An overview was obtained from the naive reading. After examining the field notes in general and the participants’ quotations in particular, we found words or expressions that related to such things as sadness, failure in childhood or adolescence, abuse, anxiety, and powerlessness in the context of past experiences. These were clustered under the theme: ‘The significance of previous experiences’. We also found patterns related to pain, distress, insomnia, anger and irritation at not being as able as before. These were listed under the theme ‘Restrictions in everyday life’. Further, we discovered a number of positive statements that indicated joy, liberation, desire, strength, resolution of inner tensions, increased self esteem and desire to take action. We grouped these under the theme ’Restoration of inner resources’. The three themes were then analysed, interpreted and discussed. The results are reported in the following section.
The significance of previous experiences
The analysis showed how previous experiences influenced the patients’ present life and functioning, and hence, their CLBP. For example, the loss of a close relative had triggered anger and sorrow that could have led to self-destructive behaviour, as evidenced by the following statement:
"“I am angry that my sister allowed herself to die and leave her daughter, who was a year old. I wished that I was dead instead. It is really sad to talk about it. I have been on the ropes since then.”"
It is well known that bereaved people can have an unconscious urge to ‘be in the grave themselves’ and can lose a grip on their own lives.
And another statement:
"“I took so much Somadril, just the thought of it makes me nauseous. I was saturated in medicine. I don’t understand how it’s so easy to get prescribed medicine. It was the Somadril that put me completely down in the depths. I felt that I had no idea what I was doing, when I took so much medicine. And it was not to commit suicide that I took so much and was hospitalised.”"
Throughout the quotation, a feeling of sorrow was expressed, which is thought to have caused self-destructive behaviour in the form of medicine overdose. Other themes that came up in the study were self-blame and shame. Self-blame means I have done something wrong
and shame means I am wrong.
Self-blame thus focuses on the action and can be healthy, if one really has done something inappropriate to another person, as this can sometimes be rectified. In contrast, however, shame is ranked with sin and inferiority [18
]. From the above quotation, it seems that the patient felt it was shameful to take so much medicine, and went on the defensive by projecting the blame onto the general practitioner who prescribed the medicine, as it was too uncomfortable for the patient to admit responsibility.
Other previous experiences turned out to relate to being let down during childhood. One patient, who as an eight year old had been forced to act as an adult at home for an alcoholic mother and an absent father, made the following statement:
"“I grew up with a mother who was always drunk and from the age of eight I had to be ‘mother’ for my two younger siblings, and made sure that they did not realise that she came home drunk or saw that I cleaned up vomit in the stairway.”"
The quotation suggests a feeling of being let down. An unhealthy and reversed mother-child/father-child relationship, where the child takes responsibility for the parent, in this case the mother, is seldom something the person is conscious of, since they don’t know of any other way. From additional notes taken during the interview, it was seen how the patient, now as an adult, despite pain, depression, stress and a poor financial situation, still had to spend most of her free time being a mother for her own mother without herself receiving any support. Theoretically speaking, we can speak of the concepts of victim, saviour
and the violation triangle
, also called the drama triangle
]. In the classic model, the child is the victim, while the mother is the saviour and the father is the violator, e.g. verbal violator. The child learns this behaviour. In the case under study, the mother was both victim and violator, and the patient saviour of her mother. In the individual therapy, the patient developed insight and showed that she was able to alter her behaviour towards her mother, and begin to take responsibility for herself and express her own needs, instead of being violated and manipulated.
The data also included a description of a sudden event that seemed to be the cause of fear of becoming paralysed. The patient fell down backwards three metres. The written quotation was as follows:
"“I fell off a front loader truck, and fell three metres. I was hoisted up and apparently was told that I was about to be lowered, but I didn’t hear that and we didn’t have eye contact, as we normally do. I didn’t register the message and suddenly I lost my balance and fell backwards. Something happened in my back and I couldn’t get up and run away. That’s what I have done all the other times I’ve fallen off ladders and the like. I wanted to crawl away, but I couldn’t move my muscles, I could only lift one leg a bit.”"
In the quotation, the patient describes how, after a sudden fall, he felt unable to move. He was terrified and went into a state of shock with the fear of becoming paralysed, although he was not paralysed. It can be assumed that he had a survival response, where the body instinctively reacted with a freeze response [20
], an effect of the autonomic nervous system, where the fight or flight response was not possible. Often in such a situation, the body will reserve activated energy, that is, the energy that in a split second was activated for survival but was not used. After a violent event, there is a need for peace and calm in the following hours to regulate the autonomic nervous system. Conversely, in certain situations, symptoms can subsequently arise such as feelings of unrest, aggression, powerlessness, depression, sleep disturbance, tiredness, pain and muscle tension and a lack of capacity to carry out tasks. Ten months after the fall, in the session with the psychotherapist, following was reported:
"“I was hospitalised, but was told that there was nothing wrong with me. I was given morphine, so finally I could sit up and the following day I was expected to go and get my own food, if I wanted something to eat."
"It wasn’t a pleasant experience, and I can’t stand hospitals - they smell of death. I have witnessed so many deaths: my friends who drove themselves to their deaths, my grandparents and a close friend who died at 19."
"So I wanted to get home quickly from the hospital and did so, but was in a lot of pain at home. At home, I cry a lot. Before the accident I was a lively guy who went round helping everyone.”"
The quotation expressed how the patient experienced a lack of calm, care and security. Furthermore, he felt that “the hospital smelled of death”, which gave him stress, anxiety and discomfort, which was why he chose to discharge himself. The fall caused a fractured vertebra and concomitant severe pain that prevented the patient from doing his usual activities; the experience of shock probably remained in the body and he subsequently developed depression and experienced powerlessness.
From a psychological viewpoint, the SE treatment was directed to help the patient to acknowledge that he had survived and to bodily integrate the fact that the danger had passed. [21
]. Furthermore, it created an opportunity for him to complete his flight response which subsequently allowed the stress and fear to subside.
Restrictions in everyday life
The study showed how restrictions in everyday life can affect self-worth and identity. In the notes, it is stated how patients who, despite a dysfunctional family and poor social conditions, had managed to pursue an education, get a permanent job and develop a good financial situation for herself and her children. However, a workplace accident completely changed her quality of life as demonstrated in the following quotation:
"“I fell onto a wet floor at my workplace a year ago and got back pain. I get so much pain and am wiped out after doing very little. And I take strong medicine, but I can’t even sleep at night. I can’t cope with it any longer.”"
The statement shows how this patient with severe pain had sleep disturbance and felt herself to be in a powerless situation. It seems that the patient had gone into a vicious pain cycle, where pain led to insomnia and even the most minor stressor gave increased stress/high arousal causing lack of clarity and inability to cope. The patient´s level of stress was reduced via SE.
Another patient had difficulty accepting that he couldn’t do what he previously took for granted, and it seemed to affect his perception of his own identity. This is shown in the following quotation:
"“I can no longer work 100% as a craftsman. My body, my arms, where all my strength is, are now restricted because of my back.”"
With reduced functioning as expressed here in connection with back pain, a person can be affected in relation to his/her own identity, be it in relation to the family as well as to work. Self-worth can decline along with physical and psychological limitations.
And another statement:
"“I cannot feel any emotion, there is nothing that makes me sad, I used to be hot-tempered, but of course one doesn’t lose one’s temper. I don’t get it (the anger) out of my body as I used to, when I worked and played football.”"
The statement can be interpreted as conveying a repressed feeling of anger. It seems that the anger had accumulated and become either forbidden or difficult to express. Anger often creates tension in the body and exacerbates the pain. The patient worked therapeutically and phenomenologically with the pain and anger and found that the tensions in the back disappeared in the process. Another theory could be that anger can arise after an unresolved fight response [21
]. The patient had on two occasions been faced with uncomfortable events, including the sudden death of close relatives. It could be suggested that the accumulation of energy was locked in the body and could have given rise to muscle tension and stress. And, as the patient described, he could not release this anger as he was unable to be physically active.
In the field notes, there were descriptions of how the patients with CLBP sometimes came with anxious, stressed and unfocused eyes but by the end of the psychotherapeutic session they were calm, and their eyes were seen to have become relaxed and clear. They became present, felt better about themselves and were more able to grasp the situation and take action.
Pain and depression can lead to feelings of inadequacy, both physically and mentally. Lack of sleep, confusion in everyday life and an uncertain future were characteristic of the participants, who described themselves as having myriad thoughts and being on the brink of not being able to cope. It is known that stress-activating life events [22
], here exemplified by a complex set of symptoms related to back pain, affect depressive states.
It can be assumed that when stressors and worries become overwhelming and all internal resources have been used up, stress emerges. Stress is defined in the Encyclopaedia [23
]as ‘the physiological reaction that occurs in animals and people due to threatened or actual damage to the organism or physical and/or psychological activity at the limits of the individual’s coping capacity; stress-inducing factors are collectively called stressors’. It is well known that in cases of long-term stress, people find it difficult to come out of the situation on their own [24
]. If CLBP is seen as a constantly present stressor that extends into depressive symptoms, then it seems that everything becomes self-perpetuating.
Restoration of inner resources
The study showed, particularly in descriptions drawn from the end of the course of therapy, how an ability to tap into inner resources began to re-emerge. One female patient, who had experienced loss and sorrow and who had been self-destructive, was quoted as saying:
"“My goal is to get back to work in the town and stay living in the little community, so my children can continue to go to school there. I can feel that I’m about to wake up, instead of being the little pathetic one.”"
The study showed how, in the course of the therapy, the patient had arrived at a place where she could take responsibility and wanted to get back to work and out of the victim role. From being in a self-destructive and depressive condition, it seemed that the patient’s inner resources had now come up to the surface again and could be used.
In the field notes, another patient described how she was busy trying to satisfy everyone but herself, then at the end said:
"”I want to open my heart to myself”"
From this quotation, it can be interpreted that the patient was beginning to take care of herself. It appears that the patient had arrived at an insight where she felt that she was worth something and was ready to take herself seriously in order to move on and cope with her LBP. It was not enough that, as before, she was available to everyone else. She expressed that she experienced an inner happiness and freedom; probably a way out of her depression and pain.
For the six patients included in this study, Gestalt therapy and SE appeared to be effective for depression and therefore presumably also for pain. As the study was qualitative, it is not generalisable to people suffering from similar conditions. However, the findings are of sufficient interest to be considered in the design of future research.