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Talking pain – seeking validation: Social interaction in pain


ResearchBlogging.org

While we might laugh about the so-called typical ‘I will fix it’ response of some men when their partners talk about problems (when what the woman really wants is a hug), it seems that much of our research into pain behaviour, particularly verbal expressions of pain, has missed something. I’m not a major reader of relationship literature, but I do read a lot about pain behaviour, and something I’ve noticed is the almost exclusive orientation toward the operant conditioning model when it comes to expressing pain in a social setting.

In operant model of pain behaviour, these behaviours are enacted to communicate to others. Responses to those behaviours may reinforce or punish those behaviours – and there is a good deal of evidence to support this model. It seems to be supported by evolutionary theory in that pain behaviours elicit resources from others, and serve to obtain help. One focus of therapy traditionally is to reduce the number of pain behaviours, in order to reduce the identification of the individual with helplessness or the sick role.

Cano and Williams, in this paper, suggest an alternative view of particularly verbal utterances about pain in relationships – they suggest considering an interpersonal process model of intimacy.

In this model, the things we say that disclose emotional content serve to foster and strengthen intimacy if they are met with empathy and validation. Cano and Williams state: ‘verbal communications about one’s thoughts and feelings about pain, may entail attempts to disclose emotion, recruit emotional support, and build intimacy.’
They go on to say ‘An empathic and concerned response from the partner may also contribute to intimacy. Emotional validation, including empathic responses, enhances the emotion regulation process for both partners because such responses allow each person to process stressful or aversive stimuli.’

In other words, if the partner doesn’t respond empathically, this is usually interpreted to mean rejection and disregard for the partner and usually negatively affects emotion regulation, but when the partner does respond with empathy, the relationship is stronger and more intimate.

What might this mean in therapy?
Well, up until now, operant theory has supported the idea of reducing or minimising pain behaviour, including talking about pain or eliciting emotional or practical support from a partner. This process model suggests that some types of communication may serve to improve the relationship. Validation of emotional content by the partner has in one study correlated negatively with punishing spouse responses, while invalidation correlated positively with punishing spouse responses – and the emotional content (rather than the words) made the major difference between the two types of response (Cano, Barterian & Heller, 2008).

This suggests that a simple ‘let’s eliminate the negative’ may not benefit the relationship. Strong relationships enhance coping, and relationships are strengthened when what one spouse is seeking is matched by the other spouse.

Empathy, caring, concern, and closeness may be desired when a person with pain discloses emotion, not ‘‘expertise” or problem-solving, which could signal invalidation of emotion.

This may mean clinicians helping partners (and families) learn to communicate more effectively – and something that has become very apparent to me is how poorly we as humans can communicate about pain, especially when it comes to setting boundaries, asking for help, or seeking emotional support. It takes a good deal of skill to express what it is that we really want, and to clarify or restate what we want if initially we fail to get it.

Assertiveness has a bad rap very often – it can mean all sorts of strident and aggressive ways to ‘get the point across’, when in fact it is simply about being respectful of each other and oneself.  A good number of factors can get in the way of effective communication such as long-standing scripts ‘I should be able to cope alone’, ‘I must not disagree’, ‘I don’t have the right to ask’, as well as limited skills in regulating emotions when the message isn’t received in the way it was hoped.

At the very least, something we can do as clinicians is listen to the people we are working with, and while we don’t want to reinforce helplessness (which, by the way, we will do if we offer ‘solutions’ rather than simply acknowledging the situation), we can help people feel more comfortable with difficult emotions if we ourselves can be mindful and allow ourselves to ‘sit with’ those very emotions.  By modelling effective communication ourselves, we can help validate and strengthen our relationship with the person, while not necessarily attempting to ‘fix’ or ‘reduce’ the distress.  Then we can turn the conversation to things that are good, achieved and helping the person move on.

Some brief pointers as to how:

  • ask about what the person has been up to rather than how their pain is
  • if they say they’ve had a hard time, acknowledge this ‘It’s been a real challenge to get here’.  Then pause – and add ‘it’s really great to see you here, how did you manage it’ as a way to move on towards positive coping
  • when they foresee snags or problems, acknowledge that it’s not easy to do what we’re asking.  Then ask what they think is the ‘next best step’ towards doing what you’re currently working on.
  • respond to the emotional content by empathic reflection, rather than getting caught up in how to solve the practical problem – that’s probably not what the person is asking for, and even if it is, empathy can go a long way towards helping the person accept that you are there for them rather than to ‘fix’ them

The paper by Cano and Williams goes on to discuss appropriate research strategies that might help us understand more about interactions in couples.  It’s difficult for me to read this without adding ‘if you can get the couple to come in!’ because so often people seem to think that they ‘should’ cope with ongoing pain alone.  It would be great to see far more emphasis on people and their relationships and social context in the next ‘new wave’ of chronic pain management.

Cano, A., & Williams, A. (2010). Social interaction in pain: Reinforcing pain behaviors or building intimacy? Pain, 149 (1), 9-11 DOI: 10.1016/j.pain.2009.10.010

Cano A, Barterian JA, Heller JB. Empathic and nonempathic interaction in
chronic pain couples. Clin J Pain 2008:678–84

6 comments

  1. As a sufferer of chronic pain, I’ve spent several years trying to cover things up, in a sense, faking it till making it, and in public focusing on positive things. It seems to be in line with what this website is talking about. However, it has led to two issues.

    1. Having done the inverse, I have let myself be vulnerable and show pain to those I am most intimate with. This has led to those closest to me being most worn out from my vulnerabilities. I see your recommendations as good information for them.

    2. Having tried to stay positive in the face of adversity, most people I encounter have no inkling of my disability, or the constant pain I am in. I am not asking for a pity party, but how am I to ever get the sort of reinforcement wherein I am rewarded for persevering through adversity, if no one knows what is happening to me?

    Some days, I just spend in depression and do not go out, since the pain is so bad. So few people know what I am going through, and those that do often do not have the skills necessary to cope in a way that is productive…

    Just some thoughts, some things that may need guidance for those of us on the receiving end.

    Darin

    1. Hi Darin, while I can’t make recommendations specifically for your situation, I can empathise with your situation, it sounds really difficult.
      I hope that the information I’m putting forward on my blog encourages people to be authentic, honest and respectful about their own experience, but at the same time, acknowledge that as individuals, whether clinicians or people with chronic pain, we don’t have all the answers. This means that sometimes when we have done what we know how to do, and it’s still not working out well, then we might need to seek more help from somewhere else. I hope this applies to everyone! And I apply this to myself as a clinician and someone who also has chronic pain. I’m glad to hear that the suggestions I’ve made for people who are hearing you talk about your pain make sense.
      I can understand that ‘putting on a happy face’ can feel really fake – and it does hide your problems from others. I don’t know that there is a one-size-fits-all answer to this. For me it has been a process of recognising that my pain is my problem, and is part of who I am – so accepting that there are times when I need to slow down or change what I do has become ‘normal’ for me. There are times too when I want extra help or acknowledgement for having coped with a difficult time, and I’ve decided it’s best for me to ask for that rather than wait for someone to ‘get it’!! But by focusing on what is good, works well, is positive I find I look much less at what isn’t working, and I don’t look to others for that acknowledgement.
      I’ll dig out some readings on relationships and communication and write some more on this very important topic.

  2. Excellent post.
    The social is pretty much ignored by most, even htose who espouse the biopsychosocial view of chronic pain.

    What I like most is that these researchers didn’t get stuck in the dogma of a strongly held view.
    Disclosure is so important. Losing one’s voice about pain increases isolation, and helplessness.
    Very few things, or maybe none, in recovery from chronic pain involve black/white answers. Just as finding the right amount of distraction AND the right amount of pain monitoring is key to recovery, the same likely holds true for everything, including finding the right amount, style, process,.. of communicating about one’s pain.
    Neil

    1. Hi Neil, I agree! For so long I’ve tried to find papers that discuss the social/cultural/political aspects of pain and it’s a very difficult job indeed! The manner in which these two authors go about reviewing the prevailing model is what I’d consider a truly scientific approach – let’s see whether the predictions of that model hold true, and whether there may be another hypothesis that explains more, has fewer assumptions, ‘works’ better, and in this case, provides for more options in management.

      It’s no easy task to study pain behaviour and relationships. I’ve seen fewer and fewer couples attend pain assessments – the attitude from some couples is that pain is an individual affair, and it’s ‘up to the person to learn how to deal with it’. This is even supported in many insurance models where the costs associated with including family members in pain management are not covered. Maybe it reflects our eurocentric view of the world in which ‘individual responsibility’ is valued while family, whanau or community is less important.

      It’s also difficult to study social aspects of pain because it’s not easily reduced to numbers or simple experiments – there are so many variables that influence pain behaviour and communication. This can mean when studying these aspects, qualitative methods need to be used, and in many quarters, qualitative methodologies are seen as weak.

      Every day as clinicians we hear individuals tell their stories about how their lives and those of the people close to them are affected by pain. We don’t nearly as often hear the stories directly from the family members of the person with pain. As a social species it does seem kind of odd to see the social relegated to last place when studying pain.

      Final point: our New Zealand ACC system (insurer for personal injury caused by accident) has a Comprehensive Pain Assessment that consists of three parts – biomedical, psychosocial and functional. Not so long ago, the ‘psychosocial’ component was amended to read ‘psychological’ – what does this say about the current attitude towards considering the ‘social’ aspects of pain?

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