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The Role of Collective Guilt in the Identity of German Running head: INTEGRATED CMT AND TMS TREATMENT AN INTEGRATION OF CONTROL MASTERY THEORY AND THE THEORY OF TENSION MYOSITIS SYNDROME FOR THE TREATMENT OF CHRONIC PAIN: THE CASE OF “JAMES” A DISSERTATION SUBMITTED TO THE FACULTY OF THE GRADUATE SCHOOL OF APPLIED AND PROFESSIONAL PSYCHOLOGY OF RUTGERS, THE STATE UNIVERSITY OF NEW JERSEY BY JUSTIN DANIEL BARKER IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PSYCHOLOGY NEW BRUNSWICK, NEW JERSEY AUGUST 2019 APPROVED: ___________________________ Daniel Fishman, Ph.D. ___________________________ Jeffrey Axelbank, Psy.D. DEAN: ___________________________ Francine Conway, Ph.D. INTEGRATED CMT AND TMS TREATMENT Copyright 2018 by Justin Barker INTEGRATED CMT AND TMS TREATMENT ABSTRACT Chronic pain is a national health epidemic and chronic back pain is one of the most common pain symptoms. Research suggests it is insufficient to explain chronic back pain as being predominantly due to structural issues of the spine. The theory of Tension Myositis Syndrome (TMS) offers an alternative explanation for the etiology of back and other somatic pain, namely, that pain serves a distracting function against repressed, negative emotions. Anecdotally, hundreds if not thousands of individuals have experienced a significant reduction in pain following the principles of TMS treatment as outlined by the medical doctor John Sarno. However, there is a dearth of high-quality research on the treatment of TMS and using a TMS- informed approach in psychotherapy. The purpose of this study is to examine the potential efficacy of a psychotherapy integrating the theory and treatment of TMS with Control Mastery Theory, a psychodynamically-influenced and empirically supported psychotherapy model. The study analyzes the 44-session treatment of “James”, who, was experiencing significant chronic back and other somatic pain and had been told by medical doctors that structural issues were not the cause of his pain. A battery of self-report quantitative pain measurements was used. James’ quantitative results and qualitative self-report indicated his pain did not decrease throughout the course of treatment, despite evidence suggesting a strong therapeutic alliance and James fitting almost all of the personality characteristics common among TMS patients. A psychodynamic explanation of the results is offered, incorporating the results of the Shedler-Westen Assessment Procedure. Recommendations are made for future chronic pain psychotherapy treatment and research. ACKNOWLEDGMENTS First and foremost, I want to thank James. None of this would have been possible without you. Thank you to my dissertation chair, Dan Fishman. You are an erudite professor and Renaissance man. I believe your passion for the pragmatic case study is a genuine gift to the field of clinical psychology. Thank you to my dissertation committee member, Jeff Axelbank. You helped the dream of a dissertation focused on chronic pain and TMS become a reality. I am full of gratitude that I was able to train under your supervision and develop as a TMS-informed therapist. It was an honor to be in the trenches with you while I did clinical work. Thank you to the late John Sarno. You helped me to heal and forever changed the trajectory of my life. Thank you to Antonia Fried. You were vital in my development as a therapist. Through your supervision, I found my most authentic therapist self. Your kindness and support meant the world to me. Thank you to JHW. Here’s to the V12 and a second prime. Thank you to my parents, Kate and Charles Barker. We did it. I love you both. Lastly, to all of my clients: I am honored that you let me sit with you in your pain and joy. Words cannot do justice to what you mean to me. iii TABLE OF CONTENTS PAGE ABSTRACT ...............................................................................................................ii ACKNOWLEDGEMENTS .......................................................................................iii LIST OF TABLES .....................................................................................................viii LIST OF FIGURES ...................................................................................................ix CHAPTER I. CASE CONTEXT AND METHOD .....................................................1 The Rationale for Selecting this Particular Client for Study ................1 The Clinical Setting in Which the Case Took Place .............................2 The Methodological Strategies Employed for Enhancing the Rigor of the Study ...........................................................................2 Sources of Data Available Concerning the Client ................................3 Confidentiality ......................................................................................3 II. THE CLIENT........................................................................................4 III. GUIDING CONCEPTION, WITH RESEARCH AND CLINICAL EXPERIENCE SUPPORT ................................................6 The Pain Epidemic ................................................................................6 The Insufficiency of Structural Models of Back Pain ..........................7 Other Evidence Suggesting the Insufficiency of the Structural Model .............................................................................9 Psychotherapy and the Treatment of Pain ............................................10 Psychodynamic Therapy and Pain ........................................................12 Tension Myositis Syndrome (TMS) .....................................................13 iv TMS Treatment .....................................................................................16 Psychotherapy for the Treatment of TMS ............................................17 Empirical Support for TMS and TMS Treatment .................................18 Anecdotal Support for TMS and TMS Treatment ................................20 Control Mastery Theory (CMT) ...........................................................21 Empirical Support for CMT ..................................................................24 Rationale for Integrating TMS and CMT .............................................25 Integrating TMS and CMT ...................................................................26 Summary ...............................................................................................29 IV. ASSESSMENT OF THE CLIENT’S PRESENTING PROBLEMS, GOALS, STRENGTHS, AND HISTORY ...........................................31 Presenting Problems and Medical History ............................................31 Quantitative Assessment Measurements...............................................33 Quantitative Assessment Measurements Results ..................................35 Patient Goals for Therapy .....................................................................38 Relevant Psychosocial History .............................................................39 Presentation at the Beginning of Therapy .............................................40 Strengths ...............................................................................................44 Diagnosis...............................................................................................45 V. CASE FORMULATION AND TREATMENT PLAN ........................46 Formulation ...........................................................................................46 Treatment Plan and Treatment Goals ...................................................50 VI. COURSE OF TREATMENT ...............................................................55 v Phase 1: Sessions 2-20 ..........................................................................55 Sessions 2-3: Developing rapport, early defense analysis, psychoeducation, enhancing understanding of pain and mindbody interactions ...................................................................55 Sessions 4-5: Increase in affect (guilt), further psychoeducation, superego testing, building narratives ............................................61 Sessions 6-8: Needing to see improvement before Committing (increase in ambivalence), further exploration of guilt and anger ..........................................................................66 Sessions 9-13: Increase in emotional vulnerability, pain reduction, increased commitment to TMS theory, focus on external transformation .................................................................69 Sessions 14-18: Frustration with progress, increase focus on and expression of anger and frustration ........................................74 Sessions 19-20: Further increase in frustration, interpretive summaries of central psychodynamics .........................................78 Phase 2: Sessions 21-24 ........................................................................80 Sessions 21-24: Resistance followed by deep emotional processing and development of emotional pain narrative .............80 Phase 3: Sessions 25-34 ........................................................................87 Sessions 25-30: Heightened resistance after Phase 2, analysis of resistance, further discussion of guilt and anger, increased attack on therapy ...........................................................................87 Sessions 31-34: Further attack on the therapy, confrontation, acceptance of non-commitment ....................................................93 Phase 4: Sessions 35-41 ........................................................................102
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