Extremes too hard to comprehend

THE ARMFUL

For every parcel I stoop down to seize

I lose some other off my arms and knees,

And the whole pile is slipping, bottles, buns–

Extremes too hard to comprehend at once,

Yet nothing I should care to leave behind.

With all I have to hold with hand and mind

And heart, if need be, I will do my best.

To keep their building balanced at my breast.

I crouch down to prevent them as they fall;

Then sit down in the middle of them all.

I had to drop the armful in the road

And try to stack them in a better load.

Robert Frost

Pain dyads 

The third piece in The Conversation’s series on pain covers some interesting ground. Dr Toby Newton-John, Clinical Psychologist and senior lecturer at University of Technology Sydney, discusses the powerful influence a partner can have on a person experiencing chronic pain:

“Partner responses to patient pain behaviours (those expressions of pain such as limping, or grimacing or lying down) are basically divided into solicitous or punitive behavioural categories.

Solicitous responses are overly protective responses – where the partner does everything he or she can to prevent the patient’s pain from getting worse, including getting medications, encouraging rest and taking over jobs or duties.

Solicitous partners also tend either to not support, or actively dissuade, the patient from engaging in so called “well behaviours”, such as exercising, out of concern the pain may worsen.

On the other hand, punitive or negative responses to pain behaviours are the partner’s expressions of annoyance, exasperation or sheer frustration at the patient’s pain (“If I have to hear about your bad back one more time I am going to scream!”).

Over time, these response styles have markedly different effects on patients. The research evidence shows that patients whose partners tend to respond in consistently solicitous ways become more and more disabled by their pain over time.

They are less active, less functional, take more pain medication and are less likely to remain at work. While there may be depressive symptoms reported, these patients typically also report high relationship satisfaction and good social support for their condition.

In contrast, patients whose partners tend to respond to their pain with punitive responses are more physically functional. However, their reports of relationship satisfaction are very low.” (emphasis added)

I’m always wary of dichotomies, and the statement “basically divided into solicitous or punitive behavioural categories” got my false dichotomy radar tingling. I wasn’t the only one – the very first response to the piece at The Conversation raised this concern as well. However Dr Newton-John has responded to this, and other concerns in the comments section, which is worth reading.

A diverging road?

The difficulties that people with chronic pain and their partners face brought to mind Frost’s words; “Extremes too hard to comprehend at once”. On the face of it, both ‘choices’ – solicitous or punitive responses – lead to unhelpful extremes that the partner could not have comprehended singly, let alone both at once. But unlike the dualistic choice faced by the protagonist in Frost’s most famous (and most famously misunderstood) poem, the partners of people in pain don’t face a simple choice of left or right at a diverging road in a yellow wood.

Instead, the words of The Armful seem much more suited. Words that evoke a feeling of quiet desperation as one struggles, with all I have, to hold on to nothing that I should care to leave behind, with hand and mind and heart if need be. And words that capture the seeming futility as I crouch down to prevent them as they fall, but ultimately drop the armful in the road.

Stacking them in a better load

But, there is a glimmer of hope in the final line – the possibility of stacking them in a better load. Dr Newton-John suggests that partners should be included in interventions for people experiencing persistent pain, and there is evidence that including a partner in pain interventions can help to reduce pain, psychological disability and pain behaviour, reduce fear of movement and rumination about pain and increase self-efficacy and pain-coping.

Keefe and coping

A lot of work on pain coping, especially in couples, has been done by Frank Keefe, one of the superstar headliners who will be joining us at EP3 2016. One of the important findings of Frank’s work is that people can be taught how to stack their problems (the poem isn’t really about parcels, bottle, buns…) ‘in better ways’. Coping Skills Training (CST) includes reconceptualising pain and pain control, training in relaxation, goal setting, activity pacing, distraction techniques, and cognitive restructuring, and can include hypnosis or other imagery techniques. CST can help reduce pain, improve quality of life, and reduce the suffering of people experiencing disease related pain (such as cancer pain). The thing I like about the coping framework comes from the definition of coping used – cognitive and behavioural efforts to master, reduce or tolerate demands. This trio of ‘outcomes’ provides some nice, non-threatening space within which people experiencing pain can work and not feel like they have failed.

The quickest road

So, despite the (let’s face it – horrible) headline, not helping a partner with chronic pain may not be the quickest road to recovery. There’s lots that a partner can do to help – they, like the person in pain, just need some education, help, guidance, training, empathy and understanding.

-Tim Cocks