Social context and acceptance of chronic pain: the role of solicitous and punishing responses

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1 Pain 113 (2005) Social context and acceptance of chronic pain: the role of solicitous and punishing responses Lance M. McCracken* Pain Management Unit, Royal National Hospital for Rheumatic Diseases and University of Bath, Upper Borough Walls, Bath BA1 1RL, UK Received 13 August 2004; received in revised form 23 September 2004; accepted 4 October 2004 Abstract Much of the behavior of chronic pain sufferers happens in social contexts where social influences can play a role in their suffering and disability. Researchers have investigated relations of social responses with verbal and overt pain behavior and, more recently, with patient thinking, such as catastrophizing. There has not yet been a study of social influences on patient acceptance of chronic pain. The purpose of the present study was to investigate the relations between solicitous, punishing, and distracting responses, from significant others in the patient s life, with components of patient acceptance of pain. 228 consecutive patients referred to a multidisciplinary pain center provided data for this study including their responses to the Chronic Pain Acceptance Questionnaire and the Multidimensional Pain Inventory. Primary results showed that, as predicted, both solicitous and punishing responses from significant others were negatively associated with acceptance of pain. These relations remained, independent of patient age, education, pain level, and level of general support from the significant other. These results suggest that social influences can play a role in patients engagement in activity with pain present and their willingness to have pain without trying to avoid or control it. q 2004 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. Keywords: Chronic pain; Behavioral models; Social influences; Acceptance; Multidisciplinary treatment 1. Introduction Researchers and clinicians have long appreciated the influences of social responses on chronic pain. In the past social responses were considered for their potentially reinforcing or punishing effects on overt pain behavior (Fordyce, 1976). More recently researchers have examined the social context of emotionally distressed thinking (Boothby et al., 2004; Sullivan et al., 2001). All of this work has focused primarily on influences of marital partners or significant others on the behavior of the pain sufferer. The goal of the study presented here was to further examine significant other responses in relation to patient acceptance of pain. Studies show generally that solicitous responses from significant others lead persons with chronic pain to show * Tel.: C ; fax: C address: lance.mccracken@rnhrd-tr.swest.nhs.uk. more pain and disability (Block et al., 1980; Boothby et al., 2004; Flor et al., 1987; Lousberg et al., 1992; Paulsen and Altmaier, 1995; Romano et al., 1992, 1995). Results regarding punishing responses show that angry or ignoring responses do not appear to have punishing effects on pain behavior, as one might predict. In fact, they show positive associations between ostensibly punitive significant other behavior and patient reports of emotional distress, disability, and pain (Boothby et al., 2004; Cano et al., 2004; Kerns et al., 1990; Schwartz et al., 1996). Traditionally the role of social responses in chronic pain has been framed as a problem of contingencies of punishment and reinforcement in relation to observable pain displays. Another way to frame these responses is to consider what they add to the experience of pain, to sensations of pain, thoughts about what these sensations mean, and emotions. The presence of pain, discouraging thoughts, and uncomfortable emotions provide occasions for choice, for example, to either engage in or avoid activity /$20.00 q 2004 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. doi: /j.pain

2 156 L.M. McCracken / Pain 113 (2005) (McCracken, 1998). How do responses from significant others influence those choices? Numerous studies demonstrate that patients function better with pain when they accept it, when they are willing to have it without trying to change it, and without taking it as a reason to avoid a situation (McCracken, 1998; McCracken and Eccleston 2003, 2004a,c). Chronic pain patients who report greater acceptance of pain also report less avoidance, anxiety, depression, and disability, fewer medical visits, and better work status (see McCracken et al., 2004b for a review). Acceptance of chronic pain includes two components: Activity Engagement and Pain Willingness, including patients doing activities regardless of pain, and doing relatively little to avoid or control pain (McCracken et al., 2004a). It appears likely that acceptance develops, in part, from experiences with pain, including social influences. This study investigates relations between significant other responses to pain with patient acceptance of chronic pain. The measure of significant other responses included solicitous, punishing, and distracting responses. It was predicted that solicitous responses would negatively correlate with acceptance because these responses are expected to encourage avoidance and assistance seeking. It was predicted that punishing responses also would negatively correlate with acceptance because these responses, most directly, are invalidating of patient experiences, add to their aversiveness, and are expected to promote avoidance. The examination of distracting responses was exploratory only. 2. Methods Participants in this study were 228 consecutive adult referrals (66.7% women) to a university pain management center in the US. The mean age was 47.3 years (SDZ2.1) and education level was 13.9 years (SDZ2.5; 90.8% completed 12 or more years). Most were married (56.6%; 20.6% never married, 15.4% divorced, 7.5% widowed). The largest group of patients was white (80.3%; 16.7% black, 1.8% Hispanic, 0.9% Asian). Low back pain was the most frequent primary complaint (57.7%); the remainder of patients reported pain in lower limbs (13.7%), cervical region (7.0%), upper limbs (6.6%) or other (15.4%). A significant number of patients were not working due to their pain problem (42.5%). All participants completed a number of standard measures as part of an initial assessment during their first visit to the center. The forms they completed provided information about patient background variables and a 0 10 rating of usual pain in the last week. Patients also completed the two primary measures employed in this study, the Chronic Pain Acceptance Questionnaire (CPAQ; McCracken et al., 2004a), and the Multidimensional Pain Inventory (MPI; Kerns et al., 1985). The CPAQ is a 20-item measure of acceptance of chronic pain. It was derived from a longer, 34-item, measure originally developed by Geiser (1992). The CPAQ has two subscales that assess Activity Engagement (eleven items; e.g. Despite the pain, I am now sticking to a certain course in my life ) and Pain Willingness (nine reverse-keyed items; e.g. I would gladly sacrifice important things in my life to control this pain better ), measuring patients engagement in important daily activities regardless of pain, and relative absence of attempts to control or avoid pain. Previous results show that acceptance of pain is a distinct construct from coping with pain, and is substantially distinct from distraction, ignoring, praying and hoping, or simply increasing activity as means to manage pain (McCracken and Eccleston, 2003), but has a strong negative relationship with avoidance (McCracken, 1998). The subscales and total scale of the revised CPAQ are internally consistent (az ) and reliably predict patient functioning, lending additional support to their adequacy as measures of the acceptance (McCracken et al., 2004a). The two subscales from the CPAQ are summed to form the Total Score. The subscales are moderately intercorrelated (rz0.36, McCracken et al., 2004a). The Total Score was considered the primary variable of interest and the subscales were used to allow more detailed analysis of these separate facets of acceptance. The MPI is a 61-item measure of the impact of pain. It includes 13 scales derived from factor analysis: pain severity, interference, affective distress, life control, social support, four types of daily activities, and specific responses to pain from a significant other. Only the scores for Social Support and the specific spouse responses were used for purposes of this study. The Social Support scale includes three items (e.g. How supportive or helpful is your spouse (significant other) to you in relation to your pain? How worried is your spouse (significant other) about you because of your pain? ). The specific significant other responses include Solicitous (six items; e.g. Asks me what he/she can do to help, Tries to get me to rest ), Punishing (four items; e.g. Gets frustrated with me, Gets angry with me ), and Distracting (four items; e.g. Tries to get me involved in some activity, Turns on the TV to take my mind off my pain ) responses. All items on the MPI are rated on a scale of 0 6. Internal consistency values for these four scales are adequate (az ; Kerns et al., 1985). The Social Support score was used primarily to control for background differences in patients general support received from their significant other, less tied to particular displays of pain. The patients who were married reported on responses from their spouses. All other patients were asked to report responses by their primary partner or from their closest significant relationship. 3. Results Preliminary analyses showed that acceptance subscale scores but not the Total Score were correlated with age; Activity Engagement was correlated at rz0.18, P!0.01, and Pain Willingness was correlated at rzk0.16, P!0.05. Each of the scores was correlated with years of education, Activity Engagement rz0.17, P!0.05, Pain Willingness rz0.14, P!0.05, and Total Score rz0.18, P!0.01. Each of the acceptance scores also was correlated with the 0 10 rating of usual pain in the past week, Activity Engagement rzk0.21, P!0.01, Pain Willingness rzk0.27, P!0.001, and Total Score rzk0.27, P! The acceptance scores were unrelated to gender, a dichotomous

3 L.M. McCracken / Pain 113 (2005) Table 1 Correlations of social support and spouse responses with acceptance of chronic pain Social responses marital status variable (married or not), or chronicity of the pain complaint. Table 1 includes correlations between Social Support and significant other responses to pain and the three scores from the CPAQ. All of the correlation coefficients were negative in direction, as predicted for the Solicitous and Punishing Responses. The correlations of Social Support with the acceptance scores were relatively weak and did not reach significance for Activity Engagement. The correlations with Pain Willingness tended to be higher than with Activity Engagement. Both Solicitous Responses and Punishing Responses achieved larger correlations than the Distracting Responses with the acceptance scores. Next, hierarchical regression analyses were done to examine unique and combined relations between the social response variables and the acceptance scores. In these analyses, age and education were tested for entry as these variables had achieved significant correlations with the acceptance scores. Pain was entered into the equations next to control for its associations with the acceptance scores. Then, the Social Support variable was entered to control for potential differences across patients in general support from their significant other. Finally, the three specific significant other responses were entered simultaneously so that their relations with the criterion variables could be examined separate from the background variables entered on earlier steps. Table 2 includes results from the regression analyses. Overall the spouse responses accounted for 8.9% of the variance in Activity Engagement, 15.0% of the variance in Pain Willingness, and 15.0% in Total Acceptance, over and above the variance accounted for by relevant background variables. All relations between spouse responses and acceptance scores were negative. Punishing Responses showed the strongest relationship with acceptance, and Solicitous Responses accounted for a somewhat smaller relationship with acceptance. Distracting Responses did not demonstrate a significant relationship with acceptance when considered simultaneously with the other spouse responses. 4. Discussion Activity engagement Pain willingness Total acceptance Social support K0.10 K0.16* K0.15* Solicitous responses K0.22** K0.31*** K0.30*** K0.27*** K0.29*** K0.32*** Distracting responses K0.14 K0.20** K0.19** *P!0.05; **P!0.01; ***P! Results from this study demonstrate that social responses to pain are related to patients acceptance of chronic pain. Table 2 Hierarchical regression analyses of social support and spouse responses in relation to acceptance of chronic pain Predictors DR 2 Beta Total R 2 Activity engagement 1. Years of education 0.042** Age 0.026* 0.18** 3. Pain 0.041** K0.15* 4. Social support K Solicitous responses 0.089*** K0.18* K0.26*** Distracting responses K *** Pain willingness 1. Age 0.038** K0.18** 2. Pain 0.035** K Social support 0.029* K Solicitous responses 0.15*** K0.21* K0.32*** Distracting responses K *** Total acceptance of pain 1. Years of education 0.041** Pain 0.046** K0.14* 3. Social support K Solicitous responses 0.15*** K0.22** K0.33*** Distracting responses K *** In these analyses age and education were tested for entry (stepwise) in the first block and retained in the equation, if they significantly predicted the criterion variable at entry. Pain and Social support were entered next in sequence. Finally, the spouse response variables were entered simultaneously as a block. *P!0.05; **P!0.01; ***P! As predicted, Solicitous and were negatively correlated with the Activity Engagement and Pain Willingness, components of acceptance, as well as the Total score from the CPAQ. These relations held independent of age and education, pain level, and level of general Social Support from the significant other. Social Support and specific Distracting Responses from significant others were not strong predictors of acceptance. These results add to the numerous studies showing relations between Solicitous Responses from significant others and pain behavior (Block et al., 1980; Flor et al., 1987; Lousberg et al., 1992; Paulsen and Altmaier, 1995; Romano et al., 1992, 1995), Punishing Responses and disability and distress (Boothby et al., 2004; Kerns et al., 1990; Schwartz et al., 1996) and to recent studies of the social context of catastrophzing (e.g, Boothby et al., 2004; Cano, 2004). The present study also extends previous methods by bringing in a different framework around patient behavior in a social context. The traditional operant approach to chronic pain ostensibly was a focus on overt pain behavior and largely social contingencies of reinforcement. The cognitivebehavioral approach intended to subsume that approach but included a role for patient thoughts, emotions, and cognitive coping strategies. The recent studies on catastrophizing show attempts to bring together the influences of private experiences, such as thoughts and related emotions

4 158 L.M. McCracken / Pain 113 (2005) into a context that crosses the person s skin, in a sense, a context with social elements. The present study of social influences on acceptance is to similarly bridge the divide between influences in the social environment of the pain sufferer and influences that are private, the context of their feelings of pain, their thoughts about their situation, and their emotions. This approach to chronic pain that incorporates acceptance is based on a functional contextualist, or clinical behavior analytic, approach to behavior and suffering (Hayes et al., 1999). Within this framework the form or frequency of thoughts, feelings, beliefs, and sensations are not necessarily primary clinical targets of change but rather their functions are. For example, a common clinical challenge is a patient who will not engage in physical exercise, feels fear of exercise, and thinks that exercise will cause them damage, in the absence of any evidence or experience to substantiate that thought. Frequently psychological methods are applied to such cases to dispute or call into question the patient s discouraging thoughts about exercise, and reduce feelings of fear, in the service of increasing engagement in exercise. Within a contextual approach one would not need to target thoughts and feelings for change in this case but would aim to reduce the influence of the thoughts and feelings on the acts of avoidance through cognitive de-fusion or mindfulness exercises, and by bringing in other positive guides for action, such as values, in the place of aversive feelings (Hayes et al., 1999). Acceptance is not conceptualized as a decision or belief about pain, a helpless behavior pattern, or a positive belief of some kind. It is a process by which patient behavior becomes less entangled with unnecessary influences from thoughts, feelings, and sensations, so that free choices can be made in the direction of healthy life functioning (see McCracken et al., 2004b). Patients with chronic pain have a variety of experiences with pain, fatigue, other physical symptoms, emotions, and a range of thoughts. When all of these private experiences occur they mix with, and sometimes overwhelm, other influences of their environment on behavior, particularly choices that are made to avoid or control an unpleasant experience, or to carry on functioning with the experience present. It is argued here that these are key choice points where social influences can and certainly do play a role to determine the action taken. The present results lend support to this argument. It appears that when significant others act in solicitous ways, by encouraging rest or taking over patients duties, these responses may lead to reductions in behavior consistent with acceptance. When a pain sufferer is experiencing pain, or some other experience that provides an opportunity for avoidance, on an occasion where solicitous social responses have occurred in the past, then avoidance may be more likely to occur. On this occasion Activity Engagement regardless of pain or acts of Pain Willingness are relatively unlikely to occur. A fully contextual view is that the result of the solicitous responses to pain is not merely to enhance all avoidance and displays of pain but rather to increase these responses in the future in situations where they have been reinforced. For chronic pain sufferers those typically include situations where some pain, other symptoms, moods, and thoughts about pain, are present. The story regarding punishing responses is perhaps more complicated. Punishing can be used as a technical term. In order for it to be applied in a true technical sense it must be demonstrated that a history of contingently applying the presumed punishing event resulted in a decreased rate of the presumably punished response in the target situation. From within the traditional operant approach to chronic pain the term punishing often has not been used in a true sense. It was intended to relate to decreases in pain behavior but these have not been reliably shown. The current results lend support to the notion that punishing responses from significant others have a negative relationship with acceptance of pain, and thus may be truly punishing in this context. Our results show that angry, irritated, frustrated, and ignoring responses to pain behavior are related with less Activity Engagement, less Pain Willingness, and less Total Acceptance. These responses from significant others are likely to shape a number of behavior patterns in the individual pain suffer. They may be invalidating of the pain sufferer s feelings, making those feelings less acceptable, and experiences to avoid. They may lead the pain sufferer who feels disbelieved to try to show that they are right in the way they feel and act, again a form of avoidance (avoidance of being wrong or being accused of exaggerating). These punishing responses may reduce behavior that leads to contact with the significant other, which could bring additional consequences. It seems certain that they could add to the emotional aversiveness of the pain experience and therefore lead to a greater likelihood of avoidance, and less likelihood of behavior in the direction of acceptance, a process perhaps more akin to negative reinforcement than punishment. The relatively weak results from examination of distracting responses were not a surprise. It was reasoned that distracting responses can function in a number of ways, negatively, as attempts to move the patient away from pain, or positively, as attempts to helping the patient engage in productive or meaningful activity. The weak negative relations with scores from the CPAQ suggest that distractdistracting responses predominantly function to increase avoidance. Social support similarly was not highly related to acceptance variables. One interpretation of these findings is that this relationship is diminished because the Social Support measure is less focused on significant other responses specifically to pain behavior, which is the relevant context for acceptance. There are a number of limitations to the current methods. Significant other responses were assessed from the patient s point of view. As patients perceptions they may differ from

5 L.M. McCracken / Pain 113 (2005) the actual significant other responses. Significant other responses were not experimentally manipulated and definitive causal statements are not possible. Clearly these social processes are complex and reciprocal. Behaviors entailing activity engagement and pain willingness will, no doubt, occasion social responses that are different from the social responses occasioned by behaviors showing avoidance and struggling for control. As is a usual limit in studies like this, all subjects are treatment seekers and thus their experiences may be quite different from the larger group of pain sufferers who do not seek specialty care. Finally, our methods rely on group data. Functional relations between social responses and the behavior of pain sufferers can only be fully understood, and therefore effectively manipulated, in the context of individual cases with their unique histories and individual circumstances. Group-based results can, however, suggest possible targets for further study and provide guidance to bring to individual cases. As additional results accumulate related to social influences on patient behavior in general, and acceptance in particular, further treatment implications will no doubt emerge. In a direct sense, treatment programs that aim to enhance acceptance are situations were social influences (the therapist or treatment team) are employed in the service of changing behavior patterns that entail acceptance (e.g. McCracken et al., 2004d). In summary, social influences bear relations with the behavior patterns that constitute what we have called acceptance of chronic pain. It is suggested that Solicitous Responses may enhance patients tendencies to avoid pain and related experiences and Punishing Responses may add to the aversiveness of pain experiences in ways that similarly enhance avoidance. Behavior that functions as avoidance, in general, is opposite to behavior that entails acceptance. Of course the real suffering comes when that behavior to avoid pain, enhanced by social responses, is also behavior directed away from such things as family, friends, health, and productive functioning. Marshalling social influences, including cultural, family, and therapeutic, in the other direction would seem to be needed. Acknowledgements Thanks to Fiona MacKichan for initial analyses and discussion of these data. References Block AR, Kremer EF, Gaylor M. Behavioral treatment of chronic pain: the spouse as a discriminative cue for pain behavior. Pain 1980;9: Boothby JL, Thorn BE, Overduin LY, Ward LC. Catastrophizing and perceived partner responses to pain. Pain 2004;109: Cano A. Pain catastrophizing and social support in married individuals with chronic pain: the moderating role of pain duration. Pain 2004; 110: Cano A, Gillis M, Heinz W, Geisser M, Foran H. 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