“The social” – a brief look at family

Our most important relationships, the ones we learn most from, probably occur in families (Bowlby, 1978). As kids, even before we begin to speak, we observe our family members – and there’s reasonable evidence showing that how well these early relationships develop influences our experience of pain and how we express it.

I had the occasion to read a little about adolescent and children’s pain, and the influence of parents on young people as they grow up. There’s a great deal of research interest in children’s pain because children with persistent pain grow up to be adults – usually also with persistent pain. And good evidence that parents with persistent pain can, through mechanisms including depression and catastrophising, influence pain and disability in their children (Brown et al., 2022; Brown et al., 2021).

The research is fascinating. Some studies investigating predictors of chronic pain in children, some investigating disability – and a small number of studies looking at what we can do to help parents cope with the pain their children are experiencing. Not many studies (54 in a 2021 scoping review – see Lee et al., 2021). And sooooo many studies focusing exclusively, or close to, the influence of Mothers on children. Where’s Dad? Can I repeat that: where’s Dad?

More recent studies indicate the number of Fathers and Mothers – yay, we’re getting an idea of how many are recruited into these studies – and yet overwhelmingly, it’s Mothers who form the majority of participants. I wonder what effect having a Dad with chronic pain might have on a kid? And it’s only recently that oh darn animal models actually include females… it’s those pesky hormones dammit!

Turning to the next most important relationship, apart from parents, there’s a good deal of research looking at partners. Again, there exists a bias towards heterosexual couples, so we’re a little biased here. There is a wealth of material to review in this area of pain, with some brilliant research designs such as repeated interviews over 18 months, followed by 22 days of repeated daily measures (eg Martire et al., 2019); investigating people with pain problems as common as knee osteoarthritis and chronic low back pain; and examining relationships between things like sleep, caregiving burden, catastrophising, relationship satisfaction, agreement about pain intensity between partners, beliefs and perceptions about pain on interactions, anger, stress. HEAPS of fascinating research to delve into.

And yet, how many clinicians, and programmes, routinely include partners? How accessible are treatment sessions for couples to attend? Who, in a pain management team consisting of largely physiotherapy plus a dollop of psychology, looks after this aspect of living with persistent pain? Waaay back in the day, like the mid-2010s, the facility I worked in had a social worker with experience in family systems and relationships – but there are few social workers working in pain management in New Zealand/Aotearoa, and unless something has changed that I don’t know about, our national insurer doesn’t recognise the value of social workers (and, for that matter, the need to include partners in therapy for chronic pain).

When I review the many studies of this part of “the social” and compare the findings from these investigations against current clinical practice, I see an enormous knowledge and skill gap. If the questions we ask people with pain about their relationship are “how is your relationship with your partner?” we’re probably going to hear “oh they’re really supportive” or “I don’t let them know how I am”. Without adequate knowledge about the kinds of factors that negatively influence the partner’s response to the person with pain we’re likely to be oblivious to the risk of partner abuse (56% of people in this study reported past partner abuse, while 29% of the respondents had been abused in the previous year – Craner et al., 2020); we might not be aware that spouses with poor sleep because their partner was sore, were more likely to be angry (Marini, et al., 2020); that 52% of partners without pain reported high-to-severe burden of having to do more both at work and home because their partner was sore (Suso-Ribera et al., 2020) – or that if a spouse without pain did not have confidence in the pain management of their partner with pain, they were more negative (Nah et al., 2020) or that when a spouse without pain thought their partner’s pain “was a mystery” they were more critical and made more invalidating responses (Burns et al., 2019).

You see, while “the social” is complex, difficult to research, and very broad – ranging from employment status, occupation, educational status, ethnicity, culture, gender, sex – it also includes the very intimate and formative relationships we have with our family. In New Zealand/Aotearoa, with our emphasis on Te Whare Tapa Whā as a model of health and for chronic pain, where relationships with whanau are vital, isn’t it time we addressed this lack?

Bowlby, J. (1978). Attachment theory and its therapeutic implications. Adolescent Psychiatry, 6, 5-33.

Brown, D. T., Claus, B. B., Konning, A., & Wager, J. (2022, Mar). Unified multifactorial model of parental factors in community-based pediatric chronic pain. Journal of Pediatric Psychology, 47(2), 121-131. https://doi.org/doi: 10.1093/jpepsy/jsab085

Brown, D., Rosenthal, N., Konning, A., & Wager, J. (2021, Feb). Intergenerational transmission of chronic pain-related disability: The explanatory effects of depressive symptoms. Pain, 162(2), 653-662. https://doi.org/10.1097/j.pain.0000000000002066

Burns, J. W., Post, K. M., Smith, D. A., Porter, L. S., Buvanendran, A., Fras, A. M., & Keefe, F. J. (2019, Oct). Spouse and patient beliefs and perceptions about chronic pain: Effects on couple interactions and patient pain behavior. The Journal of Pain, 20(10), 1176-1186. https://doi.org/https://doi.org/10.1016/j.jpain.2019.04.001

Craner, J. R., Lake, E. S., Bancroft, K. E., & Hanson, K. M. (2020, Nov). Partner abuse among treatment-seeking individuals with chronic pain: Prevalence, characteristics, and association with pain-related outcomes. Pain Medicine, 21(11), 2789-2798. https://doi.org/10.1093/pm/pnaa126

Donnelly, T. J., Palermo, T. M., & Newton-John, T. R. O. (2020, Jul). Parent cognitive, behavioural, and affective factors and their relation to child pain and functioning in pediatric chronic pain: a systematic review and meta-analysis. Pain, 161(7), 1401-1419. https://doi.org/10.1097/j.pain.0000000000001833

Lee, S., Dick, B. D., Jordan, A., & McMurtry, C. (2021, Nov). Psychological interventions for parents of youth with chronic pain: A scoping review. The Clinical Journal of Pain, 37(11), 825-844. https://doi.org/10.1097/AJP.0000000000000977

Marini, C. M., Martire, L. M., Jones, D. R., Zhaoyang, R., & Buxton, O. M. (2020, Jun). Daily links between sleep and anger among spouses of chronic pain patients. The Journals of Gerontology: Series B: Psychological Sciences and Social Sciences, 75(5), 927-936. https://doi.org/10.1093/geronb/gby111

Martire, L. M., Zhaoyang, R., Marini, C. M., Nah, S., & Darnall, B. D. (2019). Daily and bidirectional linkages between pain catastrophizing and spouse responses. Pain, 160(12), 2841-2847. https://doi.org/10.1097/j.pain.0000000000001673

Meredith, P., Ownsworth, T., & Strong, J. (2008, Mar). A review of the evidence linking adult attachment theory and chronic pain: presenting a conceptual model. Clinical Psychology Review, 28(3), 407-429.

Nah, S., Martire, L. M., & Zhaoyang, R. (2020, Oct). Perceived patient pain and spousal caregivers’ negative affect: The moderating role of spouse confidence in patients’ pain management. Journal of Aging and Health, 32(9), 1282-1290. https://doi.org/10.1177/0898264320919631

Suso-Ribera, C., Yakobov, E., Carriere, J. S., & Garcia-Palacios, A. (2020, Oct). The impact of chronic pain on patients and spouses: Consequences on occupational status, distribution of household chores and care-giving burden. European Journal of Pain, 24(9), 1730-1740. https://doi.org/10.1002/ejp.1616

Family and friends matter

I’m going back to my series on behavioural approaches to pain management (it’s a slow process!). For the first two go here and here. Now I want to talk about the impact of family and friends on people living with pain.

The people we live with are so influential on what we do and believe about pain. It’s our parents who first taught us the relationship between the word “pain” and the experience we know as pain. It’s our parents and family who responded when we cried, who kissed it better (or not), who told us to “harden up” (or not), who took us to the doctor (or not), who showed us, through their own behaviour, how to “do pain.”

There’s a good deal of research investigating the impact of friends and family on pain behaviour (remember the distinction I make between pain-the-experience and pain behaviour or what we do when we’re sore? click). For instance, a systematic review by Snippen, de Vries, van der Burg-Vermeulen, Hagedoorn and Brouwer (2019) looked at people with chronic diseases, and the attitudes and beliefs of significant others. They found that “positive and encouraging attitudes regarding work participation, encouragement and motivating behaviour and open communication with patients” were facilitators for work participation while “positive attitudes towards sickness absence and advise, encouragement or pressure to refrain from work” were barriers to returning to work.

In another study, Burns, Post, Smith, Porter and colleagues (2019) observed spouse dyads behaviour after arguing then the person with pain undergoing a pain induction task. Spouses that believed that the patient’s pain was a mystery were significantly more likely to be perceived by the patient as giving critical/invalidating responses toward the patient during the discussion; while spouse perceptions that the patient’s pain was a mystery were related to internal and negative attributions spouses made while observing patients display pain behaviors during the structured pain behavior task (p. 1176).

In another study, this one a daily diary study with people living with osteoarthritis in their knee, found that on days when the person with pain reported more thinking the worst, their spouses were more unhappy during the day. And on the days when the partner was more irritated with the person living with pain, that person reported more thinking the worst the next morning. The link? The people with pain who were thinking the worst were also more grumpy through the day, and this was rubbing off on their partner. (Martier, Zhaoyang, Marini, Nah & Darnell, 2019).

Makes sense, doesn’t it? That when we see our loved one demonstrate that they’re sore, and they’re grumpy – and if we’re not sure they’re for real – we might be less supportive as partners than if we think their pain is for real. And over time the pattern of being sympathetic might wear thin – in fact, Chris Main (psychologist) describes a pattern of initial solicitous behaviour (the “there, there dear, I’ll fetch you a cup of tea”), then resentment (“surely you’ve recovered now?”), then anger and punitive behaviour (ignoring the person, getting irritated with them), but then feeling guilty about this (“OMG I know, it’s not your fault and I’ve been so mean”), returning to being solicitous – until the next time the partner feels fed up.

What does this mean for a behavioural approach?

Well, it’s not surprising that if one of the partners thinks the other “should be well now”, they’re likely to be unsympathetic as we begin changing the person’s behaviour. Often we’re attempting to help someone be consistent with their daily activities, and this can often begin by reducing how much should be attempted so the person can “do no more on a good day, and do no less on a bad day.”

And if the partner is really worried about the person with pain, and afraid that doing more is going to increase pain and prolong disability, it’s also not surprising that the partner is likely to be worried about us asking the person to do things differently (especially exercise!).

And don’t forget that during this time, both partners are probably trying to keep some semblance of normal going. They still have the usual household tasks to get done, to pay the bills, to get the kids to and from school, to keep in touch with extended family and friends and so on.

It’s stressful. And we add to the burden when we ask the person to do something different, whether this be doing exercises, using a mindfulness or relaxation technique, perhaps go to various appointments all around town…and if we don’t include the impact of what we expect on the partner, we’re possibly not going to have “the team” on board with the rehabilitation programme.

The very best option is to ask the person’s partner to come in to at least one of our treatment sessions, so we can spend some time talking about what we’re asking the person with pain to do, and getting an indication from the partner about their willingness to follow the programme. The next best option is to write the programme down, and include “things family can do to help” – listing the kinds of things family and friends can do (and what they should avoid doing).

You see, people we see for help never live in a vacuum. They always have a context of friends, family, home, responsibilities, expectations from them, expectations for the work we do. Forgetting about this and expecting a good result fails to recognise the embedded nature of life. Contextual factors are important, no person is an island.

Burns, J. W., Post, K. M., Smith, D. A., Porter, L. S., Buvanendran, A., Fras, A. M., & Keefe, F. J. (2019). Spouse and patient beliefs and perceptions about chronic pain: effects on couple interactions and patient pain behavior. The Journal of Pain, 20(10), 1176-1186.

Martire, L. M., Zhaoyang, R., Marini, C. M., Nah, S., & Darnall, B. D. (2019). Daily and bidirectional linkages between pain catastrophizing and spouse responses. Pain, 160(12), 2841.

Snippen, N. C., de Vries, H. J., van der Burg-Vermeulen, S. J., Hagedoorn, M., & Brouwer, S. (2019). Influence of significant others on work participation of individuals with chronic diseases: a systematic review. BMJ Open, 9(1), e021742. doi: 10.1136/bmjopen-2018-021742