Mary Jo Barrett is the director of training at the Center for Contextual Change and has had extensive experience in working with clients who suffer from physical and psychological pain. She is a faculty member at the University of Chicago School of Social Service Administration, the Chicago Center for Family Health and the Family Institute of Northwestern University. She trains counselors on sexual abuse and trauma, eating disorders, couples therapy, post-traumatic-stress disorder and compassion fatigue. The Center for Contextual Change, a community-based counseling group, has offices in Skokie and Oak Park.
Q. What is the nature of the people who come to see you about pain?
A. The people who come to see me are people who have been traumatized, physically, emotionally, spiritually, or sexually. The trauma has left them in some kind of psychic, physical or spiritual pain. The first thing I think about is that the pain, whatever its cause, has usually left them feeling powerless. They are just powerless about the pain and powerless over the situation that brought the pain. A lot of times, they are devaluing themselves. They are necessarily hopeless. That is different than powerless. Their thought is, “I have no influence over this. I am powerless over this pain.” It is a sense of feeling totally out of control and then, devalued. Their questions are, `Why is my body letting me down? What is wrong with me? Why did I deserve this? Why me?”
Q. As a therapist, how do you respond to that condition?
A. When someone is coming in feeling that powerless and devalued, I don’t start with questions. I try to create a context in which they can feel like they can get some relief, find some safety. I try to develop some understanding of why they are feeling this pain. Let’s say a guy in constant pain came to me for therapy. I would want him to tell me how I can help him live with this pain so he can regain some of his power, some of his sense of who he is. I would try to create a context that there is some hope, whatever that means.
Q. Assuming you can do that, what comes next?
A. I would probably try to figure out what are the things he is doing to try to gain power and control. Rage may be his way of taking back that control. It is a very natural human process to get angry when you feel powerless. That is why people beat people up. That is why there are gangs. It’s the same sense of powerlessness and being devalued. It is as though you are saying, “I will make other people feel as devalued as I am.”
Q. What role does rage play in that process?
A. When someone is in physical pain, rage provides a sense of release. There is this moment, I don’t know for sure, but it might be a neurobiological and chemical moment. Something goes on chemically, an endorphin is released, and it might serve as its own natural pain reliever. What I would do is find out what is the symptom. What are you already trying to do to relieve your pain? That way I would find out about drugs, alcohol, rage, self-mutilation, whatever they are doing.
Q. What do those symptoms tell you?
A. The symptoms are usually their attempts to survive the pain. So I would like to find out, what are your attempts to survive the pain? Men tend to get rageful and take out their rage externally, whether it plays out just as a fantasy or as yelling at someone. Women often turn their attempts to survive the pain internally. Women tend to maybe cut themselves or mess around with their food or drink. They do more self-destructive things, while men tend to do more things that are destructive to others.
Q. Do you see distinctions between coping with physical pain and coping with mental pain?
A. A lot of the people who have come to us who have been severely abused are enraged that as a young boy, for example, they never did anything to stop this person from sexually abusing them or bullying them or hurting them. I totally understand that. You think at the time, “One day I will come back and kill them.” The thought later about the situation is “I did nothing. I was powerless. I did nothing,” and so one way to soothe yourself even then is to have revenge fantasies.
Q. Is it OK to handle your pain that way?
A. No, I don’t think so. I think that it is OK to want power. Power is not a bad thing. It is OK as human beings to want to have influence in the world. But it is not OK to want to inflict pain and physical injury on someone else. My goal in therapy is to help him realize he was not inadequate by not doing anything as a child. The next piece will be to help him find that there are other ways to face power that are not abusive. We don’t have a lot of role models for that. But there are ways to be a powerful person and not be abusive. I would want to help him gain power that is not homicidal. I want him to have power but I don’t want him to be violent.
Q. And then what happens?
A. By the end of therapy, hopefully they have found physical, spiritual and emotional ways to have power in their lives and values in their lives where they are not inflicting pain on themselves or other people. For a guy always living in pain, I would look at a lot of alternatives, meditation for example, ways to just find some kind of peace to be able to come to terms with living in constant pain. So again, it is finding ways to learn to cope with the trauma.
Q. Let’s talk about a classic, the woman who cuts herself.
A. There are three stages of the therapy. We sit down and explain to them this is a program for trauma, for healing pain, and you will go through these stages. In Stage 1, we do a lot about helping them. Somebody traumatized as a child sees the world as a dangerous place. This woman sees me as a threat. She sees authority figures as people to be at risk with. The way she copes with that fear is she doesn’t get connected. Fight or flight. The fight is the rage part. The flight is to disconnect. Both are pretty difficult to do therapy with. They don’t trust you.
Q. How do you address that question of trust?
A. Stage 1 is about making them feel safe so they won’t disconnect. Then you identify what they want to change, really clearly. Do you want to stop cutting? OK. When do you cut? What goes on in the family? What other symptoms does she have? Then I would talk to her about my plan to help her stop cutting herself. Most of the time it’s not a suicide attempt. Then we would come to agreement. She would commit to therapy: “I am willing to do this. I am willing to see a psychiatrist for medication if necessary.” You don’t move quickly with a trauma victim. They can’t absorb the change. They come in a hypervigilant state. You have to prepare, like an artist prepares a canvas for a painting.
Q. What happens in Stage 2?
A. Once they can absorb the therapeutic intervention, then I would do a lot of imagery. Maybe some hypnosis. I would have her work with a group. Maybe medication if a psychiatrist deemed that necessary. I would help her review her own history, empower her. I would have her try to have her relationships from a position of power. If she went home for Thanksgiving, for example, she would say, “If you are going to drink, I am going to leave,” assuming alcohol made her vulnerable as a kid. I would have her go rework the historical vulnerabilities. I hope that, by doing all these interventions, with cognitive restructuring helping her change the way she thinks about things, the symptoms will be disappear. Stage 3 focuses on relapse prevention.
Q. Is the pattern of treatment the same in all of these cases, regardless of the cause of pain?
A. Yes, it is a three-stage process. I am very optimistic about how it works. We have a high success rate. I am even optimistic about offenders. They have been traumatized too. I have never worked with someone who is enraged who hasn’t been traumatized.
