Survivors of severe and prolonged trauma suffer, almost without exception, from chronic pain. It develops whether the survivor has experienced physical injury or not, and is often unresponsive to medical intervention.

As a physiotherapist at STARTTS, I became interested in understanding certain aspects of chronic pain because I noticed that a substantial number of trauma survivors seemed to strongly resist the changes in their wellbeing, which they so desperately sought. I wanted to understand this phenomenon, which is so inadequately explained by superficial and judgmental terms such as ‘secondary gain’, ‘compensation/social security neurosis’, and ‘sick role behaviour’.

STARTTS’ clients are refugee survivors of torture and trauma, which has usually occurred within the context of state-condoned persecution. However, many their behaviours can also be seen in survivors of other severe traumas such as armed conflict, childhood abuse and motor vehicle accidents.

I find that the most constructive way to view chronic pain in a trauma survivor is as a manifestation of utter anguish, and to understand that it can only be effectively addressed in the context of its traumatic aetiology.

Traumatised people have all suffered loss - maybe they have lost their homeland, the people they loved, their health, the body they used to have, their peace of mind, their sense of security or their trust in the benign nature of the world or humanity. Often survivors of trauma believe they have lost everything. Human beings have powerful and complex ways of coping with terrible loss. It is by understanding chronic pain behaviour as a way of coping with the terrible anguish of loss, that the chronicity and intractability of the pain associated with trauma may best be understood.

Pain and suffering in a survivor of mass trauma can represent a living memorial to the suffering of those who didn’t survive. Memorials are important - there is anecdotal evidence that the suffering of many Vietnam veterans was alleviated by the construction of the Washington war memorial, on which is written the names of all the soldiers who died in the Vietnam war. Many victims of conflicts throughout the world died without their names or full identities being known to their companions or witnesses to their deaths. The suffering of these companions and witnesses may be the only public acknowledgement or tribute of their living and dying that they receive.

Pain can also be a testimony to the survivors’ own loss and suffering and to the devastation that the trauma has wrought on their lives. It is a legacy to the death of the person they were and the life they had.

There is a tendency among many of us to make light of the suffering of others, often to protect ourselves from their pain. Many health professionals prefer to focus on ability and potential rather than on what is lost and damaged. This attitude can be counter-productive for someone who feels that their suffering is a tribute to unacknowledged loss. What may be needed instead, and certainly initially, is just such an acknowledgment of the loss, suffering and grief that they experienced or witnessed. With acknowledgment, the effect of the trauma on their lives is validated, and the pain may no longer be necessary. An important role that health professionals may have is to bear witness and to pay tribute.

To look on the bright side or encourage the survivor to be ‘positive’ may be sending the message to them that ‘what happened to you was not so bad’. The continuation of pain may be the survivor’s way of telling you that it was. Those of us who have not had our ability to survive tested are often awed by our survivor clients’ extraordinary endurance, strength and courage. The survivors themselves may be more aware of their own failure to protect their families, or their shame at not withstanding assault or intolerable pain and fear.

Guilt at having survived ("survivor guilt") when so many others didn’t, may complicate this picture by adding an element of self punishment to the maintenance of the memorial, ensuring that any alleviation of suffering is short lived.

Another behaviour which is often associated with chronic pain, and trauma survival, is passivity. Often the passivity occurs in tandem with an aggressive aspect. A refusal to take responsibility for one’s own recovery severely reduces the likelihood of such recovery occurring.

This is a complex phenomenon often affected by pre-trauma attitudes towards autonomy and individual responsibility. By observing the progress of trauma survivors towards recovery over several years, I have come to regard passivity as another way of coping with unbearable loss and anguish.

A prerequisite to the development of post-traumatic stress disorder is a response to a trauma involving both horror and helplessness. (It has been observed that people who actually did something to get out of a traumatic situation, or ease the plight of others, are far less likely to develop symptoms). A feeling of helplessness does tend to characterise traumatised people. Their lives have been shattered by forces utterly beyond their control, which they have managed to survive through luck rather than any deliberate actions on their part. They have learnt, through bitter experience, of their own vulnerability and of the fragility and unpredictability of human life. It is not surprising they are left with a lack of belief in their own effectiveness, and even with a profound conviction that they are not agents in their own lives.

But the picture is more complex than this. For instance, it is common for a clinician to feel, when working with trauma survivors, that they are fighting the client’s symptoms alone and without their support. Sometimes it is easy to detect a certain satisfaction on the client’s part as the clinician’s ineffectiveness to reduce the pain is demonstrated and the client’s belief in their symptoms’ intractability is validated, again and again.

What is the meaning of such resistance? Most trauma survivors see themselves, quite accurately, as innocent victims. What happened to them was utterly undeserved and not their fault. And to make this piece of cruel and unjust reality bearable, a piece of fairy tale thinking develops. Namely, that one day, the sufferer will get what they deserve and they will be restored to their former pre-traumatised state (which is often idealised). Some one who thinks like this will not get better because a magical overnight improvement is the only form of ‘better’ that they will accept.

But of course, recovery from trauma is not like that. It consists of a slow building up of small incremental changes, and it requires hard consistent and highly motivated work on the part of the injured person. It also requires a clear-headed understanding of the problems that need to be overcome. Such understanding is not available to someone who is waiting for justice to be restored. A state of waiting involves denial of the true effects of the trauma. To acknowledge the extent and permanency of the damage means to acknowledge that their former life and their former selves are altered beyond redemption and that the travesty of justice involved can never be rectified. To acknowledge such a loss is to feel unbearable grief and probably anger, and yet recovery is not possible without a realistic appraisal of what is gone and also, conversely, of what is left.

The denial involved in passively waiting for justice and wellbeing to be restored- and the belief that they can be without any active involvement on the victim’s part- protects the innocent victim of trauma from intolerably painful feelings. Becoming an active participant in one’s recovery requires feeling the terrible pain of loss and anger, not just once, but over and over again. Such mourning and anger will be a constant companion in the process of recovery.

This may explain why there is often resistance, even blindness, to small improvements. To recognise improvements involves recognition of what has gone; to feel enthusiasm about any change is also to face how much one has lost; to feel the arousal of hope is to open one’s heart to the risk of further bitter disappointment; to accept responsibility for one’s own recovery is to give up waiting for justice to be dealt to those who are truly responsible for the damage caused. If health professionals suggest that recovery may only be achieved by the sufferer accepting responsibility this implies that those who are truly responsible need not be held accountable.

Health professionals are attempting to facilitate change in their clients. To change, all of us must drop our defensive protective habits, defense mechanisms, the assumption of passivity and the refusal to take responsibility for our actions. However, these mechanisms come into operation for the very purpose of defense, and when the need for protection and defence is very great, as it is in those who survive severe trauma, they are not only deeply entrenched but very important. They help the traumatised person tolerate an existence which may otherwise be intolerable, and they will only be parted with as the person feels they can tolerate life without them. Health professionals need to be aware of these defensive behaviours and respect them for their function and importance.

Judith Herman Trauma and Recovery

Paula Raymond Yacoub, Working with Torture and Trauma Survivors: a Manual for Physiotherapists and Bodyworkers. A STARTTS Publication.