Perspectives of participants undergoing holographic memory resolution ® for chronic pain and associated biopsychosocial symptoms: A qualitative study

Abstract

Holographic Memory Resolution^® (HMR^®) is a mind-based intervention without somatic movement used to treat individuals with conditions including depression, anxiety, post-traumatic stress disorder, and chronic pain. No studies on the lived experiences of HMR exist. This phenomenological study explored the perspectives of a subset of participants undergoing HMR in a larger open-label trial for chronic pain, dysphoric memory, and accompanying biopsychosocial symptoms. Eighteen participants were interviewed one-month post-HMR regarding their lived experiences. Thematic analysis revealed HMR facilitated: (1) Awareness of Coping Strategies and personal creation of a safe place, visualization of color, and use of a metaphorical lockbox to store traumatic memories, (2) Reframing of the Memory, (3) Relief and Release of Pain, and (4) Life Integration, which involved getting their voice back and feeling empowered to strengthen connections with others. Findings highlight HMR as an impactful mind-based tool to control chronic pain and provide relief for associated biopsychosocial symptoms.

Introduction

Chronic pain affects 21% of adults throughout the United States, and 8% experience chronic pain that interferes with life or work activity (Nahin et al., 2023). Chronic pain is defined as persistent or recurring pain for greater than 3 months (Dydyk and Conermann, 2024; Treede et al., 2019). The definition has evolved over time, and the International Association for the Study of Pain (IASP) convened a task force in 2019 to further define chronic pain. They noted chronic pain as maladaptive, with unpredictable biology, that is not consistently characterized by tissue damage. Other mechanisms such as psychological abuse or social injury interplay and often exacerbate chronic pain (Raja et al., 2020). As a result of the task force’s work, an ICD-11 code for chronic pain was adopted (Treede et al., 2019).

It is widely recognized that depression, anxiety and post-traumatic stress often co-occur with chronic pain, but it is less understood what characteristics predispose individuals to these overlapping symptoms (Cohen et al., 2021). Many studies reveal the harmful effects of adverse childhood events (ACEs) on adult health both physically and emotionally could contribute to the chronic pain experience (Walton et al., 2021). An increasingly well-established relationship now exists between childhood abuse and neglect and chronic pain in adults, associated with biopsychosocial mechanisms of anxiety and depression (Tidmarsh et al., 2022; You et al., 2019). Emotional trauma can occur at any stage of the lifespan, including as a neonate or prior to the child developing the ability to verbally express the trauma (Opendak and Sullivan, 2019). The traumatic experience becomes associated with dysphoric emotions that can be frozen at a specific moment in time. As fragments of the memory associated with the trauma are stimulated, dysphoric emotion resurfaces within the body (Gregorowski and Seedat, 2013).

The body’s painful response to traumatic events is rooted in the adreno-corticotropic-hypothalamic-pituitary-limbic axis. This neurobiological mechanism floods the body with stress hormones and chemicals that disrupt the functioning of the immune system. In turn, the inflammatory response stimulated by the dysphoric emotion can manifest as pain within the body (Abdallah and Geha, 2017). Thus, treating chronic pain requires an approach that addresses the biopsychosocial root of the pain. A recent United States pain task force recommended a multidisciplinary approach to treat pain, by applying the biopsychosocial model to pain care which includes complementary and integrative health treatments as part of best practices (U.S. Department of Health and Human Services, 2020).

Holographic Memory Resolution^® (HMR^®) is a mind-based intervention without somatic movement used to treat individuals with a variety of conditions including depression, anxiety, post-traumatic stress disorder (PTSD), and chronic pain. Developed in the early 1990’s, HMR facilitates client-generated language and imagery via client-centered interviewing to change the emotional component of a dysphoric memory and improve biopsychosocial distress (Healing Dimensions ACC, 2022). Gaddy et al. conducted a feasibility trial to evaluate the use of HMR in individuals suffering from chronic pain and biopsychosocial symptoms. Results indicated significantly improved depression, anxiety, overall symptom burden, and PTSD symptoms in a sample of 60 participants. An in-depth description of HMR and full results of this trial are reported elsewhere (Gaddy et al., 2024).

The aim of this study was to explore qualitative perspectives of participants who received HMR for chronic pain and its accompanying biopsychosocial symptoms.

Materials and methods

Design and setting

This mixed-methods study commenced between October 2021 – July 2022 at two U.S. locations, a rural multispecialty clinic in the Northwest and a metropolitan clinic in the Southwest. The qualitative component of the study was conducted approximately 1 month following each participant’s HMR intervention. The study was approved by a central Institutional Review Board.

This study is reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007).

Participants and recruitment

A subset of participants recruited and enrolled in the landmark study comprised the sample for this qualitative study conducted between January - July 2022. Recruitment for the landmark study was conducted via community flyers and referrals (provider and patient-patient). Study recruitment was advertised on internal employee boards and preregistered on an independent, institutional registry. Prospective participants with matching diagnostic codes from recent encounters at both study sites were also mailed flyers. Eligibility for the landmark study included age 18 years or older and self-reported pain scores ≥4 on average via a 0–10 scale (10 being the worst possible pain) for at least 6 months and could be from any pain source including headaches. Individuals with thought disorders or suicidal ideation were excluded along with those taking mood altering substances that could potentially interfere with beta, alpha, and theta wave ranges (for example, cannabis, benzodiazepines, opioids, and lithium) as the intervention required participants to enter alpha/theta state. When individuals close their eyes, they go from beta to alpha to theta state; participants were not EEG monitored. Participants were required to be abstinent from alcohol 48 h prior to the first session and for the study duration. Consent for the qualitative interviews was included in the landmark study consent.

Participants for the qualitative study reported here were purposively selected to include a range of characteristics including the intervention site, sex, race, and healthcare versus non-healthcare employment, since many of the participants were healthcare workers.

Data collection

All interviews were conducted by one female BS-prepared research associate (YM) with 8 years’ experience in qualitative interviewing and analysis and who had been trained by experienced, published qualitative PhD researchers, including JMB who has training and expertise in qualitative research methods and qualitative data collection and analysis, as well as experience providing care to individuals with pain. The participants had no established relationship with the interviewer. The qualitative interviewer (YM) had experience in other mental health qualitative studies but no clinical training nor experience in HMR. She presented this to participants prior to the interview to inspire unbiased descriptions of their lived experience with HMR. The interviewer telephoned each purposively selected participant approximately 1 month after their final session and invited them to share their experiences with the HMR intervention in an open-ended interview; no other persons were present for the interview. Telephone interviews were conducted due to the geographically distanced participant sample and the constraints of the COVID-19 pandemic. A semi-structured interview guide with prompts and follow up questions was developed by JMB and YM based on other published phenomenological qualitative work; therefore, the interview guide was not pilot tested. Open-ended questions were asked; interviewer prompts further explored participant responses with relevant follow up or clarifying questions. Figure 1 includes the semi-structured qualitative interview guide. Field notes were taken during the interview to pursue follow-up questions. Telephone interviews were recorded, professionally transcribed verbatim and then validated to ensure accurate capture of responses. All interviews were deidentified for analysis. No repeat interviews were conducted, interview transcripts were not returned to participants for comment or correction, and no participant feedback was requested. Participants were offered a $10 gift card for interview completion.

Figure 1.

Semi-structured qualitative interview guide.

Qualitative analysis

Interviews were conducted until saturation was met, which was after the 18th interview; that is, no new data were identified that provided information for new codes or new emerging themes (Saunders et al., 2018). A phenomenological study was conducted to examine the lived experiences of patients with chronic pain who participated in HMR and to validate quantitative findings from a mixed methods companion study (Gaddy et al., 2023; Gale et al., 2013; Neubauer et al., 2019). The qualitative research team was comprised of five qualitative researchers, three of whom were trained and experienced in qualitative research methods (JMN, YM and WT) and two who were in training (BK and LAR). The qualitative researchers were naïve to the practice of HMR, that is, none had received nor studied HMR. The five research team members independently read through all transcripts once for initial impressions and understanding. As a group the research team identified general themes and initial coding ideas from the data. The researchers independently read through all transcripts again for additional understanding. Each transcript was coded by at least four of the five research team members in 12 group sessions using Atlas.ti software (ATLAS.ti Scientific Software Development GmbH, 2020). Codes were inductively developed from the transcripts, notes, and discussions through an iterative process; the coded data were grouped and regrouped in categories to develop a codebook; coding and category revisions to the codebook were made after each coding session via consensus of all five researchers. All transcripts were reviewed again and recoded by the research team according to the finalized codebook. The codes and categories were developed into final themes.

Results

Sample

Twenty-two of the 60 landmark trial participants were contacted for interviews; 18 responded and agreed to participate. Four were unable to schedule an interview or did not respond to the phone call (see Figure 2 for the consort flow diagram). Participants were primarily female (77.8%) with mean age 53.1 years (Table 1). Interviews lasted between 9 and 26 minutes.

Figure 2.

Holographic memory resolution consort flow diagram.

Table 1.

Participant characteristics (n = 18).

Characteristic	Participants n (%)
Age in years, mean	53.1
Sex at birth
Female	14 (77.8)
Male	4 (22.2)
Race
American Indian/Alaskan native	1 (6.6)
Asian	1 (6.6)
Caucasian	16 (88.9)
Ethnicity
Non-hispanic or non-latino	18 (100)
Marital status
Married or partnered	9 (50.0)
Single	6 (33.3)
Divorced	2 (11.1)
Widowed	1 (6.6)

Qualitative findings

Four major themes emerged from the data: (1) Awareness of Coping Strategies, (2) Reframing the Memory, (3) Release and Relief from Pain, and (4) Life Integration. Themes One and Four included subthemes; all themes are described below with relevant interview quotes identified by participant interview/quotation number.

Theme one: Awareness of coping strategies

Participants expressed the importance of using strategies taught through HMR to cope with their pain and traumatic experiences. They discussed how they practiced these strategies and applied them to their current life situation.

Safe place

Participants described finding or envisioning a metaphorical safe place to relax, meditate, and find relief from their presenting pain and stressors. Two participants described:

It’s like being in a cocoon, I guess...there’s nothing on the outside, it’s your own comfort place... For me it was being in the mountains [with] the water and the smell of the trees and the sky... (2:6)

I have a safe place that I go to...and that just has helped me a lot. (6:8)

Another participant described using the safe place for pain and daily stressors:

[HMR] gave me tools to find a safe place... [with] stressors throughout my day, or if I’m getting a headache, to find a safe place and to kind of meditate, relax... I’m not very good at describing it, but it works. (4:6)

Color

Some participants visualized a color that depicted their safe place or a painful or traumatic memory. Through the HMR process of discharging the dysphoric emotions attached to their traumatic memories, the color changed and transformed to a more positive color according to their unique perspective.

We worked on associating different colors and feelings with that safe place, and being able to visualize it and go there in your mind when you need to. (1:3)

One particular skill we did was assigning a color to a pain or a memory... As we worked through the memory the color changed, and then being able to metaphorically fill my body with the new color is something that I use every day now… I can close my eyes and I can visualize filling my body with the color that was associated with the relief from that memory, and really, it’s astounding, it does bring a sense of calm and it isn’t really associated with the original memory anymore, it’s just a tool that I can use. (3:4)

Lockbox

Participants described essentially creating a lockbox as a type of psychological barrier to avoid obsessive thinking about intrusive stressors.

One thing that I’ve started is kind of building a lockbox that you put things that you don’t have the bandwidth to deal with right now...you just kind of lock it away in there and save it for when you can, or if it’s not something productive, then you leave it in there…that’s been really helpful. (1:3)

[HMR] is more or less putting these bad memories, these painful things, in a lockbox, and you bury it somewhere...therefore, you can’t get it out, and I found that real easy, helpful to me, because a lot of mine come up usually during the night….if I wake up, I say nope, I can’t get to it, I’m not going to. It’s helped me get rid of some very painful memories. (6:2)

Theme two: Reframing the memory

The participants attributed the process of HMR to reframing the memory. They described how memories were reframed and dysphoric emotional tags were discharged. This allowed previously avoided or suppressed traumatic memories and the dysphoric emotions attached to those memories to be released. As two participants shared:

I uncovered things that I hadn’t thought about for decades. Very, very painful things, that I think I just had stuffed away... [The practitioner] said I didn’t have to go through that memory again, but I could rewrite it. So through that process, I have several really traumatic memories that are no longer traumatic for me, they’ve been reframed and I feel like at last...I’m able to let those memories go. (3:6)

[Recalling] things that were painful to remember... and then going through the process of kind of imagining a different scenario or a better scenario... I remember it being kind of intense and sort of, and painful, and then also it was very soothing to [kind of imagine...that color going through everything] … and just redoing it for my brain. Even though I still remember the original, I feel like it alleviated some of the pain, the intensity, but maybe even the meaning of the memory, the meaning I had created around it. (9:6)

Theme three: Relief and release of physical pain

Some participants described physical relief of pain that resulted from working through their dysphoric emotions associated with traumatic memories and emotional stressors. The examples below exemplify the inter-connectedness between the body and the mind.

One participant agreed to participate in HMR to address physical back pain but discovered emotional pain was presenting as physical pain. They presented at their first session in a wheelchair, and then became mobile after two sessions.

When I first started [HMR], I had a lot of pain, and I needed to use a wheelchair to get to the room where we had our sessions, and leave in the wheelchair, and by the time my last two sessions happened I was the one that was pushing the wheelchair. That is how much I had changed physically with pain and relief of pain to be able to do that, so I became physically better during the sessions, and it has remained better since. The pain has not come back. (5:12)

One participant sought HMR to help resolve chronic migraines and neck pain, which the participant attributed to their depression.

[HMR] showed me why I’m holding so much pain in my neck, it’s just because when I was younger I would hold my stress in my shoulders and my neck, and letting go of those emotional traumas has helped me relax, and with that it has helped my neck. (15:5)

One person described struggling emotionally with grief from the deaths of loved ones, causing all-consuming pain. HMR helped participants work through this grief to get emotionally back to where they were prior to the deaths.

It just felt like I had all this sadness that, emotionally I just couldn’t get a grasp on no matter how hard I tried… I didn’t realize that grief, depression or anxiety was pain. I didn’t think there was “emotional” pain, I only thought pain was “physical” pain. (11:4)

Other participants shared that their physical pain was alleviated as they were able to release their emotional pain.

I definitely had some physical pain, but I would say more from an emotional perspective probably…. Even though I still remember the original [pain], I feel like it alleviated some of the pain, the intensity. (9:0-9:7)

I just have a more positive outlook overall and I’m less emotionally taxed by dealing with a lot of anxiety… If I can put something away in that lockbox or if I can spend a minute in my happy place to kind of reset my attitude, then you know the whole day seems to go better (laughing), and when you are putting a positive kind of spin on the things that happen and not dwelling on the negative, then it rolls over onto pain management. (1:17)

Theme four: Life integration

Participants described the benefits of HMR cascading throughout their daily lives. HMR presented new ways to examine their feelings and express them to others.

Getting their voice back

There was consensus among participants that HMR helped them to feel empowered. Participants described having more of a voice in their life and being empowered to take ownership of their feelings.

There was one situation that arose with my husband that I discussed in HMR, and I was able to resolve that. I would say that I had more of my voice. I was empowered to speak up and say some things very directly that I had avoided before. I kind of re-imagined the precipitating event, recognized what I wanted to have said, and then I was able to actually go and do that. (9:10)

One participant described feeling empowered to set healthy relational boundaries, separating their feelings from other people’s feelings:

I feel safer because my feelings are really my feelings… I know now where [other people’s] feelings start or mine end. (8:6)

Other participants with experiences of empowerment further attributed HMR to feeling restored to who they were before the traumatic event occurred.

I was able to put those feelings in a different place in my mind and not feel like I was so full of just pure pain from these people not being in my life. And so, in that aspect, it changed my life. I feel like I am who I was before my dad passed away. (11:15–11:16).

Strengthening connections with others

The feeling of empowerment helped participants to change their perceptions of family relationships.

I was able to share with [my sister] the work that I had been doing and how I was able to reframe what was going on, and use the visualization and the color therapy, to not only treat my sister differently, but think about her differently and have a better perspective on the entire situation and how I had freedom to react in a different way. (3:9).

Discussion

This study reported qualitative perspectives of participants undergoing HMR who were enrolled in a larger open label trial for chronic pain and its accompanying psychosocial symptoms. Participants found HMR to be useful as they became Aware of Coping Strategies taught during the intervention, which involved finding a metaphorically Safe Place, the use of Color that was sometimes transformed to a more likable color, and the use of a Lockbox to keep traumatic memories at a distance, which prevented them from encroaching on their wellbeing. Secondly, participants were safely able to Reframe their traumatic memories, allowing dysphoric emotions to be released. Third, participants reported Release from Pain, as they recognized the bond that their dysphoric emotions had on their physical pain; both pain and function often improved with the use of HMR. Finally, participants described how HMR was Integrated into their lives and for some, gave them back a Voice, and for others, allowed them to strengthen personal Connections with others. Important to note is that of the 18 individuals interviewed, one participant stated that HMR was not helpful; therefore, like all therapies, it may not be effective for everyone.

The coping strategies used in this study such as identifying a safe place are not unique to HMR. There is consensus among mental health professionals that safety plays a central role in humans in that safety secures survival, facilitates restoration and exploration, and enables life integration of concepts with psychotherapy (Podolan and Gelo, 2023). In HMR, clients identify a safe place, which is not always a happy place, but rather a place where they feel safe. It has also been established that humans perceive colors with little variability, and yet color takes on a unique meaning to everyone (Zeki et al., 2020). This is attributed to the language assignation of color that is unique to each person’s emotional experience (Safran and Sanda, 2015). As a result, language assignation to the color corresponds to an emotional experience that is inimitable to that individual. HMR is unique in its integration of the client assigning a color to an emotional experience (Gaddy et al., 2024).

Reframing, defined as introducing new viewpoints or stimulating other viewpoints to explain a given situation (Luciani and Convertini, 2024), was another major theme as it facilitated discharging dysphoric emotions and reframing traumatic events to contribute to healing for the participant. The person’s attachment to the traumatic event is tied to the affective charge which activates the fight-flight-freeze cortisol reaction. Reframing in HMR assists the person in reducing pain not by addressing the historicity but by reducing the emotional charge associated with encoding of the trauma.

In persons with chronic pain, each has a unique pain experience, as defined by IASP, in which personal and emotional perspectives are interwoven into the chronic pain cycle (Raja et al., 2020). In some types of therapy, the therapist reframes context for the person to suggest the physical pain is related to emotional distress (Luciani and Convertini, 2024). In HMR, however, persons reframe their pain situation themselves through self-discovery. Once they feel safe and use the other coping strategies within HMR, they are able to see how an earlier traumatic experience trapped them emotionally and contributed to their pain experience.

Another therapy that reframes memory is eye movement desensitization and reprocessing (EMDR) therapy. The goal of EMDR is to reprocess memories either partially or completely to treat a current clinical condition (Laliotis et al., 2021). A variety of conditions have shown a positive improvement with EMDR including somatoform disorders, mood disorders, anxiety disorders, pain, neurodegenerative disorders, mental disorders of childhood and adolescence, and sleep (Scelles and Bulnes, 2021). Its use in chronic pain is promising, especially with high pain levels (Suárez et al., 2020; Vock et al., 2024). EMDR is different from HMR in many ways. With EMDR the individual is aware of the reason for the anxiety; therefore, reflecting on a memory is necessary to conduct treatment. Participant memory of childhood trauma is not a part of EMDR, and EMDR does not use physical symptoms as an entry point into treatment (Hase, 2021). To contrast, in HMR the dysphoric event is often unknown or trapped in the past, and the individual uncovers the trauma in a safe environment so they can separate it from the physical pain.

Release from physical pain was an important finding in this study. Abundant literature exists on the use of cognitive-behavioral therapy and other mind-based therapies in the management of chronic pain, and yet systematic reviews report only small improvements (Alaiti et al., 2022; Skelly et al., 2020). Participants in this study perceived the bi-directional mind-body relationship between emotional and physical pain, and many reported improvements in physical pain and function. Through HMR, participants learned that emotional pain manifested as physical pain, and conversely, physical pain contributed to emotional distress. Participants described learning their physical pain was rooted in dysphoric memories or emotionally intense experiences. As a result, they identified their physical pain was connected to their emotional pain, allowing them to focus on emotionally-based coping strategies. Results are promising, and personal perspectives from participants in this study are compelling.

Finally, participants were able to use what they learned from HMR and Integrate concepts into their lives, which makes sense physiologically in terms of stress hormones. The relationships between stress, homeostasis, and their impact on the brain and body are well known. Stress engages the sympathetic medullary system (SAM), thereby triggering the hypothalamic-pituitary-adrenal (HPA) axis to release cortisol, which can lead to irreversible physiological damage and negative mental health outcomes (James et al., 2023). In addition, as dysphoric emotions increase adrenaline and cortisol, they can hijack the individual’s cognition and contribute to irrational thoughts. Chronic stress, especially that experienced during childhood and adolescence, can have a deleterious effect on cognition (James et al., 2023). HMR combines coping strategies and reframing in a safe environment, allowing the individual to self-identify the traumatic memory that is contributing to the stress and chronic pain, and possibly neutralize the stress response. This could eventually allow the individual to become more regulated in their thought processes and apply HMR concepts into their daily life including personal empowerment, getting their voice back, and strengthening relationships with others.

In summary, while other therapies include some components of HMR, it is differentiated in its targeted, client-centered safety approach that taps into the subconscious memory. As the individual identifies the pain, they often recall a traumatic event and remember the context, time, and circumstances of the event. They then recognize dysphoric emotions related to the experience and subsequently reframe the event and discharge dysphoric emotions. The safety-centered approach allows clients to recall previously unrecognized subconscious memories. The goal is to not only intervene on historical emotional trauma that can present as chronic physical or emotional pain, but also to improve self-management of current traumatic emotional stressors. In our study, many participants learned to interrupt previously programmed traumatic stress reactions, thereby avoiding retriggering dysphoric emotions, allowing them to maintain calming effects even in the face of new daily life stressors.

Limitations

The authors note some study limitations. First, the sample was homogenous and primarily female and Caucasian; results may not be transferable to diverse populations. Secondly, long-term follow-up was lacking; it is unknown how well the benefits of the treatment have been sustained. Finally, the HMR protocol varied as sessions were scheduled according to the participants’ schedules. Those attending treatment from out of state received HMR within a condensed week, and this subgroup was not large enough to determine whether this impacted their response. However, both groups participated in interviews, and both perceived significant benefits.

Opportunities for research are plentiful. Future studies could help define the optimal schedule of HMR and number of sessions needed to sustain positive results. Our clinical experience reveals former participants requested an HMR refresher session to reinforce coping strategies learned, and practitioners have conducted these sessions outside of the clinical trial. Their return for these sessions does give insight into the value they feel from HMR. Most importantly, a randomized controlled trial is essential to fully measure the impact of HMR on chronic pain, and more qualitative work longitudinally would also shed light on the benefits of HMR.

Conclusions

To our knowledge, this is only the second HMR study reported in the literature aside from the landmark trial. The positive results discussed quantitively, and now the qualitative perspectives illustrated in this study, shed light on the potential benefits of HMR for chronic pain. In some cases, participants reported decreased physical pain, and in other cases, participants experienced improvement in physical and emotional functioning. HMR is another mind-based tool in the armamentarium to control chronic pain and has potential for positive impact. Further studies are needed to support HMR for chronic pain and for other conditions in which dysphoric emotions and traumatic memories impact wellness.