Hypnosis and Suggestion in the Treatment of Pain

MRS. TAKAKI is 89 years old, but she still walks every day around the block with her dog. Both of them are old, and this year they are both walking slower with each passing month. Although Mrs. Takaki doesn’t speak much English, and I know only five words of Japanese, I still look forward to our morning encounter as I return from jogging. She is in a perpetual bowing position as she walks. When I bow to her, she laughs and nods her head. Then she says several rapid phrases that I can only hope is a blessing on me and my family. She takes my hand this morning and slowly uncurls her fingers, gnarled with rheumatoid arthritis. A smooth pebble slides from her hand into mine.

She laughs as she sees the pleasure her gift has brought me. I know where I’ll put it: In the pot with the Bonzai tree she gave me last year. Her body is as twisted as the Bonzai, but she has a genius for simple beauty. Once a month, she invites me for a tea ceremony. During the tea ceremony, she always rubs her painfully arthritic hands together for a long time over the hot charcoal. Once a week, I take fifteen seconds to wheel her garbage can out to the curb alongside my own. Every morning, when I see her shuffling toward me at the end of my jog, I thank her silently.

The management of pain in elders is neglected in the training of physicians, psychologists, and providers of social services (Ferrell, 1991). Yet, the prevalence of pain has been estimated to be 100 percent greater in those over the age of 60 compared to those under 60 (Crook, Rideout, & Browne, 1984). There is some evidence, for example, that at least 80 percent of elderly people have some form of arthritic pain (Davis, 1988). As our population of elders increases, and as we all grow toward older age, the importance of understanding how to treat pain in this age group becomes more apparent. When we care for the elderly, we are caring for our grandparents, our parents … and our future selves.

In this chapter we illustrate and discuss nonpharmacologic treatment of problems related to pain. We assume that analgesics and other classes of medication will be used as needed for all patients in pain. Discussions of medication for pain for elders may be found in Kepes (1983).

What we wish to address here is how our relationship with and response to an elderly man or woman who is our patient create a context within which suffering is understood. Recall now the discussion from Chapters 1, 4, and 5 that the experience of pain and suffering is powerfully determined by the meaning of pain to the patient and by the influences of culture, family, and past experience. The patient’s needs for empathy, dependence, or autonomy affect how and when the individual experiences pain and suffering. Expressions of pain (“I feel so much pain!” or “I don’t get around much anymore”) may generate either support or avoidance by a caregiver. Often, there are attendant emotional consequences, mostly discouragement, pessimism, and depression.

To understand the experience of pain in elders more clearly, let us consider the various meanings that pain may have for those in the later years of life. Some elders fear and resent pain because it heralds a decline toward increasing loss of function and, ultimately, death. Such an elder may respond to pain with denial or with much complaining and anger, sometimes turned toward a physician or family members. Elders who deny pain because of fear may try to push themselves toward greater activity, or they may retreat physically and emotionally into a dark hut of depression.

Mr. Willis stopped taking his medication. This occurred after one of his cancer specialists complained that another specialist had been wrong to change one of the medications. This was extremely upsetting to Mr. Willis. He felt that somehow it was his fault that there was a disagreement between his physicians.

Many clinicians are so awkward around pain and death that they retreat from human contact with the patient to technology or “facts” to try to maintain a sense of control. Often, patients such as Mr. Willis with a terminal or chronic illness feel guilty or angry when problems arise in their treatment. Understandably, due to the physicians’ retreat, the patient is likely to feel abandoned.

Mr. Willis returned to see me (WF), his family physician, because he didn’t know what to do. He appeared sad. He often felt like crying, he was fatigued, his sleep was disturbed, and his appetite gone. He also said that he and his wife, to whom he had been devoted for 48 years, had never had marital problems-until recently. As he became more depressed, Mr. Willis ruminated more and more about his illness and pain.

I invited Mrs. Willis into the examining room, and said to her, “Your husband says that you’re just not getting along very well for the past couple of months. Is that your feeling about it?” She agreed. I asked, “Well, what is it? What’s the problem as you see it?”

Mrs. Willis admitted that she was fed up with his complaints of pain. “I just hate him being sick all the time and moaning and groaning and lying around and complaining. I’m tired of it.” Mrs. Willis felt that her husband was depressed. She had said this over and over again to some of the doctors who were taking care of him. The only response either of them received was a suggestion to see a psychiatrist. This was not helpful. Mr. and Mrs. Willis did not need to see a psychiatrist or any additional doctor. They needed to discuss these problems in detail with the doctors already treating Mr. Willis.

This dilemma is common for patients who receive fragmented care. The cardiologist deals with heart and lungs and the urologist with the prostate but nobody treats Mr. Willis as a whole person with feelings about his present predicament. The alternative, of course, to such “partialist care” is comprehensive care, which includes consideration of physical, emotional, and familial influences on the patient. (This care requires more than technical knowledge, of course; it also carries the additional, sometimes onerous requirement that the clinician be willing to compassionately attend to the patient’s feelings—and to tolerate the clinician’s own feelings that are naturally evoked in the process.)

I told Mr. Willis that I would resolve the dispute between the other physicians about his medication. Then I said, “There is nothing in your history or exam that would suggest that you’re at death’s door. On the contrary, there’s every indication that you could feel a lot better if your depression were treated.”

Mr. Willis seemed interested. He appeared pleased that his wife had been invited into the session and that they had began to discuss what was happening between the two of them. They had not talked about that before. She hadn’t really issued a specific complaint; she had just been angry. So now the problem was out in the open: She was just tired of the complaining.

Mr. Willis was given a prescription for antidepressants and was encouraged to return for more discussion of his fears and needs, which, subsequently, he did. As the weeks passed, he changed from a sad, morose person to somebody who was hopeful and could smile readily. As this change occurred, his complaints of pain decreased significantly.

For Mr. Willis, pain was a recurring reminder of loss that seemed to drive him deeper into depression. Other elders appear to experience pain not so much as a threat but as a nuisance—and perhaps a severe one. They do not seem, however, to suffer fear or anguish in relation to the pain. Instead, some elders laugh at their pains or remark that the pain is a valuable part of their present existence. Some have been heard to make comments such as: “When I wake up in the morning and feel my joints ache, I know I’m still alive.” Why do some elders feel this way about pain while others experience pain as a severe threat?

Part of the answer lies in the meaning of the pain. Like everyone else, an elder’s interpretation of a pain sensation is affected by the location, severity, frequency, and duration of the pain, all of which are clues to both the patient and clinician about the possible morbidity of the condition represented by the pain. In addition, factors such as environmental contingencies, a desire to be stoic, and the elder’s degree of equanimity versus anxiety in everyday life will all affect the experience and the expression of pain.

Understanding the role of pain in the human condition is a lifelong challenge. Symptoms are often attributed to life events that may or may not truly be causal factors. Such explanations are useful for both the patient and physician to understand and discuss, particularly with regard to self-limiting types of pain problems. Although the practical value of such explanatory models decreases when more serious, aggressive biological disease is present, even then an appreciation of the patient’s understanding of his or her pain may provide an opportunity to relieve anxiety and suffering to some degree.

Elderly patients, in particular, often present unusual combinations of symptoms. Sometimes they have pain for reasons that are unclear; other times they may have no discomfort associated with an illness or trauma that would ordinarily cause pain. For example, an elder with pneumonia may have no cough or fever; the only symptom may be falling down.

Although some elders tend to embellish their symptoms, our clinical experience suggests that elders more frequently downplay the severity of their symptoms. Perhaps some elders simply do not experience their symptoms as dramatically as a younger person. This blunting may reflect actual age-related changes in the nervous system that result in slowing and reduction of afferent stimulation, thereby assisting in the process of coping with pain. Or perhaps blunting of symptoms occurs because elders develop another psychological way of coping with discomfort. They may notice aching joints but, having become accustomed to many aches and pains, think them unworthy of mention. In summary, we see that reporting of symptoms is affected by (1) sensory-perceptual changes, and (2) coping strategies that may include denial, self-distraction, or reinterpretation of the symptoms as a natural part of growing older.

One of the most salient themes of old age is the tension between dependency, on the one hand, and separation and isolation, on the other.

Raul and Julia had lived in a quiet suburban neighborhood for 30 years. For many years, they had no reason to move. However, with advancing years, they began to feel isolated from their children. Though they had several children, they all lived some distance away. The Salcidos didn’t belong to any church or social group. They had a large number of close friends, but those friends had their own families and activities, and there was nobody whom they felt they could call on for an extended period of assistance if one of them became critically ill.

They were increasingly aware of the possibility that one of them could have a stroke or fall and break a hip or have some other major problem. They had both already experienced a taste of disability: Julia had moderately severe arthritic degeneration in her hips and spine. Sometimes she had difficulty getting out of bed for days at a time. Raul had chronic muscle pain from fibromyalgia, and he also suffered from moderate emphysema and recurrent bronchitis. They both agreed that they would rather die than become so debilitated that they would have to be cared for by strangers.

Raul and Julia discussed their concerns with their children, whose response was unanimous: “We would like to be involved in your care if you have any problems. Is there any way that you would consider moving closer to where we live? If you wouldn’t mind moving to our rural area and buying some property right next door, we would love nothing better than to be involved in your care for whatever time it takes. It would be an honor, a pleasure.”

Some of the other Salcido children also considered moving to the same small town, because they had visited there and loved it. So it happened that, over the following couple of years, a few other siblings did move to that town. Still Mr. and Mrs. Salcido debated. Because it was so remote, there was no doctor in the town, and so, although they would have family close by, getting medical care would be quite an ordeal.

As they were considering all of this, a doctor moved to that small town and set up her office a stone’s throw from where one of their children lived. The Salcidos now felt that a change was feasible. They bought an old house on a lot next to one of their son’s homes. It required extensive renovation to make it habitable; in fact, when they moved in, late in the fall, there was no running water or electricity installed yet. They spent the entire winter in that house without electricity or running water, working on the renovation.

Mrs. Salcido, who was fairly frail and continued to have daily back pain, did much of the interior repainting in the huge house. The following summer, a friend asked her where she found the strength to do this. She said, “It was strange. Every night as I went to bed in a sleeping bag on the floor I felt so tired I wondered if I would die during the night. But as I fell asleep I thought of how much fun it would be to get up the following morning and finish painting the next wall. It was such a joy to see each ugly, dirty wall covered over with beautiful, fresh paint. I haven’t felt that much energy for years. I haven’t seen my husband have such energy for years. I don’t know where it comes from. He works 15-hour days and he’s 80 years old! He groans with fatigue and he can hardly walk at the end of the day, and yet he’s up at 5 or 6 the next morning already working!”

The Salcidos’ story illustrates the potential advantages of living with challenges that the elder finds manageable and familiar. These challenges may include cleaning the house or yard or walking a mile each day to pick up mail or groceries. People do not have to live like pioneers to experience these physical challenges. There are everyday physical challenges such as gardening, cleaning, and volunteer work that are healthful, both physically and spiritually. The purpose of these familiar challenges is to add meaning, purpose, and value to life. When life has lost its meaning and purpose, symptoms are often experienced with overwhelming severity.

There were times when Mr. Salcido felt his muscles and joints aching so badly that he could hardly get out of bed. His physician suggested some anti-inflammatory medication. Mr. Salcido declined, saying, “I respect your opinion, but first I want to find other ways.” He preferred alternate medical treatment whenever possible. He heard from a friend about bee pollen, a nontraditional alternative that suited his rebellious style. He took some bee pollen, drank some herbal tea, and within two hours felt much better. Over the following days, as he became more active in his garden, his aches and pains continued to improve markedly. Was it the pain that changed, or his suffering from his pain? Or was it both? His answer was: “Oh sure, I still ache. Almost all the time. But the aching isn’t as bad, and it doesn’t bother me as much, because I enjoy what I’m doing.”

When physicians hear stories of dramatic improvement due to herbs or bee pollen, a part of them wants to say, “Oh come on!” But this reaction serves only to maintain a particular view of how people function, rather than fostering understanding of the patient’s viewpoint. It’s critical to start with the patient’s point of view.

That was what Mr. Salcido’s physician did. She encouraged whatever worked well for him, accepting his language, experience and values, as long as he was not harming himself. How often do clinicians and family honor elders who take such initiative? Often they are ridiculed or patronized instead.

Many individuals interacting with health-care professionals use alternative methods of care that are quite effective for them. They may avoid mentioning these to their clinicians because of fear that they would be ridiculed, and that their confidence in their treatment would be compromised.

The Salcidos have lived in their beautiful, comfortable house for about four years now. The raw forest and rocky fields around it have been transformed into beautiful gardens. Each year they set a new goal: an extension of the garden or a new fence.

Once, Mrs. Salcido went to visit friends in a city that was a three-hour car ride away. For some reason, possibly because of sitting in a very sagging seat and moving very little during the long ride, she developed severe back pain. By the time she returned from the trip two days later, she could not get out of the car without assistance.

She went to her physician and asked what to do. The physician examined her, then asked, “What do you feel that you need to do? Do you feel you need to move or that you need to stay in bed?”

Mrs. Salcido said, “Well, I feel like I need to move but I’m worried about hurting myself.”

The physician answered, “If you feel you need to move, then do anything it takes to move.”

During the next week, Mrs. Salcido moved around her house on her hands and knees. She couldn’t stand up. Each morning she slid out of bed onto the floor and crawled to the bathroom, where she pulled herself up on the toilet. Then she crawled down the stairs, still on hands and knees, to the kitchen, where she prepared some breakfast with her husband’s help.

Of course, her husband and family helped her frequently. They encouraged her to do what she could, but they also said, “Let us know if you need something.” This seemed to be just the right balance for her. Within a week she was up on her feet, bent over, walking with assistance. For the next three months she walked around, bent over, hanging on to the wall. She forced herself to get out and walk every day. She forced herself to clean the house. Now, a year later, she walks upright. She makes sure that she walks a half-mile every day to pick up the mail.

This illustrates the importance of having family support that encourages autonomy rather than dependency and helplessness, support that encourages independence while acknowledging increasing limitations in strength, memory, and physical stamina as the years pass. This case also illustrates the importance of relating recommendations to the personal style and belief system of the patient. In this case, the patient felt that movement was important, and this was fully supported.¹

Patients are often unaware that problems of life may be disguised by symptoms such as pain; yet this is often the case. Discussing this as a possibility requires sensitivity and a solid relationship of trust and confidence with the patient.

The clinician needs to be ready to hear a variety of messages that are communicated by pain complaints. These messages may speak of loss, conflict, difficult changes in life circumstances, stress, isolation, failure, or of lifelong personality problems. These messages may also speak of the patient’s determination and perseverance. Acknowledgment of these messages is essential to appropriate treatment, of course. But more, this acknowledgment can be profoundly nourishing to the patient, because it expresses deep understanding and honors a life and a soul.

However, such communication is not easy. The patient, preferring to focus merely on the pain, may resist the clinician’s attempt to attend to other issues. However, it is essential that the clinician be clear about his or her judgment of the problem, while listening patiently and observing, gradually helping the patient refocus on nonmedical issues. Doing so may not only reveal unresolved life problems but also facilitate the patient’s awareness of his or her strengths. This awareness, in turn, helps remind the elder of the importance of his or her place in the scheme of things, which may be important to keeping a person alive.

There are two important types of nutrition: One is the food we eat, and the other is the knowledge of our meaning, life purpose, and value. When the awareness of meaning and purpose is lost, we tend to feel that there is no longer a place in the world for us. In this condition, sometimes people lose the will to live—but they may be aware only of pain, for which they seek treatment.

In some cases, the clinician’s primary task is to help reconnect the person to his or her place in the scheme of things. That may happen partly through just valuing a patient so clearly he or she is reminded: “You have a value. You’re still important.”

Honoring a patient’s values often requires flexibility and patience on the clinician’s part. We need to know and honor the person’s way of dealing with the world. Is this an individual who really wants to control her destiny, in terms of large and small decisions? Or does she prefer a much more passive response to her own care? It will not help to say to the latter person over and over again, “Well, what do you think you need?” She will answer, “What do you think I should do, doctor?”

Elders may exercise control by asking questions, expressing wishes, or insisting on the continuation of a long tradition of doing things in a certain way, whether the pain is major or minor. If they have many other disabilities or if their voice and power are taken away in a number of ways, then to insist on a particular medication or on a certain method of treatment is not a helpful strategy. Having a firm opinion may enable the person to maintain a sense of self; it is a way of controlling his or her destiny. If the treatment threatens or removes that sense of self, then elders feel that they have no rudder, no sense of direction, energy, or autonomy. Paradoxically, we sometimes try to remove pain in people who feel they have nothing left to hold onto but the pain. Flexibility is the first step in treatment.

As a part of her active life, Mrs. Yee loved to go dancing with her husband, and she loved to travel. She developed pain in her knee while she was dancing. It had started to improve a little, until a few days later when she went dancing again; then it hurt even more. The knee was swollen and she could hardly walk. After the pain continued unabated for a week, she became very worried about it, so she came to see me.

On examination of her knee, I (SL) found no indication of any severe ligament damage or other serious injury. It appeared to be a combination of mild “wear and tear” in her joint and mild muscle strain. She was reassured that, if she would abstain from dancing for a while, do some exercises, put ice on it, and just take care of it, it would get better in six to eight weeks. She was satisfied with this recommendation.

Returning to my office about a month later, she said that she was feeling much, much better. After pulling and pressing and hammering her knee, I agreed with her that she was doing much better. Mrs. Yee said, apologetically, “I guess I should tell you that I went to see a Chinese doctor.” She studied my face very closely as she said that, waiting for my reaction.

I replied, “No, I’m happy for you to get any kind of help that seems useful to you. Did you feel it was helpful?”

She said, “Yes, I think it was helpful. They wrapped some medicine, some kind of herbs, around my knee and put an ace bandage around that and made it feel better. Every day I would put that on and they told me to continue to do the things that you told me to do like the exercises. But the herbs would help also, so I felt both together were really helpful. But I was afraid that you would be angry with me for going to somebody else.”

I remarked that I thought she was very fortunate to be able to draw expertise from more than one world, and to bring both of those worlds together to work on her problem.

She said, “I’m so relieved that you’re not angry. Do you think I should continue to see that Chinese doctor?”

About two weeks later, she came back for another visit. She had started very carefully dancing again, and reported that she had very few problems with her knee. She said, “You know, I’ve been thinking a lot about going to see the Chinese doctor. I don’t think there was anything in that medicine that helped me, but I think it was really important for me to go see him because when I was a little girl that was the kind of doctor we saw in China.”

Mrs. Yee had considerable insight into her own needs. She recognized that she could obtain needed extra reassurance from her own culture and background. She found reassurance in the familiar.

Effective patient education and reassurance require the clinician’s time and willingness to learn about the patient’s worst fears. These fears are lurking in the dark until a clinician who is willing to listen calls them forth.

Allen Barbour (1995) describes the process of learning how to listen to the psychological meaning of a patient’s pain complaint in Caring for Patients: A Critique of the Medical Model. He stresses the importance of recognizing that many somatic complaints are a socially acceptable way of saying: “I’m afraid. I’m lonely. I’m suffering from loss.” Barbour’s observations suggest that an isolated focus on somatic complaints can accentuate the patient’s experience of loss. It is as if the clinician is saying to the patient, “Your sense of loss isn’t even important to me.” The goal, Barbour suggests, is to search for implicit messages and then respond to those messages, as well as to the explicit somatic complaint: “I understand that you feel lonely. I’m glad you came to see me!” This response may be expressed in words, in the clinician’s behavior, and in tone of voice. The patient needs to know that the clinician finds value in the encounter.

While listening with concern to the patient’s complaints about pain, we also focus on strengths. Acknowledging the patient’s strengths in an enthusiastic, affectionate way can be part of a process of helping him to revive the vital, healthy part of himself. Acknowledgment of a patient’s appearance and of her interests also enhances the strength of the therapeutic relationship and helps to diffuse the focus on somatic complaints.

Mr. Billings, strong, independent, and self-sufficient, could pass for 70. At the moment, however, everything was hurting—his back, shoulders, hands, knees, feet, and so on. I (WF) said, “George, you’re 82 years old and you really are in excellent shape. Look at you—running the community garden, working hard. What’s wrong with you? You’re just really in good shape.” The next two visits he came in and said with a smile, “Gosh, you know I’ve been really feeling good. I’m really in pretty good shape.”

There is a danger that, while reminding elderly patients of their strengths and good functioning, we may seem patronizing or merely dismissive. It is essential to genuinely respect the patient, to be sincere when communicating honor and value toward the elder. There needs to be a marriage between the two forces: On the one hand, we listen seriously to the specific complaint; on the other, we respond both directly and (when appropriate) indirectly to any underlying concerns. Finding the right balance is a challenge requiring the mind of a strategist and the heart of an artist. We need to be active and attentive, but at the same time quiet and observant. And we need to be mindful of our own needs and motivations when dealing with a patient; otherwise, we will inevitably discover, too late, that we have not been listening, that we have been patronizing.

A few years ago, Siegel (1990) proclaimed that, in case after case, loving one’s patients was an essential, powerful tool missing from North American medicine. We share his concerns about the sterility and weakness of high-tech medicine. But narrowly developed ideas often hold a paradox, simultaneously representing both strength and weakness. For us, what was missing from his book was the rich complexity and puzzling uncertainty of most of human life. The author’s view seemed to be that if we are sufficiently sweet, intuitive, and loving, our patients will recover their health—independent of the particular problem. Such a reaction is understandable, given the opposite view, which is that health and illness are unrelated to human emotions and to the consequences of life events. However, one can hope for an approach to human experience that synthesizes such limited points of reference and includes the broad and deep complexity of human life.

One day we discussed these issues with an elderly patient, who was quite eloquent. He said, “Personally, I’d like to go to a doctor who is kind, loving, and sensitive, but who also looks at my ear, or examines my abdomen and thinks about it and orders some tests when appropriate. If I see a therapist, I’m not looking for a sweet goody-two-shoes. I want somebody who’s sensitive, sure—but I also hope he’s tough and honest. I want people taking care of me who are thinking, real human beings. Those kinds of people get tired, impatient, or bored at times. If I want somebody who does nothing but love me, I’ll go see my mother. She’s not critical. She’ll sit there and hold my hand and say, ‘You’re so wonderful.’ She’ll pat my head and say, ‘I’m so glad to see you.’ But she’s not going to be a good physician or therapist for me.”

We need to struggle with this idea. Many patients want help from clinicians who are sharp intellectually, and who don’t mind thinking, analyzing, being critical; they also value clinicians who are willing to risk the possibility of “causing trouble” in a kind way, by being thoughtful and bringing up disturbing possibilities. We all need that. It is in that context that love becomes alive and compassionate. It becomes real. And we need to remember that this alive quality does not exclude irritation, confusion, and impatience.

Sometimes, we tell our elderly pain patients that we are confused about the best treatment. For example, “Right now I feel like a blind man. I feel confused and uncertain about how things are going with you. I need more information. Until I get that, I’m not sure how to proceed with relieving this pain.” Often, we don’t really feel what we’d call an “affectionate” concern; instead, it may feel like a commitment that is that is alternately bitter, passionate, and sweet in its fierce determination. The clinician may say to herself, “Even though I don’t feel an affectionate concern for this patient, I’m struggling with this because I do care for her as a patient and I want to help her.”

When we’re dealing with a patient who has any kind of medical problem, whether pain or something else, if we genuinely like the person, that affection seems to have its own therapeutic value. But it is not always elicited within us in the same way or to the same degree. If you really don’t resonate with or like someone, how can you do as good a job? Some long-term pain patients are very frustrating. Because of the chronicity of their pain, and the reluctance of many care-providers to become committed to a long-term professional relationship, many of these patients become dishonest as they try to cope with their pain and the reaction of their surroundings. Such patients may view the care provider as an obstruction to obtaining what they need. Manipulative behavior develops when suffering is not relieved, and/or when drug dependence occurs. This is difficult to deal with.

One of the most effective things we can do with such difficult patients is to lay all of our cards out on the table, including the fact that we feel frustrated and that we’re not sure where we’re going. This may have a very therapeutic effect. Paradoxically, such frank communication, if free from blame (no easy task!), may help the clinician and patient feel like a team again, just when they were beginning to feel like they were adversaries. At the very least, clear communication promotes honesty and helps to diminish the patient’s manipulative behavior and the caregiver’s avoidance.

Elders are as able as younger patients to benefit from therapeutic interventions based on imagination and suggestion, although the themes that occupy the imagination vary with the patient’s age. The imagination of youth is often filled with the same images that are found in popular books and films: cute animals, action and adventure, or romance. Elders, on the other hand, often use imagination as a tool to help put events of the past and the future into a perspective, in order to find, or deepen, the meaning of their present circumstances. When one simplifies these two extremes as a search for physical experience and mastery among the young versus a search for meaning among the elderly, this contrast brings to mind Erik Erikson’s views of human development and reminds us of the importance of a developmental perspective.

Mr. Kay had suffered from trigeminal neuralgia for nearly four years. The side-effects of the several medications he had tried were worse than the pain itself. He had also tried acupuncture, herbal medicine, biofeedback, and meditation without any resolution of his symptoms. He experienced a severe attack about every two weeks, with frequent, aching pain in between. In fact, at our first meeting, he rated the present intensity of the aching pain as 4 out of 10.

Mr. Kay had restricted his activities severely in the past six months. An accomplished amateur violinist, he participated in local concerts and sat on the board of directors of a large metropolitan opera company. Aside from his family, including his eight grandchildren, music was the passion of his life. He also enjoyed cooking gourmet meals for friends and family. As his pain increased in intensity and frequency, he had become more withdrawn, and he felt his usual rich and varied life slipping away.

Born in Poland, Mr. Kay was sent, at 14, together with his mother and sister, to the concentration camp at Auschwitz. His father was taken prisoner by the Nazis and was never seen or heard from again. Miraculously, Mr. Kay, his mother and sister all survived Auschwitz. After liberation and several months of rehabilitation, they recovered their physical health, and subsequently emigrated to the United States. Mr. Kay met his wife in America, where they raised a family and developed very successful professional careers.

When I (SL) first met Mr. Kay, I was struck by his warmth and good humor. He expressed great hope that hypnotic treatment would be helpful in relieving his dreadful pain. After we had talked for a while, I asked him if he would like to have an experience that he might find both pleasant and interesting. He eagerly agreed and asked what he should do. I invited him to sit back in his chair and to close his eyes in order to more easily notice some pleasant scenes. He smiled and commented that he often did this on his own, when listening to music. I suggested that he allow his mind to float freely until he noticed some pictures, images, or thoughts that seemed particularly pleasant to him. At the same time I also suggested slow, deep breathing, and I made comments about the deep relaxation that he could experience from his face and head all the way down to his toes.

After three or four minutes of relaxation, Mr. Kay mentioned that he had a picture of the San Francisco Symphony Orchestra in his mind. He could see it clearly and described it in detail. With some encouragement he began to hear the music more clearly. It was one of his favorite pieces: the “Moonlight Music” from the opera Capriccio, by Richard Strauss. With deep feeling, he described the music as sensual, sweet, and slightly melancholy. After several minutes, he sighed, and said with a little smile, “The music has finished.” I invited him to gradually return to my office and open his eyes. When his eyes opened, he blinked, then slowly smiled.

“What a pleasant experience,” he said. I asked him whether the aching pain he had been experiencing had changed “in any way.” He stopped for a moment to think, and then said, with some surprise, “Yes, actually it’s completely gone. Now that I think of it, I don’t notice any pain.”

We had several subsequent treatments, each one lasting at least 45 minutes. He particularly enjoyed spending time listening to music during these sessions, and he reported that the music felt like a deep, healing fluid that washed away his pain and suffering.

What was additionally meaningful to him about these experiences was that they were an affirmation of the decision he had made when he came to the United States to devote himself to living life to its fullest. Enjoyment of the arts, including poetry, literature, and music, was a fulfilling way of enjoying life with friends and loved ones. All of these experiences seemed to act as an antidote to the horrors he had experienced in the Nazi concentration camp. He also commented that whenever he recalled a memory of the years he spent in the Nazi camp, the intensity of his pain would suddenly increase. Therefore, he felt very cautious about recalling any memories at all from his childhood, for fear that unwanted memories would return, causing him great pain. Rather, he preferred to devote himself entirely to his family, music, and all the beauty in life that he could capture and experience.

It was very tempting for me to assume that somehow his pain was connected to a denial of feelings or recollections that needed to be expressed or reexperienced. On various occasions when the topic arose, I wondered out loud whether it would be helpful for him to go deeper into some of those feelings and experiences. Each time he listened thoughtfully and agreed to consider that question. He never seemed irritated or impatient that I had posed the question. Finally, he said that, although he had understood the logic of what I had wondered, he trusted his judgment in leaving all of those bad memories behind.

A new question arose in my mind: Were there any pleasant memories and experiences from the past that might have been discarded along with the horrible ones? I asked him if he would like to journey back to times in his childhood that were pleasant. He seemed surprised and at first a little wary, but then agreed that he would be willing to find out.

I asked him then, as I had each time before, to allow his mind to clear, to close his eyes, to take several deep breaths, then to experience himself traveling to whatever place and time he would like. For a few minutes, he appeared as deeply relaxed as usual during our sessions. Then the expression on his face seemed somehow more intense than usual. He began to speak slowly, softly, as if recounting a dream, while in the midst of it. He saw his old family home back in Poland. He described in detail the fresh green grass and the trees that grew around the house. He saw the front door, the deeply textured wood and the polished brass handle. He opened the door and went inside. He found himself in the bedroom where he slept as a child.

After some long moments of silence, he smiled and spoke of the wallpaper and the texture of the paint on the ceiling. Then there followed a long silence as he appeared deeply involved in some scene. After about 20 minutes I invited him to gradually return to the present whenever he was ready. After three or four minutes, his breathing seemed to indicate a gradual arousal from a deep concentration and a shift in his consciousness back to this room.

Finally, he opened his eyes and smiled. His eyes filled with tears as he described the texture and color of the wallpaper in his bedroom. He had even noticed a spot on the wall where he had once scratched away the wallpaper down to the paint as he lay in bed and listened to the birds in the trees outside. Nobody but him knew about this spot because it was right next to the mattress. Now when he saw that familiar, long forgotten wallpaper, a series of pleasant memories began to return.

Next, he had felt himself outside, in winter. He was walking through the snow with his sister. They were holding hands with their mittens, coats, and scarves wrapped around them. He felt warm and secure. The sharp freshness of the cold, winter air brought back the exhilaration of being outside playing. He felt again how the two of them gradually became tired and hungry and went back inside for a warm dinner around the family table. He remembered all this with tears in his eyes, which I imagined was going to lead to an expression of grief, perhaps over the loss of this golden period of his life.

To the contrary, Mr. Kay was glad to discover that he still had such strong memories and images. He said, “I haven’t had those vivid memories for years and years, and I’m so grateful to have them back. I feel like they’ll never leave me now.”

Since he had fewer and fewer pain attacks and was less bothered by the aching in his face, we agreed that we could postpone any further meetings. We did not meet for several months, at which time he came back, saying that he had had a series of pain attacks in his face during the past three weeks. He attributed these to an increase in fatigue and stress related to an illness his wife had recently experienced.

We had one session, during which he spent about 20 minutes deeply relaxed, listening again to the “Moonlight Music” from Capriccio in his mind. As he opened his eyes after listening to this music he sighed and said with a smile, “This is just like taking medicine, except better. I feel so lucky to be able to have the pain stop so easily and pleasantly.”

He called me about a week later to say that everytime he felt he was going to have some pain, he would sit quietly for a while with eyes closed. Sometimes he played one of his favorite musical recordings; at other times he would listen to the music in his head, accompanied by an image of the orchestra. He was happy to report that in every case it helped him to feel relief from the pain. His pain continued to diminish, and follow-up after one year revealed that he had had only a few pain attacks since that time.

Mr. Kay’s case illustrates ways in which this kind of imaginal approach can, with very few explicit suggestions, help patients to discover a path that proves to be helpful. Although I was tempted to explore what must have been a deep well of emotional pain, I was, fortunately, able to resist. Instead, I respected Mr. Kay’s wishes to leave those memories buried. Doing so freed me to then think of the potential value of reexperiencing pleasant memories, which Mr. Kay was able to do, with evident benefit. This case helps me to remember the importance of not being too closely wedded to my psychological hypotheses and personal wishes for a patient, but to hold them in my mind while I explore other, perhaps less obvious avenues.

Although Mr. Kay improved substantially, other patients with quite similar symptoms have not. We need to be ready to consider with the patient a variety of treatment options, ranging from psychological to medical and surgical.

Although Mrs. Birch loved to tell funny stories and to make jokes, her humor always seemed to have a bitter edge. She had seen family physicians, internists, cardiologists, gastroenterologists, neurologists, rheumatologists, psychologists, and psychiatrists for complaints that included blurred vision, weakness, dizziness, nausea, fatigue, chronic headache, pain in her jaw, her throat, her chest, and her abdomen.

The most constant of these complaints were headache and chest pain. She had complained of many of these symptoms on and off for years, but they seemed to have increased in severity and frequency within the past few months. A number of the physicians and mental health professionals who had evaluated her thought that she appeared a little depressed at times. Yet neither antidepressants nor individual psychotherapy had been helpful in relieving the depression.

Her physicians told Mrs. Birch several times that they had no idea why she continued to suffer so many problems, despite EKGs, EEGs, chest x-rays, treadmill tests, endoscopy, barium enema, CT scans, psychotherapy and counseling. Various treatments had been tried, often with initial enthusiasm and determination on Mrs. Birch’s part to feel better; inevitably, within a few weeks she reported feeling no better—sometimes even worse—and terminated whatever the current treatment regimen happened to be.

Because I (SL) was known by my colleagues to have effectively used imagery and suggestion in some difficult cases, Mrs. Birch was referred to me. She seemed quite cooperative and enthusiastic about whatever I could offer; however, nothing I suggested or attempted, over a period of several meetings, seemed to help her in any way.

Mrs. Birch was surprisingly active for a woman with so many physical ailments. She had been married for more than forty years, and she and her husband seemed to have quite a congenial, even affectionate relationship. Both had recently retired, Mr. Birch from his position as a bank executive, Mrs. Birch as a director of purchasing for a large department store chain. Both had been, and still were, involved in a variety of charities and community projects. Their three children and several grandchildren all lived within a hundred miles, and they enjoyed frequent family gatherings.

What was most immediately striking to me about Mrs. Birch was her very attractive appearance. Her hair still had much of the same honey blonde color of her youth, although now liberally mixed with gray. Her fair skin was slightly tanned and only slightly wrinkled, mostly around her mouth and eyes. If I had not known better, I would have guessed her age to be at least 15 years younger than it was. About 5’6”, she had almost the same weight and figure as she had 30 years previously. I knew this from seeing photographs in an album that she brought one day, to show me pictures of her children when they were babies. On the first page of the album was a wedding photograph of herself and Mr. Birch. She was so strikingly beautiful that I felt my heart stop for a second. She was scornful of dieting, but she was careful to eat and exercise in a way that maintained her slender and athletic appearance. She and her husband played tennis, usually with friends, everyday.

Unlike other “impossible patients” I had seen, I actually enjoyed seeing Mrs. Birch in my office since, in spite of her complaints, she was usually very pleasant, often quite funny. I told her a number of times I could imagine her having a successful career as a nightclub comic, because of her ability to see humor in almost every experience. However, her humor often took the form of a bitter satire, suggesting seething anger beneath the humor.

Finally, I told her frankly that if I expected to understand and solve her problems, I probably would have resented her coming to see me again and again. She would have only reminded me of my shortcomings as a clinician.

“But I have to admit,” I told her, “I don’t know how to help you. That thought makes me feel quite sad, because you are such a sweet, good person.”

To my amazement, Mrs. Birch just smiled at me for a moment, and then said softly, “Thank you.”

She said these two words with such feeling that it seemed as if she felt I had offered her more than a simple compliment in the context of announcing my own limitations. She asked if she could come back again in a few weeks.

I was about to reply, “If it helps you …,” but I remembered that nothing seemed to help and, perhaps intuitively, I realized that wasn’t really the point. So I simply said, “Yes, please, come anytime you like.”

So our meetings continued like this, for several weeks more. Mrs. Birch reported to me about her ongoing panoply of symptoms, often appearing truly miserable and ill. But she also never failed to report about more happy topics, such as her grandchildren or an upcoming trip with her husband. These topics seemed to lift her out of the gloom a little, yet she always finished with a look of such unhappiness! She remained an enigma to me, no matter what questions I asked her or what possibilities I considered. I inevitably apologized for having nothing helpful to offer her, and she always smiled sweetly in response and thanked me with far more expression of gratitude than I imagined I deserved.

One day she left an urgent message at my office, asking me to call her immediately. When she answered the phone, her voice sounded very strained. Her chest pain had returned, this time more severely than ever before. The pain radiated up to her jaw and down into her left arm. She felt as if she could hardly breathe. Briefly, I considered telling her to go to the emergency room.

Then she said softly, “It was horrible.” Her voice sounded as if she were crying.

There was a long silence, unbroken except for her uneven breathing. Finally, she whispered, “The dream.”

“What was the dream?” There was no answer. “When did you have the dream?” Still no answer. I looked at my watch. I had patients waiting for me. I wondered if, in spite of all the tests, Mrs. Birch was having a heart attack. I felt exasperated and worried. Then, finally, she said, “Last night. It woke me up. I couldn’t go back to sleep.” Her voice was full of tears.

Again, I felt torn between my curiosity about the dream and my worry that she was having a heart attack while telling me about the dream. “Can I just ask you a few more questions about the chest pain you’re having? When did the pain start?”

Okay, I thought. Maybe she is having a heart attack, but we apparently have to find out what this dream is about! “Mrs. Birch, can you tell me a little about the dream?”

“You can’t remember the dream? You said it was horrible. Can you remember any part of it?”

“If it’s too much to think about right now, we don’t have to talk about it. I do want to check out what’s causing the chest pain, though.”

“What do you mean?” I asked, in spite of myself, because I believed she needed emergency medical evaluation, yet, at the same time, I did feel that this dream might be an important key to understanding her chest pain. But, like Mrs. Birch, I didn’t want to think about it just at this moment.

“The dream was so frightening. I was in a car. That’s all I remember. I wish I could make it go away. I feel like I’m dying.”

Again, I thought of treatment options. Refer her to somebody? The psychiatrist or psychologist she had seen previously? Have her come see me at the end of the day? Go the emergency room immediately? I was very confused and uncertain. Maybe just a few more questions would help me to feel clear.

“Mrs. Birch, do you think it would be helpful for you to find out more about the dream?”

“Yes, I do.” Her voice sounded more calm now, with even a hint of authority to it.

“Then, would you mind closing your eyes for a few moments? See if you can let the scene that you remember—the one with the car—come back into your mind.” Again, there was silence, unbroken only by her uneven breathing. I felt like I was beginning to get chest pain, myself, from a growing anxious thought that I was being a complete fool.

“Good. Describe everything you can see.” As foolish as I felt, this exploration of her dream seemed deeply important, not only to resolving her immediate chest pain but also to the resolution of her chronic complaints.

“The car is a convertible. I’m driving it. My mother is sitting in the front seat, beside me. I feel like I’m young … maybe 15 or 16. I’m wearing a real pretty dress I had at that age. That’s all.”

“We’re out in the country somewhere. There’s a policeman standing in the middle of the road.” Now her voice sounded afraid and tearful again.

“As long as you feel that you can, keep telling me everything that’s happening.”

“He’s holding out a hand, signaling me to stop the car. He’s walking over to the car.…” At this point, Mrs. Birch began to sob audibly.

“Is there anything else?” I continued to feel compelled, somehow, by the belief that our exploration of this dream was very important.

“He’s smiling. He bends over, and … he bends over and puts his hand inside my dress, over my breast. He just keeps on smiling at me!”

“I pushed his hand away, but—” Again, her story was interrupted by sobs. After a moment, though, she continued. “I tried to push him away, but he pulled out his gun and held it in my face!” Now she burst out crying like a child with a broken heart. I sat with the phone to my ear, hearing what I imagined to be a lifetime of pain, finally being released.

After a few minutes, Mrs. Birch confirmed my guess that her chest pain was gone. I asked her to see me at the end of the day. When we were alone in my office that afternoon, she began to tell me her painful secret. At the age of 16, she had been raped by a friend of her family. Like many women who are raped, she felt somehow culpable. Confused by fear of her parents’ disapproval and guilt about whether she had been responsible for the rape, she had kept the secret hidden, all to herself, for 50 years. Adding to her pain, the young man then forced her to have sexual intercourse with him several more times during the next year, until he moved out of town. He threatened to send a letter to her parents unless she acquiesced to his demands.

The dream was, fortunately, a window through which Mrs. Birch gradually came to see a part of herself in a new light. As we continued to meet, over the next several weeks, I attempted to provide a safe and supportive context in which she could feel no longer alone with her pain and in which she could experience, from an adult’s point of view, that this adolescent girl was not to blame for the rape. She was finally able to begin healing the pain that had plagued her for so long.

Of course, there had been nothing that any of her many clinicians could do until Mrs. Birch was ready. Her state of readiness depended, presumably, on a multitude of factors—within herself, her family, and her relationships with others.

One may wonder about the process of a patient’s developing readiness for therapeutic change. How this state of readiness develops, in any person’s life, seems as mysterious as how and at what point a particular blend of ingredients has cooked for exactly the right amount of time to provide tasty relief of hunger. My ability to help Mrs. Birch was, fortunately, not dependent on my initially knowing what her problem was; rather, it required more patience on my part than anything else—patience both with her seeming lack of progress, and with my seeming inability to be helpful. In retrospect, I recall expression of my lack of understanding not as a strategic self-effacing gesture, but as an honest expression of my state of bafflement—combined with a curiosity and a willingness to persist. To be honest, there must have been a part of me that felt some optimism about something in our relationship, or I could not have sustained my energy with Mrs. Birch.

Although she was an enigma, Mrs. Birch was not merely a passive recipient of treatment. In retrospect, I now see that she was an active partner in her healing. As much as her understanding allowed, she continued to search for the cause of her suffering—buried for years (literally and symbolically) in a forgotten chest. When her dream occurred, she urged me on, reassuring me that the dream was, in fact, the key to the chest.

This experience also illustrates how imagery can provide a highly effective window for viewing intrapsychic material that is temporarily beyond verbal expression. Having finally been brought to conscious awareness and understanding, the suffering no longer needs to be expressed somatically.

Lest we be too thrilled by the satisfying resolution to this case, we need to remember that not all cases of inexplicable pain complaints can be so pleasingly resolved. In many similar cases, the patient may well have an unidentified medical problem; in the case of a somatoform disorder, the underlying cause may be multifactorial and not readily uncovered by a dream or any other means.

Here are some specific psychosocial strategies that are helpful in caring for elders suffering from pain:

1. Develop a trusting relationship over time. This means continuity and regular scheduled visits. Make it clear that you will be the caregiver who will work with the patient on the pain problem.

2. Establish ground rules. This is especially important when potentially addicting drugs are needed to control of the pain. In addition to coordination of care by the primary physician, there should be agreement that the emergency room is not to be used for obtaining drugs and that any change is the established dose will be made as a joint decision between you and the patient.

3. Utilize appropriate community resources. If the elder is isolated, effectiveness of care will be enhanced by addition of a visiting nurse or public health nurse to the team. The local Council on Aging may have a friendly visitor program that can be brought to bear. If the elder is disabled, programs like Meals on Wheels can provide nutritional support and a daily visit.

4. Pain is a family affair. “Significant others,” family, or friends should be involved with the patient’s care. Encouraging a spouse or involved family member to accompany the patient to the office is important. Understanding the involved caregiver’s perspective may be extremely valuable in approaching the pain problem.

5. Utilize physical activities. Since function is so important, we urge regular physical activities with specific instructions, such as, “I want you to walk around your block twice daily.” Use available physical therapy, which will likely involve stretching exercises, to improve strength and range of motion, as well as a specific program for rehabilitation. This may be an indispensable support in enabling the patient to feel better and become more active.

6. Use relaxation techniques and imaginal or hypnotic techniques. Help the patient practice deep breathing and relaxation while visualizing serene scenes. Tape record this process, so the patient can practice these techniques at home, using the tape recording as both a motivational tool and a memory aid.

7. When there is emptiness and a dearth of meaning in the patient’s life, help the elder “get a life.” Refer the patient to a social worker, who can, for example, suggest specific volunteer activities.

There is something profoundly sad and unfair about pain in old age—insult really is added to injury. Whether the voice of a wounded heart, opportunities lost, the complaint of tired, crumbling bones, or a merciless cancer, pain is a cruel intruder in what could have been a time of accomplishment, satisfaction, reflection and peace.

Caring for elders and their pain is often discouraging and difficult; at the same time it is work that heals our future self. The process of integrating the emotion of the pain with the medical facts helps us to find a healing path that is at once practical and heart-felt. Youth and renewal in old age are often abandoned beneath a blanket of hopeless gloom or futility sought through medication or empty distraction. Elders in pain deserve our acknowledgment of the sadness that coexists with the dissatisfaction of our best, most optimistic efforts. This sadness is neither depression nor self-pity; rather, it emerges from an honest recognition of the loss brought on by the pain of age. It may be that only through expression of this sadness will we find our way to the compassion and energy necessary to experience renewal and healing.

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