Chronic Pain & Somatic Distress

Diane, 58, retired teacher

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.'

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.

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.

Maurice Merleau-Ponty

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.

Simone Weil

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.

6 Formulations

Select 2–3 modalities to compare side by side:

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.