Recent studies have shown that a high percentage of all chronic pain patients also struggle with traumatic stress. Findings also demonstrate that individuals who suffer from posttraumatic stress disorder are at much higher risk for developing chronic pain.
The Complex Relationship Between Trauma and Pain
Although the correlational relationship between trauma and pain is clear, it is quite complex. The following qualities of trauma are helpful to consider when working with clients who experience persistent pain that is not responding to usual courses of treatment:
1) Trauma may have caused the pain through accident, injury, disease, natural disaster, surgery or other medical procedures, loss, other overwhelming events, or the accumulation of “little t” traumas such as a toxic work environment.
2) Persistent emotional and physical pain becomes traumatizing in itself. If the pain does not seem to have an underlying causal link to trauma, eventually the pain can become a trauma.
3) Unresolved trauma that predates the pain can help to trigger current unmanageable pain situations. For example, a client who has suffered a traumatizing illness or accident which has necessitated multiple surgeries and hospitalizations may respond relatively well to treatment until the accumulation of interventions becomes too overwhelming and the client can no longer summon a healthy response.
4) Early childhood trauma including prenatal, perinatal, and postnatal difficulties as well as emotional/physical/sexual abuse, neglect, loss, and other relational trauma can create distress which can set the stage for later emotional and physical pain.
5) Insecure attachment relationships in early life, including disorganized, avoidant, and ambivalent attachment experiences can become barriers to trusting the body, developing reliable self-regulation and self-soothing, and trusting professionals to help.
The Problem of Addiction
Chronic, unmanaged pain has become epidemic in our culture. Estimates are that more people suffer from pain than those suffering from heart disease, cancer, and diabetes combined. Prescription drug medications are a central part of chronic pain treatment and can lead to addiction through complex chemical reactions.
For example, when cortisol, one of the foremost stress hormones, is chronically depleted due to dealing with chronic situational and posttraumatic stresses, more dopamine, which generates feelings of well-being, is then automatically released by the brain. If an individual then takes medication that stimulates dopamine, the production of cortisol becomes even lower. This sets up a situation where an individual does not have reserves to counter stress and also has cravings for more and more pleasure and reward.
Most experts in the field of addiction view addiction as a neurobiological disease that results in impaired control over drug use, cravings for more and more pleasure, and compulsive use of drugs despite increased harm. Pseudo-addiction may occur when pain is under treated so that patients become more medication seeking in order to find relief.
Working with dependencies and addiction usually involves treating multiple diagnoses, especially those connected to anxiety and depression, which are often related to undiagnosed and untreated trauma. Careful monitoring of patients is necessary so that daily life functioning and quality of life keep increasing. An experimental approach to medications often helps. That involves using medications in smaller doses to support clients while they are learning appropriate skills. The focus of treatment is “Skills not pills.” Instead of taking medication away until the patient is less addicted, often the more effective route is to keep adding tools to work effectively with the patient’s pain until gradually the patient is more confident about the reliable relief that is created by his/her own efforts at self-regulation. Those efforts do not have the side effects and other addictive risks that often accompany uses of pain medication.
The Polyvagal Blueprint of Intervention
Until recently, there has not been a model of intervention that could effectively help to treat the triple threat of trauma, pain, and addiction. In the early 1990’s, Stephen Porges (1995) and other neurobiologists began to study polyvagal theory, which has helped us to understand the interplay between the sympathetic and parasympathetic branches of the nervous system in generating and maintaining pain.
The vagal nerve is the longest in the body. It is a cranial nerve that exits the brainstem and travels through almost every system in the body. It functions as a “brake” that slows our heart and other organs, and enables us to calm down. There are three branches of the polyvagal system; the interplay between them and various aspects of the brain keep us in balance in terms of our overall health and well-being.
What we now know from Porges’ work is that the ventral vagal or social engagement system is in charge during nonthreatening situations. It helps us to relate to others and to ourselves. It also helps us “down-regulate”or calm the sympathetic fight/flight system and keeps us in a “window of tolerance.” Without the “vagal brake” the individual would be flooded with feelings of anger and fear related to fight-flight responses to threat. These unregulated feelings can get passed on in our reactions to others and/or become an internal trap of activation that can serve as an invisible “strait jacket,” limiting our sense of well-being and balance.
During times of traumatic threat, which is perceived as life-threatening to the organism, the ventral vagal arm of the polyvagal system is overridden by the sympathetic survival responses (fight and flight). The amygdala turns on the alarm and the hypothalamus turns on a cascade of chemicals to help the organism mobilize energy to meet the threat by running away or fighting back effectively. There is increased blood flow to body muscles, decreased flow to the thinking brain, and increased vigilance. In other words, the organism’s natural defense system is working as it is designed to do.
If both of the ventral vagal/social engagement system and the fight/flight response do not match the threat, then the dorsal vagal system is turned on. This is the most primitive of the polyvagal systems and is triggered by lack of oxygen in tissues and muscles, as the fight/flight responses have been expressed. It is displayed as an immobility response which shuts down many functions of the body, leading to a decrease in heart rate and respiration and accompanied by numbness. Although immobility protects survival by conserving energy, it can be lethal over a long period, leading to serious health problems.
The Pain Trap
The polyvagal system helps us understand what we can call the “pain trap.” Because when we are threatened, our brain’s frontal lobes (which govern observation, language, and perception) are turned off, we are left with our body’s more primitive responses. The perception of threat turns on the sympathetic fear response, which in turn activates bracing in bones, tissues, and muscles, which can lead to constriction and pain. That then stimulates more fear, bracing, constriction and pain, resulting in an endless cycle.
If we don’t find ways to interrupt this vicious cycle, serious problems including chronic pain occur. Fortunately, polyvagal theory suggests a blueprint that can intervene successfully in this complex process.
The Polyvagal Solution
The most primitive branch of the polyvagal system, which is connected to the dorsal vagal shutdown response and the reptilian brainstem, manages most of the important somatic rhythms including heart, breathing, digestion, sleep, immune response and so forth. Teaching special breathing patterns (e.g. Circle breathing) can begin to re-regulate rhythms disrupted by trauma and help develop skills for self-regulation in general.
The sympathetic/adrenal branch of the polyvagal system that directs the fight/flight defense system can be rebalanced and re-regulated by completing defensive movements that have remained incomplete or frozen through the mechanisms of trauma, and releasing energies that have been stuck along with the movements. Other interventions include following and staying with sensations related to the felt sense to discover new somatic patterns, and working with pendulum rhythms to shift between areas of overactivation and areas of dissociation and numbing in order to restore homeostasis and present time awareness.
Finally, the ventral vagal or social engagement system can be repaired and restored by working through attachment issues related to trust and safety in the therapeutic relationship, and also by identifying and resolving internal attachment conflicts related to family of origin, using ego-state therapy. The following case example demonstrates my work with a client who has been struggling with the triple challenges of pain, trauma, and addiction, using the polyvagal system as an intervention model.
Doug, age 42, was referred to me by his psychologist for help with his intractable back pain. Since 2007, Doug has been on disability and unable to work. His sleep was disturbed by pain so that he rarely got more than 2-3 hours of rest per night. His activity was limited so that he could not sit, stand or walk for more than 20-30 minutes at a time. He could not bicycle or hike or even participate in social activities without withdrawing and resting in a separate room.
When we discussed the history of his symptoms, he believed that his back problems began in 2005 while he was working with a start-up company for which he moved heavy boxes of computer and other IT equipment. When I responded that it seemed that there might be additional factors since his disability had actually worsened since he had stopped working and removed that stress from his life, Doug paused for several minutes and then offered the fact that he had been in a serious bicycle accident in 2004, that he had had a back surgery in 2005, and that it was likely that the computer job had probably made his situation worse. “I guess I’m not very clear about the timeline of these experiences. I don’t like to think about them very much.”
After gathering information about his accident and the surgery that followed, I asked him, “Is there anything else you’d like to share with me that might help me get to know you better?” Again, Doug sat in silence before responding, “Well, I don’t know...I think there’s a part of me that doesn’t believe I can ever manage this pain. It doesn’t matter what I do, it’s never the right thing. I’m just a fuckup.”
I inquired whether this part of him was present now and how he experienced this part. Doug responded, “Yes, he’s always here. That’s who’s calling me a ‘fuckup.’ He’s been doing that a long time.” I next asked whether it would be OK for me to talk to this part of him. After Doug nodded, I suggested he go inside himself to locate the voice inside who was calling him a “fuckup” and to signal me when he had found him.
After his next nod, I said to Doug, “Ok I’m going to talk to this part of you. I’d like you to listen and notice what happens inside:” ...
”I’m very glad you came forward today and are willing to talk with me. Obviously you have a lot of power and strong beliefs about how Doug should be. Doug’s lucky to have you out for him, but I think there’s one problem in this situation for you. And, that’s that he doesn’t really appreciate what you do for him. I want to ask you whether you’d be willing to help me to help him to deal with the pain in a different way so that you would feel better about who he is and so he could appreciate a new kind of help from you. What do you think?”
Following another long pause, Doug opened his eyes and said, “Wow, that was interesting. It’s very quiet and calm inside. It’s like he was really listening to you.” As we discussed this experience further, I explained that when there were inner conflicts of this intensity, sometimes no intervention with pain would be successful. That’s because the energy of this part could block the intervention by devaluing it as well as the results obtained.
In summary, after about an hour of contact, Doug and I found the clear link between trauma and his pain. We also started working on a major internal conflict, while at the same time strengthening our connection with each other. In Polyvagal terms, we had started our interventions with the ventral vagal social engagement system. As Stephen Porges has pointed out, the ventral vagal pathway provides one of the most efficient and effective ways of helping a person move out of defensive reactions that can create and maintain persistent or chronic pain.
The next intervention was to teach Doug special breathing techniques based on Somatic Experiencing™ to help him track pain sensations so that he could begin to shift pain pathways into a place of greater balance. We started by having him stretch out comfortably with pillows supporting his body, and then noticing the differences between the right and left sides of his body. We also focused on differences between site-specific pain and more neutral sensations, and between the upper and lower pain centers.
Next, Doug learned to imagine that he could breathe up or through less painful pathways and breathe out along the more painful ones. By exploring about 15 different possibilities, we identified the breathing pathways that brought reliable relief and/or balance. Doug practiced these exercises on his own and found that his pain numbers began to drop from between 8-10 on a 10 point scale down to 6-8 within only 4-6 sessions.
As he began to feel more hopeful and confident about his own ability to regulate his pain levels, internal dynamics also changed so that the inner voice began to sound more positive and genuinely supportive. At this point, Doug and his partner went on a 4-day vacation at the beach and Doug over exercised by taking a long walk in the sand to prove that he had really made some positive changes through his therapy. As we processed this during the next session, Doug revealed that he had been using Vicodin without telling me, mainly for sleep, but also to regulate times when he exceeded the boundaries of healthy exercise (breaching his window of tolerance). Fortunately, we had a solid enough relationship that we could process what had happened, discuss addiction and where he was in the addictive process, and agree that it was important for me to talk with his primary care doctor to coordinate our efforts.
The primary care doctor explained that she had recommended Respiradol for sleep, as well as for his anxiety and depression. She also said that Doug had refused to take it, explaining that he was “too sensitive” and that it had not worked in the past. We agreed that with Doug, it was important to take a “start low and go slow” approach. I explained later to Doug that we would start with less than 25% of the recommended dosage, and would be monitoring him carefully. Both of us wanted emails from him every day the first week at the start, specifying his physical, emotional, and cognitive reactions to the medication and the results of his sleep, including how rested he felt upon awakening, how many hours he was sleeping, and how his depression and anxiety symptoms were responding. We also agreed that he would visit his primary care doctor weekly to manage his pain medications until he was stabilized on a specific medication and dosage.
Simultaneously, Doug and I increased the focus on specific tools to help him regulate his fear and anger responses. What seemed to work best for him were to identify sensation centers or pathways in his body that were related to emotional feelings of fear and anger triggered by various experiences during the week. We would then help him “pendulate” from these sensations to more neutral locations in his body, shifting his attention back and forth from the fear/anger sensations to neutral and positive sensations. Eventually, he was able to expand his awareness of neutral and positive reactions and to do the pendulation exercise on his own to create more emotional and physical balance, which led to less pain and gradual decrease of his use of the Respiradol as well as the pain medications. In other words, Doug was able to use new-found skills in self-regulating his emotional and physical pain to decrease his reliance on and addiction to medications.
As his (sympathetic) defensive reactions decreased and his ability to trust and work with other professionals and his own resources increased (ventral vagal), dissociation and related fragmentation which resulted in distraction and confusion of inner messages (dorsal vagal shutdown) also began to resolve. Doug described himself as feeling more present with others and more able to follow through on goals he had set for himself.
This article has presented a basic introduction to the idea of a Polyvagal solution when working with the triple challenges of pain, trauma and addiction, along with one clinical case that demonstrates how this approach was applied in a clinical situation that included all three challenges. There are many more resources that can help you learn more about this approach including references, readings and a free 90-minute audio download to a Master Class webinar I presented on Pain, Trauma, & Addiction: Working with the Triple Threat to Health and Well-Being. To receive this bonus for your library, please contact Peggy Knudson Peggy@maggiephillipsphd.com. She would be happy to send you the links to retrieve this program at no cost to you.
Boone, S. & Steele, K. (2011) Coping with Trauma-Related Dissociation. New York: Norton.
Levine, P. (2011). In An Unspoken Voice: How the Body Releases Trauma and Restores Goodness.
Levine, P., & Phillips, M. (2013). Freedom From Pain. Book, Audio CD, mp3, kindle formats available through amazon.com.
Karr-Morse, R. (2012). Scared Sick: The Role of Childhood Trauma in Adult Disease. New York: Basic Books.
Phillips, M. (2007) _Reversing Chronic Pain: A 10 Point All-Natural Plan for Lasting Relief. _Berkeley, Ca: North Atlantic Books.
Porges, S. (2011). Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation. New York:Norton.
Scaer, Robert. (2012). 8 Keys to Brain-Body Balance. New York: Norton.
Van der Kolk, Bessel (2014).The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York: Viking Adult.