A Master’s Project Weber... · 2017. 12. 14. · Post-Traumatic Stress Disorder (PTSD) Post-Traumatic Stress Disorder (PTSD) in the DSM-5 can be characterized as a specific or several

Running head: THE BIOPSYCHOSOCIAL IMPACT OF TRAUMA 1

The Biopsychosocial Impact of Trauma Through a Lens of Chronic Pain

A Master’s Project

Presented to

The Faculty of the Adler Graduate School

______________

In Partial Fulfillment of the Requirements for

the Degree of Masters of Arts in

Adlerian Counseling and Psychotherapy

______________

By

Laura Weber

______________

Chair: Tamarah Gehlen

Reader: Erin Rafferty-Bugher

______________

July 2017

THE BIOPSYCHOSOCIAL IMPACT OF TRAUMA 2

Abstract

The biological, psychological and sociological aspects of trauma and corresponding somatic

symptoms, such as chronic pain, are central to understanding and healing the embodied self.

Trauma can occur during any stage of life and manifest in ways that are difficult to identify, and

have especially adverse effects on the growing brain. Trauma, chronic pain, depression and

anxiety disorders, and substance use disorders are increasingly comorbid. Neuroimaging can

help trace the autonomy of the brain that is impacted by trauma, chronic pain, and stimuli that

would evoke similar emotions. The rational and emotional brain can also provide details on how

information correlated with trauma is received and processed. Trauma can manifest as a somatic

complaint and can help lead to creating a new embodied self. Chronic pain is one of the most

recognized somatic complaints, and there is an epidemic in the United States. While chronic

pain is often categorized by physical sensations alone, it is multifaceted and involves mental and

emotional aspects as well. The mind and body are dependent on reciprocity, the body creates

warning signs to help the psyche register what is needed to stay safe, and subsequently behaviors

for wellness are demanded by the brain. Safety is often needed with relationships or self, and the

body will create a language that often goes unheard. Art therapy is a holistic approach that

addresses somatic complaints linked to trauma, which can help individuals recognize the

language of the body, and help foster healthier relationships through forging meaning, building

new identity, and re-establish wholeness.

Keywords: Biopsychosocial, developmental trauma, trauma, somatoform disorders,

chronic pain, anxiety, depression, Adlerian, social interest, organ inferiority, art therapy


Table of Contents

Abstract ........................................................................................................................................... 2

Introduction ..................................................................................................................................... 5

Normal Reactions to Abnormal Experiences in Life ...................................................................... 6

Developmental Trauma ............................................................................................................... 7

Post-Traumatic Stress Disorder (PTSD) ..................................................................................... 9

Dissociation and hyper-arousal ............................................................................................. 11

PTSD and somatic symptoms. .............................................................................................. 12

Somatoform Disorder................................................................................................................ 13

Chronic Pain.............................................................................................................................. 15

Comorbid Chronic Pain and Depression, Anxiety, and Substance Use Disorders ................... 17

Depression and chronic pain ................................................................................................. 18

Substance use disorders and chronic pain. ............................................................................ 20

A Perception of the World Creates the Reality of the Mind ......................................................... 21

Brain Development and Trauma’s Impact ................................................................................ 22

Brain Anatomy .......................................................................................................................... 24

The frontal cortex. ................................................................................................................. 25

The medial prefrontal cortex. ................................................................................................ 26

The anterior cingulate cortex (ACC). ................................................................................... 26

The hippocampus. ................................................................................................................. 27

The anterior insula. ............................................................................................................... 27

Subcortical regions................................................................................................................ 27

Amygdala. ............................................................................................................................. 28

Hypothalamus ....................................................................................................................... 28

The Rational and Emotional Brain ........................................................................................... 29

The rational brain. ................................................................................................................. 30

The emotional brain. ............................................................................................................. 31

Psychological Purpose for Pain ................................................................................................ 34

Organ Inferiority ....................................................................................................................... 37

Concepts of Social Interest ........................................................................................................... 40

Trauma’s Impact on Social Interest .......................................................................................... 41

Attachment. ........................................................................................................................... 42

Chronic Pain’s Impact on Social Interest.................................................................................. 43

Empathy. ............................................................................................................................... 45


Substance Use Impact on Social Interest .................................................................................. 45

Healing Through Therapeutic Relationships ............................................................................ 47

Healing trauma and chronic pain .......................................................................................... 50

Art therapy ............................................................................................................................ 56

The art process, the client, and the art therapist. ................................................................... 59

Adlerian art therapy. ............................................................................................................. 59

Trauma. ................................................................................................................................. 60

Trauma and pain. .................................................................................................................. 61

Art therapy interventions. ..................................................................................................... 63

Pain and metaphors. .............................................................................................................. 64

Conclusion .................................................................................................................................... 67

References ..................................................................................................................................... 70


The Biopsychosocial Impact of Trauma Through a Lens of Chronic Pain

Introduction

The timeframe from birth to age four is the most developmentally crucial period for a

child and carries great potential to impact the rest of their lives. The developing brain

encompasses the ability to create coping tools to keep the embodied self safe. Coping tools that

are formed in the brain to help aid toxic stress, can later become maladaptive and cause

disruption in establishing and fostering relationships, and exacerbate physical and mental health.

The greater the amount of adverse childhood experiences (ACEs) the likelier the outcome of

poor health and mental wellbeing in adulthood. Trauma causes psychological dysfunction and

often manifests in physical symptoms, one being chronic pain. Trauma and chronic pain are

often comorbid with depression, anxiety and substance use disorders.

Neuroimaging can demonstrate the connection the brain has with pain, not only physical

pain, but also the emotional and social aspects of pain. For instance, one neuroimaging study

completed by Eisenberger, Libermean, and Williams (2003), involved reviewing electrical brain

activity of participants who were social excluded during a virtual ball tossing game. The results

demonstrated significant similarities between injury to social connections and physical pain;

specifically, more activation in areas of the anterior cingulate cortex (ACC) and the prefrontal

cortex, during the exclusion (Eisenberger, Libermean, & Williams, 2003). Somatic complaints,

like chronic pain, are often warning signs that suggest the embodied self no longer feels secure

or at home, and these physical manifestations can serve to embody a new sense of self.

Treatment for trauma-induced physical complaints through a biopsychosocial model verses

through the biomedical model can have great implications in assessing and treating an individual

as a unified organism. Art therapy is one modality that treats chronic pain that manifests from


trauma through a holistic approach by addressing physical, mental and social domains of the

individual, that often stem from early life experiences.

Normal Reactions to Abnormal Experiences in Life

The Diagnostic Statistical Manual 5th edition (DSM-5) is a tool that was formed by

international mental and chemical health experts, that describes trauma and classifies responses

to trauma and adverse experiences, but a substantial amount of the manual lacks criteria of one’s

internal felt experience (American Psychiatric Association, 2013). Somatoform Disorder is one

diagnosis found in the DSM-5 that describes medially-unexplained somatic complaints, and

these symptoms often correlate with reactions to adverse experiences or trauma in life, and one’s

internal outward expression. Chronic pain is one outcome of an adverse experience, and

typically causes excessive thoughts, feelings, or behaviors related to the distressing symptom.

As we begin to understand the complexity of trauma that is experienced by individuals, we are

seeing an emergence of chronic pain and co-occurring disorders, that is often linked to adverse

experiences in childhood. The DSM-5 reports somatoform disorder may manifest by, “1.

Disproportionate and persistent thoughts about the seriousness of one’s symptoms. 2.

Persistently high level of anxiety about health or symptoms. 3. Excessive time and energy

devoted to these symptoms or health concerns” (American Psychiatric Association, 2013, p.

311). One can conclude, if an individual is spending most of their time focused on a medical

complaint, it has psychological purpose, and is often related to developmental trauma or

adulthood trauma. Nonetheless is a fact that developmental trauma can predispose a child to

adulthood trauma, co-occurring disorders, and is also a predictor of early life expectancy due to

somatic complaints (Nugent, Goldberg, & Uddin, 2016). Therefore, understanding the

complexity of one’s internal experience and outwardly physical expression, can aid in future


treatment considerations and better aid in identifying and healing wounds from trauma that

manifest as physical complaints later in life.

Developmental Trauma

It is evident that mental illness is rooted in childhood, and the developmental years of a

child impacts their future wellbeing. There is a plague of high ACEs in the United States and the

American Psychiatric Association has neglected to establish a diagnosis for children who have

experienced trauma. Of children ages 6-17 in the US, more than half (53%) have experienced a

traumatic event in childhood, more than a quarter (28%) have faced two or more childhood

traumatic events, and a quarter (15%) have endured three or more childhood traumatic events

(Balisteri, 2015). Yet, Post-Traumatic Stress Disorder (PTSD), remains as the only specific

diagnosis found in the DSM-5 for children who have experienced ACEs or toxic stress. When

Developmental Trauma Disorder (DTD) was proposed by van der Kolk (2014) the American

Psychiatric Association responded with this rejection letter:

The notion that early childhood adverse experiences lead to substantial developmental

disruptions is more clinical intuition than a research-based fact. There is no known

evidence of developmental disruptions that were preceded in time in a causal fashion by

any type of trauma syndrome. (Chapter 10, Section 1, para. 1)

Therefore, Developmental Trauma Disorder (DTD) is not currently a diagnosis; however,

“developmental trauma” is a term that is still frequently used by professionals. Teague (2013)

characterizes developmental trauma as a child’s exposure to a single severe traumatic

experience, or several traumatic experiences in significant relationships and/or surroundings, and

particularly impacts the child’s developmental tasks (Teague, 2013, p. 621). Van der Kolk

(2014) reports that the commonalities found in children with developmental trauma include, “(1)


a pervasive pattern of dysregulation, (2) problems with attention and concentration, and (3)

difficulties getting along with themselves and others” (Van der Kolk, 2014, Chapter 10, Section

1, para. 1). Children who have developmental trauma are often given insufficient diagnoses of

Depression, Attention Deficit Hyperactivity Disorder, Reactive Attachment Disorder,

Generalized Anxiety Disorder, Separation Anxiety Disorder, Attention Deficit Hyperactivity

Disorder (ADHD), Oppositional Defiant Disorder (ODD), and Conduct Disorder (Teague, 2013,

pp. 612-613).

Developmental trauma includes various experiences that affect the developmental

process of a child (Teague, 2013, p. 611). Abuse, distress, inconsistent behavior, neglect,

frightening behaviors by caregivers and deprivation; inflicted on a child, can often result in

ACEs that can manifest in trauma and somatic experiencing. The younger a child is when

trauma occurs the more complicated it is to heal, and the likelier the trauma can result in serious

physical, mental, and social impairment (Perry, 2006, p. 152). “Interpersonal trauma, early onset

of the trauma, and duration of the traumas,” can also initiate and exacerbate the effects of

previous trauma (Teague, 2013, p. 612). It is suggested a child with developmental trauma will

demonstrate their experiences of adversity through their mental and behavioral conditions and

essentially act in ways that protect oneself from danger or threat (Purvis et al., 2014, p. 356), and

the lack of vulnerability often manifests in somatic complaints later in life.

Essentially, developmental trauma impairs and negatively affects the mental, emotional

and social domains in children (Teague, 2013, pp. 611-612). Trauma compromises the creative

self which helps children form identity, take accountability, and shapes their lifestyle. Holistic

and phenomenological theories believe all characteristics of the human organism are connected,

and thus a traumatic experience can leave powerful impressions of disruption on the essence of


the individual (Saltzman, Matic, Marsden, 2013, p. 226). There are social and psychological

effects of trauma, and a child or adult who exhibits poor behaviors or physical health concerns

are still often stigmatized, or not recognized. If educational and human service divisions were

provided with the knowledge that developmental trauma leads to feelings of a strong sense of

inferiority, discouragement, disempowerment, and an imbalanced stress system (Perry, 2006, p.

49), it could greatly improve these domains of the individuals impacted by developmental

trauma. Early interventions with a child could reduce the risk of them experiencing new trauma

and minimize the possibility of predisposing their future children to ACEs. By working to

recognize and address trauma and somatic experiencing it is then possible to change societal

systems of parenting, childcare, and home and educational settings, and this has the capacity to

change the mental and physical health of generations to come.

Post-Traumatic Stress Disorder (PTSD)

Post-Traumatic Stress Disorder (PTSD) in the DSM-5 can be characterized as a specific

or several traumatic experiences, that are often accompanied by symptoms of reliving the

event(s), negative emotions or behaviors, distressing thoughts, the inability to feel pleasure,

dissatisfaction of life, and dissociative or hyperarousal states. Trauma is conceptualized in a

variety of different ways in research, as well as how it is defined in the field. Perry (2007)

explains, PTSD is a disorder that stems from the maladaptive continuation of correct responses

during a traumatic experience; and the human brain is the organ that mediates these during-

trauma adaptive responses and after-trauma maladaptive responses, that correlate to the toxic

stress (p. 1). Van der Kolk (2014) reports, the definition of trauma, is unbearable and

insufferable, and trauma habitually involves not being seen by another, not being heard by

another, or not being felt with the heart of another (Chapter 4, Section 4, para. 2). Mate (2016)


indicates, trauma is an outcome of abuse, neglect, or relational stress, and this leads to the

disconnection of one’s essence or the separation of one’s essential qualities of joy, vitality,

clarity, wisdom, power, strength, and courage. Trauma is an adverse experience that results from

an individual being exposed to toxicity, and consequently the unified organism changes physical,

mental, and/or social aspects, to keep it safe but creates distance from self and others.

Trauma can be re-experienced in the same way it was originally experienced, and can

leave imprints on emotions, minds, biology, relationships and immune systems (Van der Kolk,

2014, Chapter 3, Section 2, para. 6). It can trigger emotions, physical sensations, aggression, and

behaviors, and cause the body to freeze and dissociate, or be hyper aroused in fight for survival

(Van der Kolk, 2014, Chapter 3, Section 1, para. 4). Trauma is experienced and remembered in

tiny pieces and often has sensory components like sounds, smells, and images, but rarely is

trauma experienced in its entirety during or after the actual occurrence (Van der Kolk, 2014,

Chapter 3, Section 1, para. 4). Until resolution has occurred, trauma continues to be relived and

cycles in the present, through sensory and emotional experiences that occurred during the time of

the occurrence (Van der Kolk, 2014, Dissociation and Reliving section, para. 1). Trauma can

lead to re-experiencing and essentially creates a self-fulfilling prophecy, because the individual

who experienced the trauma believes that the state they experienced will never go away, and they

will experience it the rest of their life; and in many ways often do. Thus, ACEs are a predictor of

adulthood toxic stress, and while the traumatic circumstances vary, the emotional internal

experiences and the correlating physical manifestations of adulthood traumas, are often similar to

those in childhood.

One’s experience of a traumatic experience is unique and may include different responses

of emotions, bodies, minds, biology, immune systems or disconnection; conversely, the same


types of emotional and somatic responses for one individual reappear, and in adulthood the

responses can be demonstrated in his or her early recollections (Van der Kolk, 2014, Stuck in

Fight or Flight section, para. 2). It is unthinkable for most individuals who have not experienced

a specific trauma to think that the individual who experienced it, would ever want to relive their

trauma. However, the individual who experienced the specific traumatic event often relives the

trauma, through the essence of emotions and somatic sensations, and these can assist the

individual in feeling alive from the numb life they are currently living (Van der Kolk, 2014,

Stuck in Trauma section, para. 5). Early recollections, an Adlerian technique, can expose the

correlation between trauma in childhood that is relived in the same way in adulthood, and can

help heal somatic complaints related to their internal experience of trauma.

Dissociation and hyper-arousal. Dissociative or hyper-arousal states are normal during

the experience of trauma, and help the individual survive, but later in life, if they continue to

persist, they will often cause serious impairment and chaos, and are linked to anxiety, depression,

chronic pain, and substance use (Perry, 2006, p. 50). In dissociative states, an individual will

move into a surreal conscious state and become so disengaged from the present moment, they

become numb to emotional or physical pain (Perry, 2006, p. 182). Essentially, what occurs is the

brain sends signals to the body, to prepare for injury, and blood flow moves to the torso to

minimize risk of blood loss (Perry, 2006, p. 50). When trauma induces extreme dissociative

states, the individual becomes separated from the world or self, and later in life, highly stressful

situations stimulate the same separation from images, thoughts, sounds, sensations, and smells

(Van der Kolk, 2014, Chapter 4, Section 9, para. 1). Dissociation is often a useful safeguard tool

for an individual to defend themselves against feelings of being judged and labeled by others,

and causes behaviors of avoidance and protection, and quick responses; which puts strain on


health, safety and the capacity to connect with others (Teague, 2013, p. 619). While some

individuals’ response to trauma is for the body to go into a highly-sensitized state in which minor

stressors cause a massive response, the opposite end of the spectrum is an extreme version of

dissociation that is found in individuals with antisocial disorder that includes fatal numbness

(Perry, 2006, p. 118). Individuals who dissociate can experience impaired memory, confusion,

different personalities, lapses of time without recalling what happened, and often have repetitious

behaviors or compulsive behaviors related to substance use (Teague, 2013, p. 618).

PTSD and somatic symptoms. Gupta (2013) reports, PTSD is likely correlated with the

highest amount of medical complaints, among any other mental health disorder, in both children

and adults (p.86). Trauma causes the stress system to keep producing stress hormones due to

perceived threats, and this often leads to different types of somatic complaints such as headaches,

unexplained pain, oversensitivity to sound or touch, or soreness. The hormones can cause

hypervigilance or dissociative states which can distract the individual from the here and now, or

from fully being present in daily life (Van der Kolk, 2014, Chapter 10, Section 5, para. 7). The

stress and hormones can also be linked to somatic sensations such as unexplained dizziness, cold

hands and feet, shortness of breath, sore arms and legs, tinnitus, headache, neck soreness, blurry

vision (Gupta, 2013, p.86). Individuals who have encountered a traumatic event often cannot

describe or recognize their feelings because they are unaware of what purpose the symptoms

have (Van der Kolk, 2014, Chapter 6, Section 7, para. 2). The body can create coping

mechanisms that will help the individual survive at the time of the trauma, and then the body

often will not return to the same state it was in prior to the experience, unless healing occurs

(Teague, 2013, p. 619). Therefore, one can assume, identifying the purpose of the individuals’


somatic complaints in correlation with their emotions and internal experience, can support future

treatment considerations.

Somatoform Disorder

It is common for somatic complaints to appear in medical and mental health fields and

research demonstrates they are often manifestations of trauma (Gupta, 2013, p.86). There are

several terms that have been used to describe physical conditions in psychology, which include

“complaints for which there is not physical or medical basis, somatic symptoms/complaints,

physical symptoms/complaints, bodily symptoms, functional somatic symptoms (FSS),

somatization symptoms, and medically unexplained physical symptoms (MUPS)” (Chaturvedi,

& Desai, 2013, p. 31). When physical symptoms cannot be explained medically they are often

looked at from a psychological standpoint, and can be diagnosed in the DSM-5 as a Somatoform

Disorder. The American Psychiatric Association (2013) report:

Individuals with somatic symptom disorder typically have multiple, current, symptoms

that are distressing or result in significant disruption of daily life, although sometimes

only one severe symptom, most commonly pain [emphasis added], is present (criterion

A)…The symptoms may or may not be associated with another medical

condition…Individuals with somatic symptoms disorder tend to have very high levels of

worry about illness (Criterion B)... Chronic somatoform pain is characterized by

distressing but medically unexplained pain in combination with abnormal beliefs and

behaviors regarding the pain, with a minimum duration of 6 months. (p. 311)

Somatic symptoms are often thought of as bodily distress and include subjective

experiences, which makes it hard to quantify or qualify; the experiences cannot be seen or felt by

others and therefore assessment becomes difficult. One challenge with qualifying results is it is


not easy to differentiate between fatigue, numbness and tingling, burning sensations, tension,

headaches, or churning sensations (Chaturvedi, & Desai, 2013, p. 32). The amount of pain

verses the severity of pain, and which organ is affected, can be perceived differently, and age and

circumstances also are taken into consideration (Chaturvedi, & Desai, 2013, pp. 32-37). For

instance, one may argue a long-lasting migraine is only one physical symptom and involves

more misery, than the initial onset of arthritic pain that includes multiple but bearable aches

(Chaturvedi, & Desai, 2013, pp. 32-37). Bodily symptoms can be classified under the

somatoform diagnosis as mild, moderate, or severe; however, this is also dependent on the type

of impairment (Chaturvedi, & Desai, 2013, p. 32). If a somatic experience, such as pain, is

subjective and influenced by one’s opinions, feelings or perceptions it would be necessary to

consider person-centered approaches and a closer evaluation of one’s internal experience.

Somatic symptoms can be linked to any of the ten main functions of the body which

include the cardiovascular system, digestive system, endocrine system, integumentary system,

lymphatic system, muscular system, nervous system, renal system, reproductive system, or

respiratory system. Common somatoform symptoms include nausea, abdominal distress,

diarrhea, feeling sickly, abdominal pain, dizziness, chest pain, fainting spells, pain in extremities,

vomiting, palpitations, weakness, feelings of choking, chest discomfort, lightheadedness, panic

attack, derealization, depersonalization, chills or hot flushes, and fear of dying or losing control

(Chaturvedi, & Desai, 2013, p. 33; Gupta, 2013, p. 95x; Gupta, 2013, p. 87; & Hassan, & Ali,

2011, p. 315). Physical complaints have been found in impairment of immune system, diabetes,

chronic pain, sleep disorders, respiratory functions, and neurological and gastrointestinal

disorders (Gupta, 2013, p. 88). Essentially there is a high prevalence, and poor understanding of

somatic symptoms and this has made it difficult to correctly assess and treat; however, the


correlation between adverse experience and trauma cannot go unrecognized. In one study,

involving one-hundred and sixty-one children and adolescents, who had experienced neglect

and/or abuse were administered a checklist for somatic symptoms and 95% endorsed one or

more somatic symptom (Kugler, Bloom, Kaercher, Truax, & Storch, 2012). Yet, the broad range

of somatic symptoms that correlate with trauma is beyond the scope of this paper, and thus the

remainder of the paper will focus on the most common somatic symptom, pain (American

Psychiatric Association, 2013, p. 311).

Chronic Pain

Chronic pain is a prevalent and costly somatic symptom, and is often comorbid with

trauma (Asmundson, 2014, p. 717). A report from the Institute of Medicine (2011) claims that

about 100 million adults in the United States suffer from chronic pain and that the annual health

economic costs to the country are up to $635 billion. The World Health Organization (2017)

suggest, among adults globally, headache disorder has a 50% pervasiveness. Headache is also

the top physical complaints presented to a physician in a medical setting (Chai, Rosenberg, &

Peterlin, 2012). The Global Burden of Disease Study (2013), reported the sixth leading cause

worldwide for lost years due to disability is migraine headaches (World Health Organization,

2017). Moreover, Smith (2013) confirms, “As costly as it is widespread, back pain is a leading

cause of disability for Americans and costs the U.S. economy over $100 billion annually in

treatment costs alone, not to mention the costs of lost productivity, legal and insurance costs, and

immeasurable misery” (p. 188). Pharmaceutically speaking, the U.S. population expended

approximately 80% of the world’s opioid prescription drugs from the years 2000 to 2010; which

alone signifies the country’s chronic pain epidemic, and that countries outside the US are


prioritizing treatment modalities that exclude medication-assisted therapies (MATs) (Vowels,

McEntee, Julnes, Frohe, Ney, & Van der Goes, 2015, p. 574).

Pain is found in the musculoskeletal system and conditions include, “fibromyalgia,

regional pain disorders including temporomandibular joint pain, chronic low back pain and other

ill-defined regional pain syndromes such as reflex sympathetic dystrophy” (Gupta, 2013, p. 94).

These syndromes have strong correlations with the central nervous system, conversion disorders,

traumatic experiences, and particularly rape (Gupta, 2013, p. 94). Chronic pain is a perceived

and subjective state (Henne, Morrissey, & Conlon, 2015, 712), and sensations such as an ache,

burn, or sting are associated with pain perceptions as well as where the sensation is located on

the body, and the length of time it lasts (Bushnell, Ceko, & Low, 2013, p. 502). Kip et al. (2014)

has created three groups of pain experiences, somatic is in relations to musculoskeletal tissues,

visceral correlates with internal organs, and neuropathic linked with nerves:

Somatic: Aching, dull, sharp, knife-like, throbbing, spasm, pounding, stiffness, sore,

bruising, pulling, hurts, twisting, like being hit, tense hard, friction, irritating, grabbing.

Visceral: Pressure, Squeezing, deep, dull, cramping, sickening, constant, steady,

tightness, gassy/bloated. Neuropathic: Burning, tingling, shooting, stabbing, jabbing,

shock-like, piercing, radiating, gnawing, pinching, touchy, sensitive. (p. 2)

Some of the primary diagnoses associated with chronic pain include neuropathic pain,

migraine, lower back pain, and arthritis, and these diagnoses can exacerbate negative mood, poor

sleep, and impair daily functioning (Katzman, Pawluk, Tsirgielis, D'Ambrosio, Anand, Furtado,

& Iorio, 2014, p. 260). An individual’s subjective and phenomenological experience of pain is

reliant on their private logic and perceptions of themselves, others, and the world; this is based

on their opinions, biases, expectations, and fictions, that influence how the world appears to them


and can be changed (Powers, & Griffith, 2012). Individuals with comorbid trauma and chronic

pain habitually identify other mental health symptoms that effect their life, such as depressed

mood, loss of interest in activities, extreme worries or fear, use of substances, and disruption in

sleep.

Comorbid Chronic Pain and Depression, Anxiety, and Substance Use Disorders

Research indicates that chronic pain is often comorbid with anxiety, depression, and

substance abuse (Barrett & Chang, 2016, p. 346; Coren, 2016, p. 394). Barrett and Chang (2016)

found, “An estimated 52% of patients have a diagnosis of chronic pain, 5% to 13% have

depression, and 19% have SUDs. These estimates are likely low because 50% of primary care

patients with depression and 65% with SUD are undiagnosed or do not seek help” (p. 345).

Gupta (2013) stresses the significance of first recognizing how often PTSD co-occurs with other

mental health symptoms such as depression, anxiety, pain, and second how this often leads to

confusion of identifying correlating somatic complaints in clinical practice (p. 86). Essentially,

recognizing how trauma, chronic pain, anxiety, depression, and substance use are interrelated can

help enhance future assessment tools, provide necessary details in neuroimaging studies, foster

individualized treatment, and indicate the importance of a multidisciplinary teams.

The relationship between chronic pain ailments and mental health symptoms is

bidirectional (i.e. Depression can predict the onset of chronic pain, and chronic pain the onset of

depression) (Katzman et al., 2014, p. 260). Katzman et al. (2014) reports, “In primary care

settings, more than 27% of patients with chronic pain meet diagnostic criteria for comorbid

depression” (p. 260). The relationship between pain and anxiety also appears to be bidirectional,

and Katzman et al. (2014) identifies anxiety disorders, which include generalized anxiety

disorder (GAD), panic disorder, and social phobia, is two times as likelier with individuals


experiencing chronic pain than individuals without chronic pain (Katzman, et al., 2014, p.260).

Higher rates of chronic pain, including migraines, back pain, and arthritis, are also found with

those diagnosed with generalized anxiety disorder (Katzman et al., 2014, p. 261).

There is often confusion with diagnosing medically explained and medically unexplained

somatic symptoms that co-occur, as well as understanding underlying trauma, anxiety or

depression that manifests in somatoform disorders (Chaturvedi, & Desai, 2013, p. 37). Although

pain is considered as impairment to the nervous system, the mind and body are consumed in a

variety of disruptions that often include a collection of pain and sleep disturbances, depression,

anxiety, and substance use (Katzman et al., 2014, p. 260). Martinez, Sánchez. Miró, Lami,

Prados, and Morales (2015) indicates that pain often reveals anxiety, and sleep quality often

accompanies depression. An individual who struggles to decipher between emotions and

physical sensations, is essentially inclined to assess pain as threatening which can dictate

secondary emotions (i.e. depression, anxiety, anger) (Martinez et al., 2015, p. 134). This

indicates the strong association between the inability to describe or identify emotions and

feelings with exaggeration of pain, sleep disorders, anxiety and depression (Martinez, et al.,

2015, pp. 132-133). Therefore, it is evident that clinical conditions can be improved with

modalities that increase an individual’s emotional intelligence by attaining knowledge to

communicate their internal experiences of feelings and emotional experiences.

Depression and chronic pain. Depression often co-occurs with chronic pain, for

instance it has been recognized that 80% of individuals that experience migraines are also

diagnosed with depression (Goli, Asghari, & Moradi, 2016, p. 67). Depression frequently

increases pain sensitivity or perception of pain, it fuels negative cognitions, and pain

catastrophizing plays an intermediating role between depression and pain intensity (Goli et al., p.


67). Individuals with depression often report an increase of pain sensitivity, inflammation,

anhedonia, lack of appetite and negative attitudes (Barrett & Chang, 2016, p. 346). Depression

often is connected to lack of energy or individuals who are emotionally drained and have

disturbances in sleep; and in most cases cocaine makes a great pair with the individual’s brain

chemistry (Mate, 2008, p. 42-23). Depression and sleep impairment also has a strong correlation.

Depression is a predominant feature that affects pain experience, and is typically linked with

higher pain sensitivity (Linton, & Shaw, 2011, p. 704). There is a hyperalgesic effect caused

from interruption in sleep, and this often leads to decreased pain management and greater pain

sensations (Katzman et al., 2014, p. 260). Consequently, treatment geared toward depression

and sleep improvement may reduce pain intensity.

Sleep disorders. There are a high number individuals who’ve experienced trauma who

report subjective sleep disturbances (Gupta, 2013, p. 90), with one study reporting 87% (Mahere

et al., 2006, p. 567). The American Psychiatric Association (2000) indicate, seventy-percent of

individuals who seek treatment for trauma report insomnia and nightmares have impacted their

life. Insufficient sleep disrupts the neuroendocrine stress system and greatly contributes to an

individual’s PTSD sensitivity (Gupta, 2013, p. 89). The co-occurrence of PTSD and sleep

disorders have been reported to exacerbate an individual’s view of their physical health and

therefore negatively affect daytime symptoms, increase depression, and suicidality (Gupta, 2013,

p. 89). Poor sleep patterns lead to agitation and can consequently aggravate headaches,

unexplained pain, sensitivity to touch or sound, and the lack of concentration or attention (Van

der Kolk, 2014, Chapter 10, Section 5, para. 7). First line treatment for comorbid PTSD and

sleep disorders have been impervious and yield poor clinical results (Gupta, 2013, p. 89). The


co-occurrence of sleep disruption, depression, and sensitivity to pain are interrelated, and have

great implications for future treatment.

Substance use disorders and chronic pain. Individuals who are chemically dependent

often have traumatic histories or ACEs, and almost always depend on substances to provide

alleviation (Mate, 2008, p. 36). Mate (2008) references his experience with individuals and

states, “The question is never ‘why the addiction?’ but ‘why the pain?’” (p. 36). Neuroimaging

has revealed that individuals with a history of trauma, have irregularities in brain regions that are

consistent with the same brain regions in scans of individuals who are chemically dependent, and

indicate it is likely that the areas affected by trauma predispose individuals to additive behaviors

(Perry, 2006, p. 189). Hassan & Ali (2011) emphasize, 30% of individuals who are chemically

dependent and have a somatic disorder in clinical presentations, also met criteria for depression

or anxiety disorder (Hassan, & Ali, 2011, p. 316). Olsen and Alford (2006) found, of clients

with substance use disorders, chronic pain disturbs 24% to 67%, and it is often overlooked and

undertreated (p. 111). Untreated somatic manifestations have frequently led to relapse in

individuals with a history of addiction (Hassan, & Ali, 2011, p. 316). Trauma can lead to

psychological and emotional pain and narcotics help relieve the sensations. Individuals will

readily report that they use a substance to self-medicate for the type of pain they are experiencing

(i.e. migraines, back pain, or chest pain).

Individuals who depend on substances almost always have a history of physical pain and

emotional pain, and an individual who is chemically dependent may either exhibit the pain

overtly or it may be concealed in the unconscious (Mate, 2008, p. 36). Individuals who are

chemically dependent will often evoke dangerous experiences to make their life vibrant and alive

again in contrast dissociative states, numbing, lack of self, vulnerability, and emotional


dysfunction (Mate, 2008, pp. 29-30; Van der Kolk, Lessons from Vietnam Veterans section, p.

497; Perry, 2006, p.182). The brain’s natural heroin-like substance is dopamine which kills pain

and produces a calming sense of distance from one’s troubles; dopamine can be released during

self-injurious behaviors, and opioids can create similar calming effects (Perry, 2006, p. 182). A

large majority of drugs, for example cocaine and heroin, are first identified as physical

anesthetics, although a main function is to alleviate psychological distress. Mate (2008) reports,

“Infant animals separated from their mothers can be soothed readily by low doses of narcotics,

just as if it were actual physical pain they were enduring” (p. 36). One can conclude from this,

narcotics such as methadone, cannabis, cocaine, morphine, codeine and heroine can help relieve

pain in a similar way an individual can be comforted by the connection of another human, and

therefore social aspects are crucial for treatment and future research of individuals with chronic

pain and substance use.

A Perception of the World Creates the Reality of the Mind

A child is born innocent, and their future behaviors are dependent on how their ongoing

environment and relationships have changed their perception of the world, and their mind’s

reality. An individual’s identity is formed through the brain’s continuous reorganization and the

establishment of new neural connections throughout life (Van der Kolk, 2014, Prologue, para. 8).

During trauma neurons in the brain compensate for injury and adjust their activities in response

to the event; consequently, one-way trauma can restructure the brain is by coping and

interpreting bodily sensations in an atypical way. Toxic stress impacts the brain’s interpretation,

identification, and organization of sensory information; which is necessary to interpret the way

one understands someone or something (Van der Kolk, 2014, Chapter 2, Section 2, para. 6).

Therefore, identifying regions of the brain affected by trauma and creating new neural pathways


can have huge implications on reducing subjective and perceptual experiences of chronic pain,

like aching, throbbing, burning, shooting, squeezing, stinging, soreness, or stiffness.

Brain Development and Trauma’s Impact

The developing brain can be altered by the slightest of decisions or any a type of stimuli,

and can carry profound implications on an individual’s intelligence quotient (IQ) and/or

emotional intelligence (EQ) (Perry, 2006, p. 121). Patterns are created and molded in the brain,

and the more an individual uses certain areas of their brain the more prone the brain is to

function in the same consistent configuration (Perry, 2006, p. 66). The same is true when an

individual doesn’t use certain areas of the brain, like the cortical regions that regulate the stress

response; the more they don’t use this area of the brain the more they are predisposed to turning

off the functioning capacities (Perry, 2006, p. 66). The greater the length of time an individual

stay on the same pathway, it increasingly becomes molded in the brain, and the harder it is to

stray from that pathway to mold a new pathway; neuroplasticity is unique for every individual.

The body and brain grow at a different speed from utero through adolescence. Before

adulthood, the brain has different spurts of growth, whereas the body grows, in general, equally

throughout birth to adolescence (Perry, 2006, p. 247). The fastest growth of the brain happens

during utero, and after birth the brain has exponential growth till the age of four (Perry, 2006, p.

247). A large portion of the brain’s nervous system is developed during the first four years, and

is 10% away from the size of an adult brain (Perry, 2006, p. 247). During this period, a child’s

brain is ever so impressionable and susceptible to long-lasting positive or negative effects (Perry,

2006, p. 247). Caretakers have the potentially to benefit a child’s developing brain by providing

safety through foreseeable patterns and fostering respect through encouragement, or can cause

great harm to the brain through toxic behaviors, stress, and neglect (Perry, 2006, p. 247). The


brain is predisposed to multiple vulnerabilities and the developmental years can hold great

potential to influence the rest of the child’s life.

Perry (2006) reports, during development the brain grows sequentially, from the

lowermost brainstem, to the upper cortical region, and if trauma occurs during developmental

years the brain’s anatomical integrity is adversely affected (Perry, 2006, pp. 222-223). As more

threat or danger is experienced by an individual, the brain progressively functions from lower

areas of the brain and the individual tends to escalate to an increasing level of stress, and

eventually a panic state (Perry, 2006, p. 49. Individuals move into a survival state, so they can

have proper reactions and can respond in a time sensitive way (Perry, 2006, p. 49). The brain is

compromised by trauma during developmental years and research has shown that ACEs correlate

to early onset mental health disorders, and these disorders predict chronic pain in adulthood (Von

Korff, Scott, & Gureje, 2009).

One societal assumption is that when one experiences pain the outcome will have greater

value for the price of their hard work; however, this is inaccurate because pain is caused by the

brain sending the body warning signals, that function, to indicate a need to stop or make a

change to something in life (Bushnell, Ceko, Low, 2013, p. 508-509). Establishing a thorough

understanding of the way the brain works can provide the necessary details to effectively

understand the association between trauma and chronic pain, and one way is through

neuroimaging because it helps identify neurophysiological changes related to pain that occur in

different brain regions (Flor, 2014, p. 193). Flor (2014) indicates, there is numerous brain

alterations that have been linked to chronic and acute pain; however, the level the brain changes

that appear in neuroimaging continues to be argued due to the possibility of comorbidity with

anxiety and depression states (p. 188).


Brain Anatomy

The neurons in the brain are responsible for communicating signals from one cell to the

other, through neurotransmitters, and the signals are received by receptor sites, and this creates

synapses. The signals only correspond to the receptor sites at which they fit (Perry, 2006, p. 23).

The signals or synaptic connections create systems of neuron to neuron links in the brain to allow

the brain to function by managing, sensations, perceptions, thought processes, emotions, and

movement (Perry, 2006, p. 23). Neuroimaging uses magnets to indicate neural activity in the

brain and spinal cord, and is a helpful tool that demonstrate how chronic pain and affects

different regions of the brain.

Flor (2014) reveals areas that lit up areas in the acute pain procedures were “the anterior

cingulate cortex (ACC), the amygdala, the periaqueductal gray, the anterior insula and the

nucleus accumbens to be associated with affective and motivational process; the primary (S1)

and secondary (S2) somatosensory cortex, the posterior insula, and the thalamus with sensory

processing; and frontal areas, including the ACC, with the cognitive modulation of pain” (Flor,

2014, p. 188). Another study by Busnell, Ceko, and Low (2013) indicates of the same brain

regions during imaging studies lighting up when activated by noxious stimuli: the ACC, the

amygdala, S1, S2, anterior cingulate, insula, prefrontal cortex (PFC), thalamus, and cerebellum

(p. 502-503). These studies show regions in the cortical, limbic, midbrain, and brainstem

activated during fMRIs. The regions of the brain that light up during fMRs all have different

functions in relation to pain. For instance, the somatosensory cortex and secondary

somatosensory cortex translate communication about sensory traits that include the place of the

pain and the length in persists. The ACC and the insula comprise the limbic system or the

emotional parts of the brain and serve to translate the emotional responses to pain and the


purpose of the pain. The insula controls pain effects and sensation, and the ACC manages the

subjective encounter of pain (Bushnell, Ceko, & Low, 2013, pp. 502-503). In addition, there are

many descending pain pathways that are associated with pain alleviation including activity

change through attentional states, and different emotions (Bushnell, Ceko, & Low, 2013, p. 503).

Neuroimaging studies can help trace what regions of the brain correlate with different stimuli

associated with pain and trauma.

The frontal cortex. The prefrontal cortex allows individuals to perceive and assess what

is happening around them, and make conscious decisions by foreseeing what may happen if

different responses are executed. The capacity to function from the prefrontal cortex and stay in

a mindful state can help maintain relationships (Van der Kolk, 2014, Chapter 4, Section 6, para.

2). When the brain is in a mindful state, and encompasses the ability to calmly and impartially

recognize thoughts, feelings, and emotions, it allows the frontal cortex to manage, constrain, and

coordinate the automatic responses that were pre-established in the emotional brain (Van der

Kolk, 2014, Chapter 4, Section 6, para. 2). An individual primarily functions from their cortex

when they are calm and this is where executive functioning takes place or the ability to plan,

focus, remember, and read and write (Perry, 2006, p. 49). Prefrontal cortex neurophysiological

messages highlight the connection of physical symptoms, emotional regulation, memory,

attention, and perceptions (Kradin, 2011, p. 38).

When an individual relives a traumatic memory, the sensual experiences are relived, the

frontal lobe shuts down, which often includes the ability to articulate feelings, the sense of time

in the environment, and the thalamus which regulates senses and motor signals in regulation of

consciousness (Van der Kolk, 2014, Chapter 11, Section 3, para. 6). Frontal lobes are crucial for

empathy, and without activation individuals lack curiosity, originality, and are caught in habitual


ways of shallowness and repetition (Van der Kolk, 2014, Chapter 4, Section 4, para. 3). The

same repetitious behavior that is recognized with obsessive compulsive disorder and substance

abuse disorder; which are linked to trauma and chronic pain. Functioning from the frontal

cortex, and living in a mindful state, allows one to empathize and connect with others.

The medial prefrontal cortex. The medial prefrontal cortex or the “watchtower” is the

area that indicates instinctive variabilities in pain (Flor, 2014, p. 189). However, the level the

brain change is still argued due to the comorbidity with anxiety and depressive disorders and the

lack of deciphering between the variables (Flor, 2014, p. 188). The medial prefrontal cortex

helps regulate and lower emotional activity within the amygdala, and naturally continues the

elimination of created emotional responses after the stressful experience becomes irrelevant

(Gupta, 2013, p. 88). In dissociative states corticolimbic areas of the brain (rostral anterior

cingulate, hippocampus, and amygdala), are hindered and there is intensified activation in the

medial prefrontal cortex anterior cingulate cortex (ACC). These states also minimize activity in

the insula which increases modulation of emotions, and this is parallel to decreased pain

sensitivity recognized in dissociation (Gupta, 2013, p. 89).

The anterior cingulate cortex (ACC). During emotional activity, the ACC regulates the

degree of outward expressions of feelings of distress during emotional responses, and is

important for social interactions (Gupta, 2013, p. 88). The Rostral ACC is the affect and

intuitive or visceral part of the ACC which controls neuroendocrine and sympathetic reactions

(Gupta, 2013, p. 88). Affect involves the outward expression of feelings and emotion, facial

expression or body motion that indicates emotion. Sympathetic reactions to toxic stress are

linked to generalized pain syndromes that often include chest pain, migraine, inflammation and

restlessness (Gil, Wang, Gu, Donello, Cabrera, & Al-Chaer, 2016). The sympathetic nervous


system linked to the anterior cingulate cortex (ACC) plays a large role in chronic pain and with

more studies it could lead to new findings for healing chronic pain.

The hippocampus. The Hippocampus operates by an individual’s perception of stimuli

in their surroundings and to indicates safety, or it helps recognize and assesses the context of the

environment in which the distressful stimuli first appeared. It also has a role in interpreting

emotional and impartial memories (Gupta, 2013, p. 88). The same stimuli that triggers the

reliving of a traumatic event, and the somatic experiences linked to the sensual experience.

The anterior insula. The Anterior Insula is involved with interoception or the

perception of the body, and helps individuals understand and feel emotions, and likely has a key

role in the development of somatoform and medically unexplained symptoms related to PTSD

(Gupta, 2013, p. 88). The insula is the origin for all subjective feelings that stem from the body,

and sensory, emotional, and bodily feelings (Gupta, 2013, p. 88). The stimuli produced in the

gut or the internal organs that has been shown to correlate with the insular cortex includes, “pain

from muscle and skin, joint ache, itch, burning and pricking sensations, vasomotor flush, touch,

sexual arousal, coolness, warmth, heartbeat, dyspnea, “air hunger,” and vagal input from visceral

fullness, nausea, cramps, distension of the bladder, esophagus, stomach and rectum” (Gupta,

2013, p. 88). The somatic complaints or physical symptoms listed often cannot be explained

medically and have been linked to trauma (Gupta, 2013, p. 88).

Subcortical regions. When the subcortical regions of the brain are activated an

individual has heightened senses and becomes progressively aware of their physical state, which

essentially helps them recognize threat (Perry, 2006, p. 49). Shifts in the subcortical regions

happen subconsciously and without awareness, and the subcortical regions are important for

managing one’s breathing, digestion, hormonal secretion, immune systems, and heartbeat (Van


der Kolk, 2014, Chapter 6, Section 4, para. 5). If the subcortical regions sense ongoing danger or

are stressed they become flooded, and a variety of somatic complaints have been linked to these

regions and reported by individual’s seen for trauma (Van der Kolk, 2014).

Amygdala. Van der Kolk (2014) reports, when the amygdala senses danger, a message

is sent to the hypothalamus and brain stem, and these initiate the autonomic nervous system

(ANS) and the stress-hormone system to facilitate the body to respond to the threat (Van der

Kolk, 2014, Chapter 4, Section 5, para. 2). The Amygdala is essential for fear conditioning, and

evaluates potential danger or threat and uncertainness in an individual’s surroundings (Gupta,

2013, p. 88). The amygdala entails fear recollection and activates the autonomic nervous system,

which can greatly impact different functioning of the organs in the body and is also linked to

sleep patterns (Gupta, 2013, p. 88).

The amygdala impacts rapid eye movement (REM) sleep phase, which involves a vivid

dreaming state, higher heart rate and energy during sleep; REM sleep is a vital role of good

health and functioning during wake hours. Hyperactivity in the amygdala from PTSD can

impact the regulation and manifestation of both REM and non-REM sleep (Gupta, 2013, p. 90).

The amygdala initiates neural activity in different regions of the brain which have mutual

connections with REM-on and REM-off cycles, these brain regions often include the basal

forebrain, hypothalamus, anterior hypothalamus, brainstem, and nucleus, which has mutual

connections (Gupta, 2013, p. 90). Sleep disturbances are reported by 70% of individuals seen for

trauma (American Psychiatric Association, 2000), and is linked to higher pain sensitivity, poorer

perceived physical health and depression (Gupta, 2013, p. 89).

Hypothalamus. The hypothalamus stimulates the pituitary gland, and

andrenocorticotropic hormone exudes from the pituitary gland, which stimulates adrenal glands


and creates the hormone cortisol. Cortisol supports the body and produces a continuous amount

of blood sugar which helps the body to regulate and restore its normal functioning by coping

with the persistent stress (McLeod, 2010, p. 1). Cortisol helps the body deliver stored glucose or

energy from the liver, and moderates inflammation from injury. While cortisol is released from

the adrenal cortex it helps inflammation but also increased amounts compromises the immune

system (McLeod, 2010, p. 1). Inflammation is the body’s natural response to protect itself from

physical or emotional injury, and often manifests as chronic pain. Cortisol is a hormone released

from the adrenal gland that helps the body survive and alarms the body of danger; however too

much cortisol imposes on sleep and inhibits oxytocin. Oxytocin is an intimacy chemical, and

provides the feeling of love, security, empathy, and trust. It relieves stress, and is long-lasting,

whereas dopamine, a short-term gratification chemical which often feels intoxicating, is released

by many drugs linked to addiction.

The Rational and Emotional Brain

The rational left-side and emotional right-side of the brain play important roles in

behavioral functioning and the balance of mind, body and soul. The rational brain provides

objective, logical thoughts and ensures equilibrium, while the emotional brain offers more

subjective artistic and intuitive responses. When an individual describes a traumatic experience,

it is often easier to function from the rational brain, as opposed to communicating from the

emotional brain or the core–the heart–of the experience (Van der Kolk, 2014, Stuck in Fight or

Flight section, para. 6). In other words, an individual will almost always articulate their

experience from their left-brain (rational) and share the description of the traumatic event in full

comprehension of external experiences, and will find it is much more difficult to convey from

the right-brain (emotional), visceral, and sensory internal experience. When functioning from


the rational brain an individual describes the objective details and facts of their traumatic

incident. Whereas, when an individual is utilizing the subjective emotional brain the individual

may describe the emotions and sensations experienced during the trauma. The wise mind is

created when the rational and emotional mind operate together in unity.

Two main factors that play a role in an individual’s pain experience is their cognitive and

emotional processes (Bushnell, Ceko, & Low, 2013, p. 502). Pain can be destructive to emotions

and cognition, and negative thoughts and emotions intensify pain; and positive emotions and

cognitions such as memory and attentiveness can decrease pain or interpretation of pain.

Bushnell, Ceko, and Low (2013) indicate, an individual’s negative expectations can entirely

setback analgesic effects of a therapeutic dose of remifentanil, an opioid, as oppose to a placebo

analgesia where the expectation of pain relief is crucial. Thoughts and emotions also work

together to enhance the psychological state of an individual. Psychological distraction or

alteration, and emotional welfare can also influence the perception of pain. Essentially pain and

general cognitive and emotional functioning are interrelated, and this indicates that chronic pain

can exacerbate cognitive problems, anxiety, and depression, and vice versa (Bushnell, Ceko,

Low, 2013, p. 508).

The rational brain. The neocortex involves executive functioning or problem solving,

memory, attention, language, decision making, rationalizing, and overall how an individual

processes information. Trauma affects cognitive areas of the brain by decreasing an individual’s

ability to comprehend, and inhibits language centers of the brain to function properly (Van der

Kolk, 2014, Chapter 3, Section 2, para. 3). Teague (2013) further suggests when the brain is

developing and is affected by trauma it can cause interruptions in social functioning, problem-

solving tasks, and language development (p. 615). Individuals who don’t develop these skills


often struggle in altered social settings with acclimating, and as mentioned previously struggle to

access their prefrontal cortex or the ability to remain calm in social settings.

The cognitive areas of the brain influence how some individuals think about their pain;

which include beliefs, interpretations, catastrophizing, negative thoughts, and expectations.

Cognitive processes help decipher what the pain means and lays the framework for behaviors

(Linton, & Shaw, 2011, p. 702). The left-cognitive-side of the brain can indicate how an

individual is translating their pain, and how their distress from pain can fuel negative thoughts.

Pain catastrophizing is an example of a thought process that amplifies the experience of pain, or

where a somewhat minimal symptom is turned into a catastrophic event (Linton, & Shaw, 2011,

p. 704). The link between pain and negative feelings is bidirectional; pain can generate negative

feelings, and negative feelings influence pain that fuel negative thoughts, attention, and overt

behaviors. The cognitive assumptions of pain and perception of pain (i.e. the purpose of pain,

how long it persists, and the ways to treat pain) can help individuals recognize the warning sign

of pain, and whether they are either adaptive or maladaptive.

The emotional brain. The limbic system is at the core of the central nervous system,

encompasses the emotional brain, and its primary responsibility is to ensure safety (Van der

Kolk, 2014). Emotions stimulate the limbic system, and an area within called the amygdala; the

amygdala notifies the body of threats and if threat is verified, the body consequently goes into a

stress response. Powerful emotions originate from the mind, gut, and heart; which are deeply

interconnected through the vagus nerve, and this nerve also controls and expresses emotions

(Van der Kolk, 2014). The purpose of emotions is to repair the bodies equilibrium, and to return

it to safety, or to warn of danger, which is central to trauma.


The crucial value of experiencing emotions is apparent, they are important for continued

existence, and have an invigorating individualistic vivacity. They are important for adapting,

deciphering, and helping an individual recognize imperative information in the world. Emotions

can help an individual recognize threatening or harmless stimuli, and are what can foster or

danger existence. Individuals would be immobilized without the ability to taste, see, touch,

smell and hear; they wouldn’t be able to establish the difference between pain and pleasure, or

cold and hot, or night and day. Emotions are essential to the operation of senses, and create

identity (Mate, 2008, p. 41). Mate (2008) reports, “They make life worthwhile, exciting,

challenging, beautiful, and meaningful” (p. 41). If emotions are central to controlling the

functioning of senses, and trauma can impact our senses, then can we treat chronic pain by

regulating our emotions or the intense metal activity linked to pleasure or displeasure?

Emotional development. Developmental trauma can compromise a child’s affect, or the

changing of emotions throughout time and ability to identify, regulate, express and create

meaning through emotions (Teague, 2013, p. 615). For instance, one may have the inability to

recognize feelings of fear or anger, regulate the emotion, and understand why it is important

through creating meaning and purpose, and establishing a goal. Identifying upsetting thoughts

and feelings, self-soothing and self-kindness, and putting human anguish into perspective are

things that may be lacking in the affect development of the child who’s been exposed to

adversity (Teague, 2013, p. 616). When a child doesn’t have the capacity to regulate affect, they

are unable to utilize their unconscious cognitive skills to process certain emotions when they

emerge, and this is often the cause of trauma (Teague, 2013, p. 615).

Developmental trauma can lead to overwhelming feelings and intolerable emotional

states, which consequently lead to believing things are out of control, the harm is irreparable, and


that it is reasonable to no longer feel emotionally or physically (Van der Kolk, Prologue, Section

1, para 5). Mate exclaims, a child’s main protection from trauma is the body’s ability to

automatically suppress emotions and this subsequently helps the child endure what otherwise

would be devastating (Mate, 2008, p. 41). Fear of vulnerability also leads to a child’s inability to

experience emotions or forgetting what it feels to ever have experienced emotions, it distances

one from others and self, and creates emptiness (Mate, 2008, p. 41). The areas of the brain that

deactivate during a state of trauma, can stay shut down long after the episode and these are the

areas of the brain that transmit emotions and form self-identity and provide an individual with

emotions (Van der Kolk, 2014, Chapter 6, Section 3, para. 6). For an individual to regain control

of their life, they must first identify and appreciate the embodied self through all its internal

feelings and emotions and external physical sensations (Van der Kolk, Chapter 2, Section 9,

para. 1). Intuition or deep inward feelings that are unrelated to thought processing can help an

individual identify their body in all realities, and understand what is needed to address the

experience of pain.

Alexithymia. Alexithymia is associated with a concrete way of thinking and can be

defined as the struggle to establish and express emotions, difficulty in distinguishing between

physical sensations and emotion, and failure to imagine. Individuals who suppress emotions

often find themselves incapable of feeling positive emotions such as joy; this is because when

they are suppressing emotions they either suppress all or none, there isn’t a filter (Mate, 2008, p.

41). Individuals with alexithymia often have more attentiveness to their body and identify

somatic sensations as biological when often they are psychological (Martinez, et al., 2015).

Alexithymia also exacerbates fear of pain, which consequently causes anxiety and confusion in

deciphering between anxiety and fear of pain. Alexithymia is often linked to chronic diseases


and significantly relates to pain, fatigue, and mental distress. Emotions can cause physical

problems rather than something to be noticed that warrants consideration. What is your body

telling you? Individuals with alexithymia need to expand on their ability to recognize the

correlation between their physical sensations and their emotions. Martinez et al. (2015) identifies

increasing levels of pain correlates with emotional dysfunction, and a decrease of the

management, expression, and identification of emotions. The ability to identify and recognize

the purpose of emotions can help contribute to one’s ability to relieve the sensation of hurt.

The inability to imagine often is a symptom of alexithymia, and can greatly affect the

overall quality of life. Imagination is important for an escape from reality and everyday routine.

It allows an individual to daydream about vacation, sex, events, love, or a better life, and makes

life fascinating and endless. Imagination allows an individual to identify desires and envision

new opportunities, it facilitates the departure from what once was, and makes dreams turn into

reality. Imagination relieves pain, stimulates creativity, mitigates boredom, enriches enjoyment,

and deepens our closest relationships (Van der Kolk, 2014, Chapter 1, Section 4, para. 10). An

individual who struggles to imagine and has rigid mental functioning and flexibility, needs hope

and goals, and the capacity to envision an improved and healthier future. (Van der Kolk, 2014,

Chapter 1, Section 4, para. 10).

Psychological Purpose for Pain

An individual who has experienced trauma often struggles to communicate their physical

feelings or sensations because they are often unaware of what function they serve (Van der Kolk,

2014, Chapter 6, Section 7, para. 2). Pain is a subjective experience and an individual’s response

to it in a psychological way can aid in the ability to cope with it, and consequently achieve

improved or desired health (Linton, & Shaw, 2011, p. 701). There has been extensive research


focused on whether the mind can construct physical symptoms or disease, such as pain, and how

an individual’s pain perception is reliant on the meaning and context. Smith (2013) suggests

chronic pain can serve as a psychological defense mechanism that redirects attention away from

emotions that are too distressing to address (p. 189). Wilberg (2011) explains, the physical body

is the outer physical expression of an individual’s soul or mind, and their personal feelings,

tastes, or opinions. An individual’s bodily sense of self is their essence of their subjective felt

body or lived body. Wilberg reports “That is why all illness begins with a vague sense of “not

feeling ourselves” – and yet can lead us in turn to “feeling another self” – and to bodying that

self in new and more fulfilling ways of “being-in-the- world” (p. 316). For instance, physical

pain can serve as an emotional sedative (Smith, 2013, p. 189), which essentially numbs feelings,

emotions, and sensations caused by something or someone that is threatening to the internal-self.

Therefore, if pain can numb emotions it can distract the individual’s emotional self-awareness

including connection their emotions have with their surroundings or events.

Assumptions are formed by environment and social settings and can influence how an

individual experiences or processes pain. Societal beliefs often involve ideas that hurt equals

harm–or to be broken, and that pain means to stop–to avoid injury, and that sleep is the best

medicine, especially for pain and to recuperate the body (Linton, & Shaw, 2011, p. 703). These

expectations drive behavior and ways to cope with pain, and often predict the prognosis and

treatment prognoses of pain (Linton, & Shaw, 2011, p. 703). For instance, a high number of

individuals with chronic pain will sleep more, which can lead to further mental impairment, not

being present, or rumination (Angheluta, & Lee, 2011, p. 115). An individual has thoughts about

the source of pain, how to manage it, and the amount of time it will persist (Linton, & Shaw,

2011, p. 703). Individuals often struggle to manage their pain, and frequently will try passive


techniques, such as sleeping more, and this can lead to living in the trauma and furthermore

mental impairment, not being present, inability to experience joy, or rumination.

Illness is a natural aspect of life, and plays an important role in the circle of life and

dying. Wilberg (2011) verifies, “The war that biological medicine wages on disease is part of a

general war against the basic existential realities of aging and death – a war that is one of the

most unnatural and unhealthy aspects of modern culture and its science” (Wilberg, 2011, pp.

311-314). An individual’s perception is unique and it depends on their private logic to process,

store and retrieve information through their individualistic psychological state, and respond to

the world accordingly (Perry, 2006, p. 249).

Pain can demand awareness, and can be beneficial because it necessitates proper

reactions to dealing with the injury (Linton, & Shaw, 2011, p. 702). Attention has a

psychological purpose to increase behavior, and therefore attention connected to pain is likely

linked with anxiety and worry and the demand for action (i.e. avoiding or fleeing). Maladaptive

attention to pain, can be referred to as vigilance, or an individual’s heightened awareness to

sensations of pain that may be recognized as intense pain to a seemingly small injury. Vigilance

can help the individual avoid awareness to circumstances in their life and concentrate that

awareness on pain. Distraction interventions, such as art therapy, for pain, are purposeful

because they help redirect attention to other things (Linton, & Shaw, 2011, p. 702).

Can pain be defined as a behavior? Linton and Shaw (2011) indicate pain is an internal

form of behavior which is a private event, and pain can be regarded as a group of behaviors such

as taking analgesics, receiving ongoing care, or resting (p. 704). Pain can be conceptualized in

the same way as a psychological problem, such as anxiety or depression. The behaviors centered

around pain are created by emotions and thoughts, and are specifically conditioned by


environments (Linton, & Shaw, 2011, p. 704). Evaluating the environment of an individual and

factors that influence pain, can provide insight on what changes need to occur for the pain to

reduce.

The emotional and sensory experience is unique for every person and can be governed by

the psychological state, background, and perception of pain (Bushnell, Ceko, & Low, 2013, p.

502). There are several psychological symptoms that are linked to reliving a traumatic

experience (Gupta, 2013, p. 86). Many individuals who have experienced trauma struggle to

identify what they are feeling because they cannot recognize the psychological purpose or

meaning of their presenting physical sensations (Van der Kolk, 2014, Chapter 6, Section 7, para.

2). Pain is a subjective experience and an individual’s response to it in a psychological way can

aid in the ability to cope with it and achieve improved health (Linton, & Shaw, 2011, p. 701).

Consequently, it can be concluded pain demands attention to life events, vigilance may increase

pain and avoidance behaviors life events, and distraction may decrease pain intensity.

Organ Inferiority

The body’s language and its functions are always more honest than one’s verbal language

or mental comprehension of their circumstances (Griffith, 1984, p. 434). Adler described

physical symptoms and illness not as a liability, but more so by external demands and inferiority

of the organ, which often include the life tasks of work, love, social, spiritual, and self

(Ansbacher, & Ansbacher, 1956, p. 24). Adler believed, physical symptoms and complaints

were influenced by cultural changes, social implications, and alterations in one’s living

environment (Ansbacher, & Ansbacher, 1956, p. 24). To heal, the individual must understand

how their somatic symptom achieves what it desires. While most organ illness functions and has

purpose, if it persists it later becomes maladaptive and exacerbates other areas of body, mind, or


lifestyle (Adler, 1956, p. 438). An organ has its own dialect and unless an individual believes

that what the organ is saying fits with their lifestyle or it is in the interest of their final fictive

goal, the individual will overlook the communication of the organ (Dreikurs, 1973, p. 144).

Through the biomedical model pain is often treated through surgery or medication, and in some

cases this treatment is necessary; however, emotional distress from rejection and abandonment

can cause pain, and psychological and social aspects are not always assessed or addressed. Best

practice would include a holistic model of care which concentrates on all aspects of the

individual’s needs, and Adlerian theory favors holistic integrative approaches.

Adlerian psychotherapy conceptualizes physical symptoms in relationship to illness, as

psychological manifestations, and Adler defined these expressions as organ jargon (Powers, &

Griffith, 2012). If an individual can better understand the physical symptom they can expose the

meaning or the function of the illness. The location, intensity, associated feelings, regularity and

profile of the illness, and what Adler more specifically categorized as organ jargon, can help

lead to the discovery of the role of the illness. The timing of an individual’s physical symptoms

and correlation to other experiences going on in their life (i.e. starting a new job and back pain),

can help reveal the meaning of the somatic complaints. To address a somatic symptom, an

individual must unfold themes or patterns between their psychological state during the time the

symptom began or persists, and episodes of occurrence and non-occurrence. A starting point is

to place emphasis on all life tasks, including work, love, social, spiritual, and self; to help unfold

the connection the mind has with the body. Other question may unveil connections the mind has

with the body, “how would your life look if you didn’t have the physical symptom?” (Powers, &

Griffith, 2012).


The existential and phenomenological aspect of pain is to search for the meaning of the

symptoms rather than the cause (Wilberg, 2011, p. 304). The language the body discloses an

individual’s opinions even more so than their consciousness is aware of, and often the words the

individual speaks does not align with the dialect of the body (Griffith, 1984, p. 223). An

individual’s body language is a very complex biological expression, and is unique from other

individual’s expressions and communication.

Somatic symptoms such as chronic pain can be viewed in an existential lens as a healthy

and beneficial part of life, similarly to coping with a problem in life. Wilberg (2011) identifies,

mental, emotional, and psychological states, are somatic experiences or subjective physical

sensations, and this is bidirectional (p. 304). Chronic pain is a living embodiment of the

individual and is an indicator and metaphor of something painful, anguishing, or discomforting

in life that needs to be addressed, usually a relationship. Chronic pain is an existential feeling or

emotional sickness that has the capacity to help heal or make self whole again (Wilberg, 2011, p.

304). Chronic pain can be viewed as a learning process or the ability to forge meaning and build

identity. Healing is encompassed through allowing the body to aid in transformation of the

bodily sense of self. The inwardly felt body (embodiment) can permit us to feel a new sense of

self than the one previously experienced. The mind and body thrive together in a natural

harmony of thought, feeling, and action, and strive towards the Adlerian final fictive goal that

was created by the undivided embodied self (Powers, & Griffith, 2012). Chronic pain is an

illness of human relationships and is a powerful expression of the health of the individual’s

human relations with self or others (Wilberg, 2011, p. 304).


Concepts of Social Interest

Van der Kolk (2014) expresses, an individual’s mind will become an expert in joy,

curiosity, and collaboration when it feels secure and loved; and when it feels afraid and

unnecessary, it will focus on managing feelings of abandonment and anxiety (Chapter 4, Section

3, para. 6). A traumatic experience can leave an individual questioning whether they were a

cooperative participant or a victim, and can consequently cause the struggle between deciphering

pleasure and pain; and love and terror (Van der Kolk, Chapter 2, Section 3, para. 4). Feeling safe

and feeling safe within relationships, is a huge component to living a life of value and

significance. Supportive relationships are very different than being in the company of others.

Social interest, connectedness, empathy, and reciprocity is of utmost importance (Van der Kolk,

2014), Adler described this as the ability “to see with the eyes of another, to hear with the ears of

another, and to feel with the heart of another” (Griffith, & Powers, 2007, p.135).

Trauma during developmental years can interrupt a host of natural social capabilities;

foremost the ability to build security and trust in relationships. Developmental trauma can also

cause cognitive interruptions that affect social skills, like decision making, problem-solving,

language development, and acclimating to new settings. It leads to the inability to process,

identify, and regulate emotions that are needed to build healthy relationships. Developmental

trauma can cause externalizing (i.e. being disturbing or disruptive to others) or internalizing of

behaviors (i.e. isolation, or somatic complaints). Dissociation from developmental trauma can

lead to impaired memory, confusion, different personalities, and lapses of time without recalling

what happened or fugue states, all which cause social disconnection


Trauma’s Impact on Social Interest

An infant cannot survive on its own without the touch of a human, and by nature humans

are incapable of being without the connection of others. Humans evolved from hunter and

gatherers, and their very existence has always depended on the formation of groups and finding

value for every member (Perry, 2006, p. 118). For an individual to be biologically successful the

brain must operate in these three ways, first it needs to survive, second it needs to reproduce, and

third if it has young, it needs to defend and care for the young till they are capable of caring and

protecting themselves (Perry, 2006, pp. 66-67). These three functions of the brain are supported

by the ability to preserve relationships, and consequently make humans social creatures (Perry,

2006, p. 118). Interactions with others, environment, and experiences alters the chemistry of the

developing brain, and as a subsequently can lead to a spectrum of life events and circumstances.

The relationships that are formed during childhood, influence and carry great value to

relationships in adulthood. An individual’s mind, body, and soul, is driven by connectedness and

the partnership in social systems and tasks of life (Van der Kolk, 2014, Chapter 2, Section 4,

para. 4). The more we contribute and connect with others the healthier we are through social

embeddedness (Powers, & Griffith, 2012).

Infants connect with their caretakers on emotional and physical levels, (Van der Kolk,

2014, Chapter 10, Section 8, para. 8), and develop by perceiving voices, facial expressions, tone

of voice, tempo of movement, actions, and posture. All forms of communication transform a

child’s physiological and psychological makeup, and is key to their survival (Van der Kolk,

2014, Chapter 10, Section 8, para. 8); which therefore makes communication an important

element to understanding trauma and stress. Humans are the number one predator, and therefore

humans are very in tuned with assessing others non-verbal and social expressions for safety,


humans also rely on mirroring others, and the ability to respond and to reflect (Perry, 2006, p.

118). The severest traumas in every characteristic is that of the break between relationships,

either that of belonging and self, or connection with others, and this disruption is even more so

devastating on a child (Perry, 2006, p. 231). Love cannot be established through isolation, and

one cannot find love within themselves unless they have experienced love and have the love of

another (Perry, 2006, p. 234). Gemeinschaftsgefühl, the community feeling of belongingness

suggests one is shaped by others, and contributes to others in life (Powers, & Griffith, 2012).

Attachment. The intense emotional bond that stems between the caregiver and the child

is what is referred to as attachment (Teague, 2013). If a secure attachment is formed, the child

will have increased adaptive thoughts and behaviors, and feel as though their caregiver is

available, trustworthy, and responsive. Developmental trauma can interrupt the child’s

development to build security and trust in relationships, later in life. Often, insecure attachments

direct avoidant behaviors and the lack of decision-making skills needed to develop relationships

(Teague, 2013).

An experience that can be threatening to the embodied self, can result in a struggle to

build or establish an intimate relationship (Van der Kolk, 2014, Chapter 1, Section 2, para. 5).

After the embodied self is exposed to a terrifying event, it is hard for one to open-up and become

vulnerable, especially because often they can no longer trust self anymore or trust others (Van

der Kolk, Lessons from Vietnam Veterans section, p. 400). Worry triggers or what-if

likelihoods, consequently initiate disruptive behaviors, attention, and cognitions (Linton, &

Shaw, 2011, p. 704). Trauma often leads to people separating others into categories of

individuals who can identify and are trusted, and can’t identify with their experience, and cannot


be trusted (Van der Kolk, 2014, Chapter 1, Section 5, para. 5). Therefore, it is common to search

for individuals that can be trusted and that can provide us with courage to move forward.

Chronic Pain’s Impact on Social Interest

Chronic pain and strained relationships are interconnected, chronic pain can disrupt

relationships, and relationships that are strained can be a precursor to chronic pain. Individuals

living with chronic pain often experience emotional, physical, and perceptual challenges within

their relationships, and depression and anxiety are often co-morbid which can lead to rumination

and distress over the future or past (Coren, 2016, p. 394). Chronic pain and psychological

distress has a substantial role in the ability for those to connect emotionally (Henne, Morrissey,

& Conlon, 2015, p. 710). Individuals with persistent pain regularly complain of misfortunes (i.e.

break up or loss of a loved one), exaggerate symptoms, or can be unwilling to take on household

responsibilities, or perform everyday tasks, which essentially put strain on the relationships.

Feelings of rejection can also exacerbate emotional connectedness. Mate (2008) reports, brain

regions that translate and create physical sensations of pain, during neuroimaging, will also

become activated during social ostracism and rejection. Furthermore, Mate (2008) indicates,

“When people speak of feeling “hurt” or having emotional “pain,” they are not being abstract or

poetic but scientifically quite precise” (p. 36). Emotional connectedness is the antidote to

feelings of shame and guilt that are related to disconnection, insecurity, chronic pain, and trauma.

Emotional connectedness is often characterized by an essence of empathy and intimacy in

a relationship, and partners who are experiencing chronic pain often report to lack emotional

connectedness in their relationship (Henne, Morrissey, & Conlon, 2015, p. 710). Lack of trust is

not only experienced by the individual experiencing chronic pain, but it is bidirectional in the

relationship. Van der Kolk (2014) reports, establishing connectedness through trust and safety in


relationships is key to mental wellness and living a life of significance and fulfillment (Safety

and Reciprocity section, para. 1). Emotional connectedness in relationships has implications on

decreasing anxiety and depression, and reduction of perceived stress; and therefore, depression

and anxiety comorbid with chronic pain is predominant in relationship difficulties (Henne,

Morrissey, & Conlon, 2015, p. 711). Perception can also be a factor in how individuals believe

they are emotionally connected to the relationships. For instance, Henne, Morissey and Conlon

(2015) identified, “Women frequently reported difficulties with emotional connectedness

because others failed to understand their pain. These women also reported feeling less tolerant

of other people’s complaints and issues and attributed a lack of ability to respond emotionally

directly to pain or resultant fatigue” (p. 713). Therefore, pain can contribute to an ongoing cycle

of not feeling empathized by others, and not being able to empathize with others, and this

significantly disrupts emotional connectedness.

In opposition to pain disrupting emotional connectedness it has also been recognized to

cultivate emotional connectedness. It has been shown that behaviors related to pain can

contribute to the fostering of intimacy and enhance emotional interaction with a loved one. For

instance, the individual in the relationship who is not experiencing the pain will increase their

efforts of support because they are desperately trying to minimize the destressed individual with

chronic pain. In addition, observing a loved one in pain can activate a number of pain sites in

their brain, even more so than when observing an unfamiliar person in pain (Bushnell, Ceko, &

Low, 2013, p. 503). The chronic pain acts as a mechanism. to assist the individual complaining

of the pain, with fostering intimacy and vulnerability in the relationship. If the individual with

chronic pain has a relationship that validates emotions and feelings, new intimacy can grow or be

established.


Empathy. Empathy, connection, safety and a witness to an individual’s traumatic story

can contribute to the healing process of the brain and is essential for somatic sensations, like

pain, and the perceptions related to it. Brain imaging studies have shown empathy, positive and

negative emotions, placebo administration, and attentional states, influences the neuro activity in

afferent pathways associated with pain (Van der Kolk, 2014, Chapter 4, Section 4, para. 1).

Neuroimaging also indicates that the frontal lobes are essential for empathy and trauma-informed

treatment (Van der Kolk, 2014, Chapter 4, Section 4, para. 1). Brene Brown (2008) claims,

empathy needs to be learned and that it fuels connection and involves; the capacity to take the

perspective of others and see the world through their lens, to stay out of judgment, to

comprehend other’s feelings and emotions, and to effectively express one’s feelings and

emotions (p. 37). The quality of Empathy is essential for interconnectedness, and yet it is

becoming less predominant for many reasons. Society often values intelligence quotient (IQ) as

opposed to emotional intelligence (EQ), and individuals in individualistic societies become

competitive which results of superiority, which in turn makes it difficult for vulnerability and

empathy to be established (Perry, 2006, p. 242). Empathy is one capacity that can modify pain

perception. Empathetic reciprocity is needed in relationships and educational and health care

settings could greatly benefit from incorporating psychoeducational courses on connection and

empathy.

Substance Use Impact on Social Interest

Chemically dependent individuals often report how their feelings of isolation strongly

correlate to their psychological states in childhood. The feelings in childhood often are

connected to feeling dismissed, rejected or abandoned (Mate, 2008). Individuals with co-morbid

chronic pain and trauma often resort to using substances to self-medicate for pain. Drugs can


mimic a sense-of-belonging feeling, and can provide the nurtured feeling that infants receive

when they are cradled as infants. Regularly the drug becomes the most important relationship to

the individual and everything else becomes secondary. Mate (2008) notes, “Like patterns in a

tapestry, recurring themes emerge in my interviews with addicts: the drug as emotional

anesthetic; as an antidote to a frightful feeling of emptiness; as a tonic against fatigue, boredom,

alienation, and a sense of personal inadequacy; as stress reliever and social lubricant” (p. 33).

Often individuals with substance use disorders struggle to feel vulnerable unless they are under

the influence. A drug provides an individual the ability to engage in life, and feel a sense of

belonging while being safeguarded from the pain, and often it provides liveliness that was lost

due to trauma (Mate, 2008). Substance use often provides motivation and an increased ability to

socialize, as opposed to feelings of isolation and rejection, and fear of vulnerability when not

under the influence (Mate, 2008).

Individuals with addictive behaviors are often perceived in society as inferior, and

struggle to find the dignity and compassion of others, the only way the individual feels normal is

when under the influence, which often leads to dependency (Mate, 2008, p. 43). Addictive

behaviors are most commonly frowned upon and shamed, “the frantic self-soothing of overeaters

or shopaholics; the obsession of gamblers, sexaholics, and compulsive internet users; or the

socially acceptable and even admired behaviors of workaholic” (Mate, 2008, p. 2). It is no

wonder they find relief in their addictions, an escape from the societal norms, and a way to

overlook the stigmatization and judgement they face for being “an addict.” Sometimes

individuals are so entrenched by their addiction, it has created their self-concept, and the very

thought of abstinence can be threatening the loss of self (Mate, 2008, p. 45). While some

struggle with loss of self-identity through sobriety, others feel a life of values and in truthfulness,


is so incomprehensible and unachievable it becomes too distressing or painful to even entertain

the thought (Mate, 2008, p. 48). Individuals who are chemically dependent often find it difficult

to increase emotional tension and display anxiety in being vulnerable or engaging in a close

relationship (Halužan, 2012, p. 100).

Healing Through Therapeutic Relationships

There are several professionals that treat comorbid trauma and chronic pain and it can

often go unrecognized because there is often a lack of integration from professionals. The broad

range of professionals involved in the treatment may include mental health practitioners,

psychiatrists, physicians, substance abuse counselors, social workers, nurses, art therapists,

acupuncturists, occupational therapist, yoga instructors, chiropractors, and massage therapists

(Smith, 2013, pp. 188-190). Despite the number of professionals there are to treat co-morbid

trauma and chronic pain, there continues to be barriers with successful outcomes. Asmudson

(2014) indicates, there is a high prevalence of co-occurring PTSD and chronic pain, and it is

linked to deficient prognosis, lack of continuity of care, higher acuity rates, social strain, higher

doses and use of opioid prescriptions, and high individual and societal expenses (p. 717). Clients

who present with co-morbid trauma and chronic pain often have more difficult cases, and a

vicious cycle of traumatic memories are triggered by pain, and the pain triggers the traumatic

memories (Kip, Rosenzweig, Hernandez, Shuman, Diamond, Girling, & McMillan, 2014, p. 2).

Pain symptoms and trauma can also be an obstacle for a client to entirely engage in treatment,

and may cause the client to terminate services impulsively (Asmundson, 2014, p. 718).

Medication assisted therapies for chronic pain have grown in popularity, and there is an

alarming rise in sales of prescription opioids, emergency hospital visits, and deaths associated

with use of hydrocodone, oxycodone, and other opioid medications (Cobaugh, Gainor, Gaston,


Tai, Magnani, Mcpherson, Painter, & Krenzelok, 2014). The U.S. has an opioid epidemic of

misuse and dependency, prescription opioids are recognized for the analgesic effect and are often

prescribed to individuals with chronic pain and substance use disorders. It is 4 times likelier for

chemically dependent individuals to be prescribed opioids than individuals who are not, and

individuals who are addicted often receive stronger opioids and higher analgesic regimens

(Katzman et al., 2014, p. 261). Psychiatric medications work by duplicating chemical signals

and trick the body into functioning in the same ways natural neurotransmitters in the brain enable

the body to function (Perry, 2006, p. 23). Additionally, neuroimaging studies show that

psychological factors activate intrinsic modulatory systems in the brain, including those involved

in opioid related pain relief (Bushnell, Ceko, & Low, 2013, p. 502). Highly addictive

prescriptions such as oxycodone, morphine, and the fentanyl patch are long-acting opioids

(LAO), and are often preferable to short-acting opioids (SAO) with an immediate onset (Olson &

Alford, 2006, p. 263). Prescription opioids used to treat or manage pain can exacerbate other

substance use, self-injurious behaviors, and creates a risk of overdoses and other opioid related

misfortunes (Kip et al., 2014, p. 2). Many drugs provide the brain with a short-term lasting

chemical called dopamine, that is similar to the long-lasting chemical the brain provides of

oxytocin. Oxytocin is the chemical of love and reduces stress, it is the chemical that makes one

desire to be in a group that is comprised of safety and respect, and involves generosity, trust, and

empathy (Sinek, 2014, p. 59). One would conclude treatment that targets psychosocial aspects of

the individual could reduce pharmaceutical interventions.

Early interventions, integrated treatment, and targeting shared vulnerabilities are three

ways to heal comorbid trauma and chronic pain (Asmundson, 2014, p. 718). Treatment for one

condition is deficient and treatment for all co-occurring disorders, including developmental


trauma, chronic pain, anxiety, depression, and substance use, is more effective. A

multidisciplinary approach in the health field is creating new avenues and is yielding higher

efficacy (Smith, 2013, p. 191) and new psychosocial interventions (Smith, 2013, p. 190), and

holistic approaches such as art therapy and somatic therapy, have been more recognized. New

research is needed for the implementation of new health care teams and approaches. Gupta

(2013) affirms, there is extensive research on somatic complaints that correlate with PTSD, and

limited research that addresses treatment for somatic complaints associated with PTSD (p. 95).

Katzman et al. (2014) argued, epidemiological research related to chronic pain indicates strong

associations with depression, anxiety, sleep, and substance use, and therefore psychological and

social aspects are necessary to comprehending and treating pain (p. 263). An integration of

emotional, cognitive. and behavioral coping strategies and systems can be learned and further aid

in the treatment of trauma and chronic pain, and other co-occurring disorders (Linton & Shaw,

2011, p. 704).

The power of the mind to regulate physical wellbeing is a new trend that the Western

world progressively is adopting from Eastern cultures (Bushnell, Ceko, & Low, 2013, p. 502).

Such psychological interventions have been used to decrease stress levels and to manage pain

(Bushnell, Ceko, & Low, 2013, p. 502). However, it is often difficult for individuals to

participate in psychological interventions, because often in Western cultures mental health

modalities are viewed as lower in rank and there are many stigmas around mental health (Flor,

2014, p. 193). There is no one-to-one relationship between the amount or type of organic

pathology and pain intensity, but instead, the chronic pain experience is shaped by a myriad of

biomedical, psychosocial (e.g. patients’ beliefs, expectations, and mood), and behavioral factors

(e.g. context, responses by significant others) (Dansie, 2013, p. 19). The effects of psychological


treatments can be demonstrated in brain scans and peripheral measures, and these

neurophysiological modifications can increase a client’s motivation for psychological and

holistic interventions for the treatment of somatic symptoms. Cognitive behavioral therapy,

meditation, hypnosis, and relaxation techniques, are a few mind-body approaches, that

individuals are exploring to help manage and decrease pain (Bushnell, Ceko, & Low, 2013, p.

504). Flor (2014) reports, demonstrating psychological interventions help on structural and

functional domains of the brain, and can also increase an individual’s acceptance because of the

scientific aspect that contrasts one’s initial skepticism (Flor, 2014, pp. 193-194). Demonstrating

the areas of the brain that are pain-related can also encourage clients to engage in additional

psychological pain treatments as opposed to solely medical treatments (Flor, 2014, p. 193).

Thus, while the US has made major advancements in utilizing the biopsychosocial model in

health care, education, and research, we still have a long way to go.

Healing trauma and chronic pain. Van der Kolk (2014) reports, recognizing the

uniqueness of top down and bottom up regulation is key for comprehending and treating

traumatic stress (Van der Kolk, 2014, Chapter 4, Section 6, para. 5). Approaching the brain from

the brainstem to the prefrontal cortex addresses the autonomic nervous system (ANS). Focusing

on the autonomic system involves movement, breathing and physical contact. While breathing is

central to the ANS it also involves voluntary control; whereas most functioning from the ANS is

involuntary (Van der Kolk, 2014, Chapter 4, Section 6, para. 5). Central emotional portions of

the brain can be found in lower regions, and provide the capacity for interconnectedness, as well

as stress management (Perry, 2006, pp. 222-223). Targeting the brain from the prefrontal cortex

to the brainstem requires increasing your awareness of the sensations experienced in your body,


as within yoga, mindfulness, or meditation (Van der Kolk, 2014, Chapter 4, Section 6, para. 5).

Bessel van der Kolk (2014) emphasizes:

1) top down, by talking, (re-) connecting with others, and allowing ourselves to know and

understand what is going on with us, while processing the memories of the trauma; 2) by

taking medicines that shut down inappropriate alarm reactions, or by utilizing other

technologies that change the way the brain organizes information, and 3) bottom up: by

allowing the body to have experiences that deeply and viscerally contradict the

helplessness, rage, or collapse that result from trauma. Which one of these is best for any

particular survivor is an empirical question. (Prologue, Section 2, para. 8)

The polyvagal theory essentially puts relationships front and center for healing trauma,

and focuses on strengthening the body’s system for regulating arousal. Outside of regulating

arousal, almost all mental impairment, comes from forming relationships that are rewarding and

practical (Van der Kolk, 2014, Chapter 5, Section 3, para. 5). Trauma can affect the functioning

during wakefulness and sleep, and impair several organs and systems, especially the nervous

system which encompasses emotion, more specifically the ANS and the emotional limbic system

(Gupta, 2013, p. 87). The ANS has authority over non-voluntary movement and regulates blood

flow, heartbeat, digestion and breathing. The ANS is comprised of the sympathetic system

(energizes) and parasympathetic system (restrains). The ANS is activated by breathing and when

an individual breathes in, they activate the sympathetic half, and when breathing out, they

activate the parasympathetic half. The ANS can be intensely impacted by others facial

expressions, tone-of-voice, and body posture in the surroundings. Van der Kolk (2014)

indicates, “All of the little signs we instinctively register during a conversation—the muscle

shifts and tensions in the other person’s face, eye movements and pupil dilation, pitch and speed


of the voice—as well as the fluctuations in our own inner landscape—salivation, swallowing,

breathing, and heart rate—are linked by a single regulatory system” (Chapter 5, Section 2, para.

1). Independently, the physical presence of others makes an individual feel calm, rejected,

trigger rage, feel heard, or provide a witness to our story (Van der Kolk, 2014, Chapter 4, Section

6, para. 5).

One can recognize the importance of understanding psychology for the treatment of

trauma, and consequently the treatment of somatic complaints that co-occur with trauma.

Individuals with trauma, first need safe and consistent environments, and non-judgmental

atmospheres, where they feel empowered and can connect and self-regulate (Perry, 2006, p. 154;

Purvis et al., 2014, p. 357). Individuals who have experienced trauma are hypervigilant to every

form of communication because they need to assess the relationship for safety and security.

Before comforting an individual, clinicians must first be able to be calm themselves (Perry,

2006, p. 118). Mate (2008) reports that the individuals he works with often lack self-compassion

and struggle to care for themselves, which consequently makes them extra sensitive to health

care providers and additionally cautious to identifying authentic care and dedication to their

wellbeing (p. 25). Individual’s who’ve experienced trauma need safety and respect because they

are highly in tuned with fine details of non-verbal cues, facial expressions, and tone of voice, just

as if they were in a state of trauma.

Humans are instinctively proficient in identifying emotional changes in other humans and

animals. The smallest of details in body posture such as the angle of the neck, and facial

expression, such as wrinkles between brows, can signal security, disbelief, alarm, or calmness

(Van der Kolk, 2014, Chapter 5, Section 3, para. 3). Mirror neurons are activated during any

type of interaction with another individual and subsequently others disclose an individual’s inner


experience. The essential goal is to truly feel heard and seen, and held in the heart of another;

however, this is not always the outcome during the mirroring experience (Van der Kolk, 2014,

Chapter 5, Section 3, para. 3). Kradin (2011), confirms the therapist being able to manage

transference and countertransference, and the ability to develop empathetic, supportive, and

reliable therapeutic relationships, is of outmost importance (p. 52). Self-blame often occurs with

trauma, and helping the individual to identify that it is not their fault and it wasn’t a shortcoming

of their own, holds great value. Shame and guilt are often attached to trauma which makes an

individual feel they are a mistake or they made a mistake, and connectedness is the antidote to

guilt and shame (Brene Brown, 2008). Mate, (2008) empathizes:

What happened to you is truly horrible. There is no other word for it, and there is nothing

I can say that comes even close to acknowledging just how terrible, how unfair it is for

any being, any child to be forced to endure all that. But no matter what, I still don’t

accept that things are hopeless for any human being. I believe there is a natural strength

and innate perfection in everyone. Even though it’s covered up by all kinds of terrors and

all kinds of scars, it’s there. (p. 128)

The first step to healing trauma is being a witness to the individual’s experience, and to

help them verbally express the event; however, it is often not enough to reduce somatic

experiences that are connected to the event. Van der Kolk (2014) explains, automatic physical,

emotional and hormonal responses, that are stuck in fight, flight, or freeze, and are dictated by

the fear of danger, does not necessarily change just through the experience of telling a traumatic

story (A New Understanding section, para. 3). Individuals who are experiencing trauma need to

return to the present, and recognize that the threat of their experience has passed (Van der Kolk,

2014, A New Understanding section, para. 3). Van der Kolk (2014) reports, his experience with


treating individuals that have a history of trauma has led him to direct his attention away from

the exact description of the traumatic experience, and shift towards helping them tolerate

emotions, sensations, and responses, that occur during therapy without being seized by them

(Chapter 11, Section 2, para. 12). The importance is placed on providing a safe place for the

individual to process the emotions, sensations, and reactions to their trauma, and minimize the

intensity.

The knowledge of living in the present based on experience and observation, is the start

of healing, only when you accept and feel your visceral and somatic experiences can you start to

heal and let go (Van der Kolk, 2014, Trauma and the Loss of Self section, para. 4). Building

awareness of physical sensations can help heal an individual from the brutality of their past by

restoring them to the present of the here and now (Van der Kolk, 2014, Chapter 6, Section 9,

para. 2). Van der Kolk (2014) reports when he works with clients his first objective is to help

them express their feelings in their body; pressure, heat, muscular tension, tingling, caving in,

and feeling hollow, and reports these are physical sensations that lie beneath emotions like anger

or anxiety (Chapter 6, Section 9, para. 2). Bringing awareness to the sensations of the body

helps contribute to the awareness of the meaning and context of the perception of pain.

The goal is to help draw out energy that is blocked or frozen by trauma, and essentially

welcome energy that was once enabled, or trapped by danger or fear. Often individuals need

help with the ability to notice and identify toxic stress that is manifesting in the body, and

surfacing as somatic symptoms such as chronic pain or migraines, and a clinician can helps

bridge emotions to physical sensations. One can never entirely embrace the essence of their life

without being aware of their body and fully embracing its primal intuitive nature or visceral

aspects (Van der Kolk, 2014, Revolutions in understanding mind and brain section, p. 564).


Therapist should hold deep value on the ability to provide a traumatized individual with safety,

for their emotions trapped in the body to pass and let go. Van der Kolk (2014) indicates, trauma

is programmed in the viscera, or in ones’ emotions and intuition, and is often associated with

autoimmune and skeletal/muscular disorders; yet many therapeutic theories do not concentrate

on communication of the mind, brain, and viscera to regulate emotions, which therefore demands

an extreme shift in assumptions for treatment (Van der Kolk, 2014, Chapter 5, Section 9, para.

8). A shift that involves addressing emotions and emotional regulation, because pain often

generates negative feelings, and negative feelings may influence pain and fuel cognitions,

attention, and overt behaviors. The internal process of healing is connected to experiencing

emotions and visceral responses, and a desire for a witness to one’s experience. Being an

important part of a group setting can have a visceral experience of power and competence.

Chronic pain can exacerbate all areas of life and self-concept; including physical, mental

and chemical health, relationships with colleagues, family and friends, quality of life, and work

(Angheluta, & Lee, 2011, p. 114). Dansie (2013) reports, “Satisfactory treatment can only come

from comprehensive assessment of the biological etiology of the pain in conjunction with the

patient’s specific psychosocial and behavioral presentation, including their emotional state (e.g.

anxiety, depression, and anger), perception and understanding of symptoms, and reactions to

those symptoms by significant others” (p. 20). The “ACT-UP” (Activity, Coping, Think, Upset,

People’s responses) assessment tool helps unfold the psychosocial dynamics of pain, and

assesses how the individual’s pain impacts their overall life, what coping tools have been

developed, their anxiety and depression related to pain, and other’s reactions to their pain

experience (Dansie, 2013, p. 20-21). Understanding the purpose and meaning of pain can help

contribute to forgiveness. One positive psychology study examined forgiveness and the


correlation it has with chronic pain (Saffarinia, Mohammadi, & Afshar, 2016, p. 212). The study

demonstrated that interpersonal forgiveness and resiliency could improve symptoms of

individuals with chronic pain; specifically, aspects of re-communication, realistic understanding,

and control of resentment and revenge (Saffarinia, Mohammadi, & Afshar, 2016, p. 212).

Resiliency and forgiveness are connected because an individual that is capable of forgiveness is

able to heal through thinking and behaving in a way that repairs their strained relationships and

circumstances (Saffarinia, Mohammadi, & Afshar, 2016, p. 212). Unfolding the meaning of

chronic pain can contribute to forgiveness, and forgiveness is linked with better management of

feelings of resentment, anger, and fear, coping skills, resiliency, higher intimate satisfaction and

commitment in relationships (Saffarinia, Mohammadi, & Afshar, 2016, p. 212).

Art therapy. Individuals with comorbid chronic pain, trauma, anxiety, depression, and

substance use disorders, frequently need more intense treatment but struggle to find providers

that can address all angles of their health, and this consequently leads to a vicious cycle

(Katzman, et al., 2014, p. 261). Katzman (2014) highlights the importance of an approach and

treatment that incorporates all aspects of an individual and the majority or all their symptoms (p.

261). Nonpharmacological interventions can help clients with the anxiety, quality of life,

depression, sleep, pain and substance use disorders (Katzman, et al., 2014, p. 263). Art therapy

provide an alternative approach to traditional talk therapies, and help individuals with emotional,

behavioral, cognitive, somatic, and learning conditions. Art therapists utilize art medias to

support individuals on their path to achieving health, and fostering awareness. It allows clients

to address their symptoms through verbal and non-verbal forms of communication and “helps

people resolve conflicts and problems, develop interpersonal skills, manage behavior, reduce

stress, increase self-awareness, and achieve insight” (American Art Therapy Association, 2017,


para. 1). Art therapy is a holistic approach that can yield better prognoses and corresponding

mental heal and well-being outcomes, through helping address comorbid trauma, chronic pain,

anxiety, depression, quality of life, pain, substance use, and sleep (Chrone et al., 2013; Katzman

et al., 2014; Henne, Morrissey, & Conlon, 2015,).

Art therapy can support individuals in activating their sensory worlds, help them feel

empowered to express their emotions, or solve problems with relationships through self-

discovery. Halužan (2012) identifies, the purpose of rehabilitation through art therapy is: to

stimulate sensory systems, increase perceptual awareness, relieve emotional strain, unfold new

ideas through pictures, freely execute inner beliefs through images, increase self-awareness,

foster motivation for change, modernize problems, improve creative thinking capacities, enhance

positive outlooks, initiate graphomotor development, and promote group alliance (p. 101).

Fostering empathy, safety, trust, respect, encouragement, and emotional kindness creates an

atmosphere that is strived for by the art therapist, and this consequently can decrease

inflammation in the body (Bushnell, Ceko, & Low, 2013, p. 505; Lebedeva, 2014, p. 148). The

safety fostered through the art therapist and the media often motivates a client to express

emotions of fear, or feelings of being scared, anxious, embarrassed, inadequate, or helpless.

When rapport and safety are established, Halužan (2012) exclaims, an individual’s experience

can be unfolded, and solutions can be effortlessly unfolded (pp. 104-105). Individuals can make

decisions and feel in control, by making decisions and exploring different art materials such as

watercolor, clay, collage, or colored pencils. The art making process often becomes a distraction

or the sensory experience helps the client live in the present rather than live in the fear of the

future or the lonely and saddened in the past, which are important aspects of healing chronic

pain.


The art therapy concept of sublimation can often occur, and an individual’s once socially

improper impulses are unconsciously explored in an enjoyable way, and often emotions that

were suppressed can unravel during sublimation. Not only are sensory systems activated and

explored, but an individual’s aptitudes are strengthened, self-discovery is encouraged, problems

are scrutinized, cognitive barriers are limited, emotions can be expressed through colors, and

challenging circumstances are responded to in creative capacities (Halužan, 2012, pp. 104-105).

Lebedeva (2014) reports, “Since the experience can be implemented in art images, the objective

of art therapy is the development of skills of the self-management of emotional states, the

optimization of an emotional state and emotional background of activity (attraction, empathy,

sympathy, compassion, “emotional tension”), enhancement of viability and stress tolerance,

changing attitude towards oneself and one’s problem” (p. 147). Individuals who can take

accountability for their well-being within their art demonstrate better efficacy in results, than

those who concentrate on finding a cure and struggle to find ways of overcoming their conditions

(i.e. chronic pain) (Angheluta, & Lee, 2011, p. 119).

However, just like any other clinical approach art therapy does not affect every client in

the same way, and in best practice gaging the client’s acceptance of art therapy can help yield

results. Integrative treatment can allow art therapists to work closely with their other health care

providers to communicate the valuable information gained in the art making process and

maximize results with individuals. Art therapists are encouraged to be mindful when sharing

client art with untrained art therapists or outside providers because it can be harmful (Angheluta,

& Lee, 2011, p. 126). For instance, the art product of a client can lead to a provider interpreting

meaning from their own experience, or projecting their thoughts without a client’s description

and verbalized meaning.


The art process, the client, and the art therapist. In opposition to talk therapies, art

therapy provides another relationship of the art, and a three-way conversation develops between

the therapist, the individual, and the art. The relational process between the art, therapist, and

client provides encouragement, insight, and restores wellbeing (Rosen Saltzman, Matic, &

Marsden, 2013, p. 241). A triangulating relationship of communication is created and the

imaginative art process, and art product, allows a safe guard for a client to feel comfortable to

express interpersonal thoughts and emotions. Art therapy interventions related to the problem

often include representing the problem through art mediums and creating three-way conversation

between the art, client and art therapist (Kirkham, Smith, & Havsteen-Franklin, 2015, p. 398).

Although the art process is typically more important than the product, the product can also be a

helpful tool during a directed experiential for recognizing details of the individual’s lifestyle,

family constellation, early recollections, and gender guiding lines (Rosen Saltzman, Matic, &

Marsden, 2013, p. 227). The art therapist is sensitive to the importance of interpretation and

meaning, and has extensive training in clinical assessment, particularly to avoid imaginicide or

the clinician’s projection on the individual’s art.

Adlerian art therapy. Art therapy restores wellbeing of the client through trust, positive

attachment, sense of belonging, cooperation, encouragement, and connection (Rosen Saltzman,

Matic, & Marsden, 2013, p. 229). Helping individuals recognize insights, mistaken beliefs,

attitudes, emotions and their lifestyle problems through the art process, can help activate the

prefrontal cortex and consequently manage symptoms better (Rosen Saltzman, Matic, &

Marsden, 2013, p. 228). Rosen Saltzman, Matic, and Marsden (2013) confirms that Adlerian art

therapy is a holistic approach because it encompasses a variety of expressions, which include

creative, cognitive, symbolic, perceptual, affective, kinesthetic, and sensory (p. 226). Art


therapy has demonstrated efficacy in psychological well-being, life’s social tasks, and

transformations in physical symptoms (Angheluta, & Lee, 2011, p. 117).

Trauma. Trauma often leads to emotional social and physical impact on and

individual’s life and wellbeing. Adlerian art therapy is a holistic approach to healing, because it

embraces physical, cognitive, emotional, and social aspects of an individual’s life (Rosen

Saltzman, Matic, & Marsden, 2013, p. 223). The mind, body, and soul of an individual who

experienced trauma, are often off balance and are holistically overwhelmed. The art-making-

process illuminates a mind-body experience and glimpse of the individual who experienced

trauma, for the therapist to witness. After art making the individual who experienced trauma can

feel emotionally connected and relieved from their disconnected and emotionally unregulated

lives (Rosen Saltzman, Matic, & Marsden, 2013, p. 227). The process of creating art reconnects

an individual’s homeostasis through repairing balance in the mind and body, and draws out the

traumatic experience and establishes one’s lifestyle beliefs, in a safe and encouraging therapeutic

environment (Rosen Saltzman, Matic, & Marsden, 2013, p. 241).

Trauma often involves a violation of one’s boundaries, and the art process can leave the

individual feeling safe and capable of protecting themselves in that moment, and consequently

provides them with the courage to address it in the future (Rosen Saltzman, Matic, & Marsden,

2013). While trauma can sometimes silence the individual, art therapy provides a safe way to

explore the memories that are often unobtainable. The creative self can allow the individual who

was impacted by trauma to access their trauma in the present and in an endurable and contained

way. The establishment of social structures, implementing coping skills, reframing the trauma

narrative, self-advocacy, self-compassion, and empowerment, are all benefits during the art

therapy treatment for trauma (Rosen Saltzman, Matic, & Marsden, 2013).


Trauma either results in the individual wanting to regain power, or leaves the individual

with the loss of physical and mental integrity and subsequently feeling empowered (Rosen

Saltzman, Matic, & Marsden, 2013). Trauma impacts an individual’s lifestyle, and they often

struggle with sensory impairments, personality shifts, and feeling insecure. For instance, one

study found participants felt sensory-based symptoms after a sexual abuse or assault experience

that included, “flashbacks, hyperarousal, impulsivity, eating difficulties, enuresis, encopresis,

somatic complaints, self-harming, and an overall difficulty with sensory integration” (Rosen

Saltzman, Matic, & Marsden, 2013, p. 226). The art process and the art therapist can help

contain the memory of trauma, and it’s correlating disturbing thoughts, feelings, and physical

sensations. Through art therapy, kinesthetic, perceptual, cognitive, sensory, affective and

symbolic elements that were harmed during a traumatic experience can be repaired (Rosen

Saltzman, Matic, & Marsden, 2013). This indicates the benefits art therapy can have on

individual with a history of trauma and somatic experiences related to the trauma.

Trauma and pain. Pain in art therapy can be symbolical for a toxic threat to ones

embodied self. The overall intention for the art therapist is to provide safety and allow clients to

imagine and interpret their experience of pain while finding coping tools to resolve interpersonal

conflicts (Angheluta, & Lee, 2011, p. 127). The art therapist acts as a guide to self-expression,

helps alleviate current pain symptoms through art, and encourages the externalization of stress in

the form of emotions (Crawford, Lee, & Bingham, 2014, p. S67). Art therapy interrupts the

barriers an individual has with the intangible nature of describing chronic pain and allows an

individual to freely express their pain through the modality of art (Kirkham, Smith, & Havsteen-

Franklin, 2015, p. 399). It allows individuals to identify how they cope with their pain, control


the effects of their pain, and develop ways of permanently coping and diminishing pain

(Kirkham, Smith, & Havsteen-Franklin, 2015, p. 404).

External artistic representations can offer the art therapist and the individual awareness

into an individual’s internal world and enhance the understanding of their perceived world of

pain. In one study, the description of the images of pain included violence, suffering,

persecution, danger, and assault (Kirkham, Smith, & Havsteen-Franklin, 2015, p. 400); which

emphasizes the relationship pain has with traumatic experiences. The individual’s enhanced

awareness can help them recognize influences that cause pain to flare up and coping tools that

can decrease flare-ups; the capability to identify these aspects during an art therapy intervention

can permit an individual to illustrate metaphors that depict their past, present experiences and

hopes for their future (Angheluta, & Lee, 2011, p. 121). Mood and emotional stability can better

be managed through self-expression because of the ability to lose critical evaluation and better

govern how one feels (Lebedeva, 2014, p. 149). Lebedeva (2014) points out art therapy can keep

individuals busy, limit the attention of the manifestations, and direct attention from negative

occurrences to aesthetical representations (p. 149). Art therapy can help bridge the client to the

present moment and distract them from their pain sensations, the threat of their diagnosis, and

connect the mind and body.

Trauma can be threatening, distressing, and toxic to and individual’s sense of self and

personal values, and this is often easier to represent through imagery (Kirkham, Smith, &

Havsteen-Franklin, 2015, p. 404). Butler and Moseley (2008) report, pain is the brains reaction

to a perceived danger (p. 26), and the important part of treatment is understanding what the brain

is implying the threat to be (Angheluta, & Lee, 2011, p. 113). When the stimuli or the memory

is extracted through the art process, the amygdala evokes the fear and threat response to the


trauma, and the prefrontal cortex manages the emotions and intense feelings felt by the

individual who experienced the trauma (Rosen Saltzman, Matic, & Marsden, 2013, p. 227). The

art therapist provides a safe place for the individual to have reactions to trauma that were trapped

in the body, and often include sensory impairments, emotional dysregulation, flashbacks, and

somatic sensations, and can affect different areas of the lifestyle and events that occurred during

the trauma (Rosen Saltzman, Matic, & Marsden, 2013, p. 226). The artistic representation can

include the primal meaning of their trauma, and colors like red are often used to illustrate the

energy, movement, or heat of their pain. (Kirkham, Smith, & Havsteen-Franklin, 2015, p. 402).

Art therapy evokes the psychological meaning for the pain, and the sensations that are connected,

which is healing by nature.

Art therapy interventions. There are several art therapy interventions that can be

utilized to address pain. One metaphor intervention involves having the individual create the

image of pain and build conversation with the art therapist about what discoveries and insight the

has unfolded (Kirkham, Smith, & Havsteen-Franklin, 2015, p. 405). Pain journals, another type

of intervention, can be utilized to exhibit pain throughout a course of time, can foster mind-body

awareness of how pain looks on different days, and depict how pain correlates with emotions,

surroundings, relationships, and stress levels on different days (Angheluta, & Lee, 2011, p. 115).

The “pain monster” intervention requires an individual to choose any art medium to represent a

“pain monster,” and after the individual demonstrates how they would personally defeat or

overcome the monster. Art therapy interventions can also be provided in the form of homework

assignments and can be excellent for self-care.

Art therapy interventions allow an individual to address psychological and physiological

experiences that are connected to the experience of chronic pain related to trauma, and allows it


to be processed (Angheluta, & Lee, 2011, p. 118). Crawford, Lee, & Bingham (2014) reports,

art therapy is exclusive because it engages an individual on a mental, physical and spiritual level,

and allows them to move through each aspect aesthetically (p. S73). The art-making experience

can lower stress levels, bring clients to the present through activating their senses, decreases

physical tension, is calming, allows individuals to communicate more openly, fosters self-

awareness and problem solving, provides insight to relationship difficulties, and offers the ability

to express through images of lines, shapes and colors (Halužan, 2012, p. 99).

Pain and metaphors. Art therapy is a holistic approach that addresses somatic

complaints, such as chronic pain, and addresses the meaning verses biological approaches that

often focus on the cause of the pain. Art therapy is one modality that focuses on physical illness

and complaints as highly individualized expressions with symbolic meanings (Wilberg, 2011, p.

315). Providing an embodied metaphor to a person’s somatic complaint or illness is a holistic

approach that clarifies the meaning and initiates the process of healing. For example, recognizing

a heart condition as an embodiment of “loss of heart,” “heartlessness,” “faint-heartedness,” and

“cold-heartedness” (Wilberg, 2011, p. 315). Through a holistic lens, Art therapy can search for

the meaning of one’s chronic pain in a myriad of their life, through social relationships, finances,

functional impairments, perceptions of health, and surroundings (Barrett & Chang, 2016, p. 345).

The subjective nature of the report of an individual’s experience of pain can be a barrier

with most interventions; however, art therapy provides an alternative for the individual to

describe the nature of their pain. Art therapy can help illustrate the multifaceted presence of

characteristics and relationships between and individual’s pain, body, social framework, and self-

concept (Kirkham, Smith, & Havsteen-Franklin, 2015, p. 399). It can provide an individual with

the alternative of demonstrating what their pain looks like and what it means, as opposed to


trying to find the words to express the emotions or feelings attached to pain. Art provides a tool

to discover internal interpretations of their world, and through the art visual an authentic

experience of pain sensations can be expressed; “sharp, burning, radiating, shooting, electrical,

cramping, pressure, throbbing” (Kirkham, Smith, & Havsteen-Franklin, 2015, p. 404).

The art allows the individual to address emotions by describing what they represented as

pain and what types of feelings arose (Kirkham, Smith, & Havsteen-Franklin, 2015, p. 399);

which is often a barrier in talk therapies. Portraying coping mechanisms for pain can enhance

awareness of an individual’s specific problem, and the connecting desires and fears (Kirkham,

Smith, & Havsteen-Franklin, 2015, p. 400). A study conducted by Kirkham, Smith, & Havsteen-

Franklin (2015), encouraged participants to draw pain, and results ranged from vivid, intense,

abstract pictures, pain that was objectified as revengeful or ominous, images composed of red

and black color, and time-based elements in other pictures (Kirkham, Smith, & Havsteen-

Franklin, 2015, p. 398). Kirkham, Smith, & Havsteen-Franklin (2015) report, “The images and

accounts provide a powerful insight into the internal world of the pain sufferer and the subjective

experience of chronic pain” (Kirkham, Smith, & Havsteen-Franklin, 2015, p. 398). Helping am

individual feel the inter-individual and intra-individual differences of the perception of pain can

help the individual truly feel heard, witnessed, and that the art therapist is feeling with the

individual, or empathizing.

Metaphors help connect the rational and emotional mind and provide needed insight on

different components of the created image. The expansive amount of ways to represent pain can

further demonstrate the uniqueness of an individual’s experience of pain. Angheluta and Lee

(2011) report, metaphors are a tool that can help connect the meaning that occurs from the art-

making experience to the present reality of the individual (Angheluta, & Lee, 2011, p. 120).


Chronic pain is a phenomenological experience, and it is constructed from the individual’s

encounter and perception, and often gender, culture, identity and personal relationships play a

role in in the individual’s experience and ability to cope with pain (Angheluta, & Lee, 2011, p.

113). Kirkham, Smith, and Havsteen-Franklin (2015) assessed pictures created by individuals

depicting pain that were vivid, strong, and abstract, and the individuals that created the pictures

discussed their pictures as illuminating “suffering and punishment” (p. 400). Furthermore, the

individuals used colors to exaggerate the meaning and reported black represented hopelessness

and cruelty, and red portrayed heat and danger (Kirkham, Smith, & Havsteen-Franklin, 2015, p.

400). The images in this study demonstrate a temporal element, and while demonstrating new

ways of coping, understanding, and looking at pain, it also secures hope.

Art therapy for the treatment of somatic symptoms such as pain can help one resolve and

heal internal wounds related to the symptoms, and can provide validity to reactive responses that

may have occurred during the process of healing. Chronic pain affects the body, mind, and spirit

and research indicates person centered complementary and integrative medicine therapies help

recognize the individual’s role in their goals towards healing can provide a comprehensive and

effective way to manage and treat chronic pain (Crawford, Lee, & Bingham, 2014, p. S66). In

one study with 30 women participants, by Lebedeve (2015), biochemical blood tests indicated a

decrease of extreme responses in the body, and improvement of various systems, including the

immune, endocrine, and nervous (Lebedeva, 2014, p. 151). “Artistic activity not only distracts

from pain and unpleasant feelings on the background of treatment procedures but also enhances

the resilience of the organism, improves the indicators of the immune system, and creates the

motivation for the fastest recovery” (Lebedeva, 2014, p. 149). Evidence base art therapy

interventions that entail health projects have shown several benefits which include improved


self-esteem, feelings of interconnectedness, ability to imagine, broadening of perspective, mental

health, and social interest Crone, et al., 2013, p. 280). Angheluta and Lee (2011) conclude art

therapy for chronic pain needs further research and while interest has been demonstrated for the

use of art therapy as a modality for treating chronic pain, there have only been a few peer-

reviewed articles that present on this topic (Angheluta, & Lee, 2011, p. 128). Future research

geared towards art therapy as a modality for chronic pain, would aid in treatment for co-morbid

trauma, substance use, anxiety and depression.

Conclusion

As the health field begins to understand the complexity of trauma, professionals are

noticing the correlation trauma has with chronic pain and co-occurring disorders and the need to

address all components. Trauma, chronic pain, depression and anxiety disorders, and substance

use disorders, and sleep disorders are increasingly comorbid. Traumatic experiences in

childhood recycle later in life, and although the circumstances and experiences are unique,

similar emotions and physical sensations will reappear later in life. This signifies the need to

treat developmental trauma foremost, and recognize the link between adulthood trauma with

early experiences in childhood, and Adlerian early recollections is one intervention that can help

establish the correlation. Trauma is an adverse experience that results in an individual being

exposed to toxicity, and consequently the unified organism makes changes to physical, mental,

and/or social aspects to keep it safe. The brain is one organ that is malleable and has the capacity

to transform in a way that will help keep the embodied self secure from the threat. Other organs

connected to the brain and the autonomic nervous system also respond to toxic stress, and can

manifest as somatic complaints that signify change is needed for new identity or wholeness.


There is a chronic pain epidemic in the US, and chronic pain often indicates rejection or lack of

acceptance from a relationship or relationships in life, including the relationship to self.

“I’m hurt” or “I’m in pain” is quite literal way of identifying emotional pain; yet the

human organ has a dialect, Alder calls this organ jargon, and it often goes ignored in favor of the

biomedical model. In neuroimaging, the same brain regions that indicate physical pain also light

up for emotional rejection, or abandonment (Mate, 2008). The embodied metaphorical

expression for chronic pain is the felt internal long-lasting emotional rejection of self and/or

emotional rejection of others towards self. An individual’s chronic emotional pain is not only an

indication of isolation and being out of touch with his or her mortality, but also an indicator that

the individual yearns to feel a sense of belonging and reestablish wholeness. However, despite

chronic pain’s connection to social and mental domains it is often treated using the medical

model through surgery or opiate analgesics.

While the biomedical model is often used to treat pain, extensive research indicates that

the biopsychosocial model is more effective at assessing mental and social domains linked to

pain, and is essentially a more comprehensive treatment. Additional research on the

biopsychosocial model of trauma through a lens of chronic pain, would have great implications

for future treatment. Art therapy is a component of Adlerian holism that can be utilized to help

heal chronic pain related to developmental trauma, through the physical, mental and social

domains. Art therapists help individuals heal by creating awareness that talk therapies alone

struggle to achieve. Through the modality of art therapy, individuals can confront their somatic

experiences and empower themselves with increased psychological awareness. Art therapy can

help individuals feel what Adler referred to as Gemeinschaftsgefühl, and help establish social

interest in the Adlerian 5 tasks of life; work, love, social, self, and spiritual. Through this


process, they can build identity through creating a new meaning of integrated experiences and

can help an individual re-establish wholeness through discovering a new normal.


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