Publications
APS Bulletin • Volume 14, Number 3, 2004
Pain Clinic Perspectives
Steven Sanders, PhD, Department Editor
Family Therapy for Persons with Chronic Pain
Robert D. Kerns, PhD, and John D. Otis, PhD
Editor’s Note:
This is the second in a series of summaries of articles published in Seminars in Pain Medicine, Volume 1, 2003, edited by Allen Lebovits, PhD. This issue of the journal reviewed most of the mainstream psychological/behavioral interventions used with pain patients today, with an emphasis on critiquing the scientific evidence supporting their use. Application of these methods to children and as part of an interdisciplinary pain treatment program also is critically reviewed. As Dr. Lebovits highlighted in his introduction, “Only through an evidence-based approach can the specialty of pain psychology be advanced, and, more significantly, patients suffering from pain can be helped.”
In keeping with the increasing demand for empirical documentation on the efficacy of treatments across disciplines that treat pain patients, psychological/behavioral interventions also must be subject to scrutiny. The articles in Seminars in Pain Medicine, Volume 1, summarized here and in future APS Bulletin issues, provide up-to-date information that reviews and critiques the empirical science behind psychological/behavioral treatment for pain patients. The APS Bulletin editorial staff extends thanks to Dr. Lebovits for his help in arranging for the publication of these summaries and to Elsevier, the publisher of Seminars in Pain Medicine, for giving permission to do so.
As always, comments and thoughts are encouraged and welcomed. Please send your correspondence to ssanders@siskinrehab.org.
Theoretical Context
The role of the family in the development and perpetuation of chronic pain conditions has drawn considerable empirical attention in recent years (Kerns & Otis, 2003). Although family systems and family stress theories remain the dominant models in the family therapy literature, more generally, these perspectives have had a limited impact on advancing our understanding of family relationships in the context of chronic pain. In contrast, an operant-behavioral model of chronic pain that hypothesizes a central role of social contingencies for displays of pain (e.g., grimacing, complaints of pain, withdrawal from activities and responsibilities) in the perpetuation of pain and pain-related disability has fostered research on the role of pain-relevant communication involving significant others, especially marital dyads. A cognitive-behavioral transactional model of family functioning that attempts to integrate aspects of family stress theory and the behavioral perspective on chronic pain has also been elaborated (Kerns, Otis, & Wise, 2003).
Despite strong conceptual interest in the role of the family in chronic pain and the expanding empirical literature in this area, few explicit models for family treatment of chronic pain have been articulated. Importantly, however, each of the models that have been described encourages a primary focus on the overall adjustment of the family by promoting the adoption of a flexible and constructive problem-solving approach to addressing the many challenges posed by the experience of pain by a family member.
Empirical Support
Saarijarvi and colleagues (1991) published a series of papers on the only randomized controlled trial of a couples treatment for chronic pain that employed a family systems perspective. A total of 63 persons with chronic pain and their partners were randomly assigned to receive couples treatment or to a nontreatment control condition. Treatment consisted of five, monthly 1- or 2-hour sessions. Significant differences between the two conditions in reports of global marital satisfaction and psychological distress, including somatization, were reported at follow-up. However, no differences on measures of pain and pain-related disability, or on measures derived from physiatrist and physical therapist examinations, were observed.
Moore and Chaney (1985) were the first to report on the efficacy of a cognitive-behavioral treatment approach that included the spouse of the person experiencing pain and that utilized a randomized controlled design. Forty-three persons with a range of chronic pain conditions were randomly assigned to receive either a patient-only group treatment or a couples group treatment, or to a waiting list control condition. The treatment groups consisted of eight 2-hour sessions with identical content, specifically, education about a multidimensional model of pain, problem-solving skills training, relaxation skills training, assertiveness training, and advice for altering contingencies for patient expressions of pain and for promoting increased activity. Both treatment groups improved significantly, relative to the waiting list control condition, on measures of pain severity, pain behavior, somatization, and overall adjustment.
Other more recent studies testing the efficacy of cognitive-behavioral, operant conditioning, and coping skills training with arthritic, myofasical, and other chronic painful conditions have shown similar findings. While the treatment conditions were effective, adding family, couples, or spouse involvement did not improve outcome.
Conclusions
In summary, research suggests that there is substantial interest in including family members in pain treatment in attempts to promote improved outcomes for persons with pain and broader benefits for significant others. It is particularly noteworthy that there is evidence for the efficacy of couples interventions informed by different theoretical perspectives, including family systems, operant-behavioral, and cognitive-behavioral models. Randomized controlled designs, appropriate control conditions, and multivariate approaches to evaluating outcomes are important strengths of existing research. Despite these efforts, however, the failure to demonstrate the incremental effectiveness of psychological pain treatments that include family members on pain-relevant outcome variables is disappointing.
A number of challenges to clinical investigators in this area can be cited. One is the development of treatment protocols that accommodate to differences in family functioning and other family-related factors hypothesized to be involved in the perpetuation of the experience of pain and other negative outcomes, for the person with pain as well as family members. As just one example, different patterns of pain-relevant communication (e.g., generally solicitous versus negative or inattentive) may call for different intervention strategies. The design of strategies that can maximize the involvement of family members in fostering adherence to pain coping skill practice recommendations probably deserves more explicit attention. Although the development of reliable methods for the assessment of key family variables has contributed substantially to progress in this area of research, refinement of measures to improve their responsivity to change as a function of psychological treatment may be necessary. And finally, efficacy of these approaches may be limited by the sole focus on the person with pain and a single family member. The continued development of psychological interventions involving multiple family members and controlled evaluations of these approaches is strongly encouraged.
References
Kerns, R.D., & Otis, J. (2003). Family therapy for persons experiencing pain: Evidence for its effectiveness. Seminars in Pain Medicine, 1, 79–89.
Kerns, R.D., Otis, J.D., & Wise, E. (2002). Treating families of chronic pain patients: Application of a cognitive-behavioral transactional model. In R. J. Gatchel and D. C. Turk (Eds.), Psychological approaches to pain management (2nd ed.). New York: Guilford Press.
Moore, J.E., & Chaney, E.F. (1985). Outpatient group treatment of chronic pain: Effects of spouse involvement. Journal of Consulting and Clinical Psychology, 53, 326334.
Saarijarvi, S., Rytokoski, U., & Alanen, E. (1991). A controlled study of couple therapy in chronic low back pain patients: No improvement in disability. Journal of Psychosomatic Research, 35, 671–677.
Robert D. Kerns, PhD, is Professor of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT, and Chief, Psychology Service, VA Connecticut Healthcare System, West Haven, CT.John D. Otis, PhD, is psychologist, VA Boston Healthcare System, Boston, MA,and Assistant Professor, Department of Psychiatry, Boston University School of Medicine, Boston, MA.