From pain through chaos towards new meaning: Two case studies (original) (raw)
From pain through chaos towards new meaning: Two case studies
Jennifer Bullington Ph.D. a,*, { }^{\text {a,*, }}, Charlotte Sjöström-Flanagan RPT, ADTR b { }^{\text {b }}, Kristina Nordemar OTR, MTR c { }^{\text {c }}, Rolf Nordemar M.D. c,d { }^{\text {c,d }}
a{ }^{a} Ersta Sköndal University College, P.O. Box 4619, SE-116 91 Stockholm, Sweden
b { }^{\text {b }} HCMC, Vietnam
c { }^{\text {c }} St Goran Pain Clinic, Mariebersg. 5, 11281 Stockholm, Sweden
d { }^{\text {d }} Karolinska Institute, Stockholm, Sweden
Introduction
Chronic pain is a disruptive experience with far-reaching consequences in the somatic, psychological, social, and existential realms. Many people suffering from chronic pain are on long-term sick leave or disability pensions as a result of their inability to work, often resulting in very low quality of life with social isolation and suffering, not only for themselves but also for the people around them. Despite the advances made in health care in terms of better medication, better diagnostic aids, new operation methods, and the introduction of complementary treatment strategies such as acupuncture, much of Europe’s population ( 15−40%15-40 \% ) suffers from chronic pain (Brattberg, Thorslund, & Wikman, 1989; Eriksen, Ekholm, Sjogren, & Rasmussen, 2004; Zimmermann, 2004). Unlike acute pain, where one can often see a causal, biological reason for the pain and understand it as a logical and important protective signal, chronic pain is often not comprehensible in these terms. Stricken individuals experience a meaningless suffering that breaks down their personality and depletes them of energy, initiative, and joy of living (McWilliams, Cox, & Enns, 2003). Pain influences the patient’s family life, mood, and belief in the future, all of
- Corresponding author.
E-mail address: jennifer.bullington@comhem.se (J. Bullington). ↩︎
- Corresponding author.
which color everyday life to a high degree (Arntz & Claassens, 2004; Cano, Gillis, Heinz, Geisser, & Foran, 2004; McBeth, Macfarlande, & Silman, 2002). The medication and operations that are prescribed in these cases often give the patients undesirable side effects such as drowsiness, constipation, nausea, itching, dependence, dysestesia, or loss of motor function.
In order to understand chronic pain, one must first of all be aware of the mechanisms involved regarding noceceptive and neurogenic pain, which have become known during the last few decades. But this knowledge is not in itself sufficient, since pain is an experienced emotional state that is bound up with the person’s self-perception and cognitive functions. A combination of cognitive psychology and neuro-physiology offers a model of understanding somatic pathology, especially with regards to deepening the understanding of subjective experiences of ill health (Eriksen & Ursin, 2002, 2004). Pain is an experience of threatening or ongoing tissue damage that can appear even if there is no demonstrable injury, and sometimes there may be injury without the experience of pain. Sociologists (Burry, 1982; Frank, 1995; Williams & Bendelow, 1998) as well as philosophers (Nordenfelt, 1987; Toombs, 1992) have emphasized the psychological, existential aspects of health and illness. It is therefore important to bridge the gap between natural scientific research and human scientific research to reach an understanding of the complex processes that include nociception, transmission, modulation, central representation, and interpretation, as well as emotional and cognitive experience (Chapman & Nakamura, 1999). The discovery of central as well as peripheral sensitization has helped to understand the way in which the body regulates pain transmission and can even give an explanatory theory as to how emotional and cognitive mechanisms can influence transmission (Bennett, 2000). However, it is not enough to merely focus upon the patient; one must also be aware of the importance of the interaction between patient and the health care professional for successful treatment. In our experience it is necessary to follow the readiness of the chronic pain patient for treatment-readiness concerning all aspects of daily life, not only the specific physical problem. The rehabilitation plan needs to be adjustable according to the person’s continuously changing needs, in order to give the individual a chance to move from a passive position to active participation in his or her own recovery process.
The interpersonal encounter between patients and health care professionals contains psychological, social, and existential aspects and is a part of the healing process, leading to growth and maturity for the one seeking help as well as for the professional (Gadow, 1991). In music therapy, one can facilitate the process of connecting to that which is existentially significant for the patient, thereby helping to transform experiences of pain and suffering into those of meaning (Salmon, 2001). In dance/movement therapy the understanding of individual movement patterns, formed from early infancy and molded throughout life from everyday experiences, can be of paramount importance for exploring new meaning to the way a person can cope with difficult life situations (Kestenberg, Loman, Lewis, & Sossin, 1999). The patient’s experience of pain, suffering, disability, and loss of function are extremely important aspects of the medical encounter. Especially in the care and treatment of people with chronic pain, it is necessary to reflect upon the clinical encounter and better understand the dynamics of trust, healing, growth, and reconciliation, all of which play an important part in successful treatment and rehabilitation. To understand the subjective, life-world aspects of suffering and to enter into a healing relationship with the person
suffering from chronic pain are recognized today as equally important as ascertaining information about somatic factors (Cassell, 1999).
Theoretical perspective
We have in a previous article (Bullington, Nordemar, Nordemar, & Sjöström-Flanagan, 2003) introduced an approach to understanding chronic pain as a state of chaos where the individual lacks meaning-bearing structures and concepts needed in order to make their life understandable. Pain fills their consciousness and the individual lacks ways in which to understand or influence their situation. They may also lack faith in the healthcare professional’s desire and ability to help them. Our earlier work has convinced us that chronic pain is lived and constituted as chaos, and that the healing process has to do with the patient’s ability to work out a sense of new personal meaning and order from this chaos. In the cases studied in our previous work we found that the successful rehabilitation process moves through the initial phase of receiving the medical diagnosis (which provides the patient with a socially acceptable name for their suffering, as well as giving them a sense of control and some kind of “meaning” in order to try to structure and understand their experience) to a therapeutic journey which allows for new, previously non-articulated meaning to be brought forth, a meaning that brings together isolated pockets of painful thoughts, feelings, and memories that become gradually integrated in the present life-world of the patient. Successful rehabilitation was understood as a reintegration and ordering of chaotic experience. In the course of successful treatment, the body became once again “mine,” no longer the broken machine, and the patients’ sense of identity was strengthened. They regained the capacity to project themselves into a future with goals and projects to be realized, often revitalizing connections to the past and significant others as well. Non-verbal therapy treatments such as dance/movement therapy and music therapy were shown to be extremely helpful in this process, as they do not begin with verbal, cognitive material but rather with the body and emotions. Nonverbal therapy forms can be especially helpful in loosening up the rigidity on all levels (bodily, emotional, and cognitive) characteristic of persons with chronic pain. This rigidity can be understood as one of the ways in which pain patients keep everything apart. Pain literally locks the body in a stiff, rigid armor, hindering freedom of movement and forcing attention to body sensations rather than thoughts, feelings, memories, or the beckoning of the world. The body rigidity is often paralleled by a reduction in the emotional register. To “loosen up” is to gain flexibility of body and psyche and acquire a sense of new possibilities, an experience that was found to be one of the turning points in the therapeutic process.
Because chronic pain patients suffer not only from their pain, but also from an experience of disintegration and chaos, an experience that often leads to a problematic sense of self, it is important not only to treat the “objective” body, but to also take into account the “lived” body of the patient. The lived body is the mind-body unity understood in a meaningful context (Bullington, 1999; Honkasalo, 2000; Merleau-Ponty, 1945/1962). The perspective of the lived body enables the clinician to meet the patient without immediately withdrawing into an objectifying stance. Who is this person who has this pain? How does she/he live it? How does she/he experience her world? The theoretical understanding guiding our studies
is the phenomenological insight as to the nature of the lived body, and the attention paid to the meaning-bestowing activity of the human being.
Aim
The aim of this study was to investigate if the theoretical construct “meaning out of chaos,” used previously in order to describe the successful rehabilitation of patients with chronic pain (Bullington et al., 2003), could be helpful in understanding the rehabilitation process of two long-term pain patients at a specialized pain clinic. The two cases were analysed in terms of meaning evolution from body meaning to symbolic content in order to generate further knowledge about the psychosocial, existential aspects of the pain-rehabilitation process and to further develop the theoretical construct “meaning out of chaos.” The treatment accounts that served as empirical data for the study are presented from the treating clinicians’ point of view, with mind-body issues in focus. The aim of the study was not to evaluate specific therapy treatments but to follow and trace out the process in which body meaning, expressed in terms of somatic symptoms, evolved towards new meaning previously unarticulated on a verbal level.
Method
A focus group was formed consisting of a researcher within the field of psychosomatics and a group of clinicians (n=3)(n=3) working with chronic pain patients in a specialized pain clinic in a large Swedish city. Because the overall aim of the project was to deepen the clinicians’ understanding of existential, psychological, and psychosomatic aspects of chronic pain, the chosen method of investigation was a focus group comprised of interested clinicians with relevant backgrounds. The focus group consisted of an occupational therapist/music therapist, a psychosomatically oriented physiotherapist/dance therapist, and a medical doctor/researcher with a background in pain medicine, rheumatology, and psychosomatic medicine. The researcher leading the discussion group was a psychosomatician with a background in philosophy, psychology, and body-oriented psychotherapy. A common interest in the mind-body challenges involved in treating patients with chronic pain, as well as a desire on the part of the clinicians to discuss their work, constituted the inclusion criteria for focus group participation. The group met during the course of two years (2002-2003) approximately once a month, with each meeting lasting one and a half hours. Documentation of the first phase of this work (six months) has been previously published (Bullington et al., 2003). In the second phase of the work documented in this article, the focus was on two long-term patients at the clinic in ongoing treatment who were followed during the course of eight months. These two patient cases were judged by the team to be fitting illustrations of the long-term therapeutic process involved in the rehabilitation of severe chronic pain. The patients were initially given the choice to participate in either music or dance/movement therapy as part of their rehabilitation interventions, which also included acupuncture and medical analgesic treatments. At the time of the study they had already been in treatment at the clinic for more than one year. The
treatment strategy of the multi-professional team was to integrate the somatic, psychical, social, and existential aspects of the pain problem, and to work together in order to help these patients who had previously not been able to find sufficient relief for their suffering.
Material recounted by the clinicians from their concrete patient work served as the starting point for the group’s reflection. The meetings, which all took place at the pain clinic, were carefully documented by the researcher in terms of detailed notes that were then sent out to the group participants after each meeting. These notes were first structured and condensed by the researcher. These working notes then served as the raw data for the analysis, which was performed by the four co-authors. No one specific qualitative method, such as grounded theory, was used, but the common techniques involved in qualitative interpretative analysis such as condensation, coding, structuring, thematizing, and hierarchically organizing were the main methodological tools. The meaning of the clinical accounts was brought out through reflection and discussion, both in the context of the final focus group meetings and individually between sessions. Interpretations were worked through during the final group discussions where alternative interpretations were suggested and discussed. The final interpretations were anchored in a process of common reflection and argumentation where all group members found the interpretations to be satisfactory.
The case studies
The case of Denise
Denise was a 30-year-old woman from the Middle East who had fled to Sweden with her husband after being persecuted for political activity in her homeland. After several years of distress, a painful divorce, and finding herself alone with an infant, she developed severe pain symptoms in her back. Following an incident at her workplace after lifting a heavy object, she became so inhibited from pain that she was scheduled for back surgery. Declining surgery, Denise was on long-term sick leave, arriving at the clinic after having tried a variety of conservative treatments with little or no effect. By this time she had also developed diffuse pain sensations in several other places in her body, pain so severe that she was at times bedridden. She was diagnosed with central sensitization and fibromyalgia.
The initial assessment suggested deep-rooted unsolved psycho-social issues involving her family and leaving her home country. It also showed a lack of conscious awareness regarding basic body functions, emotional availability, and defined boundaries to self and others. She was very tense and stiff in her body movements, giving a frail impression as she walked with minimal torso involvement and feet carefully touching the floor. She stated in a barely audible voice that “apart from the pain in her back,” she was fine. The therapist suggested that she join an ongoing dance/movement therapy group focused on increasing conscious awareness of the body. Denise participated in the group but kept a low profile. She would do the guided warm-up movements in the sessions but would withdraw into a passive, observing stance when the group was encouraged to explore how their own personal movement connected with how they were feeling. After nine sessions Denise stated she was convinced that her symptoms were “only somatic.” Although she had felt a connection
with some of the other group members, she did not feel she needed group therapy. She had no idea about mind-body connections and no contact with her feelings. The therapist suggested that she could come back into the open dance/movement group if she changed her mind. After this break in treatment, her symptoms increased severely and she sought out a physiotherapist for an orthopedic assessment, expressing her worry about her growing pain. She became more and more panic-ridden about her condition. The medical rehabilitation doctor gave her a local anesthetic in her back and a series of acupuncture treatments at this time.
Three months later Denise approached the dance/movement therapist again and stated she was now ready to continue therapy, this time on an individual basis. At the beginning of one session she shared a dream. A small bird was sitting in its cage that suddenly started to fill with water. The bird was eagerly drinking the water but as the water was getting higher she realized the bird was going to drown. The door to the cage was locked and there was no way out for the bird. Denise had awakened with a start but in the therapy session had no associations to the dream except to state that she had felt very scared. It had been like a nightmare and she couldn’t understand why she would dream of a bird, as she didn’t like animals of any kind. In speaking about the dream in the session she became consciously aware of strong emotions of fear: fear of the body, of the unknown, of annihilation, of losing her mind, of the future. Her body became very tense and she was holding her breath as she spoke. She stated that she feared that the pain in her back would increase if she breathed “too much” and that her body would literally “break.” Denise preferred to sit in a chair with back support during this session “to protect her back.” The session became focused around finding ways of breathing into different parts of the body, gradually finding ways of moving that would not “hurt” her back, but anchor her experience in reality. Gradually, the rigidity of the body loosened. Breathing into her hands, the movements grew from at first merely visible flow adjustments to a hesitant and gentle exploration of how she could move her hands and arms in front of her without hurting her back. As she adjusted herself in the chair, while visible straining movements in her hips channeled a peripheral focus, she was able to test the support of her feet to the floor. The breath flow in her torso fluctuated between widening and narrowing as she became calmer by the fact that she was able to breathe and did not “break.” From a peripheral focus in a “dance of her arms and legs,” she was able to get closer to her center, her back, in a safe manner. The aim of this therapy session was to help Denise experience her body, and particularly her back, as part of herself rather than something alien and threatening. After four individual sessions she again left therapy, looking for another way to get rid of the pain problem, but again with the open invitation to come back to the therapist for continued treatment.
A few months later Denise approached the therapist one more time to ask if she could schedule both group and individual sessions, as she felt more ready at this time to continue her therapy work. She also stated that after her last therapy she had bought a pet bird for her son and herself and that she was starting to like animals. She felt inspired and curious and wanted to explore these new feelings. During the ongoing therapy her intellectual focus diminished and she became more present in her body. It was when she realized how she could breathe into her body-even into her back, where it was the most painful-that she became aware of “what her body had to say.” When Denise allowed herself to be connected to her breath flow in the stillness of the moment, with eyes closed, some of the most profound
images came to her. She would interpret the images together with the therapist and explore the relevance of these images for her own life. In one session she expressed her fear of the pain and experienced it as if she were “carrying around a big heavy stone in her back.” When exploring this metaphor on a body level, the heaviness of the stone became associated with deep sighs of sadness. Despite the agony, she was able to stay with the moment and after enduring the “stone” for what she stated felt like an eternity-in reality only a few minutes-a new image came to Denise, an image of “water flowing around the stone.” The flowing water became a highly emotional experience for Denise and gave a feeling of having “more space in her back” and a sensation of lightness in her body. As she began to test the new feeling in her body, she moved from sitting on the pillow on the floor to lying down and carefully bending, stretching, and turning her back. To her great surprise during this time, she did not experience any pain at all.
During the next eight sessions Denise explored her body through many different metaphors and on each occasion Denise would experience the same calm, peace, and free feeling of just being. At these moments she would get in touch with memories of her family and homeland. She would verbalize her intense sorrow at her father’s death a year earlier, which had coincided with the time in her rehabilitation process where her inner chaos had been the strongest and her frantic search for a “cure” the most intense. She began to raise questions regarding life and death, issues that she could now approach. She was able to speak of how closely connected she felt to her father in terms of belief systems and how this helped her in her own existential search for finding a new personal meaning in life. She associated back to the bird in her dream and concluded that she had been so afraid of everything that she had nearly “drowned” in her own worry. Denise’s body attitude and quality of movements changed over the time of the therapy. At the end of the therapy her posture was more assertive and coordinated, involving her whole body in a firmer gait pattern. She now dared to “move her back” knowing she “would not break” and she accessed a deeper breath flow in the body. She spoke with a voice of conviction and words of comfort to others and started to integrate into a social structure, both inside and outside of the therapy group. Although she would at times still be reminded of the pain in her back she was no longer fearful of the pain, as she had experienced that the pain could change and actually disappear. After a total of 20 group sessions and 12 individual sessions of dance/movement therapy over a year and a half, Denise was able to get beyond her pain and imagine a future. She took an active role in her recovery, making the ritual of “tuning of the body instrument” part of her daily routine. She found a way to break her isolated life pattern by resuming some of the academic studies she had wanted to take up again.
The case of Ingrid
The other long-term patient followed by the group, whom we will call “Ingrid,” was a Swedish woman in her late twenties. She had become ill several years before with muscle aches and numbness that gradually became tiredness and dizziness, diagnosed finally as fibromyalgia. Orthopedic and neurological tests could find no underlying disease that could cause her symptoms and she had not been helped by any medication. Her own desire was to get a referral to the pain clinic since she understood that her pain had something to do with her earlier traumatic life situations. Several years earlier her father had suddenly moved
out, leaving the entire family paralyzed. Ingrid’s role quickly became the one upon whom everyone could lean, and even her own mother needed her to be a “mother.”
Ingrid started music therapy once a week, and, inspired by the music, initially used drawings to try to show how she felt. The music used was performed with oboe, a solo piece by A. Marcello in D Minor. She felt sad and embarrassed but was helped by the music to stay in touch with her feelings. She was reminded of her grandparents’ summer cottage, her only secure place, which was no longer in the grandparents’ possession.
She described herself in images as sad, stiff, and grim, no longer capable of taking responsibility for those around her. She described her situation as “chaotic” and said that she had a severe feeling of anxiety when alone. She filled in a relationship map that showed clearly that her situation was unbearable. She had a very difficult relationship with her mother and siblings as well as with her father and his new family. There was also a new relationship with the mother’s new husband and his daughter and a relationship to Ingrid’s grandfather as well as to her own husband and his daughters from a previous marriage. From the map one could see that she was the link between all these people, between her mother and her father, her grandfather and her father, her father and his brother, and so on. She said that she was tired of supporting the entire structure of her family and had a hard time thinking and feeling. She said that she herself needed security. The goal of therapy became to help Ingrid reflect over her own situation and to develop new perspectives on her behavior. With the therapist she was able over time to develop a sound attachment as a point of reference for her new endeavor, something that had been seriously lacking in her previous life.
The therapist used music therapy with guided imagery in the following sessions, which meant that Ingrid could let the music carry her (security) while letting herself get in touch with her feelings. In the dialogue with the therapist Ingrid told her that she felt alone and sad and felt that she carried everything that had ever happened or would happen in all her relationships. The next session she arrived to the therapy wearing a neck brace. The therapist focused on the somatically expressed symptom by choosing to give Ingrid an acupuncture treatment. After a few more sessions with acupuncture, Ingrid opened up again, speaking about her burdens, and guided imagery was used again as a way to work through each individual family relationship that involved her day-to-day life. She listened to music, a modernized version of Bach’s “Jesu bleibet meine freude,” played on a piano, soft and playful. After awhile she recognized the theme and remembered that her grandmother had played this piece many times. She saw herself together with her grandmother, who had been a warm and kind person, with a strong presence, who had time to care for others. The music consisted of two themes “speaking to each other” like a dialogue. Music helped her stay in touch with this feeling for many minutes and after the session she described an easiness in her body, expressing to her therapist that things would be better. After this, problems with her husband started to come into focus, problems that she had not been able to explore as long as her physical pain had been in the center of her attention.
The “relationship map,” initially used as a way to approach the problems that Ingrid had experienced, changed its appearance at this point in time. As each individual person in Ingrid’s extended family situation was worked through in music and image, she was able to let go of the intensely painful burden she had carried for the entire family in the crisis following her father’s abandonment of the family. From having depicted herself as being
surrounded by so many “needy” people, shown on the map as many closely surrounding people, the map slowly opened up allowing more space around herself. She could now begin to participate in her extended family life while at the same time keeping her personal boundary intact.
With the help of her therapist, Ingrid was finally able to make some demands on her husband, even though it meant getting into an open conflict, something that she usually avoided. In one session she found an image of peace and security from her grandmother’s home, which became a place for comfort and safety in her mind. She said to her therapist that she felt that she was on the right track, feeling better than she had felt for a long time. She had managed to put some boundaries between herself and others, and she was able to set a reasonable limit to her responsibilities to others. As her anxiety reactions lessened, Ingrid was able to verbalize her relationship to her mother and feel that it was all right to be alone. Her self-confidence grew. During this time she became pregnant and gave birth to her first child and enjoyed the experience of being a mother. The baby gave her a sense of importance and strengthened her relationship to her husband. After 30 sessions of therapy during the course of two years, Ingrid was able to put her pain aside. She was not entirely free from pain, but she was no longer a prisoner of the pain. Pain was no longer a problem. Her quality of life was high and she was able to complete some long-term projects that had been impossible a few years before.
Findings
Chaos I and chaos II
The two case studies provided an opportunity to apply and further articulate the theoretical concept “meaning out of chaos.” This concept was developed in our previous work (Bullington et al., 2003) in order to describe the successful rehabilitation process of patients with chronic pain at a pain clinic. We found through an analysis of our cases that the pain experience is lived and constituted as chaos and disintegration, and that the healing process has to do with achieving a sense of meaning and coherence out of chaos. The move from disorientation towards a sense of coherence (being “put together again”) was experienced by the patients on all levels, from the bodily emotional register to the cognitive level of self-understanding and identity. In the course of successful treatment, the body became once again “mine” and no longer the bothersome broken machine, emotions were experienced and accepted, memories could be brought together with associated feelings and body sensations, and the experience of self became connected temporally to the past and the future, as well as to the present life situation and significant others. Ordering chaos was a process moving from diagnosis through a phase of heightened self-awareness towards responsibility-taking on the part of the patient. This concept was further developed in the analysis of our two cases, which were the result of interpretations made on clinical material during focus group discussions over one year.
We were able to further articulate the concept of “chaos” in two ways. Initially, we found that chaos (chaos I) could be a term describing the lack of structure and meaningful coherence in the patients’ life situation, often appearing already at the initial meeting. This
chaos is understood by the clinician but not by the patient. Chaos I is exemplified by the patient’s lack of understanding, or denial, of any inner needs other than the magical “wish for removal of the problem.” One could say that the cases are examples of a “disintegration” of experience, although the patient’s experience is not chaotic at this point. Chaos I describes the patient’s limited conscious awareness of any aspects of life that could be relevant for his or her problematic situation, except for the somatic symptoms initially presented to the medical team. As the patients became ready to start the therapeutic process, our examples showed how chaos became more visible in their lives and in their own experiences. The lived chaos, which the patients experience as extremely difficult we call “chaos II.” Let us now illustrate these two aspects of chaos with some examples from our case studies.
To exemplify chaos I we may first look at the case of Denise. In the initial body/mindawareness interview/movement assessment with her therapist, she said that everything was perfectly all right and that her only problem was her back pain. The assessment, however, indicated to the therapist several problematic areas on a body level as well as on a psychosocial level of which the patient was clearly unaware. Ingrid’s therapist described their first encounters as if Ingrid had a big bag of problems that she threw out onto the floor of the therapist’s room. The therapist felt as if it was her job to pick up these objects (problems) and give them back to Ingrid in some kind of order. It was obvious that Ingrid didn’t have a clue as to how she could begin to tackle her complicated situation, having no idea as to how to sort out and prioritize all the demands being made upon her. Chaos II is best illustrated by the case of Denise, who time and time again interrupted her therapy when things became too intense for her. Her experience was that things she had not previously given meaning started to emerge and caused a great amount of anxiety. Chaos II can also be seen in the case of Ingrid, who approached her psychosocial problems carefully, withdrawing back into the somatic realm when the experiences became too intense. Her aggravated symptoms and neck brace after a session where she started to get into touch with overwhelming feelings shows how precarious this journey can be.
Therapy process
The therapeutic treatment process in these two cases shows how the patients’ initial disintegration of experience (i.e., thought/feelings/memories split off from conscious awareness) gives way to a chaotic state when these split-off pockets of meaning begin to break through to awareness. If there is not enough “structure” present in order to contain this surge of new meaning, the experience will be overwhelming and the patient withdraws from their therapy. In a way, it would seem that the therapy process actually brings the patients into chaos. Treatment is a process through chaos wherein the chaos is ordered so that meaningful connections are made which help the patient integrate mind and body. The body ceases to be the only medium of expression. An example of this can be seen in the course of Denise’s therapy. An early dream (nightmare) in therapy was that she had seen a bird in a cage, a bird that was thirsty (Denise was thirsty). Suddenly, the cage was filled with water and the bird was almost drowned. Later on in therapy, as one of the many images explored through movement and metaphor, Denise drew a picture of a stream of water flowing freely through her body, and stated that this flowing water did not frighten her at this point, it was something nourishing rather than threatening. Later on in therapy, she described herself as
having a big red mouth in her back where her pain was, enclosed in a locked chain. In a later movement experience, Denise explored the mouth and locked chain in her back, depicting herself in a picture without a head. In the group feedback after the session someone pointed out that she had no head in the picture, to which she replied, “Yes, I have a head, it just hasn’t come out yet.” Meaning is on the way, slowly transforming itself from body to verbal levels of significance having to do with the life world of the patient, and the head is on its way out. The red mouth later on became a red ball, which she described as a symbol for that which was tiresome with her back pain. The ball was replaced by a stone that was gradually reduced to gravel by the soothing water running through her body, filling her with a feeling of calmness. In this state she no longer felt pain in her back. The transformation from mouth to ball to stone to a positive feeling she could feel inside herself can be seen as a move from body to higher order levels of meaning. The talking back disappeared as she herself began to take charge of her life, rather than letting the pain wipe out her world. During the course of individual treatment she began to understand her difficulties not only in terms of back pain but also in terms of deep-rooted issues of loss relating to her family in her home country.
Ingrid’s therapy process had to do with boundary work and ordering the many taxing relationships that obstructed her path. After some time in therapy her relationship map showed a freer constellation, where Ingrid no longer was the sole link between important people in her life. Her anxiety about her hopeless situation and her fibromyalgia had developed into a capacity to stop and think about her boundaries and responsibilities, without being overwhelmed. Ingrid found that she could indeed think and make decisions for herself.
Meta-perspective
Another aspect of ordering chaos that became apparent through these two cases was the importance of a meta-perspective in the process of moving from body meaning to articulated content. A meta-perspective involves the ability to see oneself outside of one’s concrete experience of the painful body. One can take a perspective on the pain, and can think about one’s situation. For example, Denise learned to concentrate and gather herself in relation to her pain. She could see the pain and stand away from the pain, examine it, feel other things besides pain, and realize that she did not have pain all the time. This is part of the structuring, differentiating work needed to build a platform for the new self. Instead of being the pain, one can experience a self in relation to the pain, which is the first step towards managing this pain instead of being consumed by it. Ingrid was also able to transcend her pain by allowing her problematic life situation come into the fore, to be dealt with together with her therapist. Without the security of the therapeutic relationship, this new platform is difficult to build. It takes time and courage and needs the holding space of a long-term therapy. The time aspect cannot be stressed enough, since much of the somatically oriented treatments do not take this type of process into account. Patients who “don’t get better” with traditional medication or physiotherapy are often labeled “problem patients” and are dismissed without having received proper health care.
Rather than alienating themselves from their bodies, both patients began to understand the importance of being aware of simple body signals that could help guide them through their daily chores. The treatment process had to do with gradually helping the patient to see
patterns, differentiate parts in an overwhelming whole (be it thoughts, feelings, memories), and find a structure to problems and see a variety of alternatives leading to solutions. The result of this work is that new realms of meaning are opened up and a new subject is born, a subject who is neither disassociated nor chaotic. This progression illustrates the hard struggle that some people have to go through to break the powerful barrier placed between difficulties relating to painful thoughts and feelings and the conscious, everyday experience of the patient.
Discussion
It is not uncommon to characterize the efficacy of psychotherapy in terms of “meaning transformation” (Power & Brewin, 1997). Sometimes the suffering person comes to therapy with painful meaning that cannot be integrated into every day experience and managed, and at other times it can be about the absence or loss of meaning. “Meaning” can be understood as a system of cognitive content, basic assumptions, beliefs, desires, order, and coherence that makes life worth living. Anxiety arises when meaning emerges in the course of life that cannot be handled within the framework of the current meaning system. The selfnarrative is an extremely important source of meaning, as it provides us with our basic sense of who we are and where we are going. Therapy provides a space where problematic meaning can be ordered and new meaning created. Persons with complicated, chronic, psychosomatic pain are often plagued by meanings that are unmanageable, such as feelings of overwhelming guilt and shame, extremely negative self-images, and traumatic episodes impossible to contain. The creative art therapies, using non-verbal communication through primary process expression, can sometimes be the format needed to help patients with severe pain to find a way of expressing themselves without words. Therapy offers them a safe place from which they can explore new ways of being and new ways of dealing with their life situation (Sjöström-Flanagan, 2004).
The therapy work in the two case studies shows a journey from chaos to meaning. The meaning achieved had to do with re-appropriating a sense of self and finding a new platform from which the patients were able to get on with their lives. Pain became reduced to the margins of the experiential field, while problematic areas of their lives were brought into focus and worked through. The process from chaos to order takes time and involves all aspects of the patients’ life situation, involving courage, dignity, and responsibility. Both Denise and Ingrid discovered that they could make decisions with a sense of resoluteness they had not felt before. They had given up the “victim position” where things were done to them. Instead of focusing on being the victim of other people’s wrongs, an increased awareness of self could help them reclaim their rightful place in life. To be in charge of life meant to take responsibility for one’s actions individually as well as collectively. Increased conscious awareness helped the patients to understand that keeping balance and structure in life is a continuous lifelong process that does not stop when discharged from the clinic. In our discussions and analysis of our cases, we also noted that not all patients were willing or ready to take this “journey.” The journey of creating new meaning, perhaps formulating difficult thoughts and feelings for the first time, can be time-consuming and even initially increase the pain experienced in the body, as many aspects of life are involved in realizing a
cure. The team needs to be adaptable enough to follow the patients’ process on an intuitive level and adjust the treatment approach accordingly. The method of choice at the moment, whether creative modalities of dance/movement or music therapy, acupuncture or body awareness exercises, talk therapy or medical advice, always aims at integrating the mind and body so as to allow meaning to take form and be expressed at the proper level, moving the process forward.
The therapist’s empathy and endurance is of vital importance for the successful rehabilitation of patients who suffer from chronic pain. It may be trying for the therapist as well to dwell in the patient’s chaos, but it is important that the therapist not lose touch with the hope that the patient will be able to find a new structure and meaning through the ordering of the chaos. To try to reduce chaos too quickly by giving large doses of medication may impede this process from moving along. The therapist may need counseling or supervision to be able to contain and persevere in these difficult processes. As this process moves on it may be necessary at times to take a “time-out” and let the patient try other methods in order for them to cope with the pain situation. As seen in our cases, the breaks in the therapy process were often followed by new incentive and inspiration to come back and keep working in the therapy process. One should regard the somatic path as a part of the therapy process and as an expression of the difficulty many chronic pain patients have making the connection between mind and body.
The goal for the multidisciplinary teamwork at the pain clinic is to find a broad, existential base from which to work with the patients. Many patients ask, “Why do I have this pain? What is the meaning of all this?” We know that struggling with pain raises deep questions that need to be dealt with. Our cases have confirmed the importance of being there for the patient, in an encounter which Buber (1970) calls the “I-Thou” encounter. The therapist is moved by the patient’s life story and both are confronted with the mysteries of life and suffering. The goal is to find a broader and deeper existential meaning in one’s life situation, to improve the patient’s relations to others and to strengthen his or her ability to project a possible future from the given life situation. To be willing and able to make this journey, both patient and therapist will have to be able to endure times of chaos, anxiety, and perhaps even periods of aggravated pain. It may also be the case that in some instances no meaning will ever emerge and in these cases one must concentrate on symptomatic pain reduction. However, it is our experience that given time and patience, new meaning will emerge, and new ways of thinking and feeling can become differentiated out of chaos in many cases. In these cases, it is worthwhile to invest in the work of long-term therapy rather than the shortterm solution of giving painkillers, which can be likened to putting shade over a sprouting bud. Our work with persons who suffer from chronic pain has convinced us that there is no short cut or magical route to health and well-being, but there is a rewarding path, which if taken enriches the lives of both the health care provider and the patient.
References
Arntz, A., & Claassens, L. (2004, May). The meaning of pain influences its experienced intensity. Pain, 109(1-2), 20−2520-25.
Bennett, G. J. (2000, January). Update on the neurophysiology of pain transmission and modulation: Focus on the NMDA-receptor. Journal of Pain and Symptom Management, 19(1 Suppl.), 2-6.
Brattberg, G., Thorslund, M., & Wikman, A. (1989, May). The prevalence of pain in a general population. The results of a postal survey in a county of Sweden. Pain, 37(2), 215-222.
Buber, M. (1970). I and thou. New York: Charles Scribner’s Sons.
Bullington, J. (1999). The mysterious life of the body: A new look at psychosomatics. Stockholm: Almqvist & Wiksell International.
Bullington, J., Nordemar, R., Nordemar, K., & Sjöström-Flanagan, C. (2003). Meaning out of chaos: A way to understand chronic pain. Scandinavian Journal Caring Science, 17, 325-331.
Burry, M. (1982). Chronic illness as biographical disruption. Sociology of Health and Illness, 4, 167-182.
Cano, A., Gillis, M., Heinz, W., Geisser, M., & Foran, H. (2004, January). Marital functioning, chronic pain, and psychological distress. Pain, 107(1-2), 99-106.
Cassell, E. J. (1999, October 5). Diagnosing suffering: A perspective. Annals of Internal Medicine, 131(7), 531−534531-534.
Chapman, C. R., & Nakamura, Y. (1999, December). A passion of the soul: An introduction to pain for consciousness researchers. Conscious and Cognition, 8(4), 391-422.
Eriksen, J., Ekholm, O., Sjogren, P., & Rasmussen, N. K. (2004, March). Development of and recovery from long-term pain. A 6-year follow-up study of a cross-section of the adult Danish population. Pain, 108(1-2), 154−162154-162.
Eriksen, H. R., & Ursin, H. (2002, April). Sensitization and subjective health complaints. Scandinavian Journal of Psychology, 43(2), 189-196.
Eriksen, H. R., & Ursin, H. (2004, April). Subjective health complaints, sensitization, and sustained cognitive activation (stress). Journal of Psychosomatic Research, 56(4), 445-448.
Frank, A. (1995). The wounded storyteller: Body, illness, and ethics. Chicago: University of Chicago Press.
Gadow, G. (1991, Summer). Suffering and interpersonal meaning: Commentary. Journal of Clinical Ethics, 2(2), 103−107103-107.
Honkasalo, M.-L. (2000). Chronic pain as a posture towards the world. Scandinavian Journal of Psychology, 41, 197-208.
Kestenberg, A. J., Loman, S., Lewis, P., & Sossin, K. M. (1999). The meaning of movement, developmental and clinical perspectives of the Kestenberg Movement Profile. London: Gordon and Breach Publishers.
McBeth, J., Macfarlane, G. J., & Silman, A. J. (2002, April). Does chronic pain predict future psychological distress? Pain, 96(3), 239-245.
McWilliams, L. A., Cox, B. J., & Enns, M. W. (2003, November). Mood and anxiety disorders associated with chronic pain: An examination in a nationally representative sample. Pain, 106(1-2), 127-133.
Merleau-Ponty, M. (1945/1962). Phenomenology of perception. London: Routledge & Kegan Paul.
Nordenfelt, L. (1987). On the nature of health: An action-theoretic approach. Dordrecht: Reidel Publishing.
Power, M., & Brewin, C. R. (Eds.). (1997). The transformation of meaning in psychological therapies: Integrating theory and practice. Chichester: John Wiley & sons.
Salmon, D. (2001, Autumn). Music therapy as psychospiritual process in palliative care. Journal of Palliative Care, 17(3), 142-146.
Sjöström-Flanagan, C. (2004). Creative arts therapy in the rehabilitation of chronic pain, movement and metaphor-Reflections by clients and therapist. Nordic Physiotherapy, 8, 120-131.
Toombs, K. (1992). The meaning of illness: A phenomenological account of the different perspectives of physician and patient. Dordrecht: Klewer Adacemic Publishers.
Williams, S. J., & Bendelow, G. (Eds.). (1998). Pain and the ‘dys-appearing’ body, in the lived body: Sociological themes, embodied issues. London: Routledge.
Zimmermann, M. (2004, May). Chronic pain: Epidemiology and management in Germany. Orthopade, 33(5), 508−514508-514.