Thursday, August 24, 2017

Therapy with a Chronic Pain Patient

This article provides an account of how psychotherapy can make a real difference in the life of a person living with chronic pain. By describing the actual treatment of a chronic pain patient, the article shows how therapy can complement the efforts of medical providers in assisting people in living fuller, more meaningful lives. The description of the actual patient has been altered to protect the person’s privacy.


Living with chronic pain is such a difficult challenge because so many factors can influence the person’s pain experience. Over the past several decades, researchers and medical providers who treat chronic pain have become more aware of the importance of psycho-social factors  - daily stress, family relationship difficulties, lifestyle issues, job dissatisfaction to name a few – in a person’s recovery from injury and leading a full life. In fact, studies of factors that lead to recovery vs. continued suffering and disability have consistently shown that factors such as maladaptive beliefs and coping styles, lack of emotional support, job dissatisfaction, and depression are stronger predictors of continued suffering and disability than the severity of the physical injury. These concerns cannot be fully addressed by medical providers however much they may try to take these into consideration. This article presents how psychotherapy can help with these factors and assist a person living with chronic pain in leading a fuller, more satisfying life.

Description of the Patient

Florence is a 59-year-old married, African-American female with three adult children. She presents as attractive, younger than stated age, lively, articulate, stylishly dressed, and with an engaging sense of humor. She is a college graduate, who had a career as an administrative assistant until she became disabled due to Lupus at age 41. Since then, Florence has been trying to establish her own mixed-media art business, has had volunteer and leadership positions in a community service organization, and has attempted to establish a connection with a church. However, she has felt unable to fully pursue these interests because of her strong sense of obligation feeling unfulfilled in life and living with a sense that life has been passing her by.

Florence reports that she was a relatively healthy and active working mother until she began to experience symptoms of lupus around age 40. Since that initial diagnosis, Florence has encountered other complications: Arthritis, Raynaud’s Syndrome, Fibromyalgia, Chronic Fatigue, Gastric Reflux and Sleep Apnea. She has twice undergone double knee replacement surgery and surgery on both her feet.

Florence has viewed her medical problems as evidence she is “broken”, “useless”, a “burden” or “liability”’ to her family and has lived with the fear that they will give up or abandon her. She has developed a pervasive pattern in important relationships – such as her marriage, her family of origin, her children, medical providers, and her artist colleagues and studio owners – of trying to “keep pace”. She would work her needs around what others wanted, trying to please and make it easier for others. When Florence began therapy, she would report how her efforts to help or please others would leave her exhausted, sore and unable to function for days after. She frequently talked about how she would try to “keep pace” with what others needed until her body “gave out”. Her focus on pleasing others left little time for her own interests: her art, participating in a church, singing in a choir. It was hard for Florence to feel entitled to measure that would help her chronic medical problems – pacing herself, getting regular safe exercise, getting sufficient rest, and limiting activities (like standing for long periods of time, lifting) that exacerbated her pain. She frequently reported feeling not understood by her medical providers, and not reassured by their responses to her questions and concerns. However, she continued to try not to “ruffle feathers” and would leave medical appointments with lingering doubts.

Her Sense of Self

Florence grew up the youngest of four children in a family environment where she felt deprived of security and love. Her mother was depressed and angry throughout Florence’s childhood, in large part due to difficulties in her marriage to Florence’s father. Her father was an absent figure in her life due to his work and alcoholism. Florence grew up feeling unwanted, at times hated by her mother, who would often tell her children she never wanted kids. She doubted that she mattered to her father. She came to think of herself as the “odd one” in the family, the least appealing, least capable, as inferior. From an early age, she developed the pattern of trying to please others to protect herself from feeling unloved and unimportant, and to gain some sense of acceptance from her family. Florence left home at age 16 and married her husband after becoming pregnant with her eldest child. She entered her marriage anticipating she would finally feel loved and wanted. But she soon found herself feeling undeserving and only important if she could please her husband. This intensified with her husband’s devotion to his work, his over involvement with his family of origin, and his emotionally reserved nature. Florence increasingly feared that her husband would abandon her if she did not please him or keep pace with his agenda. Her efforts to make things easier for others only intensified her her loneliness and lack of self-regard, and left her feeling increasingly hopeless about her future and the future of her marriage.

What the Therapist Did That Helped

· Therapy provided a consistent and sustained relationship where the exclusive purpose has been to assist Florence in leading a fuller, more satisfying life, and fulfilling her aspirations in life. Florence experienced someone – in this case her therapist – as genuinely wanting to understand her experience rather than encouraging or criticizing her inclination to seek the favor of others. This allowed Florence to let go of her need to prove her goodness and worth in session by talking about her endless efforts to please others. This, in turn, opened the door for Florence to share, in a more authentic manner, her own lack of self-regard, distrust of others, and her lack of real fulfillment in her life.
· Therapy has helped Florence gain insight into the origins of her automatic people pleasing: to protect herself from hurt and rejection, earlier in her life, by attending to the needs of others. This allowed Florence to see her habit as an understandable reaction to difficult circumstances and as a coping response over which she could gain some control.
· Florence’s therapist helped her understand that her sense of inferiority and unimportance was a consequence of her experiences with family members earlier in her life. The therapist provided the space for Florence to begin to question the validity of her low self-regard. This helped Florence be more open to the idea that being herself was valuable in its own right, and that her unique perspective, talents, and interests were elements to be nurtured, not dismissed as defects or liabilities.
· The therapist helped raise Florence’s awareness of how much she had been oriented to gaining the favor of others in her daily life. This made it possible for Florence to begin to judge for herself if her automatic people pleasing was counterproductive to her desire to improve her life.
· The therapist helped Florence look for opportunities to let go of her protective habits of pleasing others, keeping peace in order to more directly confront difficulties in important relationships in her life – family member, medical providers, colleagues. Florence began to experience herself as standing up for herself. This bolstered her faith in her inner strength and resilience, increased her self-respect, and diminished her feelings of failure.

As therapy progressed, Florence has been able to accomplish the following:

· Florence has been able to impress upon her husband and adult children how committed she is to her art, the importance of church involvement to her emotional and spiritual well-being, and the necessity of taking better care of herself physically. Her husband’s positive response, in particular, has helped F. feel more secure in his commitment to her.
· Florence has joined a church where she has become an active participant in religious studies and a member of the choir. Having a spiritual home and contributing to the spiritual growth of others has strengthened her sense of goodness as a person.
· Florence resigned from the studio/gallery where the policies, expectations, and the physical layout of the building were hindering her creative process, creating increased physical pain, and providing little benefit in terms of sales. Working at her home and developing her own business website has been a more satisfying arrangement for her.
· Florence was able to attend to her physical warning signs that something was not right following her earlier knee replacement surgeries. She persisted in sharing these concerns with her medical providers, did not allow herself to be placated by responses she found neither reassuring nor convincing, and she sought other opinions until her concerns were satisfied. It was ultimately determined corrective surgeries were needed and these subsequent procedures were successful.
· Florence has been more comfortable letting go of her urge to be at her family’s beck and call. She has gained confidence in her ability to decide for herself her obligations to her family and has been more at peace with the limits she sets with her family.