Fifteen years of chronic low back pain following a car accident. Multiple surgeries, opioid dependence (now tapered), ongoing gabapentin. Pain at 6-7/10 daily. Has organized her entire life around pain avoidance — stopped traveling, gardening, seeing friends. Says: 'The pain is real. I'm not making it up. The last doctor looked at me like I was crazy.'
History
No psychiatric history before the accident. Happily married 32 years. Two adult children. Retired early due to pain. Husband accommodates — does all housework, drives everywhere. Previously active, social, and engaged. Now describes life as 'the couch and the TV.'
Clinical note: Chronic pain is where the mind-body problem becomes clinically urgent. Diane's insistence that 'the pain is real' reflects a history of being dismissed — and she's right: the pain is real. But it's also maintained by central sensitization, fear-avoidance, and behavioral withdrawal, all of which are modifiable. ACT has the strongest evidence for chronic pain acceptance and functional improvement (Hughes et al., 2017; Veehof et al., 2016). CBT for pain has moderate effects on catastrophizing and disability. Clinical hypnosis has a growing evidence base (Adler et al., 2021). The SE formulation — unresolved freeze from the accident — is plausible but less empirically supported for chronic pain specifically. The husband's accommodation is clinically significant: well-meaning solicitousness reinforces pain behavior (Fordyce, 1976). Any treatment should involve him. The opioid history adds a layer — Diane has already been through one difficult reduction and is wary of anyone suggesting her pain is 'all in her head.'
Where Approaches Genuinely Disagree
Is the pain real or psychological?
CBT
Pain catastrophizing and fear-avoidance maintain chronic pain. Cognitive restructuring and graded exposure help.
vs.
Somatic Experiencing
The pain IS real — it lives in the nervous system. The body isn't lying. It needs completion, not correction.