With reference to the case study, Ken is a fifty-three-year-old lifelong building labourer, currently on long-term sick leave owing to back trouble. He smokes, worries about the family finances, and has begun arguing more frequently with his wife, Carol. His father-in-law died a year ago. This essay will assess Ken’s level of stress from a biopsychosocial perspective, examine cognitive coping mechanisms that Ken could employ to alleviate the pressures of life, and consider the nature of his back pain with reference to the biomedical model and psychoanalysis.[^]

As noted in Gross (2010), Holmes and Rahe (1967) listed forty-three life events that occurred in the months prior to the onset of illness in five thousand patients. These life events comprised biological factors (for example, illness), social factors (for example, a change in the number of arguments with spouse), and psychological factors (for example, a revision of personal habits). One hundred judges were then informed that marriage had been assigned a weighting of 500, and were asked to provide a figure for each life event according to the perceived intensity and time necessary to accommodate the event’s impact relative to marriage. The mean value assigned to each life event by the judges was divided by ten, forming the numerical weightings of the life events used in the Social Readjustment Rating Scale (SRRS).[^]

An application of the SRRS to Ken’s circumstances during the last year would result in a score of at least 209: Ken’s father-in-law (a close family member) has died (63 points); Ken is on sick leave owing to back trouble (personal injury or illness – 53 points), consequently experiencing a change in his financial state (38 points); he is arguing more frequently with his wife (35 points); and he has experienced a change in his work hours and conditions (20 points).

Following the guidelines of Holmes and Masuda (1974, cited in Gross, 2010), a score of 209 over a twelve-month period means that Ken is experiencing a moderate life crisis. According to the SRRS and its associated research, Ken is currently at risk of serious health deterioration as a result of the stresses of life. His circumstances render him increasingly susceptible to sudden cardiac death, non-fatal heart attacks, diabetes, leukaemia, and tuberculosis. The fact that Ken smokes almost doubles his likelihood of suffering a heart attack compared to that of a non-smoker (British Heart Foundation, 2015), so managing his stress is of paramount importance.[^]

One technique that could help Ken to manage his stress is meditation, a technique with the aim of restoring calm and balance to cognitive functioning. Weschcke and Slate (2012) outline a series of meditative exercises that empower individuals to manage stress and effect desired change in life. They cite the experiences of many pupils who have reported major benefits while following a meditative procedure they term ‘out-of-body travel’. These experiences include: accelerated learning of specialist subjects; increased knowledge of future employment paths; therapeutic releases from fear; resolutions of grief; and healing experiences. This latter benefit of meditative practice could help Ken to alleviate his back pain as well as manage stress.[^]

Since depression often accompanies chronic pain (Bradley, 1995, in Gross, 2010), it is important that Ken pays attention to his cognitive processes. Walton (2015), summarising eight recent studies into the effects of meditation, highlights the empirical benefits of its practice: mindfulness meditation is as effective as antidepressants in the treatment of depression; the brain’s structure changes favourably in response to mindfulness meditation, with increasing hippocampus cortical thickness linked to better regulation of emotion, learning and memory, and decreased amygdala brain cell volume linked to a decreased response to stress, fear and anxiety; and mindfulness training is effective in helping people with addictions. Ken can expect improvement in his mood, fewer arguments with his wife, a decrease in stress, and an improved chance of smoking cessation if he follows a course of mindfulness training.[^]

This evidence of the mind exerting an unequivocal influence over physical matter directly contradicts a core belief of the biomedical model. Other long-held views of this model include: responsibility for treatment lies with the medical profession; the idea that there is no health spectrum – an individual is either healthy or ill; sick individuals are victims of biological changes beyond their control; disease stems either from uncontrollable internal physical changes or from external sources that invade the body, causing physical changes; and illness never has a psychological cause at its root (Gross, 2010).

Practitioners following the biomedical model would be keen to pinpoint the physical origin of Ken’s back pain. In order to specify both the cause of his pain and the form of treatment required to restore normal functioning, a variety of scans would be used: an X-Ray helps identify broken bones or other skeletal defects; computed tomography (CT) or magnetic resonance imaging (MRI) scans would help to analyze soft tissue or disc damage; and an electromyogram (EMG) would determine possible nerve or muscle damage (Derrer, 2014).[^]

If Ken’s back pain confounds medical science in the sense that it stems from no discernable physiological cause, a psychoanalytical approach could prove fruitful. As will be seen, the psychoanalytic conception of ‘neurotic illness’ blends the topics of stress and pain into a unified theory that can be used to cast light upon Ken’s psychological and somatic experiences.[^]

Freud (2010a) states that the human psyche is comprised of three mental agencies: the ‘id’; the ‘ego’; and the ‘superego’. The id is the oldest mental agency, concerned with the satisfaction of innate needs. Present from birth, the id operates on an unconscious level. The ego arises out of the id, controlling voluntary movement, deciding if and when the id instincts are satisfied, and focussing on self-preservation. As a result of the long period of childhood common to all humans, parental influences- and, later, the influence of teachers and respected public figures- leave an indelible imprint on the human psyche. This imprint is termed the superego.[^]

Since the ego has to satisfy the conflicting demands of id, superego, and reality, a weakening of the ego- as a result either of the insatiable demands of the id or the remorseless nature of an excessive superego- will lead to neurotic illness. A psychoanalyst aims to increase the ego’s self-knowledge in order to restore normal functioning. This is achieved through: information provided by the patient; the patient’s free associations; analysis of ‘parapraxes’ (slips of the tongue); and dream interpretation.[^]

The assurance of complete discretion on the part of the psychoanalyst, coupled with the patient’s willingness to elucidate all his observations relating to his illness, no matter how trivial, constitutes the ‘analytic pact’ (Freud, 2010a). Assuming that an analytic pact is established and respected between Ken and his psychoanalyst, a series of self-reports will be disclosed by Ken, providing sufficient material for a psychoanalytical diagnosis.[^]

The following account, gleaned from notes taken over several sessions, will be used for the sake of applying psychoanalytical theory to Ken’s purported back pain:

[Ken:] My back pain began six months ago… I got out of bed one morning and was in so much pain that I couldn’t go to work, I couldn’t carry on with my normal daily life… The pain is constant, all the way up my spine… My sick pay will soon run out and my wife and I have frequent arguments about money… She won’t let me go to the pub with my friends, and complains that I spend money on cigarettes… We’ve argued more since my back stopped me helping her with my mother-in-law… I used to work all day and spend my time off helping Carol care for Joan after her husband died a year ago… That was a real pain in the as-, pain in the neck… All my life I’ve carried this family… I don’t know how I did it so long… Where there’s a will-

[Psychoanalyst:] – there’s a relative?

[Ken, laughing uncontrollably:] You said it… I dreamt last night that we were going to Joan’s house to celebrate her winning the Health Lottery, and Carol made me sit with a barbell on my shoulders, saying that my back pain was related to bad posture and this would help. But when we got there, Joan was in a deep sleep and the ticket next to her bed was not a winning one! Next thing I knew, I was in the kitchen drinking with my old work friends – well, it seemed a shame to let the celebratory champagne go to waste. God alone knows where the barbell had disappeared to. Carol didn’t approve.[^]

From a psychoanalytical point of view, Ken’s back ‘pain’ can be interpreted as an ego compromise. Working all day and dedicating his spare time in service of Carol and Joan, Ken was at the mercy of his superego’s demand to act selflessly. Ken’s desire to spend time socialising, satisfying his drives toward alcohol and nicotine, was neglected over a period of six months. The clamour for gratification growing ever stronger, Ken’s ego compromised between the conflicting demands of id and superego in the form of neurotic illness: his back pain. This illness removed him from the twin burdens of employment and care assistance, reducing the demands of his superego and allowing limited id expression.[^]

The site of this neurotic illness- all the way up his spine- is unsurprising when the wording of Ken’s self-reports is taken into consideration. He states that he couldn’t ‘carry on’, that he has ‘carried‘ his family all his life, and describes having to care for Joan as a ‘pain in the as-, pain in the neck‘, descriptions which all relate to the vertebrae. The fact that he modifies the latter aforementioned description suggests conscious correction of a repressed (and, therefore, unconscious) hostility towards his mother-in-law. This irruption of unconscious ideas in speech is consistent with Freud’s (2002a) concept of parapraxes.[^]

Conforming to the expectations of society and the demands of his superego, Ken is unable to publicly articulate his wish for Joan’s death. Ken’s laughter at the psychoanalyst’s joke, with its implication of the financial benefits arising from such an event, is again demonstrative of ill will towards Joan, since Freud (2002b) suggests that laughter at tendentious jokes is a result of the liberation of psychical energy that was previously used to maintain an inhibition.[^]

Freud’s (2010b) concept of dream ‘condensation’, whereby separate trains of thought are represented by one item in the dream-work, is apparent in the end-of-dream celebration: Joan has ‘lost’ the Health Lottery (died), Ken drinks with his workmates (signifying a return to work and socialising activities) with no weight on his shoulders. Sensitively working through Ken’s dream in the analytical situation could help Ken to arrive ‘independently’ at the same conclusion as the psychoanalyst. Freud (2010a) stresses the importance of leading the patient to make the final, diagnostic leap, so as not to overwhelm the patient and provoke resistance.[^]

Through a discussion of the associations that Ken is able to make in relation to the manifest content of his dream (Joan is in a ‘deep sleep’ having failed to win the Health Lottery… Ken is able to drink with his work mates as Joan lies ‘sleeping’… Ken no longer has a weight on his shoulders at the dream’s conclusion… Carol doesn’t approve of Ken’s celebration), Ken might correctly identify the latent thought processes that provoked the dream, recognising his back pain as a neurotic illness stemming from his unwillingness to live a life of unremitting servitude.[^]

In conclusion, an application of the SRRS to Ken’s current circumstances categorises him as being in a moderate life crisis. This biopsychoscocial assessment of his level of stress suggests that he is at an increased risk of serious health deterioration. The cognitive practice of meditation, particularly mindfulness meditation, would help Ken during this difficult period. Literally changing the structure of the brain in favourable ways, it would reduce his level of stress, combat the depression that often accompanies chronic pain, help him gain better control of his emotions and therefore argue less frequently with his wife, reduce his dependence on nicotine, and could help to alleviate his back pain. The biomedical model admits no such influence of mind over physical matter, and a biomedical practitioner would send Ken for extensive scanning in order to localize the source of his pain. In the absence of an obvious physiological cause for Ken’s back pain, a psychoanalyst would surmise that Ken is suffering from a neurotic illness, stemming from a weakened ego’s inability to mediate the demands of id, superego, and reality.[^]