Imagery for Pain Relief

A Scientifically Grounded Guidebook for Clinicians

David Pincus, Anees A. Sheikh

• Publisher: Routledge
• Year: 2010
• eBook ISBN: 9781135841768
• Topic: Médecine
• Subtopic: Ergothérapie

Imagery for Pain Relief, the first book of its kind, familiarizes the reader with basic scientific information about pain and mental imagery and shows why imagery is a valuable tool for pain management. Scientifically grounded and easy-to-read, it provides readers with a wealth of practical information, including imagery techniques that have been successfully used in the past. This is a useful text not only for physicians and clinical psychologists, but also for counselors, social workers, nurses, and graduate students in all health related fields, including sports medicine.

CHAPTER 1

Pain

A Primer

To lessen the suffering of pain, we need to make a crucial distinction between the pain of pain and the pain that we create by any thoughts about pain.

Dalai Lama and Cutler

(1998, pp. 209–210)

What is pain? This is a question we tend not to ask unless we are in pain, and then the answer is pretty simple. “Here?” the doctor asks, pressing with strong and knowing fingers. “Ouch! Yes that’s it! And please don’t do that again.”

In a sense, this is what we will be doing in this chapter. We are going to take a deep and probing look at pain. This is something we don’t ordinarily do. Although it is a universal human experience, we go to great lengths to avoid pain, to avoid talking or even thinking about pain. Let’s take a few moments to do what we don’t normally do.

Although we tend to point to affected areas that hurt and call that pain, pain is more than this. Pain is abstract. You can’t see it or touch it directly. I know it hurts when you touch it, but there is much more happening. Pain is an experience, a universal experience of humans and other complex creatures (Kleinman, Brodwin, Good, & DelVecchio-Good, 1992). As such, pain is phenomenological at its core—which means that it is fundamentally a subjective and a private experience. There is no thermometer for pain. Just like colors, each of us experiences pain in our own way and must take it on faith that our perceptions are in line with those of others.What is blue? How is it different from red? What is cold and what is hot? What is a dull ache or a sharp stab?

As a negative, repetitive, and inescapable part of our lives, each of us develops a relationship with pain. Like any other relationship, conflict and domination by pain may lead us to become isolated and worn down. Furthermore, to some degree each of us is in denial of our relationship with pain and of the inevitability of our upcoming pain experiences. This is especially true for those of us who enjoy long, pain-free intervals, allowing us to forget the inevitability of its return.

Yet pain marks the beginning and also the end of life (for most of us) and peppers our remaining existence with moments of suffering. When will you next feel pain? How long will it last? How many times will you feel it over the course of your life, and how much will you suffer? Will it hurt when you die? What about after death?

The experience of pain is like a visit from a ghost in some ways. Like a ghost, pain comes and goes in its own unpredictable manner, invisible and often undetectable by others—including the best modern medical technology. Like a ghost, pain reminds us of our frailty, connects us with our earliest sufferings, and is a specter pointing to our inevitable deaths. Like a visit from a ghost, pain is a private experience, somewhat indescribable and often scary. Talking about a pain experience with others will tend to turn them away from you, to be socially uncomfortable, and could lead them to question your honesty and your motives. While few of us will ever see a ghost, each of us will experience pain, and many of us will eventually experience a haunting.

Webster’s dictionary defines pain primarily as punishment, and elaborates: “to impose a penalty on for a fault, offense, or violation (Merriam-Webster Inc., 2008). Further, pain and punish each share the same Latin root, poena, which means “penalty.” Think about this connotation. Pain is equivalent to punishment? Penalty? One may reasonably ask, “So what’s the crime?” If the pain sufferer is at fault, what was the violation or offense? It seems that blaming the victims of pain is nothing new, dating back at least 700 years to Old France (Douglas Harper, 2001), where the word punishment first emerged: it is entrenched even in the language we use to describe the experience we call pain.

Similarly, this one-word definition, “punishment,” shines a light onto the social context of pain that most chronic pain survivors could describe readily. The experience of pain is usually accompanied by two related interpersonal processes: social stigma and self-doubt. People surrounding pain sufferers actively blame them, looking for reasons to justify the sufferer’s suffering. If there has been a penalty, there must have been a foul. At the same time, friends and family tend to distance themselves psychologically and emotionally from the afflicted by finding differences of virtue between themselves and the sufferer, differences that will keep the ghost of pain from visiting them. It is human nature to try to make sense of senseless suffering.

As this process occurs on an interpersonal level, a converse process unfolds within the sufferer. Sufferers themselves tend to distort the context of pain in the opposite direction—desperately looking for external causes, ideally a physical cause, to explain away the pain. At the same time they tend to overlook any habits (cognitive, emotional, behavioral, or social) that might inadvertently be increasing their suffering. Pain sufferers are one of the few groups of people who are actually relieved to find out that something is physically wrong with them. This is a telling irony within modern culture and its difficulties in understanding pain.

At the same time, pain patients tend to ask themselves on a less conscious level, “Why me? What crime did I commit? When will my penalty be served? Maybe I am to blame?” What a load to carry around along with a raging set of aches and pains. No matter whether one is actively trying to make sense of pain by finding the crime for which the sufferer is being punished or one is a sufferer trying to escape judgment, pain automatically brings with it a social and personal wrestling match involving blame and stigma. Why is this necessarily so?

Social psychologists have identified two well-known processes that govern our social perceptions: the “fundamental attribution error” (Ross, 1977) and the “just-world bias” (Lerner, 1980). The fundamental attribution error is our tendency to blame victims, which research has repeatedly shown to be automatic, pervasive, and universal, barring some minor caveats in collectivist cultures (see Norenzayan & Nisbett, 2000). Our tendency to blame victims is not just a long-standing cultural tradition that has been folded into the etymology of our language for pain; it is a byproduct of our brains and really cannot be helped (Nispett & Ross, 1980; Tversky & Kahneman, 1974).

You see, brains are designed to make sense of the world and to reduce emotional discomfort. We blame victims not because we are unjust but because blame provides the simplest answer to explain a victim’s suffering and in the process it makes the world seem safe and predictable for the rest of us. A safe and predictable world is generally a nice place to live. The downside of course is that the world is not really as safe or as predictable as we tend to imagine, particularly in regard to pain, which, again, you will experience.

Similarly, we have an inherent bias to believe in a just world, where bad people are punished (i.e., pain) and good people are rewarded (i.e., pleasure). Wouldn’t this be great, if it were true? Alas, people who are in pain are, on the whole, just as worthwhile (or naughty) as everyone else—no more, no less. This imaginary world where pain equals punishment is, however, the most adaptive possibility for a meaning-dependent organ like our brains. In fact, we should thank our brains for reducing our fears of unpredictable and unjustified pain and suffering to the lowest level it is able to muster. This blame-the-victim, just-world fantasyland in which we all live to some degree allows us to move on to more pressing and complex problems.

Of course there is one time in which we make an exception to these neurologically based biases, when we are the ones who are suffering. When it happens to us, a third, well-known cognitive bias naturally kicks in: the self-serving bias (Bradley, 1978; Fletcher & Ward, 1988). The self-serving bias leads us to overestimate external causes and to underestimate internal ones, the opposite of the fundamental attribution error. This self-serving bias is adaptive inasmuch as it preserves our somewhat false sense of mastery over ourselves and our integrity while at the same time making things appear simpler than they really are. Again, the brain likes to keep things as simple as possible.

The downside of this simplicity, however, particularly with chronic pain, is a mind-set in the pain patient that the world is in fact unjust. Why else would someone be repeatedly punished for a nonexistent crime unless the world was cruel and mean? And if the world is unjust, doling out punishment in the absence of crimes, why would one foolishly hope for amnesty, for relief? Why would one try to free one’s self from pain? Why would one listen to those who say, “You know there are some things you can do to relieve your suffering.” Or even worse, “You know we’re going to imagine your pain away; how does that sound?” More hollow words from a nonsufferer who doesn’t understand the cruel nature of universal crime and punishment. After all, this is just another message calling for the admission of wrongdoing, personal blame, and a desire for repentance; it is just one more voice screaming not that it desires to help but instead that it is all your fault.

Ultimately, pain, particularly chronic pain, brings with it all of these negative connotations and multi-layered conflicts. Sufferers are in conflict with pain itself, with an unjust world, with others who appear to indict them for their wrongdoings, whether they are trying to help or not. Similarly, sufferers are in conflict with themselves on some level as they try not to focus on those things that would justify their punishments. After all, are any of us really that innocent that we couldn’t search our personal histories and find some crime that is worthy of punishment?

Varieties of Pain

In Western culture we love to label things. This is especially true in science and medicine. Of course, labeling is not uniquely Western; all human cultures name things, and in so naming they shape and construct reality to some extent. Inasmuch as pain is a human experience firmly within the purview of Western science and medicine, there is no paucity of different ways to semantically slice and dice the experience of pain (for more detailed and technical classification systems for chronic pain, see Merskey & Bogduk, 1994; Turk & Okifuji, 2001).

One common strategy in typing pain is to use its location, as in lower-back pain, dental pain, joint pain, and pains in the neck. This allows us to come up with a plethora of types of pain from head to toe. Another common strategy is to type pain according to its cause, for example, inflammatory pains, neuropathic pains (i.e., related to nerve damage), even central pain (related to information processing in the central nervous system), which is the newer and less stigmatizing term for “all in your head.” Causetyping leads to problems as such, because pain is always multiply determined, with causes ranging across scales, from large-scale socioeconomics down to the level of molecules.

One broad and very important dimension we use in classifying pain is time, as in chronic pain, which lasts a long time, versus acute pain, which is shorter in duration. The length of time at which acute pain becomes chronic pain is a bit fuzzy, varying from expert to expert (Hardin, 1997). Merskey and Bogduk (1994) define chronic pain as “pain which persists past the normal time of healing…. In practice this may be less than one month, or more often, more than six months” (p. xi). The primary type of acute pain for which imagery has been shown to be effective is procedural pain, which arises from some medical treatment, for example, following knee surgery (i.e., Cupal & Brewer, 2001), cancer treatments (i.e., Syrjala & Roth-Roemer, 1996), or childbirth (Achterberg, Dossey, & Kolkmeier, 1994).

There are times when there is no initial physical cause for a pain condition, in which case the line between chronic and acute may be defined by duration, somewhere between 1 and 6 months. Of course some conditions, like arthritis, are chronic by nature, as is the pain that comes with them. Other specific examples of chronic pain include the pain that accompanies irritable bowel syndrome or headaches, which may then be further subdivided, for example, into tension-type, migraine, cluster headaches. Of course, most of these common examples are actually recurring rather than chronic per se. They come and go, with flare-ups, but never quite go away. Using the metaphor of the unwelcome houseguest, these types of pain will leave for a little while, leaving a mess behind them and then returning all too soon.

Because time is such an important factor in determining our experiences of and relationships with pain, a more useful distinction than simply chronic versus acute might involve the different manner in which chronic pains come and go. Pain that is always there is distinct from pain that comes and goes regularly and also from pain that comes and goes unpredictably. An unwelcome visitor who is always there must be managed differently from one that comes once per year or that pops in unexpectedly.

The key distinction between chronic and acute pain then is the relationship the sufferer forms with the pain. Again, pain is a familiar, emotionally charged, meaning-laden, unwelcome, yet inevitable visitor for all of us. The meaning of such a visit is completely different, if it is for an afternoon versus a weekend, if pain is going to stay only for tea, or if it is going to tag along with everything we do. On human experiential and relational levels then, the differences between chronic and acute pain run far deeper than an issue of duration.

Pain in Modern Medicine: Round Pegs and Square Holes

After the primary definition connecting pain to punishment, Webster’s does in fact provide a more medical, less criminal, secondary definition of pain: “Usually localized physical suffering associated with bodily disorder (as a disease or an injury); also: a basic bodily sensation induced by a noxious stimulus, received by naked nerve endings, characterized by physical discomfort (as pricking, throbbing, or aching), and typically leading to evasive action; b : acute mental or emotional distress or suffering: GRIEF” (Merriam-Webster, Inc., 2008). Examining this sequence of definitions one finds that punishment comes first; next comes the physical manifestation of pain, related to injury and nerve endings, and the emotional and psychological elements are listed third. Generally speaking, this set of definitions is an accurate characterization of the way pain is interpreted by most of us. Our first reaction to pain is either, “Woe is me” (if it is our pain), or “Shame on you” (if it is someone else’s); our second reaction is to look for physical damage, and finally we attend to the mental and emotional aspects of suffering. We usually ignore the social and relational aspects altogether.

Pain is viewed primarily as a physical phenomenon within Western culture. While pain is among the least likely reasons for seeking mental health treatment, pain is the most commonly reported symptom within physical health-care systems, and treatment costs are in the multibillions worldwide (Hardin, 1997). It would be accurate to say, then, that pain is one of the largest moneymakers for the world’s health-care industry. In the United States it is estimated that between 24 and 80 million Americans (10%–30%) are suffering from significant pain of one sort or another at any given time. Take a moment to think about this in human terms. Imagine you are in a small movie theater, with 20 seats in each row. You would find two to five people in each row who are in significant pain. Of course, the people in the worst pain probably would prefer to stay home, but you get the point. So take a look around you the next time you are out, virtually anywhere, and you probably will be in the presence of several pain sufferers. If pain really is some sort of cosmic punishment, then naughtiness must be very widespread indeed.

The standard treatment for pain due to injury, medical procedures, and the like (e.g., relatively temporary pain that is to be expected) is to prescribe sufficient doses of pain medications to produce analgesia. However, when pain is the primary issue, such as with a chronic condition like back injury, headaches, or fibromyalgia, pain survivors often will obtain care at a clinic specializing in pain. Within such clinics, professionals including physicians, physical therapists, and mental health professionals will ideally work in multidisciplinary teams. Pain may be treated by mental health professionals in private practice as well. In either setting, integrating the care and interventions within a biopsychosocial framework is most important so that the left hand knows what the right hand is doing, so to speak. Ideally, patients’ treatments should be individually tailored to fit the specific pains they are encountering and also to fit their own unique biopsychosocial makeup.

The physician might use assessments including scans, such as computed tomography (CT) or magnetic resonance imaging (MRI), blood tests, test of autonomic functioning, and electromyography. Physical therapists may assess for rigidities and flexibilities in the musculoskeletal systems using range of motion, vestibular perception, and other tests. Similarly, mental health professionals should obtain detailed accounts of patients’ multiple psychosocial domains, including full developmental histories, personality assessments, and social assessments. Within and across each of these domains, you should listen carefully for information about your patients’ relationships with their pains, what you might call their “pain narratives.” Listening in this manner, you will gain all of the detailed information required for professional purposes, such as paperwork and reporting to the other members of the team. But in addition you will gain an experiential sense of the pain, a more human understanding. Your patients will also gain from having shared their experiences in a holistic manner such as this.

As you tune in and listen to this pain narrative, it will be important to observe your patient’s process as well as the content of what is said. For example, understanding where and when the pain has been involved in the client’s development of relationships with self and others would provide a deep level of narrative content. At the same time, understanding how the client reacts to and relates with the pain would provide a deep level of narrative process. Content in assessment represents the plot of the story, what happens, whereas process represents themes and symbolic meanings, how and why things are happening. You will want to determine the depth and breadth of the pain, how far it reaches across your patient’s phenomenological existence in both time and space. How does pain come and go, and how extensive is its negative impact?

Clarity and objectivity in assessment are important as well. Analogue rating scales (e.g., 1–100) of pain intensity and interference across different times and life domains or visual analogue scales using colors to capture different pain intensities (e.g., red is intense and blue is less intense) and size to represent functional interference (from tiny to huge) are quite helpful in this regard.

No matter how medical and objective you may try to be, pain is so tied to perception and immediate social situation that pain assessment can never be completely objective. This often ignored fact is one reason why pain treatment has always been a thorn in the side of the prevailing biomedical paradigm in which it is frequently treated. Think about it. Pain is the most frequently reported symptom in medical practices across the world, yet physicians have no objective tools with which to measure it—no pain thermometer, no pain x-ray. Furthermore, it is unlikely that such a tool will ever be bu...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• Foreword by Ernest Lawrence Rossi, PhD
• Preface
• Acknowledgments
• 1. Pain: A Primer
• 2. Imagery: More Than Make-Believe
• 3. Imagery for Pain Relief: How Does It Work?
• 4. The Process of Image Therapy
• 5. Pain Management: Simple Techniques
• 6. Pain Management: Deeper Techniques
• 7. Pain Management: Deepest Techniques
• 8. Imagery for Children in Pain
• 9. The Gift of Pain and Suffering
• References
• Subject Index
• Author Index