Chronic Pain & Somatic Distress
Diane, 58, retired teacher
Fictional teaching case
Compare the formulations ↓Presentation
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.'
Read the full case history and clinical context
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.'
Compare how approaches understand this case
Two approaches to begin with; change them below. These are starting examples, not a clinical ranking.
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Showing 2 of 6 formulations.
ACT
Pain is real and present. But Diane's suffering comes from the struggle against pain and the experiential avoidance that has progressively narrowed her life. She has fused with the identity of 'pain patient' and abandoned her values (connection, activity, engagement) in service of an unwinnable war against sensation.
Creative hopelessness: 15 years of fighting pain, has it worked? Willingness to have pain while moving toward values. Cognitive defusion from 'I can't do anything because of pain.' Values clarification: what matters beyond pain reduction? Committed action (small steps back toward gardening, friends, travel) with pain present.
"You've spent 15 years trying to get rid of the pain, and your life has gotten smaller every year. What if the pain stays at a 6, and you go to the garden anyway?"
CBT
Pain catastrophizing (magnification, rumination, helplessness) amplifies the pain experience. Fear-avoidance beliefs ('movement will cause more damage') maintain deconditioning. The behavioral withdrawal from valued activities (gardening, socializing, traveling) has created secondary depression and reinforced the pain cycle.
Pain neuroscience education. Cognitive restructuring of catastrophic pain appraisals. Graded activity scheduling: progressive re-engagement with avoided activities. Behavioral experiments testing fear-avoidance beliefs. Relaxation training.
"The thought 'I can't do anything because of the pain.' Let's test that. Last week you walked to the mailbox. The pain was there, and you did it anyway. What does that tell us about what's possible?"
IFS
A Protector part has organized Diane's entire life around pain avoidance: it believes that any movement or engagement risks catastrophic harm. This part took over after the accident and has been running the show for 15 years. Underneath it, an Exile carries the terror of the accident, the loss of her former identity, and possibly grief about the life she's lost.
Get to know the Protector that keeps Diane on the couch: what is it afraid of? Appreciate its intention and ask its permission to go further, because in IFS a protector does not step back because it has been argued out of its strategy. It steps back when it trusts that what it is guarding can be handled. When Diane can meet it from Self rather than from her own frustration with herself, it can let her reach the Exile underneath: the terror of the accident, the grief for the woman who gardened. Unburdening that Exile is what makes the protector's job unnecessary.
"The part of you that says 'stay on the couch, don't risk it': it's been working so hard to keep you safe. Can you ask it what it's afraid would happen if you went back to the garden?"
Clinical Hypnotherapy
Chronic pain involves central sensitization: the nervous system has amplified the pain signal beyond what the tissue damage warrants. Hypnosis can modulate pain perception by accessing the same top-down processing pathways that maintain the amplification. How much Diane gets from it depends largely on hypnotizability, a fairly stable trait that motivation and willingness do not substitute for, so the honest first step is to assess it rather than assume it.
Hypnotic induction with progressive relaxation. Direct suggestion for pain modulation (turning down the 'volume knob'). Glove anesthesia technique. Ego-strengthening suggestions. Self-hypnosis training for daily pain management. Imagery for nerve pathway calming.
"As you relax more deeply, I'd like you to imagine a dial, like a volume control, and this dial controls the intensity of the sensation in your back. Notice what number it's at now. And very gradually, begin to turn it down, just one number at a time..."
Narrative Therapy
'Pain patient' has become Diane's totalizing identity: it has consumed the teacher, the gardener, the traveler, the friend. The medical system reinforced this by treating her as a collection of symptoms. Her husband's accommodation, while loving, further authors the pain-dominated story. Diane has been storied by her pain.
Externalize the pain: how has it influenced her relationships, her identity, her daily choices? What has it stolen? Then, find unique outcomes: moments when Diane was more than her pain. The garden, the classroom, the friendships. Re-author: who is Diane when pain is present but not in charge?
"Pain has been writing your story for 15 years. It retired you early, it took your garden, it put you on the couch. But pain didn't book this appointment, and pain didn't get you into the car this morning. You did. That's the first thing it hasn't managed to write. How did you pull it off?"
Somatic Experiencing
The car accident created a freeze response that never completed. Diane's nervous system is still bracing for impact 15 years later. The chronic pain is partly maintained by this unresolved autonomic activation: the muscles are in chronic protective contraction, the nervous system remains in threat mode.
Slowly and gently renegotiate the accident. Track where the bracing lives in the body. Allow incomplete defensive responses to complete (the arms pushing against the steering wheel, the head turning away). Pendulation between activation and resource. The goal is not pain elimination but nervous system re-regulation.
"When you think about the accident (not the story of it, but the body memory), what happens in your back right now? ... Can you just notice that tightening without trying to change it?"
Where Approaches Genuinely Disagree
Pain catastrophizing and fear-avoidance maintain chronic pain. Cognitive restructuring and graded exposure help.
Correcting Diane's thoughts about the pain leaves the bracing exactly where it is. The body is not misreporting, it is still finishing something. It needs completion, not correction.
Philosophical Lenses
These are not treatment plans. They are ways of seeing — philosophical perspectives that illuminate aspects of this case that clinical modalities may not address directly.
Diane's pain is not 'in her body' as if the body were a container. It is her body: her way of inhabiting the world has become pain. The car accident did not merely damage tissue; it reorganized her entire body schema, the pre-reflective map through which she moves, reaches, avoids. Fifteen years of guarding, bracing, and withdrawing have created a new habitual body that knows the world primarily as threat. The fact that she has 'organized her entire life around pain avoidance' is not a behavioral problem to be corrected: it is a description of her lived body as it currently exists. Treatment must address not the pain 'signal' but the body-subject who has become a pain-body.
Chronic pain, for Weil, is a form of affliction that attacks the soul through the body. It is not suffering that ennobles: that is a romantic fantasy. Affliction degrades. It makes the sufferer invisible to others, reduces social identity, and eventually convinces the afflicted person that they deserve their condition. Diane's opioid dependence, her shrinking world, her identity as 'the woman with chronic pain': these are the marks of affliction. Weil would say that what Diane needs is not pain management but attention: genuine, sustained, non-instrumental attention from another person who does not flinch from the reality of her suffering and does not try to fix it.
Sources & Method
This is a composite fictional case — no real client is depicted. Formulations represent how each modality would typically conceptualize and approach a case with this presentation, based on published clinical literature and training materials. Each formulation draws on the modality's own theoretical framework, key texts, and clinical principles as documented on its modality page. Full source citations for every modality are available on the Sources page.