

the relationship between chronic pain, depression, and anxiety disorders. Larry Beutler

and his associates observe that endorphins serve the function of facilitating the adaptation

to acute stress as well as serving as an endogenous analgesic for modulating the

transmission of pain. They also note that with prolonged periods of stress, endorphin

levels become correspondingly low and eventually unresponsive to external stressors.33

Biological Treatments of Chronic Pain

Biological treatments for chronic pain include a variety of options. An initial

biological treatment for chronic pain would take the form of a pharmalogical

intervention. Surgery, implants, and other medical procedures are often explored when

pharmalogical treatments fail to relieve pain. There is a vast number of pharmalogical

and medical interventions for the treatment of chronic pain. Below is a discussion on a

limited number of treatments as they relate to our Clinical Case Study subject’s

experience.

Opiates derived from the opium poppy (papaver somniferum) are by far the

earliest known treatments for pain. Carlo Flascha has recorded the ancient records of

Sumerian’s, Mesopotamian’s, Chinese, and Egyptian’s use of opium for pain relief. He

writes that an intact container of opium seeds, dated from 5500 B.C., was found in a

southern Spanish cave. Although being the earliest known treatment for pain, opiates are

one of the most widely used treatments for pain today.34

Aage Møller discusses the differences of the varieties of opiates. He clarifies that

opioids differ from opiates. Opiates are the natural derivatives of the opium poppy while

opioid is the term used for substances that bind to opioid receptors in the body and are

31

primarily synthetic or semi-synthetic substances. Opiates and opioids can work locally,

but primarily act on the central nervous system, spinal cord, brain, and specifically the

periaqueductal gray matter area.35

Bonica charts the many different types of opiates and opioids in use. Morphine

and codeine are naturally occurring opiates. Fentanyl, levorphanol, alphaprodine,

meperidine, propoxyphene, and methadone are synthetic opioids. Semi-synthetic opioids

include oxycodone, oxymorhone, and hydromorhone. Each opiate or opioid can take

different routes, have different peaks, duration and half-life times, and activate different

side effects.36

While effective for the treatment with chronic pain, side effects, addiction,

withdrawal, and paradoxical effects complicate the long-term efficiency of opiate and

opioid treatment. Møller makes a distinction between the addictive properties between

natural occurring opiates, which are highly addictive, and synthetic and semi-synthetic

opioids, which have a lower risk of addiction. Møller also outlines the side effects of

opioids. He states that respiratory and immune system suppression are two of the main

side effects of opioid use. Additionally, Møller points out that the long-term use of

opioids can produce paradoxical effects resulting in an increase to pain sensitivity.37

Antidepressants including: Selective Serotonin Reuptake Inhibitors (SSRI),

Serotonin-Norepinephrine Reuptake Inhibitors, and tricyclics, have shown effectiveness

for treating depression and anxiety in conjunction chronic pain. As stated earlier, chronic

pain conditions deplete serotonin and norepinephrine in the central nervous system

contributing to both increases in depression and chronic pain experiences. Kurt Kroenke,

Erin Krebs, and Matt Blair performed a meta-analysis study comparing various forms of

32

pharmacological treatment for chronic pain. They show that in 55 clinical trials involving

tricyclic antidepressants 76 percent showed benefits to the treatment of pain. In 17 trials

of SSRI antidepressants 47 percent showed positive outcomes for pain treatment.

Serotonin-norepinephrine reuptake inhibitors trials produced mixed results with specific

medications including duloxetine and venlafaxine showing benefit for both pain and

depression symptoms.38

Kroenke, et al. recommends a stepped approach for chronic pain treatment.

Depending on the type of pain condition, they recommend starting with simple

analgesics, like NSAIDs, moving up to tricyclics, then to topical analgesics, and opioids

at the top step.39 A stepped approach seems appropriate and responsible either as the pain

escalates or as the treatment diminishes in its capacity to reduce pain. Adequate pain

relief through pharmacological means is especially important in early treatment to reduce

the progression of acute to chronic pain conditions.

In a Newsweek article from 2007, Mary Carmichael interviewed both doctors and

soldiers involved with the pain clinics of military hospitals. Carmichael writes, “Chronic

pain is one of the most pervasive and intractable medical conditions in the United States,

with one in five Americans afflicted.” 40 She goes on to quote pain specialist Edward

Covington saying, “There is no cure for chronic pain, period.” 41 From her interviews,

Carmichael believes that the military is taking up a new strategy in avoiding chronic pain

by treating acute pain early. The military is investing in interdisciplinary pain clinics, and

programs to deliver pain management technology to the battlefield. One of the treatment

technologies they are delivering to battlefield soldiers is anesthetic pumps.

33

Intrathecal pumps are one type of device, which releases an anesthetic below the

arachnoid membrane of the brain or spinal cord. This device allows anesthetics to be

delivered to targeted anatomical sites. Blair et. al. have noted that research studies have

indicated that intrathecal delivery of morphine, serotonin, and norepinephrine has shown

an effect of modulating pain signals in the periaqueductal gray matter area, medulla,

amygdala, and dorsal horn, all sites rich in endogenous opioid receptors.42

Yet another physiological treatment for pain comes under the heading of

neurostimulation. Keith Bud and Pam Price write about neurostimulation among other

recent advances. Bud and Price describe two types of devices that currently fall into this

category of pain treatment, Transcutaneous Electrical Neural Stimulation (TENS) and

dorsal column stimulation devices. Each of the two devices uses either skin adhered or

surgically implanted electrodes that are believed to disrupt afferent nociceptive

impulses.43

There are different beliefs as to how neurostimulation works. Melzack and Wall

describe how under electrical stimulation large afferent nerve fibers contribute to central

inhibition.44 Beutler et al. state that electrical stimulation produces analgesia in equal

correspondence to the amount of endogenous opioids available at the point of

stimulation.45 There is general agreement that neurostimulation does provide effective

results for pain relief.

When all other forms of medical pain treatment fail, doctors often turn toward

surgical attempts to deaden the offending nerve. These surgical techniques are known by

the names nerve amputations, permanent nerve blocks, or nerve ablations. Nerve

amputation is a surgical severing of the nerve. Permanent nerve blocks usually involve

34

injecting alcohol or phenol to extinguish nerve tissue. Nerve ablations also aim to destroy

nerve tissue with heat or radiofrequency. Some patients may see some relief from this

form of treatment but the effects usually do not last and the damaged nerves often grow

back with greater experiences of pain.

Permanent nerve deadening techniques fail to account for neuropathic pain and

appear to be based on an outdated specificity theory. Wall states it this way,

In intractable cases where pain fails to respond to narcotics, neurosurgeons

have made lesions in many locations that were believed to be candidates

for the “pain center” or for being major message-carrying bundles. The

results are remarkably similar no matter where the lesion is made. Initially

there is a gratifying relief from pain, but within days, weeks, or months,

pain returns, often with additional unpleasant characteristics.46

Conclusion

The biological disciplines have been the primary driving force behind the

evolution of understanding and treatment of chronic pain to date. When someone is in

pain they seek a medical solution, and rightfully so. Acute pain conditions require this

response of medical attention to address illness and injury. A tremendous wealth of

information, with unrivaled complexity, has been contributed to the study of pain by the

biological field and the medical community. However, the complete understanding and

treatment of chronic pain has eluded the best medical minds. As was previously quoted in

Carmichael’s article, “There is no cure for chronic pain, period.” 47 This lack of a cure

requires changing perspectives and looking for the gaps in understanding that are missing

in the biological perspective.

Thernstrom offers us a clue of what is missing, “The biological perspective

involves a ‘depersonalization’ of pain—splitting off the disease from the suffering

35

person.” 48 In the subsequent sections, the discussion will continue to search for what can

be done with the lack of a cure, and how one can respond to depersonalization.

Cognitive / Behavioral Perspectives on Chronic Pain

This section on the cognitive/behavioral perspectives of chronic pain focuses on

the ways thinking, beliefs, and behaviors play a role in the experience of chronic pain.

This section reviews the evolution of cognitive/behavioral theories of chronic pain as

well as cognitive/behavioral treatments for chronic pain.

When Melzack and Wall were creating their gate control theory part of what they

were considering was that learned responses to pain played a role in the vast differences

people had to experience of pain. However, long before the formulation of Melzack and

Wall’s theories, behavioral psychologists were experimenting with learned behaviors. In

1927 Ivan Pavlov published his book Conditioned Reflexes demonstrating learned

behaviors in his famous experiments with dogs.49 By contrast, the initial reactions to

painful stimulus are known as unconditioned reflex. In 1937, B.F. Skinner, referring to

Sherrington and Pavlov’s earlier work, developed the concept of operant conditioning.

Skinner distinguished operant conditioning from Pavlov’s respondent conditioning by

focusing on the consequences of a behavior rather than the antecedent of the behavior.50

Skinner also sought to differentiate behavioral studies from physiological studies arguing,

“A science of behaviors has its own facts, however, and they are too often obscured when

they are converted into hasty inferences about the nervous system.” 51

In 1976, Wilbert Fordyce forwarded the concept of operant conditioning by

applying it to the study of pain and his identification of pain behaviors. Fordyce

conceptualized a wide variety of pain behaviors. They can be simple and apparent such as

36

limping, wincing, or moaning. Pain behaviors can also be more subtle and complex, such

as avoiding activity, dissociating, or withdrawing.52

Like Skinner, Fordyce was concerned about the disease model, which sought to

treat pain by correcting the underlying medical cause. Fordyce believed that, especially in

the condition of chronic pain, a learning model was more effective in conceptualizing

pain behaviors. He asserted that the learning model emphasized changing a person’s

actions or behavior. He wrote, “What initially is to be changed is what the person does,

not how he feels.” 53 Fordyce believed that attending to feelings were important, but in

the service of understanding how feelings affect a person’s discrimination between

reinforcing and non-reinforcing behavior.

In working with chronic pain patients, Fordyce observed that they often had

already lost a multitude of positive reinforcers that were previously present in their life

prior to their injury or illness, including things like freedom of movement, the benefits of

working, and an ability to make an income. In addition, the negative reinforcement of

value judgments from family and community often contributed to a perception of

punishment. From the behavioral lens, even family support can be viewed as a reinforcer

of pain behaviors, such as empathizing with expressions of pain, and discouraging

activity. Fordyce claimed that the expected response from someone perceiving their pain

as punishment, or as a denial of previously anticipated positive reinforcers, is either

withdrawal or aggression. He endorsed the concept of behavior extinction as the primary

way to address pain behaviors. As he simply stated, “Extinction occurs when a behavior

is no longer reinforced.” 54

37

In 1980, J. D. Loeser conceptualized pain behavior as the outer layer of “the

onion model”. This model was graphed as four concentric rings representing a hierarchy

of pain experience, progressing from nociception at the innermost ring, to pain, then to

suffering, and finally pain behavior in the outermost ring. Suffering, in this model, was

conceived as the affective or emotional response triggered by an aversive event.55

Fordyce incorporated this model into his work on pain behaviors and later wrote about

the distinctions between pain and suffering. He believed that suffering is observed only

by the expression of a person’s behaviors. Fordyce associated suffering with the threat or

perception of the person anticipating their own destruction. Fordyce viewed the related

anticipatory behaviors as learned responses to pain.56

To treat the suffering level of “the onion model” Fordyce included the use of

Joseph Wolpe’s systematic desensitization techniques. Wolpe had developed systematic

desensitization in 1958 to treat neurotic behavior, phobias and anxiety. Systematic

desensitization has three main steps. First, the subject is taught relaxation techniques.

Next, the subject and therapist review a progression of steadily increasing stimulus to

anxiety provoking situations. Finally, the subject imagines the anxiety-producing

stimulus while practicing the relaxation techniques.57

Fordyce used systematic desensitization in addressing the resistance of subjects to

move and exercise the injured parts of their bodies. Fordyce would have his patients

visualize lifting weights, while in a relaxed state, stopping when they perceived pain. He

would have them repeat this visualized experience imaging increasing weights and

repetitions until the patient could visualize moving without pain, at which point he would

switch them to actual lifting regimens.58

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He believed that a person’s ability to reduce suffering and chronic pain was

related to what they could do. In fact, he developed what he called “Fordyce’s law” to

emphasize this belief. The tenant expressed in “Fordyce’s law” is, “People who have

something better to do don’t suffer as much.” 59

Whereas the behavioral therapy model centers on modifying pain behavior, the

cognitive therapy model on chronic pain revolves around identifying and modifying pain

beliefs. Aaron Beck enlisted Carrie Winteroud and Daniel Gruener to co-write Cognitive

Therapy with Chronic Pain Patients. The underlying principal of this book is that

negative unrealistic thoughts, images, and beliefs about pain significantly impacts the

emotions, behaviors, and the physiological sensations of pain.60

Beck, Winteroud, and Gruener conceptualize the experience of pain as being

interrelated to the meaning that one gives to their pain. The authors describe that the

meaning one assigns to pain comes from various levels of thinking and belief. The focus

of treatment that they support is one of identifying errors in thinking, evaluating

underlying beliefs, and modifying the negative automatic thoughts and beliefs that

influence the perception of pain.61 Cognitive distortions (thinking errors) related to pain

includes: all or nothing thinking; overgeneralization; negative mental filter (selective

abstraction); magnification (of the negative) and minimization (of the positive);

catastrophizing (jumping to conclusions); emotional reasoning; should statements;

labeling; and personalization (self-blame).62

Beck, Winteroud, and Gruener propose that cognitive therapy treatment for

chronic pain would include, cognitive restructuring, assertiveness training, problem

solving, and relaxation techniques. Cognitive restructuring employs confronting negative

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unrealistic thoughts and beliefs. Assertiveness training includes teaching the patient to

directly communicate their needs and wants to others around them so that they can feel

understood in their experience of pain.63 Problem solving techniques involve breaking

problems down into smaller more manageable parts. Relaxation techniques include deep

breathing exercises, progressive muscle relaxation, guided muscle relaxation, guided

imagery relaxation, artistic endeavors as relaxation, reading as relaxation, and distraction

techniques.64

Distraction techniques offer a key method of addressing the perception of pain.

Dennis Turk, Donald Meichenbaum, and Myles Genest provide several approaches for

diverting attention away from painful sensation. Turk, Meichenbaum, and Genest

categorize cognitive strategies for treating pain into two types; strategies that try to alter

the appraisal of pain, and strategies aimed at diverting attention away from pain. They list

six methods of pain distraction techniques; imaginative inattention, imaginative

transformation of pain, imaginative transformation of context, focusing attention on the

environment, mental distractions, and somatization distraction.

Imaginative inattention involves imagining something that is far removed from

the experience of the pain, such as a pleasant day at the beach. Imaginative

transformation of pain interprets the sensation of pain as something more tolerable,

insignificant, or unreal. An example would be to imagine pain as vibration that gradually

floats out of the body. Imaginative transformation of context involves imagining a

different context to the current situation, such as seeing yourself as a movie actor in a

dramatic role after suffering a staged injury. Focusing attention on the environment

involves distracting by turning attention to the minute details of your surroundings.

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Mental distractions involve placing attention on mental puzzles, plans, or equations that

draw attention away from pain. Somatization, as a distraction technique, involves

focusing attention on the injured or hurt part of the body in an objective, dissociative

way. An example would be imagining yourself as your own doctor and writing an

exploratory report. The goal of these methods is to increase one’s ability for greater pain

tolerance.65

Chris Eccleston and Geert Crombez suggest pain distraction methods may be

ineffective because of the primacy pain has on protecting the entire organism. They claim

that the interruptive function of pain is generated by primal cognitive-evaluative

processes for novelty, intensity, unpredictability, and threat. The idea of novelty is

related to learning theory in that anything newly introduced to our environment captures

attention in order to be evaluated. Pain, by its nature, creates an attention priority. The

authors state, “The possibility of interruption, or priority reassignment, has not, to our

knowledge, been developed for any bodily sensation, including pain.” 66 Positive affect

and extreme arousal offer possible means of taking priority over pain, but only when pain

is at a low intensity. Eccleston and Crombez conceive that chronic pain can be redefined

as chronic interruption of attention. This definition of chronic pain puts a priority on

retraining focus and attention in the presence of pain.67

The ways in which pain interrupts attention can help explain why people with

chronic pain conditions have difficulty with memory and concentration. Two sources

acknowledge a relationship between pain, memory, and concentration. Dennis Turk and

Frits Winter state, “Tension as well as pain, often interferes with concentration and

memory.” 68 Additionally, Robert Jamison writes, “Patients with chronic pain frequently

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have problems with concentration and memory.” 69 Both authors note that pain

medications and anxiety/stress contribute to concentration and memory problems

associated with chronic pain.

While cognitive-behavioral studies have provided evidence of their effectiveness,

the developers of Acceptance and Commitment Therapy (ACT) find fault in the results.

JoAnne Dahl, Kelly Wilson, Carmen Luciano, and Steven Hayes in the book Acceptance

and Commitment Therapy for Chronic Pain write that a conflict exists between patient

outcomes and predetermined expectations from rehab physicians and insurance agencies.

If a patient does not improve within the predetermined timeframe their credibility is

questioned which creates more suffering. ACT attempts to address this conflict by

redefining the objectives of chronic pain treatment.70

The first major difference between ACT and Cognitive Behavioral Therapy

(CBT) is in ACT the agent of change is the patient’s own values. By identifying the

patient’s value system, ACT can be used to motivate behavioral changes in the valued

direction. The patient becomes engaged in their own treatment because they are seeing

their own values reflected to them and not being seen as someone having thinking errors

or maladaptive behaviors. The second major difference is ACT aims towards the

acceptance of pain rather than trying to escape from pain. ACT recognizes that fighting

and trying to escape from pain often tends to increase the perception of pain.71

ACT treatment involves the use of mindfulness approaches to examine thoughts

and feelings related to pain as they are, without the need to change them. Mindfulness, in

this approach, includes the development of an observer-self that helps make possible

cognitive defusion. Cognitive defusion is the process of noticing fused thoughts and

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perceptions such as the sensation of pain and the thought that the pain requires limiting

one’s movement. In defusion, it is not necessary to act on the fused thoughts but rather to

notice the linking.72

The cognitive-behavioral perspective has contributed many useful concepts,

principles, theories, and methodologies for the treatment of chronic pain. Loeser’s “onion

model” has helped to distinguish focuses for treatment, laying out practical boundaries

between nociception, pain, suffering, and pain behavior. Fordyce’s application of

Wolpe’s systematic desensitization has yielded good results in treating chronic pain. This

method is extremely useful in helping patients differentiate between body and mind in the

perception of pain. Distraction techniques also hold good promise for the temporary

interruption of pain sensations.

Finally, ACT recognizes that the evidence of efficiency for cognitive/behavioral

treatment of chronic pain is flawed. While ACT offers some reformatting of objectives in

chronic pain, treatment still falls within a cognitive/behavioral framework that questions

the patient’s motivations when there is little or no improvement. In general, the

cognitive/behavioral perspective falls short in a way that is similar to the biological

perspective. It fails to take into account the person’s whole experience, instead finding

them at fault in their thinking, beliefs, and behaviors.

Psychodynamic Perspectives on Chronic Pain

Psychodynamic perspectives on chronic pain utilize psychosomatic pathology and

somatization theories for the interpretation of pain causality. The term psychosomatic

refers to physical symptoms where psychological factors play a substantial role.

Somatization refers to the emergence of physical symptoms as the expression of inner

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psychic conflict. Chronic pain conditions are often thought of as psychosomatic

conditions, which are often met with resistance from patients because of the stigmatizing

effect. The psychodynamic perspective seeks resolution through interpretation and

insight.

The psychodynamic perspective starts with Sigmund Freud’s psychoanalysis.

Several of Freud’s theories have altered the direction of chronic pain treatment. Freud’s

early work on hysteria contributed to the development of psychosomatic theories of

chronic pain. Chronic pain is often categorized as neurogenic or pathogenic pain. Freud’s

repression theory had at its basis a pathogenic process. In this theory, an unconscious

mental impulse is met with conflicting internal resistance, which results in blocking of

access to consciousness and direct motor discharge. In the case of conversion-hysteria,

the energy of the impulse breaks through to consciousness as a physical symptom.73

Freud believed that insight into the interrelation between the ego and the libido provided

a means for alleviating both physical and mental symptoms.74

Freud believed that injury created the opportunity for neurotic symptoms to

emerge, and for motivation of secondary gain to occur. He wrote, “Persons who are

disposed to be neurotic, without suffering from a flourishing neurosis, frequently set in

motion the work of symptom development as the result of an abnormal physical change

often an inflammation or an injury.” 75 Freud used the example of a worker succumbing

to injury and subsequent disability as a means of speaking of secondary gains from the

injury. In the example, the worker is put in a position of having to beg for his subsistence.

The new form of livelihood is derived from the injury, thus creating a secondary gain.

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Freud warned about making quick judgments in such a case. Removal of the secondary

gain creates a new injury when the subject is faced with limitation of choice.76

Carl Jung, while not directly involved in writing about the treatment of chronic

pain, has contributed many important theories pertinent to its study. His interest in

symbol, alchemy, myth, archetype, imagination, and psychosomatic concepts has had

direct influences on other professionals studying chronic pain.

The importance of symbol, alchemy, myth, archetype, and imagination in relation

to chronic pain has to do with finding meaning and purpose in a condition that tends to

strip away and defy meaning and purpose. For Jung symbol, alchemy, myth, archetype,

and imagination became a way of knowing human states that are otherwise unknowable.

Concerning psychosomatic conditions, Jung believed they were as real as any verifiable

physical condition. In speaking of psychosomatic conditions Jung writes,

It is almost an absurd prejudice to suppose that existence can only be

physical. As a matter of fact, the only form of existence of which we have

immediate knowledge is psychic. We might well say, on the contrary, that

physical existence is mere inference, since we know of matter only insofar

as we perceive psychic images mediated by the senses.77

Joyce McDougall explores psychosomatic conditions from the Freudian

psychoanalytic perspective. McDougall asserts that early development of the psyche

plays a role in how psychosomatic conditions arise and are maintained. Citing

developmental theorists such as Wilfred Bion, Melanie Klien, Heinz Kohut, Margaret

Mahler, D.W. Winnicott, and Daniel Stern she maintains the role of the mother to both

protect an infant from overwhelming experience and to also act as an external modulator

of physical and psychological pain, affects how the infant introjects self-representation

and self-regulation. If the mother fails to guard the child from under stimulation or

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traumatic overstimulation then either the infant’s developing self-image may become

compromised or its psychic survival becomes threatened. Later in life, stress and internal

conflict can lead to dissociative states, psychosis, or psychosomatic discharges.78

McDougall notes that patients that frequently somatize have a strong resistance to

treatment and unconsciously try to “…protect their somatic creations.” 79 She goes on to

claim that painful states in certain individuals may even become a life affirming

reinforcer, albeit a paradoxical reinforcer. The suffering is seen as a reassurance and

verification of the continuance of living. McDougall describes this as the suffering body

becoming a strange kind of transitional object.80

McDougall finds several common traits to patients with psychosomatic

conditions. Insomnia, addiction, dependence, and an absence of affect appear to be

common in this population. She postulates that the insomnia and addiction can be traced

to a mother who uses her infant to exclusively meet her libidinal and narcissistic

satisfactions. The infant needs to create an internal image of the content mother in order

to sleep peacefully. Overstimulation, from excessive rocking, or under stimulation, from

a lack of affection, interrupts the internalization of a content mother image. Insomnia in

early childhood then becomes a predictor for later psychosomatic expressions or

addiction. Addiction in this case is seen as a futile attempt to internalize maternal self-

soothing.81 Dependence traits are also tied to attempts towards self-soothing. The

absence of affect comes from an inability to tolerate affect. McDougall states that,

“Emotion is essentially psychosomatic. Thus, ejecting the psychological part of an

emotion allows the physiological part to express itself as in infancy, leading to

resomatization of affect.” 82

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The challenge that the therapist faces with a somatizing patient is in balancing

their own libidinal and narcissistic needs in countertransference so that the patient can

gradually internalize self-soothing and learn to interpret bodily messages in full

expression.83

Gabriel Burloux, also speaking from a Freudian perspective, provides a more

detailed description to the inner workings of the chronic pain patient. He tells us that

physical pain can be diminished with the use of the principles that Freud used to treat

mental pain.84 Burloux’s solution involves resolving the economic problem, the flow of

energy problem, of physical pain. Burloux describes a psychic and physical

developmental process of pain perception that is more of a failure in learning than what

the biological and cognitive/behavioral theorists speculate. The failure appears to happen

at an early developmental period when somatic and psychic processes are merged. While

the mother provides a stimulus barrier to an infant, she also, through affective

relationship and parental presence, provides a healthy and relatively pain-free body,

something that is acquired. Whether the trauma of birth, annihilation anxiety, or the

impotence of early childhood, the failure to acquire a healthy pain-free body can be seen

as a primal wound that will be revisited later in life through repetition experiences.85

Burloux points to Freud’s writings in primarily three texts: Inhibitions, Symptoms

and Anxiety; Mourning and Melancholia; and Beyond the Pleasure Principal, to make

the case for the similarities between the theories of mental conditions and persistent pain.

Anxiety, depression, and pain share the ability to attract cathexis energies, drain the ego,

and create psychical system impoverishment. Persistent pain conditions represent the

patient using pain as a defense or protection from overwhelming mental pain.86

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The aim of Burloux’s treatment is to integrate the pain into the patient’s psyche.

The integration is first a product of interrupting the pain with distraction. As reviewed

from the cognitive/behavioral perspective, while distraction can be effective, it is only

temporary. Burloux’s intervention goes further than interrupting pain with distraction. He

conceptualizes pain as a black hole attracting all emotional energy. Once distraction from

pain is achieved, the emotional energy that has been trapped by pain is rerouted to form a

pain barrier, which distraction itself can achieve temporarily.87 Rerouting happens

through regression back to the point of early processing of excessive stimulation, and

internalizing self-soothing. There is a split between the parts of self that want to heal and

the narcissistic parts that derive attention from the pain. Self-soothing can occur by

capturing a childhood association of interest, joy, or passion that offers a glimpse into a

narcissistic source of pride and a point to reclaim lost desires.88

A key step in Burloux’s approach to treating chronic pain engages transference

and countertransference in what he describes as the role of the double. Since regression is

a key part of this treatment, he utilizes the idea of the imaginary friend, the double, which

children 4-5 years old develop out of a need to have a projection of narcissistic self

worth. In treatment, the therapist helps the transference process by initially acting as the

externalized double, and through empathy and compassion gradually helps the patient

internalize the double, simultaneously developing an observing self.89

Phillip Wilson and Ira Mintz in Psychosomatic Symptoms present several

principles related to personality development that appears to effect psychosomatic

expressions. They find that character disorders such as hysterical, borderline, obsessive-

compulsive, and near psychotic are common amongst psychosomatic clients. They also

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assert that treatment of personality disorder is essential to the resolution of psychosomatic

symptoms. In their opinion, treatment of psychosomatic symptoms without addressing

the underlying personality disorder risks the emergence of other somatic disorders.90

Wilson and Mintz emphasize the development of the body image as a key role in

healthy ego and personality development. They state,

The evolution of the body image is an essential protection against the

threat of disintegration from separation from the earliest period of life

onward. Thus, the organism is a psychophysiological entity from birth—

through fusion of emotional and bodily processes and external and internal

sensory perceptions. In this context, the term psychosomatic can be used

to encompass all physical illness.91

In the development of the body image, separation and loss in birth and

developmental progression, need to be integrated. Failure in separation and realization of

external objects lies at the heart of narcissistic positioning. In addition, narcissistic

positioning lies at the heart of character disorders.

Robert Gatchel notes that research aimed at uncovering the specific personality

disorders that are part of the pain-prone personality have come up empty. There appears

to be a wide variety of personality influences on the perception of pain. Gatchel points

out that studies that follow a progression between acute and chronic pain do find more

psychological disturbance the longer the pain is experienced. Gatchel recommends that

personality assessment be included in treating chronic pain patients as a way to improve

the outcomes of long-term pain sufferers.92

Stephen Tyrer believes that psychological and personality changes occur because

of prolonged pain and are not necessarily precursors to the development of chronic pain.

He points out that research has shown that only a small minority of chronic pain sufferers

actually meet criteria for a somatoform disorder.93 Critics point out that the theories of

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psychodynamic orientation lack supporting research and standardized treatment. The

complexity and depth of this approach makes standardized treatment and conducting

research difficult. The goals of the treatment are more subjective and require longer

periods committed to therapy.

Psychodynamic interpretations offer some insight into developmental factors in

relation to the emergence of chronic pain conditions. McDougall and Burloux offer

similar interpretations of early childhood and the stimulation barrier needed in order to

develop a relatively pain-free body. McDougall asserts that treatment necessitates the

internalization of self-soothing. Burloux provides a more detailed methodology that

includes an interruption of pain through distraction, followed by addressing narcissistic

wounds, and reclaiming lost desires.

The role of personality disorders in relation to chronic pain conditions is

controversial within the psychodynamic perspective. Wilson and Mintz believe that

personality disorders have to be treated simultaneously to avoid somatization erupting

elsewhere. Tyrer believes that personality changes are the result of prolonged experiences

with chronic pain and not a precursor.

Psychodynamic approaches to chronic pain are often greatly resisted by patients.

Part of this resistance comes from the assumption that psychosomatic and somatization

means that the basis of the chronic pain problem “is all in your head”, which leads to

stigmatization. This type of stigmatization happens in the cognitive/behavioral

perspective as well. However, with the psychosomatic perspective the immediate

experience of intense pain seems so far removed from childhood developmental issues

that it is difficult for pain patients to accept.

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Sociocultural Perspectives on Chronic Pain

Sociocultural perspectives look at the ways that pain is conceptualized within the

larger frameworks of society and culture. Many writers in this section reflect an opinion

that chronic pain has reached epidemic proportions. Issues of power and oppression are

discussed as they relate to chronic pain in society. Additionally, pain sufferers face

stigmatization, social exclusion and isolation, which add to personal suffering.

In the book The Body in Pain, Elaine Scarry paints a picture of how pain is

central to the destruction and construction of social power. At the heart of her writing is

the notion that pain defies expression. She traces how the difficulty in expressing pain

creates the difficulty in understanding pain. The perceptual difficulties of pain result in

political difficulties within the larger social containers of individual suffering.94

Pain is an internal state that can regress an individual to a point prior to

acquisition of psychic objects. Scarry states, “Physical pain does not simply resist

language but actively destroys it, bringing about an immediate reversion to a state

anterior to language, to the sounds and cries a human being makes before language is

learned.” 95 Scarry’s aim is to examine the ways in which expression of pain is either

recovered or oppressed, leading to the inclusion or exclusion of suffering groups from

society.

Scarry first examines the structures of torture and war to see how pain is used to

gain power over others. She notes that the image of weapons, not merely the weapons

themselves, intensifies the experience of pain in torture and war. However, the torturer

can exert power over another without weapons, through denying adjustment to comfort,

therefore inflicting the self-betrayal of the body as a means to further gain power. Scarry

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draws parallels between the torture victim and the chronic pain sufferer. In speaking of

the torturer, she states, “He first inflicts pain, then objectifies pain, and then denies the

pain.” 96

In recovering expression from pain, Scarry writes that imagination is central. She

writes, “While pain is a state remarkable for being wholly without objects, the

imagination is remarkable for being the only state that is wholly its objects.” 97

Imagination is also the driving force of creativity and a person’s ability to participate in

social and cultural construction through work. Society and culture are collective objective

constructions. In this context, recovering expression from pain moves from subjective

isolation out into objective participation, through imagination and revisions in self-

objectification.98

Arne Johan Vetlesen believes that Scarry is articulating that our present day

inclination is to believe that psychic pain is more powerful than physical pain.99 Vetlesen

asserts that cultural influences are both the source of much pain, and also the means of

transforming pain. He states that pain is a part of everyday life and is sourced in

fundamental conditions of dependence, vulnerability, mortality, fragility of relationship,

and existential loneliness. Vetlesen uses the concept of transportation to explain how

individuals shift pain from themselves to another in order to rid themselves of the bearing

of the pain. What is needed instead is the transformation of pain within oneself. In pain

transformation, reshaping of the pain takes place through the processing of

symbolization. Symbols allow for expression and meaning making to occur. Culture

produces the symbols that allow the reshaping; addressing the conditions of dependence,

vulnerability, mortality, fragility of relationship, and existential loneliness. Vetlesen

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warns that culture can fail us by offering only symbols that are too aggressive,

destructive, or concrete.100

Mary-Jo Delvechio-Good, Paul Brodwin, Byron Good, and Arthur Kleinman

write, “Perhaps more than other somatic experiences, pain resists symbolization.” 101 The

authors note that symbolization is not all that is resisted by the person in chronic pain.

There exists a basic distrust between many patients and health care providers. This

mistrust is worsened when both parties are frustrated by the inability to find a solution to

the pain. Mistrust is extended to the disability and welfare systems. The authors see a

crisis in social support, the growth of pain product markets, and the high cost of

medicalization.102

Delvechio-Good et. al. also write about what they call sociosomatic processes; the

interface between social stressors and how they affect the body. They note that western

culture imposes assumptions of individuals as autonomous, sovereign, independent,

rational, beings that live in a society dominated by scientific reductionist physiology.103

David Morris finds that we are in an epidemic of chronic pain suffering. It is a

silent epidemic with more than one in ten people experiencing persistent pain. Chronic

pain is a silent epidemic because you cannot point to an exact cause such as cancer or

AIDS. It is silent because it cannot be objectively verified. Morris states that in the pain

clinic where he worked, there were no cries and moans, only a deadening silence of

people sitting in the waiting room expecting never to be called. Helplessness of both

doctor and patient continue as both struggle to interpret meaning from persistent pain that

defies meaning making.104

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Morris states that previous cultures relied on mystery to inform them of how to

interpret pain. He sees a transcendent function to pain and suffering and uses the visions

of the saints to illustrate his point. For devote Christians, martyrdom has long been a

virtue to pursue. The images and stories of martyrs tell of overcoming pain by being

lifted up with heavenly visions. In looking for contemporary examples of saintly vision,

Morris cites the work of Gustavo Gutierrez a South American theologian who is working

to fight unjust social order. Chronic pain is common in the poor communities that

Gutierrez serves. Morris sees that collective pain offers a transcendent function not in

aspiring towards a heavenly afterlife but towards aspiring to political activism in present

time to confront oppressive political and economic forces.105

Authors Karl Frohm and Gregory Beehler are recommending professional

activism to confront the social problem of chronic pain. They support changes to the

biopsychosocial model of health care for chronic pain patients, replacing it instead with a

systems approach. Frohm and Beeler suggest that the professional culture involved with

chronic pain care is usually dominated by the medical community and biological

approaches. They state that current biopsychosocial approaches lack an understanding of

chronic pain, which contributes to stigmatization in society and within the healthcare

system. They claim that psychologists are better equipped to work with chronic pain

clients than physicians. Yet, psychologists are often delegated to the role of last resort

when medical model pain treatments fail. The problem the authors see is the prevailing

preference in society, and within the healthcare system, to place greater value on physical

science as opposed to the softer social sciences.106

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Valerie Gray Hardcastle takes a materialist’s perspective on the social impact of

chronic pain. She points out that chronic pain affects the individual, their family, their

friends, colleagues, employers, health care providers and society as a whole. She agrees

that persistent pain is demoralizing, frustrating, disheartening, and wearisome. She has

found chronic pain to be so common of an experience that it allows society as a whole to

minimize and disregard the suffering of individuals. Yet, despite this concern, she uses

the materialist’s philosophical point of view to deny the existence of psychogenic chronic

pain. She supports the ideas of eliminating pain talk from academic and clinical

environments. In addition, she supports relying on neurobiology to dictate the future of

pain assessment.107

The sociocultural perspective offers a view of the role society and culture play in

understanding chronic pain conditions. Scarry points out the ways pain is utilized to

assert power and create oppression through torture and war. People suffering from

chronic pain often express a feeling of being tortured by their pain, or at war with their

pain. Although war exists as a social phenomenon, an individual at war with pain feels

socially isolated. The individual in pain is thrust into a political dilemma as social

supports have become unable to meet the needs of so many suffering pain conditions that

cannot be externally verified. Solutions are offered in the transcendent functions of

political and professional activism.

Imaginal Approaches to Chronic Pain

The primary concern of imaginal approaches in psychology is reclaiming of the

soul through imagination.108 In this section, the theories, principles, and concepts of the

imaginal approach, as it may be applied to the treatment of chronic pain, is covered.

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Imaginal approaches draw from several streams of psychological discourse: post-Jungian

therapies, Shamanic practices and indigenous wisdom, hypnotherapies, and expressive

therapies.109 Specifically, what is covered in this next section is the ways archetypal

influences, ritual, initiation, symbol, metaphor, imagery; and ultimately acceptance and

meaning making play a role in the healing of chronic pain conditions.

The theories, principles, concepts and practices described in this section are

rooted in Imaginal Transformation Praxis (ITP) developed by Aftab Omer. ITP consists

of three main components; Imaginal Process, Imaginal Inquiry, and Cultural Leadership

Praxis. Imaginal Process is the distinct approach to transformative learning in-use at

Meridian, involving cultivating human capacities through attending to experience.

Imaginal Inquiry is a distinct methodology of participatory research that combines

inquiry and transformation. Cultural Leadership Praxis is a distinct approach to cultural

change through creative and collaborative engagement.110

Chronic pain conditions, by their nature, threaten our sense of identity, thus

challenging us to examine a core sense of who we have imagined ourselves to ‘be’. An

important way of looking at this are Omer’s imaginal structures and adaptive identity,

two key concepts within Imaginal Process. Omer defines Imaginal Structures as,

“Assemblies of sensory, affective, and cognitive aspects of experience constellated into

images: they both mediate and constitute experience. The specifics of an imaginal

structure are determined by an integration of personal, cultural, and archetypal

influences.” 111 Adaptive identity is defined as, “…the developing soul constellates into

self images associated with adaptive patterns of reactivity. These self images persist as

adaptive identity into subsequent contexts where they are maladaptive and barriers to the

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unfolding of being.” 112 Omer sees adaptive identity as, “Restricting experience through

personal and cultural gatekeeping.” 113 In describing gatekeeping, Omer states,

“Gatekeeping refers to the individual and collective dynamics that resist and restrict

experience. The term gatekeepers refers to the personification of these dynamics. ” 114

The personification of gatekeepers allows for differentiation and disidentification from

parts of self that resist and restrict the unfolding of new experience.115

Imaginal process focuses on restoring experience through authentic and creative

expression. Expression serves to reclaim experience in part because we are expanding

experience through expressing. However, our reclaiming of experience also relies on the

reception of our expressions. Imagination is seen as a necessary component for

expanding experience. Omer views imagination as amplifying experience through what

he terms as the four dynamisms, (diversifying, deepening, personalizing, and embodying

of experience). This serves to integrate the sensory, emotional, and cognitive dimensions

of our experience. Practices that foster imagination advance mind-body union, which

enhances our effective functioning and wellbeing.116

Post Jungian sources help to identify some of the archetypes at play in the

maintenance of chronic pain conditions. Archetypes of the hero, the wounded child, the

wounded healer, and the shaman are all found in the literature on chronic pain.

Examination of the literature on pain referencing the wounded healer and shaman

archetypes, finds further reference to ritual, initiation, symbol, metaphor, and the use of

imagery in its treatment. The Shaman is a wounded healer and is initiated through a

process that requires a transformation involving the experience of illness or injury. Omer

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states, “The Shaman is a ritual specialist. Their job is to make soul out of the

wounding.” 117

Melanie Starr Costello uses a post-Jungian perspective to lay out the dynamics

between perception, imagination, and archetype and their effects on somatic

presentations. Perception is seen as a process in which sensory responses are taken in,

organized, and mental representations are formed with imagination. Personal identity and

memory effects the way experience is contextualized and developed with meaning.

Archetypal influences also effect perception and meaning making.118

Costello observes while archetypal forces play a key role in unconscious

organization of identity and animating experience, archetypal constrictions of identity can

narrow perception, limit adaptation, obstruct symbolization of experience, and lead to

somatic presentations. Costello gives the example of the hero, culturally common in

western males, as an archetype that can limit perception. The hero archetype averts

feelings of inferiority but also effects perception of bodily signals of limitation. Ignoring

these signals and exceeding ones physical abilities can lead to injury and pain. Costello

suggests that creating an associate bridge between the conscious and unconscious

positions, hero archetype and the inferiority of the wounded child, allow for a greater

range of experience.119

In Bill Moyers’ book Healing and the Mind, from the PBS television series; he

devotes the final section to a specific archetype familiar to the imaginal approach, the

wounded healer. In this section, Moyers interviews Michael Lerner and Rachel Naomi

Remen of Commonweal, a retreat center in West Marin County. Commonweal offers

retreat programs for people with cancer. While cancer pain is not the specific focus of

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this Clinical Case Study, cancer pain is a subtype of chronic pain. Remen describes the

basic aspect of the wounded healer archetype, “The reality is that healing happens

between people. The wound in me evokes the healer in you, and the wound in you evokes

the healer in me, and then the two healers collaborate.” 120

Lerner points out that there is a difference between curing and healing. People

seeking treatment and allopathic medicine focuses on curing. Commonweal focuses on

healing, a process that draws from inner resources and intrinsic bodily processes. Lerner

believes that allopathic medicine creates the conditions for healing, but the healing

process requires the involvement of the body. Similarly, there are differences between

disease and illness, and pain and suffering. Disease is the biological definition of a

particular condition. Illness is the human experience of the condition. Pain, Lerner

describes, is a physiological phenomenon and suffering is the human experience of pain.

The importance of the differences between cure and healing, disease and illness, and pain

and suffering is that human experience may affect health in ways that we do not

recognize.121

Lerner traces the wounded healer archetype to ancient shamanic traditions. He

views the similarities of various shamanic traditions as coming from common

foundational human experiences in relation to healing. A process of spontaneously falling

ill and then recovering is common among indigenous healers. Shamanic healing attempts

to elicit awareness of the self, and consciousness and growth that leads to new insights

that help others with their illness. At Commonweal, Lerner and his staff employ imagery,

meditation, yoga, relaxation, breathing, and various other practices to help people quiet

their minds and bodies so that new perspectives on living might arise.122

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Key to understanding the wounded healer archetype is realizing it is woundedness

that allows others to trust in the healing process. The trust helps to build the healing

relationship. Remen believes that what contributes to the evoking of healing is receiving,

accepting, and understanding the pain and suffering of the other. Remen states, “But this

point about acceptance is very, very, complex. My sense is that all power comes out of

the ability to accept what is. Acceptance is what allows change.” 123

Remen finds imagery central in her work with cancer patients at Commonweal.

She states, “Imagery is the way the mind and body talk to each other…. Images are the

primal language. Maybe the first way we experience the world is through images….You

see, in a way imagery is reality because it helps connect us to what’s most real in us.” 124

Jeanne Achterberg states, “Shamanism is the oldest and most widespread method

of healing with the imagination.” 125 Achterberg explains that shamans operate from non-

ordinary reality where thoughts and things are interchangeable. Ritual, symbol, and

metaphor help blur the distinctions between real and imagined, but for the shaman there

is no distinction. The symbols the shaman uses become what they represent.126

Achterberg also writes about the shaman’s drum as a way to alter consciousness

and enter trance. She describes that the sound of drumming affects one’s ability to alter

concentration, and focus and shift one’s attention away from pain. She notes that this

appears to be biologically compatible with the gate theory of pain where the drumming

offers a competitive stimulation to the stimulus of pain.127

David Biro finds symbol and metaphor essential to solving a central problem of

pain, the difficulty in its expression. Biro states, “At its most intense, pain really does

consume everything except itself.” 128 This includes language. Intense pain can become

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indescribable and unimaginable. Suffering in intense pain includes an isolation, a turning

inward, that cuts us off from the more public “literal” world. Pain, too, invokes a fear of

annihilation or “ob-literation”. 129 Biro notes that other writers, including Scarry,

conclude that pain has no object; it is a subjective experience that resists meaning and

language. However, “…ex-pressing our pain, (literally pushing it outward)…” 130 is

exactly what most of us seek when overwhelmed by pain.

Biro suggests that the solution to the isolation of pain is in using metaphor to

remake our relationship and connection to the world. Metaphor enables the remaking

through giving words and objects to the experience of pain, which resists direct

description and expression. All words are representations of ideas or things, and not the

idea or things themselves. Metaphor, however, differs from ordinary representations.

Metaphor engages the imagination and deviates from an ordinary way of perceiving the

world.131

Biro makes a distinction between three types of metaphors and their usefulness in

transforming experiences of pain. The three types of metaphors are agency metaphor,

projection metaphor, and anatomic metaphor. The agency metaphor allows one to see

pain as inflicted by an outside agent, such as a weapon or a bacterial invasion, which has

penetrated the body. With the agency metaphor, pain is associated with the agent and

seen as an outside object. With the projection metaphor, in an effort to validate,

understand, and enlarge the self, pain is projected to an outside object, or pain can be

personified to look for a way to make it responsive. Projection metaphor blurs the

boundaries of external and internal. Anatomical metaphors are wholly internal. They

allow us to communicate our internal experience in a way that reconnects us to others in a

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more complete understanding. Examples of anatomical metaphors would be to describe

the heart as a pump, or our nervous system as an electrical network, or a pounding

headache as a hammer striking an anvil.132

Ariel Glucklich advances a theory of pain that is sourced in religious rituals, in

which pain becomes a transcendent agent. He bases his theory in neurodynamic and

psychological principles. His aim is to show that enduring pain has an effect on

transforming identity. Glucklich claims, that in relation to the self, there are two types of

pain that are not exclusive of one another, disintegrative pain and integrative pain.

Disintegrative pain weakens the ego, while integrative pain strengthens a person’s

telos.133

Glucklich lays out several models of pain for the groundwork of his theory. In the

juridical model, pain is perceived as punishment by an impersonal source such as god,

the devil, or karma. In the medical model, physician procedures are either preventive or

curative. In this model, pain is the bitter pill, or the cutting of flesh, that one bears to

either be cured, or avoid future ills. In the medical model, pain becomes a part of the

medicine. In the military model, pain is perceived as the enemy or invader. One is thrust

into a war with one’s own body or embodied soul. In the athletic model, pain is part of

the preparatory discipline one sacrifices for a future life. Glucklich compares the athlete

to the martyr, both archetypal figures engaged in self-sacrifice. In the magical model, he

compares the suffering of pain to the purifying stages of the alchemical process. Pain is

perceived as the purifying agent. In models of shared pain, it is perceived as the vehicle

of gaining communal compassion, empathy or communal identity. In psychotropic and

ecstatic models of pain, hyperstimulation brought on by ritual practice, first perceived as

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sharp and brief pain, results in ecstatic states. Pain is transformed into an intense

sensation.134

Glucklich concludes, with the help of Melzack’s neuromatrix theory and object

relation theory, that painful stimulation reduces the output that the central nervous system

forms in relation to the sense of self. This makes the “body-self” more apparent and

allows for the emergence of a new identity. He states, “As the empirical agency gives

way to a more highly esteemed reality, the center of being shifts outward, situating the

sense of self in a greater center of “Being.” 135 He also believes, “Pain may be medicine,

a test, a rite of passage, or an alchemical agent of inner transformation.” 136 What is

important is that the pain sufferer finds some meaning that aids in self-transformation.

In an anthropological study of the Commonwealth Pain Clinic (CPC), Jean

Jackson uses an ethnographic analysis to present the learnings from client-centered

discourse. Jackson interprets her learnings with concepts and principals that closely

match the concepts and principals of an imaginal approach. Here she likens the treatment

of chronic pain to an initiation ritual with liminal features. While the interpretation and

framing of the CPC’s treatment as an initiation ritual seems helpful in understanding the

program’s effectiveness, Jackson notes that this framing is unintentional in the day-to-day

operations of the CPC.137

Jackson states that the CPC’s most important feature was as a therapeutic

community. Within the community, there were various levels of authority with the

patients taking on the role of initiate. Former and veteran patients were seen as guides

and insiders, while staff members were considered outsiders and sometimes elders.

Jackson states that, “Initiation rites impart a new body of knowledge to the initiate,

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transfer a person from one social status to another, and are characterized by high levels of

both arousal and catharsis.” 138 Transformational processes at the CPC often resulted in

changes in a patient’s identity. Identity shifts often centered on gaining capacities for

living with pain. The chronic pain patient usually has already experienced significant

changes in identity prior to undergoing treatment. They may have already lost status in

community as a functional contributing member, family roles may have been altered, and

they may have either been alienated or isolated from social contact. Jackson also believes

that hospital settings further strip away identity with the unintentional ritual steps of

uniformly clothing patients in hospital gowns, placing admittance info on a bracelet, and

requiring patients to be removed from their families and communities.139

Jackson defines liminal as a state of transition. The liminal features of the

initiation rituals at the CPC involved stripping and leveling, increasing affect, and

experiencing pain. Stripping and leveling happened through the experience of pain. Here

the experience of intense pain is an equalizer and creates a sense of egalitarianism among

patients. Increased affect is also already present with chronic pain sufferers. She notes

that pain is often included in initiation rituals, as a way to assert communal authority

through humiliation. Chronic pain patients obviously do not need additional painful

stimuli, yet stigmatizing messages from staff and fellow patients often increase pain and a

sense of humiliation. Jackson notes that the CPC patients shared several experiences with

initiates of traditional rituals including powerful feelings of cathexis, strong attachment,

bewilderment, and disorientation.140

Jackson, entitling a section of her book “The Mystery of Pain”, uses the metaphor

of religious conversion to understand the transitions that chronic pain patients go

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through. Pain patients at CPC could not attribute their changes entirely to program goals

of motivation, increased movement, and medication regulation. They expressed their

changes as mysterious, inexplicable, or miraculous, without necessarily seeing decreased

levels of pain. The mystery of pain is intensified by confusing messages coming from

many sources. Professional sources have conflicting messages about how to treat pain.

There are confusing messages about identity, social status, and disability limitations.

There are confusing messages about the relationship between mind and body. There are

also confusing messages about pain as being “real” (physical) or “not real”

(psychological), coming from family, friends, coworkers, legal entities, and even fellow

patients. Jackson states that the effect of the confusion is patient disorientation and

disorganization, which becomes necessary for reorganization thoughts and beliefs.141

Jackson’s research has led her to express several principles related to

subjectification and objectification with pain. Jackson states, “Pain straddles the

object/subject boundary.” 142 She states, “…a core necessary feature of pain it its

aversiveness.” 143 Out of the aversiveness arises the objectification of pain. We want to

get rid of it. Pain is the enemy. However, when pain becomes intense, consuming

attention, it can become subjectified. We identify with it. We become someone filled with

pain.

Imaging and visualization were used at CPC to help understand the objectification

or subjectification of one’s pain. Jackson notes that often patients would visualize their

pain as living beings, as one patient described, a “pain creature”. Staff would use

imaging to lead patients towards subjectification of the pain. “Pain creatures” became

less fearful when they became more familiar. Patients were encouraged to explore the

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objects of their pain and to talk with their “pain creatures”. The focus was to change

one’s self concept in relation to pain. It required an acceptance of pain as part of a body

self-reincorporation. Patients would discover that acceptance of pain required additional

acceptance of responsibility to confront long termed ingrained behaviors, thoughts,

beliefs, and relationships that were contributing to the experience of pain.144

Imaginal approaches utilize expressive therapies to expand experience through the

four dynamisms, deepening, diversifying, personalizing, and embodying. Expressive Arts

Therapist Charlotte Flanagan describes her hermeneutical study of the metaphorical

expressions of 153 chronic pain patients over a three-year period. The chronic pain

patients of this study participated in art therapy, dance and movement therapy, music

therapy, and relaxation techniques. Expressions of metaphor were recorded and analyzed

for differences in how the metaphors related to time and space. Flanagan found that

chronic pain patients initially used metaphors that were away from the body suggesting

dissociative states. After several months in the study, patients would use metaphors that

were closer to the body suggesting increased ego strength.145

Biro and Jackson both reference the imagining of pain as a personified agent. Biro

calls this projection metaphor while Jackson refers to it as “pain creatures.” Personifying

pain and entering into dialog with it promises the expansion of experience and a way of

working with pain’s unknowns.

Eugene Gendlin has created a process call focusing that works to uncover hidden

embodied knowledge to create explicit understanding. In essence, this tool personifies a

felt sense within the body to reveal inherent meaning.146 In searching for an existing

process to dialogue with pain this technique stood out as a practical choice. This process

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aligns with imaginal approaches in that it looks to expand experience through

embodying, it follows the tenets of deep listening, and it honors the body’s inner wisdom.

Additionally, the process aligns with the idea of befriending pain.

Ann Weiser Cornell has written of the focusing process in relation to its use with

pain. She treats pain the same as other felt senses. Her approach is to first notice the felt

sense and its location in the body. The felt sense is acknowledged and said hello to it,

then the felt sense is named. The felt sense is paid attention to, with an attitude of

curiosity. Then the felt sense is listened to, taking time to patiently welcome any meaning

that comes. The meaning often comes with a memory, thoughts or beliefs, or the

realization of an unmet need.147

Jon Kabat-Zinn uses the practice of meditation to work through pain. Similar to

the process of focusing, Kabat-Zinn stresses the importance of listening to pain in order

to learn to live with it. Using mindfulness, Kabat-Zinn says that one can ride the waves of

pain by breathing into it. He states, “You learn how to work with the pain, to befriend it,

to listen to it, and in some ways to honor it.” 148 He notes that part of this practice is to

learn to uncouple the sensation of pain from the thoughts about them.

Many of the sources in this section have referred to the use of imagery and

imagination in the healing process. The use of imagery and imagination is referenced in

the sources of other perspectives as well. Within the imaginal approach, imagination is

the primary agent of change in restoring experience. Restoring experience is essential to

the treatment of chronic pain.

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Conclusion

The current theories and treatment of chronic pain suffers from dualistic

approaches that negate the whole experience of the pain patient. The biological

perspective looks for physical sources to the experience of pain. The latest biological

theories on pain acknowledge a psychological influence on the perception of pain, but

there continues to be an emphasis on searching for the neurophysiological sources

involved. The focus of cognitive/behavioral intervention ignores the nociception and pain

levels of “the onion model of pain”, instead focusing primarily on removing pain

thoughts, beliefs, or behaviors. The psychodynamic perspective sees the pain patient as

someone somaticizing a psychic conflict most likely originating from an early

developmental failure. The sociocultural perspective sees the pain patient as part of a

group that has been disempowered, oppressed, and stigmatized. While there are helpful

concepts, principles, tools, techniques, and methods in each perspective, each of these in

some way ignores the whole experience of chronic pain sufferer.

From the imaginal approach, Lerner notes that healing is different from curing.

The various approaches to chronic pain can create the conditions for healing. However,

healing draws from inner resources and intrinsic bodily processes. Engaging imagination

restores experience and helps to activate our inner resources. Omer states, “Imagination is

an innate homeostasis that balances the three aspects of experience, sensory-motor,

cognitive, and emotional.” 149

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CHAPTER 3

PROGRESSION OF THE TREATMENT

The Beginning

In late January 2012, a year before starting this study, our office received a large

package from a Worker’s Compensation insurance claims adjuster. Inside the package

was 16 inches of detailed medical documents. The package was somewhat mysterious. In

the package, there was a cryptic form letter. Neither Susan, my supervisor, or myself

recognized the client’s name listed in the documents. Susan asked me to call the adjuster

to sort out the confusion. When I called the adjuster, she told me that Michael Pena and

his lawyer had chosen our office for therapy. The adjuster stated that Michael was being

referred to us for pain management and depression. The therapy was recommended in a

psychological evaluation that occurred several months previously. She gave me

Michael’s phone number and asked me to contact him directly to set up an appointment.

It was difficult to reach Michael at first. I later discovered that he had been

screening his phone calls as a precaution to avoid talking to insurance adjusters, lawyers,

and Workers Compensation investigators. When I did finally reach him, he was surprised

that his insurance had approved the therapy visits. However, he was eager to set up an

appointment.

We met the following Wednesday evening. He came in casual dress wearing a

plaid shirt, khaki shorts, and sandals. He moved slowly and sat down gingerly. His

eyelids appeared heavy. My thought at the time was that he appeared drowsy or lethargic.

Michael had informed me that he was primarily coming in for “situational depression”.

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He explained that his depression was due to financial stress, and an inability to work. He

described the details of his work injury and his near constant pain. When asked how long

he had been depressed he replied, “Several years.”

Michael told me that he had been to see a therapist before with a woman in

Angels Camp. This took place four years earlier. He had stopped going to see his

previous therapist because his insurance was not picking up the cost and he had to pay

out of pocket. After some time and litigation, his insurance company referred him to

another therapist in Stockton. He was unable to make his appointments consistently due

his reliance on his fiancé for transportation, and the difficulty of the two-hour car trip to

Stockton. Because of the high dosage of opiate pain medications he was taking, Michael

had given up driving. After a psychological report was concluded in 2011, four years

after his injury and two years before the start of this study, Michael’s insurance agreed to

pay for therapy at our office.

Michael was seeing a psychiatrist and medical doctors regularly. He told me that

the day before his psychiatrist had changed his anti-depressant and upped his dosage of

Clonazepam for anxiety attacks. Michael could not remember the name of his new anti-

depressant. I asked him to bring me a list of his medications to his next visit.

Eager to know of the circumstances of his pain, I asked Michael to describe the

injury that he had suffered five years earlier. In his reply he also gave a description of the

myriad of problems that he had experienced since then including; multiple operations,

reinjuring himself numerous times, contracting pneumonia on two occasions, the denial

of services from his insurance company, difficulties with his pain medications, financial

problems, and the stress his injury had created in his relationship. Before this first visit, I

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had already begun to read some of Michael’s story in the medical documents that had

been sent to our office. After his telling of the story, I felt the need to review the

documents again.

I was curious about what was going on in Michael’s life just prior to his accident,

wondering if previous events played any role in his injury.

“So, was there anything happening in your life just before your accident?

Anything memorable?”

“Danielle and I had gone on a river rafting trip to the Philippines as guides. We

were having a good time there, scuba diving, golfing, and the river rapids were great. It

was a nice relaxing trip and we really needed to get away.”

“Why did you need to get away?”

“Danielle and I had been fighting a lot before we went on that trip. I had been

promoted in the previous weeks to the position of lead rafting guide. Danielle wanted that

position and I got it. Now I was her boss. She was really upset at me that I took the job

she wanted.”

When I put on my analysts cap, I started to wonder if Michael had created a

somatic escape to avoid conflict with his fiancé. I asked Michael if he thought he was

conflict avoidant and he agreed. I thought about this from time to time in my work with

Michael, but his injury was creating more conflict with Danielle than perhaps what he

was hoping to avoid.

When I talked to Susan in a supervision meeting about Michael, she seemed

surprised by the description of his injury. She thought that it was unusual for a rib injury

to be the source of a long-term disability. With a rib break, the lungs provide a natural

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splint for the bones to rest against as they heal. Michael had broken six ribs. His right

lung had partially collapsed, failing to work as a splint for the ribs. His liver was also

lacerated by the rib break. He sustained what was described in medical reports as a

buckle fracture and a non-union break. His psychological report stated that his physicians

did not appreciate the level of his pain.

My first impression of Michael was that he was very amiable. He became tearful

at several points during our initial visit. I was impressed by Michael’s willingness to

share his emotion and vulnerability. I am often surprised when a client shares their

vulnerability so early in treatment. I also feel deeply honored in receiving the trust to hold

their most vulnerable moments. In this initial meeting, I felt drawn to reciprocate his trust

by offering that I too had experienced an injury that resulted in chronic pain, and had also

experienced periods of depression during my life. I did not go into detail at this time. My

intention was to communicate to Michael that I understood through my own personal

experience the depth and complexity of his condition.

At Michael’s second visit, the following week, he provided a list of 11 different

medications he was taking. The list included two opiates for pain, Morphine Sulphate at

120 milligrams per day and Tapentadol at 100 milligrams every four to six hours for

breakthrough pain. The list also included a benzodiazepine, Clonazepam at one milligram

three times a day for anxiety, and Baclofen, a derivative of GABA, as a muscle relaxant

at 20 milligrams every six hours.1

Michael was eager to know my opinion about the medications he was taking. He

appeared to trust my opinion. I informed him of my role as a psychotherapist did not

include prescribing medications, but I would be happy to look up the medications with

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him that he was concerned about. Throughout our work together, Michael often voiced a

concern about being over-medicated. I too was concerned about him being on so many

meds at once. I was also concerned about the combination of opiates and benzodiazepines

that he was taking. I was aware that this combination had potentially dangerous drug-

drug interactions from my previous work at a drug and alcohol agency.

I phoned his psychiatrist the following week to ask about my concerns over

Michael’s medications. His psychiatrist was willing to make a change from the

Lurasidone to Cymbalta. However, he was reluctant to change any of Michael’s other

medications.

By our third week together, I felt Michael had already entrusted me with his care.

I was also starting to get a sense of Michael’s personality. He appeared to be a caring

man with a simple ambition of enjoying life. He had grown up in a vacation paradise and

made a living through physical recreation. Now through his injury his familiar life had

vanished. He had become stiff and sedentary, unable to enjoy the activities that once

brought him pleasure. In our ongoing work together, the unfolding of Michael’s story

was starting to reveal the complexity involved with his pain.

Treatment Planning

Treatment planning is a process of understanding the problems that the client

wants to work on, developing goals and objectives, and creating interventions to work

through the problems. After meeting with Michael for a few sessions, it became clear the

primary problem he was dealing with was chronic pain. Michael had initially stated that

he was coming into treatment for depression. His training as an EMT had him firmly

believing in the medical model’s conceptualization of pain. In his thinking, his

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experience of pain was directly related to the extent of his injury. He was continuing to

seek medical interventions to rid himself of pain. It felt safe for him to seek psychological

treatment for depression, but to him his pain was solely a physical issue.

Changing the focus of the therapy required educating Michael on the

psychological experience of pain. It also required my reassurance to Michael that his

experience of pain was not being dismissed or diminished as being “all in his head.” This

was a phrase he used on several occasions to communicate a fear that his experience of

pain was not being seen as “real”. Through careful explanation, I was able to satisfy

Michael’s need to understand the interrelated nature of chronic pain, depression, and

anxiety. I reassured Michael that I believed his pain was real regardless of physical or

psychological origins.

Once the focus of therapy was changed to chronic pain, I worked with Michael to

develop goals and objectives. We quickly established basic goals of lessening daily

suffering from pain, and learning pain management skills. Additionally, I wanted to add

goals of gaining an acceptance of certain levels of pain, and the goal of befriending pain.

During a supervision meeting, Susan had introduced me to the idea of befriending pain.

She said that she worked with this concept both with her pain clients and with herself for

her own chronic pain from a neck injury. Michael showed some initial resistance to these

concepts. While he voiced a willingness to explore acceptance and befriending of pain,

he was not sure how these concepts would work, or what benefit they might offer.

With these goals in mind, I continued to develop objectives and interventions.

One of my first objectives was to educate Michael about the complexity of chronic pain. I

set out interventions of teaching the differences between acute and chronic pain, and

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between curing, healing, and pain management. Another objective was to explore

Michael’s history and life experiences in relation to pain, depression, and anxiety. Here I

sought to identify the impact of pain on his past and current life including social,

vocational, and family roles, developmental influences, how he had coped with pain in

the past, and how his current experience of pain is different from past experiences.

For the goal of learning pain management skills, I developed the objective of

teaching relaxation techniques, distraction techniques, and self-monitoring of pain,

depression, and anxiety symptoms. Planned interventions around self-monitoring

included keeping a pain journal, and exploring imaginal structures related to the

experience of pain. I also planned using reflexive dialogue, and imaginal dialogue to have

Michael talk to his pain as a subjectivity.

The Therapy Journey

In my first few sessions with Michael, I sought to establish a sense of trust and to

learn more about his condition. In his third session, Michael had been telling me about

difficulties he had with sleeping. His pain often woke him in the middle of the night.

Whether lying on his side, back, or stomach the painful discomfort would eventually

break through his sleep. Once awake he would sit up in his rocking chair, as his mind

would race with thoughts of no longer knowing how to support himself, reservations

about taking too many medications, fears about reinjuring himself, and worries about his

relationship.

I asked him to consider his worries, fears, reservations, and anxieties as

gatekeeping. I introduced Michael to reflexive dialog, and descriptions of the gatekeeper,

friend, child, and subjectivity positions. I outlined for Michael the basic function of the

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gatekeeper in keeping him safe by limiting his experience.2 Most of this third session

was spent in listening to Michael’s experience of pain and anxiety and briefly explaining

reflexive dialog work. We did not actually do a reflexive dialog form on this evening. I

suggested to Michael that we would continue to explore this type of work in the

following sessions.

Michael came in quite frantic and upset to our next appointment together. He had

not attended therapy for three weeks because of illness and scheduling conflicts. Michael

had an appointment with an urologist in between his second and third session. During one

of Michael’s surgeries to amputate his rib, a medical student damaged his urethra when

inserting a catheter. The urologist was examining Michael to determine the long-term

effects of the urethra injury. Michael was upset because he claimed that the doctor

belittled him and doubted the extent of his injuries. I wondered to myself how much of

what Michael was telling me reflected what the doctor actually said to him and how

much was Michael’s interpretations of the event. Both possibilities were troubling to me.

I did not mention this concern to Michael, but he offered that he had difficulties with

previous psychological and medical testing and so he recorded the conversation with the

doctor, with the doctor’s full knowledge. Michael played back the recording to me. The

voice attributed to the doctor on the recording clearly showed prejudice and assumption.

At one point the doctor accused Michael of “taking money from the taxpayers,” and “it’s

time for you to go back to work.” Michael’s reaction to this kind of treatment was not one

of anger, which I expected, but instead one of despair and collapse.

I asked Michael how he was affected by hearing the remarks of the doctor. He

said that he felt hopeless. He said that he doubted whether his life would ever change. He

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wondered if he would have to feel this unbearable pain forever. I suggested to Michael

that the doctor’s remarks were acting as an externalized cultural gatekeeper. I explained

to Michael that the doctor’s remarks were apparently intended to instill guilt, shame, fear,

and self-doubt. Emphasizing the friend voice in this moment was necessary.

Michael had been plagued by conflicting gatekeeper voices that were paralyzing

him. One set of gatekeepers chastised him for not being able to work or provide for

himself. Another set of gatekeepers kept him from working by convincing him that any

work would cause him to reinjure his broken ribs. There was a considerable amount of

truth to both positions. In mid April, I attempted to break this logjam by helping Michael

envision how basic skills he possessed could be used in other lines of work. Michael had

always worked in outdoor professions. He was happy in his previous jobs as an EMT,

firefighter, ski instructor, and river raft guide. Several years earlier he had tried to return

to work after his injury, first attempting to work again as a river raft guide. He lasted

three days before the pain became too intense to continue working. Similar results came

when he attempted to resume ski instructor work. We were able to identify that Michael

very much liked working outdoors. He also enjoyed work that helped others. He had a

great deal of knowledge about outdoor adventures, and of outdoor safety.

I encouraged Michael to consider envisioning a job that was administrative, which

used his current skills and knowledge, but would not challenge him physically. He had

difficulty imagining holding an administrative job. First, he was concerned that his

dyslexia would be problematic in administrative work. Additionally, he emphasized that

pain, and pain medications, left him with poor memory and concentration abilities. He

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also informed me that he could not drive to a job as his depth perception and coordination

skills were altered by his opiate pain medications.

It was obvious that Michael had been thinking about returning to work for a long

time. He presented himself as someone who really wanted to return to work. However,

each possibility of working proposed challenges that he was not able to overcome. My

thinking in exploring other job opportunities with Michael was to help him restore the

sense of identity that comes with working. Furthermore, his being out of work was

contributing to his anxiety and fears about his future. I believed that his anxiety and

depression were adding to his perception of pain. Michael’s anxiety continued to cause

him sleepless nights. I suggested to him that he keep a journal and write about the

thoughts that kept him awake. We could then follow up on those thoughts as gatekeeper

voices in future sessions.

In early May Michael came in to an appointment upset and anxious, believing that

his Worker’s Compensation benefits were about to be denied. In the previous week, he

had talked to his attorney by phone. The attorney had told him that the urologist’s report

had come in and that it was unfavorable to Michael’s case. He also discovered his lawyer

had been diagnosed with cancer. Michael feared that his legal case was falling apart. He

told me that he had been losing sleep and that he was having suicidal thoughts again.

Michael presented a moderately high risk for acting on his suicidal thoughts. He

had made previous attempts. He had key symptoms of hopelessness, and anxiety. He

certainly had several contributing stressors with his high levels of pain, loss of work,

financial difficulties. His internal and external protective factors were low. He did have a

supportive partner who had intervened in previous suicide attempts. When asked,

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Michael stated that he did not have a plan for suicide. He did not possess a firearm.

However, he did have access to enough medications to overdose.

I decided the best way to intervene was to engage Michael in reflexive dialog. As

the voice of the friend, I helped Michael challenge his fear of losing his Workers

Compensation benefits. As the friend, I told him that I believed that the urologist’s report

was only a review of a portion of his case and should not affect his entire benefits. I had

previously been involved in writing reports for Social Security Disability and Workers

Compensation cases. From my previous experience, I was able to assure Michael that it is

common practice for multiple specialists to write medical reports. He had previously

received a favorable psychological report. I attempted to engage his own inner friend

voices to suspend his fears until more information could be obtained. By the end of the

session, Michael appeared to have been calmed. I asked him to make a commitment that

he would not hurt himself and that he would call me if his suicidal thoughts worsened.

Also on this evening, I offered to work with Michael more frequently on a weekly

basis rather than biweekly. I had been considering this for several weeks as I felt Michael

needed additional therapy. I told him I would see him on a pro bono basis for the weeks

that insurance did not cover. He seemed relieved by our work together, pleased by my

offer, and thanked me as he left.

The following week, Michael brought with him a copy of the urologist’s report.

We reviewed it together. While the report was not favorable to Michael’s case, the

recommendations the doctor made did not adversely affect his case. His rib injury was

not the focus of the report. Michael’s anxiousness over the report had diminished but he

was experiencing considerable pain in his side on this evening. I noticed that he was

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clutching a sofa pillow tight against his right side. When I asked him about it he said, “It

helps to have some pressure against my ribs to ease the pain.” His response reminded me

of how intense pain tightens and contracts muscles in order to immobilize painful areas.

“Would you like to try a relaxation technique?”

“I don’t know. What will I have to do?” Michael often answered my questions

with some hesitation. I managed to assure him that it would help. I guided him in some

deep breathing and asked him to imagine his body relaxing one area at a time, starting at

his feet. When we had scanned his entire body for relaxation, I had him turn his attention

to his painful side. I asked him to imagine if the pain had a shape, or a color, or a texture.

He had difficulty envisioning a shape.

“Can you sense the edges of where the pain stops?” I asked him to trace the area

with his finger. He traced an amorphous shape around the size of a grapefruit. He said he

imagined the color was red and the texture was smooth but hard. I asked him if could

describe the sensation of the pain. He said that it felt like burning sensation. I asked him

if it felt like the pain was always the same or if it was changing. He was not sure. I had

him continue to focus his attention on his side but to imagine that it was cooling and

relaxing. We did this for a few minutes then I asked him to gradually open his eyes. I

asked him if his pain was different from when we started. “It is still there but it’s not as

bad.”

I used Michael’s description of the pain as amorphous, red, and as a burning

sensation to explain to him the differences between acute and chronic pain. The feeling of

acute pain is often described as sharp, stabbing, or tearing. Cervero notes the feeling of

chronic pain is often described as burning, or shooting.3 I suggested to Michael that since

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he was experiencing a burning sensation that perhaps it was more of a chronic pain than

an acute pain.

“Does this mean it is all in my head? If it is in all in my head why can’t I do

anything about it?” Michael was concerned about his pain being primarily chronic. Even

though we had discussed some of the differences between acute and chronic pain before

he seemed fearful of the implications. I explained to Michael that chronic pain involves a

dysfunction of the nervous system and how it relays pain signals. I further explained that

chronic pain involved both biological mechanisms and psychological aspects to how it is

perceived. I told him that we could work with the psychological aspects to lessen his

experience of pain.

“Sounds like it might be difficult,” he said matter-of-factly. Michael’s resistance

was apparent, but he was still willing.

In mid June about six months after starting therapy, Michael informed me that his

insurance company was requesting him to do an invasive medical test to investigate for

hypoxia. Michael spoke about difficulty breathing especially after taking a walk. He

attributed this to the opiates he was taking. Michael started to tear up.

“Tell me about what you’re feeling right now. “

Michael paused for a moment and then said, “I am tired of going to doctors, just

to have them poke and prod me and then give me a bunch of tests. But most of all I’m

upset about how they don’t listen to me and then tell me they think I’m faking it. Do you

think I’m faking it?”

“I don’t think you’re faking it and I am going to do all I can to help you hurt less.”

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Each week I continued to do some guided relaxation techniques and deep

breathing exercises to help Michael manage his pain. He appeared to being making some

minor improvements in the amount of pain he was experiencing. I would often ask him to

rate the level of his pain on a scale of one to ten, with ten being the most amount of pain.

At first, he would rate his pain at an eight or nine. By mid June, he was reporting a pain

rating of six. When a crisis would arise, his pain assessment would rise back up to eight

or nine. It would take several weeks to bring the level of pain back down.

Crises seemed to happen often. In mid July, Michael came to his appointment

announcing that his medications had been cut off by the insurance company. His anxiety

was high, as he feared going through withdrawal symptoms. Michael’s fear was that he

would re-experience a withdrawal similar to the one that happened in the hospital in

2010, where he “blacked out” and became suicidal. Periodically, insurance adjusters

conduct a utilization review to determine the medical necessity of a medication or

procedure. In the utilization review, the adjuster has up to 14 days to make a decision.

During that time, the authorization for the payment for a medication can be delayed.

Michael was entering into such a period.

Michael’s medications cost several hundred dollars per month. He could not

afford to pay out of pocket for these medications. His fears of going through withdrawal

symptoms were a valid concern. We sat down together and talked through a plan to get

him through this crisis. First, I asked Michael to contact his doctors and psychiatrist to

see if they could provide him with samples to get him through the next couple of weeks. I

also asked Michael to inquire with his physicians as to what medications could be

rationed or titrated during this period. Next, I proposed to Michael that he could see if his

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medications were available as generics through a special low-rate medication program

available at a local pharmacy. This plan seemed to calm Michael’s anxiety.

In late July, seven months into this study, Michael was feeling good enough to go

on a camping trip in the high Sierras with his fiancé. Upon his return, he reported that he

had some challenges during his trip. He claimed that he was easily winded when going

for short day hikes. He also stated that he was experiencing more pain since his return. A

few weeks before his trip, he had some medical imaging done. He received the results

when he returned. The imaging showed that two ribs remain broken. This was

disappointing news to Michael. We finished this appointment by doing some guided

relaxation techniques.

Michael’s insurance conducted another utilization review on his medications in

early August, less than six weeks since the last one. Another pain client I had been

working with had been told by his attorney that insurance companies do this when they

are trying to force a settlement with a client. We reviewed our previous plan. Michael

experienced less anxiety as he realized that he was able to make it through the previous

utilization review.

Michael was also experiencing some stress in his home life. He told me that his

fiancé was asking him to help more around the house. He said that his pain and

medications zapped his energy. He had a difficult time completing home chores. I

suggested to Michael that he could get more done around the home if he was more

structured and disciplined with his time. In The Pain Survival Guide, Turk and Winter

suggest that a person pace oneself when attempting to recover mobility while still

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experiencing pain.4 I encouraged Michael to work on chores for a short while, then take a

break, and then return to chores, doing only what he could realistically do.

In late August, Michael received news that his mother’s lung cancer had

worsened. He was distressed that her death seemed imminent. However, he had also

received news that his own lungs were not in good shape. Medical testing results on his

hypoxia condition had arrived. His doctors prescribed oxygen to him and wanted him to

return for more testing on his heart. This raised his anxiety levels considerably. His

experience of pain increased as well.

Throughout September and October, we continued to focus his therapy on stress

reduction, sleep disturbance, and pain management. It seemed like each week he would

bring in more bad news from doctors, test results, or his mothers worsening condition. As

Michael’s therapist I was feeling overwhelmed. I could only imagine how much stress,

anxiety, fear and pain he was feeling.

Michael announced that a Workers Compensation hearing had been scheduled

late in November. In addition, his mother had been placed in hospice care. Michael’s

external stressors had been increasing in number and frequency since the beginning of

summer. I began to believe that he was not going to be able to make any progress with

therapy as long as the external stressors continued. Having the Workers Compensation

hearing scheduled gave me some hope that soon his medical treatment would not be

dictated by his insurance adjusters. I also, secretly hoped that his mother’s death would

not be long and drawn out.

Also during this same time, Michael had been attempting to convince his

psychiatrist to lower his Morphine Sulphate pain medication. He was working to develop

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more pain tolerance as the dosage was dropped. Another utilization review happened also

at this same time. Michael’s experience of pain increased with the decrease in Morphine

and with the additional stress of the utilization review. His reliance on breakthrough pain

medication escalated during this period. With the changes in medications, I asked

Michael if we could do a periodic review of all that he was taking. When I went over the

list of medications with him, I was surprised to see that his psychiatrist had placed him

back on an anti-psychotic.

The Workers Compensation hearing was postponed until after the first of the year.

Michael did however meet with his lawyers and received news that he had received an 86

percent whole person impairment rating. A rating above 71 indicates an acceptance by

the state of permanent disability. Michael was encouraged by this news. He anticipated

that his involvement with the Workers Compensation system would soon be over.

Eleven months into this study, Michael was hoping to return to driving. He had

dropped his pain medications by ten milligrams per month for four months straight. He

had restrained himself from driving because of the high amount of opiates that he was

taking. Now that he was on a lower dose, he was considering a return behind the wheel.

Michael had also been encouraged to attempt skiing again by his primary care physician.

However, with a return to both driving and skiing Michael was hesitant.

“What do you think is holding you back in trying to drive and ski again?”

“My primary concern is about my peripheral vision and reaction time. I feel real

slow.” Michael explained that peripheral vision and reaction time were important

functions to notice when he was a downhill ski racer. He was concerned that he might

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crash, reinjure himself, or get a DUI ticket driving. In attempting to strengthen the voice

of the friend, I asked him what he might be able to do to squelch these fears.

“I don’t know.” Michael was uncertain what to do. Quite often Michael seemed

caught in a paralyzing fog. In these moments, I felt paralyzed with him, unsure of what I

could say to break through to more clarity. I imagined that others might become

frustrated with him in his paralysis. Somehow, I managed not to go into frustrations with

him. I felt I understood this fog through my own experience with how pain can rob one of

decision-making abilities. I also remembered the fog of the opiates.

I suggested that if his doctor was encouraging him to try skiing that he start with

that. I suggested to Michael that he could start slowly with skiing and see what he could

do comfortably. I also suggested that skiing would be a great place to find out how well

he is doing with peripheral vision and reaction time. I thought this would be a great

activity to help Michael rebuild some of his self-confidence.

On his next visit in mid December, Michael presented some anxiety about

renewing his EMT license. He had kept it current since his injury in hopes that he could

return to work. Two years had passed since it was last renewed. It did not seem realistic

to me that Michael would return to being and EMT. This kind of work struck me as a

younger, able-bodied, man’s profession. There was also a considerable cost to renewing

his license. Michael wanted to know my opinion as to whether he should keep his EMT

license. I was reluctant to answer him directly.

“What would it mean to you to return to being an EMT?”

Michael looked at me with a great bewilderment as if faced with a complex

algebra problem. “I don’t know. I don’t know what else to do anymore.” We explored

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how work and a sense of self are interrelated, how identity is influenced by our work life.

Our time was drawing to a close for this session. We would have to resume this topic

after the winter holiday break in the beginning of the New Year.

Over the holidays, Michael had been having a lot of anxiety about his upcoming

Workers Compensation settlement, his mother dying, his relationship, and his ongoing

pain. When we met again in early January, it had been almost a year since our first

session. I was interested in taking a new approach with Michael. While my focus was on

his chronic pain, Michael kept bringing in extreme levels of anxiety. I knew anxiety and

depression played a major part in increasing pain perception. I was now interested in

changing the primary focus to working with his anxiety to see how it might affect his

experience of pain. I introduced Michael to affect theory and the concept of transmuting

negative affects into capacities. Omer spoke of transmuting the affects of anger into

fierceness, fear into courage, shame into dignity, and grief into compassion.5 Michael’s

anxiety represented fear about his future. I wanted to instill in Michael a sense of courage

to counter his anxiety. I knew that transmuting affects into capacities took considerable

time, but I felt the need to start the process. I had been thinking about how to introduce

these concepts to Michael over the winter break.

I started by asking Michael about his memory of his father’s death at age six. He

had told me this before. Now I was thinking of a beneficial way to mirror it back to him.

Michael stated what he remembered of the day that his father died. He was outside

playing in his front yard when a number of fire trucks and ambulances roared up in front

of his house. A number of men jumped off the trucks and ran inside to see what they

could do to help his father. I was curious to see if Michael could make any connections

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between this event and his later becoming a firefighter and EMT. I told him that I

imagined that he must have felt hopeless, powerless, or out of control the day his father

died. He agreed. I told him that the firefighters and EMTs must have seemed like they

knew what they were doing in those moments. He also agreed. I asked him if when he

became a firefighter and EMT what it felt like when he was faced with dangerous

situations. He recounted several examples when he witnessed severe trauma to others. I

mirrored to him, “Yet when others might turn away in fear, you helped those people. That

must have taken courage.” Michael took this in and paused. “But, I don’t feel like I have

courage anymore,” he responded.

“Do you think courage is purely a physical trait?”

“I don’t guess so,” he responded with a puzzled look on his face. I challenged

Michael to consider that his fear and anxiety could be met with courage.

“That might be hard,” he said with despondency. His resistance seemed

entrenched. Time was up for this session.

When Michael returned in late January, he brought the news that his mother had

died and his Workers Compensation case had settled. He had been with his mother at the

time of her death. He described her difficulty breathing after she had fallen into a coma.

He was having nightmares about the difficult images he witnessed during her death. He

talked about having to help the hospice worker move his mother’s body when she died.

“When I was lifting her, this black tarry goo came out of her mouth. I can’t get it

out of my mind. I hope you don’t smoke. My mom smoked a lot. I am pretty sure this

was from the smoking. Don’t ever smoke, 'cause this was truly horrible to see.” In the

process of lifting her Michael broke his rib again. I had thought Michael might have some

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relief from stressors when his mother died and his Workers Compensation case settled. I

was wrong.

The Workers Compensation settlement was disappointing for Michael. His final

whole person impairment rating was 79 percent. This gave him a permanent disability

status. The total award of the settlement was to be paid out over twenty years at a rate of

$800 per month. Michael would receive ongoing medical coverage, but it would be

distributed and monitored by the Workers Compensation system. Michael had hoped for

a larger direct cash settlement that he could use towards paying previous medical bills

and having a greater say in his medical treatment.

In February, Michael returned to skiing. He and fiancé spent a day on the slopes.

He reported that he was not aware of any increased pain while skiing but the next day he

was feeling it. He said he felt unstable and weak while skiing. I suggested to him that the

increased pain the next day might be expected as any strenuous exercise might increase

soreness the next day. He was open to this interpretation. I encouraged him to try again.

In our next session, Michael in the first time in our work together showed some

interest in a possible job opportunity. He had talked to some friends in a nearby town

who were thinking of opening a business offering hyperbaric oxygen treatment. This

interested Michael. To operate such a business one needed to have some form of medical

training and licensing. Michael thought he might be able to renew his EMT license and

participate in this business. The work was not strenuous and could be done part time. I

was glad to see his interest engaged.

As March rolled around Michael had reinjured his rib doing gardening chores at

home. He was once again experiencing a great amount of pain. At this point, I wished to

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pursue another approach. I introduced Michael to Wolpe’s systematic desensitization

technique similar to how Fordyce taught it.6 I began with a guided relaxation. In this

relaxed state, I asked Michael to imagine doing an exercise that his physical therapists

had taught him. While imaging doing this exercise I asked Michael to observe his levels

of pain. After a few minutes, I guided Michael in more relaxation. When he opened his

eyes following the relaxation I asked him to tell me what he observed with his pain. He

told me the pain had increased while he was imaging the physical therapy exercises. The

pain decreased when he went back into relaxation. This may have been the first tangible

experience where Michael realized how much of his pain was affected by psychological

factors. We had talked a lot about the psychological aspects of chronic pain, but Michael

was not convinced until we tried this technique and he could experience how much his

imagination affected his pain.

When he returned the following week, he was concerned again about the pain

being “all in his head.” He wondered, if this were so why he could not will his pain away.

To explain this I asked him to consider his heart rate and blood pressure. I asked him to

consider that it is known that anxiety and depression affects heart rate and blood pressure.

Yet knowing this does not allow us to directly lower them with will. I gave to him

examples of very skilled individuals that can do this, but I emphasized that they had to

spend much time training to accomplish this feat. I suggested to him that distraction and

relaxation techniques could give him some ability to change his perception of pain but

that he needed to practice these methods regularly.

In April Michael had injured his rib again. This time he became desperate and

consulted a doctor about having another rib amputation or a permanent nerve ablation.

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His doctor discouraged Michael from further surgeries for pain. I told Michael that I had

to agree with his doctor. Permanent nerve ablations were problematic at best, and rarely

permanent. The news that Michael was considering further rib amputations and nerve

ablations was very disturbing to me. In part, I was disturbed that Michael was

contemplating procedures that had not worked for him in the past. It was also disturbing

to feel the desperation he must have been feeling. Mostly, I was disturbed that Michael

was having difficulty with the acceptance of his condition.

Several sources had spoken of the need for acceptance in the healing process.

Remen stated, “Acceptance is what allows change.” 7 Jackson stated, “To claim, accept,

and identify with it (pain) – paradoxically, just as in martial arts tell of incorporating the

enemy – was to control the pain better than if one were to construct barricades against

it.” 8 Michael was not accepting of his pain. I wanted to know why.

In mid May, I asked Michael about where he was in relation to acceptance of his

pain condition. He told me that just could not come to accept his pain. When I inquired

more thoroughly, Michael stated accepting his pain was to accept being completely

disabled and to give up on all of his dreams of fulfillment. I challenged this belief. I

asked Michael to consider that he was linking his pain with giving up on his dreams. I

suggested to him that his pain and his dreams were separate items. He could learn to

adapt to living with certain levels of pain and keep his dreams. The word “adapt” elicited

some reflection in Michael. He once had started two non-profit companies teaching

disabled children how to ski. The companies specialized in “Adaptive Skills Training”. I

urged Michael to learn to adapt to his pain condition.

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As therapy continued into late May 2013, almost a year and a half into my work

with Michael, I was struggling to find a way to introduce him to dialoguing with his pain,

and befriending his pain, two items I felt were important in his therapy plan. After talking

to Susan about these struggles, she suggested looking into the Focusing work of Eugene

Gendlin. In Focusing, I found a frame that could help with both dialoging and befriending

pain. Although chronic pain is not specifically mentioned in Gendlin’s book, he provides

a method for dialoging with a “felt sense” to connect with the body’s wisdom.9

I used an outline of the Focusing method as described by Ann Cornell.10 As I

asked Michael to focus on his pain, he described a felt sense of a spasm in the area of his

right rib cage. I asked him to check to see if the word “spasm” was the right word to

describe the sensation. He said that “cramping” was more correct. As he focused on the

felt sense, he changed the descriptive word again to “tightness”. I asked him to say hello

to the tightness and to acknowledge that it was there. I asked Michael to imagine that he

was talking to the tightness. “What would it say?” I asked. Michael paused for a moment

and said, “I don’t know.” I asked him to take his time and wait for an answer. After a

couple of minutes of waiting he said, “It is trying to protect me.” He looked at me with a

puzzled surprised stare.

“What is it trying to protect you from?”

“From further injury?”

“Good!” I responded, “It is trying to protect you. Can you see that this felt sense

is trying to be a friend by protecting you? Isn’t that what a friend would do?”

Michael took a moment to take this in and then said, “Now that I know that, why

doesn’t it stop.”

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“Maybe it is trying to tell you something more.”

Michael was gradually accepting that his pain could be befriended. This was a big

step for him to realize. He was starting to see a way to use his pain, rather than try to push

it away.

As this section of writing concludes, I am still doing weekly therapy with

Michael. His treatment plan has been derailed by periodic attention to crisis, and more

time spent toward working with his anxiety than was expected. At this point, he seems

poised to accept his pain and adapt to his condition. Much of his treatment plan still

needs to be addressed. He has made some good progress in dealing with anxiety and

cutting back on his pain medications.

Legal and Ethical Issues

During the course of Michael’s treatment, several ethical legal and challenges

arose. These challenges took the form of suicidal thinking, his involvement with a

Worker’s Compensation lawsuit, and our pro bono arrangement.

Chronic pain patients commonly suffer a greater rate of depression than the

general population. As one might expect higher rates of suicidal ideation are also

common in the chronic pain population. Care for a client’s safety is both a legal and

ethical concern. Michael came into therapy with three previous suicide attempts. In May

2012, four months into this study, Michael acknowledged that he was having suicidal

thoughts. While he met several suicidal risk factors, with few protective factors, he

conveyed no intent and voiced no plans for suicide. He agreed to make a commitment to

not hurt himself and to contact me if his suicidal thoughts intensified.

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Michael was involved in a lawsuit with his Worker’s Compensation Insurance

carrier prior to starting treatment. The lawsuit continued through the majority of

treatment until a settlement was reached in January 2013. This lawsuit offered several

legal and ethical challenges to treatment. One of the ethical challenges was the possibility

of being called to testify. Testifying at a court proceeding concerning a client’s treatment

creates the risk of disclosing confidential information. However, there is also a risk in

compromising the therapeutic relationship. Both of these possibilities were avoided as the

case settled without the need for my testimony.

The lawsuit involvement with his Worker’s Compensation insurance carrier made

me witness to ethical abuses of his insurance company. Treatment denials, treatment

delays, and the utilization review process appear to be common ethical abuses that are

employed by the insurance companies. The utilization review process is particularly

disturbing in that clients can be denied prescription refills of pain medications for up to a

14-day period. The process ignores the dangerous potentials of medication withdrawal.

Also disturbing, the insurance companies can dictate the course of treatment through the

utilization review process. The net result is the client loses control of their say in medical

care, and as an extension control of their body.

I worked with Michael on a partial pro bono basis for the majority of the time we

worked together. He had been approved for one session per month by his insurance. I saw

him weekly. As previously discussed, working on a pro bono basis carries with it ethical

risks as the client may become overly dependent on the therapist, or the therapist may

become resentful of the client receiving benefit of treatment without paying. Michael

maintained a respect for receiving pro bono treatment and periodically inquired about

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how long pro bono treatment would continue. He never presented as overly dependent on

me as his therapist.

Outcomes

During the course of treatment with Michael, we addressed many of the concerns

that were outlined in his treatment plan. We explored Michael’s history and life

experiences in relation to pain, depression, and anxiety. I educated Michael about the

about the complexity of chronic pain and taught him the differences between acute and

chronic pain, and between curing, healing, and pain management. I also taught Michael

relaxation and distraction techniques to work through intense periods of pain.

While Michael reported both improvements in mood, and a decrease in the

perception of pain, he still had a long way to go in his treatment. At the time of this

writing Michael was making steps towards becoming more active. At my suggestion, he

signed up for a Tai Chi class at the local martial arts school. In the early spring of 2013,

he had successfully returned to skiing as a physical form of enjoyment. He also

purchased an indoor exercise bicycle, so he could participate in aerobic activity more

often. Michael also became interested in pursuing craft hobbies of tying fishing flies, and

small boat building. These activities gave him some hope in regaining an additional

means of income in the future.

Michael also started keeping a pain journal to help with self-monitoring of his

symptoms. He gradually started to build an acceptance of his pain. The concept of

befriending pain was still difficult for him, but he was making progress in this area.

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CHAPTER 4

LEARNINGS

Introduction

This chapter discusses the process of meaning making of what happened during

the course of treatment with Michael. Meaning-making or interpretive processes often

happen in an intuitive fashion. This chapter aims at breaking down the intuitive process

to ground the meaning making in theory and mythic story. Meaning making is

contextualized in theory by examining key concepts and major principles related to my

client’s personal experience with chronic pain. Myth provides an underlying framework

in which to base interpretation of both the therapy journey, and the supporting theories,

involved in the meaning making of Michael’s story.

The process of meaning making involves examining what happened; discussing

how I was affected by my client’s story; and developing meanings about my client’s

imaginal structures. These three steps of meaning-making process are supported by

noticing which of my imaginal structures were activated during therapy work with

Michael, and what I have learned about myself during this therapy journey.

Key Concepts and Major Principles

There are many psychological concepts that could describe, explain or play a part

in Michael’s progress in therapy. Below are listed a few of the most important concepts

related to the focus of this clinical case study. The first concept offered here is that

chronic pain is often seen as a psychosomatic condition. This term literally means mind

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and body. The term presents a problem to both professionals and patients. In common

usage the term has come to mean a physical condition that is “not real”, or “all in your

head”. Michael’s understanding of this term lead to resistance. He experienced his pain as

only physical. He had good reason to view things this way. He had a chronic pain

condition that was related to a physical injury. In addition, the physical injury had not

healed and he had several occurrences of ribs re-breaking, resulting in confusion between

chronic and acute pain.

Since the term psychosomatic has become problematic, another way to understand

the experience of chronic pain is through the term liminal. The principle that best

describes the liminal state of chronic pain comes from Jackson when she states, “Pain

straddles the object/subject boundary.” 1 When pain is viewed in an objective way, we

connect with its aversive nature. It becomes something to get rid of. It becomes the

enemy. However, the subtitle of this clinical case study is about “living with chronic

pain.” How is it possible to live with something that we are continually trying to rid

ourselves of, and view as an enemy?

A major principle from the biological perspective, and the International

Association for the Study of Pain, holds “Pain is always subjective.” 2 As pain is

subjective, the experience of it can be altered towards tolerance and familiarity. In order

for this to happen, Michael first had to be able to experience a separation between his

pain and his injury. This was facilitated with Wolpe’s concept of systematic

desensitization. Once this occurred, Michael could see that pain could be affected

psychologically. However, learning how to live with chronic pain was still a distant

proposition to Michael.

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Michael held a resistance to accepting his pain as being subjective. In Imaginal

approaches to psychotherapy, resistance is conceptualized as gatekeeping. Omer states,

“We conceptualize gatekeepers and gatekeeping as the ways that experience is

restricted….What is the opposite of restricting experience? Expanding the experience.” 3

The focus of the therapist working in imaginal approaches to psychology is toward

healing, restoring imagination and soul. Restoring imagination and soul relies on three

basic principles of Imaginal Process. Omer articulates these principles as, “1) Soul longs

for experience; 2) Transformation happens when we are able to have the experience that

the soul requires; 3) When transformation happens, identity shifts, doors we couldn’t see

appear, possibilities we could not imagine become readily available.” 4

The concept of the four dynamisms (diversifying, deepening, personalizing, and

embodying) have been offered by Omer as a means of exploring and expanding

experience. Expanding Michael’s experience through the four dynamisms offered a way

to both validate his experience of pain as real and to ask him to consider changing his

understanding of living with pain so that it could be tolerated and accepted.

A principle offered by Remen is, “Acceptance is what allows change.” 5 The

concept of acceptance is complex. Accepting chronic pain as part of daily life is a

difficult agreement to make. It can trigger resistance in some, and others view it as

paradoxical. Remen also spoke of healing as a natural process that come out of the

integrity of relationship between people.6 Healing is learning to live with chronic pain.

Once pain is accepted, one can turn toward changing the subjective experience of

it. If it is no longer viewed as an enemy then it can become an ally. The concept of

befriending pain involves turning ones attention toward it, not to rid oneself of it, but to

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learn to listen to it. Befriending pain expands ones experience by involving the four

dynamisms, especially personalizing, and embodying. Biro calls this way of

conceptualizing pain a projection metaphor. Projection metaphors blur the boundaries

between internal and external. As pain is personified, it makes it more responsive.7

What Happened

From the very start of treatment with Michael, he was concerned with being

labeled with a psychosomatic disorder. To Michael this label suggested that others

believed his pain was not real. For him, the pain was very real. He could locate it in his

body, and had the medical evidence of his injury. He too, had already experienced the

stigma of the psychosomatic label. His medical doctors became suspicious and

unresponsive to his complaints of pain. In addition, his workers compensation claims

adjuster had shown suspicion by denying and limiting treatment choices.

He was desperate to try anything that would rid pain from his body. In fact, by

the time he had started seeing me he had already tried a myriad of medical interventions.

Some of these interventions had worked, but only for short periods. Having experienced

intense sensations of chronic pain for several years, he was very aware of the need to talk

to someone about his feelings of irritability, depression and anxiety.

At our very first session, Michael appeared to feel positively toward me. He

trusted me enough to show his vulnerability to the point of showing tears during that first

session. He expressed this vulnerability often during our work together. Our therapeutic

relationship was almost always easy. At times, this caused me to question Michael’s

ability to express anger and disagreement. He assured me, especially with his fiancé, he

was capable of expressing anger and disagreement.

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In my explorations of my countertransference, I asked myself, “Who from my

past does Michael remind me of?” The answer that came was that he reminded me of my

uncle, my father’s twin brother, who died when I was ten years old. This was a favorite

uncle. By his early forties, he had developed several complications from diabetes. Like

Michael, he spent many years experiencing the intense pain of his medical condition. My

uncle was a sweet and caring man. Undoubtedly, this countertransference contributed the

favorable impression Michael left on me.

The initial stages of treatment centered around informing him of treatment

strategies and working with his sense of crisis and anxiety over pain medications, lack of

sleep, insurance company interactions, medical testing, reinjury, financial problems,

relationship stressors, intense pain, and his fears of not being able to work again. This

initial work included informing Michael about the complexities of a chronic pain

condition. Because of Michael’s training as an EMT and firefighter, his beliefs about pain

were very much influenced by the medical model. I found it helpful, in working with

Michael, to be able to reveal to him the latest advancements in pain research from the

biological perspective. Telling him about Melzack and Wall’s Gate Theory of Pain, and

Melzack’s Neuromatrix Pain Theory helped him understand the psychological aspects of

pain from a medical model perspective. Similarly, helping to distinguish between acute

and chronic pain helped in easing some of his anxiety about his pain.

Knowing about chronic pain from the Biological perspective does not necessarily

help one change the experience of pain. The cognitive/behavioral perspective on chronic

pain does however, offer several tools for altering the experience. Relaxation techniques,

distraction techniques, and the use of imagery and imagination are all useful tools that

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gave Michael some relief when he was experiencing intense pain. We used these tools

often in our initial sessions. However, the relief was often short lived.

A key moment occurred when I used another cognitive/behavioral technique,

Wolpe’s systematic desensitization. Following the way Fordyce used this tool, Michael

was able to find a separation between his experience of pain and his injury. Using an

imagined activity of exercising, and tracking his levels of pain, Michael was able to

realize that his sense of pain was influenced by his imagination and his psychological

state.

Despite the breakthrough of separating pain from injury, Michael came in the next

week saying, “Does this mean my pain is all in my head? If it is, why can’t I do anything

about it?” In subsequent weeks, Michael reinjured his ribs and his pain once again

became unbearable. Even though he had had an experience of separating the sensation of

pain from injury, he was, understandably, still seeking to rid himself of pain. Accepting

pain and learning to live with it was still a radical idea to him. Michael was actively

resisting acceptance of his pain.

Recognizing Michael’s resistance as gatekeeping voices, I worked periodically

with him to understand the personal, cultural, and archetypal aspects to the underlying

imaginal structures. Primarily, I saw Michael’s resistance as avoiding acceptance. Our

goals were different. Michael’s goal was to be free of pain. My goal was to help Michael

learn to live with pain. Bridging such a chasm, without denying Michael’s experience

was a difficult task. Working with Michael’s imaginal structures allowed me to challenge

his perceptions by helping him become aware of not only how others had negated his

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experience, but also how his own perceptions and beliefs were limiting his understanding

of his own experience.

A critical event in our work together occurred in May of 2013 when I introduced

Michael to the Focusing work of Eugene Gendlin. In dialoguing with his pain, Michael

was able to have a shift in his perception of pain. He was able to identify a basic message

from his pain when he repeated what he heard it say, “It is trying to protect me…from

further injury?” In that moment, Michael was able to grasp the concept that pain is

necessary. He understood that with some more work he could learn to understand it

better. The idea of acceptance became clearer for him. Befriending pain was becoming a

possibility.

Imaginal Structures

How I was Affected

For the majority of the time I was working with Michael I was enjoying the

learning process. One reason that I choose the topic of chronic pain for this clinical case

study was because there was so much conflicting and confusing information on the

subject. I wanted to know more about how to best work with chronic pain patients. The

idea that I would be engaged in continual learning throughout the clinical case study

brought interest and excitement to my work. Being able to reflect what I was learning to

Michael created a sense of purpose, a sense that I could have a positive influence on his

day-to-day living.

In addition to the interest and excitement of being engaged in a helping way with

a complex and difficult topic, I quickly discovered a sensation of being overwhelmed. In

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addition to Michael’s presentation of chronic pain, he also displayed symptoms of

depression, anxiety, irritability, lethargy, dependence on pain medications, opiate

withdrawal, and an inability to work, or drive, or completely care for himself. The feeling

of overwhelm transitioned into outrage as I witnessed the ethical abuses of the Worker’s

Compensation system denying him the proper care that he needed.

At times, I felt helpless in knowing how to assist in improving Michael’s

condition. Feelings of despair and self-doubt were also often present when working with

Michael. I sought to minimize these feelings by being a disciplined scholar, attempting to

replace the despair and self-doubt with intelligence and competence. Occasionally, I

would catch myself and remember to listen to Michael, and let him know that I was

empathizing with what I imagined he was feeling.

My Imaginal Structures

Examining one’s imaginal structures in relation to the work with a client is

essential to uncovering biases and blind spots that can lead to misunderstandings of the

client’s unfolding story. Many imaginal structures might become activated during the

course of treatment. The following paragraphs outline a few of my imaginal structures

that were activated while working with Michael. I have given names to each of these

imaginal structures to help distinguish their effect on treatment. This section explores my

imaginal structures of the Scholar, the Hermit, the Champion of the Underdog, and the

Wounded Healer.

My imaginal structure of the Scholar has a personal origin in relation to being

raised by parents who were very committed to the benefits of education. At times, I

rebelled against the authoritative positioning of this character, but also realized some of

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its advantages. This imaginal structure made itself known when I was working with

Michael by my relying on studying and literary research to counter the feelings of

overwhelm and incompetence that arose in me during the course of his treatment. The

intellectual nature of this imaginal structure finds ways of coping with the presentation of

depression and despair by providing helpful, albeit disconnected, information. Present

day dominant cultural influences appear to validate this type of imaginal structure making

it difficult to fully recognize it as problematic. The most problematic aspect of the

Scholar is its authoritarian presentation. It colludes with the arrogance of

professionalism. In addition, the arrogance of professionalism may be one of the biggest

obstacles to physicians and therapists alike when working in the field of chronic pain.

The major miss of the Scholar is the need to make a strong empathetic connection with

the pain patient.

My imaginal structure of the Hermit has to do with being at a time in my life

when I am seeking quiet and solitude. I currently live alone in a secluded home on a

forested hillside. The Hermit character of the Tarot overlooks a barren landscape holding

a lantern to illuminate the dark. A retreat into solitude gives one a chance to reflect,

analyze, and finding meaning and purpose. In relation to my work with Michael the

awareness of the imaginal structure of the Hermit was activated by the realization that he

too lives in relative isolation and solitude. Although his fiancé lives with him, she is gone

much of the day at work leaving Michael alone at home. While my solitude has been

chosen, Michael’s has not. Isolation and seclusion can be helpful in personal growth

work, but to be alone without choice can create feelings of abandonment, and limit

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potential for development. While the Scholar creates misses to empathic contact, the

Hermit avoids contact altogether.

My imaginal structure of the Champion of the Underdog most likely is the result

of multigenerational family impoverishment. Both my maternal and paternal family

lineages came from Icelandic emigrants who settled in small farming communities in the

northern mid-west. Both my parents were born during depression-era years. Out of this

experience, both parents instilled in me the values of helping others less fortunate than

myself. Through this lens, I became aware of the injustices of powerful organizations

taking advantage of less fortunate individuals. When I started working as a therapist, I

became aware of some of the cultural, institutional, and bureaucratic biases that affected

the resources available to those suffering. Seeing patients with chronic pain has helped

me realize that psychologists can make a difference both in their treatment and in

advocating for their rights in seeking a standard of care for our clients.

My imaginal structure of the Wounded Healer comes from my own experiences

with chronic pain. As I described in Chapter 1 I received an arm injury that left me in

chronic pain for several years. My experience with this wound has created an opening for

empathic relationship with my chronic pain clients. The imaginal structure of the

Wounded Healer, in my mind, also incorporates aspects of the initiate and the shaman. In

relation to Michael’s treatment, I have often reflected on both of us being initiates. I see

myself as being an initiate into the deeper mysteries of becoming a shaman/psychologist.

With Michael, I see him as being initiated into becoming an elder, learning to live more

wisely in an aging body.

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The Client’s Imaginal Structures

While examining the therapist’s own imaginal structures reveal biases and blind

spots, examining the client’s imaginal structures help reveal their larger story. In my

work with Michael, I attempted to help him understand some of the personal, cultural,

and archetypal aspects to the imaginal structures behind his gatekeeping voices. The

names that I have given to Michael’s imaginal structures include the Medic, the

Outdoorsman, the Invalid, and the Hero.

Perhaps the most significant event of Michael’s early life was the death of his

father. When Michael was only six years old, his father had been in a multiple vehicle

accident and suffered a brain injury. A vivid image from his memories of his father’s

death involved Michael playing in the front yard of his home. He sees ambulances and

fire trucks stopping in front of his house. Emergency personnel emerge from their

vehicles and run into his house. I believe these memories contribute to Michael’s

imaginal structure of the Medic. Michael’s vivid memories of ambulance attendants and

firefighters taking control in a terrifying life event forms a basis for this imaginal

structure and perhaps his future choices around occupation, as a firefighter and EMT. At

the core of this imaginal structure are Michael’s needs and perceptions around control

and his steadfast reliance on the medical model to dictate the reality of his experience

with pain.

The recall of his father’s death stirred up feelings of grief and fear. Michael had

felt like he had lost control over his medical treatment, his body, and his livelihood. The

imaginal structure of the Medic had served Michael’s early life well. He was able to stay

calm and controlled when witnessing horrific accidents and injuries. He was also able to

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recover quickly from his own injuries sustained in his early 20’s. His emergency medical

training provided him a notion of what to expect when recovering from injury. It is only

when his rib injury fails to follow the expected route of recovery that Michael is

challenged in aspects of his identity that rely on the imaginal structure of the Medic.

Another imaginal structure activated within Michael during treatment is that of

the Outdoorsman. Key features of Michael’s Outdoorsman imaginal structure include his

past experiences of physical toughness, and self-reliance. Part of Michael’s identification

as the Outdoorsman start when he develops his athletic abilities as a teenager, and

becomes a member of the U.S. Ski Team. His frequent experiences in his teens and early

20’s of camping in the high Sierras, fishing, and hunting strengthen his identification

with self-reliance. Similar to the Medic, the Outdoorsman imaginal structure is

challenged when Michael’s injury affects his sense of self-reliance and physical

toughness. As these imaginal structures fail to meet the needs of his condition, Michael’s

sense of dependence, self-doubt, and victimization develop.

Michael’s Invalid imaginal structure contained elements of his identification with

his disabilities. This side of him identified with the chronic pain, the inability to work, the

loss of friendships, and the barrenness and poverty of imagination that comes with an

almost complete focus on physical pain. Another aspect of this imaginal structure is the

in-validation that Michael has received from cultural gatekeepers, doctors and insurance

systems, which believes his pain is “not real”. This in-validation has left him in a state of

self-doubt, hot knowing whom to turn to, or who to trust in helping him heal from his

pain. There is an aspect of this imaginal structure that also in-validates his own

experience.

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Another of Michael’s imaginal structures is that of the Hero. There are facets of

the Hero that are present in both the Medic and the Outdoorsman. The imaginal structure

of the Hero merits special mention as the Hero’s journey incorporates themes of

initiation and transformation that are not necessarily present in either the Medic or the

Outdoorsman. The Hero’s journey often includes a test of courage, resistance to physical

suffering, a transformation, and the return.8 Once the journey is complete, the Hero no

longer fears death. Michael’s anxiety over his pain could be seen as an existential fear to

be overcome. I find it fascinating that Michael’s injury is to his rib cage, a cage that

protects his lungs and heart, his inspiration and courage. His test of courage is to endure

physical suffering to the part of the body that protects his heart. The word courage comes

from Latin origins that mean “heart”. Michael has always struck me as a man with a big

heart. The deeper meanings to his test of courage may include finding new ways to

protect his heart. The imaginal structure of the Hero offers some hope that Michael will

find new meanings in his suffering, but perhaps not in the ways that he expects them.

New Learnings About My Imaginal Structures

Each of my imaginal structures that I have described above, the Scholar, the

Hermit, the Champion of the Underdog, and the Wounded Healer have evolved through

reflection on Michael’s therapy. The following paragraphs outline some of the ways each

has changed.

The imaginal structure of the Scholar’s defensive position is to distance himself

from overwhelming emotion by relying on intellect and information. This creates an

inequality in the therapeutic relationship. Michael Balint states, “The more the analyst’s

technique and behavior are suggestive of omniscience and omnipotence, the greater is the

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danger of a malignant form of regression. On the other hand, the more the analyst can

reduce the inequality between his patient and himself, and the more unobtrusive and

ordinary he can remain… the better are the chances of a benign form of regression.” 9 As

the Scholar evolves into a learned practitioner, the timely provision of helpful

information is balanced with empathic connection.

The imaginal structure of the Hermit romanticizes the experiences of solitude and

reflection. The downside to this romanticizing is that isolation and social withdrawal can

lead to the exacerbation of chronic pain. The barrenness of this isolation can lead to a

poverty of imagination and a loss of soul. This imaginal structure’s evolution involves

taking the insight and knowledge that I have gained back into a larger social context.

While my own imaginal structure of the Hermit seems appropriate for me at present, it is

not appropriate for Michael.

What I have learned about the Champion of the Underdog imaginal structure is

that this particular lens provides a good empathic alignment with the client, but may have

its shortcomings when it comes to confronting patterns of victimhood. The imaginal

structure of the Wounded Healer perhaps offers the best viewpoint to balance the

providing of information, empathy, compassion, and creating a container to hold strong

emotion.

Primary Myth

The primary mythic story that I have chosen to contextualize Michael’s

therapeutic journey is the poem The Wasteland by T.S. Eliot. I chose this poem as the

primary myth initially because of its title. Wastelands are barren infertile places that are

unsuitable for long-term human occupation. The wasteland is metaphoric and

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representational of how chronic pain can render one’s body as barren, desolate, and

difficult to occupy. The word wasteland is synonymous with the words badlands,

wilderness, desert, and borderland. Any area that can be seen as vast and empty can meet

the criteria of a wasteland. The word borderland seems a particularly appropriate

wasteland term to use as a metaphor for chronic pain. Natural borders of deserts, oceans,

seas, rivers, frozen tundra, and dense forests and jungles all serve as divisive areas

between occupied lands. In the case of chronic pain, one interpretation of the wasteland

metaphor can be seen as the borderland between mind and body. The experience of

chronic pain is not wholly in either mind or body. It clearly occupies both, and perhaps

more clearly occupies the space in-between.

The Waste Land poem is long, complex, and on its surface not easily understood.

It is divided into five parts plus its beginning epigraph, and ending notes. The first section

is entitled “The Burial of the Dead”, which is followed by “A Game of Chess”, “The Fire

Sermon”, “Death by Water”, and “What the Thunder Said”. The poem reflects a tone of

alienation and loss, pain, and despair.

In his endnotes for the poem, Eliot states that the title, plan and symbolism of the

poem were inspired by Jessie Weston’s Grail legend book, From Ritual to Romance.

Weston’s book examines several versions of the Grail legend searching for the origins of

the story and significance of the similarities and differences between the variations of the

story. The Grail legend is an initiation story, where the Wasteland is restored when the

hero protagonist asks the healing question to the wounded Fisher King. Weston

references the connection between pain and the wasteland with a description as the

“…land laid waste as the result of a dolorous stroke.” 10

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Weston’s examination of Grail legends finds him tracing the origins of the story

through Celtic folklore to the Persian fertility rituals of Mithra. Weston cites three

versions of the Grail story where the 1000-year curse of the wastelands begins with an

evil act of King Amangons and his Knights who violated and stole the golden cups of the

fair maidens of the hills. “As a result the springs dried up, the land became waste, and the

court of the Rich Fisher, which had filled the land with plenty, could no longer be found.”

11 Weston further connects the curse of the wastelands to the cessation of ancient

vegetation rituals performed by the followers of Mithra in the hills and mountains of

Wales. The cessation of nature rites represents the disconnect of man from nature, and

man from his own nature, his body. My clinical case study subject, Michael, has

sustained, through his chronic pain, such a disconnect between mind and body. “I was

neither living nor dead, and I knew nothing,” is a phrase in the opening section of the

poem. This phrase describes the state of existence one experiences when chronic pain has

drawn all attention toward it.

Eliot’s poem includes many references; James Frazer’s The Golden Bough,

Dante’s Inferno and Purgatorio, John Webster’s White Devil, John Milton’s Paradise

Lost, Ovid’s Metamorphoses, William Shakespeare’s The Tempest, Virgil’s Aeneid, St.

Augustine’s Confessions, the Buddha’s Fire Sermon, and the books of Ezekiel and

Ecclesiastes from the Bible. Eliot finds references to wastelands in all these sources.

Throughout his poem Eliot alludes to wasteland images of the sea, a winter scene in

Germany, a dry stony desert, the “rat’s alley” trenches of World War I, the jungle, the

near biologically dead river Thames in the 1920’s, and the concrete jungle of London. He

appears to find a wasteland everywhere.

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Eliot is considered a modernist. However, his The Waste Land poem has many

elements that would classify it as post-modern. The poem is fragmented borrowing

passages, images, and symbols from many modern and classical sources. Line 23 appears

to be self-referencing of the poem’s fragmentation as, “A heap of broken images.” There

is no single speaker in the poem. However, Eliot notes that Tiresias is “the most

important personage in the poem uniting all the rest”. In this statement, we can assume

that Eliot’s intention is to bring awareness to multiplicity of character within a single

person.

Tiresias is the blind oracle of Greek mythology that is both male and female. He

is one of three oracles mentioned in the poem. The other oracles are Sibyl at Cumae in

the epigraph, and Madame Sosostris, “the famous clairvoyant, the wisest woman in

Europe, with a wicked pack of cards.” 12 In the epigraph, Sibyl at Cumae wants to die.

She is the prophetess that Apollo has given eternal life, but has withheld eternal youth.

She withers away until her voice, kept in a jar, is all that is left. My client, Michael, had

also reached a point of despair from his pain that he voiced a wish to die.

Patrick Trapp, in his essay, Tiresias and other seers in T.S. Eliot’s “The Waste

Land”, believes Eliot took the character of Madame Sosostris from Aldous Huxley’s

Crome Yellow. In Huxley’s book, Madame Sosostris is a character played by Mr. Scogun.

As a man dressing as a woman, Huxley’s Madame Sosostris draws a parallel to the mixed

gender of Tiresias.13

Seers or oracles have the power to foretell the future. In the epigraph, having

eternal life without eternal youth, Sibyl at Cumae wishes for her own death. In the

poem’s first section, “The Burial of the Dead”, Madame Sosostris warns of death by

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water. “Death by Water” is also the title of the poem’s fourth section. Tiresias shows up

in the third section of the poem, “The Fire Sermon”. Here Tiresias foretold of the empty,

deadening nature of sexual lust when met by indifference. Throughout the poem images

of barren emptiness, infertility, death, and the loss of youth abound. These images

conjure up the feelings and experiences one is faced with a in a life of chronic pain. The

three oracles remind us of another difficult aspect of living with chronic pain, the

inability to envision one’s own future.

The title of third section of the poem, “The Fire Sermon”, is referenced from the

Buddha’s Fire Sermon. In the Buddha’s speech, he instructs 1000 monks on detachment

and dispassion as the keys to the release from suffering. Eliot’s phrase in the poem

“Burning, burning, burning, burning,” refers to Buddha’s repeated Fire Sermon phrase,

Monks, the All is aflame. What All is aflame? The eye is aflame. Forms are

aflame. Consciousness at the eye is aflame. Contact at the eye is aflame. And

whatever there is that arises in dependence on contact at the eye -- experienced as

pleasure, pain or neither-pleasure-nor-pain -- that too is aflame. Aflame with

what? Aflame with the fire of passion, the fire of aversion, the fire of delusion.

Aflame, I tell you, with birth, aging and death, with sorrows, lamentations, pains,

distresses, and despairs.14

This phrase is repeated for each of the senses plus the body and the intellect. Then the

Buddha repeats another phrase for each sense plus the body and the intellect. Here the

Buddha emphasizes that once passion, aversion, and delusion are realized that a well-

taught disciple becomes disenchanted with the senses and the dependence on contact

experienced as pleasure or pain. Eliot’s The Waste Land is an assembly of disenchanting

images, without yet the detachment from the world of pain.

Chronic pain evokes another meaning as well from the wasteland metaphor, that

of the vast, empty, barren existence one experiences as intense pain, as Biro puts it,

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“…threatens to destroy everything except itself – family, friends, language, the world,

one’s thoughts, and ultimately even one’s self.” 15 Biro has even coined a name for the

chronic pain wasteland calling it an ontological divide.16 The ontological divide draws

attention to the existence problem of chronic pain: is it real…or is it imagined? For the

sufferer it is most real, but for the observer, the pain is so detached it becomes unreal.

At several point in the poem Eliot refers to post World War I London as the

“Unreal City”. In the poems last section, “What the Thunder Said”, Eliot writes, “Cracks

and reforms and bursts in the violet air, Falling towers, Jerusalem Athens Alexandria

Vienna London, Unreal”. All the cities he names have been devastated by war and then

rebuilt. Their unreal state reflects the disbelief that once alive and thriving, they have

fallen into vast desolate lands incapable of sustaining life. “Unreal” then comes to mean

the disenchantment, disconnection, disbelief, and the existential fear of seeing and

experiencing real devastation. This point can be seen as recalled from the poems first

section when Eliot writes, “I will show you fear in a handful of dust.”

The resolution to the poem is not straightforward. Eliot’s notes for the last section

of the poem compare the body to a prison. The line, “We think of the key, each in his

prison,” is cited as inspired by F. H. Bradley’s writing from Appearance and Reality,

“…In brief, regarded as an existence which appears in a soul, the whole world for each is

peculiar and private to that soul.” 17

In the final passages, the speaker is sailing on calm seas, and then sitting, fishing

with the wasteland behind him. He speaks, “These fragments I have shored against my

ruins.” The fragments of the poem are the myriad of literary references collected from a

large assortment of myth and epic tales. The main fragment comes from the grail story

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where Parsival, Gawain, or Lancelot, (depending on the version) eventually restores the

wasteland. The final line of The Waste Land is “Shantih, Shantih, Shantih.” It is

borrowed from the formal ending of the Upanishad which means, “The peace which

passeth understanding.” It is also known as the threefold peace of body, speech, and

mind. It is the attainment of the peace that unifies body, speech and mind and allows one

to live with chronic pain.

Personal and Professional Development

My personal development through the current of this clinical case study saw

changes in a number of areas. Throughout the previous two chapters, I have written on

the importance of an empathetic connection with a client who suffers with chronic pain.

Patients with chronic pain can and often do challenge the patience and empathy of a

therapist. Michael’s resistance at times challenged my patience and empathy as well. The

progression of his treatment moved much slower than I anticipated. Having experienced a

chronic pain condition myself, I thought I was well prepared to extend empathy and

compassion to another sufferer. Even with my own personal experience of pain, my

patience, empathy, and compassion were tested. I found it important to remember that

each individual experiences pain differently, with different intensity, tolerance, and

emotional activation. I found what worked best with Michael to expand and change his

experience with pain was a gentle encouragement.

In my professional development, I have discovered that the topic of chronic pain

has a large audience. In talking with other professionals in the small town where I live, I

have been able to offer a unique view in our discussions about chronic pain. Through this

sharing, I have become recognized as a referral source for chronic pain patients in this

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geographical area. This clinical case study has created for me an understanding of

multiple perspectives of chronic pain, and their various conflicts and differences towards

treatment. Out of this understanding, I now believe an integrated approach to treating

chronic pain is possible.

Applying Imaginal Approaches to Psychology

In the introduction chapter of this paper, I wrote about the confusion over

conflicting treatment choices available to chronic pain sufferers. This confusion comes

from psychological perspectives focusing on limited aspects of the experience of pain,

such as biological, behavioral, or developmental aspects. The various psychological

perspectives that were discussed in the Literature Review chapter each offered tools,

techniques, and theories that have had some success in chronic pain treatment. Authors

within the various psychological perspectives have borrowed each other’s successful

concepts, principles, and theories. The result of this sharing has been more eclectic than

integrated. The Imaginal approach to treating chronic pain offers an integrated solution

by focusing on the client’s full experience.

Imaginal Psychology’s primary concern is in reclaiming soul. Loss of soul can be

recognized in an individual through witnessing a loss of voice, a loss in expression, and

sensing poverty in imagination. Poverty and loss makes up the landscape of the

Wasteland. The intensity of prolonged pain can create such a landscape. Prolonged use of

pain medications can also create a similar terrain. Reclaiming soul is done with a focus

on expanding experience. Omer states, “The focus is on experience because it is where

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we find the most leverage. It is the slowest and most harrowing but has the most

profound and enduring effect and addresses regressive tendencies.” 18

In my work with Michael, I found resistance and regression. I believe part of his

resistance came from the expectation that his experience of pain was going to be denied.

He had already had his pain invalidated numerous times by various professionals before I

even started working with him. Because of this, he may have started therapy with me in a

malignantly regressed state. Michael came to therapy with the need for someone,

preferably a professional, to validate his pain as a physical reality. That was how he was

experiencing it. The complication arises when trying to find ways one can validate pain

as a physical reality, and validate his experience, while holding the belief that the

experience of pain can be altered psychologically. Michael needed to have his own

personal experience of separating the sensation of pain from a physical cause in order to

embrace the possibility of altering pain psychologically. This experience came in the

form of a systematic desensitization process.

Despite his new realization Michael’s resistance and regression continued. In

Imaginal Process, resistance to change is viewed as gatekeeping, or restriction of

experience. In order to work with restriction, expansion of experience is needed.

Expansion of experience is facilitated through the four dynamisms (deepening,

diversifying, personalizing, and embodying).19 Dialoguing with pain provided a means to

engage the four dynamisms, and expand experience.

At the outset of treatment, I had envisioned the use of dialoguing with the

subjective experience of pain as a key component of treatment in the imaginal approach.

Later into treatment, I included the concept of befriending pain as a more specific

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purpose to the dialoguing. Gendlin’s Focusing process provided a helpful method for

having Michael begin to listen to his body. Once started in this process he began to

realize the possibility of befriending pain. Michael has barely begun to work with

befriending pain, but he has already discovered that when he does it alters and lessens his

perception of pain. What he has also discovered in the process is that he is entering into a

new relationship with his body, and realizing a new way of being.

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CHAPTER 5

REFLECTIONS

Personal Development and Transformation

Just before starting to write this chapter I experienced an all night intestinal pain

from, what I believe, was food poisoning. The intensity of the pain was horrific.

Throughout the night, a plethora of thoughts ran through my mind. Much of the thought

was related to wondering if Michael’s chronic pain felt somewhat similar. I was being put

in a “practice what you preach” moment. I began to breathe deeply, attempting to relax as

much as possible. I turned toward the pain and welcomed it as a guesthouse stranger. I let

it know it had my attention. I tapped all of my internal resources to remain present. I

asked my pain about what associated fears were there. “Was I dying?” “No.” “Did I need

to go to the hospital?” “No.” “Could I stay with the pain and feel it completely?” “I’ll

try.”

Each new fear was met, as the pain continued for several hours. I listened to the

pain and got up and walked when it asked me to; rocked when it asked me to; stretched

when it asked me to; laid and rested when it asked me to. With me at each step was a

wise inner voice guiding me through. I accepted the pain as a friend, as a teacher, as a

gift, as a part of life. It left me in the morning with a feeling of the need to hold myself in

gentleness.

Becoming an expert in particular area requires study, gathering information,

analyzing theory, and applying research. It also entails developing experience. Most all of

us have had experiences of intense pain. My experience with intestinal distress gives me

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assurance that befriending pain is a viable means to finding a way to live with chronic

pain. However, could I remain as present if this experience was repeated nightly? This

tension is what the therapist needs to hold when working with chronic pain.

Pain is different for everyone. Just because I know intense intestinal pain, does

not mean I know what it feels like to live with cancer pain, or diabetic pain. Chronic pain

does not always elicit the same kind of empathy that comes with cancer pain, or diabetic

pain. With the later, there is physical source, and an expectation of death with these

conditions. Chronic pain foregoes the promise of death, although many sufferers long for

it.

Extending empathy, compassion, patience, and understanding to those with

chronic pain aids in the healing process. As a therapist my capacities of empathy,

compassion, patience, and understanding has increased through this clinical case study.

This clinical case study has also created for me a clear path to understanding what is

needed to empower change in those suffering from chronic pain.

Impact of the Learnings on My Understanding of the Topic

My first introduction to the psychological treatment of chronic pain was when I

was working as a mental health counselor at a drug and alcohol treatment center in

southern Oregon. A nurse supervisor was encouraging me to look into seeing some of the

clients at the agency who were experiencing addiction problems to pain medications. She

handed me a book on the behavioral treatment of chronic pain and started scheduling

appointments. Although the book had many good interventions, I felt that something was

lacking. My understanding of pain management at the time was similar to the common

beliefs, that chronic pain was best treated by a medical doctor. My experience at the drug

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and alcohol agency with chronic pain was short lived. I left the agency before I was able

to learn much about how to work with chronic pain and the resultant addiction to pain

medications.

When I started to study the biological literature for this clinical case study, I

became fascinated with the complexity of the problem of pain. As I studied the literature

of each new psychological perspective on chronic pain, I gained a greater understanding

of the similarities, differences, and conflicts on the subject. Each psychological

perspective offered gems of insight to the various aspects of chronic pain. Yet each

perspective also ignored or denied certain aspects of the experience of chronic pain.

The biological perspective focuses on the physical aspects of pain. The major

contributions from this perspective are many, chief among them have to do with

understanding how nerve function plays a role in the perception of pain. Evolving

theories of pain have created controversy over “true pain” and “pain that does not exist”,

or “mere unpleasantness”. Galen, Avicenna, Descartes, and Von Frey all denied the

existence of pain that could not be traced to physical causes. The search for the physical

cause of pain moved from a focus on peripheral nerves, to the central nervous system,

and continues further into the microscopic strata of neurobiology and neurophysiology.

The biological perspective has given us the ability to separate out acute pain from

chronic pain; to understand the physical links between chronic pain, depression, and

anxiety; an understanding of the workings of pain medication; and Gate Control Theory

and Neuromatrix Theory. Yet, from the biological perspective, pain has been

depersonalized and split off from the suffering person. In order to further objective

research, subjective experience is ignored.

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The cognitive/behavioral perspective has also produced many helpful

understandings to the field of chronic pain study. Skinner’s operant conditioning,

Fordyce’s pain behaviors, Loeser’s “onion model”, Beck’s adaptation of relaxation,

distraction, and imagery techniques, are all useful tools for working with chronic pain.

The cognitive/behavioral perspective suffers from some of the same problems of the

biological perspective. Its aim is to affect changes to thinking, beliefs, and behaviors in a

way that can be measured objectively. Again, the subjective experience takes a back seat

to the objective results.

A major discovery of my work with Michael included the use of systematic

desensitization. Fordyce had used this tool to address resistance to moving and exercise

in pain patients. When I used this technique with Michael, we had the unexpected benefit

of him realizing that his pain could be reduced or increased by an imagined exercise. For

the first time in our work together, Michael could see that his experience of pain was not

always connected to a physical cause. Fordyce had used this tool to move chronic pain

patients from imagined exercise to actual physical exercise. I believe that the difference

that resulted in the breakthrough for Michael was because we were focused on his

experience.

The psychodynamic perspective views chronic pain as one of many different

psychosomatic conditions. The contributions to the understanding of chronic pain from

the psychodynamic perspective include McDougall and Burloux’s notions of an

inadequate development of a stimulation barrier and the need for internalizing self-

soothing. The concept of psychosomatic comes from the psychodynamic perspective.

This moniker has become problematic because of the misunderstandings associated with

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its common usage. A focus on developmental and personality issues within

psychodynamic perspective helps in my understanding of the personal dimension of

imaginal structures. However, the psychodynamic perspective tends to negate the

physical experience of chronic pain.

The sociocultural perspective’s contributions to my understanding of chronic pain

include an understanding of how the disempowering of social groups contributes to

suffering. From this psychological perspective, one can find the cultural influences that

play a factor in the formation of imaginal structures. The cultural influences that play a

role in Michael’s imaginal structures are the primacy of the medical model in

understanding pain, the dominance of the biological treatment of pain, and the biases of

the insurance industry to only fund treatment of disease and illness that can be shown to

have a biological cause. The sociocultural perspective is primarily concerned with

understanding social dynamics and affecting social change. Individual experience is not a

chief focus of this perspective.

The Imaginal approach to psychology offers a way to integrate the biological,

cognitive/behavioral, psychodynamic, and sociocultural perspectives that have long

lasting benefits to the chronic pain patient. The focus on the chronic pain patient’s

experience is what makes the difference. When the individual perspectives; biological,

cognitive/behavioral, psychodynamic, and sociocultural, negate or reject certain aspects

of experience the chronic pain patient responds with resistance and regression. They are

often put in a position of being blamed, of not being able to overcome their own

condition, while simultaneously being told the condition is “not real”, when their own

experience tells them it is very real. Through a comprehension of all of the perspectives,

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the therapist is able to validate their experience as real, and help move the chronic pain

patient through resistance and regression by expanding the experience to include other

understandings.

Mythic Implications of the Learnings

Archetypal influences contribute to the shaping of imaginal structures. Myth

provides a means to fully consider archetypal influences affecting a condition such as

chronic pain. Eliot’s poem “The Waste Land” provided many archetypal references in an

intricate unfolding that mimics the complexity of chronic pain.

One of the primary ways that chronic pain is classified is as a psychosomatic

disorder. As previously mentioned, the term psychosomatic means both mind and body,

but its common usage is translated as “it’s all in your head.” Understanding

psychosomatic conditions as being a wasteland or borderland state helps clarify the

problems inherent in the former term. The wasteland, as an archetypal image, creates an

impression that one can move through this state. The barrenness of the wasteland is

symbolic of the poverty of imagination that results from prolonged chronic pain

conditions.

The vastness of the wasteland makes it difficult to see its horizons. How long one

will spend there is unknown. When one is in the wasteland of chronic pain, one’s future

is a mystery. In Eliot’s poem, there are three seers, foretelling a future. All speak of

death. Yet, death too is an unknown.

Eliot sees the wasteland everywhere, in the dessert passages from the Bible, in the

Hofgarten in Munich, in the foggy brown streets of London, and in the seas of the

Tempest. In Eliot’s poem, the wasteland is something one takes with them, wherever they

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go. Locked into a barren world with no escape it becomes a prison. With chronic pain,

the body is the prison. When pain is the enemy, we become a prisoner of war. Before we

are released from this prison, a peace must be made. Acceptance will allow change and

unlock the door. Eliot writes,

The awful daring of a moment’s surrender

Which an age of prudence can never retract

By this, and this only, we have existed1

The wasteland is an archetypal lens that places dimness on the world. Its emptiness

imprisons the imagination and will not let go easily. Yet, it is a lens. When that is

realized, the prison doors fly open.

Significance of the Learnings

The field of chronic pain is in disarray. There is confusion, contradiction, and

complexity. None of the conversational enclaves claims to have a lasting cure for chronic

pain. Still, chronic pain patients undergo unnecessary surgeries, are sentenced a lifetime

of pain medications, and lose the autonomy of their bodies to the medical and insurance

industries. The costs to the individual and society as a whole are tremendous.

While a viable cure is not available, healing chronic pain and learning to live with

it is indeed possible. The imaginal approach provides a means of integrating the concepts,

principles, theories, and methods of the various psychological perspectives in a way that

makes sense of the confusion, and irons out the contradictions. What unifies the various

conversational enclaves within the field of chronic pain study is the focus on experience

and the principle that “the soul longs for experience.” 2

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The major breakthrough discovered in this clinical case study involved separating

the sensation of pain from physical injury. Neither the concept of pain being separate

from injury, or the systematic desensitization method are new to the field of pain study.

What was new was that through this method my client was able to have an embodied

experience of the separation of his pain from his injury. When pain is separated from

physical injury an insight is gained that the injury is not the source or cause of the pain,

and that the pain can be altered by imagination.

Learning to dialogue with pain is significant in several ways. Firstly, it establishes

a reconnection with the body. The body, by its association with pain, becomes alienated

through medical and biological approaches. The body is further alienated by insurance

company directives limiting treatment choices, and denying benefits. The control over

one’s body is severely impacted by medical and insurance industry mandates. Secondly,

with a reconnection to the body through dialoguing with pain, a familiarity is regained.

Through objectification pain becomes an enemy, a thing we need to get rid of at all costs.

When pain is subjectified through dialogue, it is no longer an enemy as it becomes

familiar, with a deeper understanding of its purpose and affect on our life. Thirdly, as

familiarity is established it becomes possible to befriend pain through dialogue.

Befriending pain makes it possible to live with it.

The Application of Imaginal Psychology to Psychotherapy

Reclaiming the soul is the primary concern of Imaginal Psychology. Loss of soul

can be recognized by a loss of voice and a loss of imagination. Chronic pain can interrupt

a life in a way that causes these types of losses. We all suffer in unique ways. Soul

encompasses both desire and suffering. Each of these either pulls or pushes us in the

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direction of soul’s telos. Learning to be with suffering increases one’s capacity for

empathy, compassion, and understanding. It also takes courage to learn to live with

suffering. Living with pain and suffering has the ability to peel away the things that keep

us from existing in authenticity.

Imaginal Psychology is focused on listening deeply for soul’s messages. Listening

to the client’s story is at the core of this practice. Learning to understand the story

through the various lenses of imaginal structures, through the conversational enclaves of

the various psychological perspectives, and through archetype and myth give us the

ability to bring new meaning, offering new ways to hold experience, in fullness and

depth. Each lens and perspective is considered and deemed valid, not as it conforms to

objective comparisons, but as it contributes to the client’s unique subjective experience.

Current medical and psychological treatments for chronic pain are seeking either

a cure, or symptom management. Omer states, “If you do symptom management, then the

call of the soul is not being answered.” 3 Imaginal Psychology seeks healing, not cure. In

imaginal Psychology, symptoms can be mined for their meaning and contribution to the

soul’s unfolding.

The learnings that have come to light in this study contain the promise of

changing the way chronic pain is addressed within both medical and psychological

practices through using Imaginal Psychology. Advancement in the treatment of chronic

pain can be found in the acceptance and reorientation to pain as a symptom. Acceptance

and befriending of pain changes the experience of it to something bearable. Character and

identity change as one becomes someone who can bear difficult and painful experience.

The learnings indicate that psychotherapy must look not only to the treatment of body

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and mind, but to also take into account the space in-between, the wasteland, where

personal, cultural, and archetypal influences congeal in order to render suffering

meaningful in reclaiming soul.

Bridging Imaginal Psychology

The opportunity for bridging Imaginal Psychology to mainstream settings and

clients has great potential with the subject of chronic pain. Several factors are creating

this potential. First, there is no cure for chronic pain. Clients are desperate to find relief.

Each of the psychological perspective’s treatment options have had very limited success.

The biological perspective’s treatment choices include invasive surgery, and addictive

pain medications. While these options provide some temporary relief, the relief is short

lived. The treatments are expensive, debilitating, and have the potential to make the

condition worse. Biological, cognitive/behavioral, and psychodynamic treatments also

risk placing a client into malignant regression by denying certain aspects of experience.

All of the various psychological perspectives have borrowed from one another for

decades in attempts to find workable solutions to managing pain, again with limited

success. Imaginal Psychology offers a chance at changing the experience of chronic pain

by focusing on the experience.

Each of the various psychological perspectives has something to offer to the

process. The biological perspective offers the latest theories of pain. These theories are

extremely useful in recognizing that pain is a subjective experience. The

cognitive/behavioral perspective offers the helpful techniques of relaxation, distraction,

imagery, as well as systematic desensitization. The psychodynamic perspective offers

methods and theories for understanding personal developmental and personality

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characteristics as they influence the experience of chronic pain. The sociocultural

perspective contributes understanding of the cultural background and social power

dynamics that shape the experience of chronic pain. The Imaginal approach adds clarity

to the understanding of the mythic and archetypal influences that affect the experience of

chronic pain. Each of these contributions is integrated into a comprehensive

understanding using the imaginal approach’s focus on experience.

Areas for Future Research

During this study, several areas emerged as possibilities for future research. The

first of these involves a gap in the research around the psychological impact of being

given a psychosomatic diagnosis of chronic pain. It appears obvious that secondary injury

is being created by professionals that are giving this diagnosis without an adequate

explanation of the full meaning of the term. I hypothesize that some of the abusive

practices of medical practitioners and insurance adjusters would diminish if research

could show a link between the diagnosis and secondary injury.

Similarly, another gap in the research has to do with how chronic pain treatments

are dictated by medical and insurance industries. In this situation, I believe dictating

treatment options and taking away choice from the pain patient adversely affects

treatment outcomes. In both of these first two research areas, the potential for malignant

regression appears high. The relationships between malignant regression and the dictation

of treatment choices, and malignant regression and psychosomatic diagnosis are other

possible areas for future study.

The relationship between chronic pain and malignant regression maybe the source

of a plethora of future research. Dependent and obsessive personality traits were present

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in Michael’s psychological testing. Additionally, dependant and obsessive traits have

been linked to chronic pain in research not covered by this clinical case study. It would

be interesting to know if the regressive aspects of dependant or obsessive traits were

linked directly to chronic pain or could be explained by regression triggered by secondary

psychological injury.

Another area of future study involves the primacy of pain and priority

reassignment. Eccleston and Crombez researched this topic and discovered that

distraction techniques have only a limited ability to affect the sensation of pain. Other

authors have found that distraction techniques can be quite affective in disrupting pain.

This discrepancy indicates that more is needed to be known about the primacy of pain

and priority reassignment.

Lastly, a couple of authors, Jackson and Biro, spoke about personifying pain.

Jackson called this speaking to “pain creatures”. Biro spoke about projection metaphor.

With projection metaphor, we can project our pain to an outside object, or pain can be

personified to look for a way to make it responsive. Befriending pain is also a form of

personifying pain. A future area of research might seek to understand the benefits and

differences of personifications of pain that are used to identify with or disidentify from

the individual.

4

Appendix

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APPENDIX

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APPENDIX 1

CLIENT CONSENT FORM

To __________________:

You are invited to be the subject of a Clinical Case Study I am writing on the

psychological effects of living with chronic pain. The study’s purpose is to better

understand the psychological treatment aspects of chronic pain.

For the protection of your privacy, all of my notes will be kept confidential and

your identity will be protected. In the reporting of information in published material, any

and all information that could serve to identify you will be altered to ensure your

anonymity.

This study is of a research nature and may offer no direct benefit to you. The

published findings, however, may be useful to persons suffering with chronic pain, and

may benefit the understanding of the psychological effects of living with chronic pain.

The Clinical Case Study does not directly require your involvement. However, it

is possible simply knowing you are the subject of the study could affect you in ways

which could potentially distract you from your primary focus in therapy. If at any time

you develop concerns or questions, I will make every effort to discuss these with you.

If you decide to participate in this Clinical Case Study, you may withdraw your

consent and discontinue your participation at any time and for any reason up until the

publication of this study. Please note as well that I may need to terminate your role as the

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subject of the study at any point for any reason; I will inform you of this change, should I

need to make it.

If you have any questions or concerns, you may discuss these with me, or you

may contact the Doctoral Project Director at Meridian University, 47 Sixth Street,

Petaluma, CA, 94952, telephone: (707) 765-1836.

I, _______________, understand and consent to be the subject of, and to be

referred to in, the Clinical Case Study written by Anthony Scheving, on the topic of the

psychological effects of living with chronic pain. I understand private and confidential

information may be discussed or disclosed in the Clinical Case Study. I have had this

study explained to me by Anthony Scheving. Any questions of mine about this Clinical

Case Study have been answered, and I have received a copy of this consent form. My

participation in this study is entirely voluntary.

I knowingly and voluntarily give my unconditional consent for the use of both my

clinical case history, as well as for disclosure of all other information about me including,

but not limited to, information which may be considered private and confidential. I

understand that Anthony Scheving will not disclose my name or the names of any

persons involved with me, in this Clinical Case Study.

I hereby unconditionally forever release Anthony Scheving and Meridian

University (and all of its trustees, officers, employees, agents, faculty, successors, and

assigns) from any and all claims, demands, and legal causes of action whether known or

unknown, arising out of the mention, use, and disclosure of my clinical case history, and

all information concerning me including, but not limited to, information which may be

133

considered private and confidential. Meridian University assumes no responsibility for

any psychological injury that may result from this study.

The terms and provisions of this consent shall be binding upon my heirs,

representatives, successors, and assigns. The terms and provisions of this consent shall

be construed and interpreted pursuant to the laws of the State of California.

Signed this 12th day of December, 2012, at Sonora, CA.

By: _____________________________________________________________

________________________________________________________________

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APPENDIX 2

THE WASTE LAND BY T. S. ELIOT

T.S. Eliot (1888–1965). The Waste Land. 1922.

The Waste Land

I. THE BURIAL OF THE DEAD

APRIL is the cruellest month, breeding

Lilacs out of the dead land, mixing

Memory and desire, stirring

Dull roots with spring rain.

Winter kept us warm, covering 5

Earth in forgetful snow, feeding

A little life with dried tubers.

Summer surprised us, coming over the Starnbergersee

With a shower of rain; we stopped in the colonnade,

And went on in sunlight, into the Hofgarten, 10

And drank coffee, and talked for an hour.

Bin gar keine Russin, stamm’ aus Litauen, echt deutsch.

And when we were children, staying at the archduke’s,

My cousin’s, he took me out on a sled,

And I was frightened. He said, Marie, 15

Marie, hold on tight. And down we went.

In the mountains, there you feel free.

I read, much of the night, and go south in the winter.

What are the roots that clutch, what branches grow

Out of this stony rubbish? Son of man, 20

You cannot say, or guess, for you know only

A heap of broken images, where the sun beats,

And the dead tree gives no shelter, the cricket no relief,

And the dry stone no sound of water. Only

There is shadow under this red rock, 25

(Come in under the shadow of this red rock),

135

And I will show you something different from either

Your shadow at morning striding behind you

Or your shadow at evening rising to meet you;

I will show you fear in a handful of dust. 30

Frisch weht der Wind

Der Heimat zu,

Mein Irisch Kind,

Wo weilest du?

“You gave me hyacinths first a year ago; 35

They called me the hyacinth girl.”

—Yet when we came back, late, from the Hyacinth garden,

Your arms full, and your hair wet, I could not

Speak, and my eyes failed, I was neither

Living nor dead, and I knew nothing, 40

Looking into the heart of light, the silence.

Öd’ und leer das Meer.

Madame Sosostris, famous clairvoyante,

Had a bad cold, nevertheless

Is known to be the wisest woman in Europe, 45

With a wicked pack of cards. Here, said she,

Is your card, the drowned Phoenician Sailor,

(Those are pearls that were his eyes. Look!)

Here is Belladonna, the Lady of the Rocks,

The lady of situations. 50

Here is the man with three staves, and here the Wheel,

And here is the one-eyed merchant, and this card,

Which is blank, is something he carries on his back,

Which I am forbidden to see. I do not find

The Hanged Man. Fear death by water. 55

I see crowds of people, walking round in a ring.

Thank you. If you see dear Mrs. Equitone,

Tell her I bring the horoscope myself:

One must be so careful these days.

Unreal City, 60

Under the brown fog of a winter dawn,

A crowd flowed over London Bridge, so many,

I had not thought death had undone so many.

Sighs, short and infrequent, were exhaled,

And each man fixed his eyes before his feet. 65

Flowed up the hill and down King William Street,

To where Saint Mary Woolnoth kept the hours

With a dead sound on the final stroke of nine.

There I saw one I knew, and stopped him, crying “Stetson!

You who were with me in the ships at Mylae! 70

136

That corpse you planted last year in your garden,

Has it begun to sprout? Will it bloom this year?

Or has the sudden frost disturbed its bed?

Oh keep the Dog far hence, that’s friend to men,

Or with his nails he’ll dig it up again! 75

You! hypocrite lecteur!—mon semblable,—mon frère!”

II. A GAME OF CHESS

The Chair she sat in, like a burnished throne,

Glowed on the marble, where the glass

Held up by standards wrought with fruited vines

From which a golden Cupidon peeped out 80

(Another hid his eyes behind his wing)

Doubled the flames of sevenbranched candelabra

Reflecting light upon the table as

The glitter of her jewels rose to meet it,

From satin cases poured in rich profusion; 85

In vials of ivory and coloured glass

Unstoppered, lurked her strange synthetic perfumes,

Unguent, powdered, or liquid—troubled, confused

And drowned the sense in odours; stirred by the air

That freshened from the window, these ascended 90

In fattening the prolonged candle-flames,

Flung their smoke into the laquearia,

Stirring the pattern on the coffered ceiling.

Huge sea-wood fed with copper

Burned green and orange, framed by the coloured stone, 95

In which sad light a carvèd dolphin swam.

Above the antique mantel was displayed

As though a window gave upon the sylvan scene

The change of Philomel, by the barbarous king

So rudely forced; yet there the nightingale 100

Filled all the desert with inviolable voice

And still she cried, and still the world pursues,

“Jug Jug” to dirty ears.

And other withered stumps of time

Were told upon the walls; staring forms 105

Leaned out, leaning, hushing the room enclosed.

Footsteps shuffled on the stair,

Under the firelight, under the brush, her hair

Spread out in fiery points

Glowed into words, then would be savagely still.

110

“My nerves are bad to-night. Yes, bad. Stay with me.

Speak to me. Why do you never speak? Speak.

What are you thinking of? What thinking? What?

137

I never know what you are thinking. Think.”

I think we are in rats’ alley 115

Where the dead men lost their bones.

“What is that noise?”

The wind under the door.

“What is that noise now? What is the wind doing?”

Nothing again nothing. 120

“Do

You know nothing? Do you see nothing? Do you remember

Nothing?”

I remember

Those are pearls that were his eyes. 125

“Are you alive, or not? Is there nothing in your head?”

But

O O O O that Shakespeherian Rag—

It’s so elegant

So intelligent

130

“What shall I do now? What shall I do?

I shall rush out as I am, and walk the street

With my hair down, so. What shall we do to-morrow?

What shall we ever do?”

The hot water at ten. 135

And if it rains, a closed car at four.

And we shall play a game of chess,

Pressing lidless eyes and waiting for a knock upon the door.

When Lil’s husband got demobbed, I said,

I didn’t mince my words, I said to her myself, 140

HURRY UP PLEASE ITS TIME

Now Albert’s coming back, make yourself a bit smart.

He’ll want to know what you done with that money he gave you

To get yourself some teeth. He did, I was there.

You have them all out, Lil, and get a nice set, 145

He said, I swear, I can’t bear to look at you.

And no more can’t I, I said, and think of poor Albert,

He’s been in the army four years, he wants a good time,

And if you don’t give it him, there’s others will, I said.

Oh is there, she said. Something o’ that, I said. 150

Then I’ll know who to thank, she said, and give me a straight look.

HURRY UP PLEASE ITS TIME

If you don’t like it you can get on with it, I said,

Others can pick and choose if you can’t.

But if Albert makes off, it won’t be for lack of telling. 155

138

You ought to be ashamed, I said, to look so antique.

(And her only thirty-one.)

I can’t help it, she said, pulling a long face,

It’s them pills I took, to bring it off, she said.

(She’s had five already, and nearly died of young George.) 160

The chemist said it would be alright, but I’ve never been the same.

You are a proper fool, I said.

Well, if Albert won’t leave you alone, there it is, I said,

What you get married for if you don’t want children?

HURRY UP PLEASE ITS TIME 165

Well, that Sunday Albert was home, they had a hot gammon,

And they asked me in to dinner, to get the beauty of it hot—

HURRY UP PLEASE ITS TIME

HURRY UP PLEASE ITS TIME

Goonight Bill. Goonight Lou. Goonight May. Goonight. 170

Ta ta. Goonight. Goonight.

Good night, ladies, good night, sweet ladies, good night, good night.

III. THE FIRE SERMON

The river’s tent is broken: the last fingers of leaf

Clutch and sink into the wet bank. The wind

Crosses the brown land, unheard. The nymphs are departed. 175

Sweet Thames, run softly, till I end my song.

The river bears no empty bottles, sandwich papers,

Silk handkerchiefs, cardboard boxes, cigarette ends

Or other testimony of summer nights. The nymphs are departed.

And their friends, the loitering heirs of city directors; 180

Departed, have left no addresses.

By the waters of Leman I sat down and wept…

Sweet Thames, run softly till I end my song,

Sweet Thames, run softly, for I speak not loud or long.

But at my back in a cold blast I hear 185

The rattle of the bones, and chuckle spread from ear to ear.

A rat crept softly through the vegetation

Dragging its slimy belly on the bank

While I was fishing in the dull canal

On a winter evening round behind the gashouse. 190

Musing upon the king my brother’s wreck

And on the king my father’s death before him.

White bodies naked on the low damp ground

And bones cast in a little low dry garret,

Rattled by the rat’s foot only, year to year. 195

But at my back from time to time I hear

The sound of horns and motors, which shall bring

Sweeney to Mrs. Porter in the spring.

139

O the moon shone bright on Mrs. Porter

And on her daughter 200

They wash their feet in soda water

Et, O ces voix d’enfants, chantant dans la coupole!

Twit twit twit

Jug jug jug jug jug jug

So rudely forc’d. 205

Tereu

Unreal City

Under the brown fog of a winter noon

Mr Eugenides, the Smyrna merchant

Unshaven, with a pocket full of currants 210

C. i. f. London: documents at sight,

Asked me in demotic French

To luncheon at the Cannon Street Hotel

Followed by a week-end at the Metropole.

At the violet hour, when the eyes and back 215

Turn upward from the desk, when the human engine waits

Like a taxi throbbing waiting,

I Tiresias, though blind, throbbing between two lives,

Old man with wrinkled female breasts, can see

At the violet hour, the evening hour that strives 220

Homeward, and brings the sailor home from sea,

The typist home at tea-time, clears her breakfast, lights

Her stove, and lays out food in tins.

Out of the window perilously spread

Her drying combinations touched by the sun’s last rays, 225

On the divan are piled (at night her bed)

Stockings, slippers, camisoles, and stays.

I Tiresias, old man with wrinkled dugs

Perceived the scene, and foretold the rest—

I too awaited the expected guest. 230

He, the young man carbuncular, arrives,

A small house-agent’s clerk, with one bold stare,

One of the low on whom assurance sits

As a silk hat on a Bradford millionaire.

The time is now propitious, as he guesses, 235

The meal is ended, she is bored and tired,

Endeavours to engage her in caresses

Which still are unreproved, if undesired.

Flushed and decided, he assaults at once;

Exploring hands encounter no defence; 240

His vanity requires no response,

140

And makes a welcome of indifference.

(And I Tiresias have foresuffered all

Enacted on this same divan or bed;

I who have sat by Thebes below the wall 245

And walked among the lowest of the dead.)

Bestows one final patronizing kiss,

And gropes his way, finding the stairs unlit…

She turns and looks a moment in the glass,

Hardly aware of her departed lover; 250

Her brain allows one half-formed thought to pass:

“Well now that’s done: and I’m glad it’s over.”

When lovely woman stoops to folly and

Paces about her room again, alone,

She smoothes her hair with automatic hand, 255

And puts a record on the gramophone.

“This music crept by me upon the waters”

And along the Strand, up Queen Victoria Street.

O City City, I can sometimes hear

Beside a public bar in Lower Thames Street, 260

The pleasant whining of a mandoline

And a clatter and a chatter from within

Where fishmen lounge at noon: where the walls

Of Magnus Martyr hold

Inexplicable splendour of Ionian white and gold.

265

The river sweats

Oil and tar

The barges drift

With the turning tide

Red sails 270

Wide

To leeward, swing on the heavy spar.

The barges wash

Drifting logs

Down Greenwich reach 275

Past the Isle of Dogs.

Weialala leia

Wallala leialala

Elizabeth and Leicester

Beating oars 280

The stern was formed

A gilded shell

Red and gold

The brisk swell

141

Rippled both shores 285

South-west wind

Carried down stream

The peal of bells

White towers

Weialala leia 290

Wallala leialala

“Trams and dusty trees.

Highbury bore me. Richmond and Kew

Undid me. By Richmond I raised my knees

Supine on the floor of a narrow canoe.“

295

“My feet are at Moorgate, and my heart

Under my feet. After the event

He wept. He promised ‘a new start.’

I made no comment. What should I resent?”

“On Margate Sands. 300

I can connect

Nothing with nothing.

The broken finger-nails of dirty hands.

My people humble people who expect

Nothing.”

305

la la

To Carthage then I came

Burning burning burning burning

O Lord Thou pluckest me out

O Lord Thou pluckest

310

Burning

IV. DEATH BY WATER

Phlebas the Phoenician, a fortnight dead,

Forgot the cry of gulls, and the deep seas swell

And the profit and loss.

A current under sea 315

Picked his bones in whispers. As he rose and fell

He passed the stages of his age and youth

Entering the whirlpool.

Gentile or Jew

O you who turn the wheel and look to windward, 320

Consider Phlebas, who was once handsome and tall as you.

142

V. WHAT THE THUNDER SAID

After the torch-light red on sweaty faces

After the frosty silence in the gardens

After the agony in stony places

The shouting and the crying 325

Prison and place and reverberation

Of thunder of spring over distant mountains

He who was living is now dead

We who were living are now dying

With a little patience

330

Here is no water but only rock

Rock and no water and the sandy road

The road winding above among the mountains

Which are mountains of rock without water

If there were water we should stop and drink 335

Amongst the rock one cannot stop or think

Sweat is dry and feet are in the sand

If there were only water amongst the rock

Dead mountain mouth of carious teeth that cannot spit

Here one can neither stand nor lie nor sit 340

There is not even silence in the mountains

But dry sterile thunder without rain

There is not even solitude in the mountains

But red sullen faces sneer and snarl

From doors of mud-cracked houses

If there were water

345

And no rock

If there were rock

And also water

And water

A spring 350

A pool among the rock

If there were the sound of water only

Not the cicada

And dry grass singing

But sound of water over a rock 355

Where the hermit-thrush sings in the pine trees

Drip drop drip drop drop drop drop

But there is no water

Who is the third who walks always beside you?

When I count, there are only you and I together 360

But when I look ahead up the white road

There is always another one walking beside you

143

Gliding wrapt in a brown mantle, hooded

I do not know whether a man or a woman

—But who is that on the other side of you?

365

What is that sound high in the air

Murmur of maternal lamentation

Who are those hooded hordes swarming

Over endless plains, stumbling in cracked earth

Ringed by the flat horizon only 370

What is the city over the mountains

Cracks and reforms and bursts in the violet air

Falling towers

Jerusalem Athens Alexandria

Vienna London 375

Unreal

A woman drew her long black hair out tight

And fiddled whisper music on those strings

And bats with baby faces in the violet light

Whistled, and beat their wings 380

And crawled head downward down a blackened wall

And upside down in air were towers

Tolling reminiscent bells, that kept the hours

And voices singing out of empty cisterns and exhausted wells.

In this decayed hole among the mountains 385

In the faint moonlight, the grass is singing

Over the tumbled graves, about the chapel

There is the empty chapel, only the wind’s home.

It has no windows, and the door swings,

Dry bones can harm no one. 390

Only a cock stood on the roof-tree

Co co rico co co rico

In a flash of lightning. Then a damp gust

Bringing rain

Ganga was sunken, and the limp leaves 395

Waited for rain, while the black clouds

Gathered far distant, over Himavant.

The jungle crouched, humped in silence.

Then spoke the thunder

DA 400

Datta: what have we given?

My friend, blood shaking my heart

The awful daring of a moment’s surrender

Which an age of prudence can never retract

By this, and this only, we have existed 405

144

Which is not to be found in our obituaries

Or in memories draped by the beneficent spider

Or under seals broken by the lean solicitor

In our empty rooms

DA 410

Dayadhvam: I have heard the key

Turn in the door once and turn once only

We think of the key, each in his prison

Thinking of the key, each confirms a prison

Only at nightfall, aetherial rumours 415

Revive for a moment a broken Coriolanus

DA

Damyata: The boat responded

Gaily, to the hand expert with sail and oar

The sea was calm, your heart would have responded 420

Gaily, when invited, beating obedient

To controlling hands

I sat upon the shore

Fishing, with the arid plain behind me

Shall I at least set my lands in order?

425

London Bridge is falling down falling down falling down

Poi s’ascose nel foco che gli affina

Quando fiam ceu chelidon—O swallow swallow

Le Prince d’Aquitaine à la tour abolie

These fragments I have shored against my ruins 430

Why then Ile fit you. Hieronymo’s mad againe.

Datta. Dayadhvam. Damyata.

Shantih shantih shantih

NOTES Not only the title, but the plan and a good deal of the incidental symbolism of the poem were suggested by Miss Jessie L. Weston’s

book on the Grail legend: From Ritual to Romance (Macmillan). Indeed, so deeply am I indebted, Miss Weston’s book will elucidate

the difficulties of the poem much better than my notes can do; and I recommend it (apart from the great interest of the book itself) to any who think such elucidation of the poem worth the trouble. To another work of anthropology I am indebted in general, one which

has influenced our generation profoundly; I mean The Golden Bough; I have used especially the two volumes Attis Adonis Osiris.

Anyone who is acquainted with these works will immediately recognize in the poem certain references to vegetation ceremonies.

I. THE BURIAL OF THE DEAD

Line 20 Cf. Ezekiel II, i.

23. Cf. Ecclesiastes XII, v.

145

31. V. Tristan und Isolde, I, verses 5–8.

42. Id. III, verse 24.

46. I am not familiar with the exact constitution of the Tarot pack of cards, from which I have obviously departed to suit my own

convenience. The Hanged Man, a member of the traditional pack, fits my purpose in two ways: because he is associated in my mind

with the Hanged God of Frazer, and because I associate him with the hooded figure in the passage of the disciples to Emmaus in Part V. The Phoenician Sailor and the Merchant appear later; also the “crowds of people,” and Death by Water is executed in Part IV. The

Man with Three Staves (an authentic member of the Tarot pack) I associate, quite arbitrarily, with the Fisher King himself.

60. Cf. Baudelaire: “Fourmillante cité, cité pleine de rèves,

Où le spectre en plein jour raccroche le passant.”

63. Cf. Inferno, III. 55–57: “si lunga tratta

di gente, ch’io non avrei mai creduto

che morte tanta n’avesse disfatta.”

64. Cf. Inferno, IV. 25–27:

“Quivi, secondo che per ascoltare,

“non avea pianto, ma’ che di sospiri, “che l’aura eterna facevan tremare.”

68. A phenomenon which I have often noticed.

74. Cf. the Dirge in Webster’s White Devil.

76. V. Baudelaire, Preface to Fleurs du Mal.

II. A GAME OF CHESS

77. Cf. Antony and Cleopatra, II., ii. l. 190.

92. Laquearia. V. Aeneid, I, 726:

dependent lychni laquearibus aureis incensi, et noctem flammis funalia vincunt.

98. Sylvan scene. V. Milton, Paradise Lost, IV. 140.

99. V. Ovid, Metamorphoses, VI, Philomela.

100. Cf. Part III, l. 204.

115. Cf. Part III, l. 195.

118. Cf. Webster: “Is the wind in that door still?”

126. Cf. Part I, l. 37, 48.

138. Cf. the game of chess in Middleton’s Women beware Women.

III. THE FIRE SERMON

176. V. Spenser, Prothalamion.

192. Cf. The Tempest, I, ii.

196. Cf. Day, Parliament of Bees:

“When of the sudden, listening, you shall hear, “A noise of horns and hunting, which shall bring

“Actaeon to Diana in the spring,

“Where all shall see her naked skin…“

146

197. Cf. Marvell, To His Coy Mistress.

199. I do not know the origin of the ballad from which these lines are taken; it was reported to me from Sydney, Australia.

202. V. Verlaine, Parsifal.

210. The currants were quoted at a price “carriage and insurance free to London”; and the Bill of Lading, etc. were to be handed to the

buyer upon payment of the sight draft.

218. Tiresias, although a mere spectator and not indeed a “character,” is yet the most important personage in the poem, uniting all the

rest. Just as the one-eyed merchant, seller of currants, melts into the Phoenician Sailor, and the latter is not wholly distinct from

Ferdinand Prince of Naples, so all the women are one woman, and the two sexes meet in Tiresias. What Tiresias sees, in fact, is the substance of the poem. The whole passage from Ovid is of great anthropological interest:

…Cum Iunone iocos et maior vestra profecto est

Quam, quae contingit maribus’, dixisse, ‘voluptas.’ Illa negat; placuit quae sit sententia docti

Quaerere Tiresiae: venus huic erat utraque nota.

Nam duo magnorum viridi coeuntia silva

Corpora serpentum baculi violaverat ictu

Deque viro factus, mirabile, femina septem

Egerat autumnos; octavo rursus eosdem Vidit et ‘est vestrae si tanta potentia plagae,’

Dixit ‘ut auctoris sortem in contraria mutet,

Nunc quoque vos feriam!’ percussis anguibus isdem Forma prior rediit genetivaque venit imago.

Arbiter hic igitur sumptus de lite iocosa

Dicta Iovis firmat; gravius Saturnia iusto Nec pro materia fertur doluisse suique

Iudicis aeterna damnavit lumina nocte,

At pater omnipotens (neque enim licet inrita cuiquam Facta dei fecisse deo) pro lumine adempto

Scire futura dedit poenamque levavit honore.

221. This may not appear as exact as Sappho’s lines, but I had in mind the “longshore” or “dory” fisherman, who returns at nightfall.

253. V. Goldsmith, the song in The Vicar of Wakefield.

257. V. The Tempest, as above.

264. The interior of St. Magnus Martyr is to my mind one of the finest among Wren’s interiors. See The Proposed Demolition of

Nineteen City Churches: (P. S. King & Son, Ltd.).

266. The Song of the (three) Thames-daughters begins here. From line 292 to 306 inclusive they speak in turn. V. Götterdämmerung, III, i: The Rhinedaughters.

279. V. Froude, Elizabeth, Vol. I, ch. iv, letter of De Quadra to Philip of Spain:

“In the afternoon we were in a barge, watching the games on the river. (The queen) was alone with Lord Robert and myself on the poop, when they began to talk nonsense, and went so far that Lord Robert at last said, as I

was on the spot there was no reason why they should not be married if the queen pleased.”

293. Cf. Purgatorio, V. 133: “Ricorditi di me, che son la Pia;

“Siena mi fe’, disfecemi Maremma.”

307. V. St. Augustine’s Confessions: “to Carthage then I came, where a cauldron of unholy loves sang all about mine ears.”

308. The complete text of the Buddha’s Fire Sermon (which corresponds in importance to the Sermon on the Mount) from which these

words are taken, will be found translated in the late Henry Clarke Warren’s Buddhism in Translation (Harvard Oriental Series). Mr.

Warren was one of the great pioneers of Buddhist studies in the occident.

309. From St. Augustine’s Confessions again. The collocation of these two representatives of eastern and western asceticism, as the

culmination of this part of the poem, is not an accident.

147

V. WHAT THE THUNDER SAID

In the first part of Part V three themes are employed: the journey to Emmaus, the approach to the Chapel Perilous (see Miss Weston’s

book), and the present decay of eastern Europe.

357. This is Turdus aonalaschkae pallasii, the hermit-thrush which I have heard in Quebec County. Chapman says (Handbook of Birds in Eastern North America) “it is most at home in secluded woodland and thickety retreats.… Its notes are not remarkable for

variety or volume, but in purity and sweetness of tone and exquisite modulation they are unequaled.” Its “water-dripping song” is

justly celebrated.

360. The following lines were stimulated by the account of one of the Antarctic expeditions (I forget which, but I think one of

Shackleton’s): it was related that the party of explorers, at the extremity of their strength, had the constant delusion that there was one

more member than could actually be counted.

366–76. Cf. Hermann Hesse, Blick ins Chaos: “Schon ist halb Europa, schon ist zumindest der halbe Osten Europas auf dem Wege

zum Chaos, fährt betrunken im heiligem Wahn am Abgrund entlang und singt dazu, singt betrunken und hymnisch wie Dmitri

Karamasoff sang. Ueber diese Lieder lacht der Bürger beleidigt, der Heilige und Seher hört sie mit Tränen.”

401. “Datta, dayadhvam, damyata” (Give, sympathise, control). The fable of the meaning of the Thunder is found in the

Brihadaranyaka—Upanishad, 5, 1. A translation is found in Deussen’s Sechzig Upanishads des Veda, p. 489.

407. Cf. Webster, The White Devil, V, vi: “…they’ll remarry

Ere the worm pierce your winding-sheet, ere the spider

Make a thin curtain for your epitaphs.”

411. Cf. Inferno, XXXIII, 46:

“ed io sentii chiavar l’uscio di sotto

all’orribile torre.” Also F. H. Bradley, Appearance and Reality, p. 346.

“My external sensations are no less private to myself than are my thoughts or my feelings. In either case my

experience falls within my own circle, a circle closed on the outside; and, with all its elements alike, every sphere is opaque to the others which surround it.… In brief, regarded as an existence which appears in a soul,

the whole world for each is peculiar and private to that soul.”

424. V. Weston, From Ritual to Romance; chapter on the Fisher King.

427. V. Purgatorio, XXVI, 148.

“‘Ara vos prec, per aquella valor ‘que vos guida al som de l’escalina,

‘sovegna vos a temps de ma dolor.’

Poi s’ascose nel foco che gli affina.”

428. V. Pervigilium Veneris. Cf. Philomela in Parts II and III.

429. V. Gerard de Nerval, Sonnet El Desdichado.

431. V. Kyd’s Spanish Tragedy.

433. Shantih. Repeated as here, a formal ending to an Upanishad. “The Peace which passeth understanding” is a feeble translation of

the content of this word.

148

NOTES

Chapter 1

1. Melanie Thernstrom, The Pain Chronicles: Cures, Myths, Mysteries, Prayers, Diaries, Brain

Scans, Healing, and the Science of Suffering (New York: Farra, Straus and Giroux, 2010), 32.

2. John J. Bonica, The Management of Pain, Volume I (Philadelphia, PA: Lea & Febiger, 1953), 3-

4., The ancient Egyptians are the first source use the concept that the heart was the main processing center

of sensation. In the ancient Egyptian texts, pain was viewed as an intrusion into the body by evil spirits.

3. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), 4th ed. (Arlington,

VA: American Psychiatric Association, 2000), 498.

4. Walter W. Skeat, An Etymological Dictionary of the English Language, Fourth Ed., (London:

Oxford University Press, 1961), 423.

5. H. Merskey, and M. Bogduk ed., Classifications of Chronic Pain, IASP Task Force on

Taxonomy, 2nd ed. (Seattle, WA: International Association for the Study of Pain Press, 1994), 209, Pain is

defined by the IASP as, “An unpleasant sensory and emotional experience associated with actual or

potential tissue damage or described in terms of such damage. Note: Pain is always subjective. Each

individual learns the applications of the word through experience related to injury in early life. Biologists

recognize that stimuli that cause pain are likely to cause tissue damage. Accordingly, pain is the experience

that we associate with actual or potential tissue damage. It is unquestionably a sensation in a part or parts of

the body, but is also always unpleasant and therefore also an emotional experience.”

6. Ronald Melzack, “Pain: Past, Present and Future”, Canadian Journal of Experimental

Psychology 47, (December 1993): 615-629.

7. 2012 Laws and Regulations Relating to the Practice of Psychology, Section 1387.1(j)

(Sacramento, CA: California Board of Psychology, 2012), 97 The 2012 Laws and Regulations Relating to

the Practice of Psychology states: “Primary Supervisors shall have no familial, intimate, business or other

relationships with the trainee which would compromise the supervisor’s effectiveness, and/or which would

violate the Ethical Principals and Codes of Conduct of the American Psychological Association.”

8. Bill Moyers, Healing and the Mind, ed. Betty Sue Flowers and David Grubin, (New York:

Doubleday, 1993), 361.

Chapter 2

1. Aftab Omer, from course lecture notes Group Process II (Petaluma, CA: Meridian University,

June 29, 2003)

2. Bonica, 4.

3. Osama A. Tashani and Mark I. Johnson, “Avicenna’s Concept of Pain”, Libyan Journal of

Medicine, Vol. 5 (Sept 8, 2010): 52-53.

149

4. Bonica, 6.

5. Ibid., 7.

6. Ronald Melzack, Patrick D. Wall, The Challenge of Pain (London: Penguin Books, 1982), 152.

7. Fernando Cervero, Understanding Pain (Cambridge, MA: The MIT Press, 2012), 4.

8. Ibid., 1-4.

9. Melzack & Wall, The Challenge of Pain, 81.

10. Ibid., 157. Central summation is the result of excitation and inhibition impulses adding up to

produce an action potential in the central nervous system. Goldscheider speculated that pain mechanisms

for central summation were in the dorsal horns of the spinal column.

11. Ibid.

12. William K. Livingston, Pain and Suffering (Seattle, WA: IASP Press, 1998), 150.

13. Ibid., 152.

14. Cervero, 39-40.

15. Melzack & Wall, The Challenge of Pain, 159.

16. Ibid., 162

17. Gwenn Herman, and Mary French, Making the Invisible Visible: Chronic Pain Manual for

Health Care Providers (Potomac, MD: Pain Connection, 2009), 4.

18. Melzack & Wall, The Challenge of Pain, 34-36.

19. Ronald Melzack, Patrick Wall, “Pain Mechanisms: A New Theory,” Science, Vol. 150, no.

3699 (1965): 974-976.

20. Ibid., 976.

21. Ibid., 978.

22. Ronald Melzack, “Pain: Past, Present, and Future,” Canadian Journal of Experimental

Psychology 47, no. 4 (1993): 618.

23. Ibid., 619-621.

24. Ronald Melzack, “Evolution of the Neuromatrix Theory of Pain; The Prithvi Raj Lecture:

Presented at the Third World Congress of World Institute of Pain, Barcelona 2004,” Pain Practice, Vol. 5,

Issue 2 (2005): 90-91.

25. C. Richard Chapman and Yoshio Nakamura, “A Passion of the Soul: An Introduction to Pain

for Consciousness Researchers,” Consciousness and Cognition, Vol. 8, (1999): 415-416.

150

26. Vania Apkarian, Marwan Baliki, and Paul Geha, “Toward a Theory of Chronic Pain,” Progress

in Neurobiology, 87 (2009): 87-94.

27. Ibid., 84

28. Oye Guryee, Michael Von Korff, Gregory E. Simon, Richard Gater, “Persistent Pain and

Well-Being: A world Health Organization Study in Primary Care,” Journal of The American Medical

Association, Vol. 280, no. 2 (July 8, 1998): 149.

29. Francis J. Dunne, ”Depression and Pain: is there a common pathway?,” British Journal of

Medical Practitioners, Vol. 4, no. 1 (March 2001): 4.

30. Matthew J. Blair, Rebecca L. Robinson, Wayne Katon, Kurt Kroenke, “Depression and Pain

Comorbidity,” Archive of Internal Medicine, Vol. 163 (November 10, 2003), 2440.

31. Ibid., 2441.

32. Ibid., 2440-2441.

33. Larry E. Beutler, David Engle, M. Elena Oro’-Beutler, and Roger Daldrup, “Inability to

Express Intense Affect: A Common Link Between Depression and Pain?,” Journal of Consulting and

Clinical Psychology, Vol. 54, no. 6, (1986): 754-755.

34. Carlo Flascha, “On Opium: Its History, Legacy. And Cultural Benefits,” [journal on-line]

Prospect Journal of International Affairs at UCSD, (May 25, 2011, accessed February 16, 2013): available

at http://prospectjournal.org/2011/05/25/on-opium-its-history-legacy-and-cultural-benefits/: Internet.

35. Aage Møller, Pain: Its Anatomy, Physiology, and Treatment (Richardson, TX: The University

of Texas at Dallas, 2008), 155.

36. Bonica, 1647-1649.

37. Moller, 155-161.

38. Kurt Kroenke, Erin Krebs, and Matthew Blair, “Pharmacotherapy of Chronic Pain: A synthesis

of recommendations from systematic reviews,” General Hospital Psychiatry 31 (2009): 210.

39. Ibid., 206.

40. Mary Carmichael, “The Changing Science of Pain,” Newsweek (June 4, 2007): 40.

41. Ibid., 46.

42. Blair, Robinson, Katon, Kroenke, 2441.

43. Keith Budd, Pam Price, “Recent Advances in the Treatment of Chronic Pain,” In Psychology,

Pain and Anesthesia, ed. Hamilton B. Gibson (London: Chapman and Hall, 1994), 69.

44. Melzack & Wall, The Challenge of Pain, 233.

45. Beutler, Engle, Oro’-Beutler, and Daldrup, 755.

151

46. Patrick Wall, Pain: The Science of Suffering, (New York: Columbia University Press, 2000),

120.

47. Carmichael, 46.

48. Thernstrom, 154.

49. Ivan P. Pavlov, Conditioned Reflexes, Trans. G. V. Anrep (London: Oxford university Press,

1927), 377.

50. B.F. Skinner, “Two types of conditioned reflex: A reply to Konorski and Miller,” Journal of

General Psychology, Vol. 12 (1937): 272-279

51. Robert W. Rieber, Kurt Salzinger, Psychology: Theoretical-historical perspectives 2nd ed.,

(Washington, DC: American Psychological Association, 1998), 295.

52. Wilbert Fordyce, Behavioral Methods for Chronic Pain and Illness, (St. Louis, MO: Mosby,

1976 ), 49-72.

53. Wilbert Fordyce, “Behavioral Methods of Rehabilitation,” In Rehabilitation Psychology, ed.

Walter S, Neff, (Washington, DC: American Psychological Association, 1971), 77.

54. Ibid., 86-92.

55. J.D. Loeser, “Perspectives on Pain,” In Proceedings of the First World conference on clinical

Pharmacology and Therapeutics, ed. P. Turner, (London: Macmillian, 1980), 313-316

56. Wilbert Fordyce, “Pain and Suffering: A Reappraisal,“ American Psychologist, Vol. 43, no. 4

(April 1988): 278-279.

57. Joseph Wolpe, Psychotherapy by Reciprocal Inhibition (Stanford, CA: Stanford University

Press, 1958), 139-165.

58. Fordyce, “Behavioral Methods of Rehabilitation,” 101.

59. Fordyce, “Pain and Suffering: A Reappraisal”, 282.

60. Carrie Winteroud, Aaron T. Beck, and Daniel Gruener, Cognitive Therapy with Chronic Pain

Patients (New York: Springer Publishing Co., 2003), 30.

61. Ibid., 25-35.

62. Ibid., 144-146.

63. Ibid., 309.

64. Ibid.,104-118.

65. Dennis C. Turk, Donald Meichenbaum, and Myles Genest, Pain and Behavioral Medicine: A

Cognitive Behavioral Perspective (New York: The Guilford Press, 1983), 89-90.

66. Chris Eccleston, and Geert Crombez, “Pain Demands Attention: A Cognitive-Affective Model

of the Interruptive Function of Pain,” Psychological Bulletin, Vol. 125, no. 3, (1999): 357.

152

67. Ibid., 356-363.

68. Dennis C. Turk, and Frits Winter, The Pain Survival Guide, (Washington, DC: American

Psychological Association, 2006), 56.

69. Robert N. Jamison, Mastering Chronic Pain: A professional guide to Behavioral Treatment

(Sarasota, FL: Professional Resource Press, 1996), 97.

70. JoAnne C. Dahl, Kelly G. Wilson, Carmen Luciano, and Steven C. Hayes, Acceptance and

Commitment Therapy for Chronic Pain, (Oakland, CA: Context Press, 2005), vi

71. JoAnne C. Dahl, and Tobias Lundgren, “Acceptance and Commitment Therapy in the

treatment of chronic pain”, In Mindfulness-based treatment approaches: Clinician’s guide to evidence base

and applications, ed. R. A. Baer (San Diego, CA: Elsevier, 2006), 285–306.

72. Ibid., 289–292.

73. Sigmund Freud, An Autobiographical Study, Trans. James Strachey, (New York: W.W.

Norton & Company, 1935), 31-32.

74. Sigmund Freud, A General Introduction to Psychoanalysis, Trans. G. Stanley Hall, (New

York: Boni and Liveright, 1920), 335.

75. Ibid.

76. Ibid., 334.

77. C.G. Jung, The Basic Writings of Jung, ed. Violet Staub De Laszlo (The Modern Library, New

York, 1953, 1993 ed.), 591.

78. Joyce McDougall, Theaters of the Body: A Psychoanalytic Approach to Psychosomatic Illness,

(New York: W.W. Norton & Company, 1989), 41-43.

79. Ibid., 43.

80. Ibid., 153.

81. Ibid., 81-82.

82. Ibid., 95-96.

83, Ibid., 53-56.

84. Gabriel Burloux, The Body and its Pain (Paris: Free Association Books, 2004), 50-54

85. Ibid., 188.

86. Ibid., 49-54.

87. Ibid., 190.

88. Ibid., 234-237.

153

89. Ibid., 251-256.

90. C. Philip Wilson, and Ira L. Mintz, “The Symptom and the Underlying Personality Disorder,”

In Psychosomatic Symptoms: Psychosomatic Treatment of the Underlying Personality Disorder, ed. C.

Philip Wilson, and Ira L. Mintz, (Northvale, NJ: Jason Aronson Inc., 1989), 1-6.

91. Cecil Mushatt, “Loss Separation and Psychosomatic Illness” In Psychosomatic Symptoms:

Psychosomatic Treatment of the Underlying Personality Disorder, ed. C. Philip Wilson, and Ira L. Mintz,

(Northvale, NJ: Jason Aronson Inc., 1989), 35.

92. Robert J. Gatchel, and James N. Weisberg, Personality Characteristics of Patients with Pain,

(Washington, DC: American Psychological Association, 2000), 7, 18-19. Note the term pain-prone patient

first was used by George Engel in June 1995.

93. Stephen Tyrer, “Psychosomatic Pain,” British Journal of Psychiatry, (2006): 91-93.

94. Elaine Scarry, The Body in Pain: The Making and Unmaking of the World, (New York:

Oxford University Press, 1985), 3.

95. Ibid., 4.

96. Ibid., 57.

97. Ibid., 162.

98. Ibid., 324.

99. Arne Johan Vetlesen, A Philosophy of Pain, (London: Reaktion Books, 2004), 157.

100. Ibid., 88-95.

101. Mary-Jo Delvechio Good, Paul E. Brodwin, Byron J. Good, and Arthur Kleinman, Pain as

Human Experience: An Anthropological Perspective, (Berkeley, CA: University of California Press, 1992),

7

102. Ibid.

103. Ibid., 9.

104. David B. Morris, The Culture of Pain, (Berkeley, CA: University of California Press, 1991),

67

105. Ibid., 146-151.

106. Karl D. Frohm and Gregory P. Beehler, “Psychologists as Change Agents in Chronic Pain

Management Practice: Cultural Competence in the Health Care System,” Psychological Services, Vol. 7,

no. 3 (2010): 115-125.

107. Valerie Gray Hardcastle, The Myth of Pain, (Cambridge, MA: The MIT Press, 1999), 10-11.

108. Meridian University, Course Catalog 2007-2008, (Petaluma, CA: Meridian University,

2007), 4.

154

109. Aftab Omer, from course lecture notes Psychotherapy Integration I, (Petaluma, CA: Meridian

University, November 16, 2002)

110. Aftab Omer, from course lecture notes Integrative Seminar IIA, (Petaluma, CA: Meridian

University, November 15, 2008)

111. Aftab Omer, from course lecture notes Imaginal Process IV, (Petaluma, CA: Meridian

University, June 24, 2005)

112. Aftab Omer, Key Definitions, (Petaluma, CA: Meridian University, August, 2005)

113. Ibid.

114. Ibid.

115. Ibid.

116. Aftab Omer, from lecture notes TA Meeting, (Petaluma, CA: Meridian University, October 4,

2006)

117. Aftab Omer, from course lecture notes Group Process II, (Petaluma, CA: Meridian

University, June 29, 2003)

118. Melanie Starr Costello, Imagination, Illness and Injury: Jungian Psychology and the Somatic

Dimensions of Perception, (New York: Routledge, 2006), 10-14.

119. Ibid., 32-33.

120. Bill Moyers, Healing and the Mind, ed. Betty Sue Flowers and David Grubin, (New York:

Doubleday, 1993), 319.

121. Ibid., 324-326.

122. Ibid., 328-329.

123. Ibid., 361.

124. Ibid., 347-349.

125. Jeanne Achterberg, Imagery and Healing: Shamanism and Modern Medicine, (Boston:

Shambala Publications, 1985), 15.

126. Ibid., 24-25.

127. Ibid., 42-43.

128. David Biro, The Language of Pain: Finding Words, Compassion, and Relief, (New York: W.

W. Norton & Company, 2010), 19.

129. Ibid., 106.

130. Ibid., 57.

155

131. Ibid., 70-73.

132. Ibid., 16.

133. Ariel Glucklich, Sacred Pain: Hurting the Body for the Sake of the Soul, (New York: Oxford

University Press, 2001), 33-34.

134. Ibid., 16-31.

135. Ibid., 207.

136. Ibid., 210.

137. Jean E. Jackson, Camp Pain: Talking with Chronic Pain Patients, (Philadelphia, PA:

University of Pennsylvania Press, 2000), 8.

138. Ibid., 100.

139. Ibid., 102.

140. Ibid., 106-107.

141. Ibid., 135-140.

142. Ibid., 148.

143. Ibid., 144.

144. Ibid., 151-153.

145. Charlotte S. Flanagan, “Creative Arts Therapy in the Rehabilitation of Chronic Pain:

Movement and Metaphor – Reflections by Clients and Therapist,” Nordisk Fysioterapi, Vol. 8 (2004): 120-

131.

146. Eugene Gendlin, Focusing, (New York: Bantam, 1981), 6-10.

147. Ann Weiser Cornell, The Power of Focusing: A Practical Guide to Emotional Self-Healing,

(Oakland, CA: New Harbinger Publications, 1996), 11-14.

148. Moyers, 119.

149. Omer, from course lecture notes Group Process II.

Chapter 3

1. Michael’s anti-depressant was listed as Lurasidone at 80 milligrams once per day in the

evening. I was not familiar with the Lurasidone medication and so I looked it up after the therapy visit was

over. Lurasidone is listed as an atypical anti-psychotic. This concerned me as the only mention of delusion

or psychosis in Michael’s medical charts was in relation to a hospitalization for a scheduled surgery where

Michael was withdrawn from several medications at once. During that hospital stay, Michael went through

156

serious withdrawal symptoms that included, as Michael describes, “blacking out”, and a suicide attempt.

Michael told me during his second visit that Lurasidone was the new anti-depressant medication he had

been prescribed. He was planning to ask his psychiatrist that it be replaced because of symptoms of

irritability and vomiting that he had experienced since starting the medication the week before.

2. Omer, Key Definitions.

3. Cervero, 27.

4. Turk, and Winter, 39-43.

5. Omer, from course lecture notes Group Process II.

6. Fordyce, “Behavioral Methods of Rehabilitation,” 101.

7. Moyers, 361.

8. Jackson, 153.

9. Gendlin, 10-11.

10. Cornell, 2-3.

Chapter 4

1. Jackson, 148.

2. H. Merskey, and M. Bogduk ed., 209.

3. Aftab Omer, from Teaching Assistant meeting, (Petaluma, CA: Meridian University, October 4,

2006)

4. Omer, from course lecture notes Group Process II.

5. Moyers, 361.

6. Ibid., 351.

7. Biro, 16.

8. Mircea Eliade, Rites and Symbols of Initiation, (N.Y.: Harper Torchbooks, 1958), 82.

9. Michael Balint, The Basic Fault: Therapeutic Aspects of Regression, (Evanstan, IL:

Northwestern University Press, 1968), 173.

10. Jessie L. Weston, From Ritual to Romance (Paris, France: 1919), 87.

11. Jessie L. Weston, From Ritual to Romance (Paris, France: 1919), 75.

12. T.S. Eliot, The Waste Land, (London, England: 1922), line 46.

13. Patrick Trapp, Tireseas and other seers in T.S. Eliot’s “The Waste Land”. (Norderstedt,

Germany: Grin Verlag, 2006), 5.

157

14. Thanissaro Bhikkhu (tr.) (1993). Adittapariyaya Sutta: The Fire Sermon (SN 35.28). Retrieved

25 Sep 2007 from "Access to Insight" at

http://www.accesstoinsight.org/tipitaka/sn/sn35/sn35.028.than.html

15. Biro, 18.

16. Ibid., 32.

17. Eliot, end notes.

18. Omer, from course lecture notes Group Process II.

19. Aftab Omer, from course lecture notes Imaginal Process II., (Petaluma, CA: Meridian

University, March 24, 2002).

Chapter 5

1. Eliot, lines 403-405.

2. Omer, from course lecture notes Group Process II.

3. Omer, from course lecture notes Imaginal Process II.

158

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