The Social Context of the Chronic Pain Sufferer 9781487580391

Citation preview

THE SOCIAL CONTEXT OF THE CHRONIC PAIN SUFFERER

Chronic back pain and migraine headaches plague millions of North Americans. Over the past twenty years these and other forms of chronic benign pain have been recognized as serious afllictions that affect a significant segment of the adult population. Researchers have investigated the various medical and psychological aspects of chronic benign pain; now Ranjan Roy adds a critical new dimension with a study of the social forces that determine the lives of these patients and their responses to their condition. The effects of chronic pain on a patient's social system can be devastating. Roy discusses the extent to which the negative consequences can be reduced, even if the pain itself remains impervious to treatment. He considers a range of interventions that can significantly modify the negative effects of chronic pain, and discusses some of these in detail to enable clinicians to implement them. Ranjan Roy is a member of the Faculty of Social Work and the Department of Psychiatry, University of Manitoba. He is co-editor of Chronic Pain: Psychosocial Factors in Rehabilitation and author of Chronic Pain and the Family: A ProblemCentred Approach.

RANJAN ROY

The Social Context of the Chronic Pain Sufferer

UNIVERSITY OF TORONTO PRESS Toronto Buffalo London

© University of Toronto Press Incorporated 1992

Toronto Buffalo London Printed in Canada Reprinted in 2018

ISBN 0-8020-2860-8 (cloth) ISBN 978-0-8020-7360-0 (paper)

Printed on acid-free paper

Canadian Cataloguing in Publication Data

Roy, Ranjan The social context of the chronic pain sufferer ISBN 0-8020-2860-8 (bound) ISBN 978-0-8020-7360-0 (paper) 1. Intractable pain - Social aspects. 2. Intractable pain - Psychological aspects. I. Title

RB127.R69 1992

616'.0472

C92-094546-5

This book is dedicated to my nephew, Shankha (Bhaskar, to his friends) Born: 17.2.1960 Bhilai, India Died: 23.3.1989 Cambridge, Mass., USA

Contents

FOREWORD IX ACKNOWLEDGMENTS

n

PREFACE xiii

Part I: Conceptual Issues 1 Social and Psychological Issues: An Overview 3

Part II: Assessment Issues 2 Pain, Loss, and Grief 23 3 Life Events and Pain 40 4 Childhood Abuse and Neglect: Pain in Adulthood 57 5 Interpersonal Issues: The Patient's Family System 80

Part Ill: Methods of Intervention 6 Social Strategy Interventions 97

viii Contents 7 Task-Centred Approach 111 8 Dynamic Psychotherapy and Pain 125 9 Crisis Intervention 143 REFERENCES 163 SUBJECT INDEX 177 AUTHOR INDEX 180

Foreword

When the International Association for the Study of Pain promulgated its definition of pain beginning with the words 'Pain is a sensory and emotional experience .. .' it was a giant step forward for the study and management of pain, since it established the essential meaninglessness of the question 'Is this pain physical or psychological?' Freed from the constraints of this perspective on pain, clinicians and researchers were able to explore the issue of pain in every possible aspect: biological, psychological, and social. Earlier work by pioneers in the field was rediscovered and formed a foundation upon which newer efforts could be based, using technologies and skills not previously available. Clinical studies tended to emerge from multidisciplinary pain clinics where the therapeutic imperative soon demanded scientifically based information upon which to base treatments in an atmosphere of increasing cost consciousness. A further development was the recognition that chronic pain was not the same as acute pain and required more of a rehabilitative than a curative approach. It is probably true to say that sociologically oriented studies have not been prominent among published work in the pain field - perhaps because academically inclined social workers are not often found in multidisciplinary pain clinics. Ranjan Roy is one of a small number who have approached the pain problem from the unique viewpoint of the academic

x Foreword social worker, and this volume amply demonstrates how valuable and indispensable such an approach is for anyone wishing to think seriously about pain and the alleviation of suffering associated with it. In writing this book he has taken a broad view of the scope of the title, The Social Context of the Chronic Pain Sufferer, and covers a wide variety of interrelated topics, including social strategy interventions, of which the Task-Centred Approach will be of particular interest to all clinicians. In addition to being well referenced, this book has a rich clinical dimension in the form of numerous case vignettes, which ensure that the reader never loses sight of the fact that the author is writing about the suffering of real human beings who need help and understanding rather than the criticism and rejection with which they too often are met. There is value in this book for all members of the multidisciplinary pain movement. I hope and trust it will reach the wide audience it deserves. I. Pilowsky

Acknowledgments

This book was conceived and partly written during my sabbatical leave at the Department of Psychiatry, University of Manchester. I am grateful to my friends and colleagues there, in particular Brian Minty, who made my stay an enjoyable one. Brian Minty also read part of the manuscript and made valuable suggestions. I thank him for his thoughtful comments. I want to thank my wife, Margaret, who read the manuscript, and was a consultant to me in this undertaking. The patients discussed in this book have my deepest gratitude, especially four of them, whose names cannot be disclosed, who spent several hours with me discussing the early days of their Chronic Pain Society. Our conversation is reported in Chapter 7.

Preface

Chronic pain is an enigmatic problem. Despite significant progress in our understanding of this phenomenon from various scientific points of view, and the emergence of many innovative treatments, the basic puzzle this problem presents remains only partly understood. Pain is the most ubiquitous of medical symptoms. Statistics on the magnitude of chronic pain are staggering: Chronic head and back pain alone incapacitate millions of people in Canada and the United States. The patient with chronic pain often represents a failing in conventional medicine. Some of the serious difficulties faced by many pain patients, such as drug dependency, are caused by medical treatment, that is, they are iatrogenic. Biomedical approaches have achieved only partial, if not nominal, success in the treatment of chronic benign pain. The repercussions of chronic pain on both the patient and family can be massive. Loss of employment, crippling medical expenses (in the United States), domestic disruptions, litigation, and social and family breakdown are not uncommon. Despite some advances in the physical and especially behavioural treatments, chronic pain, in the main, remains impervious to permanent cure. Multidisciplinary pain clinics have mushroomed all over Canada and the United States to treat this complex biopsychosocial syndrome, and there is now more sensitivity to

xiv Preface the broader social and psychological consequences of chronic pain. Even so, systematic research on the social repercussions is almost pitifully absent. Effects on the family may be the exception to that general rule; over the past twenty years there has been a near explosion of research on the family issues of these individuals, and the literature is of sufficient richness to merit periodic reviews. Unfortunately, such interest is not evident with regard to the patient's loss of roles and the social withdrawal accompanied by loss of the support system, or how parental chronic pain affects children. This book represents a departure from the trodden path. Problems of great import, from the patient's point of view, but not necessarily from the clinician's perspective, are discussed. In the same vein, somewhat neglected treatment approaches are presented - approaches designed to consider more directly the social and relationship issues. The attempt here is to address some of the critical areas of dislocation caused by chronic pain for these individuals against the background of their social environment, primarily through a review of the literature (where there is any) and extensive use of clinical material drawn from my own practice. The book is broadly divided into three parts. The first part, comprising a single chapter, discusses in broad terms the range of social, familial, legal, and emotional problems of chronic pain patients. Following a review of the literature on the relevant social issues, a detailed case is presented. It is the story of a fully functioning human being, who in a matter of months following a work-related accident, experienced almost total social and emotional disintegration. Problems faced by this patient, a prototype, form the basis for most of the rest of the book. Part II, with four chapters, is a critical exploration of assessment issues. The first chapter is an examination of losses. Loss is a universal experience of chronic pain patients - loss of health to loss of job to loss of self-esteem. The main theme of this chapter is that the nature and extent of losses must be carefully considered

Preface xv to avoid hasty psychiatric diagnosis. An accurate assessment of the patient's reaction to losses has far-reaching implications for treatment. In the next chapter implications of life events are studied for their etiological significance in painful conditions. Also life events caused by the onset of chronic pain are considered; this is a grossly under-researched area, but clinically very important. Abuse and pain coexist, and the logic of that relationship is almost self-evident. This relationship is the topic of Chapter 4. Abuse can lead to the adoption of a lifestyle characterized by pain. Many chronic pain patients present a history of childhood abuse and neglect; the implication of those negative experiences for the etiology of pain is discussed. Sometimes, it is imperative to have a clear grasp of childhood experiences just to make sense of the patient's dilemma. Special attention must be given to the pain patient's informal network in general and the family in particular; the patient's family, in most instances, is the principal source of support. Unfortunately, chronic pain has a way of upsetting the family functioning notwithstanding the best intentions of family members. Chapter 5 explores these issues. Part III has four chapters, each describing a particular method of intervention (not commonly found in the pain literature). Social-strategy interventions, designed to resolve conflicts with bureaucracies (formal systems) and promote fellowship among people with common problems, are the subject of Chapter 6, and include a variety of approaches that range from advocacy to self-help groups. The goal of this intevention is empowerment of the patient. A common complaint registered by patients is that chronic pain creates an adversarial relationship with formal organizations and can engender enormous feelings of powerlessness. These feelings of powerlessness and lack of control can be reversed by the social strategies described. Another therapeutic technique is the task-centred approach (TCA). This is an actionoriented approach, discussed in Chapter 7, that depends on the patient's motivation to alter any unacceptable situations.

xvi Preface Patients, with the help of therapists, define their problems and devise means of solving them. Cases are presented to illustrate the efficacy and relevance of this method in treating many social conflicts commonly encountered by pain patients. lntrapersonal conflicts, which may be rooted in unresolved childhood issues, call for dynamic psychotherapy; in Chapter 8 a case is developed for treating those pain patients who have a childhood history of abuse and neglect with brief dynamic psychotherapy. Cases are presented in some detail to illustrate the complexities of this method. The topic of Chapter 9 is crisis intervention and the need for its availability in pain clinics. This is a well-tried method known for its brevity and positive outcome. The lives of pain patients are filled with crises, and it is only appropriate that suitable treatment should be available. Again, through case illustrations the benefits of this treatment are demonstrated. In short, this book is about the person behind the pain. Hence, the interventions focus on re-establishing the balance between the person and the environment rather than on the direct amelioration of the pain. In medicine, psychosocial problems are often marginalized. Such minimization may be tantamount to negligence in the context of patients with chronic diseases. Until such time that a cure for chronic benign pain is at hand, the psychosocial problems and means of solving them must have a central place in the patient's treatment plan.

Part I

Conceptual Issues

1 Social and Psychological Issues: An Overview

In the annals of medicine chronic benign or non-cancer pain as a clinical phenomenon has a relatively short history. Persons with chronic pain, most of whom suffer from back and head pain, present a considerable challenge to clinicians, for, most of these individuals are without obvious physical lesions to account for their persistent and mostly severe pain. In the not too distant past these patients received psychiatric labels which reflected the untreatable nature of their problems. The pioneering work of Beecher (1959), Bonica (1953), Livingstone (1943), Melzack and Wall (1965), Merskey and Spear (1967), Sternbach (1974), and others has resulted in a comprehensive reconceptualization of pain. Today chronic pain, a syndrome which afilicts a heterogeneous group of sufferers, is firmly viewed as a complex biopsychosocial phenomenon. The International Association for the Study of Pain defines chronic pain as pain that has lasted for three months or more and is refractory to treatment. Pain is a day-to-day experience for a significant proportion of the population. The famous Nuprin Report (Sternbach 1986) found that young people between the ages of seventeen and thirty years present a host of pain symptoms, and younger people report more pain in every site except the joints than do the elderly, whose pain in the joints can be accounted for almost entirely by their vulnerability to rheumatological disorders.

4 Conceptual Issues Epidemiological studies of chronic pain are few. Crook, Rideout, and Browne (1984), in an investigation of 500 randomly selected households, found that about 15 percent of the subjects studied reported chronic pain. Magni and associates (1990) estimated that 14.4 per cent of the U.S. population report chronic pain related to joints and the musculoskeletal system. According to the Nuprin Report (Sternbach 1986) some 32 per cent of the adult U.S. population suffer from back pain. Bonica (1974, 1977) estimated that seven million Americans are disabled by back pain and that some thirty-five million people in North America have experienced notable pain. Forty-two million Americans suffer from headaches (Adams, Feuerstein, and Fowler 1980); muscle-contraction headaches account for nearly 80 per cent of them (Waters and O'Connor 1971). DESCRIPTION OF THE PAIN PATIENT

Chronic pain patients as a group are quite heterogeneous, yet they reveal certain common patterns and attitudes. Crook and Tunks (1985) in a study comparing chronic pain patients attending a pain clinic with those attending family practice chronic pain groups found that the pain clinic group tended to report specific precipitating events, mainly work injury; they also reported more intense and constant pain and experienced difficulty in coping with their daily activities. Furthermore, they presented more somatic and depressive symptoms. Social withdrawal was common. Job loss, litigation, occupational disability, and drug and alcohol abuse were some of the longterm problems of the pain clinic group. Finally, they were heavy users of health services. Chapman, Sola, and Bonica (1979) found clear evidence of more elevated psychological disturbance in patients attending a pain clinic than in those attending an anaesthesiology clinic specializing in pain management. Similar differences were reported by Sternbach ( 1974), who found that the chronic pain patients consistently demonstrated elevation on the depres-

Social and Psychological Issues 5 sion, hysteria, and hypochondriacal scales of the MMPI, commonly known as the Conversion V profile. In an earlier study Sternbach and colleagues (1973) explained that the chronic pain patients usually decompensated very rapidly and assumed semi-invalid status. These individuals were unemployed, socially isolated, depressed, interpersonally inept, and heavily dependent on the health care system. Much of their waking time was spent either lying down or searching for a miracle cure for the pain. Pilowsky (1969) developed an illness behaviour questionnaire to examine feelings and attitudes of pain sufferers towards their illness. In several subsequent studies Pilowsky and Spence (1975, 1976) explored the illness behaviour of chronic pain patients and compared them with populations that had other medical illnesses. Their key finding was that the chronic pain population consistently scored higher than the other medically ill subjects on denial, somatic rather than psychological perception of pain symptoms, irritability and hypochondriasis. In a recent study Roy, Thomas, and Berger ( 1990) found that the illness behaviour profile of younger pain patients was equally valid with an elderly group of chronic pain patients. Depression has emerged as a significant problem of chronic pain patients; this topic will be discussed in detail in Chapter 3. The question of the etiology of depression in this population has been the subject of much debate. Is this depression reactive to the vicissitudes of life commonly encountered by pain patients, are these people more prone to primary mood disorder, or do they manifest an altogether different form of depression? The last proposition is still in question. The weight of the evidence is that lowered mood, demoralization, and vegetative symptoms in pain patients are reactions to a multitude of noxious events commonly experienced by them (Pilowsky 1988). PATIENT AND THE ECOSYSTEM

The term 'ecology' is a biological concept that describes the

6 Conceptual Issues relationship of the organisms to their surroundings. In the context of the behavioural sciences, it is used metaphorically to describe reciprocal relationships between people and their environment. This perspective facilitates adoption of a comprehensive view of people and their environment in a constant state of interaction, influencing and frequently changing each other. The usual components, sometimes described as systems, of one's environment are family, including extended family, workplace, school, church, friends, and recreational and community organizations. Chronic pain has a profoundly disruptive effect on the delicate balance that exists between the person and the ecosystem. In this section the nature of those disruptions and their consequences will be explored and analysed. Chronic pain with its medical ambiguities presents a special kind of challenge to its victims. Pain is the most ubiquitous of all medical problems and is often associated with organic malfunction. In the absence of such malfunction, the chronic pain patient confronts extraordinary problems that have the potential to damage existing relationships and to create wholly unpredictable problems with both institutions and individuals. 'How can there be pain without medical cause? Have the physicians done all that can be done to find the cause? Have they missed something? Do I have a serious disease that remains undetected?' Almost everyone has heard a story of misdiagnosis that at the end killed somebody. Sometimes quests for help lead the patient to embark on a remarkable yet futile journey through the medical world. While the patient is obsessed with finding a medical cure, the process of psychosocial disintegration has already begun, a process that will ultimately lead to disability. Social disintegration occurs at many levels, and varying degrees of dislocation are experienced with different parts of the ecosystem. In addition the very age of a chronic pain patient (on average forty-two years, with all the issues of mid-life changes and adjustments) can create its own set of problems.

Social and Psychological Issues 7 Normally, a person will have a family, friends, neighbours, and relatives at the heart of the informal network. The semiformal systems may include school, church, clubs, and the family doctor. The formal systems consist of the health care system, employment, social service agencies, financial institutions, the Workers' Compensation Board (WCB). A commonly observed phenomenon is that as the interactions between the patient and his informal and semiformal systems decline, there is an almost corresponding increase in his involvement with the formal organizations. Most chronic pain patients do not have a problematic premorbid history; therefore, any explanation for their rapid decompensation has to be sought elsewhere. Once the patient embarks on the path to chronicity, inexorable forces seem to set in which cause widespread dislocations: disrupted family relationships,job loss, litigation, conflict with the health care system and with other institutions, and a withering away of social support; this may not even be a complete list of the problems that commonly occur in the lives of chronic pain sufferers. SOCIAL AND ECONOMIC CONSEQUENCES

The social and economic consequences have been borne out by a number of investigations. Crook and Tunks (1985) compared ninety family practice patients with fifty-six pain clinic patients. Only 16 per cent of the pain clinic patients were employed compared with 36 per cent of the family practice group. A remarkable 38 per cent of the pain clinic patients but only 2 per cent of the family practice patients were disabled. In addition the pain clinic group more commonly experienced: (1) a precipitating event associated with the onset of pain; (2) more intense and persistent pain and declining daily activities; (3) the presence of somatic and depressive symptoms; (4) social withdrawal attributed to pain; (5) job loss, occupational disability, and drug abuse; and (6) frequent use of the health care system.

8 Conceptual Issues Carron, DeGood, and Tait (1985) compared 198 patients from a university pain clinic in the United States with 117 similar patients from Auckland Hospital in New Zealand. The Americans were the more disabled group, 31 per cent being on compensation compared with 13 per cent of the New Zealanders; 13 per cent of the Americans and 5 per cent of the New Zealanders were on disability insurance. Another 13 per cent of the Americans and 22 per cent of the New Zealanders were on social security. In relation to social activities 51 per cent of the Americans and 38 per cent of the New Zealanders reported substantial reduction. Crying spells were reported by over half of the patients in each group. Volinn and associates (1988) cautioned that while back pain Was a common pain complaint, most individuals were not disabled by it. They concluded that disability due to back pain was a function of distress caused by fear of job loss and economic insecurity in conjunction with individual and environmental factors. In other words, factors other than pain itself contributed to the assumption of the disabled status. The idea that the threat of job loss can lead to disability needs careful examination. Psychological distress is a fact of life for these patients. Follick, Smith, and Ahern (1985) in a comparative study of subjects with chronic low back pain or rheumatoid arthritis and the general population found that the pain subjects were most adversely affected in the areas of physical, recreational, psychosocial, and work activities. Phillips and Jahanshahi (1985) investigated the social consequences of headache in 360 subjects attending a headache clinic in London, England. Avoidance of social activities was very pervasive in these subjects. A telling 82 per cent avoided attending parties, 77 per cent avoided having visitors, 77 per cent avoided visiting family or friends, and 75 per cent avoided going shopping. An astonishing 88 per cent of these headache patients preferred to rest or lie down as much as they could instead of engaging in any activities. In a nationwide study of the prevalence of pain in the

Social and Psychological Issues 9 United States, Sternbach (1986) observed that intensity and frequency of pain were susceptible to a variety of external influences which he described as hassles. He warned against drawing any causal associations without the benefit of further research. This study is of interest for stating the idea that social and interpersonal problems can be factors in the exacerbation of pain as well as problems caused by pain. PAIN AND SECONDARY GAINS

The obscure etiology of chronic pain in conjunction with indeterminate physical findings leads the general public, and significant proportions of health care professionals, and social service and financial institutions to associate chronic pain syndrome with malingering, and to see it, therefore, as a device for securing undeserved financial compensation. In fact, malingering is a rare phenomenon. The sheer scope of physical and psychological disability presented by chronic pain patients is such that simulation is virtually impossible. The psychological status of these patients can be objectively assessed by the use of many well-established instruments. The suffering and losses experienced by them are so enormous that the very idea of their seeking financial gain (secondary gain) by faking disability due to pain is an absurdity at best. What is construed as 'gain' is no gain at all when measured against the losses. In financial terms alone the compensation or disability pay usually falls substantially short of the patient's earnings. The gain may be more relevant in the psychological domain. At its simplest, sickness may be a way of receiving care and attention and for some the only means of receiving succour. Chronic pain patients provide little evidence of psychological gain as most of them demonstrate social withdrawal, family conflict, and pervasive anhedonia. Research into malingering and compensation in the chronic pain population has thoroughly discredited the myth that people resort to elaborate plans to emulate pain and disabil-

10 Conceptual Issues ity for financial 'gain.' In an unusual study Leavitt and Sweet (1986) surveyed orthopaedic and neurosurgeons in six geographical locations in the United States. Exaggeration of symptoms and incongruity between the patient's complaint and an objective medical finding were the two dimensions commonly employed by the physicians to assess malingering. Malingering seemed to occur at about the 5 per cent level according to 60 per cent of the respondents. However, 15 per cent of the sample reported a rate of malingering of over 20 per cent in their practices. The authors concluded that even if malingering occurred at the 3 per cent level, 240,000 persons were involved in malingering. Malingering was seen as a common phenomenon by one-fifth of the respondents. The critical issue is that the two factors exaggeration and incongruity between the complaint and objective finding are the most common presentations of pain patients seen at pain clinics. Is financial compensation sufficient motive for individuals to embark on a career of chronic patienthood? Recent studies suggest otherwise. Melzack, Katz, and Jeans (1985) compared eighty-one subjects with chronic pain, twenty-seven of whom were receiving compensation, with sixty-four subjects with musculoskeletal pain, fifteen of whom were on compensation. On the Minnesota Multiple Personality Inventory (MMPI) and the McGill Pain Questionnaire (MPQ) the compensation and non-compensation groups obtained virtually identical scores. Compensation patients registered fewer visits to health professionals and scored lower on the affective dimension of the MPQ. This might have been the result of reduced financial anxiety among compensation patients. However, the main finding of the study was that psychologically and in their pain evaluation the compensation patients were not distinguishable from the non-compensation ones. The authors pleaded that the patients awaiting litigation or on compensation should be treated with the same compassion as all other patients, and this plea is important in view of the observation of Tait, Chibnall, and Richardson (1980) that

Social and Psychological Issues 11 patients face the added stress of involvement in an adversarial medico-legal system. Gallagher and associates (1989) compared eighty-seven subjects with low back pain attending a pain clinic with sixty-three subjects with low back pain who had applied for, but had not received, compensation. At the initial assessment the compensation group provided more evidence of chronicity and physical and biomechanical decompensation. These differences disappeared when the length of time out of work was taken into account. Gallagher's group concluded that exclusive reliance on physical examination and inadequate consideration of psychological factors and adjustments for age and length of time out of work would result in an incomplete and distorted clinical picture. An inference of the study was that applying for compensation was not a signal of unwillingness to return to work. Mendelson (1984) also studied subjects, with low back pain comparing forty-seven who were involved in personal injury litigation with thirty-three without such involvement; the McGill Pain Questionnaire, Zung Depression Scale, State and Trait Anxiety Inventory, Eysenck Personality Inventory, and Hostility and Direction of Hostility Questionnaire were used. The two groups scored significantly higher than the normal population on depression, neuroticism, and trait anxiety. The conclusion was that persons involved in litigation failed to demonstrate a higher level of disability or pain than did the non-litigants. Dworkin and associates ( 1986) examined the relationship between compensation, litigation, employment, and longterm treatment responses in a group of 454 chronic pain patients. Their most important finding was that the patients who were working at the time of their admission to the treatment program responded more positively to treatment than did the unemployed patients. Employment was the most powerful predictor of outcome rather than litigation or compensation. Tunks (1990) conducted an elegant review of pain and WCB

12 Conceptual Issues compensation literature to explore the questions of persistence of symptoms and return to work after financial settlement. His conclusion was that financial settlement did not resolve the symptoms or increase the chances of returning to work. He noted that the Workers Compensation Appeals Tribunal of Ontario, Canada, recognized chronic pain as a genuine pain experience that cannot be explained solely on the basis of organic findings, and accepted that unknown organic and psychological factors are implicated in the etiology of this condition. The Tribunal, furthermore, acknowledged that a certain percentage of injuries generally lead to persistent and debilitating pain for which convincing organic cause would be missing. The Ontario Tribunal, in effect, confirmed what has been known to researchers and practitioners for some time. This ruling is one of its kind, even in Canada. Adoption of this progressive and correct view by compensation boards and insurance companies will alleviate the suffering and humiliation that become part and parcel of daily living for the chronic pain patient. Could avoidance of litigation and fair settlements save money in the long run? We hope that Ontario will have an answer to that question before very long. The cumulative evidence leaves little doubt that concepts such as secondary gain, compensation neurosis, and malingering should be applied with utmost caution, and that the traditional medical judgment based on apparently exaggerated symptoms and lack of physical findings suggests urgent need for re-education of health care professionals. There always will be a few errant individuals who will fake illness for financial gain; there are always exceptions, but that is just what they are, exceptions. SOCIAL WITHDRAWAL AND LOSS OF ROLES

Social withdrawal and loss of roles are not synonymous concepts, but may be viewed as complementary, since one results in the other. Clinicians of every stripe working with

Social and Psychological Issues 13 chronic pain patients are witness to the rapid loss of significant roles and the resulting social withdrawal in these patients. The literature supports the idea that a chronic pain patient spends an extraordinary amount of time inactive which translates into a severely circumscribed level of activities; it is less specific, however, about the actual activities and roles that chronic pain patients tend to discard. Diminution or even disappearance of sexual activities is commonly observed in chronic pain patients. Emotionally, this can be a significant loss as sexuality is often tied to one's self-esteem and identity. Job loss in combination with loss of libido must constitute an insult to the ego of some magnitude. Male patients often refer to this dual loss as 'loss of manhood.' Research tends to confirm that reduction or cessation of sexual activities in pain patients is common. Two factors account for such high prevalence of sexual dysfunction. First, pain itself is a factor that generally interferes with normal sexual activity, and second, anhedonia and depression, relatively common in pain patients, tend to have a negative impact on sexual drive. Estimates of sexual dysfunction range from 45 per cent of patients and spouses to 75 per cent patients and 84 per cent spouses (Maruta and Osborne 1978; Maruta et al. 1981). In an earlier study Hudgens (1979) investigated the family functioning of twenty-four chronic pain patients and found that eleven reported sexual difficulties. Gross et al. (1980) found that nine of twenty-five patients with pelvic pain reported a history of incest and childhood sexual abuse. Such abuse is predictive of sexual dysfunction in adulthood. Roy (1988) investigated the family functioning of twelve back pain and twenty headache patients and their spouses. Sexual dysfunction was reported by 75 per cent of the back pain and 60 per cent of the headache patients. While these figures are impressive, clinical observations suggest that normal sexual function in this population is the exception rather than the rule.

14 Conceptual Issues Loss of familial roles for chronic pain patients is a common experience. Actual research in this field is limited, but the findings point in the direction of major disruption of family roles. Roy and Thomas (1989) in a study of fifty-two patients attending a pain clinic and their spouses used the Family Adaptability and Cohesion Evaluation Scale (FACES III, Couple Version) and found that family adaptability (which measures the ability of the marital or family system to change its power structure, role relationships, and family rules in response to situational or developmental stresses) was in the chaotic range of family functioning. Role functions and household responsibilities were found to be highly dysfunctional. Decision-making, family discipline, and leadership were in considerable jeopardy. A rather sad conclusion of this study was that not only did the patient's roles alter for the worse, but the spouse's role function also moved in the negative direction. Family chaos was inevitable. In a comparative study of twelve patients with chronic back pain and twenty with head pain Roy (1988) reported that 50 per cent of the former and 25 per cent of the latter were ineffective in executing their household roles. Nurturing and supportive roles for both groups were severely compromised as 75 per cent of the back pain patients and 100 per cent of the head pain patients were functioning in the ineffective range. Hudgens (1979), in a study of twenty-four pain patients and their families, noted that the patients relied very heavily on their spouses, and role conflicts were relatively common. This would suggest that patients discarded many of their former roles, and male patients experienced conflict over assuming responsibilities for household chores. This latter phenomenon has been commonly observed in clinical practice. Follick and his associates (1985) also confirmed pervasive problems encountered by chronic pain patients in the area of home management. Rowat and Knafl (1985), in an unusual study of the effects of chronic pain on the spouses found that 75 per cent of the highly distressed spouses experienced changes in the rela-

Social and Psychological Issues 15 tionships with their children and marital partners in the area of division oflabour, decision-making, family activities, and financial functioning. Overall, role-related changes for these spouses were significant. Both Rowat and Knafl (1985) and Roy and later Thomas (1989) found that reduction in familial activities on the part of the patient did not necessarily result in the well spouse assuming more responsibilities: rather the spouse's capacity to function effectively was often compromised. PAIN AND DRUG DEPENDENCY

Drug and alcohol dependency in chronic pain patients needs to be viewed in its proper context. Medication is obviously the most common remedy for pain. Over-the-counter sales for simple analgesics amount to billions of dollars in the United States and Canada each year. For an individual suffering from chronic pain the path to drug dependency follows almost a prescribed course. Failure of this individual to respond to plain analgesics leads to use of prescription drugs of greater and greater potency. Narcotics, sedatives, and in the past few years antidepressant medication are prescribed in ever increasing dosage for the control of pain. Narcotics and sedatives are addictive, but antidepressant medications are not generally so. When the pain is unremitting and continues for a number of years a common consequence indeed is psychological as well as physical dependency on narcotic analgesics and sedatives. Drug dependency in a chronic pain patient is not to be confused with the pervasive problems with drug consumption in North American society at large or the use of illicit or illegal drugs. Most chronic pain patients are addicted to prescription drugs, which for the most part are readily available to them. How pervasive is the problem of drug dependency in the chronic pain population? Halpern (1982) estimated that between 30 per cent and 50 per cent of chronic pain patients have a significant level of drug dependency on narcotics and

16 Conceptual Issues sedatives. Fishbain and his colleagues (1986) calculated that in a population of 283 chronic pain patients, 20.4 per cent gave evidence of alcohol and drug dependency. Buckley and associates (1986) reported that 71 per cent of 173 patients admitted to the University of Washington Pain Center were consuming narcotics and sedatives. Turner et al. ( 1982) also found a similar proportion for drug dependency in a chronic pain population. Finlayson et al. (1986) studied fifty adult patients with chronic pain for substance dependency and found that very little attention was paid to their problems of addiction. That illness behaviour could be sustained through abuse of analgesic medication in the chronic pain population was observed by Black (1975). Swanson et al. (1977), in a detailed study of dissatisfied patients, found that drug addiction was the most common psychiatric illness in that group. The research to date on drug addiction in this population is not clear with regard to the proportion of chronic pain patients who may already have an addiction problem before the onset of chronic pain. Making allowance for that possibility, the conclusion has to be that the problem of drug dependency in the chronic pain population is basically iatrogenic. This last point is significant in that it points to one of the many negative consequences of chronic pain. Drug dependency is an additional burden that many chronic pain patients silently bear without benefit of specific treatment for it. CASE ILLUSTRATION

In the section that follows a case is presented that encompasses many, if not most, of the problems discussed in this chapter. The aim of discussing the history of Mr A is to demonstrate the extent of the dislocations that can and do occur through the emergence of chronic pain in an individual who otherwise may have led a reasonably problem-free existence. As a direct consequence of developing chronic pain, problems

Social and Psychological Issues 17 encountered by Mr A were so substantial that no single aspect of his living was left untouched. Prior to an accident Mr A was employed as a construction worker and had the reputation of being very knowledgeable in the field of commercial construction. He was married and had a small baby. His wife worked, and together they generated a substantial income. Mr A's parents, with whom he enjoyed a very close relationship, were alive. He was a churchgoer, had an extensive network of friends, and belonged to a number of social organizations. Just before he was injured in a work-related accident, Mr A's relationship with his employer had soured considerably. Allegedly, tools (worth several thousand dollars) belonging to Mr A were stolen, but his employer refused to accept any liability. Otherwise, Mr A had enjoyed a very close and productive relationship with his employer for several years. The accident, which occurred at a construction site, was from all accounts not particularly serious. While lifting some heavy material, Mr A slipped and fell, sustaining bruises on his buttocks and back. He was off work for a few days, but seemed to make an almost complete recovery and returned to his job. He discovered, however, to his dismay, that he had difficulty doing simple chores which frequently involved lifting. Nevertheless, he persisted, though his pain worsened, and he had to take time off again. His employer remained sympathetic throughout this period. During the second phase away from work, Mr A sought medical treatment, and after extensive radiological, neurological, and orthopaedic investigations, was pronounced fit. Mr A was incredulous as his pain was, in fact, getting worse. In view of his worsening condition, he decided to file for workers' compensation benefits. His employer denied any culpability, and in view of the negative medical findings, compensation was denied. As a starting point, the patient was left with no income and a very painful lower back. From an ecological perspective, Mr A was already in conflict, albeit in the early stages, with three formal systems.

18 Conceptual Issues First, he found himself in serious disagreement with the medical system, which, from his point of view, had minimized his pain and distress, and left him feeling essentially disbelieved. Second, he was simply outraged by the attitude of the employer to whom he had offered many years of loyal service, and, third, he felt summarily dismissed by the Workers' Compensation Board. Mr A's problems were only just beginning. An immediate consequence of the combined actions of the three organizations, namely the medical establishment, the employer, and the WCB, was a dramatic reduction in his income. The combined family income of approximately $60,000 per year, dropped to $18,000, which was the annual income of his wife. Thus began Mr A's struggle on the domestic front as well as with the world outside. Regarding his trials and tribulations on the domestic front, a great reversal of fortune occurred along with an equally measurable change in his roles and attitudes. Sexual activities came to a halt. The family could no longer afford to have the baby minded, and there was no need to do so for Mr A was always at home. Simply stated, the role of the homemaker was thrust on him. Although this was surely a logical solution, Mr A did not react kindly to his new challenge as a homemaker. He enjoyed looking after the baby, but the rest of the household chores were executed with much hostility and recalcitrance. The family had no savings, and with the loss of Mr A's earnings, their immediate task became one of finding cheaper accommodation, and they did manage to relocate. All this time Mr A was not so gradually sinking into a chronic sick role. His pain continued unabated, his mood sour, and there was a great deal of tension between himself and his wife. Mr A described this phase of his life as a nightmare! Mr A's search for a medical cure gained pace. He was seen by a number of specialists, including a psychiatrist, and the findings remained negative. In the meantime primarily because of the lack of money, many other tensions emerged in the family relationships. Social outings became non-existent,

Social and Psychological Issues 19 family get-togethers became rarer and rarer, even church and social activities were abandoned. All this happened in a matter of six months. Mr A's day-to-day living became characterized by loss of social support, including spousal support. Conflicts with the institutions designed to help him essentially negated or even trivialized his pain complaints, and caused him to become thoroughly demoralized. The genesis of all this was a minor work-related accident. The patient now became obsessed with his misfortune. Mr A's inner life was characterized by shame over his failure to provide for his family; pain, which remained a mystery; and anhedonia, as he gradually lost his capacity to enjoy life. Hopelessness and helplessness were the overpowering emotions he experienced, at the basis of which was a terrific loss of self-esteem as a man, a father, a husband, and a provider. Therefore, his informal network, which had consisted of friends, parents, in-laws, church, and clubs, was no longer a source of support for him. It was at this time and in this frame of mind that Mr A's family physician, having exhausted all other possibilities, referred him to the pain clinic. It needs to be emphasized at the outset that Mr A's story is by no means exceptional. Rather, it is a common tale narrated by many patients. The chronic pain problem may have different beginnings, the formal systems involved may vary in number, the person's family situation may be varied, but in the end, the psychological and social consequences are not all that different from what Mr A experienced. Because of the elusive nature of chronic pain syndrome and the severe psychological price that it seems to extract from its sufferers, the patient invariably has an increased sense of isolation and sadness, and feelings of being misunderstood. Again the very nature of the conflicts Mr A experienced with a number of formal systems can be attributed to the complex nature of chronic pain and the poor or even total lack of comprehension of its complicated and multifaceted nature by the helping professions, family, and friends, as well as institutions.

20 Conceptual Issues In a matter of months Mr A was reduced to the level of a poverty-stricken, totally dejected, and very lonely human being who also had to contend with an enormous amount of pain. It is hard to overlook the fact that the reversal of fortune this man had to endure was catastrophic.

2

Pain, Loss, and Grief

Medicine has historically resorted to psychiatry to explain inexplicable problems such as epilepsy or Alzheimer's disease. A quick glance through psychiatric textbooks of the 1950s will reveal these two conditions described at considerable length, but only now are they readily recognized as neurological disorders. This point is raised simply to point out the preoccupation in the chronic pain and psychiatric literature with the relationship between pain and clinical depression, especially in the reductionistic mode of the biomedical model. Pain in the absence of physical cause is psychogenic. Hence, a search for a psychiatric or psychological explanation for pain is logical, and has deep roots in history as well, but even with the now vastly increased knowledge of pain mechanisms and understanding of chronic pain, the search for its psychological and psychiatric etiology continues unabated; the relevant literature will be reviewed below. This preoccupation with viewing chronic pain as a manifestation of psychiatric disorder, particularly taking the currently popular biochemical view of mental illness, has not been without a price. If chronic pain, for example, is an outward manifestation of clinical depression, then the logical conclusion is that application of current treatment for clinical depression, which is almost exclusively pharmacological, will resolve the pain problem. That is one side of the argu-

24 Assessments and Issues ment. The other side is that somatic symptoms such as headaches and other more generalized pain symptoms are commonly observed in clinically depressed individuals. The effort to some extent has been to understand the chronic pain patient within the conventional biomedical context. One price associated with such a perspective is the scanty attention given to the ecology of this individual. Depressive symptoms are common among chronic pain patients, but an explanation for those symptoms resides partly in the social environment of the person and not solely in the biochemistry of the brain. A brief review of the pain and depression literature is offered to gauge the current state of knowledge. The central purpose of this chapter is to contribute to an understanding of the negative human reactions to the extraordinarily complex and difficult circumstances that pain patients have to endure, to which they respond with hopelessness and helplessness, sadness and despair. LITERATURE REVIEW

The current emphasis on the biochemical substrate for depressive disorders has in large measure discredited or certainly minimized alternative views of depression. A review of the chronic pain literature related to depression generally confirms the preoccupation with primarily the biochemical basis of depression. There are some exceptions to that general rule. If sadness is viewed as a reaction to an unfavourable set of circumstances rather than as a primary organic disorder, the circumstances of the chronic pain patient can readily explain the presence of depressive symptomatology. Significant losses resulting in a heightened feeling of guilt, compounded by feelings of helplessness and hopelessness, constitute a not uncommon picture presented by many pain patients. Murphy (1982) compared elderly depressed subjects with normal elderly subjects in the general population and found an association between occurrence of severe life events, major social difficulties, poor physical health, and

Pain, Loss, and Grief 25 onset of depression. She further noted that subjects from a working-class background within the general population demonstrated a higher than average incidence of depression and poor health, and higher levels of social difficulties. In addition, those elderly individuals who did not have confiding relationships demonstrated a higher level of vulnerability to depression. Brown and Harris (1975) also identified several vulnerability factors in their investigations of social causes of depression in women. Vulnerability factors included early loss of mother, employment status, and having three or more children living at home. Social class and life events were also found to be important determinants. In contrast, in the chronic pain literature there is a noticeable absence of interest in the relationship between the social context of the patient and its influence on the development of depression. Estimates of depression in the chronic pain population are so variable that arriving at any firm conclusion about the rate of prevalence is virtually impossible. Pilowsky (1988) in a major review of the relationship between affective disorders and pain examined the pain-depression research from the point of view of major depression, endogenous depression, and non-endogenous depression in intractable pain patients. He reviewed ten studies investigating major depression in such patients. The number of subjects ranged from a low of twenty (Schaffer et al. 1980) to a high of 283 (Fishbain et al. 1986). Six of the studies used the DSM-III criteria, one used the DSM-II criteria, another two RDC, one used Feighner and another IECD-9. The prevalence of depression in this population ranged from 0 per cent (Maruta et al. 1976) to a high of 50 per cent (Schaffer et al. 1980). Even for the studies using DSM-III criteria, the range was from a low of 4.6 per cent (Fishbain et al. 1986) to a high of 43 per cent (France et al. 1987). Pilowsky (1988) reviewed five studies investigating endogenous depression in intractable pain patients. The prevalence of depression ranged from 2 per cent (Pilowsky 1988) to a high of 14 per cent (Krishnan et al. 1985). Comparing non-

26 Assessments and Issues endogenous depression in intractable pain patients involved a review of eight studies, and the rate of prevalence ranged from 4 per cent (Pilowsky et al. 1977) to a high of 51 per cent (Fishbain et al. 1986). Pilowsky's conclusion was that a significant overlap existed between chronic pain syndromes and the affective disorders, but not to the point where they can be regarded as equivalent. A major conclusion to be drawn from Pilowsky's review is that the estimates of mood disorders in the chronic pain population still remain a matter of speculation; the studies are indicative of the major methodological problems that continue to plague this field of research. Bond (1979) subdivided pain clinic populations into two groups. He observed that 'the larger of the two consists of individuals who appear emotionally depressed to a variable extent and who have severe pain which is presented as the leading symptom and which is often experienced in the region of the face. Both depression and pain disappear on treatment with antidepressant drugs, and it is clear that the total suffering is a consequence of mental rather than physical illness in patients who may have a history of similar illnesses in the past and often a good premorbid personality.' The essence of Bond's claim that a significant if not a great proportion of chronic pain patients suffer from mental illness and respond positively to pharmacological intervention has indeed lost ground in recent years, although the fascination with it has not. Depressive symptomatology or non-endogenous depression caused by social stressors or, alternatively, psychodynamic factors, as described by Pilowsky, merits some discussion. Romano and Turner (1985), in an outstanding review of the chronic pain and depression literature, noted that 'preliminary attempts have been made to explain the coexistence of the two syndromes (pain and depression) in terms of biological, behavioral, and psychodynamic theories .. .' One of the major paradigms for exploring depression is loss and grief as propounded by the theories of Bowlby

Pain, Loss, and Grief 27 (1980) and further developed by researchers at the Tavistock Clinic and Harvard University, but this perspective has not as yet found favour with researchers in the field of chronic pain and depression (Parkes and Weiss 1983). Swanson ( 1984), in a paper describing chronic pain as a third pathological emotion, defined chronic benign pain as an emotion. He drew analogies between chronic pain, anxiety, and depression, and concluded that chronic pain was not an endogenous depression disorder but rather a chronic pain disorder which needed a rehabilitative approach to treatment. He, nevertheless, conceded that antidepressants were often effective in treating chronic pain. The relationship between loss and depression in the chronic pain population has received support from two different sources. First, based on a psychodynamic conceptualization of pain, Blumer and Heilbronn ( 1982) proposed that chronic pain patients presented a history of past abuse, a family history of mental illness, and alcoholism, as well as chronic pain and disability. They defined the syndrome as pain-prone disorder, and as a variant of depressive disease. The concept of proneness to pain was formulated by Engel (1959) to describe individuals who embark on a 'career' of pain primarily to expiate guilt, and who often demonstrate a childhood history of abuse and neglect. Loss of affection is a common experience for pain-prone individuals (see Chapter 3). Blumer and Heilbronn's formulation, which was a variation of Engel's proposition, has been, in large measure, repudiated. In a study of a different order Haley, Turner, and Romano ( 1985) investigated sixty-three chronic pain patients and found that the women's pain reports were closely related to their level of depression, but for men, depression was more strongly related to impairment of activity. This finding is of considerable importance as it supports Fordyce's formulation that depression persists when the patient's customary reinforcing activities are disrupted because of pain. Pilowsky and Bassett (1982b) in a study of depressed and chronic pain patients found that the pain patient rested, as

28 Assessments and Issues a result of pain for an average of 4.2 hours each day whereas depressed patients rested for 0.3 hour. Pain patients placed a much higher priority on help with pain reduction and improvement of activity levels than did their depressive counterparts. Furthermore, pain patients reported a greater degree of impairment in areas of body care, motivation, and ambulation. Many investigators have reported on the declining capacity of pain patients to function in their day-to-day activities, and they have suggested that a relationship should exist between markedly reduced functional capacity and sadness and that dejection should hardly be a source of astonishment. In a rather unusual study Skevington (1983) tested the hypothesis that universal helplessness was a common characteristic of chronic pain patients. She tested twenty-five patients with back pain and twenty-five matched pain-free controls. The respondents were interviewed, and also completed the following questionnaires: (1) Locus of Control, (2) Wakefield's Self-Assessment Depression Inventory, (3) Life Evaluation and Attribution of Responsibility, and (4) Pain Adjectives. A significant positive association was found between the length of illness and depressive symptoms. No significant differences were found on self-blame between the two groups, and self-blame did not significantly correlate with depressive symptoms of pain measures. In contrast, there was a highly significant correlation between beliefs and chance happenings and depressive symptoms in the pain group, showing that strong external attributions about control are associated with high frequency of depressive symptoms. Strong beliefs and chance happenings were also strongly correlated with the reporting of intense affective pain, but not sensory or evaluative pain. Pain patients provided evidence of greater belief in internal (personal) control, as well as greater belief in chance happenings. Skevington concluded that the results of her study dispelled the claim that depressive symptoms were an expression of personal helplessness. Factors that account for per-

Pain, Loss, and Grief 29 sonal helplessness, namely greater belief in control by others and greater self-blame for failure, did not feature in the pain subjects. However, universal helplessness represented by stronger belief in chance and a strong relationship between that belief and intense pain and considerable depression was a key finding. The clinical implications of this finding are important. When the question of the pathways followed by chronic pain patients is pursued, chance seems to play a major role. A vast majority of individuals in the face of minor work-related or automobile accidents recover spontaneously. The unfortunate few who constitute the chronic pain population follow a totally different trajectory. In the absence of any coherent explanation for their suffering, belief in chance assumes some degree of predominance in their cognition. Universal helplessness is the outcome and the manifestations of that helplessness are pain and depression. Arguably, the feeling of universal helplessness is accentuated and fuelled by mounting losses that usually accompany chronic pain. Depression has many different faces ranging from readily recognizable clinical mood disorder, to depression completely masked by physical symptoms, to sadness and grief, to individuals who go through life with a depressive outlook or characterological depression (Roy 1982). A few examples will demonstrate the highly varied presentations of depression that require different formulations and interventions. CASE ILLUSTRATIONS

Helplessness and Anxiety Rather than Depression Mrs B, at age forty-one, was referred by an orthopaedic surgeon for investigation of chronic back pain associated with dizziness. The pain was of twelve months' duration, and she was substantially incapacitated by it. Her personal history revealed a very deprived background which included the death of her father when she was nine years old. The family had always lived below the poverty line. At age sixteen Mrs

30 Assessments and Issues B became pregnant; she married and five more pregnancies ensued. Her husband, though an adequate provider, drank heavily. The couple separated for six years, but were reunited. There was some evidence of problems with their teenage children. Mrs B's mental status revealed a very articulate, but somewhat anxious woman. She was fearful about her back, and in dread of harbouring some unknown, but potentially terminal illness. She was preoccupied with thoughts about dying. Apart from her fear of back pain she did not present any evidence of unusual thinking, neither was there any clear evidence of a mood of either euphoria or depression. Many years earlier Mrs B had received electroconvulsive therapy for depression. The formulation for Mrs B was that her history of a harsh and abusive childhood combined with the loss of a major figure accounted for much of her feelings of chronic resentment combined with helplessness and anxiety. Despite her fear of death and somatic preoccupation, her overall clinical presentation failed to meet the criteria of DSM-III (revised) for a major mood disorder.

Sadness as Part of Life Experience Miss C, age twenty, was seen at the pain clinic with complaints of non-organic abdominal pain. She was described as severely depressed by the referring physician. Her current pain had a two-year history, but had significantly worsened in the immediate past. Miss C's personal history was bleak. Her father deserted the family when she was two. For the following five years she was minded by a host of individuals so that her mother could continue in her full-time job. Miss C. was physically abused by her father for nearly eighteen months. Her mother married another abusive, alcoholic individual when the patient was eight years old, and he abused the patient as well as her mother. Despite these major set-backs, Miss C achieved a grade 12 education, the completion of which coincided with desertion

Pain, Loss, and Grief 31 of the family by her stepfather, leaving them in a serious financial mess. About this time, Miss C was abandoned by her boyfriend, just two weeks before their planned wedding which left her totally devastated. Miss C had a history of relationship problems with men. On two previous occasions her suitors had called off their engagement. At the time of her arrival at the pain clinic she had been unemployed for six months. Keeping a job had not come easily to Miss C. Her horrendous childhood history of abandonment and abuse left her very poorly equipped to form and maintain adult reciprocal relationships. Miss C was in deep distress over the conduct of her last boyfriend. She felt sad, rejected, and humiliated. She did not have any problems with her sleep or appetite. Her feelings of worthlessness were reinforced by a series of events. Despite the set-backs her mood was not persistently dysphoric or subject to diurnal variation. Miss C was abused as an infant, and she continued to be in an abusive situation with her stepfather. Her self-esteem was severely compromised, which created interpersonal problems, especially with men. For obvious reasons she could not trust them, and tended to be very demanding. Miss C's depressive symptoms could be understood in the context of her early abandonment and a life-long history of abuse.

Where Is the Pain? At age sixty-nine Mr D presented with a prolonged history of head pain which had worsened some three years ago at the time of his retirement. The curious aspect of this case was that despite the long history of pain, Mr D had never sought professional help until his retirement. Even then he refused to take medication for pain. Generally, he was in excellent health. Mr D had retired as a vice-president of a multinational firm, but he continued to pursue his numerous charitable and community activities. Mr D, during the first interview at the pain clinic, showed very little interest in discussing his headaches. Rather, he

32 Assessments and Issues reflected on his wife's diabetes, which had led to her blindness. He spoke without emotion, almost with clinical detachment. He was not prone to being emotional, and no one could accuse him of losing his temper. The communicative significance of Mr D's headaches as a mode of expressing distress was unmistakable. Expression of negative emotions was not in his repertoire. Conflicts had to be avoided at any cost. His indifference to his headaches raised the question of his real reasons for seeking help. For a man of his intellect and personality, seeking help through physical symptoms was more acceptable. His overwhelming feelings of anger, loss, and sadness were revealed only in the course of psychotherapy.

Grief Reaction or Depression Mrs E, at age fifty-four, presented a lifelong history of migraine which had worsened during the previous six or eight months. Her developmental history was unremarkable. Her husband had died suddenly a year before she came to the clinic. They had been married for thirty years. The marriage had been a conflictual one, in particular because the Es held very different views on child-rearing. She believed in strict discipline, he was lenient. Her headaches had, to some extent, interfered with their social life. Otherwise, it was not a serious problem. Her major source of conflict with her husband, however, was his shift work. Mrs E's teenage son left home to move in with his much older girlfriend soon after his father's death. He was convicted for drunken driving, lost his licence, but continued to drive. Mrs E was simply distraught over her son's misdemeanours. The situation with her twenty-one-year-old daughter was also distressing. The daughter was overweight, unattractive, and neglected her appearance. Life for Mrs E was quite intolerable. She blamed her husband's untimely departure for the problems with the children. She became dysphoric and virtually a recluse. Her sleep and appetite were not seriously impaired.

Pain, Loss, and Grief 33 The formulation in this case was persistent grief due to the very sudden nature of Mrs E's husband's death accentuated by (1) unresolved issues in the marriage and (2) serious difficulties with her children. These stressors played a major role in worsening her head pain. These three cases are powerful examples of grief and pain: these individuals were not clinically depressed. Carefully designed probes into their current and past problems revealed with great clarity the plausible causes for their dysphoria and demoralization. They had had a long history of pain which deteriorated in the face of untoward events, disappointment, and grief. NATURE AND EXTENT OF LOSS

Parkes (1972) furthered the work of Bowlby by refining the very intricate relationship between loss and grief. In this section that relationship will be explored in the context of chronic pain. For many patients the path to chronicity and pain commences quite unremarkably with a minor trauma or injury. The accident or injury is not a crisis, and patients provide little or no evidence of psychological disintegration. Many patients continue to maintain a rather optimistic view of the future and have no premonition of what lies ahead. Gradual dawning of the awareness that the pain is not amenable to control or cure occurs. Losses begin to accumulate and multiply at an ever increasing pace. The most obvious loss, naturally, is the patient's deteriorating health. Physical limitations imposed by pain, loss of ability to do chores, and often loss of job make up a not uncommon sequence of events. Job loss happens after a period of trial and error. In the long run, however, the outcome is highly predictable. The loss of health and work combined amounts to a loss of great magnitude. For homemakers it may not be the loss of a job, but rather the incapacity to function satisfac-

34 Assessments and Issues torily in habitual roles. Feelings of dismay and despair may not be any less for the homemaker, though there may not be any immediate loss of income involved. Tangible losses can be usually attributed to the loss of health and job. Loss of or reduction in income follows, and social and familial roles begin to be compromised. The most telling of intangible losses is the insult to self-esteem. All future goals are put in abeyance and dreams and aspirations tend to fade. The patient is inevitably demoralized, but not always depressed, at least not in the clinical sense. In the section that follows several cases are presented to describe individual reactions to various types of losses. ILLUSTRATIONS OF TANGIBLE AND INTANGIBLE LOSSES

Two cases are discussed to show both tangible and intangible losses. The difference is one of degree. Conceptually, however, this distinction has merit.

A Case of a Fallen Star Mrs F, at age fifty-seven years, arrived at the pain clinic immaculately dressed, yet with a rather sad expression. In her younger years she had had a national reputation in the performing arts. As time progressed she became a teacher in her chosen field. Mrs F had had a fall during one of the teaching sessions, hurt her back, and became disabled. She was not able to claim any compensation against her employer because of a clause in her contract. The loss of her income had serious implications for her family. She had been married for a long time and had a grown-up family, but two of her children were still living at home. To complicate matters her husband's business had failed, which forced him to declare personal bankruptcy. A significant portion of his income was garnisheed for debt repayment. Thus, Mrs. F's weekly earnings had paid for the groceries. This patient kept up an outward appearance of well-being

Pain, Loss, and Grief 35 by dressing in expensive-looking clothes, which were purchased in second-hand stores. Appearance was very important to her. Loss of income for this woman was catastrophic. It meant having to do without food. Mrs F was desperate to find a cure for her pain, and as a cure remained elusive her psychological state deteriorated very rapidly. The substance of this case is that the loss of income for Mrs F and her family had immediate and serious consequences. She was ineligible for any financial aid because of her husband's relatively high gross income. The only avenue for material assistance available to her was food banks and charity, which she refused. A combination of circumstances had made Mrs F's family highly dependent on her low income, and the sudden loss of that income without any other resource highlights the acuteness of a tangible loss. This case, prima facie, seems dramatic in so far as this family was in dire financial straits prior to the onset of Mrs F's pain. The situation was perhaps a little unusual without being exceptional. Mrs F's psychological state was directly related to her job loss. In her own mind the pain and the financial problems became completely intertwined, and she often speculated that if she could find employment, perhaps her distress level would subside and even her pain become more manageable. Mrs F was very distressed; she frequently cried during the interviews, had multiple physical symptoms, and complained of insomnia. She was, however, not persistently dysphoric and evidenced no guilt or any ideas of unworthiness. She had the overwhelming sense of unjust treatment by her employer and the health care system. She was angry. Her depressive stance (sadness and anger) did not require complex psychiatric or psychological explanation. Rather, it could be understood and explained by a common-sense appreciation of her loss of health and income.

A Case of Intangible Loss, Loss of Authority At age fifty-four Mr G was injured in a motor-vehicle acci-

36 Assessments and Issues dent, which left him with multiple fractures in his right leg and many cuts and abrasions. His past history of accidents and ill health was extraordinary. He had had surgery nine times for various reasons and numerous falls over a sixteenyear period. He had a history of diabetes and hypertension. Despite his health problems and accidents, he had worked as a truck driver until the last accident. Mr G was born in a French-speaking, working class family in Quebec. His family moved to western Canada when he was a young schoolboy. He never quite succeeded in mastering the English language, but finished grade 8 and then dropped out of school. He was barely literate. His elderly father lived with him, his wife, and three of their five children; the other two had left home. His wife had a history of severe migraine and chronic low back pain. Their eighteenyear-old-daughter also suffered from migraine. Mr G was very unhappy that his son had lived with a woman for some time and then they had a child, who still was not baptized. To a devout Catholic the situation was unacceptable, but Mr G was at a loss to find any reasonable solution. He slowly withdrew from the arguments and bickering that went on between family members. Before his accident, Mr G was a rather easygoing, kind person, who enjoyed the relationships with his friends and family. But all that changed. He withdrew further and further from all his contacts and occasionally flew into an inexplicable rage. Family members stayed away from him, and he was rapidly losing the central position he had held within the family. He equated that with his loss of income. The displacement of his paternal role caused him most grief. He had difficulty defining this role, perhaps it was respect and dignity, or words to that effect. Mr G was in a state of high anxiety mixed with profound sadness. He was anxious about his health, and sad about his family situation. He reported insomnia and loss of appetite, although there was no weight loss. He failed to respond to antidepressants.

Pain, Loss, and Grief 37 The most important loss reported by Mr G was loss of respect and his pivotal position of authority in the family. The loss of health and job to him was less consequential than the loss of respect and authority.

A Case of Calamitous Loss Mr H emigrated to Canada from the United Kingdom. His lifelong dream had been to own a business. Through sheer hard work and with very little capital he was able to start one, which in time became a very profitable venture. Mr H was married with two children - his wife was a full-time homemaker, and life was just about perfect. His troubles started with a minor motor-vehicle accident, which left him with a whiplash. Although his pain increased rather rapidly, extensive medical investigation failed to turn up any convincing physiological cause for it. Two years elapsed between the accident and Mr H's referral to the pain clinic. He seemed very stoical in the initial interview, and stated in a matter-of-fact voice that the past two years had been a 'journey through hell.' Then followed an account of incredible misfortune and loss. The business that he had built up from nothing, and in which he had had enormous emotional investment, failed leaving him penniless. His wife had to go out to work for the first time in their married life, which caused almost a complete role reversal between them. Their sexual relations came to a virtual halt. Coaching a soccer team, which he could no longer do, had been his only source of joy after the accident and the business failure. Mr H was at a loss to understand how a minor accident could cause him so much pain and grief. He told his story virtually in a monotone. He denied any sadness or grief and insisted that he could pick up the threads where he had left off, if only a cure could be found for his pain. On a day-to-day basis he was living the life of an invalid. An interesting clinical feature of Mr H's presentation was an enormous gap between the magnitude of his losses and

38 Assessments and Issues the presence of grief. His pain was the vehicle for communicating with the rest of the world the 'injustices' he had experienced. This man's life had literally collapsed around him. What was the nature of Mr H's losses? The case of a successful businessman reduced to a state of impecuniosity, obliging his wife to go out to work for the first time in their marriage, does not lend itself to any easy classification. The losses were both tangible and intangible and of great magnitude. The losses were of such cataclysmic proportions for Mr H that denial and displacement probably prevented him from total psychological collapse. He displayed some confusion about which particular loss had affected him the most, the loss of his business or his wife working for money for the first time since they were married. Those two issues were, of course, interconnected but business failure seemed more acceptable to him than his wife supporting him financially. For a traditional and proud man, the situation was unbearable. SUMMARY

The research effort to link chronic pain with clinical depression is a worthwhile biomedical quest. In the absence of discernible pathophysiology capable of explaining chronic pain, psychiatry offers an alternative. As was stated earlier, this is not the first time in history that psychiatry has assumed this responsibility. Magni (1987), in an otherwise excellent review, concluded that 'a relatively high percentage of patients with chronic pain have a family history of depression, and depressive spectrum disorders.' The implication is that in many patients pain and depression coexist and that depression has a strong genetic basis. The evidence suggests otherwise. Family history of depression is, in the first place, not that pervasive, and second, estimates of depression in the chronic pain population remain an unfinished chapter. There is as yet lack of agreement about the rate of prevalence of depression in the chronic pain population. There is

Pain, Loss, and Grief 39 wide agreement, however, that depressive symptomatology is extraordinarily common in the group. The dilemma is that chronic pain is not a homogeneous clinical concept, and people who suffer from it are not uniform (Turk and Rudy 1991). The biomedical approach defining chronic pain along some narrow spectrum of psychiatric disorder is, in part, responsible for ignoring the significance of social variables in the development of depressive symptomatology in these patients. This chapter has focused on a variety of losses that patients suffer, a natural outcome of which is hopelessness and helplessness. The patient's hitherto assumed world is in jeopardy: depression is not an unnatural outcome. The purpose of this chapter has not been to reopen the debate about the relationship between chronic pain and depression. Rather, a case has been made that chronic pain patients experience a multitude of losses, and those losses combined with a sense of futility about recovering their health dispose them towards nihilism, helplessness, and hopelessness, and what Jerome Frank has aptly described as demoralization. The clinical import of the issues discussed above is that the individual experience of each patient needs careful evaluation for the full extent and nature of the losses to be appreciated, and only then can a proper formulation of the psychological state be achieved.

3

Life Events and Pain

The quest to unravel the relationship between life events and morbidity was started by Holmes and Rahe (1967). It resulted in the development of the Schedule of Recent Life Events, and several generations of investigators have used the instrument. In their studies with navy personnel, Holmes and Rahe found a weak but statistically significant relationship between morbidity and life events. Rabkin and Streuning (1976), in a major review of the research literature, concluded that 'the vast majority of life events studies have, until very recently, relied on statistical methods of the most rudimentary nature to analyze this relationship ... Reports of obtained correlation coefficients are often conspicuously missing. When present, they are typically below .30, suggesting that life events may account at best for 9 per cent of the variance in illness.' Since those early days many new elements have been incorporated in life events research. The influence of the dimensions of events is one such innovation that explores the desirability, predictability, and controllability of an event. The roles of buffers, personality factors, coping strategies, and attribution of meaning to the event have been demonstrated to have significant bearing on the power oflife events to contribute to morbidity. There is now a body of literature on the relationship between life events and onset of pain in adults and children.

Life Events and Pain 41 This literature falls into three broad categories: (1) life events and pain onset in children; (2) life events and pain onset in adults; and (3) demonstration of the absence of that relationship. LIFE EVENTS AND PAEDIATRIC PAIN

Coddington (1972a, b) modified Holmes and Rahe's Schedule to accommodate events in the lives of children. To that end he sought advice from teachers, parents, and mental health professionals. He surveyed 3,500 healthy children to determine the amount of social adjustment these children had had to make during the previous year. A telling finding of that seminal study was that as a child 'expands his social sphere he risks the occurrence of life events, both good and bad. The amount of adjustment required often increases.' Such increases are evident at six to seven years of age, when most children start school, and again at twelve to fourteen years of age when a major jump occurs with the onset of puberty. Investigations into the relationship between paediatric pain and life events are few. Hodges and associates (1984) compared thirty children with recurrent abdominal pain with sixty-seven behaviourally disordered and forty-two healthy children. The life events experienced by these children during the preceding twelve months were assessed and the amount of readjustment was measured. Children completed the Coddington Life Events Inventory and the parents the Life Experience Survey. The abdominal pain group and the behaviourally disturbed children reported significantly more life events and stress ratings than did the healthy children. In comparison with the healthy group, the abdominal pain group reported more events related to serious illness or the hospitalization of a sibling, decreased arguments between parents, the death of a grandparent, the death of a close friend, and less acceptance by peer groups. The abdominal pain group experienced more illness-related events and changes in interpersonal issues than did the behaviourally

42 Assessments and Issues disturbed group. The behaviourally disturbed group had more experience of school failure, changing schools, and increased arguments between parents. The above study confirmed the main findings of earlier work done by Hughes and Zimin (1978), who found that abdominal pain of obscure etiology in children was positively correlated with life events that were health- and death-related. They urged caution in interpreting the fewer than average episodes of life events reported by the control group. Future research, they recommended, should take into account events prior to the twelve-month period from the time of the onset of the pain symptom. Wasserman and associates (1988) investigated eighteen girls and thirteen boys with recurrent abdominal pain and matched control subjects who were compared in regard to school functioning, family environment, life events, and social and behavioural traits. The Coddington Life Events Inventory (age appropriate) was used, but with radically different findings than in the previous study. On life events, no significant differences emerged between the abdominal pain subjects and the controls, but in keeping with the findings of Hodges et al. (1984) this study found that the pain subjects were more likely to experience more hospitalization, parental hospitalization, and death of a grandparent. The major differences between the two groups were found in health and illness issues. The pain subjects were more prone to internalize their feelings and were more anxious. These children also had a positive family history of abdominal pain. Robinson and colleagues (1990), in a complex study, compared forty-two children attending a paediatric clinic and control subjects, with seventeen children with abdominal pain and control subjects. The Children's Life Events Inventory was used. Undesirable and interpersonal-conflict-related life events were more evident in the abdominal pain group in the year prior to the onset of pain. Children from all groups reported a similar number of life events except for the year before, when the clinical groups reported a marked-

Life Events and Pain 43 ly higher number of life events. The recentness of events and their undesirability were two powerful factors in predicting abdominal pain. LIFE EVENTS AND ADULT PAIN

The literature on life events and morbidity has grown astronomically over the past twenty years. The same cannot be said about life events and adult chronic pain. Nevertheless, a sufficient body of literature exists to merit a review. Craig and Brown (1984) compared 135 patients between the ages of eighteen and sixty years from a continuous series of attenders at three gastrointestinal clinics with a matched series of control subjects. The abdominal pain group were first-time attenders at the clinics, and their pain symptom had appeared within the previous twelve months. The Bedford College Life Events and Difficulties Schedule was used. In 56 of the 135 subjects the pain was of organic origin, and systemic diseases explained the pain in another 5 subjects. The balance was pain without discernible organic cause. Severely threatening events and major difficulties were pervasive in the clinical population. These events usually happened over a thirty-eight-week period prior to the onset of pain. Fifty-seven per cent of the non-organic group, 23 per cent of the organic group, and 15 per cent of the healthy subjects experienced a severe event resulting in some kind of major loss. This study essentially confirmed a strong association between threatening life events and the onset of non-organic abdominal pain. For organic pain subjects, life events caused derailment of goals often leading to depression. The relationship between life events and acute chest pain in subjects below the age of forty years was investigated by Roll and Theorell (1987). Neuroticism, type A behaviour, and vital exhaustion were also examined. The clinical group consisting of thirty-six men and thirty-three women was

44 Assessments and Issues drawn from an emergency care unit, and a control group matched for age and sex consisted of thirty-two healthy subjects. A modified Holmes and Rahe's Schedule and Paykel's List of Life Events Questions were used. Life Events Questions were divided into desirable and uncontrollable events. All uncontrollable events were undesirable. The patient group (with sixty-eight events) had experienced significantly more undesirable events than the control group (with thirty-one) over the previous twelve-month period. The magnitude of negative life events in combination with personality factors accounted for the onset of chest pain. The association between life events and chronic primary headache (CPH) was investigated by DeBenedittis and colleagues (1990). Sixty-three patients with CPH were compared with forty-four subjects (twenty-six pain-free and twentyeight neurological patients) matched for age, sex, and socioeconomic status. The results established that the CPH patients reported a statistically significant greater number of recent life change events than the control subjects, but only during the twelve months prior to onset of headache. The death and serious illness or injury of close family members and major personal illness or injury were the most common types of stressful life events reported by the headache group. The CPH patients, in addition, reported an increase in their experience of life events prior to onset of headache. A significant increase in negative experiences based on personal ratings of the distress associated with life events during the same period had more predictive power than normative life change units for the CPH group. In other words, the patient's perception of the event, in terms of its noxiousness, had enhanced the capacity to induce morbidity beyond the standardized scores. Atkinson and his colleagues (1988) investigated the influence of stressful life events in the development of depression in patients with chronic low back pain (CLBP). A structured interview elicited life events data which assessed both self-

Life Events and Pain 45 report and interview-rated measures of life stress over a twelve-month period preceding the evaluation. Overall life events were based on Dohrenwend and Dohrenwend's Psychiatric Epidemiology Research Interview. The Beck Depression Inventory and Hamilton Rating Scale for Depression were also utilized. Thirty-four consecutive male patients attending an orthopaedic clinic composed the CLBP group. Two subgroups of CLBP patients were based on a cut-off score for depressed mood and depressive symptoms on both the Beck Depression Inventory and the Hamilton Rating Scale for Depression. Seventeen CLBP patients and nineteen control subjects were not depressed according to these measures. The major finding of the study was that depressed CLBP patients reported significantly more life events, more stressful life events, and more ongoing life difficulties than either the non-depressed CLBP or non-depressed non-pain controls. The authors concluded that 'the increased stress reported by the distressed depressed CLBP group primarily appears to be a function of events that are related to their back problems, rather than independent events.' This last finding was supported by Smith et al. (1985), who also investigated the role oflife events and psychological disturbance in patients with chronic low back pain. Negative life events were clearly associated with depression and social maladjustment emanating from the pain conditions. Specifically, negative events were associated with discouragement, depressed mood, dissatisfaction, anger, and social maladjustment. These last two studies are of considerable clinical significance. Their primary concern was not the etiological significance oflife events, but rather the multitude of changes that occur as a consequence of developing chronic pain and the impact of those events on the psychological and social wellbeing of the patients. In a rather unusual study, Oosterhuis (1984) converted 840 life events into eighty-one descriptions which covered most stressful situations. These eighty-one constructs were

46 Assessments and Issues converted into three lists depicting irritating situations, fearprovoking situations, and distressing situations. An interesting correlation was found between anger and pain in the neck, between fear and abdominal pain, and between sorrow and despair and low back pain. Another finding was that good correlations between psychological state induced by life events and the absence of organic pain at the time of examination made organic causes very unlikely. The preceding studies demonstrated a clearly positive association between life events and the onset of pain and life events precipitated by the pain problem itself. The findings of the following studies, however, are equivocal about the role of life events in the etiology of pain. Feurstein and colleagues (1985) in a comparative study of thirty-three ambulatory subjects with chronic low back pain and thirty-three healthy control subjects found that the Social Adjustment Rating Scale measuring environmental stressors was not predictive of pain. Rather, measures of specific aspects of work (Work Environment Scale) and family environment (Family Environment Scale) were more powerful predictors of pain than a general stress index. Stockton and her associates (1985) examined the relationship between life events and psychological factors and upper abdominal pain, varicose veins, gastrointestinal problems, breast lumps, and hernias. The subjects comprised 215 new surgical patients drawn over a period of twelve months. The state of anxiety in male subjects was the only significant group difference to emerge. Life events and psychological factors were discounted as having any significant etiological bearing in a number of disorders. In the same vein, Pilowsky and Bassett (1982b) investigated life event issues in a group of 114 pain subjects referred to a pain clinic, fifty-two of whom were also depressed. On the basis of a modified schedule of Recent Life Experience, depressed patients had had more life events one year prior to their presentation, and the remaining pain patients

Life Events and Pain 4 7 had had significantly more life events in the ninth and tenth year prior to presentation. Life events were not found to be significant for the development of pain. In a study of seventy-three non-psychotic subjects, eighteen of whom were without pain and forty-five of whom had pain complaints, no differences were found between the two groups in their experience of social stress as measured by life events. The presence of pain could not be accounted for on the basis of life event scores (Jensen 1988a). Jensen (1988b) compared a group oflow back pain subjects with headache subjects to determine the impact oflife events on outcome of treatment. The life events scores were not significantly different between the two groups. Neither was any significant association found between life event scores and treatment outcome. Treatment outcome was independent of the amount of social stress as measured by life events. In a retrospective study of 151 patients with temporomandibular pain and dysfunction syndrome and a matched control group, Marbach and associates (1988) found no significant difference between the groups with regard to the actual number of life events. However, significantly more illness events and social network losses were reported by the patient group. Shrinkage of the social network for chronic pain patients is commonly observed in clinical practice. Crisis theory, as proposed by Caplan (1964), provides another conceptual model for exploring the relationship between life events and their impact on people. Caplan observed that crisis was very much a part of life, but adaptation to crisis was a less predictable proposition. Many people grow from their crisis experience, while others succumb to emotional and even physical ill health. Crisis through loss of work and income is a relatively common experience for pain patients (and is discussed in a subsequent chapter). The literature points up the nature of the continuing debate over the relatively noxious power of life events in the genesis of pain. The quality of research has improved mark-

48 Assessments and Issues edly since the review by Rabkin and Strueing. Assessing the dimension of the events, buffering factors, and sophisticated statistics are some of the more apparent improvements. Prospective research is still a rarity. Life events may have some role in the etiology of pain, and that line of research should continue. Chronic pain itself is capable of generating whole series oflife events. The impact of those events on the course of the illness also requires further investigation. From a clinical stance, negative life events induced by the pain condition have much significance, if comprehensive formulation and successful treatment are desired. CASE ILLUSTRATIONS

Life events either preceding the onset of pain or as a direct consequence of the pain are commonly observed in the chronic pain population. Social and psychological issues often complicate the clinical picture. Headache patients often contact a pain clinic following experience of negative life events (Roy 1986). The key concern, however, remains that farreaching changes occur in the lives of people following the onset of pain, as the cases below will demonstrate.

Life Events as Partial Explanation for Pain The case of Mrs E was briefly discussed in the previous chapter. Here, it is further analysed to highlight the life events issues. This fifty-four-year-old widow was referred to the pain clinic for severe and persistent pain. Her husband had died suddenly some two years earlier. She was sad and withdrawn when first seen at the clinic, but soon thereafter she developed vegetative symptoms - loss of appetite and early morning awakening. Following a thorough psychiatric evaluation, Mrs E was placed on tricyclic antidepressant medication, but after six months on this there was no significant change. If anything, she was more withdrawn and less keen to continue in the pain clinic. At this point it was considered instructive to look back on Mrs E's life.

Life Events and Pain 49 Background History Mrs E was born into a middle-class family, the older of two siblings. Her mother was a homemaker and her father was a bank manager. Her developmental milestones were well within the normal ranges. She recalled her childhood as 'not particularly unhappy.' Her father was cold, distant, and authoritarian, and a rather heavy-handed disciplinarian. He never resorted to physical violence, but always found 'novel' ways of punishing the children - of whom he had very high expectations. The children lived in dread of letting their father down. In contrast, the mother was a gentle person who held considerable sway over her husband and often succeeded in modifying his unusually high expectations of the children. Mrs E was deeply attached to her mother. She was convinced that her mother enabled her and her sister to grow up in a reasonably normal environment. Mrs E had completed high school without any difficulty. Despite the strains of her early years, they had been pain free. Her first memory of headache was at age fourteen, which coincided with the onset of her menses. These early headaches were mild, lasted a short time, and cleared up spontaneously. From about age twenty, however, her headaches became more frequent and intense. At that time she was living alone, had a job, and the headaches began to get in the way of her social life. She consulted her family physician, but the pain did not improve. Despite the pain, she saw herself as a basically healthy person. At the age of twenty-four she married a man she had known for two years. Her headaches continued to interfere with their social life, becoming a source of some conflict in the marriage almost from the beginning. They had two children in quick succession. In the meantime, Mrs E's headaches got worse to the point that she could not always function, and her husband had to assume more and more domestic responsibilities - which he resented. This conflict stayed with them for the remainder of their married life. Mrs E lived with the feeling that she had cheated her

50 Assessments and Issues husband out of a 'normal' marriage because of her head pain. They had conflicts in other areas, mostly in their attitudes to child-rearing, with Mrs E being the strict one while Mr E, was easygoing. Her views on discipline were remarkably similar to her father's. Another source of conflict was Mr E's shift work. Mrs E never got used to it, and constantly criticized her husband for not having a 'proper' job. They had problems with their children. The elder of the two, a daughter, did not present any serious problems until her late teens, when she gained a great deal of weight and dropped out of school. Their son, who was 'spoiled rotten' by the father, was a very poor student, failing in many subjects. He was involved in petty thefts and driving without a licence. At the age of fifty-two, Mrs E's husband died in a dramatic manner. He returned home from work, rang the doorbell, and before Mrs E could answer the door, he had a massive coronary attack and died instantly. Following her husband's death, Mrs E's headaches took a decided turn for the worse. Her son's antisocial activities increased. He was convicted for drunken driving and later for driving while on suspension. At about the same time, he decided to move in with a 'much' older woman. All this caused Mrs E a great deal of added grief. Her daughter was leading an aimless existence. It was under these circumstances that Mrs E was referred to the pain clinic with the complaint of severe and unabating head pain. Diagnostic Considerations Mrs E was initially diagnosed as having mixed headache (mixture of migraine and muscle contraction). This is a relatively common presentation of head pain, and it is not always possible to strictly adhere to the diagnostic criteria of the Ad Hoc Committee on Headache (1962). Headaches can and do occur in the absence of any obvious psychological stress, but anxiety and depression are not uncommon among headache sufferers. Diagnostic confusion was evident in Mrs E's case. Over the

Life Events and Pain 51 decades, her diagnosis had included conversion, tension, and migraine headaches, as well as mixed head pain. Personality Dynamics Mrs E provided a great deal of evidence for her propensity to internalize her negative feelings. She was not particularly forthcoming with her positive feelings, either. She remained very dependent on her husband, partly because of her headaches, against which she had struggled rather unsuccessfully all her life. Her attitudes tended to be rigid and conventional. Mrs E was constantly horrified by the changing mores of society. It is rather doubtful if any of these factors directly contributed to the etiology of her headache. Conceivably, they contributed indirectly by contributing to her unsteady emotional state. Nevertheless, the personality characteristics observed in Mrs E are important from the point of view of intervention, as it was surmised that adaptive coping was significantly compromised by her personality traits. Social and Family Factors Mrs E, in many ways, had led a very sheltered life and lived with many unresolved conflicts. Her social life was entirely driven by her husband's activities. She had no outside interests and not one close friend. She was, essentially, dissatisfied with her lot. Her headaches, it may be argued, were one way of expressing that disaffection - the communicative aspect of pain can be very powerful. In short, Mrs E's headaches severely restricted her roles and responsibilities. Neither as a mother, nor a wife, nor a homemaker, did she derive any satisfaction. She had not worked outside the home since her marriage and had no particular social role in her community. Mostly she was the wife of so-and-so. With her husband's death, that too was lost. Assuming a sick role through her pain took on major importance in her life. The 'medical' aspect of chronic pain is often ambiguous and can be a source of misunderstanding and conflict within a

52 Assessments and Issues family. The conflict centres on the family's expectations of the patient and the patient's ability and willingness to meet those expectations. Although conflicts of this nature were very evident in Mrs E's relationship with her husband and children, with the death of her husband and her son leaving home, she was left in a vacuum. A chronic sick role was, perhaps, the only viable role left for her. Family conflict had been a part of Mrs E's entire life. A distant and harsh father, an overindulgent (compensating) mother, an unsympathetic husband, and uncaring children is a rather sad catalogue of her family relationships. Her marriage was filled with conflict and mutual hostility. Headaches provided her with an 'honourable' and justifiable way of disengaging from the family, both symbolically and physically. All the life events let loose by the death of her husband would add up to a very significant number. Mrs E, until the death of her husband, had never written a cheque or paid a bill. Morbidity was not such an unpredictable outcome. Reconsideration of Life Event Issues When life events are judged in the larger context of a patient's environment, their impact can be more carefully assessed. A major event, like the sudden death of a spouse, has the potential of spawning many unpredictable and unusual events - a process that has serious clinical implications. On reflection, Mrs E's arrival at the pain clinic so soon after her husband's death was not surprising. She chose headache rather than sadness and grief as the major problem for which she was seeking help. She was totally unprepared to take on the running of her home, management of her finances, and the responsibilities she perceived in regard to her children. Her feelings of helplessness with her son presumably interfered with her normal grieving process. So many uncontrollable and undesirable events in her life, all happening almost simultaneously, together with diminished social support, could not possibly leave her unaffected. A

Life Events and Pain 53 combination of childhood issues, a sudden death, and incidental other changes, as well as a history of head pain, created an optimal situation for sickness.

Unaware of Life Events? Mrs I, at age twenty-nine, was referred to a pain clinic by her neurologist, who wrote that Mrs I had mixed headaches and disliked taking medication. She was, however, consuming analgesics in ever increasing quantities. Could non-pharmacological treatment be considered in her case? Despite a clear request to bring her spouse for her first appointment, Mrs I came alone. She was meticulously dressed, looked a little anxious, and expressed serious concern about becoming a drug addict. Her headaches were getting worse, and she was consuming narcotic analgesics in alarming quantity. Although she denied any current difficulties, she remained very puzzled about the sudden increase in the head pain that she had learned to live with from her late teens. She was prescribed Elavil by her family physician. However, she was very unsure about the reasons for being on an antidepressant. A carefully constructed probe into her social situation revealed rather startling facts. Two of her close relatives had died in the recent past. She herself had returned to university, after several years' absence, to finish her degree. Her husband, a graduate student, was, however, totally absorbed in his thesis work. There were two young children, aged five and three years. Mrs I's return to school had upset the family arrangements. She insisted on hanging onto her family responsibilities, although at times she found it virtually impossible. She also found it impossible to ask her husband for help. This case is instructive for several reasons. First, Mrs I seemed genuinely unaware of her sense of loss and grief related to the two deaths. There was no manifestation of grief; perhaps she was expressing grief through her headaches. Second, she made a major move by her decision to

54 Assessments and Issues return to school. Again, she seemed unaware of the repercussions. Denial of life's problems seemed to be operating again. Mrs I had a vague sense of guilt about going back to school at a time when her husband's studies had reached a critical point. In any event, her decision to return to school engendered a series of readjustments in their living arrangements, most of which were stressful. The life events she had experienced were of a significant nature and gave rise to her unhappiness. Curiously, her unhappiness was expressed through her headaches, and it was for these that she sought help. Her distress found expression in her head pain. A matter of clinical import is that without the benefit of very careful probes into her life situation these very critical facts would not have emerged, and she would have persisted in her mode of denial.

Life Events and Total Devastation Mr J, who was forty-two years old, had emigrated to Canada from a Mediterranean country and, from all accounts, had settled down very well in his chosen country. He had a secure job, a car, and was buying a home - an immigrant's dream come true. He had been happily married for several years and had three children. The future looked promising. Mr J's problems began with a work-related accident involving his right hip and leg. The injuries were of a minor nature, and he thought of the accident as no more than an inconvenience. As time passed, however, his injuries, instead of improving, continued to get worse. Within a short period of six months, Mr J was almost totally incapacitated by pain. He received workers' compensation and began his search for a medical cure. His anger at the medical profession's indifference to his problem kept rising. He could not work, withdrew from his family roles, neglected his friends, and consumed a vast quantity of tranquillizers and narcotic analgesics. He became somewhat of a family tyrant, constantly criticizing the children, who in turn just avoided him. He was a conventional person with rigid views on masculine

Life Events and Pain 55 roles. His inability to work and be the 'rightful' head of the household played havoc with his self-esteem. He resented his wife for taking over some of his responsibilities, such as the family finances. All three children became problematic: the eldest son, who was nineteen, was threatening to drop out of school; the fifteen-year-old daughter was showing signs of depression; and the younger son, age fourteen, was resorting to hard drugs. Until his accident and subsequent loss of employment, Mr J had been the undisputed leader of his household. He was authoritarian, but kind and considerate towards his family. His children had genuine fondness for their father. Mr J's behaviour gradually changed, and his outbursts became more frequent. His wife left him. Devastated by the changes in his fortune, in due course, Mr J committed suicide. Unlike the previous two cases, all the changes in Mr J 's life occurred after the accident. His view of having lost his job, the most unacceptable event to him, merits further consideration. Loss of authority, loss of his undisputed position of leadership in the family, and a clear violation of what it meant to him to be a father and a husband were tied to his inability to be a good provider. Relative poverty and economic uncertainty in his own country had prompted him to seek his fortune elsewhere. Work was more than just making a living. To Mr J work and self-respect were inseparable. Mr J had a highly developed sense of justice. He fought the authorities on his own behalf, and on behalf of his fellow pain sufferers. He tried to organize a union of sorts for disabled pain patients. He lobbied politicians and professionals for changes in legislation related to workers' compensation, but without much success. All this enraged and saddened him. This case is a powerful example of the significance that individuals attach to events. Being unemployed was to Mr J, in a literal sense, a fate worse than death. Losing his job was not simply losing his means of livelihood; it went to the very heart of how he had defined himself as a man.

56 Assessments and Issues SUMMARY AND CONCLUSION

The life events literature is equivocal on the significance of events in the etiology of pain. One body of literature demonstrates that power, another negates it. The quality of research has improved since Holmes and Rahe created an objective way of measuring the impact of life events. Despite many advances in methodology, however, the findings remain problematic. Nevertheless, from a clinical point of view, a few important points should be noted. First, negative and undesirable events can and do exacerbate existing problems, and I have previously reported (1986) that such events often result in health-seeking behaviours in headache patients. Second, a minor trauma seems to have the extraordinary capacity to set off a chain of events that ultimately creates the chronic pain patient. Negative event after negative event falls upon these individuals. Despite the ongoing dispute in the research findings, the clinical relevance of life event issues for chronic pain patients is all too obvious. The three cases discussed in this chapter present rather different perspectives of change associated with life events and loss. In the first, the death of the spouse was very sudden, and the entire grieving process was complicated by personality and family factors. The case of Mrs I was truly a story of untold and perhaps unacknowledged life events. Did her headaches obliterate or become a substitute for her grief? The clinical observations pointed in that direction. The case of Mr J, the most tragic of all, on the surface eludes common sense. How can a minor injury have such awful consequences culminating in suicide? Destructive forces were unleashed by what appeared to be a minor event. Cultural values, personal pride, failure of the health care system, and perhaps even other, unknown factors led to the disintegration of a family and the death of one of its members. Research is a long way yet from explaining the individual responses to life events.

4

Childhood Abuse and Neglect: Pain in Adulthood

What possible relationship could there be between childhood physical and sexual abuse and neglect and pain in adulthood? The paramount importance of childhood events in the shaping of the adult personality was at the heart of Freud's psychoanalytic thinking. Although his psychosexual theories have been, in large measure, rejected, neo-Freudian researchers such as Bowlby and more recently Rutter and his colleagues, have confirmed and reconfirmed that childhood events exert enormous power on the health and well-being of the adult, although the exact nature of the relationship is yet to be fully unravelled. Physical and sexual abuse must count as among the most traumatic experiences a child may encounter. The long-term consequences of childhood abuse are rapidly becoming a wellresearched field: depression, antisocial behaviour, psychiatric vulnerability, persistent interpersonal difficulties, and substance abuse are indeed some of the more common long-term repercussions. Psychosomatic and psychogenic disorders as outcomes of childhood abuse are not so well investigated. However, when a significant level of injuries is inflicted on the victim of physical and sexual abuse, the abuse may cause failure to thrive in very young children as well as significant physical and neurological deficits later. It is inconceivable that psychological and physical trauma combined would not

58 Assessments and Issues predispose some individuals towards psychogenic and psychosomatic disorders. One plausible explanation for the neglect of research in this area is that the psychogenic or psychosomatic outcomes are relatively benign compared with adult sociopathic behaviour and other serious antisocial manifestations of childhood abuse. The relationship between childhood abuse and pain was first discussed as a clinical proposition by Engel (1959) in a paper entitled 'Psychogenic Pain and the Pain-Prone Patients.' He developed this concept to describe individuals who lead a life of pain and who use pain to expiate guilt. Usually, in their childhood these individuals experienced a great deal of emotional and physical abuse, the net effect of which is that as adults they have a singular inability to directly express anger. It is a tribute to George Engel that even more than thirty years after the publication of his paper, his idea continues to draw much attention. In this chapter, the concept of proneness to pain will be examined from a somewhat broader perspective than Engel originally proposed. First the concept itself will be re-examined; second, a critical review of the research literature related to proneness to pain will be presented; and, third, the literature related to (1) childhood abuse and (2) neglect will be reviewed to determine if pain-proneness in general and psychosomatic disorders in particular have been recognized as possible outcomes of childhood abuse. The following is Engel's description of the pain-prone patient: 'for the most part these patients repeatedly are chronically suffering from one or another painful disability, sometimes with and sometimes without any recognizable peripheral change. There are also patients who have only a single or occasional episode of pain, among whom essentially the same psychic mechanisms are operating. Such patients, by no means, constitute a homogeneous group and yet they have many features in common.' The features Engel referred to can be divided into two categories: first, those indicative of clear abuse or 'minimally' an abusive situation including

Childhood Abuse and Pain in Adulthood 59 neglect, and, second, others where there is no direct evidence of the presence of an abusive situation. Engel provided the following five scenarios of childhood abuse and neglect: (1) parents who are physically or verbally abusive to each other and/or their children; (2) one brutal parent and one submissive parent, the former sometimes an alcoholic father; (3) a parent who punishes frequently, but then suffers remorse and overcompensates with a rare display of affection so that the child becomes accustomed to the sequence of pain and suffering to gain love; (4) a parent who is cold and distant who responds with affection when a child is ill or suffering pain to the point that the child invites injury to elicit such a positive response from the parent; and (5) the child who deflects the aggression of a parent away from the other parent onto himself, usually with much guilt. Under all five conditions, the child would be confronted with for the most part directly abusive situations. Kempe's classic paper (1962) on the battered child syndrome appeared a short three years after Engel's on proneness to pain. Two more non-abuse related conditions which could promote pain-proneness were described by Engel: (1) parental pain or pain in a significant figure close to the child for whom the child felt responsible and perhaps even guilt and (2) a situation which led to the abandonment of feelings of aggression or pain by some sudden event where the abandonment was usually associated with guilt. The above mechanisms demonstrate the unconscious substrate for somatizing behaviour, thus offering an alternative causal explanation for pain-proneness. Clearly, they fall outside the scope of this chapter, the central focus of which is a critical examination of evidence of the relationship between childhood abuse and adulthood pain. PAIN-PRONENESS LITERATURE

Abuse and Proneness to Pain Empirical evidence for Engel's concept of pain-proneness

60 Assessments and Issues continues to be rather limited (Roy 1982, 1985a). In 1982 this concept came under close scrutiny, and the Journal of Nervous and Mental Disease devoted a significant portion of one of its issues to exploring it. Much of the discussion centred on the refinement by Blumer and Heilbronn (1982), and lack of agreement among the contributors was clear. Blumer and Heilbronn proposed that pain-prone disorder was in fact a variation of mood disorder and belonged to the spectrum of depressive diseases. This view was rejected in a re-examination of the findings of Blumer and Heilbronn by Turk and Salovey (1984), who claimed that the proponents had failed to provide empirical evidence to redefine painprone disorder as a form of depression. Blumer and Heilbronn also departed in significant ways from Engel's original formulation of pain-proneness, a central feature of which was the absence of depression. There is, however, some evidence that depression can be masked by pain, although this view has lost some ground in view of a much better grasp of the biological parameters of depression. Despite the theoretical debate about the validity of Blumer and Heilbronn's redefinition of pain-proneness their research was impressive. They investigated the pertinent history of 900 patients with chronic benign pain of obscure etiology. The 'collective history' was one of submissiveness and also of limited abuse. Only 9 per cent of the subjects had experienced physical abuse. Careful reassessment of the data failed to reveal any commonalities shared by the subjects with regard to family issues, family environment, and family characteristics. Blumer and Heilbronn's reconceptualization of proneness to pain, despite its breadth, proves of limited value for explaining the relationship between childhood abuse and subsequent pain-proneness. It needs to be reiterated that the mechanism underlying the association between childhood abuse and hurt and subsequent pain-prone behaviour is quite remarkable for its simplicity. The child has no convincing way of understanding the reasons for the regular infliction of pain and abuse by an

Childhood Abuse and Pain in Adulthood 61 authority figure other than to associate it with his or her own 'badness.' Under those circumstances pain is adopted as a means to atone for one's misdeeds and serves the critical function of expiation of guilt. This particular perspective has received limited support in the literature. Green (1978) observed a series of twenty abused children, all of whom were receiving treatment in individual psychotherapy: these children repeatedly invited punishment from their caregivers by constantly acting the part of the 'bad' child. The critical observation, with a direct relationship to pain-prone behaviour, was that these children engaged in what Green described as 'subtle forms of pain dependent activity in the form of provocative, belligerent and limit-testing behaviour which easily elicited beatings and punishment from parents, other adults and peers. Accident proneness was considered to be another form of self-destructive activity.' Green's findings are at least suggestive of the possibility that pain-prone individuals embark on a career of self-infliction of pain at a relatively young age. In a subsequent study Green and his colleagues (1981) investigated 115 abused children between the ages of five and twelve years for neurological impairment. Impairments of the central nervous system (CNS) were mainly of a very subtle nature, consisting of deficits in perception, coordination, and integration of sensory stimuli which, according to Green and his associates, would have been very difficult to detect using the usual neurological procedures. They observed that 'a vicious cycle often unfolds, consisting of inadequate or abnormal parenting, urological and behavioral impairment, physical abuse and further impairment, etc.' There is as yet no clear indication of the long-term effects of these neurological deficits, but it may be reasonable to assume that pain and suffering may very well be some of the consequences. Baron et al. (1970) noted that the cumulative effect of sexual and physical maltreatment is 'distinctly maladaptive and refractory to change.' One conclusion of their study was

62 Assessments and Issues that CNS dysfunction of an early onset is more than likely to jeopardize the acquisition of age-appropriate developmental abilities in later life. Martin et al. ( 1974) observed that a direct consequence of parental abuse of children is that it may inhibit a child's capacity for spontaneous speech and motor expression. The implication from a psychological perspective is interesting in that the child will learn to internalize painful feelings from a very young age, thus providing a fertile ground in later life for the development of psychosomatic and depressive disorders. In an unusual study of tortured children who had emigrated to Denmark from Chile, Cohn, Holzer, and Severin (1981) noted that in a group of eighty-eight children between the ages of two and six years, several were found to have secondary nocturnal enuresis, and others provided evidence of introversion and depression and experienced significant levels of problems in establishing relationships with other children of their own age. Behavioural difficulties in the form of aggressive conduct were also apparent in some children. A few developed anorexia, headaches, psychogenic stomachaches, and constipation, and others gave evidence of difficulties in concentrating as well as impaired memory. MartinezRoig et al. (1983), in a retrospective investigation of ninetyseven psychologically maltreated children, demonstrated a direct relationship between clinical symptoms and the intensity of the abuse. The children were divided into three groups according to the degree of the abuse and placed in categories A, B, and C, representing a continuum of severity from minor to major. Psychosomatic symptoms were relatively rare and only three children in group Band one child in group C presented such symptoms. Locomotor development and bodily functions, however, were compromised in thirteen children in group A, nineteen in group B, and five in group C. Behavioural manifestations of a regressive type were evident in thirteen of twenty-five children. Again, the study provided nominal support for the proposition that psychosomatic symptoms set in very early in the history of the

Childhood Abuse and Pain in Adulthood 63 abused child or, alternatively, the early psychopathology of these children leads to internalization offeelings, regression, and somatization. The point that merits reiteration is that in most studies related to the immediate, short-, or long-term effects of child abuse, psychosomatic and health-related issues tend to have low priority. In fact this remains a truly under-researched area. This is evident in an otherwise excellent study by Egeland and his associates (1983). They investigated 267 high-risk families and identified four patterns of suffering: maltreatment, physical abuse, verbal abuse, and the abuse inflicted by the psychological unavailability of the mother. While a variety of developmental and psychological parameters were tested in these preschool abused children, psychogenic and especially psychophysiological consequences were not addressed. Hunter, Kilstrom, and Loda (1985) reviewed fifty children whose initial presentations masked the presence of sexual abuse and thirty-one overt cases. They found significant differences between the two groups in that history of persistent sexual abuse was twice as common in the masked group, and school problems and psychosomatic disorders were three times as frequent. The psychosomatic problem in the masked group was mainly abdominal pain. Psychosomatic and behavioural disorders made up the second largest category of complaints. Abdominal pain was a particularly frequent presentation and usually occurred in the young adolescent who had had repeated medical evaluations, and only very careful probing and psychosocial assessment had led to disclosure of sexual abuse. When investigators deliberately set out to search for psychosomatic or psychogenic pain problems, it appears that they are there to be found. A time-honoured link exists between repression, internalization, and somatization, and the physical and sexual abuse of children would seem to furnish almost optimum conditions for the development of that pattern of coping mechanisms. For this reason alone pain-prone behaviour in adulthood emanating from these early negative childhood experiences demands our attention.

64 Assessments and Issues The association between childhood maltreatment and adult pain was investigated in two separate studies by Violon ( 1978, 1980). She investigated sixty-three chronic intractable pain patients (1978), and found that 40 per cent of the subjects had grown up in a single-parent household and another 23 per cent had been abandoned. Overall 83 per cent of the patients reported the absence of affection during the years that they were growing up. Sixty-three per cent experienced open rejection and an astonishing 37 per cent had been battered children. In her subsequent study, Violon (1980) examined thirteen patients with cluster headache and fifteen with atypical facial neuralgia. In studying their histories she noted a high prevalence of lack of affection during these patients' childhoods. They reported being battered and rejected, and growing up in affectionless families. Overall, the problems were somewhat less pervasive in the second study, and she suggested that the difference in the results was due to methodological issues. The first study was based on therapeutic interviews and the second on questionnaires. Violon observed that 'patients acknowledged in the interview what they denied when presented with a questionnaire that they must complete' (Violon 1980). Violon (1990) has offered a conceptual model demonstrating the process involved in becoming a chronic pain patient. The point of departure of this model is that the chronic pain patients usually have had negative childhood experiences, among which abuse, punitive behaviour, and neglect are dominant. These negative childhood experiences culminate in the child using pain as a way of communication or, as Engel proposed, as a way of expiating guilt leading to proneness to pain. The other alternative intrapsychic mechanism proposed by Violon is one in which the negative childhood experiences lead to neuroticism which in turn leads to proneness to depression leading to proneness to pain. The third proposition is that these negative experiences result in lack of bodily gratification so that in the child very distorted bodily perceptions are developed which may lead either to proneness to pain or proneness to depression.

Childhood Abuse and Pain in Adulthood 65 As Violon (1990) herself points out, this model is essentially limited because while the psychic factors are emphasized, communication and environmental and psychophysiological factors are not. Nevertheless, Violon's model is important as it remains perhaps the only one that elaborates Engel's proposition. Further supportive evidence for the link between early abuse and subsequent pain has been provided by Gross et al. (1980/1), in a study of twenty-five chronic pelvic pain patients. Nine of these patients had a history of incest or other forms of sexual abuse. The families in this series were also described as dysfunctional, as characterized by violence and physical assault. Gross and his associates concluded that 'the prevalent finding of family dysfunction from childhood certainly suggests more than a causal association with the development of borderline syndrome caused by incest and pelvic pain.' Wurtele and his associates (1990) investigated 135 chronic pain patients for childhood sexual abuse: 28 per cent (n = 38) of the patients revealed histories of childhood abuse; 39 per cent of the females and only 7 per cent of the males were abused. Suicide attempts, drug and alcohol abuse, and a history of rape as adults were clearly more prevalent in the abused group. This study has major treatment implications for sexually abused individuals who also suffer from chronic pain. Studies reviewed in this section tend to provide evidence for a direct association between negative childhood experiences and pain-prone behaviour leading to chronic pain. They were designed to explore such a relationship, and while there may indeed be a causal relationship between childhood factors and adult pain, the overall quality and quantity of research is not sufficient to support any firm conclusion. The proposition still remains mainly in the domain of a hypothesis. Engel's concept of pain-proneness extends beyond actual abuse to neglect and psychological abuse. There is limited

66 Assessments and Issues empirical evidence for pain-prone behaviour being unrelated to physical and sexual abuse. Merskey and Spear ( 1967) found evidence for a strong association between a high incidence of painful injuries and operations and resentful and hostile patients. Pilling, Brannick, and Swenson ( 1967) investigated 562 psychiatric clinic patients with pain as a presenting symptom. Their finding was that pain frequently substituted for anxiety and depression and was used as well to curb feelings of aggression. There was an inclination to use pain to expiate guilt. Unfortunately, they provided too limited biographical data on the subjects to determine the significance of childhood issues. In a study by CastelnuovoTedesco and Kraut (1970) chronic pelvic pain patients provided powerful evidence of the use of pain for the purpose of relieving guilt. Tingling and Kline (1966) in an investigation of fourteen men with intractable psychogenic pain, who engaged in solitary hunting to sublimate their feelings of aggression, demonstrated accident-prone behaviour, and almost all of these men came from disturbed family backgrounds; two subjects had a history of childhood abuse. Two studies provide inferential data regarding a relationship between mixed childhood issues and adult pain-prone behaviour. In an uncontrolled study of thirteen dissatisfied patients with chronic pain, Swanson et al. ( 1977) found that nine had experienced significant trauma during their developmental years. This included family disorganization, early parental loss, and parental conflict for four patients; a major childhood physical problem for three; and in two instances the early termination of education because of the need to care for an ill parent. Merskey and Boyd (1978), in a controlled study, found non-organic pain in all of six patients who reported their fathers as being rejecting, in nine of twelve patients who reported having a mother with psychosomatic illness, and in all of four patients who reported their mothers as being punishing. They concluded punishing mothers correlated with the occurrence of pain without lesion which, as Engel has emphasized, is in accordance with the psychody-

Childhood Abuse and Pain in Adulthood 67 namics of pain as punishment. Actual physical or sexual abuse was not evident in these two studies, but rather the presence of many and varied undesirable family characteristics and negative childhood experiences. Liebman et al. (1976) described a very different set of family characteristics to account for psychogenic abdominal pain in children. Their study was uncontrolled, and the statistical analysis of the data was elementary. The point to be made here is that any causal relationship between a mixed bag of family factors and proneness to pain is far from selfevident, and yet so many adult chronic pain sufferers present with a negative childhood history that it must be taken into account if the person behind the pain is to be properly understood. A few conclusions are inescapable on the basis of the preceding review. First, the actual number of studies designed specifically to explore this intricate relationship between childhood abuse and pain-proneness is very small. Only those conducted by Castelnuovo-Tedesco and Kraut (1970) and Tingling and Kline (1966) specifically addressed the question of that relationship. The other investigators basically invoked Engel's conceptualization of pain-proneness to explain some of their own findings. Taken together, these studies fail to convincingly demonstrate a clear causal relationship between childhood abuse and other negative experiences and the subsequent development of pain-prone disorder. This is partly due to their design, which, in most cases, was correlational and uncontrolled. In addition, as far as it could be ascertained, not one study made any attempt to verify the childhood experience from an independent source. The biographical data were obtained mainly from the subjects themselves, and that may raise some question about the validity of the information, especially if the abuse or other negative childhood experiences occurred at a very young age. The issues themselves in almost all of the studies concerning childhood 'abuse,' with the sole exception of Green's,

68 Assessments and Issues were very poorly defined. The type of abuse and neglect and the experience following cessation of abuse are known to be major determinants of long-term outcome, and none of these factors were adequately addressed. To establish a causal link between childhood issues and pain-prone disorder the research is in need of considerable qualitative refinement. REVIEW OF CHILD ABUSE AND NEGLECT LITERATURE

Given the relationship between childhood abuse and painproneness, it was assumed that in the larger abuse and neglect literature there would be some evidence of this relationship. To that end a very comprehensive literature review was conducted, although because the literature related to child abuse is vast only a selected review is presented here. Martin (1980) noted that there was still a paucity of research linking the consequences of childhood abuse to adult behaviour. The same observation was made more recently by Steele (1986) in his keynote speech at the Camp National Center's 14th Annual Symposium on Child Abuse. He stated that 'we do not know nearly enough about the long-term effects of maltreatment during the early formative years of life. With very few exceptions, we have not followed abused infants and children from early childhood through to adolescence and adult life stages. Most of our data of the lasting effects of early abuse come from the retrospective histories we get from older children, adolescents and adults who tell us of the maltreatment they experienced early in their own lives.' Haugaard and Emery (1989) have also expressed concern about the lack of methodological rigour in child abuse research. The same observation can be made about the consequences of early maternal deprivation, mother-child separation, and loss of a parent. The long-term consequences of these events are not as self-evident as they were once thought to be. In his massive review of the literature on maternal deprivation,

Childhood Abuse and Pain in Adulthood 69 Rutter (1989) observed that early negative experiences do not somehow automatically result in a sick personality, and that it is never too late to remedy the faults of omission or commission in those vital preschool years. There has been a proliferation ofliterature examining the relationship of childhood abuse to adulthood problems. As the following review will demonstrate, the research has focused on some very broad as well as the more pronounced consequences of childhood abuse, and the more subtle and perhaps not so subtle consequences, such as health problems, are, on the whole, neglected. A few studies report serious health and psychological problems in the short run, including psychosomatic and neurotic problems in children, as a consequence of abuse (AdamsTucker 1982; Lynch 1975; Martin et al. 1974; Martin 1980; Tsai, Feldman-Summers, and Edgar 1979; Schmitt and Mauro 1989). Martin (1980) also noted the absence of longitudinal research, but concluded on the basis of available research that the common adult consequences of child abuse were sociopathic personality, depression, and an assortment of interpersonal difficulties. Tsai and his colleagues (1979) investigated adult women with a history of childhood abuse who had been subjected to molestation. The clinical group was compared with a nonclinical group of women who had been molested, but who were well adjusted, and a control group of women who had never been molested. The clinical group revealed an MMPI profile that included higher scores on the hypochondriasis, depression, and hysteria scales, which is identical to the profile of chronic pain patients (Sternbach 1974). In a more recent study, Scott and Stone (1986) also used the MMPI to investigate psychological disturbance in adolescent and adult victims of father-daughter incest. Twenty-seven adolescents were compared with thirty-one adult victims. The overall profiles of these subjects were quite different from the findings of Tsai and his colleagues. The only resemblance was that the adult victims also demonstrated significantly higher

70 Assessments and Issues scores on the hysteria and depression scales of the MMPI. On the basis of this latter finding it may be unwise to draw any firm conclusion regarding a relationship between childhood abuse and adult pain. Between 1975 and 1979 McCord (1983) conducted a review of 232 males who had been studied forty years earlier (between the years 1939 and 1945). Ninety-eight per cent of these men were located. They were divided into four categories - neglected, abused, rejected, or loved - with regard to the type of childhood they had had. Alcoholism, divorce, and occupational success were found to be similar among the four groups. Half of the abused or neglected boys had been convicted for crimes, become alcoholics or mentally ill, or died at an unusually young age. Unfortunately, McCord did not provide any data related to the health of these individuals. Lamphear (1985) reviewed the contemporary research literature on the impact of maltreatment on the psychosocial adjustment of children. This review confirmed an observation I made some years ago (1985) that with the exception of depression and gross psychiatric abnormalities, psychosomatic problems and health-related issues are generally neglected by pain researchers. Of seventeen studies that Lamphear investigated, only one by Martin and Beezley ( 1977) even went so far as to include the physical status and neurological functions of those affected by abuse; that particular study, however, was uncontrolled. It should be noted that Lamphear only reviewed literature related to short-term effects. A study by Dehlinger and her associates (1989) confirmed that somatization may occur in abused as well as nonabused children. They investigated sexually abused, physically abused, and non-abused psychiatrically hospitalized children for post-traumatic stress. The sexually abused group most closely met the DSM criteria for post-traumatic stress, and the physically abused group least closely. In addition to the post-traumatic-stress-related symptoms, the study also included five additional symptoms: significant weight loss or gain, academic difficulty, increased somatic

Childhood Abuse and Pain in Adulthood 71 complaints, suicidal ideation and/or intent, and immaturity. No significant differences between groups were found with regard to the incidence of these symptoms. Unfortunately, the authors did not report on the prevalence of the symptoms, and the tentative conclusion has to be that these symptoms, including somatic complaints, occurred at sufficiently low levels to be non-significant. In an extraordinary study, Krug (1989) reported on eight cases of adult males who had been sexually abused by their mothers. From the point of view of pain-proneness one particular case is of interest. A twenty-eight-year-old, married, white male presented low back pain. Contrary to medical advice he engaged in weightlifting and other heavy physical exercises that continued to aggravate his pain. His workout was considered to be 'self-abuse' since an orthopaedic surgeon had repeatedly advised him against continuing this weightlifting regimen. This advice was not followed. As a child he was frequently beaten by his father, and sexual abuse by his mother began when the patient was fifteen years old. During periods of intoxication the mother became sexually aggressive, and she would lock the patient and herself in the patient's room and attempt to sexually seduce him. The father was usually in the living-room watching television during these episodes. The patient successfully thwarted all these attempts. In this case the critical point is the use of pain to expiate guilt and clearly a desire on the part of the patient to invite pain, thus confirming the underlying mechanism of pain-prone behaviour. In a factor-analytic study of adult survivors of incest, Edwards and Donaldson (1989) investigated several stressful response factors such as vulnerability and isolation, fear and anxiety, anger and betrayal, reaction to the abuser, sadness, and loss, and powerlessness, and factors corresponding to the diagnostic criteria of post-traumatic stress disorder, namely, intrusive thoughts, avoidance and intrusive emotions, detachment and emotional control, and numbness corresponding to the hypothesized stress response theme experienced by

72 Assessments and Issues survivors of traumatic events. Again, noteworthy for their omission in this study were the health-related factors. This review leads to two major conclusions. First, the health-related issues have been, by and large, neglected in the investigation of adult consequences of childhood abuse. Second, despite the proliferation of research, the precise nature of the relationship between childhood abuse and the adult effects remains unclear. This is not to detract from the fact that in clinical practice many patients are seen who have a history of abuse. It is, of course, impossible to speculate about the diligence with which clinicians investigate childhood issues, let alone sexual and physical abuse. Not so long ago, I encountered nine consecutive women in my pain clinic, all of whom had experienced sexual abuse. That in itself may be an unusual experience. What is not unusual is that systematic probing, when incorporated as a part of routine investigation, does and will reveal an abusive past for many patients, which in turn will lead to a more comprehensive formulation of the problem and, one would hope, appropriate treatment. Rutter (1989), in his Jack Tizard memorial lecture in which he traced the pathways from childhood to adult life, concluded that it is evident that the limited evidence available and the connection between childhood and adult life emphasizes the need to account for both continuities and discontinuities, and to recognize the multiplicity of pathways across the life span and the diversity of end points ... The implication, I suggest, is that just as we have learned not to polarize nature and nurture as if they were mutually exclusive alternative explanations, so also we need to get away from the unduly simplified question of whether a person's behavior is the result of past or present experiences. Not only will behavior be shaped by the biological substrate genetically and nongenetically determined, as well as by psychosocial influences, but equally both the past and present are likely to have effects. Most crucially, however, they are not independent of one another. To an

Childhood Abuse and Pain in Adulthood 73 important extent the past helps to determine the present environment through a variety of different mechanisms. Chain effects are common and, if we are to understand the developmental process, we need to analyze each of the links in the chain, to determine how the links interconnect and to study how changes in life trajectory come about ... The elucidation of the process is giving rise to these varied pathways and should provide useful leads for both prevention and treatment through improved knowledge on how changes take place, for that is what development is all about. ABUSED PATIENTS IN PAIN CLINICS

Exploration of childhood issues with chronic pain patients may not be a feature of routine investigation in many pain clinics. However, when this matter is pursued as a matter of course, interesting facts often emerge. Findings related to neglect and physical and sexual abuse are not uncommon, which is not surprising in view of the mounting evidence of the prevalence of childhood sexual abuse among women. This area needs delicate handling, and often disclosure of such events can precipitate a crisis for the patient which requires very careful clinical management. The following three examples not only provide powerful support for Engel's proposition of pain-prone individuals, but also demonstrate the psychological and emotional turmoil and the relative ease with which this type of vital information can be missed.

Neglect of Abuse Ms K, at age twenty-three, was referred to the pain clinic by her family physician for inexplicable chest and back pain. She had a history of both pains dating back to her late teens, and despite numerous investigations no organic basis for either pain had emerged. During her first visit to the clinic Ms K was in a state of high anxiety. She sat on the edge of her chair in a very taut position, rubbing her hands and speaking with considerable effort. She revealed, albeit haltingly, that she had grown up in a terrible home. She was the

74 Assessments and Issues youngest of four siblings, considerably younger than the others and grew up virtually as a single child. Her father had severe complications related to diabetes and was disabled. Her mother was virtually an alcoholic. The family situation was chaotic at best. The two parents constantly bickered and argued and occasionally fought. Those were Ms K's earliest memories of family life. The only positive events she could recall were Christmas get-togethers when people were happy and laughed and joked. She viewed her childhood years as totally miserable, devoid of any love and affection, and filled with terror and apprehension. She was simply terrified of being abandoned. Her school years were just as negative. She was shy, lacking in confidence, and somewhat backward in her learning skills. She was teased and called names by her peers and generally ridiculed at home for her lack of scholastic abilities, although it should be noted that no one in this family had ever progressed past grade 9. Reading and writing challenged her almost beyond her capacity, and mathematics was totally outside her reach. She learned to read and write with great difficulty and dropped out of school without completing grade 8. She regarded her reading and writing skills at about the grade 4 to 5 level. From a relatively young age, Ms K formed a multitude of associations with boys and became sexually active by the time she was thirteen years old. At age seventeen, she formed a somewhat permanent liaison with a man who was only slightly older than herself. She moved in with him after only a short acquaintance and for the following two years was beaten, bit, and sexually abused. Any semblance of self-esteem she might have had eroded. She described the beatings she received from this man in graphic terms. They usually assumed two stages: having her head banged against a wall repeatedly and then being pounded on her chest, which often left the upper part of her body totally bruised and gaping with open wounds. Occasionally she took herself to a hospital emergency department for treatment, but she never reported the man to the

Childhood Abuse and Pain in Adulthood 75 police. This situation persisted for two to three years with clear evidence of escalation of her partner's violence towards her. This whole matter culminated when on one occasion he produced a gun threatening to kill her, at which point a scuffle ensued and he shot himself dead. Having narrated the story, Ms K revealed that it was not just this boyfriend who had abused her, but that she had been sexually molested by her father. She was thirteen or so years old when the first incident occurred. She was alone in the house with her father, who called her over and put his hands inside her shirt. She fought him off, but he threatened that unless she cooperated he would beat her up. He also started supplying her with extra spending money on condition that she would not tell her mother about the incident. He tried on several occasions to fondle her and go further, but she managed to fend him off and finally did tell her mother. To this day she remains unsure whether or not her mother believed her story. What she does remember is an insinuation from the mother that she was inviting all these problems herself. After the accidental death of her boyfriend her chest pains began in earnest, and she began her unending search for a cure for her pain, visiting numerous clinics and health care professionals. Not until her visit to the pain clinic, Ms K informed us, had she been asked about her past. This young woman continues to be in a problematic relationship. The relationship is not physically or sexually abusive; rather, she describes her boyfriend as playing 'mindgames' with her. He frequently leaves her alone to be with his friends, and while he is with them he is not shy about boasting about his sexual conquests. She would like to terminate this liaison. She made a suicidal gesture recently following her boyfriend's refusal to come home one evening. She took seven 5-mg pills of Valium and combined that with eight bottles of beer. As soon as she had done that, however, she became very fearful of dying and kept walking to keep herself awake until her head cleared.

76 Assessments and Issues From a symbolic point of view the association between her chest pains and the abuse is difficult to ignore. Her father's attempts to fondle her, the severe beatings she received around the upper half of her torso from her boyfriend, and even fondling by her current boyfriend, which she described as very painful, must be taken into account to fully appreciate the choice of her pain sites. This is a young woman with somewhat low intellectual abilities, a very deprived upbringing virtually devoid of any kind of bonding, a poor concept of self, and an almost total lack of confidence, who for many years has used chest pain as a signal to communicate her distress. The communicative significance of her chest pain is nothing short of profound.

Was I Abused? Ms L, at age twenty-nine was referred to the pain clinic some six years after an automobile accident in which she sustained a whiplash injury. Physiotherapy, pain medications, blocks, and other forms of treatment had failed to halt the progression towards chronic and increasingly unbearable pain. Investigation at the pain clinic revealed significant soft-tissue damage which showed very little sign of healing. It was noted that Ms L's emotional state was suggestive of what amounted to acute grief. Her father had been recently charged with sexually molesting a three-year-old child. This event had triggered her own memories of sexual abuse by her father. Over the weeks these thoughts had become persistent to the point that she was obsessed with them and was afraid of losing her mind. Ms L was raised in an alcoholic family where her father drank and her mother was somewhat distant and aloof. She was the second youngest of nine siblings and was in effect raised by her two older sisters. Her father apparently abused all the daughters physically and sexually and the sons with extreme physical violence. Quite remarkably this patient had no recall of any major childhood events, including any instances of abuse that occurred before the age of eleven or

Childhood Abuse and Pain in Adulthood 77 twelve years. She did have some selective recall of her school-days and school friends, but as far as her family relationships and particularly specific events within the family were concerned, she had almost total amnesia. She had been told in no uncertain terms by her older sisters that like themselves she had been sexually abused by the father. When Ms L was eighteen years of age a very strange event occurred. Whenever she suffered an occasional back strain she usually received a back rub from her mother. On this occasion, however, mother invited father, as she left to answer the telephone, to rub the daughter's back. Father, in the process of rubbing her back, started fondling her. She was so startled and frightened by this event that she ran away from home, took herself to another city, and had the good sense to seek treatment for sexual abuse. She managed to get her life together to the degree that she married, had a daughter, and completed her high school education. She worked in the retail trade, reaching the position of manager, and until her father was charged with child molestation led a reasonably normal life. The pain from the automobile accident had created some pain problems, but on the whole she managed to cope. Her husband adopted a very unsympathetic attitude towards her revived feelings of helplessness and anger combined with profound sadness. His view was that whatever had happened to his wife was very much in the past, and he failed to comprehend her renewed feelings of distress. Ms L resorted to a primitive defence mechanism, namely, hysterical amnesia to wipe out what must have been very traumatic childhood memories. Then at the age of eighteen she was molested by her father and on that occasion she sought professional help. The accident was clearly a set-back for her but she seemed to be coping until her father was once again involved in child sexual abuse. On reflection, it was more than a coincidence that she experienced great exacerbation of her pain and was referred to the pain clinic at a time when she was going through enormous emotional turmoil.

78 Assessments and Issues This case had several of the hallmarks of post-traumatic stress syndrome, and her somatic symptom was almost inseparable from her emotional pain and agony. Her childhood amnesia may be construed as proof of repressed traumatic experiences which therapy was unable to break through. Then again, as Engel has pointed out, the very knowledge that something untoward had happened in a person's life without exact recall is capable of generating powerful emotions. Indeed, if she needed confirmation that she was sexually abused by her father as a young child, she received that in a most blatant and traumatic way when she was eighteen years old. As to the question where is the abuse? the answer has to be that it pervades her entire psychic existence.

A Pain-Prone Patient The story of Mr M is perhaps the clearest illustration of Engel's pain-prone patient that I have seen. This young man presented, at age twenty-four, with a lifelong history of head pain. He was the second of eight children. His father, now dead, had been a violent alcoholic. When he was two years old Mr M was placed in the custody of the child welfare agency; this lasted for three years. What led to his being separated from the family can only be guessed at, but violence and neglect were involved. Mr M's life, upon his return to the family, was one of persistent physical abuse inflicted by his father. The beatings were mostly in the region of his face and head. When Mr M was seven years old, his father kept him locked up in a bedroom for the entire length of the summer break from school. No child welfare agency was in sight. The father's abusive and violent conduct was not confined solely to the patient, but all the children as well as the mother were often at the receiving end of his blows. Nevertheless, Mr M was especially singled out. He would have killed himself, but for a schoolteacher who was his friend and confidant and a great source of support. The father eventually committed suicide in the presence of his family, a day that is firmly etched in the

Childhood Abuse and Pain in Adulthood 79 patient's memory as 'the happiest day of his life.' At that time Mr M was all of twelve years old. Mr M recalled that after his father's death there was relative calm in the family, and he became particularly close to his mother. After a few years he decided to cut loose from the family. His mother was beginning to control his life, and the solution for him was to leave home. Mr M lived in perennial fear of being controlled by others. Investigation led to a diagnosis of atypical vascular headache associated with migraine-like aura and muscle tension. His upbringing had been characterized by separation, deprivation, and severe physical abuse which caused exogenous pain (from beatings) and endogenous pain (from guilt and depression). Sadness and anger inhibited his capacity to form and maintain relationships. He exhibited the following signs of Engel's pain-prone patient: (1) prominence of guilt and use of pain to expiate guilt; (2) a history of harsh childhood, in which pain was routinely inflicted for discipline; and (3) internalization of anger. SUMMARY

Cases involving abuse and pain remain a source of some surprise and even amazement to many who treat chronic pain. In large measure this is due to the lack of attention to abuse and deprivation issues, for often they may be considered as being not directly relevant. Writing on this topic is weak. Although in the abuse literature there is wide recognition of the devastating repercussions of sexual and physical abuse of children, proneness to pain is perhaps the least known of the consequences. While the question of child abuse may not be central to the investigation of pain, there does need to be some awareness on the part of pain clinicians that negative childhood experiences do shape adult personality and in some instances can explain the problem of adulthood pain itself.

5

Interpersonal Issues: The Patient's Family System

Within the informal network that constitutes the core of the patient's interpersonal relations, the family occupies a position of primacy. The reasons for this are self-evident. It is through family members that most individuals derive a sense of indispensability. But while serving as the main source of nurturance, the family is also the locus of internecine squabbles and even warfare. Thus, individuals are tied to each other in a complex web of emotional give and take. Family theorists have long proposed that homeostatic mechanisms help maintain balance within a family system. Confronted with untoward events or situations, built-in corrective mechanisms are activated to restore balance. However, major negative events have the capacity to render the family system ineffectual to the point that homeostatic mechanisms simply fail. Chronic pain in a family member is one such stituation that carries the potential of creating serious conflicts and dislocations. Research dealing with the adverse effects of chronic pain on the family system has proliferated only in recent years. It can be divided broadly into three categories: familial factors in the etiology of pain, the role of the family members in the perpetuation of pain behaviours, and the undesirable consequences of chronic pain for the family system as a whole as well as for the individual member. The focus of this chapter is on the latter.

The Patient's Family System 81 The research evidence to date tends to confirm that at the level of both the family system and its individual members chronic pain can inflict measurable damage. While the research at the system level is limited and mostly uncontrolled, findings are relatively uniform. Not very many aspects of family functions escape dislocation as a result of chronic pain. In a similar vein, individual relationships and the health of family members can be significantly compromised. CHRONIC PAIN AND THE FAMILY SYSTEM

As already stated, relatively few studies have examined the impact of chronic pain on the entire family system. In one of the earliest Hudgens (1979) investigated the functioning of twenty-four couples where one partner had a chronic pain problem. These couples were assessed on six areas of couple functioning and were found wanting. A low of 61 per cent and a high of 100 per cent reported significant to severe problems. Liebman and associates (1976) applied the 'structural' model of Minuchin and colleagues (1975) to describe the family characteristics and functioning of ten children with the complaint of non-organic abdominal pain. These families demonstrated enmeshment, overinvolvement with each other, overprotective concerns, and avoidance of conflict. These two studies were uncontrolled. In a 1961 study, Kreitman and Salisbury (1965) compared twenty-one depressed patients with somatic complaints with a matched group without somatic complaints. The somatic group, many of whom had pain complaints, gave evidence of elevated levels of marital disharmony compared with the controls. Reports of general marital discord among pain patients are relatively common (Ahern, Adams, and Follick 1985; Feurstein, Sult, and Houle 1985; Mohamed, Weisz, and Waring 1978; Kerns and Turk 1984). Despite the consensus that marital problems are common among chronic pain patients, detailed investigations explor-

82 Assessments and Issues ing the issues from a systematic perspective remain limited. In 1988 I compared twelve back pain patients with twenty headache patients using the McMaster Model of Family Functioning (Epstein and Bishop 1981), which consisted of the following dimensions: (1) problem-solving, (2) communication, (3) roles, (4) affective responsiveness, (5) affective involvement, and (6) behaviour control. The findings revealed an alarming degree of disarray in these families. Problem-solving proved to be hazardous for 75 per cent of back pain and 100 per cent of headache patients; communication was pathological for 50 per cent of back pain and 75 per cent of headache patients; roles were problematic in every respect. Nurturance and support-type roles were ineffectively performed by 75 per cent of and 100 per cent of back pain and headache groups respectively. Marital and sexual gratification was deficient for 75 per cent of back pain patients and 60 per cent of headache patients. Occupational and household roles were compromised for 50 per cent of the back pain group and relatively nominal in the headache patients. Affective responsiveness, which deals with the family members' capacity to express a wide range of human emotions in an appropriate manner, was ineffectual for 66.6 per cent and 65 per cent of back pain and headache patients respectively. Affective involvement, concerned with the quality of relationships was found wanting in 83 per cent and 60 per cent of the back pain and headache groups respectively. Finally, behaviour control, which broadly translates into the rules by which families live, was gravely flawed for 83 per cent of back pain and 80 per cent of headache patients. This investigation was based on detailed and systematic interviews. It confirmed a general clinical observation that family functioning of chronic pain patients, when examined in detail, tends to be in jeopardy. In another investigation of fifty-two patients attending a pain clinic, Roy and Thomas (1989) examined their family functioning using the Family Adaptability and Cohesion Evaluation Scale (FACES III, Couple Version; Olson, Portnoy,

The Patient's Family System 83 and Lavee 1984). The level of agreement between the couples in virtually all areas of family functions was high, and statistically significant. In their overall score for Family Adaptability, which measures perception of functioning in relation to roles, rules, decision-making, discipline, and leadership, they were found to be in the 'chaotic' range of the scale, thus demonstrating severe difficulties in virtually every area of Family Adaptability. Regarding Family Cohesion, which assesses couples' perception of connectedness by examining bonding, supportiveness, family boundaries, time and friends, interest and recreation, the patients reported functioning in the extremely ineffectual range, whereas the spouses were more effective, functioning in the mid-range. The patients and the spouses in this study provided powerful evidence of discord. Family Adaptability was the major casualty, and Family Cohesion somewhat less impaired. Spouses were responsible for assuming the central task of keeping the family together, and, hence, they were in a somewhat better state with regard to Family Cohesion functions. Further analyses were conducted to assess the influence of depression on Family Stability (another attribute of the FACES III) and pain duration on Adaptability and Cohesion (Thomas and Roy 1989). Nine clinically depressed subjects were compared with forty-two non-depressed patients. Planned comparisons found that patients with a low score on Family Stability were significantly more depressed than those with a high score. This finding is as one would expect through common sense, for when pain problems are compounded by clinical depression, Family Stability would seem bound to suffer. Comparisons between short-term and long-term pain subjects on Family Adaptability and Family Cohesion were statistically non-significant. The fact that duration of pain failed to influence family functioning suggests that the process of disengagement for the pain patient commences rather early in the pain career (Thomas and Roy 1989).

84 Assessments and Issues The clinical implications of the findings related to systematic family dysfunction require acknowledgment. Chronic pain unquestionably has the capacity to wear down family ties, thus rendering all the family members victims of chronic pain. If the family as a whole is viewed as an organism, then dysfunction (chronic pain) in one part of the system has the capacity to fundamentally alter the health of the entire organism - for the worse. The extent of change at both the system and personal level will become evident in the case illustrations. Before leaving this discussion, two more studies should be briefly reviewed. In the first, eighteen college freshmen and their parents were investigated for headaches and family functioning. Headaches of a mild nature were commonplace in both groups, although the students reported more frequent, but less intense pain than their parents. On family functioning, measured by Family Assessment Measure III (Skinner, Steinhaur, and Santa-Barbara 1983), students, mothers, and fathers were found to be ineffective in five out of seven areas. Task accomplishments and role performance were two areas of effective functioning. Communication, affective expression, involvement, control, and values and norms were found wanting (Roy, Thomas, and Cook 1991). A tentative conclusion was that low-level pain in every member of the family combined with life-stage issues, such as middle-aged parents or children leaving home, created an optimum climate for disruptive family patterns. Such high levels of family dysfunction were, however, not predicted in these families and cannot be easily explained. In the second study 145 students and 55 parents (these figures include the subjects in the first study) were investigated for headache, backache, depression, illness behaviour, and family functioning. Depression was non-existent in this population; the Illness Behaviour Questionnaire (Pilowsky, Murrell, and Gordon 1975) scores were in the non-clinical range. The Family Assessment Measure revealed patterns of dysfunction that were identical to those in the first study.

The Patient's Family System 85 Pain problems, mainly of a mild nature, were commonly reported (Thomas, Roy, and Cook 1991). The implications of these two studies are far from selfevident. The family findings were not in the predictable direction. Neither were there any clear indicators from within the studies to account for these extraordinary findings. Therefore, speculation is reasonable, and life-stage issues combined with pervasive, albeit mild pain offer some direction for future research. In relation to day-to-day pain, not much information exists about coping, or for that matter, if and how non-clinical pain affects family functioning. IMPACT OF CHRONIC PAIN ON FAMILY MEMBERS

Chronic pain in a family member not only has the potential of upsetting the family system, but seemingly has the capacity for exerting substantial influence on the well-being of the other family members as well. Only the impact on the health of the spouse of the chronic pain patient has received some attention. To date children of these patients have been mostly ignored by researchers, as have the other individuals in the patient's informal network. It is perhaps not accidental that spouses have attracted the most attention. Chronic pain extracts a rather heavy price from the spouses. As the following review will show, the spouse is frequently required to assume a great deal more responsibility within the family, and has to manage with reduced financial resources and to cope with increased marital conflict, anxiety about the patient's health, loss of intimacy, and a major reduction in or even elimination of their sexual activity as well as many other relationship issues. The point to note about the research on spouses' health is that it reflects a preoccupation with their psychopathology. Social causes for spousal distress are at best under-researched. In one of the earlier studies Shanfield and his associates (1979) investigated the mental health of forty-four spouses of pain patients. Spouses reported a significant level

86 Assessments and Issues of psychiatric distress, mainly as depression. A finding of some social import was that the spouses' distress levels were significantly correlated with the levels of distress of the patients. A major criticism of this study was that the comparison group was obtained from national norms, and it is doubtful that the research subjects were comparable with the national norms. Mohamed, Weisz, and Waring (1978) found that the spouses of pain patients experienced various kinds of distress, including pain symptoms, the inference being that somatic symptoms were indicative of psychiatric disturbance. Despite the elegance of the study, the sample comprised only thirteen subjects - spouses and controls. In contrast, a few studies have reported more directly on depression in the spouses (Ahern, Adams and Follick 1985; Flor, Turk, and Rudy 1988; Kerns and Turk 1984). The paper by Kerns and Turk ( 1984) is of special interest as no significant relationships emerged between the spouses' moods and a whole host of other variables. A negative association was found between patients' ratings of depression and their spouses' level of marital satisfaction and perceived supportiveness. This finding provides some empirical proof that intimacy is often a casualty of pain and depression. Kerns and Turk (1984) also found that 50 per cent of both the patients and the spouses were significantly depressed. Rowat and Knafl (1985) addressed the question of spousal distress from a broader perspective. They identified two extreme groups on the basis of distress level in the spouses. Nearly 50 per cent of twenty-five spouses were in a high distress group. Distress was assessed on the basis of physical and emotional symptoms, together with a variety of rolerelated and social changes. The merit of this particular study is its focus on the social as well as the emotional and psychological factors in understanding and explaining the presence of high levels of distress in a large proportion of spouses of pain patients. Before proceeding to a further review of interpersonal

The Patient's Family System 87 issues, it is important to make an observation. True interpersonal research based on the impact of chronic pain on both the patient and the spouse is very rare. Even if convincing causal links could be ascertained, for example, between spousal depression and chronic pain, from an interactional viewpoint the picture would still be incomplete unless the effects of spousal depression on the patient were also demonstrated. Therefore, the existing literature is, at best, a foundation for research into the larger interactional field . At the very least, relationships, with all that they entail, cannot remain the same when one partner has chronic intractable pain and the other has depression. Sexual relations, discussed below, would probably suffer. The fact remains, however, that there is a true poverty of data on the interpersonal effects of chronic pain. SEXUAL RELATIONS

Maintaining 'normal' sexual relations when the patient has persistent and severe pain and the spouse is depressed or demoralized is almost impossible. The literature does corroborate this claim, but the data, more often than not, are based on the patient's pain rather than on a combination of the pain in the patient and depression in the spouse. Hudgens (1979) found that half of her twenty-four subjects with pain and their spouses reported sexual problems. The nature and causes of these problems were not discussed. Maruta and Osborne (1978), in their investigation of sixtysix married patients referred to their pain clinic, found that nearly one-third experienced sexual difficulties. Nearly half the male subjects attributed their sexual problems to the onset of pain. In a subsequent study of fifty married patients with pain, Maruta and colleagues (1981) found that 78 per cent of the patients had vastly reduced or even totally eliminated their sexual relations. Flor, Turk, and Scholz (1987) and myself (1988) have more or less confirmed the findings

88 Assessments and Issues ofMaruta and associates (1981); between 60 and 80 per cent of our pain patients reported marital problems. The clinical complexities surrounding sexual dysfunction in pain patients have come under some scrutiny (Roy 1989). Pain could be a legitimate cause for cessation or reduction of sexual activities in some patients. A premorbid history of sexual problems, depression in the spouse, and withholding affection or outright rejection for interpersonal reasons are some reasons. Spouses of pain patients often live with a sense of loss of intimacy and fear growing distance, and many are so overwhelmed by their change of fortune and added responsibilities that sex loses its priority. The following cases are presented to show the common as well as complex nature of sexual and interpersonal relations as reported by our patients. CASE ILLUSTRATIONS

A Simple Case When the question of their sexual relations was pursued with Mr N (age fifty-four) and his wife a rather typical picture emerged. The patient had been involved in an automobile accident that had left him with severe back and neck pain. He lost his job and was faced with financial and legal problems, and his mood become very low. Sex, both partners acknowledged, had assumed a very low priority. Their premorbid sexual relations had been good. But Mr N's pain was just too much for him to even contemplate sex. Mrs N at times wanted to approach him, as she had done at the beginning of his pain problem, but was afraid of being rebuffed. She missed sex and the closeness with her husband. She was unsure of her husband's feelings. He, too, was feeling a sense of loss and had some guilt about his absence of libido. But his loss was not total; at times he wanted to approach his wife for physical closeness. However, he felt shy and selfish. He did not want to approach her when he felt like it. Resto-

The Patient's Family System 89 ration of some sexual contact and improved communication between this couple was not hard to achieve. Chronic pain and illness can provide solutions to longstanding conflicts in marriages. The patient may use pain to 'opt' out, and the spouse may encourage the patient to disengage from tasks that are unacceptable to him, on the ground of ill health. Chronic illness in a spouse, for some, is tantamount to the answer to a prayer. Illness, instead of being a problem, provides solutions to chronic marital conflicts (Roy 1985). Alternatively, matters can be brought to a head by illness.

A Complex Case Mrs O (age thirty-eight), with a long history of head and back pain, was referred by her family physician because of exacerbation of her pain complaints. She had seen a neurologist and an orthopeadic surgeon just before referral to the pain clinic and had been told by them to learn to live with her pain. In the initial interview, Mrs O drew an idyllic picture of her home life. She had married her high school sweetheart many years ago. Her husband was now a successful businessman. They had a daughter, age fifteen, and a son age nine. Mrs O was a nurse and had worked in the same job for many years. The family situation seemed very stable. Her headaches, however, were becoming a nuisance. At times she just could not function. She would neglect her housework and opt out of social engagements, but she never missed work. It was the pursuit of this last issue that opened up the case in an unpredictable way. How did her husband and the children feel about her periodic absence from the family scene? No one liked it. Her husband was especially intolerant. He took serious exception to her growing refusal to attend business-related social events. He would remind her that her pain never seemed to interfere with her work, so how selective was she with her pain? Was she using her pain to disengage from activities she disliked?

90 Assessments and Issues This was not the only issue with her husband. In due course, Mrs O talked about many conflicts in her marriage. Her husband had a very bad temper, which intimidated her, and she felt her position in the family was no different from that of the children. Her husband was very sure of himself. Though he had never earned a degree, he now employed several people with degrees. He always knew what he was talking about and was an excellent provider. Mrs O had accepted her 'lower' position in the marriage, but was slowly beginning to rebel. The matter came to a head soon after her pain become worse. Her husband was angry about her lack of progress. He had faithfully attended all her medical appointments and was persuaded by the doctors' opinion that his wife should learn to live with her pain. He accused her of more or less using her pain to serve her own ends. He said he did not have the time for that kind of game playing and irrational conduct, that she should straighten up, that he wouldn't be where he was by being weak, that she was plain weak, that he was not going to tolerate that kind of behaviour, and that he had witnessed too much of this 'giving up' business in his employees. Mrs O reminded him that she was not in his employment. It took three sessions for Mrs O to narrate this story. In the fourth session, Mrs O stated that she had been giving serious thought for the past few months to leaving her husband. She was tired of his angry outbursts. Their son was afraid of him and the daughter constantly undermined her authority, usually with the father's approval, for he seemed inevitably to take the daughter's side. Father and daughter had formed a coalition against the patient. At this point, it was strongly recommended that the husband become involved in the treatment. Reluctantly and with much trepidation, Mrs O agreed to ask him, and he came to the following session. Mr O was a man of short stature, immaculately dressed in an Italian suit, silk shirt, and tie. Mrs O was in her habitual

The Patient's Family System 91 faded jeans and T-shirt. Mr O wasted no time. He launched into a long tirade about the greediness and the ills of the medical profession, saying that he agreed, however, with several physicians who had stated that not much was wrong with his wife, that she was making too much of her pain, and that she was plain irrational. He did not achieve his success by being weak, he said. Believing in discipline and hard work, he told how he was never one to give in and how he would never tolerate this kind of behaviour in his employees. He did concede that his wife and children were not in his employment and that, yes, at times he was insensitive to their feelings and that he did not always have the answers. This openness lasted just a short time, however, before he reverted back to his rather hostile posture. He wanted to know what the clinic was going to do for his wife. He said he did believe that she had pain, but he was not always sure about her pain - it seemed to pick and choose its time and place for getting worse. In subsequent sessions lengthy discussions took place about the family relationships before and after the onset of pain. Mr O continued to trivialize his wife's pain. Slowly, Mrs O began to voice her disaffection with him and the marriage. She was tired of being treated like an irresponsible child. She was fed up with him for always taking the side of the daughter, who also was unsympathetic to her pain. She asked her husband whether he knew that their young son was afraid of his angry outbursts, and that on occasion he had pleaded with her to leave him. Mr O's reaction was total incredulity. He said he was not a violent man and that he had never laid a hand on anyone; he said he enjoyed his son's company. Mr O was shaken up. On reflection, the turning point in the treatment was Mr O's discovery that his wife had even considered leaving him. They stayed in treatment for four months. At the time of termination, family relations were incalculably better as were Mrs O's pain complaints. This case has been described in some detail to emphasize

92 Assessments and Issues the intricacies in family relations which the research literature does not adequately address. Mrs O's pain forced this family to face up to long-standing family conflicts. The etiological issues raised are intriguing. Did the untenable family conflicts exacerbate Mrs O's pain? Possibly, but the more interesting point is the way pain was 'used' by Mrs O to convey her general unhappiness. Her pain made it impossible for the O family to function in its habitual way. She managed to heat up the family enough that normal cooling mechanisms just failed. The stability of this family was predicated on Mrs O's willingness to accept her husband's treatment of her. She rebelled, albeit indirectly through her pain, causing a crisis in the family. The crisis provided the opportunity for long-overdue changes in the way the O family functioned. CHILDREN OF PAIN PATIENTS

Literature on the effects of parental pain on children is virtually non-existent (Flor, Turk, and Rudy 1988). In my investigation of thirty-two chronic pain families (Roy 1989), I found limited evidence of problems with children. In my review of the literature on the effects of parental chronic illness and disability on the children (Roy 1990), I noted that the incidence rate of social and emotional problems in these children could not even be estimated, and that the risk factors for the children were not readily identifiable. Rutter ( 1966) reported significant problems in the children of physically and mentally ill parents. In contrast, Buck and Hohmann (1982) were unable to find any serious problems in the children of physically disabled parents; nor did Croog and Levin (1977), in their one-year follow-up of family members of myocardial patients, but in their eight-year follow-up some family members were facing adjustment problems. Clinically, as part of the family assessment, careful attention must be given to the children. They often complain of

The Patient's Family System 93 losing access to the patient. Family ties loosen; the well parent has less time for them. Often, parents have high expectations of the children. Sometimes the level of stress is such that children become symptomatic. These and other clinical observations need to be moulded into testable hypotheses for proper investigation. In the meantime, clinicians should pay close attention to the children of their pain patients. CONCLUSION AND SUMMARY

The current state of knowledge about the interpersonal issues involving the pain patients, the spouse, and especially the children is woefully inadequate (Roy 1985b). Marital and family issues have been barely touched upon, and nothing is known about the children. An impression may have been created that much is known about the spouses of pain patients; in fact, much remains that is unknown. Sex influences on the well spouse are not known, although women, as patients, seem more able to retain their normal roles. This matter merits investigation. How effective is family therapy for treating families with a chronic pain patient? There are, as yet, no outcome studies. Clinical wisdom, however, dictates that close attention to the patient's informal network, including the family, can only be beneficial. Family strengths, social support, and other ties in the informal network should exert some positive influence on the patient's ability to cope. That some spouses succumb to depression is clear. The social causes for such depression can only be guessed at, while virtually nothing or very little is known about the reasons that enable many, if not most, spouses to stay healthy in the face of considerable odds. The effective functioning of many patients despite chronic pain, and of their spouses and the family system, is also an untapped area of research. Even the clinical literature fails to shed any light on the

94 Assessments and Issues role of the informal network of pain patients, although the patients themselves often refer to the benefits of some of these relationships. One young patient informed me that without financial help from her parents, she and her husband would have been forced into personal bankruptcy. Another woman managed to leave her husband, who had become extremely unreasonable and even abusive following the onset of a major pain problem, with the support of her parents. Yet another elderly patient declared that without the love of her daughter and son-in-law, she would not want to live. These are not isolated examples of the patients' supportive networks. Network studies of chronic pain patients do not exist. Many patients speak of their close friends, and the comfort and strength they derive from them, showing that a strong support system can only be beneficial. Again, clinical exploration and research in this vital area is urgently needed.

6

Social Strategy Interventions

'Social strategies' is a generic term that describes a variety of interventions with formal and semiformal systems. Strategies range in scope from advocacy on behalf of the patient to enabling a group with a common interest to engage in self-help-type activities. Loss of control over one's destiny and a deep sense of rejection by the society at large pervade the psyche of many chronic pain sufferers. Interventions are constructed to counteract these feelings of rejection and the ensuing social withdrawal. Empowerment of the patient and his re-entry into society are the two major objectives. Conflicts with bureaucracies are experienced almost every day by patients. Those working in the bureaucracies themselves, however, tend to have a very different interpretation of events. Health care professions may claim that medicine does not have all the answers; the Workers' Compensation Board must establish the legitimacy of the claim; the employer often flatly rejects all culpability; the lawyer is only mildly optimistic about the case; unemployment insurance may not kick in for a period; city welfare may refuse assistance on totally mystifying grounds. The patient is left in a state of confusion combined with feelings of demoralization and utter hopelessness. Modern bureaucracies are very complex organizations. It takes considerable expertise to simply direct a patient to the appropriate agency for the right kind of assistance. Patients

98 Methods of Intervention often complain of 'getting the run-around.' Even if a patient finally connects with the right agency, it is often the beginning of a very frustrating and humiliating journey. Pain in the absence of florid pathology does not promote sympathy, rather it tends to engender hostility and incredulity. The veracity of the patient's claim of severe and debilitating pain is not easily verifiable. Hence, the doubts and reluctance to provide mandated service. The social strategies commonly employed are discussed below. Advocacy, promotion of social support, and self-help groups are some of the techniques I have employed in my work with pain patients. Literature on these methods that is relevant to the pain population is non-existent. The account that follows is largely based on my own experience. ADVOCACY

Advocacy is a proven and perhaps time-honoured means of achieving change. Willets (1980) defined advocacy as the act of pleading, defending, supporting, or espousing a cause, and said that such acts take on special meaning when the person for whom one advocates appears to be incapable of interceding on his own behalf. Advocacy on behalf of patients is almost a routine activity for health care professionals. Knowledge and skill are prerequisites to untangling the intricacies of a modern welfare state with its plethora of legislation that governs entitlements and the multitude of its agencies that administer those entitlements (Albert 1983). The need for advocacy stems from the difficulties patients encounter in obtaining information about their entitlements and actually receiving them. Many agencies mandated to serve public needs adopt an adversarial stance in relation to the population they are set up to serve. Public funds are limited, and they must reach those who can demonstrate the legitimacy of their entitlement. Many of the conflicts between the bureaucracies and the people can be traced to the issue of legitimacy. The burden of proof is always on the

Social Strategy Interventions 99 needy. Not uncommonly, a patient runs the risk of wrongful denial without the benefit of an advocate, or, alternatively, the advocate is brought in when the claim is denied. The task of advocacy can assume a high degree of complexity because of the special nature of the problems of the chronic pain population. Advocacy is a natural role for lawyers, but many situations do not need high-priced legal intervention. CASE ILLUSTRATIONS

The following three cases are presented to illustrate the range and scope of advocacy in day-to-day work with chronic pain patients. Mr P, a veteran fireman, was injured in a fire-fighting situation. He had been in the best of health all his life. The accident caused him severe and persistent back pain, and he was then attended by an astounding array of specialists, nineteen in all, had four unsuccessful surgeries, and was on twelve different medications by the time that he was initially seen at the pain clinic. Mr P was dismayed by the wholly unsympathetic attitude of his boss, who apparently was just about convinced that Mr P was 'malingering.' All the medical findings pointed in that direction. He was demoted and assigned to a routine desk job. The net effect of the boss's attitude was that Mr P came to be shunned by his fellow employees. No one completely believed Mr P's claim of pain and suffering, and his employers were convinced that he himself had been responsible for sustaining the injury as a result of his own negligence. Mr P stated that he felt that twenty-five years of loyal service amounted to nothing. He lived with a deep sense of injustice combined with feelings of rage and depression. A few phone calls led to the discovery of an appeal process which Mr P should have been told about at the time of his demotion. If he could provide convincing evidence to the

100 Methods of Intervention appeals board of his capacity to function in a more senior position, he stood to be reassigned. In the course of one of the telephone conversations with Mr P's superior, the latter's total lack of understanding about the chronic pain phenomenon became clear. This person apparently had very little doubt that Mr P was 'malingering.' Much re-education and persuasion sufficiently modified the boss's attitude for Mr P to be reassigned to a position more acceptable to him. A potentially acrimonious appeal process was avoided. The advocacy process is often protracted as well as taxing. The bureaucratic wheels tend to turn ponderously; phone calls are ignored, and information is very hard to come by. Mr P was fortunate to have his situation resolved in about six months, with a positive outcome. That is, of course, not always the case as we learn from the story of Mr Q. Mr Q, aged fifty-four, sustained serious back injury in an accident involving his dump truck. This accident left him almost totally incapacitated, but without any obvious explanation for his pain. He lived in mortal fear of losing his workers' compensation benefits. There was unremitting pressure on him to return to work from many sources, including the Workers' Compensation Board. The consensus at the pain clinic was that Mr Q was not ready for employment and that he might never be ready. Thus began a long and protracted dialogue between the clinic and the WCB. The pressure to return to work on Mr Q, in fact, mounted. After a very long battle the WCB did agree to a permanent settlement. In the meantime, however, Mr Q's health had deteriorated markedly, and he died a few short years later. In a study of fifty-four agencies in nine cities in the United States people either needing service or failing to fit into already established service delivery patterns were defined as defective; their difficulties in living, rather than resulting from poverty, underemployment, discrimination, or inadequate care, were seen as the results of their individual behaviours or values (Warren, Rose, and Bergunder 1974).

Social Strategy Interventions 101 Discharged psychiatric patients were the targets of those remarks. Pain patients carry an extra burden, since not very many people believe their claim of severe pain. Their overall experience in dealing with social agencies is not dissimilar to that of discharged psychiatric patients. The reasons underlying the mistrust of the psychiatric patients and pain patients are similar. Some still view mental illness as the outcome of moral turpitude or weakness of character. Pain without 'cause' shares the same stigma. Rose and Black (1985) make an important distinction between 'case advocacy' and 'issue advocacy.' Issue advocacy is the larger framework that may very well arise from the case situation. In this chapter, the discussion is centred on the empowerment of the individual; hence, the approach is case advocacy. Rose and Black (1985) noted that the process of consuming the service often consumes the person. Advocacy, for that reason, is sometimes the only avenue of seeking redress. Many patients disabled through work-related injuries develop chronic pain. Workers' compensation programs are financed by contributions from employers, and therefore workers tend to view them with suspicion. The source of the distrust is the perception that in order to serve the interest of the employer, the worker's claim of disability is minimized. Conflict between pain clinics and the WCB is not unknown. The pain clinic's judgment about the level of disability is often at variance with that of the WCB. Even if a favourable decision is obtained for the patient, there is always the fear of losing it, should the WCB decide to discontinue the benefits. To the patient, such a decision often appears arbitrary; sometimes the rationale for the decision even eludes the pain experts. Hence, the importance of the advocacy role to make a plausible case that the pain is legitimate even though an organic basis for the pain is not always discernible. Conflicts with employers are reported regularly by pain patients. Many patients feel, following work-related acci-

102 Methods of Intervention dents, that they could function satisfactorily in less onerous jobs. Sometimes that alternative is not available, but on other occasions patients form the impression that employers are not willing to take any more 'chances' with them. They are seen as 'risks' and employers would rather not have them on their premises. Whether in relation to employers or major bureaucracies, the patient feels powerless. From time to time patients are caught in legal uncertainties. Such was the case with Mrs R, aged twenty-seven, who had a long history of back pain related to an automobile accident. She lost her job, retreated from all social and physical activities, and became severely depressed. She filed a lawsuit against the 'offending' driver, but the case remained tied up in legal wrangles. She had fired several lawyers for their lack of interest in her case. Six years after the accident, her case remained unresolved. Finally, with the aid of a sympathetic lawyer, it was heard, but with devastating consequences for her. Every unsavoury detail of her past was uncovered. Lack of positive physical findings for her pain was at the heart of her legal difficulties. Mrs R was reluctant to engage in any future-oriented plan. Her main fear was that any such effort on her part would be construed as a sign of recovery and might weaken her case. She was in a doublebind. The pain clinic made a case to her lawyer that her involvement in rehabilitation was imperative if she were to improve, and she, in turn, received reassurance from the lawyer that her case was not likely to be weakened by her participation in such programs. The above three examples represent rather uncomplicated cases of advocacy. They are uncomplicated because in two only two individuals from the 'other' side were involved, and although the WCB case was protracted, the system was familiar to the pain clinic staff. Advocacy assumes great complexity if the case involves several large and unfamiliar bureaucracies. Convincing the other party about the legitimacy of claims is the essence of the advocacy role. The process is

Social Strategy Interventions 103 usually protracted, but at least in these three examples representation on behalf of the patients met with some success. If nothing else, advocacy resulted in considerable amelioration of the great uncertainties in their lives and, in two cases, it played a major role in the ultimate rehabilitation of the patients. In one case the patient was able to live out his last few years without the fear of losing his only means of income. Judged against the time and effort invested by the pain clinic staff, these were considerable achievements. SOCIAL SUPPORT, NETWORKING, AND SELF-HELP GROUPS

In a landmark paper Hinkle (1961) reported that a person's social and interpersonal environment not only exerts profound influence on mental health, but also has serious implications for physical health. In an earlier study Hinkle and Wolfe (1957) noted that one's satisfaction with life was in considerable measure dependent on strong and stable family ties. Cobb (1976) provided a succinct definition of social support, saying that social support is primarily an information system belonging to one or more of the following three categories: ( 1) information leading the subject to believe that he is cared for and loved; (2) information leading the subject to believe that he is esteemed and valued; and (3) information leading the subject to believe that he belongs to a network of communication and mutual obligation. The topic of the buffering role of social support against morbidity is large and complex (Thoits 1982), and beyond the scope of this chapter. Nevertheless, there is general acceptance that social support does exert a protective influence against ill health (Cobb 1976; Gore 1978). McFarlane and his associates (1984) in a prospective study of the relationship between stressful events and morbidity, examined the protective power of social support and concluded that the size of the support system was of less significance than the avail-

104 Methods of Intervention ability of a reciprocal and intimate relationship, usually with the spouse. Loss of social support for chronic pain patients is commonly observed by clinicians. Dissipation of support within the family, social withdrawal, and job loss combine to create a situation of almost complete disappearance of social support. Such was the situation with Mr S. He had emigrated to Canada from an African country, secured a well-paying job, and set about making a success of his life in his chosen land. He was well regarded by his colleagues and superiors, well connected with the larger community through his athletic interests (he was a national track and field star in his original country), and active in his church. This state of happiness was very short-lived for Mr S. He was involved in a workplace accident, in which he twisted his shoulder and developed pain in his neck and shoulder. Conservative treatment was of little help. Although he had sustained many injuries during his illustrious athletic career, this was different. For one thing, his pain was progressively getting worse. Mr S arrived at the pain clinic in a state of high anxiety. His marital, social, and work relations were under much strain. His wife did not speak English, and she was quite isolated and had a limited life outside a small circle of friends from her original country. They also had a young baby. Mr S transferred his attention to the health care system, which involved frequent phone calls to his caregivers and visits to the emergency department of his local hospital. He was unable to keep up with the demands of his job and his employment was terminated. The hallmarks of this patient were marked anxiety, somatic preoccupation, a sense of being changed, marked incapacity to deal with day-to-day problems, and loss of social support on a grand scale. An important component of the treatment plan was to restore Mr S's support system. In this context, the pain clinic itself assumed a central source of support for him. His pain was never questioned, and the clinic became his only means of securing treatment, thus

Social Strategy Interventions 105 ending his endless search for a cure. The plans and programs that enabled Mr S to regain his balance and significantly diminished his sense of powerlessness in an alien land consisted of group treatment, participation in self-help groups for himself and his wife, and slow rebuilding of his social relations to restore his former support system and create new ones. These social strategies were part of an integral treatment plan which also included physical and psychological components. Germain (1991) states that community support systems move on a continuum from informal help to semiformal to formal. She describes the informal as 'natural' helpers, these were sorely missing in the life of Mr S. A natural source of help is primarily the family. Extended family, neighbours, and friends are at the informal end of the continuum. All of these were in short supply for Mr S. Self-help groups, as correctly noted by Germain (1991), always begin informally, but over time may become complex, even national, organizations (for example, the Heart Foundation). Lubell (1986) has described the stages patients suffering from renal failure and requiring dialysis had to go through to form a mutual-aid group with the assistance of a professional social worker. Over a relatively short period the participants were able to use each other's experience and support, and the information they shared led to healthier attitudes towards the disease and improved morale and mental health. The development of mutual-aid groups is primarily a professional task, and in the context of chronic pain Baptiste and Herman (1982) pioneered such a group at the McMaster University Pain Clinic in Hamilton, Ontario. Although they did not conceptualize their activity in terms of self-help, that was in fact the outcome. They noted that the graduates of pain control groups truly appreciated the realization that they were not alone and that their problems could be understood by others. Mr S was a beneficiary of this group experience, which successfully combated his sense of 'unfair' treatment in a new country. Graduates of the McMaster group

106 Methods of Intervention therapy program went on to develop their own self-help group and chronic pain self-help groups have now mushroomed all over North America. Self-help groups are organized around common problems. Apart from providing mutual support and understanding of problems that are experienced from the inside, these groups are a powerful source of inspiration and motivation. A new member comes face to face with individuals who have been successful in overcoming the odds. However, the therapeutic value of such encounters has not been empirically assessed. The modelling effect may be one of the mechanisms that may explain elevated motivation, resurgence of hope, and even ultimate recovery. Winnipeg, Manitoba, has a well-established chronic pain society. The members are drawn from patients attending a local pain clinic, and the leadership of the society comes from within the group. The organization is incorporated as a nonprofit venture, has its own constitution, and elects its own board. The group meets biweekly to discuss issues of individual members, and from time to time guests are invited to engage in informal discussions. The group activities will be discussed later. First, a brief discussion of the self-help groups. Kropotkin (1902), in his classical book Mutual Aid: A Factor in Evolution, stated that sociability and the need for mutual aid are such inherent parts of human nature that at no time in history can we discover men living in small and isolated families, fighting for the means of subsistence. Unfortunately, given the profound changes in family structure in the West, more and more families do find themselves living in isolation. Mutual aid, which was seen by Kropotkin as inherent to the human condition, seems to have lost some ground. More formal self-help programs have replaced what used to occur spontaneously. Lee and Swenson (1986) noted that while mutual-aid and self-help were synonymous concepts, beginning in the 1960s, self-help groups started a process that has transformed them into highly organized, formal institutions. An example can be

Social Strategy Interventions 107 found in the history of Alcoholics Anonymous. The underlying principle of self-help is 'helper' therapy. Beyond that the value of the availability of a significant support group has to be therapeutic. Lee and Swenson (1986) explain that selfhelp is predicated on the ideology of people's need for each other, which confirms Kropotkin's observations made in simpler times. One of the more powerful definitions of selfhelp has been offered by Katz and Bender (1976, p. 9), whose basic idea is quoted here in full: Self-help groups are voluntary, small group structures for mutual aid and the accomplishment of a special purpose. They are usually formed by peers who have come together for mutual assistance in satisfying a common need, overcoming a common handicap or lifedisrupting problem, and bringing about social and or personal change. The initiators and members of such groups perceive that their needs are not, or cannot be, met by or through existing social institutions. Self-help groups emphasize face-to-face social interactions and the assumption of personal responsibility by members. They often provide material assistance, as well as emotional support; they are frequently 'cause' oriented, and promulgate an ideology or values through which members may attain an enhanced sense of personal identity.

The value of the self-help group is self-evident: sharing of problems in a non-threatening situation, readily available mutual support, learning from each other's experience, and political activism towards having members' problems heard. Alliances between the professionals and self-help groups are common, and the collaboration between the two can only enhance the overall well-being of patients. MANITOBA CHRONIC PAIN ASSOCIATION

This section is based on a tape-recorded conversation with four founding members of the Manitoba Chronic Pain Association. The conversation began with the group reminiscing

108 Methods of Intervention about the heady days back in 1983 when the association was formed. The idea for the association came from a physician (Dr Gunther Samelka) at the pain clinic. The first meeting was attended by some forty people. The main objective of that meeting was to discuss the need for such a group, and the level of enthusiasm was very high. The very idea of a group whose members would provide support to each other was welcome news for all who attended. A decision was made to elect an executive, and this executive set about the serious business of creating a safe environment where pain sufferers could meet to share their thoughts and feelings. Much anger was directed at the medical profession in those early meetings. Everyone had a 'horror' story to tell about medical mismanagement and foul-ups. The most important development was the 'fellowship and caring': a program was set up to contact every patient through personal contacts, media announcements, and leaflets available at the pain clinic. The group met once a month in those early days, and the program usually consisted of a talk by a professional followed by group discussions. Much exchange of information happened during the coffee breaks. On a few occasions the members broke up in small groups. These small groups, agreed the four 'historians,' were just about the best thing that happened. People really opened up and the closeness that they felt for each other was quite amazing. They formed a telephone support group, the idea of which was to keep in touch with each other between meetings. Something very creative emerged from the telephone support group. A distress or crisis hot-line was set up with the aid of four members. These volunteers had had no training in crisis intervention. Their most important asset was their own experience coupled with a strong desire to help. Some of the calls were quite frightening, involving threats of suicide or individuals expressing unbearable hopelessness. What did they do with such calls? Helplessness and fear were common feelings among the hot-line handlers. But they kept talking, some-

Social Strategy Interventions 109 times for hours and hours until the caller calmed down. People managing the crisis lines were rotated because the pressure on them was otherwise too much. But all four participants in the conversation agreed that the crisis phone service was one of the finest achievements of the association. They wished that there were some kind of training for crisis workers. Unfortunately, the crisis phone program was terminated, but there is a plan afoot to revive it, and this time its organizers hope to approach the idea methodically. Learning from mistakes, they said, was a powerful way to learn. What did they personally get from the association? They were unanimous in feeling that helping fellow sufferers was the greatest source of satisfaction for them. Deep friendships have evolved. Another common positive experience reported by all four participants was the availability of sympathetic listeners. No one had to explain the misery of living with unending pain. But there was also another plus side: there was always someone who was in worse shape. This knowledge helped them to place their own suffering in perspective. There were dying patients, many had lost jobs, still others had experienced marriage breakdown. You could always find someone worse off than yourself. One of the four participants in the discussion was the husband of a pain patient. He got involved in the early days of the association. His wife's suffering was unbearable to her, and he had a great need to learn about pain. He also felt that he himself needed support. His involvement with the association had a profound effect on his attitude. He became far more tolerant of his wife, and learned a great deal about her needs and her suffering. He had no doubt that without the benefit of the association he would by now be in dire straits. He was seen as a great asset by the membership. A great deal of family strife can be avoided if only more family members would attend the association meetings, was his final opinion. The association had fallen on hard times, agreed the four pioneers. The leadership had lost sight of the original goals.

110 Methods of Intervention They were more committed to fund-raising, as though that was an end in itself. The general membership had come to feel marginalized. The ambitious should never occupy positions ofleadership, agreed all four. In the past two years, the association had had four presidents, and the overall membership had declined. Meetings were poorly attended, and some of the most beneficial programs, such as the hot-line and phone-a-friend had ceased to exist. The original leadership had to come to the rescue of the association. Altruism is the driving force, said the founding president. A basic desire to help without any expectations of reward is a prerequisite for leadership. The association does not need a great deal of money. In the 'old' days they had had garage sales and raffies on a small scale. They raised enough money to buy and donate transcutaneous electrical nerve stimulation (TENS) units to the pain clinic. They had picnics and Christmas parties. People cared about each other. This was the essence of what the four members shared with each other and this author. They were not sentimental about the past, rather their commitment was to rescue the association, and they were well on their way to doing so. CONCLUSION AND SUMMARY

The popular image of therapy is of something being done to the patient in the sanctity of a health care facility. Only a portion of the patient's problems are addressed that way. A patient's suffering due to pain and ill health can be multiplied several fold by the problems that arise from the medical condition. Powerlessness is almost universally reported by patients, if asked. They may not be asked that often. Many social strategies are available to counter the factors that contribute to the feeling of powerlessness: advocacy at times is no more than a phone call; promotion of social support within and outside the family is a worthwhile objective; and there is no substitute for self-help groups. These methods of intervention are inexpensive, and the benefits to the patients can be enormous.

7 Task-Centred Approach

Psychotherapy literature is cluttered with methods, schools, and types of therapies, but not many psychotherapeutic approaches take into account the social environment of the patients. Many do not emphasize action, and others tend to be prescriptive. The objectives of the task-centred approach (TCA) are to help patients (1) define their problems and (2) find very practical and yet imaginative ways to resolve them. The principal proponent of the task-centred approach, Reid (1978), has put the dynamics simply. The patient wants something that he does not have. Taking appropriate action to obtain what he wants is perhaps the only effective means of achieving that end. The want may vary from something truly humble to complex personal goals. Regardless, the clear choice is to take action. While action is one of the foundations of TCA, another is the recognition that problems are rooted in the immediate psychosocial environment of the patient. This is a significant departure from the psychodynamic viewpoint, where the childhood trauma is at the heart of theory; TCA, in contrast, shares a common principle with behaviour therapies in their lack of concern with the past. Dogma aside, there are events and situations in a person's life for which the causes are to be found in that person's immediate environment, and there are others where the past has to be unravelled to comprehend the present. The latter is the subject-matter of the next chapter.

112 Methods of Intervention The reliance ofTCA is on the 'autonomous' problem-solving capacity of the patient. The search is for the patient's health rather than pathology. Each person is endowed with the capacity for initiating action to solve problems. However, Reid is careful to point out that problems, in the first place, have to be acknowledged. It is very difficult to work with problems that patients fail to recognize, let alone acknowledge. In other words, the proposition is that acknowledged problems are the ones with priority for the patient and therefore the ones that merit attention first. Besides, it may be presumptuous to disregard the patient's own definition of his problem. In this regard TCA, being of a short-term nature and behaviourally based, shares attributes of problemcentred systems family therapy, some elements of which were discussed in an earlier chapter. Let the patient define, albeit with professional help, what his problems are and what kinds of solutions he has in mind. Given the emphasis on 'acknowledged' problems, it stands to reason that the more specific the problem, the more amenable it is to resolution or at least modification. An erroneous impression may be that complex problems are not amenable to TCA. This is not necessarily true, as will become evident in the case illustrations. For many chronic pain patients, acknowledged problems are mostly related to lost roles and functions 'because of pain. Very few patients lack the capacity to state what they want, namely, an amelioration of their pain and a resumption of their 'normal' living, but they do not have the means to attain those goals. Frequently, however, there is a second line of identified wants, which sometimes require professional input to bring them to the fore. Patients may resist redefining their wants, but common sense usually prevails. In part, the desire to lead as normal a life as possible despite pain facilitates a redefinition of wants and priorities. Reid (1978) is emphatic that problemdefinition is the exclusive prerogative of the patient and 'reframing' of the problem is unacceptable; however, problems undergo many transformations in the dialogue between

Task-Centred Approach 113 the patient and the clinician and through this process emerge with greater clarity. The following is a functionally useful classification of problems created by Reid and Epstein (1972): (1) interpersonal conflicts, (2) dissatisfaction in social relations, (3) problems with formal organizations (discussed in the previous chapter), (4) difficulty in role performance, (5) decision-making problems, (6) reactive emotional distress, (7) inadequate resources, and (8) psychological or behavioural problems not elsewhere classified. This classification serves as a road map for the clinician in locating specific problems and helping the patient generate an accurate list. It is not without its limitations as the categories tend to overlap, and all psychosocial problems cannot be subsumed under the stated categories. Still, this classification serves as a benchmark and to that extent is a useful clinical tool. A brief description of each category follows. • Interpersonal conflict: Involving problems both within and outside the family, interpersonal conflict is basically defined as conflict between any two individuals, in which at least one of them finds the other person's behaviour objectionable. More often, however, both parties are in an antagonistic relationship with each other. • Dissatisfaction in social relations: A person may be troubled about certain aspects of a relationship without the relationship itself being in conflict. For example, a person may feel unable to express opinions to his boss or he may be living with a sense of isolation. • Problems with formal organizations: Instead of conflict with another individual, the antagonist is an organization (see previous chapter). • Difficulties in role performance: Problems are self-explanatory, with the proviso that the person is concerned with achieved roles, rather than ascribed roles due to, say, sex or social class. The issue is the discrepancy between the patient's actual and desired performance of roles . • Problems of social transition: This is broadly the area of

114 Methods of Intervention life change. Transitional situations can be very diverse, and usually pose a challenge to one's habitual modes of coping. Two types of transitions are potential transitions, such as making a decision about an unwanted pregnancy, and planned transitions, such as the decision to relocate. • Reactive emotional distress: Negative psychological reaction to a specific event is the focus of this dimension. The event must be clearly identifiable by the patient. For a problem to be considered appropriate for TCA, the following conditions must prevail: (1) the patient must 'explicitly' admit to having a problem and must demonstrate a willingness to work on it; (2) the problem must be amenable to action by the patient, albeit with the collaboration of the clinician; and (3) given the short-term focus ofTCA, the problem must be specific and of limited scope. Another characteristic of TCA is that it de-emphasizes causal factors. A knowledge of causal factors does not necessarily lead to resolution of the problem. Besides, Reid (1978, p. 43) redefined causation by saying that the 'cause of a problem can be thought of as whatever is preventing its resolution.' Intervention has two main tasks: (1) resolution of the patient's problems and (2) enhancement of the patient's problem-solving skills. • Application of TCA: TCA is a direct method of intervention. It is client-centred and relies on the proposition that client knows best. Problems to be worked on are defined as tasks, and the client should have the capacity to work on the tasks outside the treatment session. These tasks are the products of a joint decision made by the clinician and the patient. As noted earlier, even in this regard TCA has a very close ally in the problem-centred systems family therapy (see Chapter 5) which proposes that the family has the main responsibility for both identifying problems and achieving their resolution. Tasks fall into two categories: (1) general tasks, with broad non-specific directions about handling them, and (2) operational tasks, which are based on specific action plans. Ther-

Task-Centred Approach 115 apeutically, the mix is sensible as it allows the patient to be creative, while at the same time providing him with definite guidelines for accomplishing specific goals. This approach offers an effective way of building confidence and promoting the patient's sense of autonomy. CASE ILLUSTRATIONS

The following two cases demonstrate the efficacy of the TCA.

A Man in a State of Disarray Mr T (age twenty-seven) was referred by his orthopeadic surgeon for debilitating neck and shoulder pain. He had been involved in a rear-end automobile crash that caused a whiplash injury some eight months before his arrival at the pain clinic. Not only had his pain failed to respond to many interventions, but it had worsened to the point that he could barely cope with his day-to-day life. Mr T was a professional engineer and had an excellent position with a small firm. Following the accident he became unable to function in his job. Gradually he withdrew from all social activities and found himself in conflict with his sister (the only relative he had in town), his landlord, his ex-employer, his family physician, an insurance company, and his close friends. The source of the conflict was that no one believed him about his pain, and even he himself at times wondered if he was not imagining it all. Problem Identification As in almost any model of treatment, the preliminary task is to clearly establish the quality and the quantity of the problems. TCA involves not only identification but clear acknowledgment of the problems by the patient. This may not be easy, given the nature of chronic pain syndrome. The problems are considered to be caused by the pain and logically removal of the pain should restore the patient to his original level of functioning. But chronic pain is often refractory

116 Methods of Intervention to treatment. This problem leads to a departure from the TCA prescription, and a complex process begins to unfold which can and often does lead to an agreed-upon set of problems that require resolution. Mr T's problems were all in the present. But pain was his main if not only problem. Reid and Epstein (1972) have described the initial stage as the 'first level,' where the patient's understanding of the problems may be 'colored by pent-up affect.' The struggle patients and clients experience before owning or acknowledging problems is probably often underestimated. At the 'second level,' meaning the second interview, 'target problems' begin to emerge, according to Reid and Epstein. The fact is that it may take several sessions to reach the second level. Significant departure from any model of therapy is often essential to adapt to the special needs of patient or client populations. The TCA in this instance is more a guide than a prescription. The patient is often angry and demoralized at the point of entry into the pain clinic. He has met with hostility and incredulity in his journey to find a 'medical' cause for his pain. Finally, he is left with not just pain, but a disrupted life. This anger has to be dealt with, and a reasonable level of trust has to be established. A clear message that the pain, despite diagnostic uncertainty, is real has to be communicated. There must be unequivocal acceptance of the pain. The patient must have the capacity to get past finding a 'cure' for the pain to begin to address other issues of substance. The point of departure from the clinical viewpoint is the clinician's ability to convey to the patient that while cure for the pain is not at hand, the quality of the patient's life can be improved by trying to resolve the specific consequences. Once the patient shows any sign of willingness, then the process of establishing and prioritizing problems can begin. Hence, some time passed before Mr T was able and willing to get past his preoccupation with his pain, while acknowledging that he had suffered a number of set-backs. The loss

Task-Centred Approach 117 of his job was at the top of his concerns. He felt that 'loyalty' meant nothing to his employer and that at the first sign of his health problem he had been let go. Financial difficulties were beginning to loom large in his mind. He was receiving unemployment benefits, which were considerably less than his income had been. He lived in great fear of running out of these benefits and having to resort to welfare. He said that he would rather die than accept 'charity.' He had been deserted by his best friend because much of the time he had not been in the mood to do the things they had usually done together, like going to movies, playing bridge, or just 'hanging out.' He had had a major row with his sister, because she had expressed serious doubts about the authenticity of his pain and had told him to 'pull himself together' and find a job. Mr T literally threw his sister out of his apartment, which he regretted almost immediately, but he had failed to take any action to restore his friendship with her. In addition, Mr T had a problem with his landlord, the nature of which was very vague, and a 'callous' lawyer whose 'greed' for money far surpassed his interest in Mr T's case. Reid's (1978) classification of social problems presents an interesting challenge if we wish to categorize Mr T's difficulties. Arguably, Mr T's problems were reactive to the automobile accident, and they thus could come under the category of 'reactive emotional distress,' the hallmark of which is a readily identifiable event. The accident, however, was minor, and the pain that ensued from it was unusual in that it was disproportionate to the trauma sustained. But that is the nature of chronic pain. The fact still remains that without the accident, Mr T would not have embarked on his pain career. Despite the reactive nature of Mr T's troubles, then, it may be instructive to further break them down into other categories. Mr T's pain resulted in significant role changes, transforming him from a healthy, functioning, normal young adult to one in the role of being chronically sick. Interpersonal conflicts abounded. The point to note here is that Reid's

118 Methods of Intervention categories of social problems are interrelated and probably orthogonal in nature. The benefit of the classification is that it can lead to a refined definition of the problems. Mr T, for example, reacted to his trauma and pain mainly by disrupting his relationships. The reactions could have had other manifestations. The following problems were explicitly agreed upon by Mr T and the clinician: • Problem 1 Mr Thad withdrawn almost totally from his social life: His social life had been limited, even before his accident. With his pain getting progressively worse, he became almost totally house-bound and left home only to keep his medical appointments and very infrequently to buy groceries. • Problem 2 He was very unhappy about falling out with his sister: As was stated earlier, the sister was sceptical about Mr T's pain which resulted in a major quarrel, and he threw her out of his apartment. • Problem 3 He had lost his job and was experiencing financial problems: Mr T feared he would never make a sufficient recovery to return to his profession, and he also felt unfairly treated by his employer. • Problem 4 He was dissatisfied with his lawyer: There had been no action on the part of the lawyer to settle Mr T's insurance claims. Problem Assessment Mr T's intractable pain problem had turned his life upside down. Pain and depression had demoralized him to the point of complete social withdrawal; severe pain had legitimized this withdrawal. His other problems followed an almost predictable path leading to rapid social and psychological disintegration. Mr T's concern about money was somewhat exaggerated. In addition to his unemployment benefits he

Task-Centred Approach 119 had disability insurance. His anxiety, however, prevented him from taking realistic stock of the situation. His physical and psychological health was sufficiently compromised that pursuing his career was unrealistic. His somewhat catastrophic reaction to his health problem also distorted his perception of the problems with his landlord and lawyer. Given these facts, the following goals were established. • Goal 1: Implementation of plan for socializing again • Goal 2: Initiation of contact with his sister to re-establish their relationship • Goal 3: Meetings with the lawyer and the landlord to ascertain the facts • Goal 4: Development of realistic plans for returning to work It should be noted that Mr T responded rather poorly to various treatments at the pain clinic, the main reason being his non-compliance. His attitude to TCA was equivocal at best. The proponents of TCA do not adequately deal with the question of motivating clients and patients, because motivation is assumed to be given. That is too restrictive a view. In situations such as Mr T's, where the patient is thoroughly discouraged by his lack of progress, motivation may indeed be suffering. With persistence, however, Mr Twas engaged in TCA or a close version of it. Service Duration An initial contract was made with Mr T for ten sessions spread over a three-month period. The rationale for a somewhat longer time-frame was that there is always a time lag between plan and action. Action Plan A plan was carefully drawn up by Mr T with the clinician's help and suggestions, but the plan was very definitely Mr T's plan. The essential elements of it were: 1 As a starting point, Mr T would go out with his friend at least once a week. In addition, he would do his grocery shopping once a week.

120 Methods of Intervention 2 Mr T would contact his sister and attempt to resolve their differences. Once that was achieved, he would see her once a week. 3 A meeting with Mr T's lawyer was to be set up to deal with Mr T's concern and to get the facts of his case. Mr T agreed to report back to the therapist the outcome of this meeting. A similar arrangement was to be made with Mr T's landlord. 4 Mr T would postpone any immediate thoughts of returning to work. In relation to this a most critical agreement had been reached with the therapist that the pain would remain non-negotiable. This last point was agreed upon because while alleviation of the pain was an almost unachievable goal, in the meantime there was some urgency that Mr T take charge of his life. The process of setting tasks and achieving goals, while mechanistic in appearance, is truly dynamic. The treatment plan is set into motion, and problems and their solutions are rehearsed in treatment sessions. Resistance, fear, and uncertainty can easily derail well-meaning plans, and psychological support for the patient is critical. Support should come from the principal clinician, but other members of the team should also participate in encouraging the patient. The patient is aware that he is involved in the coordinated effort of the clinic as a whole, and the clinic serves as a major source of support for him. Mr T followed a rather jagged path to attain his goals. For example, he was terrified of meeting with his lawyer lest the lawyer should take offence and withdraw from the case. His initial attempts to go out once a week proved to be uncertain at best. There was always the pain to fall back on; thus he was violating another agreement. However, the goal ofreconciliation with his sister was achieved on schedule and without fuss. This, in fact, was his first major achievement. The renewal of his relationship with his sister was a major advance in the treatment. It restored some of his confidence. Over time, resumption of the friendship with his best friend

Task-Centred Approach 121 had a similar effect. His feelings that others tended to minimize his pain and suffering diminished; the pain clinic itself played a major role in that regard. Mr T's assumptive world was slowly being restored. A singular fact of life for many chronic pain patients is a profound sense of loss of control over their own life. Tasks are, therefore, in a sense rank-ordered by degree of difficulty. In the order of things, Mr T's reconciliation with his sister was a relatively simple task, but in terms of its significance, the achievement was substantial. Resolving conflicts with 'powerful' people, such as lawyers and landlords, however, was more daunting. In the case of Mr T the stated goals were realized, albeit very slowly. There was a great deal of back-and-forth movement. The treatment lasted over a year. The goals were revised and more complex tasks were added. The last task was for Mr T to obtain employment, and he was completely successful in that, too. He was hired by a large automobile manufacturer at a high salary. However, this description of the case does not begin to do justice to the uphill nature of Mr T's progress. The TCA kept his goals in the forefront. Any experience of failure was counteracted by reminders of past successes. From the therapist's viewpoint, having agreedupon goals to work with facilitated the therapeutic process. TCA is a short-term, goal-oriented, and behaviourally based approach. Its merit is that the patient from the very outset is responsible for the outcome of treatment. In addition, the task-development process in itself has some therapeutic value. The message to the patient is that 'you are capable of taking charge of your life,' and this at a time of much uncertainty and foreboding. In a simple sense TCA puts the patient in the driver's seat, and it is his show. A word of caution: the patient cannot do it alone and a gradual approach to problem-solving is desirable; and the patient should not be blamed for failure to achieve a goal. To begin with, the goals need to be of a very practical nature and well within the capacity of the patient to tackle. Initially, Mr Twas actively

122 Methods of Intervention discouraged from having 'returning to work' as a practical goal. In due course, however, he insisted upon including that goal as an attainable one. Early success, it must be reiterated, is essential in working with these patients. Also it should be noted that 'taking charge' of many aspects of living also appears to spill over into more effective pain management. What might account for Mr T's success? There are no obvious indicators. Hence, speculation may be justified. His trouble-free pre-morbid history, excellent academic and work record, basically limited, but good relationships, and perhaps in the end his own desire to resume normal living contributed to his recovery. A final point is that in a pain clinic a patient is subject to many influences and treatment modalities. Thus, it would border on absurdity to attribute Mr T's recovery to TCA alone, while, equally, it may be unwise to ignore its therapeutic prowess for effecting change.

A Simpler Case The case of Miss U (age sixty-eight) is presented to show the efficacy of TCA alone as the treatment of choice. She was referred to the pain clinic with an unremitting complaint of back pain of three years' duration. The pain kept her confined to her apartment, and she spent most of her waking hours in a supine position. She was clearly not taking adequate care of herself. She had had numerous investigations for her pain, but all the findings were negative. Miss U had never married because, she said, she had never had the time. She had started her retail business early in life and had a mother to look after. She was a person highly regarded in the business community and participated to the full in business activities. As she approached the age of sixty-five, she decided to sell her business to have more leisure and also to devote more time to her unwell mother. Her pain began in earnest some six months after her retirement. A year later, her mother died. Miss U was now without a purpose, and on the verge of assuming the status

Task-Centred Approach 123 of an invalid. When seen at the pain clinic, she was depressed, unkempt, and seeing her made it hard to imagine that in the recent past she had been a successful businesswoman. She expressed great uncertainty about her future. She also had serious doubts about the negative medical findings and was convinced that she had a serious undiagnosed ailment. Application of TCA The problems stated by Miss U included pain, as might be expected. Unlike Mr T who was very focused on pain, Miss U had a much better grasp of her social reality. The death of her mother, selling her business, and the ensuing loneliness were readily pointed out by this patient. Although she did not make any connection between her altered circumstances and pain, which very few patients do, she was cognizant of her isolation and sadness. The targeted problems to be worked on included: 1 The fact that Miss U was spending an extraordinary amount of time lying down in bed 2 The fact that Miss U was not adequately taking care of herself 3 The fact that Miss U was shunning all social contact All of Miss D's problems were clearly in the category of reactive emotional distress. She was a highly efficient businessperson and a homemaker. She enjoyed her life and had never had a day's illness. And now with things gone so wrong, she was anxious to regain her health. The contract with Miss U included six sessions over a twomonth period. The goals of treatment were a measurable level of daily activity, evidence of self-care, and restoration of social contact. The tasks were carefully designed around each goal, and within the specified time she had not only achieved her goals, but surpassed them. Grief and loss were at the heart of Miss D's pain symptoms. Given the superb state of her pre-morbid abilities, it was hardly surprising that she made a remarkable recovery.

124 Methods of Intervention SUMMARY

is only one practical approach to dealing with psychosocial problems. The overall efficacy of this method has not been rigorously evaluated. Its application with the chronic pain population is not mentioned in the literature, except in my own reports. On the basis of some years of clinical experience with its use with pain patients, I am impressed by TCA for its simplicity of application, economy, and general effectiveness. The method is easy to learn and apply. The approach makes sense to patients, who appreciate its focus on the here and now, the shared responsibility with the therapist, and most important of all, the emerging sense of taking charge of their lives - giving them a sense of empowerment. However, TCA, is only one method of therapy, and whether it is superior to others remains to be proved. TCA

8

Dynamic Psychotherapy and Pain

Psychogenic pain, or pain that has its origin in intrapsychic conflicts, is a well-established fact. Hysterical pain, pain due to conversion reaction, depression, or somatoform disorders, is far from uncommon. At the heart of dynamic psychotherapy is the assumption that the internalization of negative emotions finds expression in somatic symptoms. Under certain circumstances, unresolved childhood conflicts, as has been demonstrated by Engel (1959) and Szasz (1975), present as pain symptoms without organic cause in adults. This chapter will discuss cases where the patients' childhood issues emerged as paramount, and dynamic psychotherapy was the treatment of choice. Dynamic psychotherapy is not a very popular treatment method for chronic pain. Although cases of psychogenic and hysterical pain were reported by Freud and his followers, pain as a psychological symptom remained suspect. Nevertheless, in the contemporary literature dynamic psychotherapy as a method of treatment for psychogenic pain has not been wholly ignored, although this literature is scanty. In a review of psychodynamic formulations of pain Pilowsky (1986, p. 189) noted that: 'Systematic investigations into the validity ofpsychodynamic theories of pain have, however, been relatively uncommon. In the main, reports have been based on clinical studies of very small numbers of patients and have concentrated in particular on the relationship be-

126 Methods of Intervention tween drives such as aggression and pain.' Pilowsky ( 1986) enunciated three complex psychodynamic mechanisms dynamic view, structural view, and developmental approach - to explain the unconscious genesis of pain. An adaptational approach is the fourth mechanism, and its departure from the above three lies in the fact that it appears to combine unconscious and conscious mechanisms. The dynamic view considers the relationship between unconscious drives and the pain experience. Pilowsky (1986) postulates a direct association between aggression and pain. The structural view of pain is perhaps best represented by Szasz (1975), who has carefully articulated the role of painful experiences in the formation of the superego and the continuing role of pain in a person's psychic existence. The developmental approach involves conflicts as they relate to specific developmental stages namely, anal, oral, and genital. Pilowsky (1986, p. 185) observed that 'since the oral, anal and genital areas have special sexual significance, pain experienced in these locations will require to be understood in terms of these special attributes of the body image.' In the clinical literature the clearly delineated approaches of Pilowsky are hard to detect. Even the premise that knowledge of negative childhood events and experiences is prerequisite to the implementation of dynamic psychotherapy is not always to be found. The literature, sparse as it is, contains an odd mix of reasons for the selection of psychotherapy as the treatment of choice or as an adjunct treatment for chronic pain. There are some exceptions. Szasz (1975) and Engel (1959) provide perhaps the soundest rationale for dynamic psychotherapy as the treatment of choice for pain without organic cause, under certain circumstances. Szasz (1975) contends that the sensation of pain is probably experienced at birth through injuries accompanied by other unpleasurable experiences such as hunger, cold, and thirst. His most radical contention is that pain is an emotion. Pain and anxiety are defences used against each other. Proof of this position, ac-

Dynamic Psychotherapy and Pain 127 cording to Szasz, is that in successful treatment hysterical pain is replaced by anxiety. At the very centre of Szasz's analyses is the proposition that the ego relates to the body and its parts in the same way that it relates to objects. By adopting this line of argumentation, he resolves the Cartesian duality of body and mind. He states: 'When we consider the relationship of the body to the ego, the distinction between "organic" and "psychogenic" automatically disappears' (Szasz 1975, p. 70). From the point of view of the 'experiencing' ego, all pains are felt by the body. Like neurotic anxiety, psychogenic pain cannot be validated and the source of danger in either situation is not evident. Pain, in effect, has symbolic meanings. Szasz (1975, p. 94) narrates the story of a young woman in her late teens with complaints of abdominal, pelvic, and low back pain. Her history revealed the sudden death of her mother and a possible suicidal death of her father a year later. Szasz's remarkable conclusion was that 'having lost both her parents, [she] had no really significant object left to lose other than her body' (Szasz 1975, p. 98). Three symbolic aspects of pain are noted by Szasz (1975): pain as threat to body integrity recognized by the ego; pain as communication, serving the primary function of asking for help; and, finally, expression of pain that does not denote body pain, but rather a call for understanding of some major symbolic transformation. Engel's postulation of the pain-prone patient was discussed at length in Chapter 4. This section will further explore this concept using Engel's own application of pain-proneness in the formulation and treatment of psychogenic pain. Engel (1959) is emphatic about the psychic significance of pain in its universality. Six major and special meanings are recognized. (1) Pain is a warning for damage to the body, and pain memories are acquired over a lifetime involving the parts of the body that have experienced pain. (2) Pain eliciting a caring response, leading to relief of pain, is a universal phenomenon. Pain leading a child to crying to receiving love and attention to relief of pain is the process that converts an

128 Methods of Intervention unpleasant stimulus into a pleasant one. (3) An understanding of the relationship between pain and punishment begins early in human experience. Pain is associated with badness and in due course serves the purpose of expiation of guilt. (4) Pain, aggression, and power interact in a complex way. Aggressive drives are controlled by the experience of pain. (5) Pain has the capacity to make loss more tolerable. Even the selection of pain site may be influenced by the presumed or real pain experience of the 'lost' person. (6) Pain and sexual feelings are closely connected. Sado-masochism is an extreme manifestation of that relationship. Engel (1959) provides rich clinical material to support his thesis. A brief review of that material. follows. A sixty-one-year-old man had burning pain of the right ear. As a child he had been treated cruelly by his father and stepmother, who freqeuntly boxed his ears. He accepted his punishment, and in adult life became a 'loser.' Engel noted that patients with a harsh and punitive history often used pain as an unconscious source of gratification. A woman with a history of facial pain told how she felt responsible for the cleft palate with which her daughter had been born. She attributed the daughter's deformity to her husband's practice of coitus interruptus, which habit she described as a 'slap in the face.' This patient's facial pain began one month after the birth of her daughter. Engel noted that the location of pain may be overdetermined as in this case, involving the daughter, her mother's facial pain, and the 'slap in the face' received on a regular basis by the mother from her husband. These two case vignettes are presented to draw attention to the care that is required in getting precise historical information to develop valid formulations. In a true sense, Engel developed a 'blueprint' for the application of dynamic psychotherapy in treating psychogenic pain - actual reports in the literature of dynamic psychotherapy involving pain patients are rather rare. Pilowsky and Bassett (1982) report two cases of completed treatment. The first is of a thirty-two-year-old married

Dynamic Psychotherapy and Pain 129 woman with a history of back pain. Her developmental history clearly fit into Engel's description of the pain-prone patient and was characterized by childhood abuse and alcoholic parents. Treatment was successfully completed in twelve sessions. The patient reported substantial improvement of her pain and general psychological health. The second case involved a forty-three-year-old woman with abdominal pain. The initial focus of the treatment was on her immediate relationships. In due course the patient recounted an incident of sexual assault by her brother. This woman's pain complaint remained unchanged, but she was still very satisfied with the outcome of treatment. It was observed that improvement was still possible without pain reduction, which automatically raises the question of efficacy of psychotherapy for pain treatment. The second case provides further support for the position that when the patient is viewed in the context of her ecology, broadly based treatment is called for, frequently with favourable outcome. The other point of note is that matters of therapeutic import may take a while to emerge. In the latter case it was in the course of the eighth session that the crucial matter of sexual assault was revealed. It took one of my patients over a year to disclose an incident of brutal rape by a male superior at work as well as other critical events in her life. Following these disclosures, I changed the therapeutic direction from supportive to dynamic; this case will be discussed below. It remains a matter of conjecture whether traumatic memories are suppressed (or repressed) or, alternatively, the therapist has to gain the patient's trust before the patient can disclose matters of enormous personal hurt. Theoretically, these two positions are not mutually exclusive. The development of trust (transference) can begin to lower the patient's defences, allowing painful memories to surface, thus leading to their disclosure. An interesting clinical observation is that as long as a patient is willing to engage in dynamic psychotherapy even in the absence of any obvious past issues, chances are

130 Methods of Intervention that such events are likely to be remembered and recounted. This is especially so as resistance to dynamic psychotherapy is very high among pain patients, simply because the relevance of such therapy defies common sense. Bellissimo and Tunks (1984) have also made a clear case for dynamic psychotherapy in treating pain associated with conversion reaction, hypochondriasis, depression, and unresolved past issues. These authors convincingly demonstrate the wide range of situations suitable for psychotherapy. They acknowledge that removal of pain is not always attained through this treatment, but patients generally report improved quality of life despite pain. As for the therapeutic process itself, these authors maintain relative silence. In 1982 I described four chronic pain patients with a past experience of abuse and neglect. The psychotherapy techniques developed by Sifneos (1981) and Malan (1979) were applied with some measure of success. It was noted that dynamic psychotherapy remained a suspect method of treatment for chronic pain. Furthermore, the factors that would point to this method as the treatment of choice were at best equivocal. Malan (1979) stated that 'the aim of dynamic psychotherapy is to reach beneath the defense and anxiety, to the hidden feelings back from the present to its origins in the past, usually in relation with parents.' Hence, the minimum requirement for using dynamic psychotherapy is the presence of unresolved childhood conflicts. In the literature such strict adherence to the primacy of childhood issues is not always evident. Perhaps the term 'dynamic' differentiates Malan's approach from other forms of psychotherapy. If Malan's approach is adopted, then the pain problem itself cannot remain the focus of treatment. Pilowsky and Bassett (1982) are cognizant of that fact, which accounts for resistance to this form of treatment by pain sufferers. Once a clinical decision is reached about the viability of dynamic psychotherapy for any particular patient, a clear and concise explanation becomes a prerequisite if the patient is to be

Dynamic Psychotherapy and Pain 131 successfully engaged. The pain problem itself must become non-negotiable. Many years ago, I devised a simple explanation to engage individuals and families in therapy. The basic message is that while the pain problem itself may be refractory to treatment, patients and families do not have to be totally at the mercy of the pain. Thus I set in motion a dialogue that usually leads to discovery of many unattended problems that demand attention. The initial stage is always non-threatening as the patient begins to elaborate on the negative effects of living with pain; this process will be fully developed below. Together, the works of Merskey and Spear (1967) and Pilowsky and Bassett (1982) give a thorough treatment of the literature on most aspects of the psychodynamics of pain. The following review will thus concentrate on the more recent literature concerned with the application of psychotherapy to the treatment of pain patients. Much of the current literature simply discusses cases of successful use of psychotherapy for individuals with pain complaints (Bonger 1988; Botto 1985; Elkins 1984; Frances and Spiegel 1987; Lakoff 1983; Muse 1984; Roy 1984; Wepman 1988; Wise 1986). Some of these reports are only indirectly concerned with pain. Frances and Spiegel (1987), for instance, describe a thirty-four-year-old woman with pain in her right wrist; however, her pain problems were overshadowed by her psychiatric problems. The multimodal treatment regime included psychotherapy, but the thrust of the treatment was to address the woman's psychiatric problems. In contrast Roy (1984) reported the case of a woman with chronic headache where psychotherapy ultimately succeeded after all other treatments had failed; this woman reported significant improvement in her headaches. Muse (1984) reported the case of a forty-nine-year-old man who had been involved in an industrial accident. Psychotherapy together with sodiumamytal ultimately resolved this man's pain problem. The term 'psychotherapy' is used in widely divergent ways, describing different techniques, and at times the theoretical

132 Methods of Intervention underpinnings of the therapy are, at best, vague. An acrossthe-board comparison is impossible, given the variability in methods and the fact that the reports generally tend to involve only positive outcomes. This latter point is illustrated by a description of the power of 'interpretive' psychotherapy to resolve long-standing pain problems in four patients (Lakoff 1983). A psychogenic formulation of pain behaviour is based on a sound knowledge of the patient's developmental history. 'Analytic psychotherapy, by creating a bridge with the past, helps the patient utilize previous more adaptive resources,' concludes Lakoff (1983). It can be stated without any fear of contradiction that, with the exception of Engel's 'blueprint' for implementation (1959) and dynamic psychotherapy as modified by Malan (1979), there are no clear guidelines for selecting this treatment for chronic pain. A decided need remains for clarity about the nature of the pain problem, such as in Engel's pain-prone patient, that may be most amenable to well-defined psychotherapeutic intervention. In this respect a valuable lesson is to be learned from behavioural approaches to treating pain behaviours. In the meantime, clinicians must rely on limited guidance to make decisions about the appropriateness of dynamic psychotherapy for treating chronic pain. CASE ILLUSTRATIONS

Two chronic pain. sufferers for whom dynamic psychotherapy was chosen as the treatment of choice are described and the reasons for selecting this method of treatment are also discussed.

A Case of Success Mrs V was thirty-five years old and had a long-standing history of mixed headaches when she was referred to the pain clinic by her neurologist. In his letter of referral he stated that Mrs V had failed to respond to all his efforts and

Dynamic Psychotherapy and Pain 133 that perhaps the clinic would consider a more psychological approach to treating her headache problems. Mrs V arrived on time for her first appointment. She was a slender, plainly dressed woman, who seemed very nervous about the visit. She knew the reason for her referral to the pain clinic, and was dismayed by the fact that her headaches, if anything, were worse. She was a health care professional herself and acknowledged that the neurologist could do no more. She spoke very slowly and softly, at times her voice becoming inaudible. She was asked how she felt about her visit to the clinic. After a prolonged pause, which, as the therapist was to realize later, would be a permanent feature of these sessions, she replied that she did not know, an answer she was to give with disconcerting frequency. She had been married for several years and had two little girls. She said that the girls were no problem and that her husband was a good man and a very good provider. The headaches at times were very severe, but she rarely missed work because of them. Sometimes she did not feel like socializing, but she did so anyway to avoid arguments with her husband. This was the first clue that all was not well on the domestic front. The above information was obtained during several sessions. Mrs V never failed to keep her appointment and was always punctual. She was given a clear message that the therapeutic hour belonged to her, and she could use it in any way that she pleased. She should not feel compelled to talk or she could talk about anything she chose. Several preliminary hypotheses were developed. First, she was very unsure of herself, and for whatever reason her self-esteem was compromised. Second, she was frightened of someone or something. Third, the marital relationship was strained, and, fourth, she was probably in an abusive situation. There was no hard or soft evidence to support the last point. It was her general demeanour, which seemed to convey fear that led to the hypothesis of abuse. The entire therapeutic process from here on will be tele-

134 Methods of Intervention scoped, so that the most essential features of treatment are adequately discussed. Mrs V's treatment could be divided into two phases, here-and-now issues and issues of the past. Here-and-Now Issues The single most important problem to emerge in this respect was her complete disillusionment with her marriage. She had married on the rebound. She had been engaged to be married to another man, but he had failed to show up on the wedding day. Then came a very important clue about the troubled nature of her primary relationships. Her mother had become furious with her for disgracing the entire family with the cancelled wedding, and her father had maintained a stoical silence. Mrs V was an only child. She then refused to discuss her parents any further for a long time. Mrs V described how she did not have a long courtship, how she had been impressed by her husband's kind disposition. But, as it turned out, he was not kind, but authoritarian and at all times at the beck and call of his mother. In addition, he had a violent temper. He had never actually hit her, but then she said she never given him any cause to. She became pregnant and in quick succession had two daughters and learned to do as she was told. There was no friction in the family, although at times she felt like a non-person. Still, she said, she had the children and her job. Then one day her husband announced that the family was moving some 800 miles east. He had accepted a new position without so much as a word to her about the move. She said that the idea occurred to her vaguely then that some day she must leave this man. At this point in the therapy the possibility of couple therapy was raised, because much of her conflict was with her husband and she had shown very little inclination to leave him. She categorically refused. Close to a year had passed since she had entered therapy, and the progress had been minimal. Another noteworthy point is that she showed very little of her emotions and expressed no opinions on any mat-

Dynamic Psychotherapy and Pain 135 ter. It was the pursuit of this latter issue that had a profound effect on the therapy - and its ultimate outcome. Past Issues What might account for Mrs V's high tolerance level of distress and her almost total commitment to maintaining peace at any cost? As these two related issues were slowly and methodically explored, she revealed that one had had to know her mother to appreciate why she had learned to maintain silence or show very little emotion. She reassured the therapist that she was very demonstrative of her feelings with her children. Her own mother, she reported, probably never really wanted her. She was the only child and her parents were 'quite old' when she was born. She was unable to recall any happy childhood memories. She liked being around her father when he was home, which was not often. Her mother was distant and hostile. When asked for an example of the mother's hostile attitude, Mrs V said that for one thing, she could never please her mother. If she received an A in her schoolwork, her mother would expect an A+. So it went. She said mother was very critical of how she looked, and the way she walked, dressed, and talked. She could not remember a single occasion when she had been hugged by either parent. She liked school, but did not have any close friends and she was not allowed to invite friends home. Mrs V grew up to be a rather shy, passive, and compliant individual. Her love for education enabled her to pursue postsecondary education in health care. She continued to live at home, feeling unequipped to make it on her own in the outside world. She enjoyed her work and was not particularly unhappy. It was during this phase in her life that she was raped by a superior at her place of work. The therapist was the first and only person that she had taken into confidence on the matter of rape. She said that after that she became very depressed and even more withdrawn. If her parents had noticed this change in her, they never said anything. She said she did not tell her mother because she felt her mother would not have

136 Methods of Intervention believed her. So, she continued to suffer in silence with an enhanced sense of worthlessness until she met a man and fell in love, and this man failed to turn up for the wedding. The therapeutic process, in the main, focused on exploring her feelings about her parents, in particular her mother. It was several sessions before she was able to express any anger about the way she was treated by both her parents. The mother's hostility, the father's indifference, and the patient's need to blame herself occupied many sessions. Her belief in her own 'badness' was profound, and the process of change in this patient was almost imperceptible. Anger, or rather a flicker of it, was the first sign of a weakening of her defences. She wondered about what kind of people her parents were that they had totally failed to see her distress after the rape incident, and concluded that they just didn't care. But then they could not read her mind, and she thought that perhaps she should have told her mother. But she could not do so, she said, because the shame of being raped was just too much; she said that she felt dirty and in some ways responsible for the rape. Mrs V continued in this vein for the next four months or so. Then a rather surprising event took place. Mrs V came in for her session and announced quietly that she had made up her mind to leave her husband. Her mother-in-law was making her life unbearable and her husband always sided with his mother. Mrs V was slowly coming to terms with her past. She did not choose to be born in that family. Her mother was basically uncaring, but then she herself did not have such a great life. Mrs V was certain that her parents did not care much for each other, and as they got older her mother was openly hostile to her father. Not only was Mrs V developing a new perspective about herself, but her ambivalence towards her mother was slowly finding resolution. She made an important discovery that her mother was a very unhappy woman, and to that extent they had much in common. Her view about her father was also becoming more realistic. She was bringing him down from the pedestal, and he did not

Dynamic Psychotherapy and Pain 137 seem quite as benign and kindly to her as she had imagined him to be for much of her life. Therapy continued for another six months during which her self-esteem altered to a visible degree. She saw herself as somewhat of an unwitting victim. She could not be blamed for all those terrible things that happened to her. It was not her fault that her parents failed to show their love for her. She was capable of great love and affection, and her children were living proof of that. Despite all odds, she had educated herself and had a profession. There was now emerging a person who had confidence, albeit tentative at times, and whose overwhelming sense of guilt was on the wane. Active therapy was nearing its end. Treatment Issues The point of note in the case of Mrs V is that the childhood issues here cannot be classified as abuse or even neglect in its strictest sense. The patient was unloved and grew up feeling unwanted. However, it is critical to have some appreciation of the genesis of guilt in Mrs V. As a child she experienced rejection. Later, when she tried to please her mother, she was generally met with hostility. The only way she could understand the 'punishment' was through her own 'badness' coupled with feelings of unworthiness. Her inability to take a stand or, conversely, her desire to please at any cost, both signs of severely handicapped self-esteem, were further entrenched by the combined experiences of being raped by a person she knew and abandoned by her fiance. Mrs V, thus, accepted her husband's unkind behaviour with silence and fortitude. Engel's theory of pain-proneness was at the heart of the conceptual understanding of this case. Growing up in an affectionless environment, guilt, and use of pain for expiation of guilt were all to be found here. The second half of the treatment was modelled on Malan's dynamic psychotherapy, which entails systematic exploration of childhood experiences and dismantling of dysfunctional defences.

138 Methods of Intervention In due course, Mrs V did leave her husband and set up a home for herself and the children. Her headaches improved, but did not disappear, and she was managing them without narcotic analgesics. Followed up for the next two years, she continued to show signs of ever increasing independence. She found herself a better-paying job and was freely giving vent to her impatience and anger with her teenage children for their unreasonable demands. Mrs V acknowledged that she was no longer constantly seeking approval.

Pain and Guilt Mrs W, who was thirty-two years old, was referred to the pain clinic by her family physician. She was suffering from migraine headaches which had been getting progressively worse. A willing participant in the psychological and social investigations, she made a remarkable revelation. She wanted a divorce, and she wished the father to have the custody of their three-year-old daughter. She felt that her husband was a fine person and their daughter was beautiful, but she was not 'cut out' to be a wife and mother. She felt that the marriage was a mistake and that having the baby was a disaster. She had extreme feelings of anger towards the baby, though she was sure that she would not harm her. No one understood her (destructive) need to break up the marriage and even less her need to give up the child. The above is a summary of her initial statement. Mrs W was visibly upset and angry while she talked. When asked to explain why she was so adamant about giving up her child, she said that perhaps she had no right to be a mother and she certainly did not deserve to be married to such a nice man. She herself had only horrible memories of growing up, and she felt that just at a time when she was getting herself together and was enjoying some measure of success as a fashion model she had spoiled it all by getting married and having a baby. Mrs W's childhood had been horrendous. She had been physically and sexually abused by her father and an elderly

Dynamic Psychotherapy and Pain 139 uncle. She had also been 'offered' by the father to his close friends. Her mother had been totally 'ineffectual' and probably had known about the sexual abuse, but had failed to intervene. Mrs W was removed from her family and placed in foster homes from the age four to eight years. She was then adopted by her grandparents, who were devoted to her. When she was thirteem years old her father reappeared on the scene and some further abuse occurred, but her grandmother came to her rescue. She completed high school and embarked on her modelling career. Having become pregnant she was 'talked into' getting married by her grandparents. She had never wanted to marry. Her own parents had had a terrible marriage, and she wanted a career and independence. She felt very guilty about her angry feelings towards the baby. She said she knew that she would be a terrible mother, but the baby's father was the kindest and gentlest soul she had ever known. He would be a perfect father and he should have the baby. Treatment Issues Mrs W was in treatment for eight months. She was overwhelmed by her guilt for wanting to give up her child and wondered whether she were some kind of a monster to want to do so. Fear of intimacy was a central issue in her life. Guilt associated with incest also emerged in a very crystallized form . She was both horrified and disgusted by what her father had perpetrated, but felt guilty for having allowed him to carry on. She had been plagued by this feeling most of her life. Her headaches began early, because she could not stop thinking about her past. If she was having a good time her headaches would return and spoil the fun. Over time in therapy, Mrs W began to develop some limited understanding of the profound effect the sexual abuse had on her view of men, her general distrust of them, and on herself as a woman. She also understood that she had been a child and thus helpless to take any action against her father.

140 Methods of Intervention During the last phase of therapy Mrs W did separate from her husband and the child and devoted more time to her career. Pain continued to interfere with pleasurable activities. Pain in this patient seemed to serve the purpose of assuaging her guilt, an interpretation both Szasz and Engel had made in their observations of incest victims. There was enhanced understanding of the issue, but an unwillingness to come to terms with it. Mrs W needed her pain. She had some recognition of this last fact. After all, pleasure almost always turned into pain for her. To her mind, however, she had achieved her goal (separating from her husband and child) in entering therapy. The influence of Engel in the formulation of an understanding of this patient is unmistakable. In this case, even more so than in the previous one, the relationship between pain and guilt and the role of pain in the expiation of guilt are very clear. Treatment was once again based on Malan's dynamic psychotherapy. Was treatment successful? Probably, but only nominally. The headaches remained unchanged, but Mrs W had some understanding of her guilt and did achieve her objective of regaining her 'freedom.' SUMMARY AND CONCLUSION

Dynamic psychotherapy is not a panacea. On the contrary, its application calls for clear and unambiguous evidence of childhood conflicts. Hence, the marriage between Engel's pain-prone patient and Malan's dynamic psychotherapy. Engel himself did not propose any particular therapy, but given the psychodynamic basis of pain-proneness, Malan's approach has considerable appeal. Malan (1976) demythologized the therapeutic process by reporting detailed case examples and avoiding jargon. He recognized that many situations simply required a commonsense approach, while at the same time warning that dynamic psychotherapy was a complex activity. He had speculated that brief dynamic psychotherapy was likely to be most

Dynamic Psychotherapy and Pain 141 successful in cases of mild disturbance. This hypothesis was later revised to include more disturbed patients. How disturbed were the two patients presented in this chapter? Both of these individuals were functioning reasonably well in many aspects of daily living. Mrs W was the more disturbed of the two. Although she entered therapy willingly, showing a high level of motivation, she was not able to resolve her fundamental guilt. Interpretative therapy, especially of a brief nature, was successful only in helping her achieve her self-stated goal of separating from her husband and child. Another reason for optimism in this case was that Mrs W went on to become a very successful model. She continued to attend the pain clinic for her headaches and was periodically seen by the psychotherapist. Perhaps being freed from her source of 'badness' (as a mother), her feelings of guilt became more bearable. The case of Mrs V, however, from all accounts, was more successful. She in a real sense managed to free herself from her invisible shackles. She became assertive, conscious of her own rights, and less afraid of rejection and disapproval. The therapeutic experience allowed her to reframe her past experiences in a way that led to dissolution of much of her guilt - a substantial achievement by any measure. In comparing the two patients, it must be noted that Mrs V's childhood experiences were almost normal when judged against Mrs W's. Mrs W grew up as a seriously abused, neglected, and deprived person. Some of the damage was reversed by the love of her grandparents, but that was not enough. These examples confirm a common-sense observation that 'healthy neurotics' make the best candidates for insight-oriented psychotherapy. Dynamic psychotherapy remains, in large measure, an untried method of treatment for pain. Part of the problem is that empirical support for this method of treatment is sorely lacking. A case has been made in this chapter that discreet and cautious use of dynamic psychotherapy in carefully selected patients is likely to be beneficial, yielding positive

142 Methods of Intervention outcome. Dynamic psychotherapy should be considered when there is evidence of non-organic pain in combination with intra- and interpersonal difficulties, the sources of which can be traced back to childhood. As stated earlier, Engel's (1959) pain-prone patient cannot be successfully treated without addressing the underlying causes, and dynamic psychotherapy is the means for doing that. This cautious approach to dynamic psychotherapy in treating pain is justified even on the basis of outcome studies, few as they are. Bassett and Pilowsky (1985) failed to demonstrate significant differences between longer term psychodynamic therapy and shorter cognitive-oriented therapy for chronic pain. Hill, Beutler, and Daldrup (1B89) treated six women suffering from rheumatoid arthritis with ten sessions of gestalt therapy. These patients reported reduced levels of distress, but the therapy did not have any influence on the final outcome of treatment. Benjamin (1989), in a review of psychological treatment methods for chronic pain, concluded that psychoanalytic treatment was of very limited value in treating psychogenic pain. Nevertheless, specific problems, such as irritable bowel syndrome, may respond well to such treatment. The current state of knowledge would support the position developed in this chapter that 'brief psychodynamic psychotherapy should be considered in carefully selected cases that diagnostically conform to Engel's pain-prone patients.

9

Crisis Intervention

Crisis is an incontrovertible fact of life. As this chapter will show, patients suffering from chronic pain are very prone to crisis. However, as a clinical phenomenon crisis has a relatively recent history. The pioneering works of Lindemann (1944) and Caplan (1964) gave new understanding to this concept of crisis. Lindemann (1944) studied 101 bereaved subjects. He noted that the common symptoms of acute grief were somatic distress, preoccupation with the image of the deceased, guilt, hostile reactions, and loss of the usual patterns of conduct. On the basis of his observations, Lindemann developed a series of predictors for outcome of grief and concluded that proper management of grief reaction may prevent subsequent complications. In short, Lindemann laid the foundation for what Caplan some years later conceptualized as crisis and its treatment. The prerequisite for crisis is an event of such magnitude that it has the capacity to render the normal coping mechanisms largely ineffective. The immediate repercussion of crisis is that the person has the overwhelming feeling of being out of control. In general terms, the acute phase of crisis may last for six weeks or so, following which one of three outcomes will be evident: recovery to the former level of functioning, to better than the pre-morbid level, or to worse than that level.

144 Methods of Intervention The bulk of original research was conducted by Caplan, whose major concern was the prevention of mental illness. He recognized that programs designed to intervene in crisis situations had the potential of reversing the negative effects of crisis, thus preventing one of the more common causes of emotional disorders. Many community-based preventive programs, with crisis intervention as a major treatment method, have been established all over the United Kingdom, the United States, and elsewhere. The extent to which these programs are successful in preventing mental illness is a moot topic. Nevertheless, the value of crisis intervention in dealing with a wide range of problems, from suicidal wishes to the traumas of abused women and children, and the recognition of crisis intervention in psychiatric out-patient clinics as a powerful and cost-effective method of treatment is the lasting legacy of Caplan's clinical genius. The contribution of Bowlby (1980) to the current knowledge of loss and grief remains unsurpassed, however. He noted that when confronted with the sudden loss of a loved one individuals work through four stages of grief: (1) numbness, which usually lasts from a few hours to a week; (2) searching and yearning for the lost person lasting months and even years; (3) disorganization and despair; (4) reorganization. These stages of grief are not reactions confined solely to the death of a loved person, but are just as relevant to other types of losses, although the details may vary. Parkes (1972, 1975) further developed Bowlby's theories and provided powerful empirical evidence that the grieving process, regardless of the nature of the object loss, was fairly consistent. Refinement of the crisis process and its resolution owes much to Bowlby and Parkes, although their names are not commonly associated with crisis theory. Caplan's basic ideas of crisis are summarized below. A crisis occurs because of an imbalance between the difficulty and importance of the problem and the resources immediately available to deal with it. A crisis, generally, goes through

Crisis Intervention 145 three phases: (1) an initial rise in tension caused by the impact of the stimulus calls forth the problem-solving responses habitually employed to effect a regaining of homeostasis; (2) lack of success and persistence of the stimulus leads to an associated rise in tension and ineffectuality; and then (3) emergency problem-solving skills are called forth. If the problem continues and cannot be solved by need satisfaction or need resignation or through perceptual means, the tension continues to mount and the possibility of major disintegration increases. Caplan also noted that certain factors exerted considerable influence in determining the final outcome. The outcome is not necessarily determined by antecedent factors, such as the nature of the hazard, or personality, or the biopsychosocial experience of the individual. Of critical importance is the interplay between the external and internal factors. Caplan emphasized the primacy of the power of social support to moderate the noxious effects of crisis. In more recent years (1974, 1976, 1980), he has stressed the value of the social support system in effectively coping with high stress. Psychological stress is capable of inducing physical and/or mental illness. Mastery of such damaging stress can be facilitated by making adequate social support available to the individual. Meaning attributed to the event is also a major factor in modifying or intensifying the crisis experience. As such, perception of the event can be a significant factor in the determination of the outcome. A corollary of crisis theory is that no one is immune to crisis, and the reaction is not necessarily pathological. In fact, loss of the usual coping apparatus in the face of a major catastrophe is normal. Caplan, in fact, urged caution in stating that one should not interpret reaction to crisis as being a manifestation of psychopathology. Another corollary is that emotional crisis is a time-limited event in which crisis resolution, adaptive or maladaptive, takes place within four to six weeks. Thus, during the crisis state psychological de-

146 Methods of Intervention fences are weakened or absent, which makes previously defended conflicts more accessible. In addition, during the crisis state the individual has an enhanced capacity for both cognitive and emotional learning because of his vulnerability in this state and the motivation produced by emotional disequilibrium. Adaptive crisis resolution is frequently a vehicle for resolving underlying conflicts which can, in part, intensify the emotional crisis. Finally, a small external input can produce significant benefits within a short period. The rationale for crisis intervention is, in fact, derived from the last observation. TYPES OF CRISIS

In the crisis literature there has been debate about the types or categories into which crises can be meaningfully divided and no firm consensus on this topic has been arrived at. Hence, a common-sense approach is necessary. Some crisis situations are very common. A crisis resulting from a sudden traumatic event is probably the most familiar. In this type of crisis the event is undesirable, unpredictable, and almost invariably, uncontrollable - for example, sudden death, natural catastrophes, unexpected loss of employment. A crisis can also occur from anticipated life events, such as relocation, promotion, and similar situations. An event that is not in itself noxious may be perceived as such, and the emotional reaction to the event may trigger a crisis. Another type of crisis relates to normally occurring life-transition issues. Many adolescent problems, such as an unexpected antisocial act by a young person, may engender a major crisis for the family. Levinson (1978) has argued that a person cannot complete the transition to middle age without a personal crisis. The idea is that a personal crisis is a prerequisite to accepting a vastly modified identity. One problem with Levinson's view, and where it departs from conventional notions of crisis, is the absence of any discernible event. Crisis is embedded in the process of transition. Some crisis

Crisis Intervention 14 7 situations are specific to actual life-transition stages. For instance, 'empty nest syndrome' precipitated by children leaving home is not an uncommon problem for many middleaged parents. A crisis may also result from underlying psychopathology. A severe anniversary reaction, where grief is experienced anew and lasts for weeks, may have its roots in the psychological make-up of the person. Alternatively, a severe reaction to an otherwise neutral event may also be suggestive of underlying conflictual issues of great significance. An example is a person who experienced inexplicable and crippling anxiety upon hearing about the drowning death of a sevenyear-old girl, only to 'discover' that his own sister drowned at age six when he was four years old. Finally, some crisis situations are signs and symptoms of psychiatric disorders. A suicide attempt by an individual is not an uncommon trigger for diagnosing underlying psychiatric illness. Since emotional upheaval associated with crisis is generally not a sign of mental illness, this last category legitimately belongs to psychiatry. MAJOR ADAPTIVE TASKS

Tasks associated with the positive resolution of crisis are many and varied. Some of the crucial ones are now addressed. An immediate task is to find the meaning and significance of the event to the person. This is especially necessary in situations where the crisis nature of the event is not self-evident. It is important for the person in crisis to stay in touch with reality and to continue to respond to the requirements of the immediate environment, such as providing care to young children. Sustaining normal relationships with members of the informal network who can be helpful in resolving the crisis is critical. An equally important task is to consciously attempt to maintain some emotional stability by understanding the upsetting feelings and appreciating that the negative emotions are normal under the circum-

148 Methods of Intervention stances. Finally, maintaining a positive self-image and some sense of mastery in the face of a major catastrophe can be construed as a major adaptive task. Caplan (1964) provided some guidelines for crisis intervention. Helping the client confront the crisis is of paramount importance in order to avoid any distortions and misinterpretations. Help needs to be provided in manageable doses. A person in a state of crisis is cognitively and affectively impaired and cannot readily incorporate a large amount of facts or concentrate over a prolonged period of time. Providing the client with facts of the situation is an important task; factual information helps to place the crisis in its proper perspective. It is just as important not to give false reassurance which can only complicate the normal process of crisis resolution. Blaming someone else for the event, if untrue, should be avoided. Finally, the client must be helped to carry on with a daily routine as much as possible. LITERATURE REVIEW

This review will only consider the literature pertinent to crises associated with issues of ill health. Nothing exists on the topic of crisis and chronic pain patients. Nevertheless, topics such as crises precipitated by the diagnosis of a lifethreatening disease or the birth of a premature baby or the loss of functioning because of trauma or disease have drawn measurable attention. 'Crisis for whom?' is a most important question. Crisis experienced by mothers with acutely and chronically sick children (Hobfall and Lerman 1988), siblings of children with chronic illnesses and disability (Brett 1988), and the whole family because of the illness in one member (Rolland 1987; Reagles 1982) confirm the general proposition that crisis tends to affect all those whose sense of personal well-being is significantly challenged. Rolland (1987) has identified three major phases that characterize the natural history of chronic disease: (1) crisis, (2) chronic, and (3) terminal. The crisis phase consists of the

Crisis Intervention 149 pre-diagnosis stage, with symptoms, diagnosis, and initial adjustment period. The task of the family is to find meaning in the illness, grieve for the loss of the pre-illness family identity, move towards an acceptance of permanent change, and learn to face future uncertainty (Rolland 1987). Chronic pain presents a different order of problem. The absence of a firm diagnosis of the pain condition creates its own special kind of crisis. While the family focus is essential to appreciate the full force of a crisis event, the impact on the individual remains pre-eminent. Somatic illnesses such as epilepsy, cancer, or duodenal ulcer can lead to suicide (Hjortsjo 1987). The very idea of living with a stigmatized or debilitating or terminal disease is daunting. Crisis reaction to such a situation is expected, but first, the situation has to be recognized as being potentially crisis-provoking. Hjortsjo (1987), following his extensive investigation of the relationship between physical illness and suicide, concluded that the actual contributory nature of physical illness to suicide remained unclear mainly because of insufficient data. In this respect Ca plan's pioneering crisis intervention program with the parents of premature babies is noteworthy. Crisis situations arising from chronic diseases have direct relevance for chronic pain sufferers. In a study of forty-nine families each trying to adapt to a member with multiple sclerosis, crisis was not uncommon. Nearly half the families were able to make a positive adaptation, but the other half displayed maladjusted behaviour (Power 1985). All families went through crisis in accommodating the impact of the illness .. One wonders how many more of the families in the study might have adapted well to illness and disability in their family member had they had the benefit of crisis intervention. Woody (1985), for example, has argued that crisis intervention must be a basic facet of comprehensive health care. The reality is that crisis counselling to cope with health crisis is not always available . Beyond the crisis of learning about a threatening diagnosis, patients and families continue to experience new and novel crisis events. Episodic crises and their resolution were observed in a study of fifty chroni-

150 Methods of Intervention cally ill patients with progressive conditions (Forsyth, Delany, and Gresham 1984). A key factor in coping with the uncertainty of the disease process was promoting the patient's sense of control. Loss of control is, of course, a common accompaniment of crisis. Blazyk (1983), in a clinical paper, described the crisis arising from head injury sustained by adolescents. Head injury frequently compromised developmental progress, often resulting in significant regression in patients' behaviour. Case examples demonstrated the continued nature of the crisis, even after the acute stage of the physical trauma, for both the patients and their families. Crisis intervention with medically ill patients generally yields positive results. In a controlled study, a group of 140 hospitalized patients for whom illness, injury, or hospitalization was the crisis event and who had had the benefit of crisis counselling, was matched with a control group of 158 patients who had received no crisis counselling. The former group reported significantly lower levels of anxiety and depression than the latter and continued to function better even in the long run (Viney, Clarke, and Bunn 1985). The authors concluded that primary prevention was achieved through a treatment plan including crisis counselling. Principles of crisis theory have been applied for both patients and spouses during the post-myocardial infarction rehabilitation period by Kline and Warren (1983). They define myocardial infarction as a non-normative crisis which is potentially more noxious than a normative crisis. Dhooper (1983) investigated the crisis of heart attack as experienced by spouses and children. Crisis was a common experience in this situation, and virtually every aspect of life was affected by the heart attack. A remarkable finding of this study was that most families reported deterioration in various aspects of living several months after the heart attack. In other words, many families failed to attain the pre-morbid level of functioning. Another study reported the application of crisis intervention to deal with severe behavioural problems of non-compliant diabetics (Boehnart and Popkin 1986). Crisis

Crisis Intervention 151 intervention was justified on the ground that deep-rooted denial and other psychopathology became more accessible when non-compliance assumed crisis proportions. However, following crisis intervention, the authors demonstrated the benefit of a systemic approach to address the interpersonal issues. The overall treatment was of long duration and timeconsuming for the therapist. Crisis intervention was only the point of departure, following which long-term therapy became necessary to treat serious underlying issues associated with severe diabetes. In an unusual study, Cohen and Anderson (1986) implemented family-oriented crisis intervention to deal with the fear and anxiety experienced by family members of the victims of the third largest outbreak of botulism in the United States (October 1983). This study furnished further evidence of therapeutic benefits of the crisis intervention. The authors speculated that almost dramatic reduction of anxiety in the relatives was brought on by the fact that the patients had not died, and the relatives were better informed about the course and treatment of botulism. Intensive counselling initiated during the first week combined with an informational supportive group meeting may have had a most positive effect on the family members. Such benefits were also reported by Blazyk and Canavan (1986), who noted the commonness of crisis reaction in the patients and family members upon a patient's discharge from the acute care setting. These authors claimed that the initial crisis of a catastrophic illness had seldom been completely resolved during hospitalization. Hence, a great deal of anxiety was likely to be present at the time of discharge in all cases but those where a significant recovery had been made. Discharge from the hospital was associated with loss of hope and feelings of being abandoned by the hospital staff. Discharge also shifted the responsibility of care to the family and the patients, which could be a further source of anxiety, sometimes acute anxiety. The authors regarded the crisis following a catastrophic illness as normal and predictable,

152 Methods of Intervention and for those reasons recommended that intervention should commence during hospitalization and continue beyond. Koch-Hattem (1987) was concerned with the crisis caused by disorganization of the family system·due to chronic illness in a family member. Crisis intervention was called for in situations where the impact was deemed to be of sufficient severity to make the family non-functional. Sparks (1988) presented a conceptual model based on crisis theory to cope with cancer. The outcome of the crisis depended on personal, health, and environmental factors, influenced by a cognitive appraisal of the situation and the coping skills available. Crisis was one way of coping with physical illness of a threatening nature. Intervention was focused on the development of adaptive tasks. Cohen (1982) reported on the crisis associated with recurrence of breast cancer in a sixty-nineyear-old woman. The diagnosis of cancer, she noted, represented the first order of crisis for the patient and the family. In the particular case Cohen recounted, following the relapse and metastization, the woman and her husband were often engaged in fights and arguments. The husband was angry about the return of her disease and her impending certain death, and she was lonely and frightened. Cohen employed structural family therapy with some initial success, but the patient's condition deteriorated and she died. This case exemplified the need for crisis-oriented intervention for the patient and the spouse despite their relatively advanced age and the need for couple therapy. It also illustrated some of the problems of illness in old age, such as inflexible response to stress and mutual withdrawal. Although, this case involved a terminal disease, some of the same phenomena can be observed in chronic pain families. Crisis engendered by the patient's declining capacity, anger, hostility, and withdrawal, and at times breakdown of the family system, are not uncommon in chronic pain situations. In a crisis intervention program to treat 232 over-users of an emergency department of a middle-size hospital in Stockholm, Andren and Rosenquist (1985) found significant

Crisis Intervention 153 evidence of psychosocial problems in this group. Crisis intervention by a social worker significantly reduced the use of the emergency department by 80 per cent of the subjects. Social work intervention consisted of providing information about and clarifying the functions of the health care and social security system and advising the subjects about the appropriate sources for help. The authors argued a case for hospital-based social work crisis intervention for such patients. CRISIS AND CHRONIC PAIN

The brief review of the literature on crisis and illness confirms that crisis events are common whether the illness is acute or chronic. Chronic pain patients are just as susceptible as anyone else to suffering sudden and unexpected losses, a condition that underlies all crisis. Beyond that, however, the patients find themselves in crises that seem to emanate from their pain condition. In other words, living with chronic pain seems to amplify the patient's vulnerability to crisis. Some of the explanation may be that chronic pain induces a great deal of uncertainty, thus adding to the patient's dual feelings of helplessness and lack of control or mastery over pain in particular, and life in general. In such a state of mind, catastrophic reactions may not be unusual. This is not to suggest that the crisis experienced by pain patients is necessarily precipitated by faulty perception of an event or that the event itself is trivial, but rather that at times the extreme reaction of the patient has to be understood in relation to the vagaries of chronic pain. Hence, the crisis experienced by chronic pain sufferers may be viewed from three different angles: crisis due to misperception, crisis related to the pain state, and 'normal' crisis independent of the pain condition. This categorization is only useful for making important clinical judgments about the genesis of crisis. An example of crisis due to misperception or misinterpretation is that of a patient who, on the basis of a media

154 Methods of Intervention report, is convinced that his pain is due to undiagnosed cancer. Examples of crisis related to the pain state are too numerous to list, but a not uncommon experience of crisis occurs when the patient's only means oflivelihood, disability income from an insurance company or the Workers' Compensation Board, is threatened or when childhood sexual abuse that may account for the patient's non-organic pelvic pain is disclosed. A 'normal' crisis may be the sudden death of a valued family member. The presence of a chronically sick member enhances the vulnerability of the family to crisis, and ·that is one more reason for adopting a family orientation in the pain clinic. Family crisis may be induced by the unpredictable nature of migraine attacks and the family's inability to rally around to cope with the disruptions caused by such an event. A case will illustrate the point. Crisis intervention may or may not be an integral part of the treatment offered to patients in multidisciplinary pain clinics. What there is no doubt about is the absence of this topic in the pain literature. Crisis intervention, like other treatment methods described in previous chapters, is not a treatment for pain per se. Pain patients, not infrequently, present themselves at a pain clinic in a state of crisis. The basis of the crisis is that the pain clinic is seen as the last resort for help: There is nothing beyond. Many pain patients have by then felt rejected and humiliated in their travels through the medical world. Their assumptive world is on the verge of disintegration. Crisis intervention in that situation may be the most desirable action. A number of examples are presented to discuss the necessity for incorporating crisis intervention as an adjunct treatment for pain patients. These should also reveal the broad spectrum of crisis seen at a pain clinic. CASE ILLUSTRATIONS

Crisis is created by such a variety of situations in the lives

Crisis Intervention 155 of pain patients and their families that the task of ascertaining the more common or less common types of crises is not easy. There are, nevertheless, situations that seem to arise with some degree of regularity. Job loss is always a traumatic experience, and this particular loss is familiar to many patients. Not all patients view job loss as catastrophic, but some indeed feel such a loss to be 'the last straw' for them. An event of that kind requires carefully designed crisis intervention. Mr X, aged forty-three years, contacted the pain clinic because of his cluster headaches, since at that time he was afraid that his employers were losing patience with him for his periodic absence from work. He was an angry and hostile man, with serious family problems. His wife and two young children were intimidated by him. Family therapy vastly improved the entire situation, and as Mr X continued to make progress he had a major accident at work, with multiple fractures severely damaging his right leg. The leg failed to fully heal and he was left with a limp. Mr X reacted to the accident with total dismay. He was convinced that there was a 'conspiracy' to keep him sick. He lashed out against his family, friends, the pain clinic, the orthopaedic surgeon, who was treating him for his leg, his employers for failing to acknowledge their responsibility in causing the accident, and God. Following this outburst of rage, he became totally withdrawn. Crisis intervention was implemented with some measure of success. Daily contact was established. When he refused to see the therapist he was telephoned every day. Just as the original crisis was being overcome, Mr X was confronted with mounting dismay over his limp and associated pain in the leg and the real possibility of becoming disabled. For a week or so he simply could not be reached. His wife persuaded him to see his physician at the pain clinic. That visit, from all accounts, went well and he left the clinic reassured. A week later Mr X committed suicide. In a note to his wife he gave his reason for killing himself. He said that the prospect of job loss and the status of permanent

156 Methods of Intervention disability was not for him. He felt betrayed by his employers and thought that they could have rewarded him for his years of service by placing him in a less onerous job when he became disabled. The need to work emanates from physiological, psychological, and social factors. Loss of work for some people produces a profound sense of loss indeed, and all the features of mourning can be detected in them. When a person is forced out of work because of ill health, the mourning process can be complicated by the knowledge that returning to work may not be feasible. The lesson of this tragic case is that the pile-up effect for pain patients is a fact of life. Crisis intervention was clearly unsuccessful in this case. That, however, is not an argument against this treatment. The case is a sad reflection of the simple truth that some situations are so unacceptable that to the patient suicide appears to be the only solution. This man had the misfortune of having a major accident, in addition to his headaches. Others actually lose their jobs as a direct result of the pain problem, which in turn gives rise to a whole series of new problems. It may be accurate to state that crisis upon crisis is not unusual for pain patients.

A Case of Family Crisis It was stated earlier that chronic illness in a family can and does frequently cause crisis of disorganization. The case that follows is a relatively mild example of such a situation. Mrs Y is a woman with a lifelong history of migraine-type headache, which worsened considerably following a motor-vehicle accident. She was married and had a fourteen-year-old son and a nine-year-old daughter. Her husband was, in general, quite supportive of her. For the most part, he took over her responsibilities, about which she had much guilt, for the duration of her migraine attacks. The children usually pitched in. They were very sensitive to their mother's suffering. For example, they, had learned not to invite their friends home during their mother's bouts of headache. In

Crisis Intervention 157 short, the family appeared to rally around Mrs Y and to cope well with her periodic 'absence' from the family scene. The situation that provoked a crisis for the family started with Mrs Y being forced into retreating up to her bedroom with a severe attack of head pain. She managed to doze off only to be wakened by loud voices coming from downstairs. She managed to 'drag' herself down to the kitchen, where she found her son crying and her husband standing over him and 'yelling.' The gist of the father's anger was that he had to carry the major burden of doing all the chores, and it was high time for the son to 'act his age' and pull some weight. The boy turned to his mother and said that he had done nothing wrong and was at a loss to know what his father was so angry about. At this point Mrs Y became extremely distressed and accused her husband of blaming her for suffering from headaches. He stormed out of the house, and she called the pain clinic. Arrangements were made to see the whole family that same evening with or without the father, whose whereabouts were in doubt. The entire family showed up for the appointment. The mother and son were tearful and the father was on the verge of tears when they entered the office. Only the daughter seemed to be relatively calm. It was a while before Mrs Y spoke. She said that she was at the end of her rope, that her headaches were causing all the unhappiness in the family, and that perhaps they would all be better off if she were dead. The little girl now started to sob quietly, and then the entire family was in tears. Thus began an active process of intervention. Specific rules were established about the father's behaviour. They were all encouraged to express their love for each other. There was open acknowledgment by the husband that Mrs Y was not to be blamed for her headaches. Agreement was reached to see the family in therapy three times a week, which was reduced to two after the first week. When the immediate crisis was over, the family agreed to enter into a course of family therapy and successfully completed treatment.

158 Methods of Intervention Family disorganization, conflict over roles, lack of improvement in her pain condition, and, to a lesser extent, her son's desire to exert some independence caused the initial rise in tension, leading to a full-blown crisis in Mrs Y's family. The husband's frustration in living with the uncertainty about Mrs Y's health and her own guilt about her pain and periodic disability were the underlying factors. The crisis had the singularly positive effect of bringing to the fore many hidden conflicts, which were then systematically treated and resolved.

Crisis of Disclosure Every now and again in revealing events from the past, a patient experiences the remembering and recounting as so traumatic that a crisis situation develops rather rapidly. It then requires careful and delicate handling. Ms Z was forty-three years old with low back pain syndrome when she was accepted for supportive psychotherapy to help her deal with anger, sadness, and hostility about her lack of progress with the pain treatment. Parts of her life were very much intact. She had a good job as the person in charge of a small health care facility. After a failed marriage and several disappointing relationships she was now in a steady relationship with a talented artist. They had been living together for three years, and she said that these were the best three years of her life. She spoke of her frustration at not being able to do things and go places as she wished because of her pain. At times even her job, which she said she loved, became too much. There did not seem to be any relief in sight. Exploration of her past proved to be difficult. Ms Z was legitimately focused on her immediate problems of some gravity. Nevertheless, her allusion to her failed relationships and generally unhappy past made it possible to return to those themes to explore their relevance to her present situation. The relevance was that her happiness, once again, was short-lived. She had mentioned the last point on more than one occasion.

Crisis Intervention 159 As trust between the therapist and the patient grew, Ms Z seemed more able to discuss the particulars of her failed marriage. She had been beaten, sexually abused, and degraded by her ex-husband in every conceivable way. It was during one such session, while speaking of her harsh treatment by the ex-husband, that she started crying uncontrollably and managed to blurt out that her husband was not the first person to abuse her. She had been abused and sexually molested by her father for many years. She was so ashamed of this that she had never talked about it with anyone. Even her current partner knew nothing of this. She felt that if he found out he would probably leave her. This was the first time she had told anyone, and she said that she already wished that she had not. Lately, she had been doing a lot of thinking about her past, and slowly very painful memories from her childhood had started to occupy her. Her mother had died when she was five years old, and she had then lived alone with her father. She did not have any siblings. From a very young age she had had to take on an awful lot of responsibilities for running the house. Precisely when her father started sleeping with her was beyond her recall, and for quite a while it had seemed almost normal to her. It was only when she started high school that she began to question her father's behaviour, but she could not bring herself to tell anyone. In the meantime her father was becoming more violent. She ran away from home when she was sixteen years old and did not see her father again. She learned to fend for herself, completed high school, found herself a good job, and put herself through university. Then she got married, and the abuse and violence started all over again. Ms Z narrated her story virtually without a pause. She broke down completely when she stopped and she cried uncontrollably for a long time. She remained in a state of extreme distress for the next five or six weeks. She did not wish to share her story with her partner, lest he should decide to leave her. That particular decision was left to her,

160 Methods of Intervention and she did choose to tell him two weeks later. Arrangements were made to see her daily until the crisis passed. The intense phase lasted some four weeks, following which weekly psychotherapy was institui.ed. The nature of the crisis for Mr Z is almost too obvious to require any comment. The point of note here is that a drastic redirection of treatment is necessitated by the emergence of deeply painful, often buried, material which almost always causes major emotional upheaval. Disclosure of sexual abuse must count as one of the most painful experiences that a person can endure. Crisis is almost inevitable. Intervention has to be immediately available, and the basic principles of crisis intervention must be followed. These three cases were presented in the hope that the necessity of crisis intervention would become self-evident. Crisis intervention is a relatively uncomplicated, short-term method of treatment with the capacity of making lasting therapeutic changes. Conceivably, the cost of the unavailability of this treatment in pain clinics can be considerable. Crises develop with clockwork regularity in patients visiting pain clinics. They are often precipitated by events related to the pain problem itself, and the patients need immediate help. Failure to provide that help puts the patient at risk. In some situations, probably in all three of the cases described above crisis intervention has to take precedence over all other treatments. This is so for the obvious reason that psychological help is imperative and provides an opportunity for making lasting changes. The less obvious reason is that patients in a state of crisis are more than likely to discontinue any other forms of treatment. They will certainly not be amenable to dynamic or even supportive psychotherapies or behaviour therapies until the crisis has passed. Crisis intervention is a practical way of keeping patients involved in the pain clinic, and, having successfully coped with a crisis with some help from the clinic staff, many patients re-engage in treatment with renewed hope and

Crisis Intervention 161 higher motivation. This is to be expected as any experience of success can only have a positive effect on the patient's morale, and success for many pain patients tends to be elusive. The most persuasive argument for incorporating crisis intervention in pain clinics is that crisis for the patient presents a unique opportunity to deal with many of the underlying issues in a relatively short time. SUMMARY AND CONCLUSION

The central goal of this chapter was to make a case for incorporating crisis intervention as a legitimate treatment in a pain clinic setting. Again, the rationale for this position is strengthened only if the pain sufferer is viewed in the larger context of his environment; if artificial barriers to separate the syndrome from the individual are disallowed and the simple reality of the crisis situations provoked by the chronic nature of the problem is recognized; and if the person rather than the patient is given primacy, giving further recognition to another truth that, as such, this person is vulnerable to normal crisis experience,which is often complicated by the pain sufferer's psychological state. Given these conditions the value of crisis intervention cannot remain in question. Two of the three case illustrations give credence to one of the axioms of crisis theory and that is: during crisis people are more amenable to help as well as change, change that may never be achieved without a crisis. Crisis is an opportunity not just for the patient, but just as much for the clinician, to bring about positive change and growth. Crisis intervention is not a particularly complicated method of treatment. The skills can be easily acquired by almost any health care professional working in a pain clinic setting. There appears to be very little reason for not having this treatment in the armamentarium of pain clinic clinicians. The benefits can be enormous.

References

Adams, H., M. Feurstein, and J . Fowler (1980) Migraine headache: Review of parameters, etiology and intervention. Psycho/. Bull., 87: 217-237 Adams-Tucker, C. (1982) Proximate effects of sexual abuse in childhood: A report on 28 children. Am. J. Psychiatry, 139: 1252-1256 Ahern, D., A. Adams, and M. Follick, (1985) Emotional and marital disturbance in spouses of chronic low back pain patients. Clin. J. Pain , 1: 69-74 Albert, R. (1983) Social work advocacy in the regulatory process. Soc. Casework, 64: 473-478 Andren, K., and U. Rosenquist (1985) Heavy users of an emergency department: Psychosocial and medical characteristics, other health care contacts and the effects of hospital social worker intervention. Soc. Sci. Med., 21 : 761-770 Atkinson, J., M. Slater, I. Grant, I. Patterson, et al. (1988) Depressed mood in chronic low back pain: Relationship with stressful life events. Pain, 35: 47-55 Baptiste, S. , and E. Herman (1982) Group therapy: A specific model. In R. Roy and E. Tunks, eds., Chronic Pain: Psychosocial Factors in Rehabilitation. Baltimore: Williams and Wilkins Baron, M., R. Bejar, and P. Sheaff (1970) Neurologic manifestations of battered child syndrome. Pediatrics, 45: 1003-1007 Bassett, D., and I. Pilowsky (1985) A study of brief psychotherapy for chronic pain. J. Psychosom. Res., 29: 259-264 Beecher, H. (1959) Measurement of Subjective Response. New York: Oxford University Press

164 References Bellissimo, A., and E. Tunks (1984) Chronic Pain: The Psychotherapeutic Spectrum . New York: Praeger Publishers Benjamin, S. (1989) Psychological treatment of chronic pain: A selected review. J . Psychosom. Res., 33: 121-131 Black, R. (1975) The chronic pain syndrome. Surg. Clin. North Am., 55: 999-1011 Blazyk, S. (1983) Developmental crisis in adolescents following severe head injury. Soc. Wk. Health Care, 8: 55-67 Blazyk, S., and M. Canavan (1986) Managing the discharge crisis following the catastrophic illness or injury. Soc. Wk. Health Care, 11: 19-21 Blumer, D., and M. Heilbronn (1982) Chronic pain as a variant of depressive disease: The pain-prone disorder. J . Nerv. Ment. Dis., 170: 381-406 Boenhart, C. , and M. Popkin (1986) Psychosocial issues in the treatment of severely non-compliant diabetics. Psychosomatics, 27: 11-20 Bond, M. (1979) The suffering of severe intractable pain. In H. Kosterlitz and L. Terenius, eds, Pain and Society . Weinheim, Germany: Verlag-Chemie Bonger, B. (1988) An integrative psychotherapeutic approach to the treatment of chronic abdominal pain in a young child. Psychotherapy Patient, 4: 135-154 Bonica, J . (1953) The Management of Pain. Philadelphia: Lea and Febiger - (1974) New progress against pain. U.S. News and World Report. Washington, DC, December - (1977) Neurophysiological and pathologic aspects of acute and chronic pain. Arch. Surg., 112: 750-761 Botto, B. (1987) The use of hypnosis in behavioral dental medicine: A case study of myofascial pain dysfunction syndrome. Psychother. Private Prac., 5: 77-83 Bowlby, J . (1980) Attachment and Loss, vol. 3: Loss: Sadness and Depression . Harmondsworth: Penguin Books Brett, K. (1988) Sibling response to chronic childhood disorders: Research perspectives and clinical implications. Issues Commun. Pediat. Nurs., 11: 43-57 Brown, G., and T. Harris (1975) Social Origins of Depression: A Study of Psychiatric Disorder in Women . London: Tavistock Buck, R., and G. Hohmann (1982) Child adjustment as related to severity of parental disability. Arch. Phys. Med. Rehabil., 63: 249-253

References 165 Buckley, F., W. Sizemore, and E. Charlton (1986) Medication management in patients with chronic non-malignant pain: A review of the use of a drug withdrawal program. Pain, 26: 153-165 Caplan, G. (1964) Principles of Preventive Psychiatry. London: Tavistock - (1974) Support System and Community Mental Health. New York: Behavioral Publications - (1976) Organization of support system for civilian population. In G. Caplan and M. Killilie, eds., Support System and Mutual Help . New York: Grune and Stratton - (1980) Mastery of stress. Am. J. Psychiatry, 138: 413-420 Carron, H., D. DeGood, and R. Tait (1985) A comparison of low back pain patients and economic factors affecting severity of disability. Pain, 21 : 77-90 Castelnuovo-Tedesco, P., and B. Kraut (1970) Psychosomatic aspects of chronic pelvic pain. Psychiat. Med., 1: 109-126 Chapman, C., A Sola, and J. Bonica (1979) Illness behavior and depression compared in pain center and private practice patients. Pain, 6: 1-7 Cobb, S. (1976) Social support as a moderator of life stress. Psychosom. Med., 38: 300-312 Coddington, R. (1972a) The significance oflife events as etiologic factors in the disease of children - 1: A survey of professional workers. J. Psychosom. Res., 16: 7-18 - (1972b) The significance of life events in the diseases of children - 2: A study of normal population. J. Psychosom. Res., 16: 205-213 Cohen, M. (1982) In the presence of your absence: The treatment of older families with a cancer patient. Psychother. Res. Pract., 19: 453-460 Cohen, R., and D. Anderson (1986) Botulism: Emotional impact on family and patient. J. Psychosom. Res., 30: 321-326 Cohn, J., K. Holzer, and B. Severin (1981) Torture of children: An investigation of Chilean immigrant children in Denmark. Child Abuse and Neglect, 5: 201-203 Craig, I., and G. Brown (1984) Goal frustration and life events in the etiology of painful gastrointestinal disorder. J. Psychosom. Res., 28: 411-421 Croog, S., and S. Levin (1977) Heart Patient Recovers. New York: Human Sciences Press - (1982) Life after a Heart Attack. New York: Human Sciences Press

166 References Crook, J ., E. Rideout, and G. Browne (1984) The prevalence of pain complaints in a general population. Pain, 18: 299-314 Crook, J., and E. Tunks (1985) Defining the 'chronic pain syndrome': An epidemiological method. Clin. J. Pain, 1: 159-163 DeBennedittis, G., A. Lovenzetti, and A. Pieri (1990) The role of life events in the onset of primary headaches. Pain , 40: 65-75 Dehlinger, E., S. McLeer, M. Atkins, D. Ralphe, and F . Foa (1989) Posttraumatic stress in sexually abused, physically abused and nonabused children. Child Abuse and Neglect, 13: 403-408 Dhooper, S. (1983) Family coping with the crisis of heart attack. Soc. Wk . Health Care, 9: 15-31 Dworkin, R., D. Richlin, D. Handlin, and L. Brand (1986) Predicting treatment response in depressed and non-depressed chronic pain patients. Pain, 24: 49-59 Edwards, P., and M. Donaldson (1989) Assessment of symptoms of adult survivors of incest: A factor analytic study of response to childhood questionnaire. Child Abuse and Neglect, 13: 101-110 Egeland, B., A. Sroufe, and M. Erickson (1983) The developmental consequences of different patterns of maltreatment. Child Abuse and Neglect, 7: 459-469 Elkins, G. (1984) Hypnosis in the treatment of myofibrositis and anxiety: A case study. Am. J. Clin. Hypnosis, 27: 26-30 Engel, G. (1959) 'Psychogenic' pain and the pain-prone disorder. Am. J. Psychiatry, 26: 899-918 Epstein, N., and D. Bishop (1981) Problem-centered systems therapy for the family. In A. Gurman and D. Kniskern, eds., Handbook of Family Therapy . New York: Brunner/Maze} Feurstein, M., S. Sult, and M. Houle (1985) Environmental stressors and chronic low back pain: Life events, family and work environment. Pain, 22: 295-307 Finlayson, R., T. Maruta, R. Morse, W. Swenson, and M. Martin (1986) Substance dependance and chronic pain: Profile of 50 patients treated in an alcohol and drug dependance unit. Pain, 26: 167-174 Fishbain, D., M. Goldberg, B. Meagher, R. Steele, and H . Romanoff (1986) Male and female chronic pain patients categorised by DSM III diagnostic criteria. Pain, 26: 187-197 Flor, H., D. Turk, and T. Rudy (1988) Impact of chronic pain on the spouse: Marital, emotional and physical consequences. J . Psychosom. Res. 32

References 167 Flor, H., D. Turk, and 0. Scholz (1987) Impact of chronic pain on the spouse: Marital, emotional and physical consequences. J. Psychosom. Res., 31: 63-72 Follick, M., T. Smith, and D. Ahern (1985) The sickness impact profile: A global measure of health status in chronic pain patients. Pain, 21: 67-76 Forsyth, G., K. Delany, and M. Gresham (1984) Vying for a winning position: Management style of the chronically ill. Res. Nurs. Health, 7: 181-188 France, R. , K. Krishnan, and S. Pelton (1987) Chronic pain and depression iv. DST as a discriminator between pain and depression. Pain, 28: 39-44 Frances, A., and D. Spiegel (1987) Chronic pain masks depression, multiple personality disorder. Hosp. Community Psychiatry, 38: 933-935 Gallagher, R. , V. Rauh, L. Haugh, P . Mithons, et al. (1989) Determinants of return to work among low back patients. Pain, 39: 55-68 Gaudet, L. , and G. Powers (1989) Systems treatment in pediatric chronic illness: A parental group program. Fam. Sys. Med., 7: 90-99 Germain, C. (1991) Human Behavior in the Social Environment: An Ecological View . New York: Columbia University Press Gore, S. (1978) The effects of social support moderating the health consequences of unemployment. J. Hlth. Soc. Behav., 19: 157-165 Green, A., K. Voeller, R. Gaines, and J. Kubie (1981) Neurological impairment in maltreated children. Child Abuse and Neglect, 5: 129-134 Green, G. (1978) Psychopathology of abused children. J. Am. Acad. Child Psychiatry, 17: 92-103 Gross, R., H. Doerr, G. Caldirola, and H. Ripley (1980/1) Borderline syndrome and incest in chronic pelvic pain patients. Intl. J. Psychiat. Med., 10: 79-96 Haley, W., J. Turner, and J . Romano (1985) Depression in chronic pain patients: Relation to pain, activity and sex differences. Pain, 23: 337-343 Halpern, L. (1982) Substitution-detoxification and its role in the management of chronic pain. J. Clin. Psychiatry, 43: 10-14 Haugaard, J., and R. Emery (1989) Methodological issues in child sexual research. Child Abuse and Neglect , 13: 89-100 Hill, D., L. Beutler, and R. Daldrup (1989) The relationship of process

168 References to outcome in brief experiential psychotherapy for chronic pain. J . Clin. Psycho[., 45: 951-957 Hinkle, L. (1961) Ecological observations of the relation of physical illness, mental illness and the social environment. J. Psychosom. Med., 23: 289-297 Hinkle, L., and H. Wolfe (1957) The nature of man's adaptation to his total environment and the relation of this to illness. Arch. Int. Med., 99: 442-460 Hjortsjo, T. (1987) Suicide in relation to somatic illness and complications. Crisis, 8: 125-137 Hobfall, S., and M. Lerman (1988) Personal relationships, personal attributes, and stress resistance: Mother's reaction to her child's illness. Am. J. Community Psycho[., 16: 565-589 Hodges, K., J . Kliner, G. Barbero, and R. Flannery (1984) Life events occurring in the families of children with recurrent abdominal pain. J . Psychosom. Res., 28: 185-188 Holmes, T., and R. Rahe (1967) The Social Readjustment Rating Scale. J. Psychosom. Res., 11: 213-218 Hudgens, A. (1979) Family-oriented treatment of chronic pain. J . Mar. Fam. Ther. , 5: 67-76 Hughes, M., and R. Zimin (1978) Children with psychogenic. abdominal pain and their families . Clin. Pediat., 17: 569-573 Hunter, R., M. Kilstrom, and F. Loda (1985) Sexually abused children: Identifying masked presentations in a medical setting. Child Abuse and Neglect, 9: 17-25 Jensen, J. (1988a) Pain in non-psychotic psychiatric patients: Life events, symptomatology, and personality traits. Acta Psychiat. Scand., 78: 201-207 - (1988b) Life events in neurologic patients with headache and low back pain in relation to diagnosis and persistence of pain. Pain, 32: 47-53 Katz, A., and E. Bender (1976) Strength in Us : Self-help in the Modern World. New York: Franklin Watts Press Kempe, C. (1962) The battered child syndrome. J. Am. Med. Assoc., 181: 105-112 Kerns, R., and D. Turk (1984) Chronic pain and depression: Mediating role of the spouse. J . Marriage Fam ., 46: 845-852 Kline, N., and B. Warren (1983) The relationship between husband and wife, perceptions of the prescribed health regimen and level of func

References 169 tion in the marital couple post-myocardial infraction. Fam. Prac. Res. J ., 2: 271-280 Koch-Hattem, A (1987) Families and chronic illness. Fam. Ther. Collections, 22: 33-50 Kreitman, N., and P. Salisbury (1965) Hypochondriasis and depression in out-patients at a general hospital. Br. J. Psychiatry, 3: 607-615 Krishnan, K., R. France, S. Pelton, and S. McCann (1985) Chronic pain and depression: 1. Classification of depression in chronic low back patients. Pain, 22: 279-287 Kropotkin, P. (1902) Mutual Aid: A Factor in Evolution . Boston: Extending Horizon Press Krug, R. (1989) Adult male report on sexual abuse by mothers: Case descriptions, motivation and long term consequences. Child Abuse and Neglect, 13: 111-119 Lakoff, R. (1983) Interpretive psychotherapy with chronic pain patients. Can. J. Psychiatry, 28: 650-653 Lamphear, V. (1985) The impact of maltreatment on children's psychosocial adjustment: A review of research. Child Abuse and Neglect, 9: 251-263 Leavitt, F., and B. Sweet (1986) Characteristics and frequency of malingering among patients with low back pain. Pain, 25: 357364 Lee, J., and C. Swenson (1986) The concept of mutual aid. In A Gitterman and L. Shulman, eds. , Mutual Aid Groups and the Life Cycle. Itasca, Ill.: F .E . Peacock Publishers Levinson, D. (1978) The Seasons of a Man's Life. New York: Alfred A Knopf Liebman, R., P. Honig, and H . Berger (1976) An integrated treatment approach for psychogenic pain. Fam. Process, 15: 397-405 Lindemann, E. (1944) Symptomatology and management of acute grief. Am. J . Psychiatry, 101: 141-148 Livingstone, W. (1943) Pain Mechanisms. New York: Macmillan Lubell, D. (1986) Living with a lifeline: Peritoneal dialysis patients. In A Gitterman and L. Shulman, eds., Mutual Aid Groups and the Life Cycle. Itasca, Ill. : F.E. Peacock Publishers Lynch, M. (1975) Ill health and child abuse. Lancet, ii: 317-319 Magni, G. (1984) Chronic low-back pain and depression: An epidemiological survey. Acta Psychiat. Scand., 70: 614-617

170 References - (1987) On the relationship between chronic pain and depression when there is no organic lesion. Pain, 31: 1-22 Magni, G., S. Caldieron, S. Rigatti-Luchini, and H. Merskey (1990) Chronic musculo-skeletal pain and depressive symptoms in the general population: An analysis of the 1st National Health and Nutrition Survey data. Pain, 43: 299-308 Malan, D. (1976) The Frontiers of Brief Psychotherapy. New York: Plenum Medical Books - (1979) Individual Psychotherapy and the Science of Psychodynamics. London: Butterworths Marbach, J., M. Lennon, and B. Dohrenwend (1988) Candidate risk factor for temporomandibular pain and dysfunction syndrome: Psychosocial, health behavior, physical illness and injury. Pain , 34: 139-151 Martin, H. (1980) The consequences of being abused and neglected: How the child fares . In C. Kempe, ed., The Battered Child, 3rd ed. Chicago: University of Chicago Press Martin, H., and P. Beezley (1977) Behavioral observations of abused children. Dev. Med. Child Neurol., 19: 373-387 Martin, H., P . Beezley, E. Conway, and C. Kempe (1974) The development of abused children. Adv. Pediat., 21: 25-73 Martinez-Roig, A. , F. Domingo-Salvany, and J. Llroens-Terol (1983) Psychologic implications of the maltreated child syndrome. Child Abuse and Neglect, 7: 261-263 Maruta, T., and D. Osborne (1978) Sexual activity in chronic pain patients. Psychosomatics, 20: 241-248 Maruta, T., D. Osborne, D. Swanson, and J . Halling (1981) Chronic pain patients and spouses: Marital and sexual adjustment. Mayo Clin. Proc., 51 : 307-310 Maruta, T., D. Swanson, and W. Swenson (1976) Pain as a psychiatric symptom: Comparison between low back pain and depression. Psychosomatics, 17: 123-127 McCord, J . (1983) A forty year perspective on effects of child abuse and neglect. Child Abuse and Neglect, 7: 265-270 McFarlane, A., G. Norman, D. Streiner, and R. Roy (1983) The process of social stress: Stable, reciprocal and mediating relationships. J . Health Soc. Behav., 24: 160-173 - (1984) Characteristics and correlations of effective and ineffective social supports. J. Psychosom. Res., 28: 501-510 McFarlane, A., G. Norman, D. Streiner, R. Roy, and D. Scott (1980) A

References 171 longitudinal study of psychosocial environment on health status: A preliminary report. J. Health Soc. Behav., 21: 124-133 Melzack, R., J. Katz, and M. Jeans (1985) The role of compensation in chronic pain. Pain, 1985: 101-112 Melzack, R., and P. Wall (1965) Pain mechanisms: A new theory. Science, 150: 971-979 Mendelson, G. (1984) Compensation, pain complaints and psychological disturbance. Pain, 20: 169-175 Merskey, H., and D. Boyd (1978) Emotional adjustment and chronic pain. Pain, 5: 173-178 Merskey, H ., and E. Spear (1967) Pain: Psychological and Psychiatric Aspects. London: Bailliere, Tindall, and Cassell Minuchin, S., L. Baker, B. Rossman, R. Liebman, L. Milman, and T. Todd (1975) A conceptual model of psychosomatic illness in children: Family organization and family therapy. Arch. Gen. Psychiatry, 32: 1031-1038 Mohamed, S., G. Weisz, and E. Waring (1978) The relationship of chronic pain to depression, marital and family dynamics. Pain, 5: 282292 Murphy, E. (1982) Social origins of depression in old age. Br. J. Psychiatry, 141: 135-142 Muse, M. (1984) Narcosynthesis in the treatment of posttraumatic chronic pain: A case study. Rehabil. Psychol., 29: 113-118 Olson, D., J. Portnoy, and Y. Lavee (1984) FACES lll. Family Social Science. St Paul, Minn.: University of Minnesota Press Oosterhuis, W. (1984) Early screening of pain to prevent it from becoming intractable. Pain, 20: 193-200 Parkes, C.M. ( 1972) Bereavement: Studies of Grief in Adult Life. Harmondsworth: Pelican Books - (1975) Psychosocial transitions: Comparison between loss of a limb and loss of a spouse. Br. J. Psychiatry, 127: 204-210 Parkes, C.M., and R. Weiss (1983) Recovery from Bereavement. New York: Basic Books Phillips, H., and M. Jahanshahi (1985) The effects of persistent pain: The chronic headache sufferer. Pain, 21: 163-176 Pilling, L., T. Brannick, W. Swenson (1967) Psychologic characteristics of psychiatric patients having pain as a presenting symptom. Can. Med. Assoc. J., 97: 387-394 Pilowsky, I. (1969) Abnormal illness behavior. Br. J. Med. Psychol., 42: 347-351

172 References - ( 1986) Psychodynamic aspects of the pain experience. In R. Sternbach, ed., The Psychology of Pain , 2nd ed. New York: Raven Press - (1988) Affective disorders and pain. In R. Dubner, G. Gebhart, and M. Bond, eds., Pain Research and Clinical Management, vol. 3. Amsterdam: Elsevier Pilowsky, I., and D. Bassett (1982a) Individual dynamic psychotherapy for chronic pain. In R. Roy and E. Tunks, eds., Chronic Pain: Psychosocial Factors in Rehabilitation. Baltimore: Williams and Wilkins - (1982b) Pain and depression. Br. J. Psychiatry, 141: 30-36 Pilowsky, I., C. Chapman, and J . Bonica (1977) Pain, depression, and illness behaviour in a pain clinic population. Pain, 4: 183-192 Pilowsky, I., T. Murrell, and A. Gordon (1975) Development of a screening method for abnormal illness behavior. J. Psychosom. Res., 23: 203-207 Pilowsky, I., and N. Spence (1975) Pain and illness behavior: A comparative study. J . Psychosom. Res., 20: 131-134 - (1976) Is illness behavior related to chronicity in patients with intractable pain? Pain , 2: 167-173 Power, P. (1985) Family coping behavior in chronic illness: A rehabilitation perspective. Rehabil. Lit., 46: 78-83 Rabkin, J ., and E. Struening (1976) Life events, stress and illness. Science, 194: 1013-1020 Rahe, R., M. Meyer, M. Smith, G. Kjaer, and T. Holmes (1964) Social stress and illness onset. J. Psychosom. Res., 8: 35-44 Reagles, S. (1982) The impact of disability: A family crisis. J . Appld. Rehabil. Counselling, 13: 25-29 Reid, W. (1978) The Task Centered System . New York: Columbia University Press Reid, W., and L. Epstein (1972) Task Centered Casework . New York: Columbia University Press Robinson, J ., J. Alvarez, and J . Dodge (1990) Life events and family history in children with recurrent abdominal pain. J . Psychosom. Res., 34: 171-181 Roll, M., and T. Theorell (1987) Acute chest pain without obvious organic cause before age 40: Personality and recent life events. J . Psychosom. Res., 31: 215-221 Rolland, J . (1987) Family systems and chronic illness: A typological model. J. Psychother. Fam., 3: 143-168 Romano, J., and J. Turner (1985) Chronic pain and depression: Does the evidence support a relationship? Psycho/. Bull, 97: 18-34

References 173 Rose, S., and B. Black (1985) Advocacy and Empowerment: Mental Health Care in the Community. London: Routledge and Kegan Paul Rowat, K., and K. Knafl (1985) Living with chronic pain: The spouse's perspective. Pain , 23: 259-272 Roy, R. (1982) Pain-prone patients: A revisit. Psychother. Psychosom., 37: 202-213 - (1982-3) Many faces of depression in patients with chronic pain. Intl. J . Psychiat. Med., 12: 109-120 - (1984) Psychosocial assessment of chronic headache. Health and Soc. Wk., 9: 284-293 - (1985a) Childhood abuse and Engel's pain-prone disorder patient: 25 years after. Psychother. Psychosom. , 43: 126-135 - (1985b) The interactional perspective of pain behavior in marriage. Intl. J . Fam. Ther., 7: 71-83 - (1986) Family conflict and exacerbation of headache: A clinical report. Headache , 26: 360-364 - (1988) Impact of chronic pain on marital partners: The systems perspective. In R. Dubner, G. Gebhart, and M. Bond, eds., Proceedings of the 5th World Congress on Pain. Amsterdam: Elsevier - (1989) Chronic Pain and the Family: A Problem-Centered Perspective. New York: Human Sciences Press (Plenum) - (1990) Consequences of parental illness on children: A review. Soc. Wk . and Soc. Sc. Review, 2: 147-159 Roy, R., and M. Thomas (1989) Nature of marital relations among chronic pain patients. Contemp. Fam. Ther. , 11: 277-285 Roy, R., M. Thomas, and S. Berger (1990) A comparative study of British and Canadian pain patients. Clin. J . Pain, 6: 276-283 Roy, R., M. Thomas, and A. Cook (1991) Headache: A family affair. Headache Quart., 2: 135-137 Rutter, M. (1966) Children of Sick Parents: An Environmental and Psychiatric Study. London: Oxford University Press - (1989) Pathways from childhood to adult life. J . Child Psycho!. Psychiatry , 30: 23-51 Schaffer, C., P . Donlon, and R. Bittle (1980) Chronic pain and depression: A clinical and family history survey. Am. J . Psychiatry, 137: 118-120 Schmitt, B., and R. Mauro (1989) Non-organic failure to thrive: An outpatient approach. Child Abuse and Neglect, 13: 235-248 Scott, R., and D. Stone (1986) MMPI measures of psychological distur-

174 References bance in adolescent and adult victims of father-daughter incest. J. Clin. Psychol. , 42: 251-259 Shanfield, S., E. Heiman, N. Cope, and J. Jones (1979) Pain and the marital relationship: Psychiatric distress. Pain , 7: 343-351 Sifneos, P. (1981 ) Short-term dynamic psychotherapy: Its history, its impact and its future. Psychother. Psychosom., 35: 224-229 Skevington, S. (1983) Chronic pain and depression: Universal or personal helplessness? Pain , 15: 309-317 Skinner, H., P. Steinhaur, and J . Santa-Barbara (1983) The family assessment measure. Can. J. Com. Ment. Health, 2: 91-105 Smith, T., M. Follick, and D. Ahern (1985) Life events and psychological disturbance in chronic low back pain. Br. J . Clin. Psychol., 24: 207-208 Sparks, T. (1988) Coping with the psychosocial stressors of oncology care. J. Psychosoc. Oncol., 6: 165-179 Steele, B. (1986) Notes on the lasting effects of early childhood abuse throughout the lifecycle. Child Abuse and Neglect, 10: 283291 Sternbach, R. (1974) Pain Patients: Traits and Treatment . New York: Academic Press - (1983) The low-back loser. Post-Grad. Med., 53: 135-138 - (1986) Pain and hassles in the United States: The findings of the Nuprin Report. Pain, 27: 69-80 Stockton, M., J. Weinman, and I. McColl (1985) An investigation of psychosocial factors in patients with upper abdominal pain: A comparison with other groups of surgical out-patients. J. Psychosom. Res., 29: 191-198 Swanson, D. (1984) Chronic pain as a third pathologic emotion. Am. J . Psychiatry 141: 210-214 Swanson, D., W. Swenson, T. Maruta, and A. Floreen (1977) The dissatisfied patient with chronic pain. Pain , 4: 367-378 Szasz, T. (1975) Pain and Pleasure, 2nd ed. New York: Basic Books Tait, R., J . Chibnall, and W. Richardson (1980) Litigation and employment status: Effects on patients with chronic pain. Pain, 43: 37-46 Thoits, P. (1982) Conceptual, methodological and theoretical problems in studying social support as a buffer against life stress. J. Health Soc. Behav., 23: 145-149 Thomas, M., and R. Roy (1989) Pain patients and marital relations. Clin. J. Pain , 5: 255-259 Thomas, R. , R. Roy, and A. Cook (1991) Headache, backache and family

References 175 functioning for a group of college students and their parents. Headache Quart., 3: 73-78 Tingling, D., and R. Kline (1966) Psychogenic pain and aggression: The syndrome of the solitary hunter. Psychosom. Med., 28: 738-748 Tsai, M. , S. Feldman-Summers, and M. Edgar (1979) Childhood molestations: Variables related to differential impacts on psychosexual functioning in adult women. J. Abnorm. Psycho/., 47: 417-426 Tunks, E. (1990) Chronic pain and the occupational role, part 1. In E. Tunks, A. Bellissimo, and R. Roy, eds. Chronic Pain: Psychosocial Factors in Rehabilitation, 2nd ed. Melbourne, Fla.: Krieger Turk, D., H. Flor, and T. Rudy (1987) Pain and families, 1: Etiology, maintenance and psychosocial impact. Pain, 30: 3-28 Turk, D., and T. Rudy (1991) Neglected topics in the treatment of chronic pain patients: Relapse, non-compliance, adherence enhancement. Pain, 44: 2-28 Turk, D., and P. Salovey (1984) Chronic pain as a variant of depressive disease: A critical reappraisal. J. Nerv. Ment. Dis., 178: 1-7 Turner, J., D. Calsyn, W. Fordyce, and L. Ready (1982) Drug utilization patterns in chronic pain patients. Pain, 12: 357-363 Viney, L., A. Clarke, and T. Bunn (1985) Crisis intervention counselling: An evaluation of long and short term effects. J. Counsel. Psychol., 32: 29-39 Violon, A. (1978) Le syndrome douloreux chronique: Etude psychologique. PhD thesis, Brussels University - (1980) The onset of facial pain. Psychother. Psychosom., 34: 11-16 - (1990) The process involved in becoming a chronic pain patient. In E. Tunks, A. Bellissimo, and R. Roy, eds, Chronic Pain: Psychosocial Factors in Rehabilitation, 2nd ed. Melbourne, Fla.: Krieger Volinn, E., D. Lai, S. McKinney, and J. Loeser (1988) When back pain becomes disabling. Pain, 33: 33-40 Warren, R., S. Rose, and A. Bergunder (1974) The Structure of Urban Reform. Lexington, Mass.: D.C. Heath Wasserman, A., P . Whitington, and R. Rivera (1988) Psychogenic basis for abdominal pain in children and adolescents. J. Am. Acad. Child Adoles. Psychiatry, 27: 179-184 Waters, W., and P. O'Connor (1971) Epidemiology of headache and migraine in women. J. Neural. Neurosurg. and Psychiatry, 54: 148-153

176 References Wepman, B. (1988) The body speaks: Talk therapy with the speechless. Psychother. Patient, 4: 189-195 Willets, R. (1980) Advocacy and the mentally ill. Soc. Wk., 25: 372-379 Wise, T. (1986) Psychosomatic medicine: Integrating dynamic, behavioral and biological perspectives. Psychother. Psychosom., 46: 85-95 Woody, J. (1985) The family in the health crisis. Fam. Ther. Collections, 13: 71-82 Wurtele, S., G. Kaplan, and M. Keairnes (1990) Childhood sexual abuse among chronic pain patients. Clin. J. Pain, 6: 110-113

Subject Index

abdominal pain 30, 41, 42, 43, 46, 63, 67, 81,129 abuse (physical and sexual): adult effects of 13, 31, 68-72; case illustrations 73-9, 129, 138-40, 158-60; childhood effects of 1, 57, 61-3; childhood history of 13, 27, 30; pain and 40, 58, 60, 61, 64. See also Pain-proneness advocacy 97-103, 110 alcohol and drug dependency: causes of 4, 7, 15; fear of 53; prevalence of 15-16 antidepressant 27, 36 anxiety 27, 29, 30, 36, 71, 73, 85, 104,119; 130,147,150,151; financial 10; headache and 50; inventory of 11; pain and 66, 104, 126, 137; state of 46; trait 11 assessment: for compensation 11; task-centred approach and 118 backache 82, 84 back pain 4, 8, 11, 13, 28, 31, 36, 45, 46, 47, 71, 73, 82, 89, 99, 102,122,127,129,158 bureaucracies 97, 98, 102

catastrophe 20, 35, 119, 151, 153, 155 children 15, 25, 30, 32, 33, 34, 36, 37,49, 50, 52, 53, 54, 55,134, 138; abuse of (see Abuse); abdominal pain and 81; life events and 40-3; leaving home and 84, 146; of pain patients 92-3; sick 148 compensation 11 conversion reaction 135 coping 77, 88, 150; adaptive 51; effective 145; mechanisms of 63, 114, 143; skills 152; strategic 40 crisis: case illustrations (pain and crisis) 154-61; chronic pain and 153; clinical phenomena of 143; disclosure of 73; family and 92; family intervention and 151; hotline 108; tasks 147-8; theory 47, 145; types 146 depression (and chronic pain): abuse and (see Abuse, childhood and adult effects); abuse in spouses and 86, 88 (see also Spouse); case illustrations 29-33; causes of 5, 24, 38-9; helplessness and

178 Subject Index loss 9, 23, 24, 32, 33, 43, 47, 53, 28; life events and 43, 44, 45; 56, 66, 85, 88, 97, 104; calamiloss and 26-7, 34-8; pain-pronetous 37-8; depression and 26, 27; ness and 27, 60; prevalence of 25-6, 38; relationship of 23; earning 18, 33; grief and 33, 144; social causes of 24, 25, 26, 39; helplessness and 29; health and treatment of 23, 26; types of 29 33; intangible 35-7; job 4, 8, 33, disability 4, 6, 7, 8, 9, 11, 27, 58, 47, 55,117,146,155, 156;(oO 92,101,119,148,149,154,158 mother 25; outcome (oO 39; (oO roles 12, 13, 14; (oO self-esteem 19; tangible 34-5 ecology 5, 24, 129 employers 101-2 malingering 9, 10, 12, 99, 100 empowerment 97, 101, 124 mistrust 101 epidemiology of pain 4 family: abuse and 134; case illustrations 88--92; crisis and 92, 146, 149; function of 13, 14, 15, 85-7; history 30, 34, 36, 48, 49, 53, 54; income 15, 35, 55; roles 14, 36, 37, 54, 55; rules 14; sexual relations and 87-8; system 6, 7, 19, 81-5, 105; therapy 93, 112 grief23,26, 29, 32, 33,36,38, 50, 52, 53,56, 76,123,142,144,167 headache 4, 8, 13, 23, 31, 32, 33, 44,47,48, 49, 50, 52,53,54, 56, 62,64, 79, 82, 84,89, 131,132, 133,138,140,141,155,156 hypochondriasis 5, 69, 130 illness behaviour 5, 16, 84 intervention 29, 51; crisis 108, 143, 144, 146, 148, 161; legal 99; pharmacological 26; psychotherapeutic 132; social strategy 97, 110; task-centred 114-15 life events (and pain); adults and 41-2; case illustrations 48--55; children and 41-2

narcotics 15, 16 network 7, 17, 19, 47, 80, 85, 93, 94, 103, 147 neurotic 69; anxiety 127; healthy 141; neuroticism and 11, 43, 64 Nuprin Report 3, 4 pain clinic 4, 7, 8, 10, 11, 14, 19, 30, 31,34, 37,46,48,49, 50,52, 53, 72, 73, 75, 76, 77, 79, 82, 87, 89, 99,100,101,102,103,104, 105, 10~ 10~ 110,115, 11~ 11~ 121,122,132,133,145,165 pain-proneness: case illustrations 73-9; characteristics of 27, 60-1; disorder 27, 65, 68 personality 32, 40, 44, 51, 56, 57, 69, 79, 145; inventory 5, 11; premorbid 26 post-traumatic stress syndrome 70, 71, 78 psychogenic element 23, 57, 58, 62, 63, 66, 67, 125, 127, 128, 132, 142 psychopathology 63, 85, 145, 147, 151 psychosomatic element 57, 58, 62, 63, 66,69, 70

Subject Index 179 psychotherapy 32, 61, 111; case illustrations 132-40; chronic pain and 125, 126, 128, 129; efficacy of 129; rationale for 126, 130 roles 12, 18, 34, 93, 113; family 13, 14, 51, 82, 158; loss of 12, 13, 54, 112; McMaster model 82 sado-masochism 123 secondary gain 9 sedatives 15, 16 sexual history 13; (of) abuse 13, 57, 63, 65, 66, 67, 71, 72, 73, 76, 77; .dysfunction 13, 82, 87-8 (

social network 4 7 social strategy 98 social support 7, 19, 52, 93, 98, 103, 110, 145 social work 105, 153

somatoform 125 spouse 14, 15, 53, 56, 83, 87, 93; death (of) 52; distressed 14, 15; health of 85, 86, 93; sexual relations with 13, 87-8 suicide 55, 65, 78, 108, 144, 147, 149,155,156 therapy 78, 110, 116, 124, 130, 131; couple 134, 152; electroconvulsive 30; family 93, 112, 114, 152, 155, 158; gestalt 142; group 105; helper 107; interpretive 141 trauma (traumatic): abuse 57, 66, 158; children and 8, 111; events 72, 146, 148, 155; memories 78, 129; minor 33, 56, 117, 118; physical 148, 150 Worker's Compensation Board (WCB) 18, 97,100,101,102

Author Index

Adams, H. 4, 81, 86 Adams-Tucker, C. 69 Ahern, D. 8, 81, 86 Albert, R. 98 Anderson, D. 151 Andren, K. 152 Atkinson, J. 44 Baptiste, S. 105 Baron, M. 61 Bassett, D. 27, 46, 128, 130, 131, 142 Beecher, H. 3 Beezley, P . 70 Bellissimo, A. 130 Bender, E. 107 Benjamin, S. 142 Berger, S. 5 Bergunder, A. 100 Beutler, L. 142 Bishop, D. 82 Black, R. 16, 101 Blazyk, S. 150,151 Blumer, D. 27, 60 Boehnart, C. 150 Bond, M. 26 Bonger, B. 131 Bonica, J . 3, 4

Botto, B. 131 Bowlby, J . 26, 57,144 Boyd, D. 66 Brannick, T. 66 Brett, K. 148 Brown, G. 24, 43 Browne, G. 4 Buck, R. 92 Buckley, F . 16 Bunn, T. 150 Canavan, M. 151 Caplan, G. 47, 143, 144, 145, 148, 149 Carron, H . 8 Castelnuovo-Tedesco, P . 66, 67 Chapman, C. 4 Chibnall, J. 10 Clarke, A. 150 Cobb, S. 103 Coddington, R. 41 Cohen, M. 152 Cohen, R. 151 Cohn,J. 62 Cook, A. 84, 85 Craig, I. 43 Croog, S. 92 Crook, J . 4, 7

Author Index 181 DeBenedittis, G. 44 Dehlinger, E. 70 DeGood, D. 8 Delany, K. 150 Dhooper, S. 150 Donaldson, M. 71 Dworkin, R. 11 Edgar, M. 69 Edwards, P. 71 Egeland, B. 63 Elkins, G. 131 Emery, R. 68 Engel, G. 27, 58, 59, 65, 67, 125, 126,127,128,129,137,142 Epstein, N. 82, 113, 116 Feldman-Summers, S. 69 Feurstein, M. 4, 46, 81 Finlayson, R. 16 Fishbain, D. 16, 25, 26 Flor, H. 86, 87, 92 Follick, M. 8, 14, 81, 86 Forsyth, G. 150 Fowler, J. 4 France, R. 25 Frances, A. 131 Freud, S. 57,125 Gallagher, R. 11 Germain, C. 105 Gordon, A. 84 Gore, S. 103 Green, A. 61, 67 Gresham, M. 150 Gross, R. 13, 65 Haley, W. 27 Halpern, L. 15 Harris, T. 25 Haugaard, J. 68

Heilbronn, M. 27, 60 Herman, E. 105 Hill, D. 142 Hinkle, L. 103 Hjortsjo, T. 149 Hobfall, S. 148 Hodges, K. 41, 42 Hohmann, G. 92 Holmes, T. 40 Holzer, K. 62 Houle, M. 81 Hudgens, A. 13, 81, 87 Hughes, M. 42 Hunter, R. 63 Jahanshahi, M. 8 Jeans, M. 10 Jensen,J. 47 Katz, J. 10, 107 Kempe, C. 59 Kerns, R. 81, 86 Kilstrom, M. 63 Kline, N. 66, 67, 150 Knafl, K. 14, 15, 86 Koch-Hattem, A. 152 Kraut, B. 66, 67 Kreitman, N. 81 Krishnan, K. 25 Kropotkin, P. 106, 107 Krug, R. 71 Lakoff, R. 131, 132 Lamphear, V. 70 Lavee, Y. 83 Leavitt, F. 10 Lee, J. 106, 107 Lerman, M. 148 Levin, S. 92 Levinson, D. 146 Liebman, R. 66, 81

182 Author Index Lindemann, E. 143 Livingstone, W. 3 Loda, F. 63 Lubell, D. 105 Lynch, M. 69 Magni, G. 4, 38 Malan, D. 130, 132, 137, 140 Marbach, J. 47 Martin, H. 62, 68, 69, 70 Martinez-Roig, A. 62 Maruta, T. 13, 87, 88 Mauro, R. 69 McCord, J. 70 McFarlane, A. 103 Melzack, R. 3, 10 Mendelson, G. 11 Merskey, H. 3, 66, 131 Minuchin, S. 81 Mohamed, S. 81, 86 Murphy, E. 24 Murrell, T. 84 Muse, M. 131 O'Connor, P. 4 Olson, D. 82 Oosterhuis, W. 45 Osborne, D. 13, 87 Parkes, C.M. 27, 33, 144 Phillips, H. 8 Pilling, L. 66 Pilowsky, I. 5, 25, 26, 27, 46, 84, 125,126,128,130,131,142 Popkin, M. 150 Portnoy, J. 82 Power, P. 149 Rabkin, J. 40 Rahe, R. 40 Reid, W. 111, 112, 113, 116, 117

Richardson, W. 10 Rideout, E. 4 Robinson, J. 42 Roll, M. 43 Rolland,J. 148,149 Romano, J. 26, 27 Rose, S. 100, 101 Rosenquist, U. 152 Rowat, K. 14, 15, 86 Roy, R. 5, 13, 14, 29, 48, 56, 60, 70, 82, 83, 84, 85, 87, 92, 93,131 Rudy,T. 86,92 Rutter, M. 57, 69, 72, 92 Salisbury, P. 81 Salovey, P. 60 Santa-Barbara, J. 84 Schaffer, C. 25 Schmitt, B. 69 Scholz, 0 . 87 Scott, R. 69 Severin, B. 62 Shanfield, S. 85 Sifneos, P. 130 Skevington, S. 28 Skinner, H. 84 Smith, T. 8, 45 Sola, A. 4 Sparks, T. 152 Spear, E. 3, 66,131 Spence, N. 5 Spiegel, D. 131 Steele, B. 68 Steinhaur, P. 84 Stembach, R. 3, 4, 9, 69 Stockton, M. 46 Stone, D. 69 Streuning, E. 40 Sult, S. 81 Swanson, D. 16, 27, 66 Sweet, B. 10

Author Index 183 Swenson, C. 106, 107 Swenson, W. 66 Szasz, T. 125,126,127 Tait, R. 8, 10 Theorell, T. 43 Thoits, P. 103 Thomas, M. 5, 14, 82, 83, 84, 85 Tingling, D. 66, 67 Tizard, J. 72 Tsai, M. 69 Tunks,E. 4, 5, 7, 11,130 Turk, D. 60,81,86,87,92 Turner, J. 16, 26, 27 Viney, L. 150 Violon, A. 64, 65 Volinn, E. 8

Wall, P. 3 Waring, E. 81 Warren, R. 100, 150 Waters, W. 4 Wepman, B. 131 Weiss, R. 27 Weisz, G. 81, 86 Willets, R. 98 Wise, T. 131 Woody, J. 149 Wolfe, H. 103 Wurtele 65 Zimin, R. 42