Childhood Abuse and Chronic Pain: A Curious Relationship? 9781442672932

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Childhood Abuse and Chronic Pain A Curious Relationship? Empirical evidence is mounting to support the theory that certain individuals are prone to suffering from chronic pain as a result of childhood abuse. This is the first book devoted to a comprehensive exploration of abuse and its role in the genesis of pain. In a review of different types of abuse - childhood, spousal, sexual, physical, and emotional - Ranjan Roy probes the psychological and social consequences of abuse over time. He discusses variety in clinical presentation, course of treatment, and the failure or adverse effects of treatment. An experienced and respected psychotherapist, Roy also presents case studies from his own clinical experience to illustrate his therapeutic approach. Written by a practitioner for practitioners, this book will enable clinicians to identify pain-prone behaviour and to deal with the complex issues and challenges that patients with this condition present. RANJAN ROY is a Professor in the Faculty of Social Work and the Department of Clinical Health Psychology, University of Manitoba. He is also Consultant (Scientific) in the Department of Anaesthesia, St Boniface Hospital, Winnipeg.

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Childhood Abuse and Chronic Pain: A Curious Relationship ?

RANJAN ROY

UNIVERSITY OF TORONTO PRESS Toronto Buffalo London

www.utppublishing.com University of Toronto Press Incorporated 1998 Toronto Buffalo London Printed in Canada ISBN 0-8020-0739-2 (cloth) ISBN 0-8020-7790-0 (paper)

Printed on acid-free paper

Canadian Cataloguing in Publication Data

Roy, Ran] an Childhood abuse and chronic pain : a curious relationship? Includes bibliographical references and index. ISBN 0-8020-0739-2 (bound) ISBN 0-8020-7790-0 (pbk.) 1. Chronic pain - Psychological aspects. 2. Adult child sexual abuse victims - Mental health. I. Title RB127.R6851998

616'.0472'019

C97-931704-5

This book has been published with the help of a grant from the Humanities and Social Sciences Federation of Canada, using funds provided by the Social Sciences and Humanities Research Council of Canada. University of Toronto Press acknowledges the financial assistance to its publishing program of the Canada Council and the Ontario Arts Council.

Contents

Foreword Preface

vii

ix

1 Overview of the Literature on Childhood Abuse and Pain in Adulthood 3 2 Childhood Sexual Abuse and Pain in Adulthood: Case Studies 3 Childhood Physical Abuse and Pain: Case Studies 46 4 Childhood Neglect and Pain 58 5 Spousal Abuse 74 6 Therapeutic Approaches to Adult Victims of Abuse 92 7 Distress of Disclosure 109 8 Therapeutic Issues 125 9 Epilogue 138 References Index 159

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Foreword

Some individuals with chronic pain problems present with a significant disparity between their complaints of often severe and unremitting pain and the relative lack of objective clinical evidence for a physical cause for their symptoms. Diagnosis and management pose major difficulties in such situations. These people often spend several years passing through the hands of specialists in one area of expertise and then another to no avail, and, on the way, they may collect physical problems arising out of the very investigations carried out on them and/or from the treatments given. Each period of hope is dashed by failure until the potential for relief arises again from yet another source. Frequent encounters with professionals who attempt to provide pain relief may in themselves lead to psychological problems for the patient, namely, the generation of frustration, anger, and depression, together with intensification of the pain experience. Although perhaps not being aware of it, each clinician may be taking part in a representation in adult life of the very conditions that in childhood gave rise to the pain-prone behaviour they are observing. Today there are multidisciplinary pain clinics in many countries. Those who conduct psychological analyses and therapies have, in recent years, moved steadily towards the use of behavioural and cognitive methods for the management of pain. The popularity of psychoanalysis has mostly disappeared, chiefly because it is very time consuming, expensive, and often inconclusive in terms of outcome. Nevertheless, Ranjan Roy, who is a recognized expert in the social and psychological aspects of pain, uses a mddel that can be traced to psychoanalytic thought to throw some light on one particular issue which he explores in this book: the possible relationship between child abuse in its various forms and chronic

viii Foreword pain that has no obvious physical cause. Professor Roy has taken a very broad sweep through the voluminous and often not very scientific literature on the subject of child and adult abuse to support his text and clinical findings. He expresses his disappointment that, to date, so little is known about the mechanisms linking childhood abuse in particular with pain in adult life. The one exception is a 1959 article by George Engel, wherein Engel describes the 'pain-prone' patient. Roy proposes that Engel's theory that some individuals become 'pain prone' and, therefore, pain sufferers in adult life as a consequence of painful physical and emotional childhood experiences, gives a framework for explaining what Roy has observed over the years with patients in his pain clinic. Engel's work was produced in the middle years of this century and towards the end of a period when the psychosomatists had refined and developed Freudian theories to establish links between various forms of physical illness and emotional distress and had laid the ground for the development of Engel's propositions. Professor Roy has been intrigued in particular by two of the common features noted by Engel, namely, that physical abuse and neglect was common in the families of his pain-prone patients, and that as children they had learned unconsciously that pain may elicit affection from a parent and that guilt about the suffering of a parent may be experienced by the child as pain both during childhood and adult life. Professor Roy reports various case histories, and there are more than twenty of them, from his own clinical work illustrating different aspects of the potential contribution of abuse in childhood and adult life to chronic pain states. The studies are fascinating cameos of problems that many pain clinicians will have observed, with one important difference. It is that few clinicians give thought to the possibility that the pain sufferer in front of them has a history of abuse in childhood or adult life which may lie at the root of the pain problem and so provide a focus for therapy. This book goes a long way to supporting Roy's suggestion, on the basis of his own clinical observations and on the theoretical work done by Engel almost forty years ago, that there is indeed some kind of curious relationship between chronic pain in adulthood and abuse in childhood. Professor Sir Michael Bond University of Glasgow

Preface

The idea for this book has evolved over a very long time. I saw my first patient with a history of chronic headache and horrendous childhood physical abuse, a young man of 24, over twenty years ago. At that time only two papers, one by Engel and another by Szasz existed on that topic. My colleague, Dr Eldon Tunks, and I designed an intervention for this man based on psychodynamic principles, and then I treated him for the next two years. He made remarkable progress and in due course became almost pain free. This was the beginning of my interest in this topic. Since then, much empirical literature has emerged trying to establish a link between childhood abuse and adulthood chronic pain. While we may debate the quality of research and need for methodological refinement, as we must, no one familiar with this field will argue that from a clinical point of view this relationship has assumed great significance. I chose to write this book to emphasize that point. Once history of abuse is uncovered in a patient with chronic pain, the task is to investigate the possibility that pain may be related in some complex ways to the abuse. The next task is to offer appropriate treatment. It has to be said that despite emerging empirical evidence for a relationship between abuse and pain, treatment literature on that topic is close to nonexistent. In this book I have tried to take a very broad approach to this problem by casting a wide net to discover the health consequences, in the short as well as long run, of child abuse. Similarly, before offering my own approach to treating these patients, I examine the treatment literature for victims of abuse. In short, I try to place the specifics of abusepain relationship in the larger context of abuse.

x

Preface

This book is divided into three parts. The first part consists of a chapter, divided into two parts, and provides an overview of the literature. This chapter is by no means a critical assessment (many such reviews now exist) of the literature, but rather an annotation and overview that may be of more interest to practitioners, for whom the book is intended. This chapter explores non-pain and pain-related disorders, respectively. The focus of this book is to explore abuse and painful conditions. It is for that reason that the literature is presented separately. The first part of Chapter 1 deals with the health consequences, excluding painful conditions, of childhood abuse. The second part of the chapter examines the abuse-pain literature. This part also discusses Engel's pain-prone theory linking childhood abuse with adult chronic pain, and an attempt is made to show that there is now a substantial body of empirical evidence to support Engel's claim for such a link. Therefore, this book has a bias. There is now emerging literature that attempts to explain the abuse-pain relationship from psychophysiological, organic, and behavioural perspectives. These theories fall outside the scope of this volume, and that body of literature is not discussed here. This book, however, is concerned with the psychodynamic view developed by George Engel and in some measure by Thomas Szasz, supplemented by my own psychosocial perspectives. The second part of the book (my favourite) has four chapters and is based entirely on my personal experience of working with the patients discussed in those chapters. These patients, with histories of abuse, came to our pain clinic seeking relief from pain. Childhood sexual abuse and its relationship to chronic pain in later life is discussed through case illustrations in Chapter 2. Chapter 3 is concerned with childhood physical abuse and adulthood pain, and again a number of patients are presented exploring that phenomenon. Childhood neglect and pain is the subject matter of Chapter 4, and Chapter 5 explores the impact of spousal abuse on pain patients. This chapter is a departure from childhood issues, and I report on a few patients who reported abusive spousal relationship to show the message value of their pain symptoms to convey their predicament. The third part explores therapeutic issues in the treatment of survivors of abuse. Chapter 6 reviews with a broad brush the treatment literature for survivors. This literature is rich and innovative, but without much guidance for efficacy of treatment. Outcome research is sorely needed in this field. Chapter 7 addresses the painful issue of disclosure and how it might be dealt with in a medical (pain clinic)

Preface xi setting. In Chapter 8 I discuss in some depth a few patients illustrating the therapeutic process. In Chapter 9 I indulge in some personal reflections. This book is written by a practitioner for practitioners. Non-experts in the field of child abuse among health care professionals, and I count myself among them, must be made aware that many of their patients carry the burden of childhood abuse. Understanding the relevance of the abuse experience to their current predicament may not only facilitate a better understanding of the problem at hand, but will help chart an altogether more effective therapeutic course. My one and only goal in this book is to convey that message. I would like to thank two old friends, Dr Eldon Tunks and Dr Allan McFarlane, both professors of psychiatry at McMaster University. Eldon Tunks is in large measure responsible for my clinical interest in chronic pain, and I learned much from Allan McFarlane about the necessity of bringing critical thinking to all our clinical activities. They have had a profound influence on my clinical thinking and practice and they have my everlasting admiration. I would also like to thank my friends at University of Toronto Press. This is my fourth book with them and I have come to know many wonderful people in that organization. I would like to give special thanks to Virgil Duff, Executive Editor (my editor), and Anne Forte, Managing Editor, for their belief in me and my work. I would like to express my gratitude to Kate Baltais for copy-editing all four of my books and on each occasion doing a superb job. My friend Brian Minty of Manchester University, who read a very preliminary draft of this book and encouraged me to continue, has my deep gratitude. Finally, I want to thank my wife Margaret for her unending support for all my endeavours. This book is dedicated to my patients described in this book.

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Childhood Abuse and Chronic Pain

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ONE

Overview of the Literature on Childhood Abuse and Pain in Adulthood The long-term effects of childhood events have come under sustained scrutiny ever since Freud. That, generally speaking, a relationship exists between adult affects and events in childhood is by now beyond question. However, the precise nature of this relationship remains problematic. Life-events research studies have indeed explained the power of negative life events in the etiology of morbidity in adults, and the loss-and-attachment literature has convincingly shown the impact in later life of separations from parents and other kinds of losses in childhood. The early death of a parent and depression in adulthood is an example of this. But not all adults who experience negative events as children, nor even all children who experience the early death of a parent, necessarily succumb to later illness. Even among those who do, the type of illness that may develop remains in the domain of the unknown. Therefore, it is with some degree of reservation that the literature on childhood abuse and its later effects is examined. Even a cursory review of the literature on outcomes of childhood abuse reveals that although the psychological consequences of abuse are well documented, reports of its physical repercussions are just beginning to emerge. Review after review of the literature on long-term effects of child abuse almost completely ignores even the possibility of adverse effects on physical health. McCord's review (1983) of forty years of published reports on the effects of child abuse and neglect, never mentions physical health. The same is true of the reviews by Steele (1986) and Bagley (1991). Bachmann, Moeller, and Benett (1988) conducted a broad review of the literature on the effects on adult women of childhood sexual abuse and only very briefly mentioned the possible consequences of such abuse on physical health.

4 Childhood Abuse and Chronic Pain The review here includes both controlled and uncontrolled studies. It is more an annotation than a critical assessment of the research. This approach was adopted in order to acquaint the reader, very likely a practitioner, with the scope of the broad literature in its diversity. In the first part of this literature review, studies of the short-term health effects of childhood abuse are discussed, followed by studies considering the association with childhood abuse of two conditions that may be considered non-pain illnesses - eating disorders and HIV infection. My own clinical work with chronic pain patients is grounded in Engel's proposition of pain-proneness (1959). Thus, in the second part of this review, literature related to abuse and pain conditions is discussed in a search for empirical validation of Engel's pain-prone syndrome. SHORT-TERM EFFECTS OF ABUSE IN CHILDHOOD The immediate effects of infant or child abuse (physical and/or sexual) have been receiving a great deal of attention in recent years. This literature covers the entire period before adulthood, from birth to late adolescence. The range of topics is wide and includes investigation of damage to the limbic system (Teicher et al. 1990), non-epileptic seizures (Alper et al. 1993), and even death resulting from abuse in early childhood (Kotch et al. 1993; Oliver 1983; Sabotta & Davis 1992). Children are seriously injured and even killed (Kleinman, Marks, and Spevak 1991; Gothard, Runyan, & Hadler 1985; Starr 1988), mostly by their parents. Studies also report failure to thrive (Schmitt & Mauro 1989), high rates of illnesses (Sherrod, O'Connor, & Altemeier 1984), developmental impairment, psychosomatic and neurovegetative symptomatology (Famularo, Fenton, & Kinscherff 1992), urinary tract infection (Klevan & Dejong 1990), and neurological impairment (Green et al. 1981). We will briefly examine a few of these studies. Kotch and associates (1993) re-analysed the causes of death and reasons for admission to hospital of intentionally injured children in New Zealand. They found that 74 percent (n = 68) of the fatally assaulted children between the ages of 0 and 16 years had been either physically or sexually abused. Head and neck injuries and strangulation and asphyxiation were the two most common causes of death. Koch et al. studied the records of the 393 children aged 16 or under who had been discharged from New Zealand hospitals in 1988. The reasons for their admission included intentional injury, injury, and poi-

Overview of the Literature 5 sorting. Of these 393 cases, 228 were assessed as abused. Most of the physically abused patients were under 5 years of age and most of sexually abused patients were between the ages of 5 and 9 years. This investigation generally confirmed the view that both death and hospitalization resulting from physical and sexual abuse of children are generally under-reported. Bays and Chadwick (1993) reviewed some of the difficulties associated with diagnosing child physical and/or sexual abuse. Their conclusions support and explain the key finding of the Kotch study that abuse in children is under-reported. Schmitt and Mauro (1989) described their clinical experience of finding and treating non-organic failure to thrive (NFT) in children, not so much as a result of direct abuse, but because of parental neglect. They proposed a multifaceted home treatment program for non-severe cases of NFT. Famularo and associates (1992), in a study of 96 children - 61 of whom were abused - found several factors, including health and behaviour, that increased the probability of child abuse. Their study was directed at establishing risk factors and not at the consequences of abuse. Poor health of a child in combination with other factors can lead to child abuse, as child abuse can lead to poor health and poor development. Sherrod and colleagues (1984) investigated the temporal relationship between children's illnesses and maltreatment of these children. They noted that illness could elicit abuse and vice versa. Eighty children were divided into four groups: 11 from abusive families, 31 with NFT, 14 from neglectful families, and 24 from control families. The abused children had more accidents and more questionable accidents than the children in the other groups. High rates of illnesses in abused children declined over time; this is a very critical finding. The Sherrod study was useful for two reasons. First, it confirmed that abused children experienced more illnesses, and, second, the experience of abuse in young children depended on a complex interaction between many factors that could not be explained solely on the basis of the health of the child. Bachmann and associates (1988) reviewed the consequences of childhood abuse. They observed that abused toddlers and young children might show additional physical symptoms, for example, enuresis, encropesis, and sleep and eating disorders. They made similar observations in relation to adolescents and noted that fainting, episodes of

6 Childhood Abuse and Chronic Pain dizziness, tightness of the chest, loss of appetite, concerns with genitourinary tract, and some pain complaints may be suggestive of sexual abuse. They cited several studies in support of their observations, unfortunately, however, without making any distinctions between controlled and uncontrolled studies and even straightforward clinical reports. Evidence based on good research is still only emerging. Nevertheless, there is little doubt that somatic symptoms and even more serious and insidious physical problems may very well be some of the early and even immediate consequences of childhood abuse. Lewis and associates (1991), in a rather unique study, reported an association between childhood abuse and neuropsychiatric impairments in a group of delinquent girls. No such association was found in a matched control of delinquent boys. They also reported an association between the development of limbic system dysfunction and a history of childhood abuse. The evidence of serious injury to children inflicted by adults is mounting. More sophisticated medical methods are making more possible the detection of invisible injuries which may leave considerable damage. Some of these early injuries, such as impairment of the limbic system and other neurological deficits, may have serious and long-lasting consequences. The research evidence for such long-term repercussions is only just emerging. The potential that some chronic health problems, and not just mental health problems, have their genesis in early childhood abuse may be much greater than is known at present. LONG-TERM EFFECTS OF ABUSE IN CHILDHOOD In considering the consequences to adult physical health of abuse in childhood, an attempt is made here to analyse the evidence as it pertains to conditions that do not usually come under the rubric of painrelated disorders (the relationship of presentation of pain in adulthood and abuse in childhood is discussed at the end of this chapter). Eating Disorders Eating disorders are a complex group of difficulties that may be categorized as psychiatric, psychological, medical, or psychosomatic. Discussion of them is included in this review because they tend to be serious, with extensive implications for health involving multiple systems and

Overview of the Literature 7 even death. The studies are reviewed in the chronological order of their publication. Hall and associates (1989), in a clinical sample of 158 patients with eating disorders, found that 60 of them had a history of sexual abuse. Other than age, average 27.7 years, no other demographic information was provided and the equivalency of the abused versus the non-abused was not assessed. A key finding was that of the patients with a diagnosis of anorexia and/or bulimia 50 per cent had suffered sexual abuse. Incest with or without penetration was the most common form, followed by rape, fondling, and homosexual assault. Biological fathers were the most frequent perpetrators. It must be noted, however, that in less than onethird of the cases the abuse occurred before the age of 17 years: Even when the sexual abuse occurs in early adulthood, thus not only in childhood, it appears to be capable of engendering long-term negative health effects. The Hall study made no attempt at a causal link between sexual abuse and anorexia and/or bulimia. On the other hand, the authors reported that, once abuse was disclosed, dramatic changes in the course of treatment occurred. This was a case-finding study without the benefit of a rigorous design to measure long-term effects of sexual abuse. Three similar studies were reported which were in the nature of finding cases of abused individuals among patients with eating disorders. Oppenheimer and colleagues (1985) investigated for sexual abuse 78 patients with eating disorders. An astonishing 64 per cent of them reported that they had had unwanted sexual experiences. No causal explanation was sought. Finn and colleagues (1986) found that 70 per cent of subjects in a group of 87 women with 'possible eating disorders' reported having been sexually abused. Sexual abuse was inadequately defined, and eating disorders were not based on firm diagnosis but rather on selfreport. This investigation was poorly designed, with serious methodological flaws, which makes drawing any firm conclusions from it impossible. Calam and Slade (1989) examined the relationship between sexual abuse and eating disorders in a sample group of 130 female university students. Of those surveyed, 70 per cent responded. Of these, 58 per cent reported some form of 'unwanted sexual experience' - a vague concept; 20 per cent reported intrafamilial sexual abuse. The two instruments used in this study were the Eating Attitude Test and the Sexual

8 Childhood Abuse and Chronic Pain Life Events Inventory, and they were found to have a positive relationship. However, like the authors of the previous study, Calam and Slade did not discuss possible causal links. They cautioned that eating disorders may be just one of many triggers for sexually abused subjects. Palmer and associates (1990) reported on 158 female subjects who fulfilled the DSM-III criteria for either anorexia nervosa or bulimia. All were over 15 with a mean age of 24 years. A history of sexual abuse was obtained using the Sexual Life Events Inventory supplemented by therapeutic interviews. Forty-nine of the subjects met the criteria of sexual abuse. Experience of abuse was categorized on the basis of age. For those age 13 and below (32 subjects), fondling was the most common experience, while sexual intercourse was reported by 2 of them. In contrast, in those aged 13 to 15 years (26 subjects), sexual intercourse was reported by 15 (or 57 per cent) and fondling by 2. The authors were cognizant of a major limitation of this study, the fact that it was uncontrolled. They did, however, use established diagnostic criteria for eating disorders, and some effort was made to obtain accurate information on sexual abuse. At the very least, this study offered a tentative hypothesis in need of testing. Steiger and Zanko (1990), in a controlled study of patients with eating disorders and psychiatric patients and normal controls, reported experience of abuse by 30 per cent of eating disorder patients, 33 per cent of psychiatric patients, and only 9 per cent in normal controls. Abuse data were collected using a self-administered questionnaire, and abuse experiences of all ages were included. Hence, the incidence of abuse was not solely confined to childhood. Thirteen of the 26 subjects with personality disorder reported experience of childhood sexual abuse, and 2 of the 24 subjects without a personality disorder were sexually abused. The authors concluded that patients with an eating disorder who were sexually abused in childhood were more likely to have a personality disorder than those who were not. Again, this study did not address the question of the etiological significance of child abuse in eating disorders. Negative or Doubtful Findings This section reports a few studies that failed to find a strong association between abuse and eating disorders. In a New Zealand community sample of 301 women aged 18 to 44 years, Bushnell, Wells, and OakleyBrown (1992) studied the association between childhood intrafamilial sexual abuse and depression, substance abuse, and/or eating disorders.

Overview of the Literature 9 Subjects were selected from a larger sample for presence of depression, substance abuse, eating disorder, or any combination thereof. Sexual abuse data were obtained using a five-question test developed for the study. Forty-nine subjects responded that they had experienced some kind of sexual abuse. The results, based on comprehensive statistical analyses, suggested that a general increase in symptoms of mental disorder for those with intrafamilial sexual abuse comes from depression, bulimia, generalized anxiety and sometimes from somatization. The authors concluded that the effects of sexual abuse could be widespread and lacked specificity. The Bushnell study is important for several reasons. First, and foremost, the subjects were non-clinical; second, unlike with all the previously discussed studies, sophisticated statistical analyses were undertaken to establish the associations; and, third, the results failed to confirm a strong causal link. On the negative side, the psychometric properties of the five questions used to ascertain sexual abuse were not reported. Ross, Norton, and Wozney (1989) investigated the relationship between eating disorders and childhood abuse by comparing a variety of psychiatric patients with patients who had eating disorders. Multiple personality patients reported significantly higher (80 per cent) incidence of childhood abuse than eating disordered patients (20 per cent). This was not a negative finding, but rather it demonstrated a significantly stronger association between the two conditions - eating disorders and childhood abuse - in a group of psychiatric patients. Another study, however, failed to support this association. Finn et al. (1986) found that, in a group of 87 women with eating disorders, the actual development of the disorder was not significantly related to the history of childhood sexual abuse. In a most comprehensive, controlled study with a college population of 670 women, 29 of whom had been sexually abused, 32 physically abused, and 29 non-abused, Schaff and McCanne (1994) failed to find any direct association between eating disorder and body image disturbance and childhood sexual and physical abuse. This was a carefully designed study, using a non-clinical sample and relevant statistical analyses. Summary and Conclusions The most striking conclusion to be drawn from these studies is that although eating disorders and childhood sexual abuse often coexist, the actual nature of their relationship is uncertain. The last two studies,

10 Childhood Abuse and Chronic Pain which purported to establish causal links, in fact failed to do so. The debate remains moot, however, because studies designed specifically to investigate the significance of sexual abuse in the etiology of eating disorders are few, and replication of well-designed studies such as the one by Schaaff and McCanne (1994) must be carried out for further confirmation of their findings. The rate of prevalence of sexual abuse, however, was remarkably similar for all the studies with clinical subjects, ranging from 28 per cent to 31 per cent. The two studies with non-clinical populations reported 13 per cent and 20 per cent respectively. An important distinction exists between the two community-based studies in that while one drew its subjects from the general population, the other was drawn from college students. Nevertheless, the two community-based studies did lend some credence to the possibility of eating disorders being one of the consequences of childhood sexual abuse, whereas the clinical studies show a high rate of eating disorders in the sexually abused population. Abuse and HIV Infection A tentative relationship is beginning to emerge between childhood abuse and risk for HIV infection. Cunningham, Stiff man, and Dore (1994) generated a stratified random sample of 602 youths from a sample of 2,787 patients seen consecutively at ten different public health clinics located all over the United States. The mean age of the subjects in the sample at the time of the first interview was 16.2 years. The average age of the first abuse experience was 11.2 years. One-quarter of the stratified sample reported physical abuse, sexual abuse, and/or rape. The findings were complex. Beating or different types of abuse combined contributed significantly to high-risk behaviour. Rape or sexual abuse alone did not. In a multiple-abuse situation, sexual abuse, however, was found to be a key factor contributing to high-risk behaviour. In the second study, Bartholomew et al. (1994) investigated 1,001 adult homosexual and bisexual men attending a clinic for sexually transmitted diseases for sexual abuse and its connection to high-risk behaviour for HIV infection. The scope of the study was substantial. The fallout from sexual abuse was shown to be wide-ranging in this group of men: 370 subjects or 37 per cent reported some experience of sexual abuse either as a child or adolescent.

Overview of the Literature 11 Subjects in the abused group were more at risk for high-risk HIV behaviour. They were more likely to engage in unprotected anal intercourse and they were also more likely to have been paid for sex. They were more likely to test positive for syphilis and for being HIV seropositive. These two studies were carefully designed, and although different in scope, reached similar conclusions. Both investigated a clinical population and found with a high degree of confidence a link between childhood sexual abuse and HIV risk factors. This is a very new field of research and future research with community samples will bear out the validity of these two studies. Early effects of abuse are very diverse indeed. The problem with the body of literature that discusses this issue is, more or less, the absence of good studies. Even so, the clinical reports that exist show a wide range of conditions that might do permanent damage to abused children and cause chronic health problems. It is well established that psychological and psychiatric problems resulting from abuse are evident from the very onset of the abuse, and those effects find many and varied manifestations in adult life. The same may be true of pain and other conditions that may have their genesis in early physical and sexual abuse and even gross neglect. Eating disorders and HIV infection are two very different medical problems. Childhood abuse has been linked, though not always convincingly, to both of them. In a sense, establishing the relationship of childhood abuse to its adult consequences confronts us with the same problem as the relationship of life events and morbidity does. Negative life events account for a relatively low percentage of the variances of morbidity, though the nature of that association is far from linear. Perhaps that is at the heart of the problem of most of the investigations discussed so far. It is not just that many, if not most, of the studies could stand some methodological improvement; there are some glaring omissions in this body of literature. For example, not one study in the preceding section considered the question of resiliency. Without an adequate understanding of the 'buffering' factors or resiliency that protects individuals from morbidity, this entire field of research remains incomplete. An important component here is to establish not only the factors that give rise to ill health, but also to understand the reasons for lack of similar vulnerability in others. Another observation is that as the research moves away from clinical to community samples and incorporates a few basic principles of sound

12 Childhood Abuse and Chronic Pain methodology, the relationship between abuse and morbidity seems to decline. That is understandable. To simply examine for the presence of a history of abuse in individuals in a clinical population is often a mere confirmation of that fact, frequently without any causal relationship between the two. Unfortunately, much of the research falls short of adequately explaining, even at a theoretical level, the nature of this association between childhood abuse and adulthood medical illness. The critical question is that not just a proportion of abused children are vulnerable to adulthood physical illness, but the reasons for this association. How does one lead to the other? Mental illnesses such as depression or dissociative disorders in abused individuals lend themselves even to some form of commonsense explanation. The same cannot be said about abuse and physical illness. A problem of considerable frustration is the effort of so many researchers to establish a linear linkage between childhood abuse and morbidity. Simple correlational data are often presented as proof of such an association. All that can be said at this time is that childhood physical and/or sexual abuse may cause a whole range of psychophysiological and physical problems in adulthood. The mechanism that underlies that relationship, especially in relation to physical problems, is not self-evident, and research to date has only marginally contributed to our understanding of this complex issue. ABUSE AND PAIN: IN SEARCH OF THE RELATIONSHIP This section will explore the empirical evidence for the association between childhood physical and/or sexual abuse and adulthood chronic pain, or what Engel (1959) described as the pain-prone disorder. It must be emphasized that other theories exist to explain the association between abuse and pain. However, they fall outside the scope of this book. Engel was not the first to observe expression of somatic (physical) pain as a metaphor for emotional distress. Freud described such an association and Szasz (1975) proclaimed somatic pain as an emotion. Engel's contribution was singular in the sense that he proposed a clinical theory to explain this curious association. The significance of Engel's paper can be judged by the fact that 'pain-proneness' continues to be a much discussed concept in the literature and also as a topic for research.

Overview of the Literature 13 Before embarking on the main task of this section, the salient features of Engel's propositions are briefly reviewed. Engel (1959), in his classical paper entitled Tsychogenic Pain and the Pain-prone Patient/ described the pain-prone patient in the following words: 'For the most part these patients repeatedly are chronically suffering from one or another painful disability, sometimes with and sometimes without peripheral changes. These are also patients who may have only a single or occasional episode of pain, among whom the same psychic mechanisms are operating.' This psychic mechanism is elegant for its simplicity. Abused children are subjected to physical pain, which in turn is associated with 'badness.' Pain then begins to serve the purpose of atoning for one's misdeeds and fulfils the additional function of assuaging guilt and preventing depression. Engel identified a number of common features among his pain-prone patients. These fall broadly into two, not mutually exclusive, categories. First, situations with clear evidence of physical abuse and neglect, and, second, others. In the first category the following characteristics are evident: (a) parents who are physically or verbally abusive to each other and/or to the children; (b) one brutal parent and one submissive parent, the former sometimes an alcoholic father; (c) a parent who punished frequently but then suffered remorse and overcompensated with a rare display of affection so that the child became accustomed to the sequence, pain and suffering gain love; and (d) the child who deflected aggression of a parent away from another parent onto himself usually with much guilt. Engel's paper was published three years before Kempe's (1962) classical paper on battered child syndrome. The 'other' category included (a) a parent who was cold and distant who responded more when the child was ill or suffering pain to the point that the child invited injury to elicit a response from the parents; (b) the child who had a parent or other close figure who suffered pain or illness for which he or she in some ways felt responsible and guilty and most commonly because of aggressive impulses, acts, or fantasies; and (c) the child who was aggressive or hurting until some event suddenly forced an abandonment of such behaviour, usually with much guilt. These three features demonstrate an unconscious mechanism for somatization and offer alternative causal explanation for pain-proneness. In clinical situations all three conditions can and do coexist with actual abuse of the child. The central focus of this section will be to explore the empirical evidence that links childhood abuse with adult pain-prone disorder.

14 Childhood Abuse and Chronic Pain Several review articles have appeared on the topic of abuse and pain (Fry 1993; Laws 1993; Lesserman, Toomey, & Drossman 1995). These reviews arrived at somewhat contradictory conclusions. Lesserman and associates found compelling evidence of a relationship between abuse and functional disorders such as irritable bowel syndrome (IBS), pelvic pain, and headaches. The other two reviewers were less sanguine about the power of evidence to pronounce such a definitive relationship. In the following pages an attempt will be made to find direct as well as indirect evidence for this link. This evidence will also test Engel's proposition of pain-prone disorder. Evidence for the relationship exists at various levels. First, and foremost, is the body of research that is explicitly designed to examine that association, that is, it furnishes direct evidence of a relationship between childhood abuse and chronic pain in later life. Second, there is a small body of literature involving chronic pain patients that provides only indirect support for Engel's idea. In the final section some of the tenets of Engel's premise for pain-prone disorder will be reconsidered. It must be acknowledged that other theoretical explanations, such as behavioural, psychophysiological, and organic, are being explored to understand the abuse-pain relationship. Those perspectives fall outside the scope of this book, which is focused on psychodynamics in conjunction with psychosocial perspectives. Abuse and Pain-Proneness: Direct Evidence Abuse and Pelvic Pain

Research into the relationship between pelvic pain of uncertain origin and childhood abuse has gathered considerable momentum over the past decade. The weight of the evidence of some type of association between the two is worthy of attention. The literature is reviewed in chronological order of publication to make note of any trends. Gross and associates (1981), in a study of 25 patients with pelvic pain, found that 9 subjects revealed a history of incest or other forms of childhood sexual abuse. Most of the families in this series were described as dysfunctional characterized by violence and physical assault. The authors 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. The study was uncontrolled and had several methodological deficits. Given the scope of the study the claim of causality was premature.

Overview of the Literature 15 Harrup-Griffiths and associates (1988) compared 25 women with chronic pelvic pain with a control group of 30 women who were investigated for tubal sterilization or infertility. The equivalency of these two groups on demographic and other variables was not reported. Standardized questionnaires were used to obtain information on psychological and psychosocial factors. A key finding was a higher rate of prevalence of psychiatric morbidity in the pelvic pain group compared with the control group. In relation to abuse, 64 per cent of the pelvic pain group as opposed to 23.3 per cent of the control group experienced childhood sexual abuse. Sexual abuse as adults was reported by 48 per cent of subjects in the pelvic pain group and 13.3 per cent control subjects. A major finding was that no significant differences between patients with chronic pain and positive laparoscopy and chronic pelvic pain with negative laparoscopy on demographic factors, depression, and history of sexual abuse was found. Other than to emphasize a high rate of depression in patients with chronic pelvic pain, the paper was relatively silent on the question of the etiological import of childhood sexual abuse in this population. This is disappointing, for an opportunity was lost to at least begin to theorize about the role of childhood abuse in the genesis of chronic pain in later life. A point of note is that pain, whether psychogenic (pain without any organic cause and physical findings) or of organic etiology, was inconsequential in terms of its association with childhood sexual abuse. This is further affirmation of Engel's point that pain could be with or without peripheral change. Walker and associates (1988) raised the probability of chronic pelvic pain being a metaphor for chronic psychological pain and a way of avoiding adult sexual relations which might evoke memories of abuse and pain. Some of Engel's characteristics for pain-prone disorder are implicit in Walker's conceptualization. In a 1992 report Walker and associates reanalysed the data from an earlier shady involving 100 women attending a private gynecology and obstetrics clinic. They compared 50 patients with chronic pain with 50 admitted for tubal ligation or infertility evaluation. Of the 100 patients 30 reported less severe abuse and 14 reported more severe abuse in childhood. The less severe abuse group reported significantly more symptoms of medically unexplained somatization symptoms compared with the non-abused group. These two groups were combined and compared with the more severe abused group. The salient findings were that the women with a history of severe abuse were likely to have significantly more multiple medically unex-

16 Childhood Abuse and Chronic Pain plained medical symptoms and other psychological problems. This study raised the probability of a relationship between childhood abuse and later life somatization disorders. Rapkin and colleagues (1990) compared 31 women with chronic pelvic pain for their experience of childhood sexual abuse with 142 women with chronic pain in other locations and 32 control subjects. Information regarding abuse was obtained using a standardized interview. An interesting feature of this study was the distinction drawn between physical and sexual abuse. While the prevalence of childhood physical abuse was significantly higher in the pelvic pain group (39 per cent) than the other two groups (18.4 per cent in chronic pain group and 9.4 per cent in controls), that was not so with sexual abuse (19.4 per cent, 16.3 per cent and 12.5 per cent for the three groups respectively). No significant differences were found between subjects with an organic basis for pelvic pain and those without on their experience of abuse. An immediate point of note is the difference in the prevalence of sexual abuse in the chronic pelvic pain population in this study, 19.4 per cent, against 64 per cent in the study by Harrup-Griffiths et al. (1988). The issue of the prevalence of sexual abuse is controversial in the general abuse literature, and this confusion has been used both to support or refute findings. At its simplest, it brings to the surface the problem of defining sexual abuse and then obtaining that information in an objective manner. Rapkin et al. concluded that since sexual abuse was not preponderant in the pelvic pain group, any psychodynamic explanation for pelvic pain was weakened. Engel did suggest that the site of pain may be related to the site of abuse, but that it was not invariably so. Besides, when some of the other characteristics of pain-proneness are considered, a psychodynamic explanation remains plausible. Nevertheless, Rapkin et al. proposed a cognitive model that might suggest that a stimulus associated with aversiveness and helplessness may reactivate past representational schema concerned with previous experiences that were similarly aversive and that produced feelings of helplessness and loss of control. Even in the 'cognitive' formulation, the metaphorical or symbolic meaning of pain is unavoidable. A subsequent study contradicted a key finding of the previous two reports (Reiter et al. 1991). Fifty-two women with chronic pain with identifiable somatic cause were compared with 47 women with pelvic pain with probable somatic cause. Significant differences emerged between the groups on age, nature of sexual experience, and, most

Overview of the Literature 17 important from the point of view of this review, on their experience of sexual abuse. The authors speculated that previous sexual abuse is a significant predisposing risk for somatization and non-somatic chronic pelvic pain. Despite this observation, they expressed caution with regard to childhood sexual abuse as a cause for non-somatic pelvic pain. More recent studies also lend support for an association between childhood sexual abuse and pelvic pain (Toomey et al. 1993; Walling et al. 1994a, 1994b). Incidence of sexual and physical abuse in a group of 36 subjects with chronic pelvic pain was investigated by Toomey et al. (1993). Furthermore, the relationship between pain and psychological variables was assessed. Nineteen of 36 (52.7 per cent) subjects reported sexual abuse. A point of note is that 6 subjects reported only adult sexual abuse. Abuse was assessed using a 6-item reliable scale. No significant differences emerged between the abused and nonabused groups on demographic, pain description, or work interference variables. On the psychological variables, however, one of the most telling differences was related to 'punishing' responses to pain, which was significantly more pronounced in the abused group. The same was true of somatization. The authors cautioned that the small sample size and low statistical power may have obscured some real differences. Nevertheless, one-third of the sample had experienced childhood sexual abuse, and the most relevant finding for the present purpose was the adoption of a life of pain through somatization as well as the lasting association between abuse and punishment. Walling and associates (1994a, 1994b) investigated abuse history in patients with chronic pain. In their first study, the key findings were that women with chronic pelvic pain had a higher lifetime prevalence of sexual abuse of a serious nature than a comparison group of women with chronic headache and a pain-free group. Lifetime prevalence of physical abuse was higher in the pelvic pain group than in the pain-free women, but not in the chronic headache patients. These results supported an association between sexual abuse and chronic pelvic pain and a more general association between physical abuse and chronic pain. In their second study, Walling and associates (1994b), found that physical abuse was in fact a more powerful predictor of psychiatric symptomatology including somatization, depression, and anxiety than sexual abuse. This finding supported their earlier finding of the more generalized effect of physical abuse on the development of chronic pain problems.

18 Childhood Abuse and Chronic Pain Any conclusion about the prevalence and incidence of childhood sexual abuse in adult chronic pelvic pain patients is not possible for one reason alone - the variability in the definition of childhood sexual abuse. Despite this variability, studies taken together do suggest a link between the two. The symbolic association of pelvic pain with sexual abuse is easy to comprehend. Some of the characteristics of pain-proneness, already described, appear to be present in this population. The clinical significance of this link between abuse and pain is at the heart of Engel's concern, and the above studies justify such concern. Moeller and associates (1993), in a study of 668 women, who had a mean age 33.6 years and were attending a gynecological clinic, who responded to self-administered questionnaires, found that 53 per cent reported childhood abuse. They compared the abused with the nonabused subjects and found significantly more hospitalizations and higher rates of health problems in the abused group. This population was not exclusively pelvic pain sufferers. Fry (1993), in his review of adult physical illness and childhood sexual abuse, pointed out that the conclusions about such a relationship could not be substantiated, mainly because of the methodological shortcomings. In relation to pelvic pain and abuse, Fry expressed some optimism by concluding that 'it seems clear that this area [abuse and chronic pelvic pain] now deserves closer attention and attempts to replicate results/ The weight of evidence is such that this association appears to be more than a matter of chance. Abuse and Premenstrual Syndrome (PMS)

Two studies investigated the association between child sexual abuse and premenstrual syndrome (Miccio-Fonesca, Jones, & Futterman 1990; Paddison, Gise, Levobits, Strain, et al, 1990). Paddison and associates investigated 174 women with past history of sexual abuse and found that 40 per cent presented with symptoms of premenstrual syndrome. Furthermore, their data indicated a connection between sexual abuse and seeking psychiatric hospitalization for women seeking treatment for PMS. The second study, involving 968 subjects, found a strong relationship between those reporting sexual trauma and premenstrual difficulties (Miccio-Fonesca, Jones, & Futterman 1990). This sample was drawn from responders to a newspaper advertisement and was thus a selected sample. History of abuse was derived using a self-report questionnaire developed for the study, and 65 per cent of the abused group reported

Overview of the Literature 19 that their abuse experience was before the age of 16. Given the nature of the sample (not random) and the method of obtaining abuse data, like with the previous study, no firm conclusion should be drawn about any etiological significance of abuse in the genesis of premenstrual syndrome. These studies were uncontrolled, and as such of limited value. However, the one study using a clinical psychiatric population and another using a community-based, albeit self-selected population, perhaps have identified another area of association, that between abuse and premenstrual syndrome. Controlled studies are awaited to confirm this connection. Abuse and Gastrointestinal Pain and Disorders There is now an emerging body of research purporting to show an association between childhood abuse and various types of gastrointestinal disorders. A great deal of the material in this area has emerged from the work of Drossman and Lesserman at the University of North Carolina, Chapel Hill. Their work is reviewed below. Some other studies have also appeared of late and this area of research is providing additional support for the abuse-pain relationship. Drossman and associates (1990) reported an investigation involving 206 consecutive patients attending a gastrointestinal (GI) outpatient clinic. The patients were investigated for prevalence of abuse using a questionnaire developed by the National Population Survey of Canada. These authors also reported on adulthood abuse in this population. The data are not discussed here. Some 30 per cent of the subjects reported childhood sexual abuse and another 30 per cent reported childhood physical abuse. There might have been some overlap between the two abused groups. Patients with functional disorders (disorders without known organic cause) were more likely than were those with organic findings to report abuse. In all categories of abdominal and other pain symptoms, the abused group reported more aggregate pain. TTnere was a tendency for the abused group to report more chronic pain, more frequent visits to a doctor's office, and more surgeries than the non-abused patients. The results of this study seem to suggest a life of pain for these patients. Since no psychological data were presented, whether the pain fended off depression could not be assessed. Nevertheless, pain was indeed adopted as a way of life for many of these patients. Gastrointestinal problems associated with childhood incest, rape, and molestation were also reported in a retrospective controlled study by

20 Childhood Abuse and Chronic Pain Jenkins (1991). Twenty-five patients with abdominal pain referred for psychiatric consultation were compared with a matched control group of 50 patients admitted for general surgery. Nine subjects (36 per cent) in the abdominal pain group had been abused and four (20 per cent) in the control group had been abused. This difference did not attain statistical significance. However, that more than one-third of the subjects in the abdominal pain group had a history of childhood abuse cannot be overlooked. The method of obtaining these abuse data was not made explicit, nor was the nature of the abuse. In fact, the concept of abuse was not operationally defined for the study. It should be noted that lack of adequate reporting and failure to use standardized questionnaires make comparison between studies almost meaningless. Talley and associates (1994) investigated the association between abuse and irritable bowel syndrome (IBS). In their sample of 919 subjects, they found a relationship between IBS and sexual, physical, emotional, and/ or psychological abuse of both childhood and adulthood onset. Lesserman et al. (1996) examined the relationship between types of abuse and their impact on health. Their sample consisted of 239 female patients referred to a gastroenterology clinic. An astonishing 66.5 per cent reported sexual and/or physical abuse. The hypothesis that type of abuse was positively correlated with severity of symptoms received confirmation in that the most affected group were women with a history of rape or living in a life-threatening abusive situation. Sexual abuse was more noxious than other types of abuse in terms of health outcome, and those with first abuse in childhood did not differ from those with onset of abuse in adulthood. This study offered a variety of explanations for this association. Plausible physiological, psychodynamic, and cognitive mechanisms were postulated as explanatory models. It must be emphasized, however, that much of the question of the mechanism involved remains speculative. Scarinci and associates (1993) compared patients with gastroesophageal reflux disease and irritable bowel syndrome (IBS) with non-cardiac chest pain sufferers. The sample size was small (n = 50), and the study basically established an association, rather any causal link, between abuse and these disorders. The patients in the two gastrointestinal groups, reflux and IBS, were more likely to have been abused than the non-cardiac chest pain patients. Walker et al. (1993) investigated 28 patients with irritable bowel syndrome (IBS) and 19 patients with inflammatory bowel disease (IFBD) for prevalence of sexual abuse. The IBS subjects reported a significantly

Overview of the Literature 21 higher rate of sexual victimization, severe lifetime sexual trauma, and severe childhood sexual abuse compared with the IFBD patients. The more severely abused patients were also at significantly higher risk for a variety of psychiatric problems. A strong association between abuse and GI symptoms was also reported by Talley and colleagues (1994). Those with history of abuse were three times as likely to have a functional GI disorder than those with an organic illness. In a recent review of the literature on sexual and physical abuse and gastrointestinal disorders, Drossman and colleagues (1995) arrived at the following conclusions. A history of abuse is (1) associated with GI disorders; (2) more common in women with functional GI disorders; and (3) associated with poorer adjustment to illness and adverse health outcome. This, in fact, sums up the current state of knowledge and leaves little doubt that certain types of painful disorders, in this case functional GI illnesses, are associated with a history of abuse. Engel's proposition of this relationship continues to be empirically validated, although it must be reiterated that none of the above studies were designed to specifically test Engel's theory. Abuse and Back Pain Two studies have examined the association between childhood abuse and chronic back pain (Blair, Blair, & Rueckert 1994; Schofferman et al. 1993). Blair and colleagues (1994) investigated 27 patients with chronic back pain and found a pervasive history of emotional abuse, abandonment, and physical and sexual abuse. This was an uncontrolled study with a small sample, and as such it is difficult to draw any firm conclusions from it. Schofferman and associates (1993) identified 56 patients with failed back surgery. Twenty-seven (48 per cent) had three or more childhood risk factors, including physical abuse, sexual abuse, alcohol dependence in a caregiver, abandonment, and emotional neglect or abuse. Their major conclusion was that in failed spinal surgery patients with three or more risk factors, the presence of significant structural pathology was not likely. In contrast, in the patients with significant structural pathology, the presence of three or more risk factors was very low. This study was problematic because, although operational definitions were established for each risk factor, the judgment about the presence of risk was established using clinical interviews and not by using stan-

22 Childhood Abuse and Chronic Pain dardized instruments. This leaves room for bias and other kinds of questions about reliability and validity. Yet, on the bias of the patients' own recall, the prevalence of all kinds of abuse was found to be relatively common in this group of chronic back pain patients. Abuse and Mixed Pain Group

In this section a disparate group of studies involving many pain sites and varied diagnoses will be reviewed. Several uncontrolled studies have demonstrated varying degrees of relationship between abuse and pain. Violon, in two separate studies (1978, 1980), investigated family and childhood issues in 63 patients with chronic intractable pain. Of the subjects 40 per cent came from single-parent households, and another 23 per cent had been abandoned as children. A full 37 per cent had been battered, and 63 per cent reported rejection. The second study involved 13 patients with cluster headaches and 15 with atypical facial neuralgia. A high proportion of these subjects were battered and rejected as children and also had grown up in affectionless homes. Abuse and Chronic Pain Syndromes

Studies in this group drew their subjects from patient populations attending pain clinics. Specific diagnoses for the patients were not provided. Blumer and Heilbronn (1982, 1984), following a major reconceptualization of the idea of pain-proneness, proclaimed pain-prone disorder as a sub-type of depressive illness. This view was demonstrated to be erroneous on empirical grounds by Turk and Salovey (1984). Nevertheless, Blumer and Heilbronn's data on 900 patients with chronic pain of uncertain origin revealed interesting family issues. The subjects had a history of submissiveness and abuse. However, only 9 per cent of them provided evidence of actual abuse. Despite the breadth of the study, it failed to clarify the relationship between abuse and pain. In a chronic pain population of 151 women, Haber and Roos (1985) found that 53 per cent of the patients had been either physically or sexually abused. Although a great deal of the abuse in this sample commenced during adulthood, in 17 per cent the abuse had occurred during childhood and adolescence. There was clear evidence of a higher level of somatization as well as greater utilization of the health care system by the abused compared with the non-abused patients. The finding of greater utilization of health care lends some credence to Engel's point that these patients adopt a life of pain and sickness.

Overview of the Literature 23 Wurtle and associates (1990), in a study of 135 chronic pain patients, found that 38 subjects or 28 per cent of the sample had histories of childhood sexual abuse. Sexual abuse was defined as any self-reported sexual contact, ranging from fondling to intercourse before the age of 14, initiated by someone at least 5 years older than the subject. Seven per cent of the males and 39 per cent of the females in this group had been abused. Suicide attempts, drug and alcohol abuse, and a history of rape as adults were clearly more prevalent in the abused group. Wurtle and associates were reluctant to offer any explanation for this association of pain and abuse, but they proposed psychophysiological and psychological mechanisms as of potential etiological significance. Engel's pain-prone disorder was only indirectly recognized insofar as the child's psychological environment that often accompanies sexual abuse was potentially important. Abuse and Pain-Prone Disorder The most direct support for Engel's concept of pain-prone disorders is evident in the following two studies. Adler and associates (1989) investigated 80 patients attending a medical clinic. Twenty patients were assigned to each of four groups: (1) psychogenic pain; (2) organic pain; (3) psychogenic bodily symptoms other than pain; and (4) organic disease without pain. The groups were not matched on key demographic variables. The patients were interviewed by 14 physicians competent in assessing psychogenic pain. They used an open-ended interview. Several steps were taken to control for observer bias. The results were unequivocal in showing the psychogenic pain group as pain-prone. Some of the salient features were that parents of these patients were physically or verbally more abusive to each other than the parents of those in any other group. Physical and verbal abuse of the child was significantly more pervasive among subjects in the psychogenic group, who also showed a greater propensity for deflecting aggression directed at one parent by the other onto themselves. Parents of these patients were more chronically ill than those of the other groups. These patients frequently shared the site of pain with their parents. Sexual abuse was almost equally distributed in the first three groups, and only one case of major sexual abuse was located in the organic disease group. Although frequency of illness was equally distributed among the four groups, the psychogenic group had had more surgeries than any other.

24 Childhood Abuse and Chronic Pain Depression was not a serious problem in any of the groups, and suicide attempts were evenly distributed and virtually non-existent. Factor analyses revealed two things: (1) 'brutality-overcompensation' characterized by abusive parents and parents abusive to each other who would then engage in overcompensating behaviours; (2) 'submission-inhibition/ characterized by domineering parents who would overwhelm the child to abandon aggression and suffer sexual abuse. These two factors combined accounted for 73 per cent of the variance. The Adler study is unquestionably the most powerful for empirically validating an association between abuse and pain-prone disorder in patients with psychogenic pain. It was carefully constructed and implemented. However, several omissions must be noted. These omissions are in the domain of the abuse itself. Information was obtained from the subjects about themselves and their families. Given that the mean age of tibie patients in the psychogenic group was nearly 50, doubts can be raised about the accuracy of their power of recall. Because this study did not furnish any data on the abuse itself, such as the nature, intensity, duration, actual perpetrator, age of onset and cessation of abuse, or resiliency factors, it is legitimate to raise questions about the actual role of abuse-related developmental factors in the genesis of psychogenic pain. Controlling for abuse factors continues to be a major methodological shortcoming in the abuse literature. The strength of the Adler study, on the other hand, is that the psychogenic group was subject to a more pernicious family environment than the comparison groups. It is regrettable that Adler and associates did not take the opportunity to refine the concept of abuse, remove some of the ambiguities that are inherent in Engel's original paper, and anchor their study to concrete and well-defined measures. At the time that Engel wrote his paper, the concept of child abuse itself was vague and mostly absent from the literature, and the very existence of sexual abuse of children was firmly buried under collective denial. Therefore, Engel's omission to define these concepts with any degree of clarity is, at the very least, explicable. At present, however, there is no justification for failing to operationally define these concepts for the purposes of research. Wurtle and associates (1990) did define abuse, but that definition was all encompassing, and their underlying assumption that abuse ranging from fondling to sexual intercourse may produce equivalent outcomes is questionable.

Overview of the Literature 25 Egle, Kissinger, and Schwab (1991), in a comparative study of 75 patients with psychogenic pain and 35 patients with somatic pain, found that the psychogenic pain group provided empirical support for Engel's pain-proneness. The psychogenic group had significantly more history of physical abuse, poor emotional relationship with parents, aggressive conflict between parents, and sharing of more pain sites with significant family members. The authors concluded that Engel's features of pain-proneness were indeed more common in patients with psychogenic rather than somatogenic pain. In a study of a sample of 409 first-year university students, Roy and associates (1993) examined, among other factors, history of childhood abuse. The Assessing Environment Questionnaire was used to identify the abused subjects. Eighteen or 4 per cent reported experiencing abuse during childhood. These 18 subjects were closely matched on key demographic variables to serve as a control group. On pain variables both groups reported a wide variety of pain sites, back and head being prominent. On key variables of pain management, the abused group resorted to much greater use of alcohol and prescription drugs than the non-abused group. The mean duration of pain was also much longer in the abused group. Careful analyses of the data revealed five abused subjects who provided evidence of pain-proneness. These five individuals collectively were suffering from moderate to severe levels of pain; four were using prescription drugs. Their family functioning was compromised, as was their self-esteem. Three subjects were in the clinical range on the MMPI Anxiety Scale, and another two were in the clinical range on the Beck Depression Inventory. A tentative conclusion, based on a limited sample, was that painprone disorder could begin in late adolescence or early adulthood. A positive finding was that many young adults with a history of abuse managed to overcome the odds and lead a productive life. Abuse and Fibromyalgia

Two recent studies reported an association between abuse, not exclusively confined to childhood abuse, and fibromyalgia syndrome (FMS). Boisset-Pioro and colleagues (1995) compared 83 female patients with FMS and 161 female control patients with non-FMS rheumatological problems. The results were equivocal. Overall, abuse, while greater in FMS patients (53 per cent) than in non-FMS patients (42 per cent), failed

26 Childhood Abuse and Chronic Pain to reach statistical significance. However, significant differences were found in sexual abuse, physical abuse, and combined physical and sexual abuse over the patients' lifetimes, demonstrating an association between FMS and frequency and severity of abuse. The impact of childhood abuse was not separately analysed, but incorporated into the history of lifetime abuse. The data, however, strongly suggest negative consequences of childhood abuse for both groups of patients. Taylor and colleagues (1995) compared 40 women with FMS and 40 women without any major health problems. Twenty-six (65 per cent) of the FMS subjects and 22 controls (52 per cent) reported sexual abuse. Their conclusion was that sexual abuse did not appear to be a specific factor in the etiology of FMS. On the basis of these two studies, the question of the role played by abuse in the genesis of FMS remains unclear. It is noteworthy that the first study went considerably beyond looking at a simple association between abuse and FMS and indeed found a more complex relationship when frequency and severity of abuse over a patient's lifetime were taken into account. Any relationship between childhood abuse and adult disorders is likely to be complex and influenced by many obvious and not so obvious factors. These studies taken together suggest an association between negative childhood experiences, abuse and neglect, and pain of uncertain origin in adulthood. Subjects in most studies were drawn from clinical populations. Although that is a limiting factor, the findings of these studies remind us not only about the presence of abused and neglected individuals in the clinical pain population, but they also provide practitioners with a way of understanding and even treating these patients' chronic pain conditions. In this respect Engel's contribution is incalculable. INDIRECT EVIDENCE FOR THE LINK BETWEEN ABUSE AND PAIN Engel's concept of pain-proneness extends beyond physical and sexual abuse. Factors such as family dysfunction, neglect, and psychological abuse are also implicated in the genesis of this condition. Most of the studies in this section were uncontrolled and methodologically weak. The purpose of reporting them is to show that at least at a clinical level there has been an awareness of some connection between a negative or unhappy childhood and chronic pain in later life.

Overview of the Literature 27 Pilling, Brannick, and Swenson (1967), in a sample of 562 psychiatric patients with pain as a presenting symptom, found that pain was frequently used by these patients to curb feelings of aggression and substituted for anxiety and depression. Pain, in addition, was used to expiate guilt. Relevant family data were not provided to link these behaviours with significant childhood issues. Tingling and Kline (1966), in a rather unusual study, found an association between disturbed family background in a group of 14 men with psychogenic pain and accident-proneness - which may be interpreted as an indirect way of inviting pain. These individuals engaged in solitary hunting to sublimate their aggressive drive. The following two reports furnished inferential data in support of pain-proneness. Swanson and associates (1978), in an uncontrolled study, investigated 13 dissatisfied patients with chronic pain. Nine had experienced significant traumas in their childhood, which included family disorganization, early loss of parents, and parental conflict for 4 patients, a major childhood trauma for 3, and in 2 instances early termination of education to provide care for a sick family member. Merskey and Boyd (1978), in a controlled study, found non-organic pain in all of 6 patients who reported their fathers as rejecting, in 9 of 12 patients whose mothers had a psychosomatic (psychological factors causing physical illness) illness, and in all of 4 patients whose mothers were reported as punitive. Their conclusion was that 'punishing mothers' correlated with the occurrence of pain without lesion which, as Engel had emphasized, explained the psychodynamics of pain as punishment. The above reports did not involve actual physical or sexual abuse, but rather the presence of many and varied undesirable family characteristics and negative childhood experiences. Indirect evidence for pain-proneness in this body of literature is meagre at best, and a more uncharitable view would certainly involve questions about the poor methodology, almost all of them uncontrolled, used in most of these reports. Perhaps, the value of this group of studies is that, taken together, they generate testable hypotheses regarding the validity of family factors, other than abuse, in the etiology of pain-prone disorder. It is worth reiterating that in the general abuse and neglect literature, there appears to be an absence of awareness of any relationship between childhood abuse and adult pain. Roy (1992) reviewed the larger literature on childhood abuse and its consequences and concluded that pain as a

28 Childhood Abuse and Chronic Pain result of abuse was simply not recognized. Pain-related issues were ignored in the investigations of adult consequences of childhood abuse, and despite the proliferation of research, the precise nature of the relationship between childhood abuse and its adult effects could not be readily explained. ONSET OF PAIN-PRONENESS In this section a review of the literature that deals with short-term effects of abuse will be examined. The key question examined here is: How early do some of the signs of pain-proneness become evident? The literature is mostly indirect and comprises clinical reports and a few research studies. Another singular fact is that without the benefit of a longitudinal study, any pondering on the subject should be no more than conjecture and what follows here is in that category. Clinical Reports The literature on the short-term effects of childhood physical and sexual abuse was reviewed to determine whether pain symptoms were present in this population. A few studies emerged showing such an effect. The most telling findings were reported by Green (1978), who in a series of 20 abused children receiving individual psychotherapy, observed a tendency to invite punishment by acting the part of a 'bad' child. The significance of this observation is that in adult pain-prone patients the need to lead a life of pain is common. Besides, from an etiological perspective, it is feasible that pain begins to serve the purpose of assuaging guilt from an early age. Pain, initially experienced as a result of abuse, becomes a way of atoning for misdeeds. In discussing the phenomenon of adult self-injury, Wise (1990) provided clinical support for continuation of this behaviour which clearly has its genesis in childhood abuse. She stated that 'the victim-survivor often believes she is bad. Self-punishment based on this belief about her badness may be expressed in self-injury whenever particular needs, feelings or thoughts are experienced.' The similarity of this explanation with Engel's pain-prone patient who constantly seeks pain is unmistakable. Baron and associates (1970), based on their study, reached the conclusion that physical maltreatment is distinctly maladaptive and refractory to change. Another conclusion was that CNS dysfunction of an early

Overview of the Literature 29 onset was likely to jeopardize the acquisition of age-appropriate developmental abilities in later life. This proposition was supported by Martin and colleagues (1974), who concluded that a direct consequence of parental abuse of children was that it may inhibit a child's capacity for spontaneous speech and motor expression. Martinez-Roig and colleagues (1981) also noted that locomotor development and bodily functions could be damaged by abuse. MIXED GROUP OF STUDIES Green and associates (1981) investigated 115 abused children between the ages of 5 and 12 years for neurological impairment. Damage to the central nervous system was of a very subtle nature, consisting of deficits in perception, coordination, and integration of sensory stimuli. They noted that a vicious cycle often unfolds, consisting of inadequate or abnormal parenting, neurological and behavioural impairment, physical abuse and further impairment, etc. The long-term consequences of neurological damage resulting from childhood abuse have not been established. Yet, it may be reasonable to assume that pain and suffering may indeed be the outcome. In a study of 81 abused children, in a sample of 500, a host of medical problems was identified in the abused subjects by Hunter, Kilstrom, and Loda (1985). They found that in 50 cases, sexual abuse (at an average age of 9.2 years) was 'masked' by the medical presentation. Genital symptoms were the most prevalent, followed by psychosomatic and behavioural problems. The second largest group of problems were pregnancy related, followed by sexually transmitted diseases, asymptomatic sibling(s) of victims, and a small miscellaneous group. The Hunter study recommended a careful evaluation of medical symptoms in children that may be masking underlying sexual abuse. In that respect the medical conditions may or may not be directly related to the abuse, although the very nature of the medical symptoms presented by these 50 children indicates that they were caused, in all probability, by sexual abuse. Klevan and Dejong (1990) reported on 428 sexually abused children between 1 and 16 years of age. Eighty-four per cent of them were female. Vaginal pain was the most prevalent complaint, reported by 51 per cent of them. Other problems reported included enuresis and increased urinary frequency. The conclusion was that urinary tract symptoms following sexual abuse were common.

30 Childhood Abuse and Chronic Pain The authors offered two plausible explanations for the urinary tract symptoms. First, the symptoms could have been psychosomatic in nature because they were not strictly associated with genital contact or the gender of the child. They also noted that psychosomatic symptoms were commonly reported by victims of sexual abuse. The second explanation was that the symptoms had organic cause that could not be found. In a unique study, Cohn, Holzer, and Severin (1981) reported their findings on the effects of torture on 88 Chilean children between 2 and 6 years of age. These children had emigrated to Denmark. They presented a plethora of symptoms ranging from anorexia, enuresis, introversion, depression, and difficulties in forming trust in adults. Pain symptoms such as headaches and abdominal pain and constipation were also found. In the only controlled study of this group, psychosomatic disorders, mainly in the way of abdominal pain, were found to be common in a subgroup of sexually abused children (Hunter, Kilstrom, & Loda 1985). The authors compared 50 sexually abused children with controls and found that psychosomatic problems were three times more common in the abused group. In a retrospective review of medical charts, Malleson and associates (1992) investigated idiopathic musculoskeletal pain in 81 children. These children provided ample evidence of psychosocial distress in their lives including sexual abuse, as reported by 9 per cent of them. Given the limits imposed on this study by its design, the authors were correct to be modest in their claim. Nevertheless, the association between a variety of family issues including sexual abuse must be considered worthy of further investigation. A central implication of these reports is that neurological damage caused by abuse may predispose children to pain in later life and/or the children will learn to internalize pain and hurt from the time they are very young, thus creating a proper environment for developing psychogenic and psychosomatic problems later in life. Another observation is that children seem to manifest pain symptoms, mainly abdominal pain of uncertain origin, headaches, and (in one study) vaginal pain, from an early age. From a psychodynamic point of view, guilt appears to play a role in the children's desire to invite pain. Physiological, psychophysiological, and psychodynamic factors may interact in a most complex manner to predispose children to a life of pain and suffering. It is more than conceivable that manifestations of pain-prone-

Overview of the Literature 31 ness are detectable early in the history of the pain-prone patient. Only prospective longitudinal studies will provide a definitive answer to the question of age of onset for pain-prone disorder. DISCUSSION The literature, which may be considered impressive, does point in the direction of an association between childhood abuse and adult chronic pain. The pelvic pain and the abdominal pain literature combined with the Adler and Egle studies are particularly useful from the point of view of linking abuse with chronic pain conditions. However, that body of literature, with a few exceptions, was relatively silent on the mechanisms that might explain the relationship between abuse and pain. How strong is this association in the broader context? Two points should be noted in relation to this question. First, most of the studies reviewed in this chapter seek to show an association, but do not purport to make any serious claims about causal links between the two. Causal models are conspicuous by their almost total absence in the studies reported. The exceptions are the reports by Adler and colleagues (1989), Egle and colleagues (1991), Toomey et al. (1993) (psychodynamic), Harrup-Griffiths et al. (1988) (cognitive), Wurtle et al. (1990) (psychophysiological), and Lesserman et al. (1996) (several theoretical possibilities). These studies, at least, speculate about the plausible mechanisms. Hence, while the claim of association is justified, the question of mechanisms remains moot. Second, although a deliberate effort has been made in this chapter to link childhood abuse with Engel's pain-prone disorder, much of the literature is either oblivious to or dismissive of pain-prone disorder. Nevertheless, pain-prone disorder probably remains the most cogent theoretical explanation for the etiological import of child abuse in later life chronic pain of uncertain etiology. We shall now briefly revisit, with a more critical eye, Engel's definition of pain-prone disorder. As already mentioned, his famous paper was published in 1959, when child abuse was more than a decade away from entering into our collective awareness as a social problem of the first magnitude. Therefore, we should not be surprised that Engel was remarkably vague about abuse. Pain-prone disorder is based on the central concept of child abuse. Engel seemed to be unaware of the differential impact of various types of abuse, as a review of his clinical illustrations would verify (see Chap-

32 Childhood Abuse and Chronic Pain ter 3). In fact, strictly from a therapeutic point of view, even the actual occurrence of abuse was unimportant to Engel so long as the patient claimed that it had occurred. Fully justifiable and understandable from a clinical perspective, that position is not tenable as a research proposition, if the intent is to demonstrate chronic pain as one of the long-term effects of child abuse. Engel was either unaware of some of the other attributes of abuse, or he chose to ignore them. In any event, factors such as the type of abuse, that is, physical or sexual or some other form, duration of abuse, the relationship of the abused to the perpetrator, and other attributes of abuse were not considered. These are critical factors that may determine the nature of the trauma and its capacity for long-term damage. Despite Engel's lack of precision in defining child abuse and the relatively weak direct evidence for pain-proneness in the contemporary literature, the clinical value of Engel's contribution remains significant. He created a theory of etiology for psychogenic pain which was rooted in family violence and dysfunction. The empirical support for painprone disorder is emerging. However, the true value of this concept is that it provides clinicians with the tools to investigate the significance of abuse in chronic pain patients and to develop appropriate treatment strategies. That is not a trivial contribution by any measure. In summary, evidence for a relationship between childhood abuse and actual pain-prone disorder is on the rise. Evidence for the existence of a more general relationship between psychogenic pain and childhood physical and/or sexual abuse is even more convincing. Engel's concept of pain-proneness continues to be the most articulate clinical theory to link abuse with pain, and a great many of the clinical situations encountered in pain clinics are amenable to Engel's conceptualization.

TWO

Childhood Sexual Abuse and Pain in Adulthood: Case Studies

Engel postulated that growing up in abusive situations could lead to a life of chronic pain. In Chapter 1 the empirical evidence for his theory was reviewed. In this chapter a variety of patients whose cases involve some history of sexual abuse will be presented, and their clinical ramifications discussed. They were all seen at a free-standing pain clinic associated with a teaching hospital, and they all were referred to the clinic by physicians. They had already been thoroughly examined for organic causes for their unremitting pain, and they had already been tried on various courses of analgesic treatments. Many chronic pain patients share two common features, namely, their unresponsiveness to medical intervention(s) and their uncertainty about the cause of their pain. The patients described and discussed here were seen over many years, and because of my long-standing interest in the link between abuse and pain, along with the routine psychosocial history, a systematic history on abuse was obtained. As will become evident, sexual abuse has many faces, and how they reveal themselves in a setting like a medical clinic is diverse and often complex. For many of these patients, the pain clinic was indeed the setting in which they at last disclosed their history of being abused. Dealing with a revelation of this magnitude calls for very special skills, and because of the complexity involved, chapter is devoted to a comprehensive discussion of disclosure (Chapter 7). PATIENT 1: A CASE OF DELAYED REACTION? A 43-year-old woman was referred to our clinic because of her gradual decline into a semi-invalid status following an automobile accident some 2 years previous. Physiotherapy, analgesics, and even surgery had failed

34 Childhood Abuse and Chronic Pain to relieve Mrs A's pain. She had a history of depression, and there was some suggestion that she had attempted suicide when in her late twenties. My initial assessment was that her outward appearance gave no particular indication of suffering. In the waiting-room she was engaged in general chitchat with someone when I invited her into my office. She was well dressed, well groomed, and looked very smart. Mrs A talked with ease - just going over her history of pain that apparently had commenced with the accident. Prior to that she had held a very responsible position with the federal government. She had a bachelor's degree in psychology, and since completing university had moved up the career ladder securing ever more important positions at higher salaries. In addition to her paid career and work raising a family, Mrs A was actively involved in community activities and sports. Her personal life was somewhat less than satisfactory. She was divorced and was less at ease in talking about her failed marriage. She explained that the unhappy marriage had been the cause of her depression, and ever since, she had remained on some kind of psychotropic drugs. She had three children between the ages of 17 and 20, but only the 17-year-old was still living at home. Since the car accident, Mrs A had decompensated rapidly. Lack of energy was her single most important concern, complicated by her lack of motivation. Curiously, her complaint of pain was nominal, and she did not give any outward sign of pain. However, she gave ample evidence of suffering and said that she spent much of her waking hours lying down. It was in the context of exploring her suffering that Mrs A revealed her experience of childhood sexual abuse. She had no recall of when the abuse had started. She must have been very young. The perpetrator was her father. The abuse consisted of fondling, being masturbated, and forced to fondle her father's genitals. This continued until she was about 12. She was less clear about how and why the abuse ended. She never told her mother lest her mother would not believe her. In fact, at the time, she had not confided in anyone. On exploring Mrs A's reasons for disclosing this terrible experience now, she simply said that since the accident she had been having the same kinds of feelings of hopelessness and helplessness that she had experienced long ago. Hopelessness and helplessness were her feelings during all those years when she was being sexually molested almost

Childhood Sexual Abuse and Pain in Adulthood 35 daily by her father. Had she spoken about this to anyone at all? She answered that only recently she had told a social worker she had known for some time. Comments Mrs A's story, while horrendous, is not remarkable. A recent trauma had revived and brought to the surface terrible memories of pain and suffering that had occurred long ago. The distinction between recent and long-ago trauma is often blurred in people's minds. Mrs A only had a vague awareness of this turn of events. Nevertheless, only since the car accident had she become able, for the first time in her life, to disclose her experience of being abused as a child. She attributed her chronic depression to a bad marriage. But, and this is the important point here, even during her years of psychiatric treatment for depression, the issue of childhood sexual abuse did not surface. The readiness with which she had now informed the social worker and me of her abusive past was further indication of the 'dam having burst.' Mrs A's history of abuse provided the clinicians with a way of understanding her reaction to the car accident and her health-seeking behaviour. Her pain did not involve her site(s) of abuse. Those sites were everywhere. Although the pain was psychic in origin, she chose a somatic presentation to convey her psychic distress. This point is all important. Our knowledge about her terrible childhood enabled us to develop a formulation about Mrs A that led to appropriate intervention. Mrs A also revealed a history of remarkable resiliency that had enabled her to lead a reasonably productive life until the accident. This is an important point, and it was not adequately addressed or even recognized by Engel. Mrs A did not seek out pain or lead a life of pain. Rather, she had overcome extraordinary odds to establish a relatively healthy life, and this augured well for her recovery. A recent trauma reviving the memory and suffering associated with past trauma(s) is a common phenomenon. The presentation of psychic pain in somatic terms is also common. For example, recently widowed women and men are known to frequent their family physicians with minor somatic complaints that are commonly associated with grieving. Mrs A's presentation at the pain clinic had all the hallmarks of an individual in the throes of grief. The car accident could not account for

36 Childhood Abuse and Chronic Pain it, but her experience of childhood abuse could and did. This crucial discovery led to proper intervention and not rejection which could have easily happened. PATIENT 2: IS THE TRAUMA OF SEXUAL ABUSE EVER FULLY RESOLVED? Mrs B was 29 years old when she was referred to our pain clinic. This was some 6 years after an automobile accident that had given her a whiplash type of injury. As with many patients for whom a minor trauma starts their journey along the road to chronic pain, instead of healing and disappearing, Mrs B's pain grew worse and worse. Extensive diagnostic investigation failed to account for this mounting pain and discomfort, and finally she was referred to our pain clinic. Mrs B was married and had one little daughter. One of the clinic physicians described Mrs B to me as someone who was 'terribly sad/ He could not account for this sadness, but was quite sure that her 'medical' condition could not possibly explain it, although there was evidence of significant soft tissue damage. This type of patient is commonly seen at any pain clinic: the patient whose manifest physical damage and reported amount of pain do not match up. Indeed, Mrs B was very sad, as though in a state of acute grief. Her account of her childhood was almost entirely negative. She complained that her pain had worsened to the point that she could no longer function in her job as a clothing store manager and that she was feeling very guilty about her inability to take care of her child. Recently Mrs B's father had been charged with sexually molesting a 3-year old. This event had triggered Mrs B's memory of her own sexual abuse by her father. She had become obsessed with these thoughts and was afraid of 'going mad/ Born into a thoroughly chaotic family, Mrs B was the second youngest of nine siblings. She was raised by her two oldest sisters. Her father was an alcoholic and very abusive of his wife and children. While having no direct memory of her own abuse, Mrs B had been informed by her siblings that they had all been sexually molested by their father and that she had not been spared. A most intriguing aspect of Mrs B's history was her almost total amnesia of childhood events. She literally could not recall any major family event from her childhood, but from the age of 12 onwards her memory was significantly better. She surmised that her 'memory loss' was perhaps a sign of her terrible past.

Childhood Sexual Abuse and Pain in Adulthood

37

Mrs B's mother had been distant and aloof and was herself very much a victim. She had nine children, was married to an alcoholic, and was subjected to physical and verbal abuse throughout the marriage. She was probably also aware of the children's abuse by her husband. Her capacity for mothering was significantly compromised, yet she tried to be a 'good mother.' When she was 18 years old Mrs B had had a very frightening experience. She had a history of occasional back strain for which she customarily got a back rub from her mother - the symbolic aspect of this behaviour is that pain evoked a caring response from a parent. On this particular occasion, mother invited father (or he offered) to continue the back rub as she got up to answer a phone call. Father, in the process of giving the back rub, started fondling her. Mrs B was so startled by this development that she ran away from home and did not stop until she was about a thousand miles away. She then had the good sense to seek treatment for sexual abuse. Mrs B had managed to get her life together to the point that she completed high school, married, and had a daughter. She had worked her way up through the ranks in retail trade and reached the position of manager at a large clothing store. It is worth reiterating that although the car accident had left her with aches and pain, Mrs B had continued to function quite normally. The latest incident involving her father was unbearable to her and, like Mrs A, she chose to express her problem as exacerbation of pain and found herself at a pain clinic. Comments Mrs B is another example of a patient for whom pain served as a means of communicating emotional distress. A recent event had triggered an emotional chain reaction that posed a serious threat to her psychic and even physical integrity. Mrs B's case was different from that of Mrs A to the extent that Mrs B had been convinced that she had successfully dealt with "the demon' and was, for all practical purposes, leading a normal life. However, it is well within the bounds of probability that when her father offended against a child, Mrs B's defence that somehow she herself had escaped sexual abuse as a child was no longer tenable. She did not recover her memory or experience any flashbacks, but her level of anxiety and panic combined with feelings of being out of control had all the marks of post-traumatic stress syndrome. Al-

38 Childhood Abuse and Chronic Pain though she had an awareness of the cause of her distress, she was psychologically very distressed and was frightened by the intensity of her feelings of impending doom. Despite the obvious psychological nature of her distress, she had sought help through her somatic complaint. PATIENT 3: A LIFE OF PAIN, GUILT, AND SUFFERING At age 30 Mrs C presented at our pain clinic with a lifelong history of migraine-type headaches. Her pain had remained refractory to a whole gamut of treatments. On the positive side, she was still employed, but her pain had worsened just prior to her referral to us, and she had become fearful of losing her job. Mrs C's family history was sad and full of pain. She had no recall, but had been told by her mother that she had been sexually abused by her father, although for how long and in what way was not known, when she was 4 years old. Soon after this event(s) the father had disappeared from the scene forever. His disappearance had coincided with the diagnosis of her mother's multiple sclerosis. Her mother was hospitalized, and thus began the journey for our patient through the maze of the child welfare system. Mrs C had been in many foster homes (she could remember up to eight from the age of 4 to 14). She disclosed a history of frequent physical and sexual abuse by various foster parents, conflict with her only sibling (an older sister), attendance at a number of schools, and, generally, a very unhappy childhood. She could not recount a single happy childhood memory. Her headaches had commenced in earnest in her mid-teens, but remained unattended. She was a poor student and basically had no friends during her childhood and adolescence. At age 17, with the assistance of her sister, she had attempted to bring home her mother, who was near death in a nursing home. This proved to be almost a disaster and could not be achieved. During this period her sister became extremely aggressive and frequently beat the patient. At this point she left home. Soon after that her mother died. Immediately upon leaving home, Mrs C married an alcoholic. The marriage was a catastrophe. Almost from the beginning, her husband began to physically abuse her. At times the beatings were so severe that she required medical attention. After 3 years of persistent abuse, she filed for divorce.

Childhood Sexual Abuse and Pain in Adulthood 39 Some years later, she married her current husband. This relationship was quite satisfactory. Mr C was in the performing arts and often away from home. His absence was very hard on her, and she offered this as a reason for the worsening of her head pain. Just prior to her admission to the pain clinic, Mrs C had a huge physical fight with her sister, with whom she had maintained a very tenuous relationship over the years. Mrs C had only one sister, and she was very distressed by this fight. Seemingly, it was another factor that contributed to the worsening of her headaches and her subsequent referral to our pain clinic. Comments How does a 4-year-old child make any sense of the chain of events in her young life? Sexually abused (possibly physically hurt and certainly frightened) by her father (for being bad?), then father disappearing, mother developing a serious illness, and then finding herself in foster homes? Her little world collapsed completely around her. For guilt to play such a prominent part in Mrs C's makeup, one needs to look no further than these early events in her life. Her 'badness' explained much to herself. Headaches were just about the only bit of pain for which she did not take complete responsibility and for this problem, and this problem alone, she was free to seek help. Physical pain at times is inextricably tied up with psychic pain and suffering. They converged and coexisted in Mrs C from an early age. Sexual abuse by the father remained beyond her conscious memory, but she had little doubt that when her mother found out, her father ran away. Mrs C had felt responsible for the breakdown of her parents' marriage which, in her mind, caused her mother's illness and subsequent death. She had also felt very angry with both of them for abandoning her and, in turn, developed much guilt for having these angry feelings. The picture was indeed complex. This was yet another case of a patient for whom pain served the crucial function of motivating her to seek help from the medical world. Mrs C had always felt understood, but not necessarily helped, by her doctors, although, in practical terms, she had been unresponsive to medical treatment. In her life of pain and suffering, she stated, that although her headaches were just as bad or worse, 'doctors at least try to listen and do something.' This statement is critical. It is important to understand that perhaps her only source of succour was going to a

40 Childhood Abuse and Chronic Pain doctor's office with her headache complaints. However, it remains a matter of curiosity that numerous contacts with health care professionals had singularly failed to unearth the story of her pain and look beyond the symptoms - of headache. It might be postulated that any kind of symptom has an innate message value. In the case of Mrs C it could be speculated that her head pain contained, at least, two such messages: (1) it was a way of conveying to the world her suffering that had stemmed from much physical and sexual abuse and the resulting pain and (2) it was her only way of seeking help in a socially accepted form and receiving some nurturing. Her life had involved loss and deprivation, guilt, low self-esteem, and, indeed, pain. Without an adequate understanding of the relationship between her presenting symptom of headache and her life of abuse, it is not surprising that she had remained so adamantly impervious to all medical ministrations. Mrs C's pain, unfortunately, had assumed a selfpunishing quality. PATIENT 4: IF ONLY MOTHER HAD LIVED! Ms D was 43 years old when she presented herself at the pain clinic with complaints of multiple aches and pain. She had been diagnosed as suffering from fibromyalgia. Treatment for this condition is uncertain, and patients often have to live with a great deal of pain. By the time she arrived at our clinic, Ms D had had extensive medical investigations for her intractable and many-sited pains, all to no avail. In the course of routine psychosocial investigation, she disclosed that she once had been in a very abusive marriage. The marriage was over, but she still had the 'psychological bruises.' It was through the exploration of this marriage that her experience of childhood sexual abuse began to surface. As will become self-evident, she had coped with the sexual abuse primarily by dissociation. Ms D described a reasonably happy childhood. Both her parents had been professionals, and they had lived in a very nice part of a large Canadian city. She had been an outstanding student herself, and she and others had been convinced of her career in academia. She had a brother 2 years her junior. When she was about 11 years old her father began to molest her. This coincided with the discovery of her mother's cancer, and her mother died a year later. Ms D was then at a complete loss and found solace in her schoolwork. Her father's reaction to her mother's death amounted

Childhood Sexual Abuse and Pain in Adulthood 41 to no reaction. He behaved as though 'nothing had changed.' Ms D and her brother were prohibited by the father to talk about their mother. With the death of his wife, Ms D's father had stopped abusing her. She assumed the role of a surrogate wife and mother to her younger brother. This state of affairs continued until Ms D left home to go to university at age 17. She had never dated. She obtained a master's degree and also entered a serious relationship with a man. Unfortunately, her relationship with the man ended. She was completely lost and entered a convent where she remained cloistered for 2 years. She then entered another convent, but in a non-cloistered situation. She stayed there another 2 years and left rather dissatisfied. Spending 4 years in a convent had failed to bring her any inner peace. Her mother's death and breaking up with her boyfriend remained at the heart of her grief. But, she just could not grieve 'properly.' Up to this point, she had said nothing about her sexual abuse. Ms D gave a very detailed account of her marriage to someone she had known for several years at the university. The first months of the marriage were pleasant, but that had changed rapidly with her husband's 'increasing demands.' These increasing demands were related to their sexual activities. Ms D made no effort to conceal her 'disgust' for any kind of physical intimacy. The marriage ended in divorce, and for the second time she left the city and the province and moved to a smaller city over a thousand miles away. It was in the process of discussing the genesis of her disgust for physical intimacy that she began to recall some of the events related to her father's early overtures. During this period, she remained acutely distressed and gradually, over time, she began to unfold the terrifying tales of her father's nightly trips to her bedroom. She watched what this man was doing to her body 'from up above.' It was not really happening to her, but to some other person. This was the nature of her dissociative reaction. With her mother's rather sudden death, she had 'pushed the whole thing at the back of the mind.' This story took something like 2 months to unfold followed by a prolonged period of acute grief. This was the first disclosure ever of her sexual abuse. She stated 'how can you talk about something that you didn't even know happened?' Comments The most critical aspect of this case is Ms D's attempt to wipe out her painful memories through dissociation and later opting for a cloistered

42 Childhood Abuse and Chronic Pain existence. Solitude and a desire to leave things behind and devote her life to spiritual pursuits failed to give her inner peace. She said that during her entire monastic experience, 'something kept gnawing' at her. There was something else in her life, some unknown fear, that seemed to be beyond her grasp. During this period of her life she had been pain free. It is a matter of some curiosity that her pain began in earnest at the break-up of her marriage. For the second time in her life, she somehow or other had extricated herself from an abusive situation. Emotionally distraught and physically exhausted, she started on a not so unpredictable journey through the health care system, which singularly failed to give her any relief from pain. This was also the beginning of her social decline. A person raised in an upper-middle-class home, with a graduate degree, and a highly cultured life found herself living in a rooming house subsisting on social assistance. She regarded her social decline with an acceptance that was hard to explain. It was as though she was doing penance for her misdeeds. Ultimately, however, Ms D's pain and rather futile efforts to run away from herself came to an end soon after her arrival at the pain clinic. Her life had been filled with loss, shame, and unexpressed grief. The formation of somatic symptoms when all other defence mechanisms fail is not a dramatic outcome. It is relatively common but the underlying cause for such a massive failure of normal defences is hardly ever readily accessible to a therapist. When Ms D arrived at our pain clinic she was more ready than ever to begin the backward journey that led to the rediscovery of her abuse and pain and shame, betrayal by her parents, the two people whom she had loved and trusted, one for dying and the other for sexually violating her, followed by grief and mourning for her lost youth, and the road to some kind of reconciliation and even recovery. PATIENT 5: 'I CAN'T BE A MOTHER' Mrs E presented with a complaint of mixed headaches of many years duration. Her childhood history involved physical abuse by an alcoholic father, possibly also an incestuous relationship with him as well as with an elderly uncle. Mrs E's mother, for the most part, had been ineffectual, and eventually the child had been removed from her home. She was in the care of children's aid from the age of 4 to age 8, during which time she had been in several foster homes. Later she settled

Childhood Sexual Abuse and Pain in Adulthood 43 down to live with her grandparents, where she had a semblance of home life and also for the first time found two individuals who deeply cared for her. When Mrs E was 13 years old, her father reappeared on the scene, and he made overt sexual advances towards her. On this occasion, her grandparents came to her rescue. She never saw her father again. Mrs E had completed grade 12 and became a model. In her late teens, finding herself pregnant, she married. She felt that she had been forced into this marriage by her grandparents and had resented that fact from the very beginning. She gave birth to a daughter, but failed to bond with the baby. Mrs E had a deep sense of guilt about her attitude towards her child, but felt that the child represented what she did not want to become. Having witnessed her parents' unhappy marriage she had been determined never to marry. In any event, at the time of her admission to the pain clinic Mrs E wanted a separation and divorce from her husband. She also was quite adamant that he should assume responsibility for their daughter. She stated very emphatically that she 'hated being married': 'Being a mother and a wife is not my kind of thing.' Comments Formulation of this case was that guilt emanating from her abuse was almost unbearable for this woman. Pain was one way of expiating guilt for Mrs E. She was succeeding up to a point, as there was very little evidence of any depression. The role of pain in the expiation of guilt and fending off depression was noted by Engel (1959). This phenomenon is not commonly observed in chronic pain patients as depression is common in this population. In the case of Mrs E, however, Engel's point that pain functions almost as a substitute for depression could be detected. Despite her success in her career as a model, the thought of being a wife and mother was almost totally unacceptable to Mrs E. Those roles belonged to 'good' persons, she said on one occasion. Although she was very sure of breaking up her marriage and giving the custody of the child to her husband, she was not sure as to the reasons for her feelings. She mostly used pain as her reason for her decision plus a feeling that she could never be a good mother to her child. It was not the pain, but her abuse that was at the very heart of the way she felt about herself - as an undeserving individual. Mrs E was seen in

44 Childhood Abuse and Chronic Pain psychotherapy for 8 months. The treatment issues are described in Chapter 9. DISCUSSION It is a rather risky endeavour to try to connect a single event or even a series of events such as persistent childhood sexual abuse to pain in later life. The patients discussed in this chapter lack the certitude or strength of Engel's case illustrations. Those cases left little room for doubt about the connection between abuse and pain. That was the strength as well as the weakness of his proposition. Too many intervening variables complicate the picture in our pain clinic patients. Yet, these patients, minimally, demonstrate a central connection, and that was (1) intractable and at times severe pain and their attempt to seek help through that complaint and (2) underlying that pain or alongside it, the mostly uncovered story of childhood sexual abuse. Despite this connection, the presence of a linear relationship between the two is still very much a moot issue. This is the theme that will emerge and re-emerge throughout this book because it is indeed the common thread that connects all abused patients that we see in a pain clinic setting. A point of note is that there is no uniform response to childhood sexual abuse. Childhood itself spans several years, and it is quite likely that the specific age of the victim might influence the final outcome. These cases show the sheer variability in people's individual coping responses; they ranged from no recall of the abuse to a trauma triggering memories of abuse to a psychotherapeutic environment making it possible at last for the patient to recall events of abuse. Engel did not address the question of abuse occurring in early infancy and cessation also at a very early age. Precisely how those events could be played out in the development of adult personality and if they can be accessed to conscious memory in later life poses problematic questions. Yet, it is obvious from the case of Ms D, for example, that sexual abuse occurring in early adolescence can be traumatic enough for the memory of the event(s) to be erased. Or in the case of Mrs B, whose memory of abuse never did surface, it may be unwise to reject the idea completely that such abuse in fact may have never occurred. What cannot be denied is that her father was an alcoholic pedophile, and Mrs B was profoundly affected by what happened to her at age 18 when she was molested by her father and again when he reoffended.

Childhood Sexual Abuse and Pain in Adulthood 45 Another point of note is that these patients mostly came from dysfunctional families. This was perhaps less true of Ms D, but then it is entirely possible that she had portrayed an overly idyllic picture of her childhood. One has to wonder about the father's reaction to the mother's death. Whether the abuse was short-lived or prolonged, the outcome was pain and suffering in varying degrees. A simple observation that can be made about these patients is that they had adapted and coped with differing levels of success until something external upset whatever precarious internal balance had been achieved. Even with Mrs B, who had a long history of headache, her arrival at the pain clinic was preceded by a fight with her only sibling. Not all of these patients, by definition, were suffering individuals leading a life of pain. Mrs E's case came close to that reality. The issue of abuse resurfaced, one way or another, once they developed painful conditions and sought help for that reason. It is most unlikely that any of the patients came to the pain clinic with the idea of being treated for their past abuse. There does appear to be nominal evidence for all these individuals being 'pain-prone' all their lives. There was no direct association between the sites of abuse and the anatomical regions of pain. Neither did pain completely expiate their guilt. Pain, however, almost inevitably masked their painful past.

THREE

Childhood Physical Abuse and Pain: Case Studies

The idea that some sort of link exists between physical abuse and pain makes immediate sense. Physical abuse is inflicted with the intention of causing pain. Nevertheless, the long-term repercussions of childhood physical abuse on health are not as well researched as one might suspect. In preparing the first two chapters, this became apparent to me. Many reports tended to combine physical and sexual abuse in reporting outcome (Alper et al. 1993; Gross & Keller 1992; Kolko, Moser, & Weldy 1990). Other studies simply did not consider the health factor (Downs et al. 1992; Gross & Keller 1992). The review literature, of course, reflects this (Glod 1993; Malinowsky-Rummell & Hansen 1993; Rosenberg & Krugman 1991). In their review of the literature on childhood physical abuse, Malinosky-Rummell and Hansen (1993) explored seven divergent areas of adult behaviour, none of which included physical or psychosomatic conditions. The truth is that an extensive search failed to yield any significant literature on childhood physical abuse in relation to illness or disease in later life. Occasionally, a paper appeared, such as the one on damage to the limbic system observed in adult psychiatric patients, that associated an adult disorder with early physical childhood abuse (Teicher et al. 1990). It must be remembered that Engel premised his theory of pain-proneness on physical abuse and neglect rather than on sexual abuse. In 1959, when he wrote his seminal paper, the subject of sexual abuse was absent from the literature. However, the literature on painful disorders in later life with their antecedents in childhood sexual abuse is relatively more convincing than the literature on physical abuse. Only two studies (Arnold et al. 1990; Egle et al. 1991), discussed elsewhere, sustain Engel's formu tion; only one of them involved sexual abuse (Arnold et

Childhood Physical Abuse and Pain 47 al. 1990). The study by Egle et al. sought and received direct evidence to support a relationship between childhood physical abuse and adult pain-proneness. Two carefully designed studies by Walling and colleagues (1994a, 1994b) showed the primacy of physical abuse in chronic pain problems in later life and lent further support to the concept of pain-proneness. Patients from my practice will show with some degree of confidence the seriousness of health and pain problems that childhood physical abuse can cause in adults. The case descriptions will attempt to delineate the significance of pain in the lives of these patients and reveal the indelible impression left on them by their physical abuse in childhood. The mechanisms involved are often complex. It must be emphasized that these patients have been carefully selected to show different faces of pain-proneness, which may or may not fit neatly into Engel's model of pain-proneness, and yet they confirm his basic proposition of the significance of abuse in childhood experiences. PATIENT 6: IS THERE AN END TO MY WOES? Mr F, at age 44, was referred to the pain clinic for unremitting back and shoulder pain several years after an automobile accident. He revealed a personal history of unimaginable abuse and dramatic losses. Both his parents were alcoholics, who fought incessantly with each other, frequently in the presence of the patient and his younger brother. Mr F's earliest memories were of his parents shouting and throwing objects at each other and his efforts to calm his little brother while feeling terrified himself. Mr F had no clear recall of when his parents had started to abuse him. He must have been 3 or 4 years old, he surmised. He just did not remember a time before he was being hit by one or both parents for reasons that continued to elude him. When he was 13 his life turned around: he got into a fight with his father, knocked him out, and ran away from home. He made his way to an uncle and aunt in another town and was virtually adopted by them. He completed high school and started regular work. From age 13 to 23 he led a normal life. When he was 21 he married and had two children in quick succession. At that time Mr F was working as an ambulance driver. He and his partner answered a 911 call. There had been a head-on collision, and a woman and two little children were killed. The victims were his wife and children. His memory about the events that followed was vague.

48 Childhood Abuse and Chronic Pain He remembered living as a recluse in Vermont and drinking to excess. He wanted to die. That situation persisted for 3 years, following which he returned to the city, got himself odd jobs, drank, and fought. His anger seemed to be endless. Finally, Mr F met a recently divorced woman with two little children, the same age as his own when they were killed. This woman gradually took charge of him, got him off drinking, and helped him to re-enter society as a responsible human being. Mr F was content, felt accepted and loved, found regular work, and discovered his love for poetry. He had extraordinary facility with the English language. This blissful state lasted for 2 years, until he was involved in a motor vehicle accident. He was not seriously injured, but that was the beginning of another slow decline, this time into chronic pain, reliance on narcotic drugs, nihilism, and patienthood. Comments The pertinent clinical issues here were many, but perhaps they were not so complex. Mr F's childhood was not only devoid of love but filled with physical pain and emotional terror; his entire family was killed in a nightmarish and highly improbable situation; and, finally, he was incapacitated by his own accident. On the positive side, Mr F had found very caring substitute parents, a loving wife, and then a caring second partner. But the last straw was his own accident, which took on great symbolic meaning for him. He was convinced that he was put upon this earth to suffer. Regardless of how hard he tried, he was constantly 'thrown against a brick wall.' He just could not take it any more. His pain spoke volumes. Yet the man was not depressed. His countenance was one of acceptance. Pain indeed was the central feature of his being, as he put it. He was at a pain clinic, but he seemed unconcerned about his health or that he was unemployed or that his partner was at the end of her wits with him. He was profoundly indifferent to himself and others. Pain-proneness in the case of Mr F has a different face. Any direct link with his childhood abuse and his pain is not self-evident to him, nor is the link between physical pain and the death of his wife and children. However, his own accident and the pain that ensued seemed deserved to him. That is the connection with his childhood. Mr F's sense of his 'badness' was affirmed by his pain, which is an important aspect of Engel's proposition. Mr F was not pain-prone in any classical sense. However, when he sustained a minor injury and

Childhood Physical Abuse and Pain 49 experienced 'physical' pain, this pain seemed so deserved to him that he was not anxious to part with it. It was the pain that resulted in the unfolding of his story, and sorrow, grief, and suffering found expression in his pain symptoms. Pain confirmed, at the very least, his own feelings of 'badness' while growing up, and 'explained' to him not only the loss of his family, but also his failure to rescue them in his job - and on his work shift - as an ambulance driver. As final affirmation of his badness, he broke up his second relationship soon after starting at the pain clinic. His partner was not persuaded by his reasons for breaking up, but he remained adamant. After a brief involvement with the pain clinic, Mr F dropped out. He decided to seek redemption in his own way. Living with a certain amount of physical pain to him was an acceptable, indeed desirable, outcome. Pain serves a very powerful role in assuaging guilt. PATIENT 7:1 WAS RESCUED BY MY ILLNESS This case encompasses, in addition to physical abuse, many of the more complicated aspects of pain-proneness. Mrs G, age 35 when she first presented at our pain clinic, had a long history of shoulder pain, which had worsened, and the results of extensive medical investigations had proved negative. In spite of her pain, she led a relatively active life. She had a clerical job and managed to do most of the housework except heavy lifting. She also had a small dog-breeding business. As a long-suffering patient with chronic pain, Mrs G functioned at a high level of competence. Even her pain complaint did not seem particularly onerous. In a situation like this, it is reasonable to speculate on her reasons for being at a pain clinic. It is not uncommon for patients to experience exacerbation of pain in the face of major stressors and unexpected life changes. However, there was no evidence of any such factors in the case of Mrs G. She had been sent to the pain clinic in the hope that she could be taught psychological methods of pain management. Mrs G agreed with her referring physician that her medications were proving rather ineffectual, except for an antidepressant that helped her to sleep normally. She said she would like to have some mastery over her pain. She spoke with great ease, and, in fact, there was no outward sign that Mrs G was suffering pain. She had been married for 7 years. The marriage was satisfactory, and the nature of the relationship traditional. She took care of the house, and her husband did all the heavy chores. However, despite her state-

50 Childhood Abuse and Chronic Pain ment that the marriage was satisfactory, Mrs G, at times, seemed ill at ease discussing it. They did not have any children. She explained that her health had been a factor. Mrs G said she had never enjoyed particularly good health. She had had several encounters with osteomyelitis from age 9 to about age 14. Her illness had left no discernible negative consequences on her development. She had completed high school at 18 and had enjoyed her school experience. Her social life was somewhat constrained by her illness, but she did have several close friends. It was in the context of describing her osteomyelitis that Mrs G expressed that her father to this day felt responsible for her illness. Apparently, from age 3 on she had been physically abused (beaten) by him. This did not stop until the onset of her illness at age 9. The abuse had consisted of slapping the child with some ferocity, but not frequently (she called it 'spanking'). Mrs G offered several reasons for her father's conduct, none of which seemed all that convincing to her. She really had no idea why he would beat her other than that she must have displeased him in some way. Her mother never intervened during the beatings. The parents never argued or fought in her presence, and she thought that they got along well. The beatings stopped completely once she fell ill. The illness was accompanied by a dramatic change in her father's attitude. He became extremely solicitous, overly caring, and openly expressed guilt for ever having laid a hand on her. Her life at home changed completely once she fell ill. She received unlimited attention from both her parents which she continued to receive unabated well into her adulthood. Mrs G's husband was also very accepting of her pain and ungrudgingly helped her out whenever needed. When it was suggested that he seemed to have assumed the same caring role that her father had had, she confirmed it with a smile. Apparently, her husband had not always been caring. But with the onset of her pain problem, he seemed to have mellowed. No, he had never been abusive, just a little aloof, but he was always a good man, unlike her sister's husband who used to beat her up. They were now divorced. She herself could not imagine being divorced from her husband. He was a good man. Comments The abuse in this patient's case was described by her as 'sp king'. The implication is that it was not severe or debilitating abuse. Severity of abuse is indeed a factor in deciding long-term outcome.

Childhood Physical Abuse and Pain 51 Mrs G's case bears closer scrutiny on several grounds. That her father was abusive is beyond doubt. Whether she was severely abused or not is rendered moot by the subsequent development of her illness and her father's reaction to it. This latter factor is more telling than the fact of the abuse itself, severe or not. Her father reacted with enormous guilt. She became the 'apple of his eye/ and from the onset of her illness there was nothing he was not willing do for her. This last issue merits further perusal. The sequence in this case was not one of abuse followed by remorse and overcompensatory behaviour. That particular situation will lead a child to associate pain with reward. Mrs G's situation was analogous to that sequence except that the duration of abuse was sustained and prolonged and hence reinforcement of the abuse-reward cycle was not inherently present. However, once she succumbed to osteomyelitis, one long period of abuse, however mild, was followed by lifelong reparation. If indeed the abuse was mild and no serious harm was done to the child (a highly questionable scenario), even then the father's acts of attrition followed for the rest of his life. What were the effects of this dramatic change in his behaviour on the young girl? Undoubtedly, this change was very much in the desirable direction when the alternative is considered. After a period of uncertainty following her change of fortune, Mrs G started feeling safe and protected by her illness. To a 9-year-old, the new reality meant that as long as she remained unwell, father's love could be counted on. The reader may recall that she described her illness in rather casual terms, stating that it did not unduly interfere with her life. As she was the sole historian, the veracity of her story could not be corroborated. Perhaps that is the wrong issue. What mattered was Mrs G's recollection, perception, and experience. In relation to her illness, she had very little in the way of painful memory. It will not be an exaggeration to assert that illness substituted a less desirable form of pain for a far more comforting situation in which pain and discomfort associated with her disease became desirable. Mrs G's relationship with her husband further attested to the continuation of that phenomenon. The proposition in the case of Mrs G is that a sustained period of abuse followed by lifelong penitence and over-solicitousness by the abuser is bound to have an impact on a 9-year-old child. The most obvious outcome is likely to be an association of pain and suffering with tenderness and care. Pain evokes kindness from others. This is at the heart of Engel's idea of pain-proneness. The avenues by which pain becomes a rewarding

52 Childhood Abuse and Chronic Pain experience and culminates in seeking a life of pain were too many to be enumerated in a single paper by Engel. He, however, established a plausible clinical theory, and the case of Mrs G is an illustration of that proposition. PATIENT 8 Mr H, at age 24, was referred to the pain clinic by his neurologist for significant worsening of his migraine headaches. His history of headaches stretched well back into his childhood. In fact, he could not remember a time when he did not have headaches. It was the exploration of his childhood history of headaches that led to the unfolding revelation of the abuse heaped on him as a child. He was born into a chaotic household, being the second in the sibline of eight children. Mr H's memory of childhood was very painful. Like with the onset of his headaches, he could not clearly recall exactly when his father had started hitting him. His mother told him many years later that he was probably not even 2 when the abuse started. Brief respite came when he was removed from home by child care authorities when he was just over 2 years old. But he was returned at age 5. He was unable to recall anything about the years in foster care except that he did not remember being beaten. Once he was returned home his own recall of the beatings by his father was vivid. He was singled out by the father for punishment for shaming the family. By this time his father was drinking very heavily and was permanently unemployed. Apparently, his father's favourite site for hitting was Mr H's head. He was slapped and hit with shoes or the metal end of a belt. This time, there was no sign of any child care authorities. Abuse continued unabated, and the patient became increasingly resentful of his mother for her 'lack of willingness' to do anything. His respite from this troublesome home was school. He formed a close relationship with a teacher, and school became his place of safety and succour. But for this teacher, he said, he would have killed himself. He had been a very good student. School holidays had been most dreaded. He clearly recalled an extraordinary event that had happened when he was 7 years old. He was not sure what he had done wrong, but his father took serious offence and decided to teach him a lesson. He was confined to his room for the entire summer vacation and beaten regularly during this period. That

Childhood Physical Abuse and Pain 53 was when he started wishing for his father's death and experienced rising resentment for the rest of the family. Abuse and deprivation continued for the next 5 years. When Mr H was 12, his father committed suicide in a rather dramatic fashion in front of the entire family. This had been the happiest day in the young life of our patient. Following his father's death, the family situation became relatively calm, and Mr H slowly developed a very close relationship with his mother. He completed high school without any difficulty. Despite a more stable family situation, his headaches continued unabated. At the time of his referral to the pain clinic, he was going through a major disagreement with his mother. It took several months before the basis of this conflict came to the surface. Mr H offered this problem, his unhappiness with his job, and his fear of intimacy, which was causing problems between him and his girlfriend, as perhaps contributing to his headaches. Exploration of these areas led to the disclosure of his abuse. He had never disclosed this fact to anyone, not even his girlfriend. All his life, he had struggled with issues of autonomy and authority. He felt controlled by his mother, and yet he rebelled inwardly against any hint of authority. Comments The case of Mr H, from the point of view of pain-proneness, is almost self-evident. One of the most intriguing aspects of this case is his choice of pain site. In the sexual abuse and pain literature, this relationship is evident in women with pelvic pain. Yet, the congruence between the pain site and the site of abuse may not be a common clinical observation. Engel (1959) suggested that pain location may be a factor of past injury, site of surgery, or punishment. Furthermore, Engel noted that a careful history would uncover the original painful incident. In the case of Mr H, that was indeed the situation. It was not just a matter of a painful incident, but sustained assault to the head over a very long time. The strength of this connection was hard to judge. Lack of a physical finding combined with a successful outcome of psychotherapy probably furnished optimum support for this proposition. Mr H's headaches had remained refractory to all treatment. Psychotherapy, which lasted 18 months, did substantially resolve his headaches. These two

54 Childhood Abuse and Chronic Pain facts combined would lend credence to Engel's observation that the choice of pain site is not without psychological significance. Apart from the fact that Mr H had a violent alcoholic father, several of the other characteristics of pain-proneness were present in Mr H. This man was not depressed. Although an argument exists that pain may mask any underlying depression, Engel noted that pain may also expiate guilt, which seemed to be the case with our patient. Mr H, as noted earlier, had great difficulty in giving vent to his feelings. That was the source of his conflict with his mother. He wanted to 'free himself from her control/ but was quite incapable of doing so. Internalization of feelings is recognized as a common reason for somatic symptoms, and Engel identified it as such. In summary, Mr H's case comes close to furnishing an illustration of a classic pain-prone patient. Physical abuse, a harsh punitive childhood, unresolved issues around aggression, social and emotional isolation, and a singular inability to express feelings could be said to provide optimum opportunity for pain-proneness to develop and flourish. Much of Mr H's unhappiness and conflict found expression in headaches. It cannot be emphasized enough that until he found his way into a pain clinic and his history of past abuse was unearthed, headaches were his only outward expression of suffering. PATIENT 9 Mrs I, at age 57, came to our pain clinic with a history of unremitting severe headaches. Her headaches were diagnosed as migraine, but they had remained unresponsive to medical treatments for pain relief. She was a very friendly and open person who spoke of her hard life without much persuasion. Mrs I had grown up in a very authoritarian family in Europe. Her father was a 'tyrant/ She was beaten 'all over' from age 8 to 18. These beatings were administered in the name of keeping her on the straight and narrow. Like most abusive parents, her father did not need any reason to beat her. She was made to feel utterly useless. Her mother had usually remained a silent observer. When she was in her teens, Mrs I's parents separated but for reasons not altogether clear, she continued to live with her father. During this time, her brother was killed in the war, and soon after her father was injured and made an invalid. Following his injury and disability her father's violence towards her only increased. Fortunately, she was in

Childhood Physical Abuse and Pain 55 her late teens by that time, and she found relief in marrying a Canadian soldier and leaving her wretched home forever. Her marriage proved to be a remarkable success. Her husband made a successful transition to civilian life, and their life took on all the attributes of a relatively well-to-do middle class Canadian family. Their two children grew up to be a veterinary surgeon and a teacher respectively. In the midst of such good fortune, Mrs I continued to be plagued by mild depression and serious headaches, neither of which seemed amenable to treatment. One striking aspect of Mrs I's view of her apparent good fortune by way of a very understanding husband and two lovely and caring children, was her inability to take any credit for her own role in any of these. As she expressed it, but for her husband and his good nature, any other man would have left her. Her children had virtually raised themselves. These were her unshakable views of herself. Mrs I had had psychotherapy in the past, but to no avail. She dropped out of the pain clinic despite serious efforts to involve her in a multimodal approach to pain control. Nevertheless, during her brief involvement with the clinic, several observations were noted which might account for her unwillingness to engage in therapy and account for her incredibly self-deprecating attitude. Pain and suffering were her 'lot/ she said. Comments In Mrs I's case pain and depression were completely intermingled. Pain failed to mask or fend off depression. Her depression reached clinical proportions, and during those times she responded well to antidepressants. However, at a fundamental level, this woman had failed to overcome, despite the efforts of her husband, the terrible losses she had suffered. Abuse, parental separation, separation from her mother, the death of her brother, her father's injury and disability, and a multitude of other losses inflicted by the war were the significant events of her childhood and youth. These events were sufficiently damaging in themselves to impair the development of a healthy self-esteem. Physical abuse was the added ingredient that only deepened the psychological damage. Mrs I grew up on a steady diet of pain and guilt: the pain inflicted by physical punishment and the pain of losing loved ones, and guilt for 'not ever measuring up' - and even for living. She never reconciled

56 Childhood Abuse and Chronic Pain herself to her good fortune in having made a successful marriage or to being a caring wife and mother. Nor did she fully emerge from her sense of isolation and worthlessness. Atonement, through pain, for events from long ago and beyond her control, was adopted by Mrs I as a way of life, and she remained unconvinced that mere talking about her painful past would change anything. DISCUSSION Engel and Szasz proposed unconscious reasons for the emergence of pain symptoms with great psychological and symbolic significance underlying those symptoms. Engel, for example, cited many cases where the pain is associated with complex and sudden events. The cases cited in this chapter lack such dramatic quality. Rather, they portray one of many possible outcomes, expression of past physical and emotional pain through somatic symptoms. Patients' reasons for embarking on a career of chronic pain are far from obvious. They could have just as easily followed a different path with a very different outcome. All the patients described herein gave evidence of considerable personal strength. They were able to overcome extraordinary odds to become reasonable citizens, parents, and partners. Perhaps, that is a feature that separates this group of patients from those who embark on antisocial behaviour or become chronic psychiatric casualties. A good deal of the damage inflicted on them as children was counteracted by other, positive experiences. Mr H, for instance, had a very sympathetic teacher, and, following his father's suicide, his relationship with his mother was one of closeness. Mr F found substitute parents and almost completely overcame the ill effects of parental abuse and neglect when other ill fortune intervened. He showed great resilience in the face of inconceivable tragedy. Mrs I found a partner with great understanding. Mrs G's abusive father became a reformed character following the onset of her osteomyelitis. The point here is that whatever love or succour these patients received following or even during the periods of their abuse did not fully counteract the damaging effects, but presumably those effects were modified and this enabled them to develop many strengths. The common experience of abuse of these four patients also produced a common outcome. Lack of comprehension of the reasons for their abuse in childhood combined with persistent guilt and internalization of emotions were shared characteristics.

Childhood Physical Abuse and Pain 57 The absence or presence of depression is an issue that merits scrutiny. For the most part, the four patients described in this chapter were not clinically depressed. All of them had been on antidepressant medications at one time or another, but without much benefit except for Mrs I. Her depression at times became serious, and active psychiatric treatment usually ameliorated the common neurovegetative symptoms. But her sadness never truly left her. That is the point. The presence of pain symptoms, while serving the critical function of atonement, frequently fails to completely eliminate profound feelings of sadness.This sadness which, prima facie, has the appearance of a mood disorder is more a function of a great sense of loss that seems to be omnipresent in these patients. Pain does not always succeed in overcoming sorrow or submerging guilt, and they often coexist. Nevertheless, it is quite possible for pain and clinical depression also to coexist in situations where the depression may be of independent origin. Finally, it must be noted that the nature of the pain, whether psychogenic or pathogenic, is unimportant. Once the pain symptom appears, either as a result of trauma or a disease such as migraine or because of psychological conflict, it takes on a life and meaning of its own. For the four patients in this chapter that meaning, at least in the eyes of this clinician, seemed to be tied to a desire to atone for past 'misdeeds' or a search for love and affection as in the case of Mrs G. Only when the history of an extraordinarily punitive childhood was unravelled was it possible to understand and explain their attitudes to pain and its function in their lives.

FOUR

Childhood Neglect and Pain

Any association between childhood neglect and subsequent painful condition does not readily lend itself to common sense. Nevertheless, both Engel (1959) and Szasz (1975) were aware of that possibility. It may be worth recalling that Szasz described pain as an emotion, as did Swanson (1984) many years later, and it is on that basis that some understanding can be developed for this relationship. Engel, however, did not overtly acknowledge the role of parental neglect in the formation of pain symptoms. The closest he came to recognizing this phenomenon was his observation that children used pain to invite attention from distant and cold parents, sometimes to the point that the child invited injury to elicit a response from the parent. To do whatever has to be done to elicit affection from a parent is probably a day-to-day event in a child's life. Problems occur when that love or affection is less than forthcoming. Then the child may learn to resort to other means to seek love or simply give up. Szasz (1975) told the story of a young girl who, upon the sudden death of her mother, developed chronic pain, anorexia, and other serious health problems. In his analysis, Szasz observed that 'in her day-to-day life, [she] was quite isolated from people. Although she lived in the home of an older sister, with the sister's family, she was quite estranged from them' (p. 95). Social and emotional isolation, which translates into a life without affectionate bonds, was recognized by Szasz as fertile ground for emotional disorder mainly manifesting in somatic terms. The idea that emotional hurt can find somatic manifestation is neither new nor radical. Before any further exploration of the relationship, it is important to consider the concept of neglect. Emotional and physical neglect are its two most common forms. They may or may not be interrelated. An

Childhood Neglect and Pain 59 emotionally deprived person does not have to be physically neglected, and a physically deprived child, especially in poor families, may not be emotionally deprived. Sometimes, children are deprived on all counts. Giovannoni and Becerra (1979) classified neglect into (a) educational neglect, (b) abandonment, (c) failure to provide, and (d) fostering delinquency. Minty and Pattison (1994) provided the following definition of neglect: 'persistent failure to meet a child's essential needs by omitting basic parenting tasks and responsibilities.' They added that basic needs that are not usually met are adequate food, clothing, shelter, cleanliness, stimulation, medical care, safety, education, and love and control, in spite of parents having the economic resources to meet these needs at a basic level. Minty and Pattison (1994) noted another critical dimension of neglect. They warned that 'in order to establish neglect (as distinct from either physical or sexual abuse), evidence often has to be collected in a systematic way over a period, rather than at one point in time; and, in effect, it has to be demonstrated that the neglect is serious enough to cause "significant harm."' The focus of this chapter is on emotional deprivation. One patient described it as 'growing up in a loveless family.' That sentiment caphares the essence of emotional deprivation, and some theoretical understanding of this idea may be found in attachment theory as discussed by Bowlby and others. Attachment theory proposed that failure for an infant to attach to a mother figure (now extended to include other intimates) is likely to have a serious short- and long-term negative impact on the development of the child. Separation of mother and baby, living with a depressed mother, or growing up in an institutional environment are examples of areas of research where the validity of attachment theory has been put to the test (Biringen 1994; Eagle 1994). In this context, the work of Rutter and Rutter (1993) is instructive. Their central thesis is that while the negative consequences of childhood deprivation can be and often are negative, this relationship is far from linear. There are other less drastic outcomes. Yet, again, many abused children give evidence of overcoming extraordinary odds and grow up to be mature and caring adults. In their recent book entitled Developing Minds, Michael Rutter and Marjorie Rutter (1993) made the following observation, 'There has been a tendency sometimes to view the presence of secure attachments as the key to good relationships of all types. Certainly, secure attachments do seem to predispose to positive qualities in a range of relationships with other people ... Nevertheless, attachments constitute

60 Childhood Abuse and Chronic Pain an insufficient explanatory concept on its own' (p. 142). Disorders of attachment, which manifest in the behaviour of children and somatic symptoms, are not necessarily integral parts of these disorders. On the other hand, children do develop psychogenic and psychosomatic problems in response to a negative family environment. Some patients can clearly recall that only when they complained of poor health or more specifically of aches and pains did they receive parental attention. As adults, pain for many of these individuals becomes the only means of obtaining affection and caring. In a pain clinic setting, these types of situations are not that difficult to find. Another problem is that the literature is somewhat lacking on less obvious situations of emotional neglect. Some of the persons to be described in this chapter grew up in families that were not terribly disorganized, nor did they suffer separation or have clinically depressed parents, although the patients who were mothers themselves were often long-suffering individuals. In other words, these patients do not strictly fit the clinical description of neglect, and yet their shared experience was one of a lack of affection and warmth within the family and sometimes outside. Often they described their family relationship in terms of an overwrought mother and a distant and disengaged father. Many of these individuals also married distant and aloof partners. One patient told the story of never being able to please her mother. If she brought home an A from school, she was criticized for not getting an A+. Another grew up watching her mother physically and verbally abused by her father. Yet another did not remember ever being held by her parents or told by them that they love her. These are some of the many complex faces of emotional neglect and abuse. Like physical abuse, they vary in intensity and power to inflict damage. A remark by patients, repeated surprisingly often, was that they would have preferred to have been beaten rather than ignored, criticized, and humiliated and never made to feel good. The net effect of that magnitude of negative childhood experience is not infrequently a highly compromised sense of self and self-esteem. The description of patients in this chapter will purport to show that emotional and physical pain can coexist with considerable ease, that physical symptoms, despite the presence or absence of organic cause, take on much emotional significance, and that sometimes the roots of the pain symptoms are to be found in the childhood experience of neglect. At other times, despite the lack of any obvious relationship between pain and childhood experiences, the pain

Childhood Neglect and Pain 61 still conveys powerful messages and serves very critical functions in patients' lives. The literature on the long-term effects of neglect on health in general and development of chronic pain syndromes in particular ranges from sparse to non-existent. It is known that in the short term children can and do develop psychogenic and psychosomatic disorders in response to emotional, familial, and environmental stress. Pediatric abdominal pain of uncertain origin is often linked with emotional factors. So are certain types of headaches in children. Malleson and colleagues (1992) discussed a possible link between family factors, such as single-parent homes, and learning difficulties as well as sexual abuse and idiopathic musculoskeletal pain. In their study of 81 children with musculoskeletal or diffuse pain, 15 per cent of the subjects came from single-parent families. The onset and course of illness are influenced by a child's emotional state. The critical question is, are psychosomatic problems of childhood onset carried into adulthood. There is some evidence that headache of childhood onset can continue well into later years to the point that a patient may have difficulty in remembering the exact or sometimes even an approximate age of onset. In the childhood neglect literature, it can be said without any fear of contradiction that health outcome, which includes physical as well as emotional health, in later years has been poorly scrutinized. A common problem of studying neglect in children is that neglect rarely occurs in isolation from other forms of abuse. However, the fact of its existence is undeniable. Ney, Fung, and Wickett (1994) observed that neglect was often a precursor of abuse, and neglect in combination with other forms of abuse affected most negatively the child's perception of self and his or her future. In another comparative study of the relative impact of neglect and abuse on intellectual and academic outcomes, one conclusion was that both abuse and neglect represented significant risk factors for poor long-term intellectual and academic outcomes; this conclusion was in general agreement with previous studies (Perez & Widom 1994). That many of the negative effects of neglectful and abusive parents could be counteracted by supportive influences in the child's environment was demonstrated in a study by Herrenkohl, Herrenkohl, and Egolf (1994). They provided further confirmation of earlier propositions that while a child's primary source of affectionate bond is its parent(s), in the absence of such bonds, alternative sources of affection are capable of counteracting parental neglect.

62 Childhood Abuse and Chronic Pain From a clinical point of view, this is crucial. If a child has a distant father and an uncaring mother, are there other individuals who provide support and succour for the child? This line of inquiry is often revealing, and it explains how and why a child, in the face of all kinds of odds, becomes a caring parent and a responsible citizen, while still suffering from inexplicable pain symptoms. In the midst of describing the rather affectionless home of her childhood, a patient, with an obvious change in her demeanour, told of her summer holidays with her grandparents. On further exploration, she explained that without the support and love that she received from her grandmother in particular, she would not have lived past her early teens. Suicide was never far from her consciousness during her early years. Nevertheless, she completed college and married a caring man. This patient is now disabled with chronic pain, and without some understanding of her growing-up years, the dynamics of her pain symptoms would remain very elusive. In the rest of this chapter, a number of patients are discussed, not so much to establish a causal link between childhood neglect and adult pain, but rather to explore how these early experiences influence pain behaviour, and indeed at times even explain the phenomenology of pain. Nevertheless, it is worth reiterating that the information on neglect was based on careful reconstruction of the patients' childhood relationships which, for a variety of reasons, may be subject to a certain amount of distortion. What may not be questionable is the overall impact of these experiences on the adult personality of these patients, their capacity to engage in adult reciprocal relationships and, apparently, their capacity to suffer. PATIENT 10 Mrs J, at age 41, was referred to our pain clinic by her family physician for investigation of her headaches and general poor health combined with depression. There was also a hint of serious interpersonal difficulties with this patient. Comprehensive medical investigation had failed to yield any fruitful result, but Mrs J's complaints had continued unabated. Mrs J, a well-dressed woman, arrived punctually for her appointment. She immediately launched into a monologue about her useless and futile search for a cure for all that ailed her. She was very articulate and informed the therapist that she had studied psychology, and there was nothing wrong with her mental apparatus. For the first couple of sessions, she remained totally focused on her health issues and showed

Childhood Neglect and Pain 63 remarkable memory for every ailment she had ever had. Through all of this she managed to convey that she was very unhappy in her marriage. She had been married for 15 years and had three children. Basically, she showed a great deal of guilt about her poor health and again returned to theme of her doctors' failure to cure her. Over time Mrs J began to talk about her growing-up years, which she recalled as 'horrible/ She described her family of origin as 'highly dysfunctional/ Her father had been very abusive towards her mother, and she had witnessed many incidents of her father shouting and even hitting her mother. At these times she was filled with terror and wished her father dead. She had lived in a permanent state of dread. Mrs J was very ashamed of her family, but she had not revealed her 'terrible secrets' to anyone. She had learned to keep her own counsel and her own company. She had been a timid and shy child which, she claimed, persisted to date. In her high school years, she had had few friends. In any event, she managed to complete grade 12 and trained as a nurse and also completed a year at university. Throughout her growing-up years, she had complained of very poor health. Yet she did not miss much school. In retrospect, she was convinced that what she had had was chronic fatigue syndrome. She married, had three children, and she stopped working as a nurse. She was emphatic in stating that she had terminated her career not to raise children, but entirely because of her poor health. The most remarkable aspect of Mrs J's history was not only her ability to recall all her past illnesses with specific dates, but the sheer variety of her health problems. She was very committed to finding a biochemical explanation for her symptoms, and to that end she had sought help from a clinic in the United States. Apparently this clinic had been of considerable help to Mrs J over the years. Thus, Mrs J's major preoccupation was her health. She talked about her current difficulties without any visible external evidence of suffering, and there was no evidence of any pain behaviour. She acknowledged that her health had caused some marital conflicts, and it also had a negative effect on her relationship with her children. She had difficulties in fulfilling her role as a mother and a wife in view of the uncertain nature of her aches and pains. These pains seemingly descended on her without any warning. She used very graphic language to describe the nature of her pain, which sounded more like emotional distress rather than physical pain. When asked what her life would be like without pain, she was able to give quite a coherent response. She believed that life without pain would

64 Childhood Abuse and Chronic Pain not be dramatically different for her than it was now except that she would function somewhat better in her familial roles. This kind of response is often suggestive of pain as an expression of emotional distress. Mrs J denied any depressive symptoms, and she became highly intellectual when asked what kind of thoughts and feelings she had during these episodes of pain. She smiled throughout the interview, and there was no external evidence of any depressive symptoms. She said that she suffered from mild sleep disturbance, but again her description was rather vague. Her appetite was excellent. Comments This patient's need to be understood was very evident. Her reluctance to talk about her childhood was almost unshakable. The significance of her childhood illnesses began to assume some clarity. In the loveless environment of her family, she had received some attention only when she was sick. Then both parents would show concern for her. This was a striking revelation. Seeking succour through poor health gradually became her only means of wanting and receiving attention. This behaviour was also at the heart of her marital difficulties. The unpredictable nature of her condition made it virtually impossible for a division of roles and responsibilities, and the whole family revolved around the state of her health. Pain had become a way of life for her, the absence of which she could not even imagine. PATIENT 11 The story of 38-year-old Mr K presents a clear contrast to the previous case. The type of neglect experienced by Mr K cannot possibly leave any doubt about its horrific nature. This patient had the misfortune of being born into a family where both parents drank. Neglect of him must have commenced at a very early age. His memory of growing up in his biological family was very vague, although he had some memory of fighting and yelling between his parents. But he himself was never beaten, or if he was, he had no memory of it. What he does remember with much clarity was his experience of being moved from foster home to foster home. He was Very little' when he was first moved. He was terrified and cried and screamed, but to no avail. He was not a 'model' child. He hated every foster parent he

Childhood Neglect and Pain 65 ever had. Nothing in his life was permanent or constant. He did miserably in school, virtually failing every grade. He also failed, not unexpectedly, to form any friendships or feel close to anyone. Mr K graduated from foster homes to group homes for adolescents. By his early adolescence, it was clear for anyone to see that he was a deeply troubled person with gross impulse control problems. He probably also suffered from attention deficit. He was a man of normal intelligence, but had significant problems with schoolwork, and could barely read and write. At age 17 he lost whatever support he had had from the state and embarked on a career of crime. Initially, these crimes were petty thefts and break and entry. At age 19 he committed a murder and spent the next 10 years in prison for manslaughter. Prison life was not bad. Mr K had security - and that for the first time in his life. There were individuals in the prison system who cared. He embarked on 'improving' himself. He completed grade 12. But he was totally unprepared for life outside, and once there he missed the 'security and predictability' of prison life. Nevertheless, upon his discharge from the prison three things happened. He met a woman and had a child by her; second, he tried several jobs, but without much success; and, third, he began to experience severe and unremitting headaches and anxiety attacks. Mr K was afraid that his relationship with his partner and his child was petering out. He was not a good provider, but his headaches made it virtually impossible for him to work. He denied being abusive to his family. In fact, he was adamant that he was not going to subject his family to what he had been put through by his parents. Both his parents had died during his incarceration. This is roughly the story that Mr K told on his first and only visit. As for his headaches, the main feature was the accompanying anxiety. Not that he did not feel anxious when he was free of head pain, but the severity of his anxiety (which bordered on panic) was commensurate with the severity of his headaches. His headaches were diagnosed as 'mixed' type, a combination of muscle contraction and migraine. Analgesic and anti-migraine medications were of no help. These headaches could last up to 4 days, during which he would be virtually disabled. He was seen by a psychiatrist for his anxiety problem and was, in fact, on anti-anxiety medication without any beneficial effect. So whenever he was in the throes of a headache he drank until he passed out. This man failed to keep his subsequent appointments and our clinic lost all contact with him.

66 Childhood Abuse and Chronic Pain Comments To the best of Mr K's knowledge, he had never been physically or sexually abused. He was, nevertheless, a hugely deprived human being. His social and emotional development were compromised virtually on every measure. Following his horrific crime, he found peace and solace in the safety of his prison environment. Life outside, despite his effort to have a family and some kind of stability, proved overwhelming. He blamed his headaches for all his problems and was fearful that he was bound in the same direction as his parents. He was on the verge of becoming an alcoholic, he said. The history of early childhood deprivation combined with short-placement foster homes (he could not remember how many of these foster homes he had been in) in themselves would be capable of doing great harm to the overall development of a child. When 10 years of incarceration is combined with that, it is easy to understand this man's total inability to deal with the outside world. The pressure of trying to make a living, fear that he was going the same way as his parents, and responsibility for a young family for which he was almost completely unprepared unquestionably contributed to health and pain problems. Mr K sought help with his headaches, but during much of the only session he attended, he talked about his unpreparedness to deal with the stresses of 'living on the outside.' Regardless of the etiology of his headaches, they conveyed a sense of profound helplessness. It is perhaps not purely coincidental that his headaches and anxiety attacks commenced upon his discharge from prison. He said he was falling apart, and metaphorically and even from a realistic perspective, that was an accurate observation. What was truly amazing and sad about his story was the virtual absence of resiliency factors that often modify the negative effects of neglect and abuse. In the scheme of things, his headache was perhaps less of a problem than his inability to function in society. The fact that he showed up, at least for the first appointment, would suggest his need to seek help. It is futile to speculate on his failure to keep further appointments, other than perhaps his own assessment that he was confronted with much more serious life issues than his head pain. This man was in need of long-term and comprehensive treatment which would need to address his past and present problems including headaches, anxiety, and emergent alcoholism. Understandably, however, his propensity to stay involved in any treatment program was highly compromised.

Childhood Neglect and Pain 67 PATIENT 12 At age 36, Mrs L was referred to the pain clinic by her neurologist for persistent headaches. The headaches were diagnosed as tension type and were described as moderately severe. The patient, on average, consumed 6 tylenol 3 tablets per day. Her headaches were of some 6 years' duration and had commenced following a rather innocuous car accident. She was somewhat vague about what had brought her to our pain clinic or what her expectations were. Her headaches occasionally became severe, usually at the end of the day, and she had go to bed for a while to get rid of them. There was no evidence of depression or any other kind of psychological distress. She could, in fact, be described as a fulfilled individual who seemed satisfied with her state of affairs and not unduly worried about her headaches. Despite the headaches, Mrs L, a very pleasant woman, lived a full life. She was married and had two small children. She had married her childhood sweetheart when she was 19 and described her marriage 'as fantastic' which upon investigation received only partial confirmation. She had a part-time job as a computer programmer and worked as a volunteer at her children's school. She spoke of no difficulties in fulfilling her various duties, which also included household chores. In the first session, she spoke very freely and openly. Towards the end of it, however, she made a remark that seemed to offer some explanation for her presence at our clinic. When she was in the throes of her headaches, she said, she seemed to recall some very unpleasant experiences from her childhood. She thought that her childhood was long past and that she had overcome all the odds. These childhood memories came back to her, not that she had forgotten them, following the automobile accident. She was somewhat puzzled and worried by this development and wanted someone with whom to 'talk things out.' It was not just her childhood experiences, but also other matters from the past that she thought she had dealt with had re-emerged. She had not mentioned this to her doctors before because 'they may think that I am going off my head.' Mrs L grew up in a troubled household. She could not remember a time when her mother had not been sick. Mrs L had had to assume responsibilities for household chores and for looking after her younger siblings 'as far back as I can remember.' Going to school was her only escape. She was not allowed to bring her friends home or have any time for herself. Her main problem was that her mother had never been

68 Childhood Abuse and Chronic Pain happy with her performance. Her father had been only marginally involved in domestic affairs. Then her mother died. The entire responsibility of running the household and taking care of her siblings fell upon Mrs L when she was 12 years old. Following the death of his wife her father became clinically depressed and 'never fully recovered from it.' The next few years were 'hell' for her, and she was not sure if she was sad or happy over her mother's death. She was ambivalent. There was relief on the one hand, but also resentment that she was forced into a role that she did not want. The main theme of Mrs L's story was that she had been robbed of her childhood, and for this her mother was responsible. The car accident had revived some of her old feelings of helplessness. Mrs L's saving grace was her grade school boyfriend whom she had kept hidden from all the members of her family and married at the earliest opportunity, at 19. Marriage was 'great.' Mr L was and still is a very kind and considerate person and an excellent father and provider. But the marriage came close to dissolving when Mrs L was pregnant with their first child. 'He betrayed me,' she declared. She was most reluctant to elaborate. Mr L had had an affair, and when Mrs L found this out, her world collapsed. It took her several months to come to terms with this. Her husband was full of guilt and regret, and for all these years she had thought that she had forgiven him, and, again, since the accident and even more so in the recent past year or two, her anger and sense of betrayal had returned. This was another source of her distress, and, yet, she said, she could not wish for a better husband. There was a tendency in Mrs L to blame herself for her past problems. Although she was far from clinically depressed, she had a profound sense of sadness about her lost childhood and her husband's betrayal. Comments This patient's case is different in scope from the previous two. Here was a fully functioning person who seemed to lead an enjoyable life and, at least on the surface, gave no evidence of any psychological difficulties. There could be no question that she had successfully overcome her sad and neglected childhood. She was a mature adult, who enjoyed an intimate relationship with her husband, had two welladjusted children, was blessed with friends, and enjoyed her work. What might explain her arrival at our clinic with a pain problem with which she had lived for many years and which really had not worsened

Childhood Neglect and Pain 69 in any significant way over time? There did not appear to be a direct link between any recent trauma and a resurgence of past negative experiences. Indeed, that is a relatively common clinical presentation. Nevertheless, it would be an error to dismiss out of hand that link in the case of Mrs L. She acknowledged that these feelings had had a very insidious beginning which did coincide with the accident as did her headaches. Her headaches were, however, very pronounced right from the time of the accident. A plausible explanation may be sought in the following. There can be no question about her deprived childhood and the accompanying sense of desolation, anger, and frustration mixed with very ambivalent feelings towards her deceased mother. Mrs L had not adequately mourned her mother's death. These matters had not been sufficiently resolved, and the onset of a pain problem that engendered feelings of helplessness and anger (making her once again a victim through no fault of her own) revived many semi-resolved issues from her childhood and even later. Apart from her husband's betrayal, she had had to fight off sexual advances from a relative when she was in her teens. She did not view herself as sexually abused, but rather as unloved, except by her husband. Even that proved to be not altogether reliable, and now she wondered if she had not brought on some of her ill fortune onto herself. This reaction is almost classical in the sense that blaming oneself at a time of personal vulnerability is an extraordinarily common human response. It was also an indication that underneath this apparently welladjusted individual, there remained some hurtful remnants from her past. These matters had to be explored, brought to the surface, and, in the therapeutic context, resolved. Given the overall health and resiliency of this patient, that task was not difficult to accomplish. PATIENT 13 At age 37, Mr M was referred to our pain clinic by his orthopedic surgeon. He complained of unremitting pain in his left shoulder. This problem had started with a sports-related injury at age 14. About this time, his father had died. Prior to that Mr M had been involved in weight lifting without proper supervision and had experienced muscular pain in his upper torso. His shoulder complaint had been extensively investigated yielding no positive findings. Almost as a last resort he had been sent to our clinic for further evaluation and treatment.

70 Childhood Abuse and Chronic Pain As with all the previously discussed patients, Mr M presented a rather dismal family history. He described his family as 'useless/ No one cared, everyone drank, and the children were left to their own devices. He remembered being a very angry boy and that anger had persisted all his life. He had been an average student, had completed grade 12 and attempted university for a short time. Mr M's work history was equally chequered. He had held numerous jobs, but just did not have the staying power. Usually he got himself into fights and arguments which would inevitably result in loss of his job. Gradually he withdrew from most of his social interactions and devoted himself seriously to finding a cure for his pain problem. He was convinced that his pain was the source of all his shortcomings. Apparently he had sought psychiatric care and been told that nothing much was wrong with him. Curiously, he maintained ongoing contact with the psychiatrist as he did with his orthopedic surgeon. This convinced him even more to transfer his focus on the health care system. His story, a common one in pain clinics, was that most doctors simply did not believe that he was living with so much pain. In the meantime he was waging a war with the local welfare office. The number of clinics and physicians this man had contact with was astronomical. He acknowledged that the search for a cure for his shoulder pain was something that kept him going. He showed a marked level of preoccupation with his pain and somatic symptoms. His concentration was poor, and he was an anxious person. This patient failed to show up for further assessment. Comments Mr M's level of social isolation was striking. He literally had no friends and no family. His only source of support and, in fact, any kind of human interaction was with health care personnel. Even though he claimed that physicians often did not believe him, his major source of support remained the psychiatrist and the orthopedic surgeon. These two individuals and their staff served some of the function of family and friends. His need to be ill and, therefore, taken care of by health care professionals, seemed to fulfil some of his emotional needs. Seeking emotional support through somatic symptoms is not unusual. Mr M did not count the people at the welfare office among his friends. Based on a rather incomplete assessment, it seemed that he had failed to acquire some of the basic skills necessary to function in the adult world. It was hard to even roughly gauge the depth of deprivation he

Childhood Neglect and Pain 71 had experienced. He had not been physically or sexually abused. He had simply been ignored. At least that was my impression. To complicate matters, his father had died at about the same time his pain problem had started. The symbolic association between the two events is not easy to overlook. In the absence of more corroboration, however, it may be unwise to be any more emphatic. PATIENT 14 Mrs N was a 55-year-old woman diagnosed with fibromyalgia and when referred to our pain clinic by her family physician. She was seen only once. She was a very friendly and talkative woman, who spoke freely and without much emotion about her sad childhood. She described her childhood as abusive, but there was no evidence of physical or sexual abuse. On the other hand, she had little doubt that she had been singled out by her mother for emotional abuse. This abuse mostly took the form of humiliating her and marginalizing her. Her older sister was the preferred daughter. Mrs N grew up fully convinced that she was an unwanted child. She completed grade 12 and left home to train as a chef. Soon after she married and had five pregnancies, three successful. Her husband literally walked out on the family leaving her with three young children. She raised them herself while working as a full-time chef. One of her children was blind and lived at home, and the other two were married and settled. Mrs N was very proud of her achievement as a mother and her general capacity for overcoming odds. As she put it, she had managed to get her mother out of her system, to overcome abandonment by her husband, the sadness of two stillbirths, and the problems of having a blind child. Pain was a problem, but she was coping quite well. She gave no evidence of depression or serious emotional difficulties. She tried to maintain a cheerful outlook on life. If she did not laugh, she would end up crying, she said. She certainly had many reasons for crying. Comments The only purpose of presenting this patient's case is to show that even in the face of extraordinary odds and plain misfortune, Mrs N was a remarkably resilient woman. There is the ever-present temptation to

72 Childhood Abuse and Chronic Pain find underlying psychological conflicts for chronic pain problems, and in this case the problems were there for anyone to see. But this was not a story of gross psychopathology whose etiology could be traced back to an unhappy childhood and many subsequent losses and disappointments. Rather, Mrs N in many ways exemplified the sheer power of the human spirit and the capacity to survive and live. This story is incomplete. There must been many factors that counteracted the noxious effects of childhood neglect and other setbacks. Somehow, Mrs N's self-worth had remained intact, and in fact, grown. She was very intelligent, had an extensive network of friends, and an active social life. Without a great deal more information, it would be pure conjecture to speculate on the factors underlying her resiliency. DISCUSSION It might be instructive to restate that linking childhood neglect with chronic pain in later life remains somewhat speculative. Any claim to the contrary must be tempered by the knowledge that empirical evidence is simply not there to support such a claim. What may be less contentious is the observation, made throughout this chapter, that early childhood neglect, regardless of its etiological potential for chronic pain in later life, shapes in many and divergent ways a person's perception about pain and suffering. One universal aspect of pain is its capacity to convey suffering which at times transcends the biology of pain. This is certainly not to be viewed as a novel idea. All the recent theoretical developments confirm the multidimensional nature of pain. Given that truth, it is indeed reasonable to expect that painful childhood experiences will shape and determine a person's entire outlook on life. Chronic pain, the kind seen in pain clinics, tends to affect every aspect of a person's existence. It is in that context and against that background that the true significance of childhood neglect of the patients in the throes of painful conditions described in this chapter takes on real meaning. Each patient discussed in this chapter, despite their somewhat shared childhood experiences, is unique and the way that childhood suffering was incorporated found extremely varied manifestations and responses. A case can be made that Mrs J, with her extreme reluctance to express her thoughts and feelings and gross internalization of those emotions, found external manifestation in her vague symptoms and compromised coping.

Childhood Neglect and Pain 73 In contrast, Mrs L and Mrs N, whose suffering was enormous, showed a level of resiliency that was impressive. They were not disabled by pain and could make a success of their lives. The point to note with these two individuals is that pain and suffering were inextricably intertwined. It remains unclear why Mrs N even agreed to come to the pain clinic. Of all the patients discussed here, the story of Mr K is perhaps most telling. The horrific nature of his neglect, his homicide, and subsequent pain and anxiety give us some insight into the question of severity of neglect. The other man, Mr M, was also more entrenched than the women patients. However, his battle was of a different order. He was in search of his lost past, and, minimally, his pain symptoms provided him perhaps with a very inappropriate avenue, the health care system, to meet his emotional needs. Pain served a very critical function for him. It is perhaps risky to draw any generalized conclusion from the stories of these five individuals. Clinically, however, an understanding of the neglect in their past and a plausible relation of that neglect with the pain issues emerged to be of some import and in some instances even of paramount significance. For that reason alone, investigation of childhood neglect in our pain patients is desirable.

FIVE

Spousal Abuse

This chapter addresses a question that is grossly under-reported in the pain literature, namely, pain in adult patients because of spousal or partner abuse or even the special issues confronted by the clinicians when a patient in an abusive relationship is identified. Patients in abusive marital relations presenting with typical chronic pain problems who do present themselves at pain clinics perhaps go unrecognized. In many cases, however, an interesting association between abuse and the presenting pain complaints begins to unfold. Not infrequently, once the problem of abuse is identified and treated, pain itself recedes into the background. In my experience, issues pertaining to spousal abuse, once disclosed, inevitably take precedence over the pain problem. Nevertheless, it would be unwise to make any hasty causal link between such abuse and pain except in situations of serious physical damage resulting in complications. Another point to note is that, as with all abuse, spousal abuse has multiple manifestations. They may range from overt physical abuse with dire consequences, to occasional abusive behaviour by the partner, to emotional abuse, frequently unrecognized by the perpetrator as abusive behaviour. Many of the patients described here have been in the health care system for years without disclosing their abusive relationships or without anyone ever enquiring about them. Spousal or partner abuse is still synonymous with abuse of females by male partners. The health consequences of abused wives or partners are not very well documented. However, the estimates of women abused by partners range from 85 to 113 per 1000 couples. The latter was found in a national survey of family violence which investigated one-year rate of prevalence for couples living together. The same study found the

Spousal Abuse 75 rate of severe abuse to be 30 per 1000 (Strauss and Gelles 1986). In a Harris poll of 1793 women in Kentucky, 21 per cent reported being abused by a partner (Schulman 1979). In a sample of 406 subjects, a Canadian study found a 10.6 per cent rate of physical abuse by a partner during the previous year. An additional 13 per cent also reported psychological abuse (Ratner 1993). That the problem is of great magnitude hardly needs reiteration. There is some recognition in the literature about the health outcome of such abuse. These victims are more likely to have poor health, more pain, depression, suicide attempts, addictions, and problem pregnancies (Bergman & Brismar 1991; Helton, McFarlane, & Anderson 1987; Jaffe et al. 1986; Plichta 1992; Ratner 1993). Mortality and morbidity rates of women because of spousal physical abuse vary according to studies. Nevertheless, for the purposes of this chapter a certain amount of pertinent literature has emerged. There are two studies, for example, that directly explore the relationship between adulthood abuse of women and pain problems. There is also some evidence that women with acute or chronic health problems are more likely to receive injury from abuse (Haber & Roos 1985; Rapkin et al. 1990). PHYSICAL HEALTH CONSEQUENCES Plichta (1992) summarized the findings of several studies examining the health consequences of wife abuse. That wives receive serious injury as a result of physical abuse is well documented. Spousal abuse has been reported in a very vulnerable group, namely, pregnant women (Adams 1985; Amaro et al. 1990; Gelles 1988; Helton, McFarlane, & Anderson 1987). The extent of this abuse was reported by Helton and associates (1987). In a random sample of 290 women, most of whom were at least 5 months pregnant, 24 (8.2 per cent) reported battering during the pregnancy. Eight of the 24 sought medical treatment for the injuries resulting from the abuse. An Australian study found the rate of abuse during pregnancy to be 5.8 per cent (Webster, Sweet, & Stolz 1994). In a sample of 81 women with a history of abuse, the rate of increased abuse during pregnancy was found to be an astonishing 21 per cent. However, 36 per cent reported decreased abuse during pregnancy. This study helped to identify an especially vulnerable group of women with history of abuse, who appear to be at greater risk for abuse during pregnancy.

76 Childhood Abuse and Chronic Pain Injury as a result of physical assault has also been reported in several studies. Battery is rarely presented as the cause of injury. More common clinical presentations are anxiety, depression, chronic headache, abdominal pain, sexual dysfunction, joint pain, vaginal infection, sleeping disorders, suicidal thoughts, sexual dysfunction, and chemical dependency (Randall 1990,1991). A national survey of family violence in the United States reported the one-year prevalence rate of any woman abuse for couples living together to be 113 per 1000 couples and the rate of severe abuse to be 30 per 1000 couples (Strauss and Gelles 1986). Department of Justice records showed that 30 per cent of all female homicide victims were murdered by their husbands, boyfriends, or exhusbands (U.S. Department of Justice, Crime in the United States 1986). In two separate studies in Kansas (Schulman 1979) and Texas (Teske and Parker 1983), 17 per cent and 24 per cent of the women victims of family violence were beaten to the point of requiring medical attention. In an analysis of 481 women who sought emergency room intervention, Stark and associates (1979) found that the number of battered women using the service was 10 times higher than was recognized by the medical personnel. These authors were strident in their criticism of the medical community for its failure to recognize battering, and, even more seriously, that once recognized the victims were more likely to be blamed for their plight. They noted that 'the patients' persistence, failure to cure, and the incongruity between her problems and available medical explanations lead the provider to label the abused woman in ways that suggest she is personally responsible for her victimization.' The net result is the perpetuation of abuse and a high demand on medical services. Consequently, traumas associated with abuse were symptomatically treated, resulting in repeated visits by the victims. Evidence of long-term consequences of abuse and increased vulnerability for health problems of victims of spousal abuse is still emerging. Based on their observations of 60 battered women, Hilberman and Munson (1978) noted that somatic complaints in these women were rampant. The complaints included many pain symptoms, such as headaches, chest pain, pelvic pain, and back pain. Their findings were later confirmed in a study of abused mothers (victims of partner abuse) of boys attending a child psychiatry clinic (Stewart & DeBlois 1981). Gayford (1975) also reported that abused women had chronic ill health, made suicide attempts, used prescription psychotropic drugs, and presented psychiatric morbidity.

Spousal Abuse 77 Mullen and colleagues (1988), investigating psychiatric symptomatology using the General Health Questionnaire (GHQ) and the Present State Examination (PSE) in a random sample of 2000 New Zealand women, found that abused women had significantly worse physical and mental health than non-abused women. Similar findings were also reported in a controlled study of 145 U.S. women by Jaffe et al. (1986); they concluded: 'The results indicated that women who were victims of their husbands' physical abuse had significantly more somatic complaints, a higher level of anxiety, and reported more symptoms of depression/ Tentative support has been found for a high prevalence of spousal abuse in a chronic pain population. In the only study of its kind, Haber and Roos (1985) reported the results of a survey of 105 women seen at a university pain clinic of whom 53 per cent were abused. Of these 78 per cent were abused for the first time in their marriage. The mean duration of abuse was 12 years. In all cases pain problems followed incidents of abuse. It should be noted that no standardized questionnaires were used to define and measure abuse. Rather, the data were based on interviews. The reliability and validity of such data are, at best, suspect. Nevertheless, the presence of so many victims of partner abuse in a chronic pain population cannot be dismissed. Unfortunately, there has as yet been no replication of these findings. Rapkin and associates (1990) conducted a controlled investigation of 31 women with chronic pelvic pain, 142 women with pain in other locations, and 32 control subjects for any association between childhood and adulthood abuse of different kinds. They found that abuse in adulthood was less likely to be associated with pelvic pain, but that the pernicious nature of abuse, whether physical or sexual, may promote the chronicity of painful conditions. Some of their key findings were that 9.7 per cent of the pelvic pain patients had been physically abused and 6.9 per cent had been sexually abused in their adulthood. Among the patients with other pain complaints an alarming 16.3 per cent reported physical abuse in adulthood, and 7.8 per cent reported sexual abuse. In a follow-up study of 117 battered women in Sweden who sought emergency room care following battering, Bergman and Brismar (1991) reported that the battered women were significantly higher consumers of somatic hospital care during the preceding 15-year period compared with a matched non-abused group. The reasons for seeking care were

78 Childhood Abuse and Chronic Pain surgical disorders (not trauma), trauma, gynecological disorders, induced abortion, medical disorders, suicide attempts, and observation. In all categories, subjects in the battered group had had significantly more admissions than those in the control group. This study is significant for the long-term follow-up aspect. The findings leave little doubt about the long-term damage to health that is caused by spousal battering. Summary Case finding for abused partners remains a matter of hit and miss. Hence, it is hardly surprising that in pain clinic settings, as in other medical clinics, most of the abused spouses are missed. It would be a reasonable assumption that at least a portion of the patients seen in pain clinic settings are in an abusive relationship, and for some of these patients their pain symptomatology may well be related to the abuse. The literature on the impact of spousal abuse, while still inadequate in some ways, especially in addressing the long-term consequences, renders any debate obsolete as to its negative effects on the psychological and even physical well-being of a significant proportion of abused spouses. That pain problems of all kinds can occur as a consequence of adulthood abuse, not solely confined to spousal abuse, has gained considerable credibility in recent studies. Psychosomatic and indeed pain problems, especially those of uncertain origin, are not uncommon in this population. Depression, anxiety, and somatic symptoms are regularly found virtually in any study that investigates the health effects of spousal abuse and are common presenting symptoms. It is hardly surprising that partner abuse as a health issue has come under the scrutiny of relatively few medical specialties. As is evident from the literature discussed above, emergency room medicine and gynecology and obstetrics have made significant contributions to the identification of spousal abuse and their adverse effects on health. Family medicine (Burge 1989; Ferris & Tudiver 1992; Koss & Heslet 1992) also can play a key part in case finding. However, it must be emphasized that, given the pervasiveness of spousal abuse, it is incumbent upon all health care professionals to be aware of the signs and signals that accompany this type of abuse. These services are also strategically located for case finding and the cumulative evidence from these three sources points in the direction of gross under-reporting. Chronic pain

Spousal Abuse 79 of one kind or another appears to be a common outcome of spousal abuse, and pain clinics should undertake the task of case finding seriously and, hence, methodically. In the remainder of this chapter, a variety of patients who were victims of spousal abuse, all of whom were seen at a pain clinic, will be discussed. The patients have been selected to show the wide-ranging manifestations of abuse and their many different faces. These patients represent all ages and social classes. Abuse in all of them surfaced as a result of careful investigation, and the course of treatment in many of them was dramatically changed as a result of the revelation. As stated at the outset of this chapter, causal links between abuse and pain were neither self-evident nor sought. Nevertheless, in some of these patients that link was more apparent than in others, as perhaps in the case of Ms O. PATIENT 15 At the age of 23, Ms O was referred to our pain clinic by her family physician for inexplicable chest and back pain. She had a history of both pains that dated back to her late teens, and despite numerous investigations no physical cause for either pain had been found. During her first visit to the clinic, Ms O 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. Albeit haltingly, she revealed that she had grown up in a terrible home. She was the youngest of four siblings, considerably younger than the others, and thus virtually an only child. Her father had had severe complications related to diabetes and was disabled. Her mother was an alcoholic. The family situation had been chaotic at best. The parents constantly argued with each other and occasionally fought. Those were Ms O'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 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

80 Childhood Abuse and Chronic Pain her lack of scholastic ability, although, it should be noted, no one in this family had ever progressed past grade 9. Reading and writing challenged her to the point of dismay, and mathematics was totally beyond 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 O had formed a multitude of associations with boys. By the time she was 13 she was sexually active. At 17, she formed a somewhat permanent liaison with a man. He was only slightly older than herself. She moved in with him after only a short acquaintance and for the following 2 years was beaten, bit, sodomized, and sexually abused. Any semblance of self-esteem she might have had simply vanished. Over time she was able to describe 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 with open wounds. These beatings apparently occurred without cause or provocation, but sometimes they followed her reluctance to engage in anal sex. Occasionally she took herself to a hospital emergency department for treatment, but she was never asked about the cause of her injury. She never reported the man to the police. This situation persisted for 2 to 3 years with clear evidence of escalation of her partner's violence towards her. This whole matter came to a dramatic end, when on one occasion he produced a gun threatening to kill her. She had no doubt about the seriousness of his intent. She tried to take the gun away, a scuffle ensued, and he accidentally shot himself dead. Having narrated the story, Ms O revealed that it was not just this boyfriend who had abused her, but that she had been sexually molested by her father. She was 13 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 hand 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 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 somehow responsible for inviting all these problems.

Spousal Abuse 81 After the accidental death of her boyfriend, Ms O's chest pains began in earnest and then began her unending search for a cure for her pains, visits to numerous clinics and health care professionals. Not until her visit to our pain clinic, Ms O informed us, had anyone enquired 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 'mind games' 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. Comments From a symbolic point of view the association between Ms O's chest pains and the abuse is difficult to ignore. Her father's attempts to fondle her, the severe beating she received around the upper 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 compromised 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 Ms O's chest pain is nothing short of profound. PATIENT 16 Mrs P's case presents a dramatic contrast to Ms O. This 62-year-old woman was referred by her gynaecologist following a hysterectomy. Although the surgery was routine and uneventful, Mrs P continued to complain about severe pain, which she claimed had been directly caused by the operation. A curious thing happened during her first visit. She was accompanied by her husband (we encourage our patients to bring their partners for their first visit for psychosocial assessment), but he stayed in the

82 Childhood Abuse and Chronic Pain waiting room when she entered my office. Mrs P was well dressed and looked younger than her 62 years. Yet, she was tense and on the verge of tears. She began by giving a detailed account of her health and the genesis of her pain complaint. By this time she had gained some composure, but as she approached the end of her story and the part about her disagreement with the obstetrician, she became extremely agitated. Then she told a fantastic story. Two days postoperatively, she had been visited by her surgeon late one evening. In the process of conducting an internal examination, she claimed, he had deliberately hurt her. She could feel his fingers pressing down harder and harder in her vagina. The pain was so intense that she screamed and was told not to be a baby. Mrs P had no doubt that she had been sexually assaulted by this physician. Had she told this story to anyone? Only her husband, who did not believe her. At this point, with her permission, he was asked to join her. Mr P was quite indifferent to his wife's distress and dismissed her story as plain fantasy. His response opened up a potential avenue for exploring their marital relationship. Mrs P was unwilling or perhaps unable to pursue the matter, other than to opine that he (Mr P) never ever took her side on any matter. Mr P then stormed out the room. For the next few sessions, Mrs P remained preoccupied with her experience with the surgeon. She was advised to seek legal counsel and was informed about her right to file a formal complaint with the hospital authorities. She declined to take any action on the ground that she would not be believed. After all, her own husband did not believe her. During this period she also provided some background about herself and her family. She had been married for 40 years. There was one child, a son. Her life had been quite uneventful and she described the early marriage years as 'almost happy.' She had been busy raising their son, and she also had a job in the retail trade (from which she would have to retire at age 65), which she cherished. Mrs P had grown up in a middle-class home. Both her parents were caring individuals, and her memory of her growing-up years was very positive. She completed grade 12 and started working in the retail business. Before her marriage, she had had a very active social life. A few years into her marriage, she noticed a change in her husband's attitude. He had become very critical of her. As she put it, "There was no way of pleasing him/ Gradually his criticisms gave way to shouting at her and humiliating her in public. She gave several examples of how

Spousal Abuse 83 he would openly criticize her for ineptness and stupidity. He had the whole world convinced that she was a 'stupid woman/ Even their son was led to believe that his mother's opinions did not count for much. This persisted for several years. Major changes occurred with the departure of their son, who moved to another province. She described the subsequent period as the most stressful. Her husband's behaviour towards her took a turn for the worst. From just verbal abuse, he became increasingly menacing towards her. It was still a few more years before he tried to choke her. Somewhere during that period, when she was in her early fifties, she was diagnosed with clinical depression and was placed on antidepressant medication. She failed to disclose her domestic situation to the psychiatrist or her family physician whom she had known for years. She explained that they would not have believed her. Everyone seemed to regard her husband as a friendly and charming individual, and she was fearful of ridicule if she accused him of abusing her. Even her son had difficulty accepting this when she finally told him. At the time of her admission to our pain clinic, she was still on unsupervised antidepressant medication. The world-view of this woman was that of a rather sad and lonely person who had a chronic battle with depression. The abuse had gradually escalated to more incidents of choking, and a year before Mrs P was seen at our pain clinic, she was hit on two occasions around her left shoulder area. She became increasingly fearful of inviting her husband's wrath. She described her day-to-day life with this man 'as living on eggshells/ She described a Christmas dinner with a few friends and her son and daughter-in-law. Mr P was in a 'wretched frame of mind' that day. He was critical of everything Mrs P did. He seemed very angry with her. At the dinner table, he was critical of the table setting, the food, and her appearance. She became so distraught that she left the table and locked herself in her room. On another occasion, she was so frightened by a choking event that she took refuge in her friend's house. Apparently, her husband had lost his temper when she disagreed with him on some trivial matter. He became enraged, put his hands round her neck, and shook her vigorously. When Mrs P finally disclosed the abuse to her son, at the behest of the therapist, his attitude to all of this was one of incredulity. He was very close to his father and just could not bring himself to believe that his father was an abusive person. Mrs P had only one friend who believed her, who constantly urged her to go to the police. On one

84 Childhood Abuse and Chronic Pain occasion, following another episode of choking, she threatened to call the police. Her husband's reaction was to encourage her to call them. The police would have no problem in recognizing that he was married to a 'deranged' woman, he announced. She was completely trapped. Comments As the story unfolded, Mrs P's original complaint about the surgeon receded into the background as did her pain complaint. Suffice it to say that a woman had arrived at the pain clinic, almost in a state of crisis complaining of assault by a surgeon, who ultimately told a very sad and terrifying story of her life with an apparently sadistic husband. But she did not want to leave him. She was seen in psychotherapy for 18 months. PATIENT 17 Mrs Q was 35 years old and had a long-standing history of mixed headaches. She was referred to our pain clinic by her neurologist, who, in his letter of referral, stated that Mrs Q had failed to respond to all his efforts and suggested that perhaps the clinic would consider a more psychological approach to treating her headache problems. Mrs Q 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 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 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 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.

Spousal Abuse 85 The above information was obtained during several sessions. Some observations were made. 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 single most important problem to emerge was Mrs Q's complete disillusionment with her marriage. She had married on the rebound, having been engaged to be married to another man, who failed to show up on the wedding day. Then came the 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, while her father had maintained a stoical silence. Mrs Q was an only child. She 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 had never given him any cause. She became pregnant 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 unfeeling man. What might account for Mrs Q's high tolerance of distress and her almost total commitment to maintaining peace at any cost? Her own mother, she reported, probably never 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 Q 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+ and so it went. She said that her mother was very critical of how she looked, and the way she walked, dressed, and talked. She

86 Childhood Abuse and Chronic Pain could not remember a single occasion when she had been hugged by either parent. She liked school, but she did not have any close friends, and she was not allowed to invite friends home. Mrs Q grew up to be a rather shy, passive, and compliant individual. Her love for education enabled her to pursue post-secondary 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 her confidence on the matter of the rape. After that she became very depressed and even more withdrawn. If her parents had noticed this change in her, they never said anything. She did not tell her mother because she felt her mother would not have 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. Comments The pertinent question to be asked here is whether or not Mrs Q was in an abusive marital relationship. Regardless of differing opinions that professionals may proffer, Mrs Q herself never thought otherwise. She lived in an oppressive environment where she continued to be treated like a non-person. This was a continuation of her life with her mother. She did not dispute that she had tolerated her marital situation without protest. Nevertheless, she was treated like a third child by her husband and her mother-in-law. Her past, in a sense, caught up with her and her feelings of inadequacy, uncertainty, and being marginal were all reinforced in her marriage. Is that abuse? Parental abuse constituted some form of emotional neglect. Her marital situation was, in part, brought about by a combination of her choice of mate and paternalism. The weight of the evidence would suggest that she was in an abusive situation, albeit at the lower end of the abuse spectrum. In her mind, however, she was clear about the abuse inflicted upon her by her husband. Another question that may be legitimately asked is the relationship between her family situation and headaches. This is a problematic question, and the answer is somewhat speculative. Unlike with some of the

Spousal Abuse 87 previous patients, where such a relationship was almost self-evident, here no such direct evidence came to light. Yet, the message value of Mrs Q's headache and her help-seeking behaviour held out some clues about her personal and marital distress. The chronicity of her stressful family life may also have contributed to the psychophysiological nature of the headache. Psychotherapy did not altogether alleviate her headaches, though they were substantially modified. The value of psychotherapy in this case will be discussed in Chapter 9. PATIENT 18 Mrs R was a 44-year-old woman with a very complicated medical history. She had been referred to our pain clinic by her family physician, who was puzzled by her unresponsiveness to conventional treatment for pain management. Mrs R had been born with a congenital hip problem and had had bilateral prosthetic replacement. Unfortunately, she did not have a correction until her third or fourth year of life, which left her with difficulty in walking and chronic pain. She had had subsequent corrective surgeries, but in 1993 she fractured one of her hips, and this was followed by another hip replacement surgery. She used a shoulder crutch for walking. She had unrelenting pain in the lower back region and suffered from periodic bouts of severe muscle contraction headaches. Her first visit at my office was memorable for the reason that upon being asked how things were on the domestic front, she burst into tears, accused me of being unfeeling, and was on the verge of walking out of the office. She was persuaded to stay on, but she maintained a stoical silence for most of the rest of the session. Over time, however, Mrs R became a willing participant and eventually agreed to enter into psychotherapy. She drew a very complex picture of her growing-up years. Her childhood memories were mixed. As a sick child, she had received a great deal of attention from both her parents. Her two sisters still harbour negative feelings about the special treatment their parents gave her. She developed serious psychiatric disorders in her teens. Her parents did not get along with each other. Her father was an alcoholic and occasionally engaged in physically but mostly verbally abusive behaviour towards the mother and sisters. However, he was very protective of Mrs R. As a young child, she had enjoyed her special

88 Childhood Abuse and Chronic Pain relationship with her father, but as she grew older, she became resentful of his drinking and abuse. She lived in perpetual fear of her father's drunkenness and the ensuing abusive behaviour. Mrs R married at the first opportunity after a short relationship. It did not take long for her to recognize that her husband was a rather controlling, non-communicative, and undemonstrative person. She was somewhat intimidated by him. It must be emphasized that his behaviour towards her at that time could and should not be viewed as obviously abusive. Neither did she view it as such. He was a very good provider. Very early in the marriage she developed anorexia, her weight dropping down to 74 pounds. Her husband was unaware of her difficulties and basically ignored her declining health. She, of course, continued to have problems with her back and hips. She had two children in quick succession, and the children brought some semblance of stability into her life. Problems became serious, at least in her mind, when her children grew up. Her sense of being controlled by her husband almost assumed obsessive proportions. She began to rethink and redefine her relationship with this man. There was no doubt in her mind that living with this man had made her into a permanent depressive. She concluded that she was not only oppressed, but emotionally abused. She was puzzled by this as there had been no real change in him for the better or worse. He had always resented her going out on her own or her antipathy to their religion or her inability to manage money or her dislike of his mother. The list was endless. She wanted to leave him, but how? She was not an altogether well person. She was financially dependent on him. Could she really look after herself? He was always there when she needed him. She was smothered by selfdoubts and unresolved questions. Mrs R's husband was away on business a great deal of the time. She enjoyed his absence. She felt free to do as she pleased then, which was mostly to visit her friends for coffee, or cook or not cook as she wished, and in general do as she pleased. Another source of her enjoyment during his absence was that she was not compelled to visit his mother. The mother-in-law had always been critical of her, and, to make matters worse, her husband always sided with his mother. Mrs R very deeply resented her mother-in-law's interference with her private family matters. Soon after Mrs R entered therapy, the situation came to a head. The entire family was invited to her in-laws for Thanksgiving dinner. The

Spousal Abuse 89 mother-in-law expressed some disaffection with Mrs R for something she had done or not done. Mrs R got up from the table and informed her husband that she was leaving and that he should call her when he and the children were ready to leave and she would pick them up. This was her first act of defiance in her entire married life. Following this event her husband did not speak to her for many days. Her own feelings of oppression in this marriage gathered increasing momentum, and the central theme of our sessions revolved around her many plans to leave this man. At the time or writing, she was still in the marriage with ever growing feelings of frustration and seeing no easy way out. Comments Could Mrs R be classified as an abused individual? Certainly not in a legal or criminal sense. In this way, this case shares many of the same characteristics of the previous case. Yet, at some point in her life, Mrs R concluded that she was not just in an oppressive situation, but that her husband's behaviour towards her amounted to emotional abuse. For her, a woman in her forties, to have to seek her husband's permission even to go out for coffee with friends and account for every penny she spent was no longer a matter of an authoritarian spouse, but signs of cruelty. She was deprived of all her legitimate roles as a wife and partner, and she was finding it harder and harder to accept that reality. DISCUSSION The literature on spousal abuse points in the direction that it is relatively common and that it kills many and that it permanently scars countless victims. Among the scars, long-term physical problems directly emanating from abuse are beginning to be understood. Research is just beginning and the initial findings should alert health care professionals to be aware and vigilant that certain types of somatic complaints or injury are signs of spousal abuse. It must be clear to the reader that the patients discussed in these chapters were not only diverse, but even raised questions about the legitimacy of describing some of them as abused. The second issue is the connection between pain and abuse. Was such a connection evident in any of these patients? Before answering that question, it must be acknowledged that in the minds of at least two of these women such a relationship was present. The last two patients were in very little doubt

90 Childhood Abuse and Chronic Pain that the oppression and marital tension contributed to their pain. Clinical evidence in both cases was of an indirect nature. In the case of Mrs Q there was the curious phenomenon of headaches which she almost always had when she was home and rarely, if ever, at work. It should be recalled that Mrs Q never missed work. In the case of Mrs R, she was invariably better and more energetic when her husband was away on business. The fact is that Mrs Q being at work or Mrs R's husband being away simply meant relief from tension and, at last, from selfreported pain. In some ways, these two patients' cases are better conceptualized as ones of paternalism, an inevitable outcome of which is oppression, rather than abuse. Their husbands were certainly unaware of any wrongdoing let alone of being engaged in behaviours that their spouses viewed as abusive. Nevertheless, their conduct had a profound effect on their wives. The case of Ms O was striking both for the symbolic association between her site of pain and the target of brutal beatings. She was also by far the most severely abused person among those in this group of women. The fact that her abuse remained undetected for so long should be a matter of concern. She was not particularly articulate, and she was poor. She was easily intimidated by authority such as hospitals and white coats, and it is equally possible that she was never given adequate time and opportunity to explain her predicament. Finally, there is the case of Mrs P. There is no question that she was in an abusive situation. That she had organic basis for her pain was also clear. Yet, her referral to the pain clinic was preceded by an unrelated event that ultimately uncovered her abusive husband. As for the abuse by the surgeon, nothing came of it and before long, that matter receded into the background. Still, it would be a mistake to overlook the simple truth that her main complaint on entering the pain clinic was abuse at the hand of a surgeon. Regardless of the details or for that matter even the veracity of her allegation, the more troublesome story of abuse by her husband took the central stage in her treatment, and, at the time of completion of her treatment, her pain complaints were sufficiently under control for her to be discharged from the pain clinic. It must be stated that victims of spousal abuse are probably seen at pain clinics more frequently than is appreciated. Haber's study points in that direction. Unfortunately, the markers for spousal abuse are poorly developed. Nevertheless, when the problem is recognized and effectively dealt with, pain complaints may very well improve or even dis-

Spousal Abuse 91 appear. At the very least, the clinical setting presents an opportunity to extricate a victim from an abusive situation and begin the process of emotional healing.

SIX

Therapeutic Approaches to Adult Victims of Abuse

Even a casual examination of the therapy literature on the victims of (mostly sexual) abuse reveals an incredible variety of interventions. They range from conventional group and behavioural therapies to music and art therapy to traditional individual and family therapy to imaginative use of video and hypnosis. Much of the voluminous literature is clinical, an exception being two controlled studies on the effectiveness of group therapy with victims of childhood sexual abuse. The literature can be broadly categorized by methods of intervention, namely, group approaches, family approaches, cognitive-behavioural approaches, individual approaches, and a pot-pourri of novel and innovative approaches. Because of the sheer amount of literature, this selected review constitutes an overview of the state of the art rather than a critical assessment of outcome. This review excludes treatment for perpetrators of abuse. It is also noteworthy that while the effects of child abuse on survivors range from mild to crippling, many survive the ordeal and lead normal lives without the benefit of any therapy (Valentine & Feinhaur 1993). This chapter is organized as follows: first, a consideration of the notso-common methods of treatment is followed by a review of the group methods. Then family approaches will be considered, and the last section will explore individual methods. The final section is a short review of the literature on the treatment issues of abused spouses and partners. A POT-POURRI OF METHODS It must be stated at the outset that methods of intervention discussed under this heading are by no means unusual, yet they are not exten-

Therapeutic Approaches to Adult Victims of Abuse 93 sively reported. A good example of such a method is self-help or support groups. In recent years a few papers on the value of the self-help group approach for victims of abuse have made their appearance (Finn & Lavitt 1994; Frawley & Mclnerney 1987; Knight 1990; Schiller 1988). Two of these papers highlighted the benefits of self-help groups for victims of incest (Frawley & Mclnerney 1987; Schiller 1988). Frawley and Mclnerney described a group of eight women in an Australian city, all victims of incest, who, having met through a sexual assault centre, decided to form a self-help group. Women between the ages of 17 and 30 years met on a weekly basis for 16 weeks and then at infrequent intervals. The authors were impressed by the group's capacity for selfhealing. The same sentiments were echoed in a paper by Schiller (1988). In a California town, she surveyed 42 female victims of incest, aged between 19 and 52 years, who were participants in a self-help program, to determine the effects of incest on their lives. Although nearly 80 per cent of the participants were optimistic about their future, they were less sanguine about overcoming low self-esteem, achieving personal goals, and coping with compromised financial status. Schiller concluded that the effects of incest were lasting in nature and an indirect conclusion was the limited benefit of the self-help group. Knight (1990) adopted an innovative approach to self-help groups for victims of abuse and proposed ways of fostering and developing them. She described a model of a self-help program for adult female survivors with emphasis on developing the leadership role from within the group and some of the critical issues that required discussion in such a group. Her paper provides some guidance in setting up self-help groups for survivors. Finn and Lavitt (1994) described a novel development in the self-help movement using computer-based communication. They listed the advantages that included providing greater access to support, diffusing dependency needs, meeting the needs of those with esoteric concerns, reducing social barriers, and others. On the down side, a computerbased self-help group may encounter destructive interactions, superficial self-disclosure, promote social isolation, and limit access to noncomputer-based populations. An extension of the last point was the absence of one of the key ingredients, that is, face-to-face meeting, of self-help groups. With the proliferation of Internet communication, however, this new development is not without promise. The usefulness of cognitive-behavioural treatment has also been recognized by several authors. Fallen and Coffman (1991) adapted this

94 Childhood Abuse and Chronic Pain approach to treat survivors by incorporating standard techniques such as activity scheduling, automatic thought log, and personal schema elucidation. These techniques promoted management of negative thoughts and depression and anxiety resulting in a new awareness of the client's view of self. Hartman and Burgess (1986) used a cognitive-behavioural conceptual framework to understand the process by which the experience of trauma was incorporated. They proposed tools to explore two phases associated with the experience of abuse, that is, (1) the phase of the sexual abuse and recovery, and (2) the manner in which the abuse was processed. Understanding these processes could influence the outcome of treatment. Hoier (1987) also argued for the cognitive-behavioural approach as the treatment of choice for victims of abuse. Several case illustrations were provided to support her argument. Janas (1983) broadened the base of cognitive-behavioural treatment by incorporating it in analytical hypnotherapy. The crisis of abuse followed a predictable pattern, and Janas suggested ways of implementing various elements of treatment to maximize the benefits of intervention. The contribution of Foa and her associates (1989; Smucker et al. 1995) is most noteworthy in any discussion of cognitive-behavioural techniques in the treatment of abused persons. Almost all her abuse-related work has been either on rape or child sexual abuse manifesting as posttraumatic stress disorder (PTSD). Foa and Rothbaum (1989) conducted an exhaustive review of the literature on application of behavioural psychotherapy to treat PTSD. Their conclusion was unequivocal. They discussed the relative merit of exposure-based procedure and anxiety management technique to treat PTSD associated with combat and rape and found that both techniques were effective, but a combination of the two was likely to produce the most desirable outcome. More recently Foa and her group have reported two behaviouralcognitive methods to treat PTSD (Foa et al. 1995; Smucker et al. 1995). In the first of these reports, Foa and associates discussed the pros and cons of fear activation during exposure treatment in 12 sexual assault victims, aged between 29 and 55 years. Their results showed that subjects expressing more anger during the reliving experience of the trauma, but showing less fear were less likely to benefit from this therapy than subjects experiencing more intense fear during reliving the assault. In other words, patients who continue to re-experience the event with great fear and intensity are likely to benefit more than those whose fear

Therapeutic Approaches to Adult Victims of Abuse 95 response is modified. This work confirmed the adage that the more acute the symptom, the better the outcome of treatment is likely to be. In their second study, a new treatment method, imagery rescripting, was described and its efficacy tested with PTSD subjects. The treatment essentially is a technique that interdicts the pathological schemas that PTSD patients tend to display during their reliving experience. These schemas are replaced by creating adaptive schemas. The authors described the treatment and its theoretical underpinning with much clarity, and they provided preliminary data to suggest its effectiveness in significantly reducing PTSD-related symptoms. Sex therapy for survivors has also come under scrutiny. Rowe and Savage (1988) traced the genesis of sexual problems in adulthood in survivors of child sexual abuse. The dynamics involved in the experience of abuse varied, and hence they urged that treatment must take into account the specifics of individual experience. They offered a typology for explaining these varied experiences and demonstrated their value in therapy with case illustrations. Weiner (1988) also explored the common sexual difficulties of survivors of intrafamilial sexual abuse. These difficulties included issues of trust and vulnerability, powerlessness, and control and guilt. Weiner presented a case of couple therapy to deal with problems of the wife's failure to experience orgasm, the roots of which were traced to repressed memories and the husband's premature ejaculation. Couple therapy was shown as a useful mode of intervention in dealing with abuse-related sexual difficulties. The contribution of the feminist movement to the entire field of women's abuse is considerable. Three recent papers have presented important aspects of the feminist perspective in the treatment of victims and survivors. Hepburn (1994) examined some of the implications of the feminist perspective in planning treatment for male victims. He noted that males, more than females, tended to respond to anxiety with aggression and anger to avoid pain and depression. In planning treatment for male victims therapists should prepare clients for the emergence of this behaviour, validate and contain it by providing a supportive milieu, and resolve it by helping the client to achieve a balance between intimacy and independence. Anderson and Glod (1994) raised objection to the labelling process of abused women and revisited the notion of 'survivor.' They noted that 'a return to consciousness raising, a basic feminist tenet, offers women to explore language and acquire control over the naming of their own

96 Childhood Abuse and Chronic Pain experience.' Their plea was that a therapeutic environment should make it possible for women to find their own language and thus avoid reducing painful experiences to predetermined labels. Sanders (1992) proposed incorporating feminist perspectives in systemic therapy. The specifics of that were not clearly identified. Nevertheless, her method of intervention recommended a historical approach, that is, a systematic exploration of the relevant systems with which the client had ever interacted. Case examples were provided to show the therapeutic value of this approach. The therapeutic use of videotape has also appeared in recent literature. In one paper authors described a 5-step approach in which a videotape made by the survivor with the assistance of the therapist was watched by a team of therapists, and the tape was used to confront the survivor by the therapeutic team (Roesler et al. 1992). This method was used with 27 cases in the context of ongoing therapy and was employed basically to break through survivor's denial. One possible risk to the survivor was vulnerability to suicide. Aruzo (1994) also described the use of videotapes whereby patients watched tapes of their own sessions from the 'outside' (as observers), which resulted in the correction of distortions and enabled them to appreciate accurately their degree of distress, thus promoting self-empathy and healing. Music as a therapeutic tool has also been reported (Slotoroff 1994; Ventre 1994). Slotoroff described a technique that combined cognitivebehavioural method with drumming. The drumming technique was developed in an in-patient short-term psychiatric setting with abused adults and adolescents. The author claimed that this treatment promoted self-control and an increased sense of power. Two case illustrations were provided to demonstrate the effectiveness of this intervention. Ventre (1994) used music therapy in the treatment of a 32-year-old woman with a history of abuse. Guided imagery and music were the main therapeutic ingredients in healing the wounds of abuse. The goal of discussing such a wide variety of interventions in the preceding section was to simply alert the reader to the various kinds of innovation being undertaken by therapists of many stripes. As with much of clinical literature, there was a marked tendency to tell stories of successful outcome with these therapies. Yet, that may be too harsh a judgment as many of the interventions, such as computer-based therapies, were novel. Clinicians tend to keep an open mind on new developments in psychotherapies and operate on the principle of 'use whatever works.'

Therapeutic Approaches to Adult Victims of Abuse 97 GROUP THERAPY There is no easy explanation for the popularity and proliferation of group interventions with survivors of abuse. The literature in this area can only be described as rich, and there is little doubt that this brief review will omit many articles of import. Unlike many other methods of intervention, group therapy has been evaluated for its effectiveness, and those few papers will be presently discussed. To begin with, however, an overview of recent literature is presented. Even a casual glance at this body of literature reveals an extraordinary diversity. The virtues of short-term and long-term group treatment, group therapy with one or two therapists of different gender, only women's group, only men's group, or mixed groups are all extolled. Psychodynamic, behavioural, or eclectic groups also find favour by group therapists. However, when it comes to the principal goal of therapy, which is to create a distress-free life for the survivors, perhaps not surprisingly, there is remarkable consensus. Space only permits a rather limited review of this topic. A number of recent papers deal with women's groups (Apolinsky & Wilcoxon 1991; Axelroth 1991; Darongkamas et al. 1995; Hall 1992; Menen & Meadow 1993; Turner 1993). This is not unexpected, as a vast majority of victims of sexual abuse are women. Menen and Meadow (1993) presented a long-term open-ended group therapy program for treating women survivors. They emphasized that their model was predicated on building on the strengths rather than on the psychopathology of the survivors. Two female co-therapists were found to be effective. Core issues discussed in the sessions included power and control and conflicts around intimacy. The authors postulated that ongoing process could instill hope in group members and provide a chance for an indepth reworking of the core issues of childhood sexual abuse within a trusting and supportive environment. Hall (1992) also proposed a 'slow-open' group for female survivors. However, she made a case for a combination of a male and a female therapist, as the presence of a male therapist, she argued, enabled the participants to 'work through their feelings about men/ Threadcraft and Wilcoxon (1993) concurred concerning the advantages of mixed gender co-therapy, but in short-term treatment. Seven of 10 women in their report completed a 10-week counselling program. On objective measures, participants recorded decline in depression and rise in self-esteem. The authors concluded that their finding contradicted the

98 Childhood Abuse and Chronic Pain assumption that the therapist of choice in the treatment of survivors had to be a woman. Turner (1993) also subscribed to the value of short-term therapy with incest victims. In a similar vein, Apolinsky and Wilcoxon (1991) implemented a group therapy program for women survivors which comprised of 10 weekly 2-hour sessions. They combined person-centred, psychoanalytic, gestalt, behavioural, and other therapeutic models into their group therapy. Removal of guilt, anger management, empowerment, and enhancement of self-esteem were some of the goals. Bruckner and Johnson (1987) reported on two treatment groups for male survivors. Each group consisted of five and six members respectively. Participants were in their twenties and thirties. Most of them had had some form of individual treatment. Treatment comprised six sessions of 21/* hours duration each. The topics discussed included disclosure, feelings of anger, sex education, the victim as offender, and intimacy and trust. Therapy was provided by a male and a female team to counteract any gender-based anxiety. This was not an empirical study, but the authors concluded, based on clinical observations, that group treatment was equally beneficial for men and women. Group therapy for men sexually abused as children was reported by Isley (1992) and Friedman (1994). Isley noted that prevalence and incidence of sexual abuse of male children was under-researched. The male victims were prone to maintain silence about their abusive experience. Yet, they entered adulthood with many unresolved issues. Isley proposed a short-term psycho-educational model for intervention with these men. Friedman, on the other hand, described a long-term psychoanalytically oriented combined individual and group therapy program for the male survivors with a male therapist. The group consisted of 14 members with a male therapist. Individual participation in the group lasted anywhere between \l/2 to 2 years. The therapeutic approach consisted of exploration of basic personality and relationship problems with special attention to gender-related conflicts which culminated in the reestablishment of trust, development of intimacy, resolution of shame and guilt, and general empowerment. Knight (1993), unlike the previous authors, advocated mixed group therapy. Her contention was that sexual abuse literature had presupposed that survivors were mostly, if not, exclusively females. In this article, based on her own clinical experience, she proposed a rationale for group therapy for survivors of both sexes. The benefits of such a

Therapeutic Approaches to Adult Victims of Abuse 99 group facilitated communication between sexes and provided an opportunity to work on relationships with the opposite sex by confronting stereotypes about men and women and issues of anger and loss. Knight noted that the mixed groups were more emotionally charged than allfemale groups and that it was important to give careful consideration to the selection of group members. Gilligan and Kennedy (1989) described a novel approach by including hypnotherapy into their group treatment for a mixed-gender group. The therapy comprised 12 sessions and covered topics ranging from envisioning a positive future to secrets of disclosure and sexuality. These authors were alert to some of the problems associated with a mixedgender group, such as feelings of intimidation by female victims by the mere presence of males. They reported a very favourable outcome. This overview of the recent literature on group therapy with survivors showed the sheer variety of group therapy methods and, as such, also created confusion as to what may be the most effective. To determine whether there are indeed any guidelines about what may be considered the most effective combination and permutation, or perhaps at a less ambitious level, whether group therapy is at all effective, a review of the few recent outcome studies is presented below. Group Therapy and Outcome Three outcome studies are reviewed (Alexander et al. 1989; Fisher, Wine, & Ley 1993; Follette, Alexander, & Follette 1991). The first of these studies, by Alexander and associates, reported a time-limited (10 weeks) group treatment program offered to two groups of women with another group wait-listed for the purpose of control. Sixty-five women (mean age 36 years) with history of childhood sexual abuse (mean duration 7 years) were recruited through advertisement (which poses some questions about sample bias). These women had to be non-psychotic, free of drug addiction, and non-suicidal. The subjects were randomly assigned to one of three conditions: (1) wait-list group; (2) interpersonal transaction (IT) group; and, (3) process group. Therapy was provided by advanced doctoral-level clinical psychology students. Several measures of outcome related to depression, social adjustment, psychiatric symptoms, and fear were used pre- and post-treatment and in a 6-month follow-up. Appropriate statistics were used for data analyses. The results were unequivocal. Improvements were evident on all the outcome measures. Both treatment groups performed equally well com-

100 Childhood Abuse and Chronic Pain pared with the wait-list group. Improvement was maintained at the 6month follow-up. The significance of this study is simply that it ranks as the first to show the benefits of short-term group therapy to treat victims of childhood sexual abuse. Having demonstrated the benefits of group therapy, the same researchers (Follette, Alexander, & Follette 1991) conducted further analyses to develop predictors of outcome. Less education was associated with poor outcome as was being currently married. Apparently many partners were unaware of the abusive past of the people they were married to and thus could not be supportive. Sexual abuse involving actual intercourse or oral-genital sex compared with touching and fondling also predicted poor outcome. Subjects with higher levels of depression and general distress also did poorly, confirming an adage that 'healthy' persons do well in therapy. An unstated conclusion was that for the less educated, more seriously abused, and married women who had not disclosed abuse to their partners perhaps a different approach to therapy had to be envisaged. The final paper in this section was by Fisher and associates (1993). In their study, they compared 32 group therapy completers with 22 dropouts. These were depressed women with severe childhood as well as adult abuse histories. There were interesting similarities with the findings of the previous study. More married subjects dropped out of therapy, as did less educated ones. Severity of abuse was another factor that predicted dropouts. The more severe the abuse, the higher the likelihood of dropping out. On psychological profile, the dropout group seemed more 'adapted' to their victim roles. A current abusive situation also influenced dropping out. In their recommendation for therapy for the dropout group, the authors were emphatic that any current abusive situation had to be resolved and safety rather than therapy for these women was the primary concern. Access to women's shelters, job-training programs, social assistance, and support were their primary needs. Therapy would come later. FAMILY THERAPY Much of the family therapy literature is given to treatment of abused children rather than adult victims. Nevertheless, some clinical literature can be found on the latter topic, much of it on couple therapy.

Therapeutic Approaches to Adult Victims of Abuse 101 Avis (1992) observed that despite the epidemic proportions of physical and sexual abuse in our society, family therapy has been singularly invisible and unresponsive. The conceptual limitations of family therapy were seen as major obstacles. Avis proposed a feminist perspective to conceptualize abuse and discussed family therapy predicated on those principles. In a critical analysis of system-based family therapy's application to treat abusive relationship, she concluded that the behaviour of the abuser was often 'neutralized' in the systemic paradigm and noted that as long as we continue to train therapists in systemic theories without balancing that training with an understanding of the non-neutrality of power dynamics, we will continue producing family therapists who continue to collude in the maintenance of male power and are dangerous to the women and children with whom they work. Her solution was to adopt a feminist perspective by recognizing the power issue, dealing directly with the abuser by challenging the male domination. Avis articulated one of the main reasons for family therapists' desire to maintain some distance from abusive families. The assumptions of systems-based family therapy are severely challenged in the face of a recognizable perpetrator of violence in a family system. The notion of 'no one person is to blame or is responsible for the family problems' becomes untenable in the face of violent behaviour on the part of one family member. It is hard to view abusive behaviour in a family member as just another metaphor. Menen and Perlmutter (1993) warned therapists that undisclosed sexual abuse may be a contributing factor to couple dysfunction. This was a logical consequence of the finding that married survivors of sexual abuse performed less well in group therapy than single persons. Nondisclosure of abuse to their partners was seen as a key reason for their less successful outcome. Chauncy (1994) noted that male partners of sexually abused women increasingly sought treatment with their own concerns rising out of unresolved issues of their partners' past abuse. Some of the concerns expressed by 20 men, whose partners were survivors, were focused on relationship issues, sexual issues, these men's difficulty in expressing their own needs, and dealing with relatives. Chauncy's approach included individual as well as couple therapy that combined the use of insight and safety of the therapeutic relationship to promote growth. Busby and associates (1993) made similar observations in the context of family therapy. They found that many family members participating

102 Childhood Abuse and Chronic Pain in family therapy had an abusive past, and these problems manifested in a variety of ways including psychiatric disorders such as post-traumatic stress disorder and mood and personality disorders. The authors compared 148 non-abused with 83 abused subjects and found the abused subjects to be significantly more pathological on objective measures. They pointed out some of the conceptual problems of dealing with these families solely in the 'here and now' context or, alternatively, that marital problems were symptoms of the trauma of abuse. To promote healing, issues related to the trauma had to be addressed directly and probably in individual therapy. It was further noted that empirical evidence was lacking to demonstrate the superiority of one approach over the other. The main recommendation was that therapists must have the skills to recognize signs and symptoms of abuse in couples and families and have training to deal with these problems from multiple theoretical perspectives and treatment modalities. Family or couple therapy in itself may or may not be the treatment of choice. On the other hand, combining such therapies with individually based treatment may prove to be the most effective. McCarthy (1986) proposed the adoption of a cognitive-behavioural method to couple therapy for survivors. This author opened up critical areas such as the victimization syndrome with a couple referred for therapy with problems of inhibited sexual desire. The key element in this approach was to understand and modify the process of victimization with all its deleterious consequences. It is worth noting that family therapy with abused children and their family members has gathered a great deal of momentum in the literature. This approach is relatively new, but a considerable body of literature already exists on the topic. Family therapy for adult survivors, on the other hand, is unlikely to involve either the perpetrators of abuse or members of the family of origin. For that reason, literature on family therapy with adult survivors is virtually non-existent. In the context of this book, couple therapy involving the victim and the partner is likely to be the most common form of 'family' intervention. The importance of couple therapy was brought out in a few papers discussed earlier. Often partners are unaware of the abusive past of the survivors. That can potentially create almost insurmountable interpersonal conflicts. I have employed couple therapy with varying levels of success, and some of those cases will be discussed in a subsequent chapter.

Therapeutic Approaches to Adult Victims of Abuse 103 INDIVIDUAL PSYCHODYNAMIC INTERVENTIONS Engel (1959) proposed a blueprint for psychodynamic psychotherapy for adults with an abusive past in his classical paper already discussed. In more recent years interest in psychodynamic therapy has come into its own. Psychodynamic psychotherapy is an insight-oriented non-directive psychotherapy designed to explore childhood conflicts usually inaccessible to the conscious mind. Conceptually, childhood abuse lends itself well to this mode of treatment, although empirical evidence in its favour is sadly missing. Roy (1992) discussed its application in the treatment of victims of childhood abuse who presented with problems of chronic pain. I adapted my therapy to Malan's approach to psychotherapy and Sifneos's Short Term Anxiety Provoking Techniques (STAP). In many cases, however, treatment was anything but short. Several books and articles have appeared on the topic all during the 1990s (Olio & Cornell 1993; Davies & Frawley 1994; Gardner 1990,1993a, 1993b; Patten et al. 1989; Sanderson 1990). Patten and colleagues (1989) found post-traumatic stress disorder to be a useful diagnosis to conceptualize and treat sexual abuse. The underlying mechanism of this approach was to create an opportunity for the victim to be gradually transformed into a survivor whereby the negative experience was to be perceived in a more realistic way. The four stages of sexual abuse, according to Patten and colleagues, are (1) traumatic sexualization, (2) somatization, (3) betrayal, and (4) powerlessness, which cause a predictable pattern of response in the victim. Therapy was directed at interdicting much misperception and misinterpretation of the traumatic event(s), and thus the process of therapeutic resolution of the ill effects of the trauma was begun. Gardner (1990,1993a, 1993b) in a series of papers, presented psychodynamic therapy as a means to treat survivors. She also anchored her rationale for this approach to post-traumatic stress syndrome for the simple reason that a survivor's response pattern to long ago events is not dissimilar to the response of victims of war or atrocities or unimaginable traumatic events. Repression was not an unusual response to deal with these events, which in turn created a host of psychological symptoms such as reliving in some form the traumatic experience and unbearable feelings of guilt and often depression. In therapy, recalling and reliving these experiences in the safety of the therapist's office takes a central place in the therapeutic process. Gardner described this process as exploration of 'historical sets' which

104 Childhood Abuse and Chronic Pain translates into recovery of repressed events. In keeping with this model of intervention, she fully recognized the centrality of transference in therapy. She raised interesting issues related to the gender of the therapist, more or less recommending a female therapist. She warned that, despite the gender issue, utmost caution was necessary to maintain a non-exploitive attitude. Although psychoanalytic in orientation, Gardner rejected any subscription to a Freudian notion of childhood sexual fantasy and, as an alternative, offered a feminist perspective to countermand any relationship between abuse and childhood sexual fantasy. Finally, Gardner conceptualized the therapeutic process as dynamic creation, meaning that creativity was at the heart of that process. Others have described the same phenomenon as self-discovery. Sanderson (1990) chose to describe psychodynamic psychotherapy as 'experiential/exploratory/ which is an explanation of the therapeutic process associated with this method. This intervention leads the patient to re-experience of feelings and emotions related to the abuse, which fosters catharsis and abreaction to the trauma. She, like Gardner, also emphasized the necessity of establishing a positive therapeutic alliance with the survivor because this therapy could engender a great deal of anxiety as well as unpredictable response. An additional complication was often introduced by the unravelling of unconscious material which could be highly distressing for the client. Yet, facilitating recall was at the heart of the psychodynamic approach as it validated the survivor's experience of abuse and thus began the task of healing. Olio and Cornell (1993) described the need for modifications required in traditional psychotherapy to treat adult survivors. These authors placed very high priority on denial and dissociation commonly observed in abused patients. Another issue of import noted was memory loss and lack of disclosure. This latter problem could give rise to unique difficulties in treatment because of the lack of identification of the source of the problems. The third area of significance in these patients were flashbacks and regression. It should be noted that all these seemingly disparate areas are intertwined. Denial, lack of disclosure, or loss of memory could be the function of the same intrapsychic processes. Because of the unique set of problems that survivors present, Olio and Cornell also proposed some modifications in the therapeutic process. For instance, they recommended a more active stance by the therapist than is usually associated with dynamic psychotherapy. A more active approach, to their minds, would promote a 'responsive environ-

Therapeutic Approaches to Adult Victims of Abuse 105 merit' and prevent the therapeutic environment from becoming too controlling or highly emotive. They described their goal of treatment as 'integration of self and affective experience.' Davies and Frawley (1994), in a most comprehensive discussion of the psychoanalytic approach to the treatment of survivors, concentrated on some very central concepts such as dissociation and its multiple functions and the complexity that surrounds transference and countertransference. Their work was enriched by thoughtful and detailed case illustrations. Spousal Abuse The treatment literature on spousal abuse is voluminous. Five papers dealing with couple and family therapy and published during 1990s are briefly discussed here. The reason for including this particular topic in this chapter is that while there is no clear evidence of any association between spousal abuse and chronic pain, occasionally patients with pain symptoms who also happen to be in abusive relationships are seen at the pain clinic, and sometimes their symptoms may be related, psychologically and/or biologically, to the abuse. Cases of clinical relevance will be discussed in Chapter 9. It should be recognized at the outset that spousal abuse is widely prevalent and both morbidity and mortality caused by such abuse is considerable. Seeking and finding safe shelter must have very high priority. Yet, the therapeutic literature has grown in leaps and bound in recent years. The goal of such therapy is either to prevent abuse or to enable the abused person to extricate from the abusive situation and deal with the effects of abuse, such as low self-esteem, guilt, depression, and social isolation. The use of group, individual, and couple and family therapy in spousal abuse cases are all reported in the literature. Medical intervention to deal with the physical damage caused by abuse is also common. Bowker and Maurer (1987), in a survey of 1000 battered wives of whom 330 responded, found that only 8 per cent found medical intervention to be very effective and 45 per cent found it ineffective. The rest were in the middle. The availability of medical help in itself was not sufficient guarantee for proper medical intervention. Margolin and Burman (1993) presented various treatment options and argued that the choice of therapy was a function of the theoretical

106 Childhood Abuse and Chronic Pain view of abuse adopted by the therapists. Social and individual factors were determinants of treatment for the batterer or the battered for couple therapy. Couple therapy, predicated on the principles of transactional analyses, was reported by Gerbi (1994). The goal of this approach was essentially to promote an understanding of this behaviour, tone down emotional responses, and increase their repertoire of interaction. Interdiction of habitual routes to violence was its principal goal. Balcom (1991) anchored his couple therapy to the concept of shame. He claimed that internalized shame and being shame bound can make some men prone to violence within marriage, especially when coupled with male socialization patterns. Identification of shame as an issue by the couples and then working through what Balcom described as defences of shame formed the core of his approach. Chamow (1990) reported a case of couple therapy involving an abusive couple. He proposed that a combination of couple and individual therapy maximized benefit by helping the couple to develop a sense of individuation and separateness. His case represented a couple in symbiotic relationship engaged in a cycle of abusive behaviour. Kirschner and Kirschner (1992) also proposed combination of individual, couple, and family therapy to treat spousal abuse. Using a case study they demonstrated the healing role of the therapist who assumed the figure of a surrogate parent and employed techniques to reverse the balance of power between the abuser and the abused and thus mobilize the resources of both partners to begin mutual healing and reparation. DISCUSSION The treatment of children in abusive situations has come under sustained scrutiny over the past two decades or more under a U.S. government funded multi-year evaluation (Cohn & Daro 1987). Lay counselling, support groups, and group therapy showed greater success with clients experiencing sexual abuse than any other forms of abuse. Overall though, treatment efforts were not all that successful. Child abuse and neglect tended to continue despite early and often expensive treatment (Cohn and Daro 1987). Although there is no parallel evaluative program for the treatment of survivors, there is no particular reason to be sanguine about that either. A simple fact must be noted. Although the clinical literature is rich and extraordinarily varied, offering a potential therapist a plethora of

Therapeutic Approaches to Adult Victims of Abuse 107 therapeutic choices, the empirical support for many, if not most, of the therapies is sorely lacking. With the exception of group therapy for survivors, for which a limited amount of empirical evidence is available, the rest of the therapy literature for survivors remains theory driven. This may simply be a sign of the relative newness of the field, or, alternatively, it may be argued that outside of behavioural therapies, the efficacy of most psychotherapies remains untested. Even a brief excursion into a sample of the most current literature confirms the amount of experimentation that is going on in treating a very vulnerable group of individuals. Regardless of the therapeutic approach, most therapists show a very high level of agreement on the negative consequences of childhood abuse. The goals of therapy, regardless of its theoretical base, also tend to be commonly shared. That group therapy is perhaps the most commonly used, certainly more commonly reported in the literature, is perhaps not altogether surprising. This body of literature is striking for its richness. The sheer variety of therapeutic approaches in group therapy for survivors is telling. Much experimentation is associated with this particular approach. A noteworthy fact is that group therapy, unlike other treatment approaches, has received a limited amount of empirical support for its effectiveness in the treatment of survivors. Reasons of parsimony and sound therapeutic rationale seem to justify this popularity. Most survivors have shared memories, and an opportunity to bring them out into the open with each other begins to counteract the sense of isolation, badness, and guilt. This process has enormous therapeutic value. Additionally, in a group of survivors the pain and suffering is understood and accepted without any fear of contradiction. That also has great curative power. Cognitive-behavioural techniques are coming of age and the contribution of Foa and associates is cause for optimism. From all accounts, this therapy tends to be very short term, is rooted in sound theory, and the outcome studies are showing very positive results, especially in the treatment of PTSD. Family therapy does not appear to be the therapy of choice for survivors. Its application is widely reported in treating abused children and their families. For the survivor, couple therapy for the survivor and partner is a little more common, but if the literature is any indication of its application, it appears that this method is used rather sparingly. Surprisingly, psychodynamic psychotherapy is less widely used than it might be expected. Childhood conflicts and durable damage accruing

108 Childhood Abuse and Chronic Pain from them that manifests in a multitude of ways in an adult is fertile ground for such psychotherapy. Its lack of popularity, at least based on the limited literature on the topic, may be a function of training, time, and money. Long-term psychotherapy has fallen out of favour, and the cost associated with this treatment is unarguably high. Yet, a case can be made that childhood abuse and neglect with all their devastating consequences is well suited for dynamic psychotherapy.

SEVEN

Distress of Disclosure

History of sexual abuse in our pain clinic is not actively sought, and there certainly is no effort spent on finding explanation for patients' current difficulties in their childhood history of sexual abuse. Patients choose to reveal their past abuse of their own volition, sometimes after many months or even years of working with a therapist. The decision to share information about sexual abuse is filled with terror and peril for the patient. Shame and guilt are ubiquitous in this population. Self-blame is almost universal. Hence, disclosing past abuse of any kind is an act of courage as well as a time of heightened emotional distress. This distress often manifests as a crisis. I have previously described the usefulness of crisis theory to conceptualize and treat, in the short term, the trauma of disclosure (Roy 1992). LITERATURE REVIEW Before the issue of the clinical relevance of crisis theory to disclosure of abuse is considered, a brief review of the pertinent literature on this topic is presented. There is very little literature on disclosure of childhood abuse by adults (McNulty & Wardle 1994; Roesler 1994). Roesler reported on the effects of disclosure on adult psychological functioning. He compared a group of abused subjects who disclosed their abuse in childhood with a group that waited until adulthood to do so. The findings were complex. On a number of psychological and psychiatric measures the childhood disclosure group showed significantly

110 Childhood Abuse and Chronic Pain worse reaction to disclosure than did the adult subjects. Yet, the symptoms of those who waited until adulthood to disclose were just as severe as the symptoms of those who disclosed during childhood. The author noted, 'keeping the secret did not result in a better psychological adjustment in later life/ This finding confirms my own experience that disclosure during adulthood tends to be a traumatic experience and that many of these individuals remain psychologically disturbed. A very interesting finding of the Roesler study was that severity of abuse was not a factor that predicted disclosure in any particular life stage, but was related to severity of symptoms in adulthood. Another factor where the two groups did not differ was the type of abuse, such as incest or penetration. In other words disclosure was not determined by the type of abuse. The overall conclusion leaned in the direction that early disclosure in itself may or may not be beneficial. It may be reasonable to assume that early detection is preferable so that treatment can be instituted to prevent long-term psychological damage. McNulty and Wardle (1994) reviewed the psychiatric consequences of disclosure in abused patients and concluded that disclosure itself is a highly negative experience and is potentially the primary cause of engendering psychological and psychiatric symptomatology in these patients. They observed that worsening of psychological state following disclosure was a consequence of intense affect that surrounded the memory of abuse.They considered the possibility that disclosure itself may be a primary cause in the development of psychiatric symptoms. This proposition clearly lends support to the adoption of crisis intervention in the early stages of disclosure. Loss of social support was another reported consequence of disclosure. McNulty and Wardle proposed that therapists help these patients to develop strategies to cope with psychological distress and ensure that social support systems remain available to them. An important observation they made was that disclosure of abuse to intimates or professionals was not always a positive experience. West (1985), in a study of college students and family practice patients, found that only 15 per cent and 17 per cent of the two populations found that their confidants to whom they disclosed their experience of abuse were understanding. Reaction ranged from disbelief to anger in intimates, and the information was not always understood or believed by professionals. Many had regrets about disclosing their abuse. It should

Distress of Disclosure

111

be reiterated that research literature on adulthood disclosure is pitifully small, and McNulty and Wardle (1994) drew some of their conclusions mainly by extrapolation. There is much in the general body of disclosure literature addressing the medico-legal issues, especially in relation to children (Elliott & Briere 1994; Kavarola & Foy 1993; Keary & Fitzpatrick 1994). That body of literature falls outside the scope of this chapter. A few of the other aspects of disclosure of abuse by children include the psychiatric condition of children 12 months after disclosure (Merry & Andrews 1994), assessment of disclosure (Kalichman 1992), and parental response to disclosure (Everson et al. 1989; Howard 1993; McGee & Painter 1991). As noted earlier, the controversy of false memory syndrome is also a non-issue here for the simple reason that, in a strictly clinical setting, what matters is the patient's belief that the abuse actually happened. This disclosure is not made for some legal or monetary advantage, but is presented as a part of the patient's painful past, mainly to explain his or her current difficulties. Disclosure of this information is almost inevitably the product of trust between the patient and therapist. In some cases memory tends to emerge as a direct result of therapy, and in others patients never did lose their memory, but for a variety of reasons, they failed to disclose earlier. In either situation veracity of the memory is unequivocally accepted. In a secondary setting, such as a pain clinic, which by definition is far removed from any setting dealing directly with issues of abuse, such trust evolves over time, and even then patients do not readily share such information. One patient was in therapy for over a year before she disclosed an episode of rape by a work-mate and serious emotional neglect by her parents. This patient is discussed in the next chapter. CRISIS OF DISCLOSURE Limited as the literature is on adulthood disclosure, there is some suggestion that it can be a traumatic experience With grave consequences. The key question that must be asked is what is it about disclosure of events, in many instances, from many years ago that has the power of rendering a human being helpless and distraught to the point of despair. To fully appreciate this phenomenon, two points should be ad-

112 Childhood Abuse and Chronic Pain dressed: (1) the nature of crisis which requires here a brief discussion of crisis theory, and, (2) the experience of disclosure itself with all its capacity for generating powerful and even irrational and frightening emotions. A prerequisite for crisis is a negative event of such magnitude that it can render the normal coping mechanisms totally ineffectual. The sudden death of a loved one or an unexpected loss has that capacity. A feeling of being out of control is a common response. The acute phase of a crisis lasts 6 weeks or so before some form of resolution sets in. Recovery from crisis may be at the pre-morbid level - or above or below it. The bulk of the original work on crisis was conducted by Caplan (1964, 1974, 1980). He noted that crisis tended to have three phases: (1) an initial rise in tension occurs, caused by the failure of habitual problem-solving responses employed to regain homeostasis; (2) the 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. Disclosure of abuse, at least in my experience, has been observed to follow a similar path. In the absence of an event, the disclosure itself takes on the aspects of an event, not of the distant past, but something that the patient experiences anew, in the present. Such is the power of memory. In the crisis literature much debate has occurred over types of crisis. This is an important issue for our understanding of disclosure as a crisis. A crisis emanating from a sudden disaster is readily understood. Events associated with this type of crisis are generally uncontrollable, undesirable, and unpredictable. Crisis can also happen from anticipated life events and even normally occurring life-transition issues. Unresolved issues from the past have the power, in a given situation, to cause crisis. A severe anniversary reaction, where grief is experienced anew and lasts for weeks may be a function of personality, psychopathology, and an inability to come to terms with the loss. Psychopathology is often the basis for crisis in psychiatric patients. In relation to crisis associated with disclosure, perhaps none of the above explanations is entirely convincing. Disclosure of childhood abuse for many patients is an admission of enormous guilt and shame, all rooted in a massive misinterpretation of the actual basis of their suffering and a misplaced belief system. Reliving the past events is another dimension of the emotional arousal which is the basis for post-traumatic stress syndrome. A very important function of disclosure, not always evident in the literature, is the opportunity for the patients to grieve - for their lost childhood, for the loss of

Distress of Disclosure 113 trust resulting from betrayal by a parent or other adult, and for the loss of their innocence. Then there is the actual disclosure, which is associated with much risk taking in the mind of the patient. Will she be believed? Another aspect of disclosure is to reveal one's weakness and 'badness/ When some or all of these elements are present, it is not difficult to appreciate that the patient is likely to go through much emotional distress and even crisis. Crisis, as seen over the years in patients at our pain clinic, has many faces and many different origins. In some instances related and even unrelated events have led to disclosure. Incidentally many, if not most, of the incidents of abuse were disclosed for the first time in the pain clinic setting. Even when the fact of abuse had already been disclosed before, revealing that information to the therapist was by no means an easy task. Other than for one female patient, who almost casually told the story of being molested by her babysitter (a boy of 16) when she was 5 or 6, retelling of the abuse to another professional was never devoid of fear and apprehension. (This female patient had evidently worked through her conflicts emanating from the abuse long before her arrival at the pain clinic, and abuse was not an issue in her therapy there.) In the rest of this chapter a number of patients will be discussed to show the nature and types of crisis of disclosure and some ways of dealing with these crises within the constraints of a pain clinic. PATIENT 19 Mrs S was 43 years old with lower 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 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 3 years, which she declared as the best 3 years of her life. Yet, pain was interfering with her day-to-day life. She spoke of her frustration at not being able to do things and go places as she wished to because of her pain. At times even her job, which she loved, became too much. There did not seem to be any relief in sight. Exploration of her past proved difficult. Mrs S was legitimately focused on her immediate problems of some gravity. Nevertheless, her allusion to her failed relationships and generally unhappy past made it

114 Childhood Abuse and Chronic Pain 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 mentioned the last point on more than one occasion. As trust between the therapist and the patient grew, Mrs S 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 her ex-husband, that she started to cry uncontrollably and managed to blurt out that her ex-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 done so. 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 5 years old, and she then lived alone with her father. She did not have any siblings. From a very young age she 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 violent. She ran away from home when she was 16 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. Mrs S narrated her story virtually without a pause. She broke down completely when she stopped and cried uncontrollably for a long time. She remained in a state of extreme distress for the next 5 or 6 weeks. She was listless, felt uncontrollable anxiety, lost her appetite, and experienced serious sleep disturbance. Then she had periods of uncontrollable crying. She had to take time off work. She did not wish to share her story with her partner, lest he should decide to leave her. In the meantime, he was becoming very concerned for her and cancelled his engagements to be with her. She told him 3 weeks later. Arrangements were made to see her daily until the crisis

Distress of Disclosure 115 passed. The intense phase lasted some 4 weeks, following which weekly psychotherapy was instituted. Individual therapy was supplanted by couple therapy. Her partner was supportive and very understanding from the very beginning, and, overall, crisis intervention and subsequent therapy proved helpful to both of them. Comments The nature of the crisis for Mrs S 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. PATIENT 20 Mrs T, a 36-year-old woman, was referred to our pain clinic for management of chronic intractable pain associated with spinal deformity. She was referred for a psychosocial assessment as she reported difficulties in coping, depression, and lack of confidence. She was a petite individual, who evidently had difficulty in walking and did so with the aid of a cane. She was remarkably well dressed and she spoke quite freely and with ease. Her command of the English language was impressive. When this was commented on, she revealed that she was a poet, although her formal education did not get past grade 11. Almost without prompting, she began to tell her life story, which was filled with chaos and sadness. Both her parents were alcoholics. Perhaps, because of her physical deformity, she met with much rejection by her father, and mother was, at best, indifferent. Her two older sisters were favoured by their father. From a very young age, she had a sense of being different from others, and this feeling became acute during her teens at school. She became a loner, filled with self-doubt and worse, self-hate. Mrs T's problems took a serious turn for the worse during her midteens. At this point in her story, she paused and warned the therapist that she was about to reveal something for the very first time to a professional. She was asked if she was sure about her course of action,

116 Childhood Abuse and Chronic Pain and she replied in the affirmative. She prefaced her story by clarifying that while her parents were cruel to her, they did not physically or sexually abuse her. Sexual abuse came from an unexpected quarter. She had formed a casual friendship with a young man of her own age. One evening, he persuaded her to go for a car ride, took her to a secluded stop, and raped her. This rape was planned, as he had a friend waiting for them. He and his friend raped her repeatedly and then dumped her outside her house. She remained very calm as she narrated this story in some detail. She had had no one to turn to. Her mother simply would not have believed her, and she had no friends. At this point, Mrs T became very quiet and started to weep almost silently. She wept for a long time. Then she calmed down. She hoped that she had done the right thing by sharing this information with the therapist and seemed almost relieved for having done so. She went on to talk about an abusive marriage where she was physically and sexually assaulted by her husband and how she had managed to leave him. She left this session 'feeling good.' When she showed up for her next session, she was very agitated and said that after the last session she had not been able to shake off the memories of her rape. She was seriously thinking of suicide. She had attempted suicide in the past. She wondered if the therapist shared her view of herself as a totally unworthy and even a 'dirty' human being. Her overwhelming feeling was one of worthlessness combined with hopelessness. She did not wish to live. In addition to arranging to see her frequently, a psychiatric assessment was conducted to ascertain risk of suicide and necessity for hospitalization; the psychiatric opinion was negative on both counts. The patient had a very negative response to her disclosure of being raped and was suffering from a post-traumatic stress disorder. She was having flashbacks. She was clearly in a state of crisis, as all her normal coping mechanisms had broken down. Crisis intervention was implemented which involved establishing boundaries around this person, assuring some level of safety at home, and frequent contact with the therapist and the pain clinic staff. As it emerged, she was currently in a relationship with a supportive man, who himself was a victim of child sexual abuse. This man was living with her, and he agreed to take time off work to stay with her until the crisis subsided. The acute phase of the crisis lasted about 3 weeks following which weekly therapy sessions were resumed.

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Comments Mrs T's reaction to disclosure was not unusual. Although she showed some distress during disclosure, the full impact of the disclosure was somewhat delayed. Later on in therapy, she acknowledged that she was prone to flashbacks, but she had learned to cope with them, and although they caused her much dismay these flashbacks had been of short duration. She was somewhat surprised that talking about her past, would drive her 'round the bend.' She had expected to feel better by sharing her experience with the therapist. Instead, she decompensated to the point of actively considering suicide. This case serves as a major warning to therapists, especially those who may have limited experience with survivors and their disclosure of childhood trauma. Reaction can be delayed, and monitoring the patient after disclosure is of utmost importance. Mrs T's experience of disclosure turned out to be one of terror and psychological disintegration and, in the final analysis, it enabled her underlying psychiatric disorder to surface. Active treatment for her trauma was now possible. PATIENT 15 Ms O's case was presented in Chapter 5. She was a 23-year-old woman who had grown up in a chaotic household. She was of limited intelligence and reported a life of extraordinary abuse and suffering. She was repeatedly assaulted by her first husband, whose preferred site for hitting her was her chest. On numerous occasions she had been seen at hospital emergency departments, but her abuse was never explored. Her husband accidentally shot himself dead. Ms O also revealed that her father had attempted to sexually abuse her when she was 13, but she had successfully fended him off. Not until her visit to the pain clinic and this particular session, Ms O informed us, had she been asked about her past. No one had asked her, and she had never volunteered to talk about it. Her reluctance to disclose was complicated by the fact that when she had tried to tell her mother, she was met with indifference at best and blame, at worst. Ms O's response to disclosure was a far cry from the last two cases. On reflection, Ms O had come prepared to share her story and needed minimal prompting. One surprising element of the story was that the health care system had shown little or no interest in her condition to

118 Childhood Abuse and Chronic Pain pursue either the psychological basis for her pain or the physical cause of her chest wounds on many visits to the emergency department of various hospitals. This patient reported having a great sense of relief after disclosure, and this feeling persisted. Unfortunately, this young woman continues to be in a problematic relationship. It is not physically or sexually abusive; rather, she describes her boyfriend as playing 'mind-games' 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 end this relationship. She made a suicidal gesture following her boyfriend's refusal to come home one evening. She took seven 5 mg pills of Valium and drank eight bottles of beer. As soon as she had done that, however, she became fearful of dying and kept walking to keep herself awake until her head cleared. Comments From a crisis point of view, Ms O did not find disclosing to be particularly distressing. It certainly did not assume crisis proportions. On the contrary, she reported feeling somewhat relieved that finally she was able to tell her story without fear of contradiction or disbelief. In the remainder of this chapter, two more patients who were discussed in previous chapters will be revisited and examined from the viewpoint of disclosure. These two cases are somewhat unusual in that one involves a woman in her sixties who was in a longstanding marital abuse situation (Patient 16 in Chapter 6) and the other is a patient, only 29 years old, whose father was convicted of molesting his grand-daughter, the patient's niece (Patient 2 in Chapter 3). PATIENT 2 As Mrs B was discussed at some length in Chapter 3, only information relevant to disclosure is presented here. When 29 years old this patient was referred to the pain clinic, some 6 years after an automobile accident that caused her to have a whiplash-type injury. She was married to a very supportive man, and they had one little daughter. Mrs B was described to me by one of the clinic physicians as 'terribly sad.' He could not account for this sadness, but was quite sure that her 'medical' condition could not possibly explain it.

Distress of Disclosure 119 She was indeed very sad, as though in a state of acute grief. She gave an account of her childhood which was almost entirely negative. She complained that her pain had worsened to the point that she could no longer function in her job as a clothing store manager. She was feeling very guilty for her inability to take care of her child. Recently, her father had been charged with sexually molesting a 3-year-old-child, her niece. This event had triggered her own memory of sexual abuse by her father. She had become obsessed with these thoughts and was afraid of 'going mad.' This was her disclosure. Other than to her husband, she had not been able to talk about this to anyone. Mrs B grew up in a thoroughly chaotic family. The second youngest of nine siblings, she was raised by her two oldest sisters. Her father was an alcoholic and very abusive of his wife and children. While having no direct memory of her own abuse, Mrs B had been informed by her siblings that they had all been sexually molested by their father and that she had not been not spared. A most intriguing aspect of Mrs B's history was her almost total amnesia of childhood events. She literally could not remember any major family event from her childhood, although from age 12 onwards her memory was significantly better. She surmised that her 'memory loss' was perhaps a sign of a terrible past. Mrs B's mother had been distant and aloof and very much a victim herself. She had had nine children, was married to an alcoholic, and was subjected to physical and verbal abuse. She was probably also aware of the children's abuse by her husband. Her capacity for mothering had been significantly compromised, yet she had tried to be a 'good mother.' Mrs B had a very frightening experience when she was 18 years old. She had had a history of occasional back strain for which she got a back rub from her mother (the symbolic aspect of this behaviour is that pain evoked a caring response from a parent). On this particular occasion, mother invited father (or he offered) to continue the back rub as she got up to answer the phone. The father, in the process of giving the back rub, started fondling her. Mrs B was so startled by this development that she ran away from home. She then had the good sense to seek treatment for sexual abuse. She managed to get her life together to the point that she married, had a daughter, and completed high school. She rose through the ranks in retail trade and reached the position of a manager at a large clothing store.

120 Childhood Abuse and Chronic Pain A recent event had triggered a chain emotional reaction that posed serious threat to her psychic and even physical integrity. Mrs B was surprised and frightened by her reaction. She was only vaguely aware that her emotional turmoil was triggered by her father's conviction for child molestation. She had tried to talk to her husband, but he was less than supportive. His advice was that her father's conduct was predictable, and it was high time for his wife to leave the past behind. From a psychological viewpoint, Mrs B was in serious difficulty. Her symptoms were a mixture of acute anxiety mixed with feelings of overwhelming sadness. She could not put into words what she felt towards her father. She showed very little anger. All her feelings were focused on herself, and careful exploration brought to the surface her 'loathing' for herself. This horrible incident, she said, had revived her feelings of being 'dirty and unworthy.' This latter feeling was substantiated by her apparent lack of interest in her young daughter. She was a horrible mother, she proclaimed. Intervention called for crisis management, but was complicated by her husband's very hostile attitude to any suggestion of psychological therapy. Her condition was conceptualized as massive decompensation (a common feature of crisis) triggered by an extremely emotionally charged event. In that sense, this was a classical crisis where there was an event of such magnitude that it rendered the patient almost totally incapable of employing her normal coping techniques to deal with stressful situations. She was seen for a couple of sessions, following which she was persuaded by her husband to discontinue therapy. Fortunately, she remained involved with one of the clinic's physicians, who was able to monitor her mental status and also provide a great deal of psychological support. After about 2 months following the 'event,' she began to regain her sense of mastery and started on the path to recovery. Comments It is worth reiterating that despite her pain problem, which brought her to our clinic, Mrs B was a very well-functioning human being. She was a mother, a wife, and held a responsible full-time position. Those factors were in her favour in terms of recovery from her latest trauma. However, when her father offended against a child, her defence that

Distress of Disclosure 121 somehow she had escaped sexual abuse as a child was no longer very tenable. She did not recover her memory or experience any flashbacks, but her level of anxiety and depression combined with the feelings of being out of control created a state of panic for her which she described as intolerable. PATIENT 16 Mrs P's case was presented in Chapter 5. This 62-year-old woman was referred by her gynaecologist following a hysterectomy. Although the surgery went smoothly, she continued to complain about severe pain, which she was convinced was a result of the operation. During her first visit, she was accompanied by her husband, who stayed in the waiting room when she entered my office. Obviously in distress, she began by giving a detailed account of her health and the origin of her pain complaint. She gradually collected herself, but as she approached the end of her story and her disagreement with the obstetrician, she became very distraught. She then told the story of how two days after surgery, she had been visited by her surgeon. In the course of an internal examination, she claimed, he deliberately hurt her. The pain was so intense that she screamed and was told not to be a baby. Mrs P was convinced she had been sexually assaulted by this physician. She told this story to only her husband, who did not believe her. At this point, with her permission, he was asked to join her. He was quite indifferent to his wife's distress and dismissed her story as plain fantasy. His response opened up a potential avenue for exploring their marital relationship. Mrs P was unwilling or perhaps unable to pursue the matter, other than to express the opinion that he (Mr P) never ever took her side on any matter, at which point, Mr P stormed out of the room. Mrs P revealed that a few years into her marriage, she had noticed a change in her husband's attitude. While he had always been critical of her, gradually his criticisms gave way to shouting at her and humiliating her in public. She gave several examples of how he had openly criticized her for ineptness and stupidity. This state of affairs had continued for several years. Once her son left home, her husband became increasingly menacing towards her. When she was in her early fifties, she was diagnosed with clinical depression and was placed on antidepressant medication. She did not disclose her

122 Childhood Abuse and Chronic Pain domestic situation to the psychiatrist or her family physician. She explained that they would not have believed her. Everyone seemed to regard her husband as a friendly and charming individual, and she was fearful of ridicule if she accused him of abusing her. Even her son had difficulty accepting this when she finally told him. The abuse had gradually escalated to more incidents of choking and a year before she was seen at the pain clinic, she was hit on two occasions in her left shoulder area. She became increasingly fearful of inviting her husband's wrath. On one occasion, he lost his temper when she disagreed with him on some trivial matter. He became enraged, put his hands round her neck and shook her vigorously. As the story unfolded, her original complaint about the surgeon receded into the background as did her pain complaint. During this entire period, she remained in an acute state of anxiety. The primary focus of early therapy was to ensure her physical safety and reduce her level of fear and anxiety. Yet, she did not want to leave her husband. Neither did she want to involve him in conjoint therapy. Her feeling was that being involved in the pain clinic alone would prevent her husband from engaging in abusive behaviour. Gradually, over some 3 months, she regained her composure and informed her husband that she had informed the therapist of his behaviour. His attitude was one of defiance. At the same time, she began to notice a change in his behaviour towards her. He left her alone, which was, more or less, what she desired. She stayed in therapy for some 18 months and made very good progress. Comments This case is of special importance as the abuse was ongoing, which accounted for much, if not all, of her distress. Her immediate safety was an issue. She created a quandary for the therapist by her decision to stay with her husband. Fortunately, her assessment that the pain clinic served as a safety net was correct. She also took some risk in informing her husband that she had shared with the therapist information about his abusive behaviour. Again, that proved to be quite effective in preventing further episodes of abusive behaviour. This patient's attitude towards the therapist was, 'Now that I have you on my side, I have nothing to fear.' She did not wish to be referred to a safe house or any other program for abused spouses.

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DISCUSSION Unfortunately, the issue of disclosure of adult survivors must be recognized as a highly under-researched topic. Even the clinical literature is negligible. Yet, clinicians have to deal with disclosure of adult survivors on a routine basis. In this chapter a case has been made that crisis theory lends itself to conceptualizing and intervening with disclosure. Normal signs and symptoms associated with crisis are commonly found in disclosure situations. In the absence of a discernible event, the disclosure itself assumes all the attributes of a highly negative event. Reliving the past with its intense and painful emotions recreates the abusive situation in the present in a remarkably realistic way. Past and present tend to get blurred. Crisis is also an opportunity to intervene as the normal defences are usually absent or significantly down, and this creates the right environment for change. Proper management of disclosure can and does lead to substantial amelioration of pain, shame, and the humiliation of abuse. This observation is purely clinical, and empirical evidence is called for to substantiate this hypothesis. At a commonsense level and based on what is known about the efficacy of crisis intervention, this is an entirely reasonable hypothesis. The patients discussed in this chapter presented many different faces of disclosure as well as differing responses to the event. It is true that many if not most find disclosure to be a traumatic event, but that is not inevitable. One of the patients experienced relief upon telling her story and feeling that at last she was understood by the clinician. In other instances, some specific event triggered the crisis which culminated in disclosure. The patient who had abdominal surgery and felt violated by the surgeon was a case in point. In another case conviction of a father for child molestation caused major emotional trauma, again resulting in disclosure. This case was especially interesting as this patient had had treatment for abuse in the past. Yet, the power of the recent event caused a major relapse. Another point of note was that these patients showed various levels of functioning. Some were functioning very well, others were not. Despite their high level of functioning, the experience of disclosure caused considerable emotional disarray. The only person who failed to react in a strong manner was also a person who had had great difficulties in virtually every aspect of living.

124 Childhood Abuse and Chronic Pain Short-term intensive intervention, in the face of a disclosure, appears to have some merit. Most of the patients described above had longer term therapy. None of them was referred to more specialized treatment facilities for survivors. The patients had a very strong connection with the pain clinic and showed a marked preference for the clinic to deal with the issues of abuse. Three out of the five patients responded positively to both crisis intervention and the long-term treatment that ensued.

EIGHT

Therapeutic Issues

A review of the treatment literature for survivors established that a wide variety of interventions were available and much experimentation with novel treatment methods was apparent. The literature also showed that not much outcome research was available to guide the therapist about the choice of treatment. Nevertheless, a group approach was by far the most preponderant form of treatment, and the sheer variety of group approaches employed to treat survivors was impressive. As was discussed in Chapter 1, there are many ways of explaining and understanding the abuse-pain relationship, and it is more than likely that methods of treatment based on specific theoretical constructs will emerge in due course. Within the confines of a pain clinic, the range of expertise available is limited. I have employed a psychodynamic approach to treat patients with a history of abuse. This is more a function of my training than any other factor. It must be recognized that this method of therapy is not being offered as a panacea. In the absence of any treatment literature for abused chronic pain patients, this chapter provides an opportunity to explore treatment issues. The treatment that I am most experienced with is a combination of short-term therapy, as proposed by Malan (1979), and some of the features of Sifneos's Short Term Anxiety Provoking (STAP) technique (Sifneos 1979). Both of these are complex methods, and any reader interested in them should refer to the source. It must be pointed out that because of my background in social work, I always view and seek to understand the person in the context of the environment. The patients in this chapter will purport to show that without an adequate understanding of the current social and family

126 Childhood Abuse and Chronic Pain issues of a patient, a proper conceptualization of the case cannot be achieved. At times, some cognitive techniques make their way into the therapy I use. Eclectic is perhaps the best way to describe my treatment method, whereby the critical significance of the past as it affects the present, which is the underpinning of psychodynamic psychotherapy, is the major influence in my efforts to treat this patient population. Psychodynamic psychotherapy is certainly not commonly employed in treating chronic pain patients. There are several reasons for this, the two most prominent being (1) the patient's general unwillingness to engage in that form of therapy, the root of which can be found in her or his unshakable belief that the pain has some kind of physical origin, and (2) most of the patients would fail to meet one of the indicators for this type of therapy, significant childhood events that might, at least, in part explain their current predicament. The third objection is that there is no empirical evidence in support of this therapy for successful treatment of chronic pain. Nevertheless, Pilowsky and Bassett (1982) summarized the thrust of psychodynamic psychotherapy in the following words: 'A patient's symptoms and problems are meaningful creations of the patient, but the meaning may be more or less outside his awareness.' Engel's view of pain being regarded as punishment by abused patients, substantiated by Toomey et al.'s (1993) findings, furnishes such an example: 'Treatment involves helping the patient achieve awareness within the context of a confiding and safe relationship with the therapist.' This condition will become clear in the case examples that follow. Several patients are discussed here for the purpose of illustrating treatment issues and to give the reader some idea of the nature of therapy. To do justice to any description of the therapeutic process, a very detailed, almost session-by-session account and presentation of the entire therapeutic process is called for. That temptation has been avoided here because I feel that a separate book would be required to fully discuss that topic. Patients selected for this chapter cover a wide range of abusive situations. Most, but not all, of the patients' past issues of abuse assumed a central place in therapy. In others, here-and-now problems remained central. PATIENT 3 Mrs C was discussed in Chapter 2. At age 30 she came to our clinic with a long history of migraine headaches. Despite a variety of treatments

Therapeutic Issues 127 her pain persisted. She was still employed; however, over the previous few months her pain had been getting worse. As a child, this patient had been physically and sexually abused by her father, who deserted the family when she was 4. Just prior to her father's disappearance, her mother was diagnosed with multiple sclerosis and hospitalized soon after that. From age 4 till about 14 Mrs C was in eight foster homes. She was frequently abused by foster parents, but even more so by her older sister, placed with her in these homes. At one point, with the assistance of her sister, she attempted to set up a home for their mother. This did not work out. She and her sister continued to quarrel and even had physical fights. At 17 she left home. Mrs C married an alcoholic who subjected her to brutal physical abuse. After 3 years of marriage, she divorced him and then lived by herself for a number of years until 3 years before first coming to the pain clinic, when she had started living with her current partner. This relationship, while quite satisfactory on the surface, was not without tension. Her partner was a professional musician, which meant that he was frequently away from home, and this was a source of some grievance for the patient. Beyond that, the relationship was viewed as satisfactory by both partners. Just prior to her admission into the pain clinic Mrs C had had a major altercation with her sister, whom she had not seen for some time. When they did meet an argument broke out, and very soon they were in a physical fight. Mrs C was extremely distraught by the situation and could not get it out of her mind that she should have such a horrible relationship with her only sibling. She became increasingly preoccupied with this issue and during this time began to have more frequent attacks of severe headache. She began missing considerable time from work, and this fact eventually brought her to the clinic. Brief Review of Treatment Mrs C was seen over a period of 8 months. Her intrapsychic conflicts emanated from a sense of guilt over her father's desertion when she was 4 years old, particularly as this coincided with her mother's illness; the mother died when Mrs C was in her late teens. Mrs C harboured an inordinate amount of hostility towards both her parents, and this was a major source of guilt. The picture was complicated by her perception that she had contributed to the separation of her parents which had caused her mother's illness and death. She experienced pain and anxiety over not being able to look after her mother as she grew up.

128 Childhood Abuse and Chronic Pain Raised in foster homes from a relatively young age, this patient had internalized a great many of her feelings, and her physical pain served two important functions: It became a way of communicating her distress and pervasive feeling of helplessness. At the same time, this was a simple way for her to receive a measure of succour and nurturing. At the interpersonal level Mrs C's problems seemed to centre on her inability to trust and her basic lack of confidence in herself which left her vulnerable in any relationship. As already stated, her marriage had lasted 3 years during most of which time she was, once again, both physically emotionally abused. In the course of her treatment Mrs C developed considerable insight into her feelings of guilt and recognition that the situation was well beyond her control. She also developed some understanding of the function of her headaches. She recalled the 'hurt' caused by her father when she was very young. She demonstrated more willingness to express her negative as well as positive feelings, and this had a salutary effect on the relationship she had with the musician. She was able to convey to him quite categorically that she did not like his absence from home, and he was able to make a change in his employment to spend more time with her. She also made an important decision about a career change. She continued to have some headaches. However, both the intensity and frequency of her head pain was substantially reduced. PATIENT 21 Mrs U also presented with headaches of many years duration which had failed to respond to treatment. The headaches had not interfered with her life to any great extent until quite recently and, by and large, she had a happy home and marital relationship, but of late the situation had significantly deteriorated. She had been the only child in a family where the mother was very cold and distant and the father was stern and punitive. She had felt thoroughly unappreciated and unloved in that family. She recalled feeling lonely, isolated, and unwanted. This was more a case of neglect than abuse. Mrs U left home at 16, lived on her own, and worked until she married at age 30. She had viewed her marriage as satisfactory from all accounts until a year or two previous when her husband had started working away from home. He was at home only at weekends, and this coincided with their only son, who was 17 at the time, becoming some-

Therapeutic Issues 129 what rebellious and difficult to control. The husband on his part did not see any problem with their son. It was also at this time that the patient's headache problem became exacerbated, and she clearly recalled having the same feelings of abandonment and being unloved as she had had as a child. Treatment Issues Mrs U was seen in supportive psychotherapy for a relatively short time, and the focus of intervention was to help her resolve her dilemma over her husband's absence, recognizing her son's adult status, and developing interests away from home and family just for herself. She discontinued treatment after about ten sessions reporting improvement in her headache and family situation. As was noted earlier, Mrs U was seen in supportive therapy, and the history of the therapy was rather chequered. She was very resistant to discussing her past and dropped out after a few sessions. She focused on the 'here and now' issues, especially the conflict with her son, displacing anger at her husband who was home only on weekends. She experienced an exacerbation of her headaches which coincided with her husband's out-of-town employment. While she recognized that he was doing it out of necessity, she nevertheless felt rejected. Her son's disobedient behaviour did not help. Mrs U's headaches served a very important function in the family. She claimed that she lived for others and especially her family. She boasted that in their long marriage she had never had an argument with her husband. She felt ignored by the two men in her life except when she had headaches. They 'fussed' over her when she was unwell. Her husband even stayed at home then to look after her. To what extent Mrs U benefited from her brief encounter with psychotherapy is moot. She reported improvement with her headaches and then dropped out of the clinic. In the meantime she did become more aware of her repressed anger, her desire to please, and her tendency to internalize all her feelings, especially in relation to her husband. Malan (1979) described several patients demonstrating 'simple problems that are accessible to common sense,' and presumably Mrs U's case could fit that description. At the very least she recognized that the source of her frustration was not her son, but her husband. She also developed some insight into the purpose of her headache. Her abusive past had robbed her of much self-esteem.

130 Childhood Abuse and Chronic Pain PATIENT 8 Mr H's case was presented in Chapter 4. At age 24 he was referred to the pain clinic by his neurologist for significant worsening of his migraine headaches, the history of which stretched well back into his childhood. In fact, he could not remember a time when he had not had headaches. It was the exploration of his childhood headaches that led to the unfolding of the abuse that had been heaped on him as a child. He was born into a chaotic household, being the second in the sibline of eight children. He could not clearly recall exactly when his father had started hitting him. He was probably not even 2 when it had started. Brief respite came when he was removed from home by child care authorities when he was just over 2 years old and returned at age 5. The beatings started in earnest when he was returned to his parents. His father's favourite site for hitting was Mr H's head. He was slapped and hit with shoes or the metal end of a belt. The abuse continued unabated, and the patient became increasingly resentful of his mother for her 'lack of willingness' to do anything. School holidays were most dreaded of all. He vividly recalled the summer when he was 7. He was not sure what he had done wrong, but his father took serious offence and decided to teach him a lesson by confining him to his room for the entire summer vacation. During this period he was beaten regularly. Abuse and deprivation continued for the next 5 years. Then, when Mr H was 12, his father shot and killed himself in front of the entire family. In summary, Mr H was a severely abused young man, whose choice of head as his site of pain was more than a coincidence. Physical abuse, a harsh punitive childhood, unresolved issues around aggression, social and emotional isolation, and a singular inability to express feelings were the hallmarks of this case. Much of his unhappiness and conflict found expression in headaches. Treatment Issues Mr H had an abusive father who not only beat him on a regular basis, but one year kept him locked in his room for the whole summer - for over 2 months. Mr H remained in treatment for a year and a half. Initially, he was totally preoccupied with his father's brutal behaviour towards him and how delighted he had been over his father's suicide. This posture began

Therapeutic Issues 131 to ebb and was replaced by a more remorseful attitude. Mr H began to wonder what kind of a life his father had had that had led him to drink and do the horrible things that he did to all the members of his family. Simultaneously, Mr H reflected on his mother's inability and perhaps even unwillingness to intervene on behalf of the children and protect them. Mr H became very depressed and tearful, and this was accompanied by marked exacerbation of his headaches. He cancelled several appointments and locked himself up in a darkened room. He returned looking extremely ill, stating that at long last he knew why at times he had felt so resentful of his mother and her demanding ways. He felt that his mother was as guilty if not more so than his father for abrogating her duty to protect the children. Mr H could not recall a single time when his mother had tried to intervene on his behalf when he was being beaten by his father mostly around his head either with a stick or shoe. Mr H stayed in this stage for several months during which time he severed whatever remaining connection he had with his mother. As the therapy progressed Mr H's overly sympathetic attitude towards his father diminished, and the excessive display of hostility towards the mother also subsided. In other words, a more balanced view of the situation began to take shape within him. He began to seriously contemplate marriage and a change of career. Mr H was in a semiskilled job, but he was very articulate and intellectually above average. For most of his adult life he had felt that he was destined for better things. At this point, he found that he had a genuine gift to be a professional disc jockey, and he gave up his secure employment to follow a career in show business. At the time of the termination of therapy, Mr H was for the first time in his adult life free of any narcotic analgesics and on no pain medication. In fact, during the last 3 months of therapy he became painfree and continued to maintain his improvement in the subsequent follow-up. PATIENT 17 Mrs Q's case was discussed in Chapter 6. By age 35, which is when she was referred to the pain clinic by her neurologist, Mrs Q had a longstanding history of mixed headaches. Although the headaches were very severe, she rarely missed work because of them. Sometimes she

132 Childhood Abuse and Chronic Pain 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 single most important problem to emerge in this case was Mrs Q's complete disillusionment with her marriage. She had married on the rebound, having been engaged to another man who failed to show up on the wedding day. Then came the important clue about the troubled nature of her primary relationships. Mrs Q's mother had become infuriated with her for disgracing their entire family with the cancelled wedding, while her father had simply remained silent. Having disclosed this, Mrs Q then refused to discuss her parents any further for a long time. She described her husband as authoritarian and at all times at the beck and call of his mother. In addition, he had a violent temper. While he had never actually hit her, she had conscientiously striven not to give him any cause. There was no friction in the family. However at times she felt like a non-person. Still, had the children and her job, and felt 'content' until 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. It was then that the idea occurred to her, vaguely, that some day she was going to have to leave this unfeeling man. Gradually, she revealed that one had to know her mother to appreciate why she (Mrs Q) 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 had probably never wanted her. She was the only child of parents who had been 'quite old' when she was born. She was unable to recall any happy childhood memories, although she had liked being around her father when he was home, which had not been often. When asked to illustrate with an example of her mother's hostile attitude towards her, Mrs Q said that, for one thing, she could never please her mother. She had liked school, but she had not had any close friends there, and she had not been allowed to invite friends home. Later, at work, she had been raped by a fellow worker. This therapist was the only person in whom Mrs Q confided this information. Summary A neglected upbringing combined with an oppres ve marriage mitigated against Mrs Q's self-esteem. Her life was devoted to the well-

Therapeutic Issues 133 being of others. She was in a nurturing position without having had any of her own emotional needs met. It is reasonable to assume that her head pain was one source for seeking and receiving nurturance. Treatment Issues Mrs Q's therapy was prolonged, and, for the purposes of clarity, the therapeutic issues and the progress of therapy are discussed under 'Here and Now' issues and 'Past Issues.' Here and Now Issues

As already reported, Mrs Q's marriage was unsatisfactory. She had married after a very short courtship and on the rebound. For a long time she steadfastly refused to discuss her parents. Mrs Q had soon learned that the man she had married was authoritarian and very much his mother's boy. He also had a violent temper. While he had never actually hit her, she had never given him any cause to. She had two daughters and learned to do as she was told. There was no overt friction in the family, although at times she felt like a non-person. She made sure that her husband remained unaware of her disaffection. When her husband made a career move without any consultation with her, Mrs Q promised herself that she would leave him some day. Given the nature of marital conflict, the question of couple therapy was discussed, but she categorically refused even to entertain the idea. She had no intention of saving this marriage. Very little progress was made in therapy during the first year. Yet, she was insistent on continuing therapy and attended each session without fail. She had shown little or no emotion and refused to express opinions on any matter. It was the pursuit of this latter issue that had a profound effect on the therapy - and its ultimate outcome. Past Issues

Mrs Q's high tolerance of unpleasantness and her close to total commitment to maintaining peace almost at any cost was nothing short of remarkable. These two issues were slowly and methodically explored, and she, almost for the first time, began to reveal her painful past. Her mother was almost a tyrant, whom Mrs Q just could not please. Mrs Q grew up to be a shy, passive, and compliant individual. She completed high school and entered college to train in the health care field. She lived at home and had very little in the way of social life. But

134 Childhood Abuse and Chronic Pain she had enjoyed her work and not been particularly unhappy. Her world was turned upside down by an event which made her retreat further into herself, and it had a profound effect in shaping her view of herself and the outside world: 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 the rape. She said she did not tell her mother because she felt her mother would not have 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 at 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 had been 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 her 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 totally failed to see her distress after the rape incident, and she concluded that they just did not 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 of the shame of being raped was just too great; she said that she felt dirty and in some ways responsible for the rape. Mrs Q continued in this vein for the next 4 months or so. Then a rather surprising event took place. Mrs Q 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 Q was slowly coming to terms with her past. To complicate matters her husband became seriously ill, and she nursed him through his illness. This event, however, did not change her resolve to leave him. She returned to the main theme in her therapy: her birth family. Her mother had basically been uncaring, but then she herself had not had such a great life. Mrs Q 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 Q 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

Therapeutic Issues 135 woman, and to that extent they had much in common. Her view of her father was also becoming more realistic. She was bringing him down from the pedestal, and he did not seem quite as benign and kindly to her as she had had imagined him to be for much of her life. Therapy continued for another 6 months, during which her selfesteem altered to a visible degree. She saw herself as somewhat of an unwitting victim. She could not be blamed for all the terrible things that had 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. Having made all the necessary arrangements, and having prepared her children, she informed her husband about her decision to leave. He went into a deep depression and sought psychological help. She left him, but stayed in touch, and he had unlimited access to the children. Mrs Q had achieved her goals. She still had headaches, but they were manageable. She was discharged from the clinic. Treatment Issues The point of note in the case of Mrs Q is that the childhood issues here cannot be classified as abuse or even neglect in the strictest sense. The patient was unloved and grew up feeling unwanted. However, it is critical to have some appreciation of the genesis of Mrs Q's guilt. 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 two experiences of being raped by a person she knew and by being abandoned at the alter by her fiance. Mrs Q, thus, accepted her husband's unkind behaviour with silence and fortitude. Engel's theory of pain-proneness was the heart of the conceptual understanding of this patient. Growing up in an affectionless environment, guilt, and the use of pain for expiation of guilt were all to be found here. The second half of the treatment was modelled on Malan's

136 Childhood Abuse and Chronic Pain dynamic psychotherapy, which entails systematic exploration of childhood experiences and dismantling of dysfunctional defences. In due course Mrs Q did leave her husband and set up a home for herself and her children. Her headaches improved, but did not disappear, and she was managing them without narcotic analgesics. Followed up for the next 2 years, she continued to show signs of ever increasing independence. She had 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 Q acknowledged that she was no longer constantly seeking approval. DISCUSSION Three patients reported improvement in their pain and were discharged from the clinic. One dropped out, and another did not improve. Unfortunately, there are no outcome studies related to the efficacy of dynamic psychotherapy with chronic pain patients. These four patients were seen in psychotherapy for varying lengths of time. The theoretical base for psychotherapy was drawn from the work of Malan (1979). Sifneos's (1979) influence is also evident in my approach, although it should be stated that short-term anxiety-provoking psychotherapy (STAFF) with its oedipal focus was not strictly implemented. The work of Pinsky (1975) and that of Pilowsky and Bassett (1982) were also helpful in clarifying some issues and certainly in providing further justification for the use of dynamic psychotherapy with patients with chronic pain. Dynamic psychotherapy was thought to be most efficacious in these cases, given the nature of the early childhood problems and the persistence of interpersonal difficulties in adulthood. Exploration of intraand interpersonal conflicts with focus on the genesis of guilt, reorganization of defences, and reconstitution of self-esteem was the central thrust of intervention. The focus was on the person rather than the symptom of pain. Transference was encouraged, and working through the issues of transference with the therapist was the main thrust of the therapeutic process. Since the problems in all four cases were rooted in family upheaval, physical and emotional punishment, and guilt, in varying degrees, it stands to reason that the intervention was based on an understanding of the family dynamics. In a secondary setting, such as a medical clinic, treatment of past abuse has to be undertaken with caution. First and foremost, skilled

Therapeutic Issues 137 clinicians must be available. In the absence of that, patients must be referred to experts. In the pain clinic in question most patients were unwilling to be referred out. An added advantage of keeping them in the clinic was that their current pain problems and their history of abuse were theoretically combined under the concept of pain-proneness, and the expectation was that successful treatment of the abuse issues would also ameliorate the pain. That was true in some, but not all, of the cases. It must be emphasized that dynamic psychotherapy is not a panacea, and its success in the treatment of pain and abused patients awaits empirical validation. Exploration of the family dynamics and their impact on the emotional and psychological growth of the patient is likely to be effective. For the most part, these patients were seen on a weekly basis. Occasionally, the frequency was higher during the early phase of treatment. For our present purposes, the therapeutic process was substantially telescoped.

NINE

Epilogue

This chapter re-examines the major issues discussed throughout this volume. If there is a central message contained in this book, it is that childhood abuse and pain have a complex relationship. The task of identifying it is difficult in a medical setting. Yet, once it is identified and addressed, the outcome can be very positive, and, potentially, it can change the life of the patient for the better. Pain remains probably the least known outcome of childhood abuse, and this is borne out by even a casual examination of the literature. The reason for this omission is that the much discussed outcomes such as depression, post-traumatic stress syndrome, and anti-social behaviours, especially in abused men, are more prevalent and certainly more visible. Nevertheless, the empirical evidence for an association between abuse and pain, while still building, merits attention. Beyond chronic pain, 'physical' disorders as long-term consequences of abuse require further scrutiny. RESEARCH ISSUES To recall some of the salient points from the reviews of the literature, the first and foremost issue has to be the quality and quantity of research. It can be said, without engendering debate, that on both counts, research on the question of abuse and pain, though constantly improving, falls short. So far as the quality is concerned, Fry's assertion that any such link has not been convincingly demonstrated is substantially true. Substantially, because the direction of findings, despite some methodological shortcomings, such as selected samples, suggests a

Epilogue 139 positive association. Drossman and colleagues presented a more optimistic picture. The benefits of improved research design should be brought to bear on future investigations. Simple correlational studies must give way to more complex methodology to establish causal links. Having said that, it has to be acknowledged that the whole field of abuse and its health consequences has progressed to a point, from a clinical viewpoint, where the evidence has to be taken seriously. Engel and Szasz gave us the clinical tools to understand this relationship from a psychodynamic perspective. The work of Adler and associates and Egle and associates has lent some empirical support to their proposition. Others have proposed alternative theories, cognitive, psychophysiological, and physiologic, to explain this relationship. Those propositions should also come under scrutiny. A point needs to be made about abuse in adulthood and its relationship to the development of chronic pain. This association is moot because related research is very scarce. There is some suggestion in the abuse - pelvic pain literature that some of the patients were abused as adults. Therefore, the discussion on spousal abuse and pain discussed earlier must be regarded as tentative. Clinically, this association has significant implications for treatment. CASE FINDING The responsibility of identifying such a relationship and providing effective treatment is entrusted to clinicians. The first and foremost task of any clinician working in a pain clinic is to recognize the significance of childhood abuse. Most clinicians, regardless of specialty, now have a greater awareness of major depression in these patients. Most, if not all, clinicians involved in the treatment of chronic pain are acutely aware of a complex relationship between chronic pain and depression. This state of affairs was not achieved without persistent attention given to this matter in the pain literature. Sadly, however, the topic of pain and abuse has received only sporadic treatment in the mainstream literature. In fact, there exists a vacuum in the literature as far as treatment of pain patients with history of childhood abuse is concerned. Case finding is a problematic issue. Abuse in the chronic pain population may not appear to be very pervasive. Incursion into this area of a patient's life may not be welcomed by the patient. It could be construed

140 Childhood Abuse and Chronic Pain as invasion of privacy by some. 'What has my pain got to do with all this?' may be the sentiment expressed. As it is, chronic pain patients are besieged by doubt about the veracity of their pain complaint, and any suggestion that their current pain problem might be somehow related to childhood abuse must be untenable to many. A safer approach is to incorporate a few questions related to childhood in routine investigation. Many pain clinics use standard questionnaires for patients to complete at the point of admission. That may be another opportunity to obtain some basic developmental information pertaining to home and school. During psychosocial investigation, case finding can occur under two different situations. First, and by far the most common (in our pain clinic), are patients who simply allude to their experience of abuse as part of growing up. Second, and this is more complex and rarer, are those patients whose memory of abuse surfaces in the course of psychotherapy. The limitation of this observation is that it is confined to one person's experience. Nevertheless, as a starting point, in the process of investigating relevant past experiences of pain (and frequently depression) any and all clinicians can ask simple questions about negative childhood events or memories. Questions such as 'What is your early memory of pain? Were you ever hit so that it caused you pain?' Questions must be pertinent to the patient's main concern, which is pain. That alone may reveal pertinent information regarding abuse. This approach is analogous to the investigation of mood, suicidal ideation, and other psychosocial issues routinely incorporated in the medical investigation of chronic pain patients. In other words, clinicians~ need to recognize the intrinsic value of this information as its revelation might lead to a comprehensive reassessment to determine its significance in relation to the presenting pain problem, in particular, and the patient's overall well-being, in general. TREATMENT ISSUES Stories of some 21 patients were discussed in this book. They had one common factor binding them and that was abuse experienced either in childhood or as adults. Most of these patients disclosed their abuse for the first time in the pain clinic. Not one of these patients themselves made any kind of connection between their abuse and pain.

Epilogue 141 The message value of pain to communicate their abuse was strong in several cases. It must be emphasized that pain was not necessarily psychogenic, and several patients had organically caused pain. This is an important point because any type of symptom regardless of its etiology can and does have a message. The task of unravelling that message is difficult and intricate. Types of abuse include physical, sexual, and emotional. Sometimes, all three were embedded in a single case. Without risking the danger of any exaggerated claims, and strictly clinically, many of these patients made significant gains as a direct consequence of treating the abuse experience in a therapeutic environment. The actual proof of amelioration or modification of pain once abuse issues are treated remains an uncharted territory, and only carefully designed controlled studies can provide a definitive answer. In the meantime, however, pain clinic clinicians have to operate on the basis of the postulate that if abuse in some ways contributed to the formation of pain, treating those issues may indeed be beneficial. This is not an unreasonable view. The treatment strategy for this group of patients is essentially based on very limited guidance from the literature. Psychodynamic psychotherapy, even from a commonsense perspective, with its focus on childhood issues that shape the patient's adult personality and conflicts, often manifesting in somatic symptoms, appears to be a reasonable treatment of choice. Both Engel and Szasz discussed such an approach. Other treatment approaches such as behavioural, cognitive, or group therapy, have not been reported to any extent. With the exception of group approaches, this is also largely true of the treatment of abuse victims in general, as was evidenced in a previous chapter. To return to a consideration of pain and abuse from a clinical perspective, the psychodynamic explanation remains the most convincing in cases of psychogenic pain or pain in the absence of organic pathology. The question of physical damage resulting from childhood abuse and its long-term effects is uncharted territory. Nevertheless, the possibility exists that a percentage of children who sustain physical injury from abuse will continue to suffer its ill effects well into adulthood. Empirical evidence for this, however, is yet to emerge. Not all pain clinics are equipped to deal specifically with problems related to past abuse of their patients. However, most clinics employ psychologists and social workers and have access to psychiatric ser-

142 Childhood Abuse and Chronic Pain vices. As a starting point, these experts can be trained to recognize the relevance of childhood abuse to the pain complaints. Medical experts might consider the significance of injury inflicted by childhood abuse and its effects on the current pain problem. As was discussed earlier, such a relationship is emerging in the research literature between childhood sexual abuse and pelvic pain and gastrointestinal disorders, among others. A comprehensive investigation will produce the necessary information on the basis of which judgments can be made about the value of the past abuse to an understanding of the current pain issues. Several issues emerged from the disclosure of abuse. First and foremost was the absence of literature on the consequences of disclosure. It is, of course, imperative that information regarding the availability of treatment for abuse in the local community must be made available to the patient. In the event of a crisis, the clinic has to determine whether it has the ability to handle it. Otherwise, the patient must be referred to psychiatric services. Many cities now have specialized programs for victims of abuse, and that may be another alternative. If indeed there is strong evidence of an abuse-pain relationship, treatment can be carried out in the clinic itself. In any event, the patient may require the benefit of group therapy, in addition to the pain clinic treatment. Such treatment should be sought out. Long-term psychotherapy, which many of these patients seem to require, is an expensive proposition and is viewed with some suspicion so far as its efficacy is concerned. Another related issue is that of the availability of such a therapist on the pain clinic staff. In my opinion, referring a patient for psychotherapy to an outside source is less than satisfactory. Patients often resist such a move, and just as importantly many psychotherapists do not have the necessary background in pain management. Third, the interdisciplinary nature of pain treatment is somewhat compromised by referring the patient out. However, the non-availability of a psychotherapist on the pain clinic staff may require such a move. Regular contact between the therapist and pain clinic staff can ameliorate some of these concerns. It must be made clear that my preference for dynamic psychotherapy is rooted in my own training and limited clinical support for this approach, however limited, in the literature. The sad truth is that health care professionals in pain clinics to date have not shown much interest in this group of patients. Much experimentation with treatment approaches such as the cognitive-behavioural method and group therapies is required. Short-term treatment methods, for economic reasons,

Epilogue

143

must be tested in carefully designed studies. To date, there are no such studies. Finally, it must be stated that the purpose of writing this book was to bring to the attention of those practitioners who take care of chronic pain sufferers that many of these patients have a past and/or current history of abuse. This information has been shown in the research as well as clinical literature to be of considerable value. Chronic benign intractable pain syndrome has proven be an extraordinarily difficult problem to treat. Although great strides have been made in our understanding of this phenomenon, and new and improved medical and psychological treatments have evolved, no one will disagree that we remain very far from finding a panacea for effective treatment of this very debilitating syndrome. Hence, it is incumbent upon practitioners to explore every new avenue that presents itself that may improve our collective understanding of, what some have described as, the puzzle of pain. Childhood abuse and its implications for adult pain sufferers are no longer matters of pure conjecture. For some patients this connection may be the only way to explain their experience of pain. Pain is an emotion, and the notion that psychological distress can find somatic expression is not revolutionary. What may be revolutionary is our capacity to recognize that factor in our day-to-day work with chronic pain sufferers and to offer them relevant treatment. This is not an unattainable goal.

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Index

Abandonment 13, 21, 36, 37, 59, 71, 105,127,128 Abdominal pain 18,19, 20, 21, 30, 31, 61, 76,121 Abortion 78 Abuse (types): physical 4-5, 9-13, 16-17,19-21, 23, 25-9, 32, 37-8, 40, 42, 46-7, 49, 54-5, 59-60, 71, 74-6, 127,130; sexual 3, 4-6, 7, 9-12, 14-15,17-18,19-21, 23, 27-30, 32-40, 44, 46, 53, 59, 61, 71, 77, 92, 94-5, 97-101,103,106,109,116-17; spousal 74-9, 89-90,105 Accident 74-9, 89-90,105 Addiction 75, 99 Adolescence 4, 24-5, 38, 44, 65,127 Alcohol 13,21,23,25,36 Anorexia 7-8, 30, 58, 88 Anxiety 9,17, 25, 27, 37, 65-6, 73, 76, 94-5, 98,103-4,114,120,122,125, 134 Attachment 3, 59-60 Attention deficit 65 Battered spouses or children 13, 22, 76-8,105 Bulimia 7-8

Chronic fatigue syndrome (CFS) 63 Coping 44, 71-2,112,115,117 Crisis 84, 94,110,111-13,114-23 Death 3-4, 7, 38, 40-1, 48, 53, 55, 59, 68-9, 81,112,127 Disclosure 34, 41, 93, 99,104,109-11, 124 Dissociative 12, 41 Encropesis 5 Enuresis 5 Fibromyalgia 25-6, 40, 71 Flashback 37,104,116-17,121 Foster parents 38, 64, 127 Gastrointestinal problems 19-21 HIV 4,10-11 Homicide 73, 76 Hysterectomy 81,121 Incest 7,14,19, 93, 98,110 Injuries 4, 6, 75 Irritable bowel syndrome (IBS) 14, 20

160 Index Memory 35-7, 39, 44, 47, 51-2, 63-4, 82,104,110,112,119,121 Message value 40, 87 Morbidity 3,11-12,15, 75-6,105 Mortality 75,105 Musculoskeletal system 30, 61 Neglect 3, 5,11, 21, 27, 46, 56, 58-62, 64, 66, 72-3, 86,106,108, 111, 128 Non-organic failure to thrive (NFT) 5 Osteomyelitis 50-1 Paternalism 90 Pedophile 44 Pelvic (pain) 14-8, 31, 53, 76-7 Perpetrator 7, 24, 32, 34, 74, 92, 101-2 Personality disorder 8,102 Premenstrual syndrome (PMS) 18 Psychodynamics 14, 20, 27, 31, 103-4,107,125 Psychogenics 13,15, 23-4, 27, 30, 32, 57,60 Psychopathology 72, 97,112

Psychosomatic problems 4, 6, 27, 29-30, 46, 60, 78 Punishment 17, 27-8, 52-3, 55,126, 135 Rape 5,10,19-20, 23, 86, 94, 111, 116,134 Resiliency 11, 24, 35, 66, 69, 72-3 Self-help 93 Self-injury 28 Social support 110 Suicide 23-4, 34, 53, 62, 75, 77, 96, 116-17 Survivor 28, 92-8,101-6,117,123,125 Therapy (types): cognitivebehavioural 92-4, 96,102,107; couple 95,101-2,106-7,115,133; family 100-2,105-6; group 92, 97-100; hypnotherapy 94, 99; music 96; psychodynamic (psychotherapy) 103-4; shortterm 98 Urinary tract infection 4