spouses

Musing on “the social” in pain rehabilitation


What do we think about when we consider “the social” as a factor in pain rehabilitation? Do we think of socioeconomic status? Maybe employment status? Perhaps societal attitudes towards pain and recovery? Do we ask if the person has someone they trust in their life? Maybe we even discuss how a relationship is going, whether the person sees their friends and family?

Have we forgotten that possibly the most potent influences on pain behaviour are the people around the person we’re seeing?

It will be no surprise to anyone reading my work over the past 10 or more years (yes, really! it HAS been that long!) that I love reading older pain theorists, researchers and historic approaches to pain. We can learn so much from the pioneers in this area – people like Waddell, Loeser, Main, and Fordyce. While some of the details of theoretical advances may have been superseded, the ideas they promoted remain as potent as ever.

Fordyce, in particular, attracts my interest. Bill Fordyce was a clinical psychologist who pioneered behavioural approaches to reducing disability for people living with persistent pain. Rather than offering repeated surgeries or medications, Fordyce looked to how what we do (behaviour) is reinforced by people and situations around us. From his work, we learned about activity pacing (decoupling the relationship between activity and pain by adopting a quota-based approach to activity), time contingent medication (using medications according to a time schedule rather than “as needed”), and we learned a great deal about how other people’s responses to an individual’s behaviour could inadvertently increase or reduce the frequency of that behaviour.

Why is this important? Well, aside from the way pain behaviours develop from childhood (crying? Mama will cuddle you. Want something? Cry – and Mama will cuddle you), responses from a person’s partner will likely influence both verbal complaints and physical movements (pain behaviours) such as grimacing, bracing and guarding, and in surprising ways. In fact, in an electronic diary study where people with chronic low back pain and their partners (who had no pain) were asked to record responses five times a day for 14 days, researchers found that when a spouse observed their partner’s pain behaviour at one time, they’d be more likely to be critical or hostile towards that person at a later time. If the spouses believed that the person with pain was “trying to influence their feelings” at the first observation, their responses were more likely to be critical or hostile – and it was the attributions made by partners that mediated between pain behaviours and the subsequent criticism leveled at the person (Burns, Gerhart, Post, Smith, Porter, Buvanendran, et al., 2018).

The so what question is sure to come up for some people. Why do we care? It’s not like we can do anything about this, is it? Well… you know me – writing about this stuff isn’t just for fun! The first thing to know is that if something is influencing a person’s behaviour and especially their disability, rehabilitation professionals should be aware of it. Relationship “stuff” is part and parcel of rehabilitation because it’s part of the person’s context. Secondly, it’s not about judging whether this is good, bad or indifferent – it’s about recognising an influence on the person and considering how we might support that person to respond in a way that enhances their recovery. Finally, we need to recognise how behavioural expressions and responses to them influence us. An earlier study by the same researcher (Burns, Higdon, Mullen, Lansky and Wei, 1999) found that expressions of anger and depression by the person influenced the therapeutic alliance with the health professional and this was perceived both by the person and his or her therapist.

Should we, can we do anything to help?

First, to the “should.” Whether we like it or not, these influences are occurring – so they are having an effect anyway, and both on us and the person we’re working with. We are also constantly influencing our patients because we’re inherently social animals. It’s just that we’re probably oblivious to our influence, and consequently are likely to react rather than respond. While I don’t advocate clinicians who haven’t undertaken specific training in relationship work to begin “therapy”, there are some basic things we can and I think, should, do. We should because we’re already influencing anyway – so let’s do something helpful.

The second is, can we do anything to help? Well, yes – because as I’ve said above, we’re influencing anyway. Everything we say and do will likely influence the person we’re seeing and possibly their partner and family.

The first thing we can do is let the person we’re working with know that what they say and do influences the people around them. This might be a revelation to some! We can let them know that this communication is not deliberate, and neither is the interpretation by the partner. It’s part of being human and social.

The next thing we do is offer some information to the person and their partner. Preferably written or video – something that the person can share with their partner. This information should be about the nature of persistent pain (in particular), and that a person’s pain behaviour is unintentional. In other words, that what a person does is explicitly not intended to make the partner “feel bad for them” (ie garner sympathy – in fact, quite often it’s the opposite of what the person really wants!); that they’re not intentionally wanting to avoid doing something; and finally, that they’re not intending to “give in to the pain too easily”.

Another thing we can share with the person and their partner is that because pain is personal and internal, openly communicating about what’s going on is important. None of us are good at mind-reading! The responsibility for obtaining help has to be with the person living with pain, not the person who is observing. This might mean the person with pain needs to think about what they want their partner to do. Often it’s nothing – no fuss, no molly-coddling (been dying to use that word for a while!). But if the person does want something, it’s really good to be specific and clear: “I can’t lift this, can you give me a hand”. This doesn’t mean taking over, BTW!

Where possible, I think it would be great to ask partners and family to be involved in rehabilitation. I wonder at insurers who don’t allow partners or family/whanau to be involved in rehabilitation. I think it’s detrimental – because increasingly, we know that the social context of daily life is such an important influence on disability. Asking partners to be part of rehabilitation might be a bit easier under “lockdown” conditions in many countries at the moment, but even without these conditions, perhaps recording selected parts of sessions, even having a meeting (virtual or face-to-face) might allow partners to be part of their loved one’s rehabilitation journey.

Burns, J. W., Gerhart, J., Post, K. M., Smith, D. A., Porter, L. S., Buvanendran, A., . . . Keefe, F. J. (2018). Spouse Criticism/Hostility Toward Partners With Chronic Pain: The Role of Spouse Attributions for Patient Control Over Pain Behaviors. J Pain, 19(11), 1308-1317. doi: 10.1016/j.jpain.2018.05.007

Burns, J. W., Higdon, L. J., Mullen, J. T., Lansky, D., & Wei, J. M. (1999). Relationships among patient hostility, anger expression, depression, and the working alliance in a work hardening program. Annals of Behavioral Medicine, 21(1), 77-82.

Why can he go surfing but can’t do the vacuuming?


ResearchBlogging.org

Social contract theory is a theory drawn from evolutionary psychology – a ‘cheater detection’ system if you like. Following on from yesterdays post about detecting faking in pain, this study examines the judgements observers (in this case, friends and relatives of people with pain) in a study where four vignettes were presented. Each vignette varied in terms of four cues: the person continuing or stopping liked tasks, continuing or stopping disliked tasks, the availability of medical evidence, and the pain intensity as rated by the person.

Many variables have been studied with respect to how accurately observers judge another person’s pain – attractiveness, gender, ethnicity, social class, as well as the context (return to work or post-surgical), and the characteristics of the observer (parent, caregiver, spouse, clinician).

Results from past studies have included: unattractive patients were judged to suffer from more pain than physically attractive patients (Hadjistavropoulos et al.1990, 1996, 2000). Generally, higher reported pain intensity appeared to invite higher estimated pain intensity. When comparing sufferers’ self-reports and observers’ estimates, however, low reported pain intensities were overestimated and high reported pain intensities were underestimated (Chibnall and Tait 1995; Chibnall et al. 1997; Krokosky and Reardon 1989; Tait and Chibnall 1997; Zalon 1993).

For health professionals, some studies found no associations (Dudley and Holm 1984; Everett et al. 1994; Hamers et al. 1997; Oberst 1978; van der Does 1989), others found that less experienced observers gave higher pain estimates than did more experienced observers (Mason 1981; Perry and Heidrich 1982; Lenburg et al. 1970).

In terms of contextual cues, the absence of medical evidence to support the person’s report of pain has been associated with lower estimates of pain.

Yesterday I briefly discussed the idea of malingering being the purposeful faking of health problems in order to gain financial benefit: in this study, the evolutionary value of the ‘social contract’ is used as the theoretical model for evaluating our sensitivity to these responses. Social contracting is a situation where the ‘‘individual is required to pay a cost, or meet a requirement, to an individual (or group) in order to be eligible to receive a benefit from that individual’’ (Cosmides 1989, p.197).

It makes sense that as humans we have some systems developed to determine whether we are being exploited and that the normal ‘contract’ between people is being disturbed. There is empirical support for humans being sensitive to cues for cheating from both human and animal studies (Cosmides 1989; Gigerenzer and Hug 1992;Wilkinson 1990) – but as we saw yesterday, we can be deceived reasonably readily, so it makes sense for us to be particularly sceptical about situations where we may be manipulated.

In a situation where one person is likely to receive benefits (caring or free food, for example) because of their reported pain, it makes sense for the observer to be more aware of cues suggesting that the individual receiving the ‘benefits’ is not actually in pain (Williams 2002). This has been studied before, and it has been found that suspicion of cheating or faking leads to conservatism and underestimation of pain. This can explain why such weight is given to medical evidence by health care professionals even when the relationship between ‘evidence’ from radiology and pain, for example, is fairly weak. This is especially true in cases where time off work, or other ‘special’ treatment is given as a result of confirmation of a ‘real’ problem.

The hypotheses in this paper were:
– the combination of two behaviours (continuing liked and
stopping disliked activities) would be judged as unfair
and lead to lower pain estimates, whatever the level of
pain,
– there would be no effect on pain estimates of the
presence or absence of medical evidence, and
– pain as reported by the patient would affect pain
estimates by relatives

Although the results were from a very small group of respondents in the end (only 23% of the initial group recruited actually responded with complete questionnaires), some interesting findings were obtained.
– people who stopped doing things they liked were interpreted as ‘having to stop’, and this was perceived as fair
– people who stopped things they didn’t like but continued with things they did like, were perceived as being unfair
– behaviour of characters reporting high pain was estimated to be fairer

The authors suggest that perhaps greater pain meant greater recognition of the cost in pain incurred by doing any tasks, or that more leeway was exercised in judgements of behaviour as fair or unfair.

– more pain was attributed to patients who stopped liked tasks
– highest pain levels were assigned to patients having stopped both liked and disliked activities
– lowest pain estimates were assigned to patients who had stopped disliked but continued liked chores, the combination which also received the lowest fairness ratings

The authors comment that these findings ‘support our hypothesis concerning lowering of pain estimates by individuals close to someone with persistent pain if they judge patients to be behaving ‘‘unfairly’’, that is, ‘‘accepting the benefits’’ of having pain—of being permitted not to do some tasks—‘‘while not meeting the requirement’’—of being unable to do other preferred activities.’

– participants’ estimates were not significantly affected by presence or absence of medical findings in this sample

– higher given pain intensities led to higher estimated pain intensities
– there were systematic discrepancies in estimates since low given pain intensities were estimated as higher and high given pain intensities as lower.

Some food for thought – this is a first cut study using social contract theory as a framework for determining a priori predictions as to which cues are salient, and in which direction. I look forward to finding out more on this – it may help us help our patients reflect on their behaviour, as well as the ways in which family members interpret and respond to patient’s behaviour.

There are some limitations to this study – in particular the small sample size, and the use of written vignettes rather than video-recorded scenarios. But for making us think? I think it’s great.

If you’ve enjoyed this post, there will be more tomorrow – and don’t forget you can use the RSS feed above to subscribe, or you can simply bookmark this page and come on back! I love comments and always respond, so don’t forget to let me know what you think of the topics I cover (***pssst! I don’t bite!***)

Kappesser, J., C. Williams, A.C. (2008). Pain judgements of patients’ relatives: examining the use of social contract theory as theoretical framework. Journal of Behavioral Medicine DOI: 10.1007/s10865-008-9157-4