In my last post (here) I gave a definition of trauma, as it is typically operationalised in research settings. I noted that Trauma (with a capital T) “… as used in DSM5 PTSD or ICD-11 PTSD/CPTSD is a more restrictive term than adversity, yet adverse childhood experiences are widely studied as contributors to some forms of chronic pain.” I also gave a definition of ‘adversity’ – “includes potentially distressing or traumatic experiences occurring throughout life, such as abuse, neglect, parental loss, family discord, assault, partner violence, workplace abuse, national displacement, and social injustice (p. 600)” from Lumley et al (2022). When reading research into trauma, ACEs and chronic pain, remember this is what the researchers are talking about, not the popularised idea ‘trauma.’
Most of the research into Adverse Childhood Experiences (ACEs) uses some measure to establish the level of adversity an individual has been exposed to. Items are similar to those below (from Finkelhor et al., 2013), and people may be asked questions such as “At any time in your life, did you get scared or feel really bad because grown-ups in your life called you names, said mean things to you, or said they didn’t want you?” or “When someone is neglected, it means that the grown-ups in their life didn’t take care of them the way they should. They might not get them enough food, take them to the doctor when they are sick, or make sure they have a safe place to stay. At any time in your life, were you neglected?”
A good question to ask is whether all adverse experiences have the same impact – is being exposed to repeatedly move home as traumatic as being bullied at school? Is having parents constantly argue as traumatic as having teachers poke fun at a kid who prefers reading to playing ball games? I don’t know the answer – and interestingly, the research doesn’t point to any particular adverse event as more or less traumatic, but suggests that (1) it’s how the individual experiences the trauma that matters, and (2) the cumulative effect of multiple traumas, not just during childhood but as a consequence of, or subsequent to exposure to ACEs.
Just to throw another spanner in the works, people who are neurodivergent (eg have ADHD, Autism Spectrum Disorder, auditory processing disorder, dyslexia, dyscalculia, dyspraxia, sensory processing disorder… there is a long list and this is only a few!) are more likely to experience ACEs such as being excluded from social circles, being bullied, being physically punished and/or exposed to physical violence – and are also at greater risk of developing chronic or persistent pain problems.
Back to trauma. So if trauma and adverse life experiences are many and varied, have a cumulative effect, are influenced by low socioeconomic contexts, and have an impact on the way our neurobiological systems develop, what does this mean for therapy? Today I’ll look at one approach.
Lumley and colleagues have conducted many studies looking at ’emotional exposure-based therapy’ for people with chronic pain. Their approach is to offer people with what they describe as ‘centralised pain’ or nociplastic pain (such as fibromyalgia) therapy that focuses on four principles and techniques (Lumley & Schubiner, 2019):
- People need to learn that their brain is ‘the organ that generates or amplifies primary pain’ and they use experiential examples to help people recognise the link between emotions, their brain, and their pain.
- People also need to learn that their brain has been shaped by previous experiences, and their approach requires people to ‘help recognise, disclose and process their traumas and conflicts’ because they believe that avoiding uncomfortable experiences such as trauma memories ‘leaves patients feeling helpless and fearful, preventing both psychological growth and the reduction of pain and other symptoms.'(p. 30)
- Therapy helps people face their experiences, experience them and ‘adaptively express’ them.
- During therapy people are asked to recall a situation, express their feelings about the situation in words, tone, facial expression and body movement – and are supported to ‘rescript’ their story using ‘adaptive’ emotions that weren’t present at the time.
- Finally, people are asked to identify their needs and feelings in relationships, and these kinds of new ways of communicating are practiced in therapy.
Schubiner first developed his therapeutic approach based on Sarno who thought that musculoskeletal pain ‘stems from the mind’s blocking of unconscious emotions, particularly rage’ and asked people to uncover and express these emotions. Lumley followed a slightly different path but in both cases, these men argue that by identifying previously unacknowledged emotions and learning how to express these in a more ‘adaptive’ way, people can develop the capacity to be more comfortable with these experiences, and adjust the way their nervous systems respond and consequently reduce their pain.
There are some studies showing positive outcomes from what is now called Emotional Awareness and Expression Therapy – such as Ashar et al., (2021) and Yarns et al., (2020). But I have some discomfort with this approach.
Here’s why.
The EAET approach argues that chronic pain, particularly what they describe as ‘centralised pain’ is the direct result of repressed trauma, or experiences individuals have avoided experiencing. While there’s good evidence (see last week’s post) that ACEs and Trauma influence the way our nervous system works, and there are associations between ACEs, Trauma and greater prevalence of nociplastic pains – what I don’t see is evidence that repression or avoiding distressing emotions or experiences directly causes these changes. It seems to me that the neurobiological adaptations are in response to threat in a developing human, and even in the presence of open awareness and disclosure of trauma, people develop these adaptations. It’s perhaps less about the repression and more about having experienced them that matters.
So why is learning to approach (or not avoid) distressing experiences helpful? Good research shows that avoiding or controlling situations or memories that remind us of adversity narrows the range of things we feel comfortable doing. The mind’s ability to remind us that ‘better be safe than sorry’ is remarkable, and responsible for us learning not to leap off tall buildings, avoid dark alleys, and in my case, spiders. There are times, though, when being a bit over-protective isn’t so good – when my little kids needed me to remove a big white-tail spider from their bedroom, my spider phobia kicked in and left me in a real quandary. Do I listen to my over-protective mind and RUN! from the spider – or do I do what was needed to make sure my kids slept in a safe space and remove it?
I have no arguments with therapies that help people learn how to approach discomfort and begin to develop confidence that they can manage these encounters successfully. This is the foundation of graded exposure therapy for pain-related avoidance, and is part of ACT.
What I have less confidence in is the attribution of pain to ‘repressed’ trauma. Repression is a term that derives from Freud and has been elaborated upon by others. The essential idea is that repression is negative because maintaining that ‘lid’ on things requires energy – and that by recovering the traumatic content, the impact of needing to keep those memories under wraps is reduced. In a review on false and repressed memories, Otgaar and colleagues (2022) point out that contrary to the idea that people repress traumatic memories, research shows traumatic experiences are generally well-remembered. This isn’t believed by people in the general public – and even therapists – and this widespread belief can lead to unhelpful digging around to uncover these traumatic experiences. And doing this can be pretty hazardous because, as Otgaar et al (2022) show, around 30% of people can be swayed into ‘remembering’ a false autobiographical event especially when being repeatedly asked and when using guided imagery. I wonder what effect the probing might have on physiological arousal…
So to summarise: Trauma (as defined last week), and ACEs, certainly have an effect on a developing nervous system, and from there, on our overall sensitivity to noxious stimuli. There’s reasonable evidence that learning to be willing to approach/be exposed to stimuli that has been threatening in the past allows the nervous system to adapt, and for us to be more flexible, particularly if we develop skills to down-regulate a stress response (more on this next week!). Whether learning to do this requires people to ‘uncover’ or relive traumatic experiences is arguable, and it’s even less clear whether ‘repressed’ trauma is a thing at all. Finally, I don’t believe there is evidence to support the idea that nociplastic pains are caused by ‘repressed trauma’ or ‘repressed emotions.’
What this leaves me with are some more questions (of course).
How much should therapists delve into the content of a person’s ACEs or trauma? How much does talking about, or remembering past trauma, help with current pain?
If a therapy like ‘pain reprocessing therapy’ or EAET has an effect – and in one study, a greater effect than CBT – on pain, what is it about this form of therapy that’s effective? Is it a case of take the blue pill and do it all, or are there components of this approach that don’t require the cathartic ‘reliving’ of trauma that can be useful?
Given the widespread nature of ACEs, should every clinician working in chronic pain be ‘trauma-informed’ and what does this mean anyway?
More to come over the next few weeks! like and subscribe (as they say)
Ashar, Y. K., Gordon, A., Schubiner, H., Uipi, C., Knight, K., Anderson, Z., Carlisle, J., Polisky, L., Geuter, S., Flood, T. F., Kragel, P. A., Dimidjian, S., Lumley, M. A., & Wager, T. D. (2021). Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2021.2669
Finkelhor, D., Shattuck, A., Turner, H., & Hamby, S. (2013). Improving the adverse childhood experiences study scale. JAMA Pediatr, 167(1), 70-75. https://doi.org/10.1001/jamapediatrics.2013.420
Lumley, M. A., Yamin, J. B., Pester, B. D., Krohner, S., & Urbanik, C. P. (2022). Trauma matters: psychological interventions for comorbid psychosocial trauma and chronic pain. Pain, 163(4), 599-603. https://doi.org/10.1097/j.pain.0000000000002425
Lumley, M. A., & Schubiner, H. (2019). Emotional Awareness and Expression Therapy for Chronic Pain: Rationale, Principles and Techniques, Evidence, and Critical Review. Curr Rheumatol Rep, 21(7), 30. https://doi.org/10.1007/s11926-019-0829-6
Otgaar, H., Howe, M. L., & Patihis, L. (2022). What science tells us about false and repressed memories. Memory, 30(1), 16-21.
Yarns, B. C., Lumley, M. A., Cassidy, J. T., Steers, W. N., Osato, S., Schubiner, H., & Sultzer, D. L. (2020). Emotional awareness and expression therapy achieves greater pain reduction than cognitive behavioral therapy in older adults with chronic musculoskeletal pain: a preliminary randomized comparison trial. Pain Medicine, 21(11), 2811-2822.