“Now I Have Hope ”: Rebuilding Relationships Affected by Chronic Pain

Abstract

Introduction:

A novel couple-based intervention was created to address the individual and interpersonal needs of people with chronic pain and their romantic partners, as research has shown that pain negatively impacts both partners. A pilot study revealed positive outcomes in both partners, though the extent to which improved relationship functioning contributed to these outcomes is unknown. The purpose of this study was to examine couples’ experience of the treatment to determine whether addressing relational flexibility was appraised by couples as playing an important role in this novel intervention.

Methods:

Fourteen couples who completed the treatment participated in interviews and gave feedback about the intervention. Interviews were analyzed using a multi-phase thematic analysis to provide information about the treatment effects and mechanisms of change from the couples’ perspectives.

Results:

Couples described the intervention as essential in rebuilding their relationships that had been negatively impacted by the effects of chronic pain.

Discussion:

The presence of chronic pain had contributed to feelings of isolation, helplessness, and resentment within relationships. Participants valued this dyadic treatment because it enhanced their communication, connection, and intimacy. Their reports reinforce the importance of targeting both partners in pain treatment when relationship distress is present, as the improvements made in individual treatment are unlikely to be maintained if patients return to environments that are unsupportive and distressed.

Introduction

Partner-assisted inverventions for chronic pain do not target the relational and individual difficulties experienced by both members of the couple. Yet, couples who report higher than average levels of conflict and lower levels of perceived support may benefit from interventions that focus on the relationship (Martire, Schulz, Helgeson, Small, & Saghafi, 2010). Interventions that address relationship problems are needed because people with chronic pain who experience interpersonal distress show less improvement on measures of physical functioning and drop out of individual interdisciplinary pain treatment at higher rates (Carmody, 2001). Interventions that address both partners’ needs are also warranted given that pain negatively impacts relationship satisfaction for both partners and the non-pain partners’ mood, anxiety, and overall wellbeing in chronic benign and malignant (e.g., cancer) pain (Geisser, Cano, & Leonard, 2005; Hagedoorn, Buunk, Kuijer, Wobbes, & Sanderman, 2000; Leonard & Cano, 2006).

In this study, we examined couples’ experiences of a novel, integrative couple-based intervention for chronic pain and relationship distress that focused on teaching couples psychological and relational skills (Cano, Corley, Clark, & Martinez, 2018). An important step in this work is to determine the potential mechanisms of this treatment, especially from the patient perspective. This study offers insights into how this therapy may rebuild relationships marked by the negative impacts of chronic pain.

Methods

Participants

The original treatment study was approved by the Institutional Review Board of Wayne State University and registered with clinicaltrials.gov (see NCT02316288 for detailed information about study protocol and measures). Couples were recruited by online advertisements, newspaper advertisements, and brochures in community pain clinics. Participants were eligible if they met threshold levels of pain interference (at least one partner rating pain interference as ≥ 3 for ≥ 3 months using the Brief Pain Inventory (Cleeland, 1991) and relationship distress (at least one partner reporting ≤ 25 on the 7-item Dyadic Adjustment Scale; Sharpley & Rogers, 1984). Eligible couples were randomized to the intervention (17 couples, though two did not begin the intervention) or education-control (6 couples) condition using a 3:1 ratio (see Supplemental Material 1 for information about the control condition). Fourteen of the 15 couples who completed the intervention accepted the invitation to be interviewed. Twelve couples were heterosexual and two were same-sex female couples, and the average relationship length was 26.05 years (SD = 15.36). Individuals were on average 60-years-old (SD = 9.45; range: 44–79 years) and the sample was predominantly Caucasian (67.9%; 21.4% African American, 3.6% American Indian/Alaskan Native, 3.6% Mixed, and 3.6% unknown). In eight couples, both partners reported chronic pain, and in the six remaining couples, only one partner reported pain. The average pain duration of the 23 participants with pain was 17.89 years (SD = 14.81).

Intervention

Mindful Living and Relating aimed at improving individual and relationship wellbeing by building psychological (e.g., pain acceptance, mindfulness) and relational flexibility (e.g., emotional validation, empathy) skills. Each couple met with a therapist for six weekly 1.5-hour sessions that included mindfulness- and values-based skills training and homework review. Example activities included a handholding meditation, value clarification activities, and emotional disclosure exercises (see Table 1 for weekly session topics and Cano et al., 2018 for detailed intervention description).

Table 1.

Overview of intervention session activities and homework assignments (Adapted from Cano et al., 2018).

Session	In-Session Activities	Assigned Homework
1	Mindfulness-based: Breathing meditation Values-based: Anniversary exercise	1a: Practice breathing meditation 1b: Complete anniversary exercise
2	Mindfulness-based: Body scan meditation Values-based: Developing values statements from anniversary exercise and introduction to the values compass	2a: Practice body scan meditation 2b: Complete values statements 2c: Complete values compass
3	Mindfulness-based: Leaves on a stream meditation (Hayes, Strosahl, & Wilson, 1999) Values-based: Developing goals that align with values	3a: Practice leaves on a stream meditation 3b: Complete goals development
4	Mindfulness-based Psychological Flexibility: Mindful handholding meditation Relational Flexibility: Mindful listening and communication skills Values-based: Psychological Flexibility: Select one values-based action goal to complete (from Session 3) Relational Flexibility: Emotional disclosure: Identifying and disclosing positive emotions about one’s partner while the partner practices listening and acceptance of emotions.	4a: Practice mindful handholding meditation 4b: Complete a values-based action 4c: Emotional disclosure: Practice identifying and disclosing positive emotions about partner (to partner)
5	Mindfulness-based Psychological Flexibility: Loving-kindness meditation Relational Flexibility: Mindful listening and communication skills Values-based: Psychological Flexibility: Select one values-based action goal to complete (from Session 3) Relational Flexibility: Emotional disclosure: Identifying and disclosing negative emotions about pain and stress while partner mindfully listens	5a: Practice loving-kindness meditation 5b: Complete a values-based action 5c: Emotional disclosure: Partners was instructed to record their negative feelings about pain or stress for three days and then begin daily sharing on the fourth day.
6	Mindfulness-based: No new skills; review of Session 5’s activity Values-based: No new skills; review of Session 5’s activity Wrap-up: Develop an individualized plan for continued practice and brainstorm solutions to barriers	Follow individualized plan

Analysis

Partners were interviewed as dyads in a Wayne State University laboratory (see Supplemental Material 2 for interview questions). Research assistants transcribed the video-recorded interviews and the content was analyzed by the first-author using a multi-phase thematic analysis (Braun & Clarke, 2006). Phase one utilized a theoretical analysis at the semantic level, such that interview content directly related to the feasibility of the intervention was identified. The second phase evaluated the data for content outside of the main research task. Codes and themes were identified using an inductive analysis at the latent level; that is, the interview content was evaluated for underlying concepts, beyond the explicit content identified during phase one. After the themes were conceptualized and considered to adequately and accurately reflect the data, phase three involved re-coding the interviews to refine the newly identified themes. All authors helped to refine the themes, and, to establish rigor, this report includes only the themes that were agreed upon by the authors.

Results

Eleven codes emerged in phase two of thematic analysis, which were collapsed into three sub-themes: emotions, communication, and intimacy, which encompass the key processes and domains of change during the intervention, as reported by participants. These sub-themes were conceptualized as being part of an overarching theme of relationship rebuilding, which is defined in this context as the transition from relationship distress and isolation to relationship conection and renewal, via the three domains of change (see Figure 1 for the themes and included codes). Of note, couples’ references to their relationship were spontaneously reported in response to the feasibility and acceptability interview questions, highlighting the value of this overarching relationship domain and the importance of multi-phase data analysis.

Figure 1.

Qualitative Themes and Included Codes

Emotions.

Five couples credited the intervention for improvements they observed in distress. Overall, the majority of partners felt negatively about their relationships and were unsure how to manage uncomfortable emotions. Participants with pain endorsed feelings of “despair” and frustration, and discussed their partners’ ongoing feelings of helplessness because they could not reduce pain. Couples also described helplessness in terms of not knowing how to address distress with one another, as they were worried about saying something they would regret or exacerbating their partners’ pain. Some participants with pain expressed ongoing mixed feelings towards their partners, including feeling like a “burden” on some days while feeling anger on others because their partners could not fix their pain.

Individuals with pain also acknowledged the difficulties faced by their partners without pain, including increased psychological distress, which some partners with pain perceived as the result of the burden of their own daily pain. They shared their previous experiences of conflict with their partners, which often revolved around decreased time spent together and feeling misunderstood. For example, one woman shared that “all that I could do was lay on the couch…and he would go to events and I couldn’t go with him, and he got a little resentful. He didn’t understand that I couldn’t do it because of my pain.” Many couples realized that working together in treatment helped break this cycle by encouraging perspective-taking and disclosing and processing both positive and negative feelings. Additionally, some couples expressed increased awareness of the connection between emotions and pain, and described improvements in pain-related symptoms through the process of working through uncomfortable emotions with their partners.

Communication.

Although the majority of participants had struggled with uncomfortable emotions within their relationships, many couples acknowledged their tendencies to suppress these emotions, rather than openly communicate with their partners; as such, a pattern of communication codes emerged across interviews. The majority of couples spoke about a transition from a relationship in which they “bottled up” negative thoughts and feelings to a place where they could disclose emotions without concern about being disloyal or fear that an argument would begin. Eleven couples credited the intervention for enhancing communication, learning how to take their partners’ perspective instead of being so inner-focused, and providing an opportunity to express intimate feelings. Specifically, seven couples cited the disclosure exercises, which prompted partners to express both positive and negative feelings to their partners (weeks 4 and 5, see Table 1), saying the activities prompted dialogue and allowed time for active listening without trying to fix the problem. One woman even described the activity as an “integral moment” during therapy, as being able to speak honestly without placing blame lead to a notable change in her relationship. One husband also noticed that “after we went down the negative road it seemed like nothing crazy, but it seemed like…”, and his wife naturally completed his thought: “it brought us closer.” Couples appreciated the opportunity to confide in one another and relate positively, and they also learned to communicate how each other’s actions affected their mood and subsequent pain.

Intimacy.

Some couples reported that they were unsure how to approach the problem of an upsetting lack of intimacy prior to treatment. One woman with pain shared:

The intimacy has been missing from our relationship for a long time. That was one of the serious things that I felt like we needed to focus on… I didn’t expect it to happen from this but it did and thank goodness…it’s a definite benefit to me.

Nine couples praised the mindful handholding meditation for enhancing emotional and physical closeness. One woman spoke about how powerful it was to feel her husband’s pulse during the exercise, and how those tangible moments helped her feel connected and reminded her of their past together. One man described this activity as “partner building,” while another woman described it as enhancing intimacy because “it gave us the opportunity to embrace each other with our hands.” Couples described this activity as devoted time together, praising it for giving them the opportunity to share intimate moments without arguing. As one woman stated as she discussed feeling like the intervention put her and her husband on the right track to continue strengthening their relationship: “Now I have hope.”

Many couples identified pain as a barrier to quality time, leading to feelings of burden, hostility, and resentment towards themselves and their partners. Couples reported that the treatment format was beneficial in relearning how to be present with one another. This quality time plus participation in value-based activities led one woman to declare that her husband was “top priority and everything else was secondary.” The majority of couples described preferring a dyadic approach to treatment over individualized care due to the intervention building in weekly opportunies for quality time. One woman who previously attended individual therapy also reported that she preferred the dyadic approach of working towards mutual goals, together. As one woman with pain described:

You can’t expect a person to change completely in one step…the change has to occur in baby steps and I realized that I was being much too hard on [my husband] in my expectations …it’s a progression of change that you need to work on. You need to be working at it and it will get better as time goes along if both people want it to get better.

Her eloquent disclosure describes an invaluable level of insight into any psychological treatment: change is a gradual process. However, when paired with a loved one, both partners can more efficiently work towards mutual goals because each individual is energized by the motivation of the other. During this intervention, couples learned an array of skills that enhanced emotions, communication, and intimacy, which allowed couples to begin the process of rebuilding their relationships and continue to develop effective methods to support and connect with one another following the end of treatment.

Discussion

The results of this study highlight the importance of relationship skills building for couples with pain and relationship distress. Couples described the relationship rebuilding activities as important in enhancing their communication, emotions, and intimacy, which partners described as crucial elements in improving the pain-related feelings of helplessness, burden, and resentment towards their partners. Gains in traditional treatments, which do not address relationship distress, may be compromised if the patient returns to an unsupportive environment (DeLongis, Holtzman, Puterman, & Lam, 2010). Shifting to an interpersonal approach addresses the critical role that relationships play in assisting partners to make meaningful, sustainable improvements and rebuild relationships adversely affected by chronic pain. Traditional treatments delivered in community agencies, medical centers, and private practices can be modified to include essential components that are relevant to couples with chronic pain (e.g., psychoeducation on pain and relationships, specific pain-related emotional disclosure prompts, teaching partners how to validate pain disclosures, etc.)

A limitation of the study is the small convenience sample. Although it is likely that poor communication, feelings of frustration and burden, and low intimacy are likely to explain distress in other samples, a larger sample is needed to test the generalizability of the results. Nevertheless, the current findings suggest that couple-based treatments that address relationship distress and the needs of both partners should be investigated further.