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After Jim’s injury, he was laid up in the hospital for a while, then came home and hadn’t worked since—over four years ago. He couldn’t sit up or concentrate long enough even to do therapy. He was severely depressed and in pain twenty-four/seven. Two surgeries and countless epidural injections had left him no better, and, in fact, worse after the last surgery; now he had burning and tingling down his right leg that kept him from resting, so he was up and down all night. Mary nursed Jim in the hospital and at home for as long as she could, but finally money was running out and she was compelled to return to work. At the time, she still had one of her kids at home, whom she felt she was abandoning because she had to leave to work nights as a nurse at a local hospital. It was actually a relief to be out of the house (though she hated herself for feeling it). At least she could care for people who got better. And she didn’t have to live with them—with their pain, their complaining, their depression, and their anger. At home, that’s mostly what dominated her life and the life of her family. Jim tried his best, but it seemed like his best wasn’t nearly enough. The pain was getting the best of him, and driving them both, not to mention the kids, crazy!

Thankfully, Mandi was out of the house, recently graduating from college and going on to graduate school. She wanted to help, even offering to quit school and return home, but Mary categorically refused. The last thing she wanted was for her successful daughter to get sucked into the downward spiral that had become their life. Ross had become more sullen and withdrawn lately. Mary was sure he was missing his dad. They were both subject to Jim’s moodiness—one minute shouting, the next crying. Mary knew it was taking its toll on her teenaged son and didn’t know where to turn.

When chronic pain is introduced into the family, everything changes. Along with these changes, a variety of confusing and negative emotions often develop as the whole family is thrown off balance by role reversals, medical concerns, financial and legal worries, and other lifestyle shifts. It can be difficult for even a well-functioning family to adapt in a positive way; in fact, it is uncommon to see a healthy adjustment to such a trauma.

While every family’s experience is unique, there tends to be a pattern to how families respond to chronic pain, which may occur rapidly or over a long period of time. When a member of the family becomes disabled by chronic pain, the rest of the family steps up and takes on more responsibilities. These responsibilities can include earning money for the family, doing household chores, caring for children, and any other functions the person in pain fulfilled in the past but is now unable to fulfill. As family roles change, each person’s sense of self has to readjust. Mary had stopped working as a nurse to become a full-time mom, and all of a sudden she had to figure out how to earn a living for the family when Jim could no longer work. Jim’s pain changed his identity as the breadwinner, and also caused him to be absent from activities he enjoyed with the kids—soccer practice, helping them study, etc.

With the role shifts, everybody suffers an incremental loss as a little bit is chipped away from their sense of self and the part of them that was defined by their relationship with the person in pain.

A shift you may have experienced is that suddenly ______________ has become the central figure in your life, with everyone else revolving around him or her: running, getting, doing, trying to make things better, compensating for, and trying to fill the vacancies. This can leave you with little time to take care of or enjoy yourself. You may be feeling resentful or depressed, but you may believe that these feelings are inappropriate because you are not the one in pain. You have become less interested in your own needs, because _______________ is the one who needs attention.

Mary’s role as Jim’s caretaker eventually became her primary identity. This continuous sacrificing of her own needs to the needs of another led to her feeling overwhelmed by feelings of anger, sadness, and guilt, which began negatively affecting her own health.

Often with chronic pain, everyone in the family system feels like they’re carrying a burden. Everyone feels victimized by the pain, but may not be communicating their feelings to each other or seeking support to help them cope, at a time when they need support the most.

{exercise} 2.1

Am I Out of Balance? _________________________________________

Please answer “Yes” or “No” to the following questions. Fill in the blanks with the name of your family member who has chronic pain.

Yes	No	Does your life revolve around _______________?
Yes	No	Is your well-being dependent on _______________’s well-being?
Yes	No	If _______________ hurts, do you hurt, or are you unable to have fun, concentrate on your work, or take proper care of yourself or others in your life?
Yes	No	Do you feel guilty when you are impatient, annoyed, or simply not there?
Yes	No	Is your life spinning out of control in your attempts to help?
Yes	No	Are you depressed, angry, fearful, anxious, irritable?
Yes	No	Are you unable to see any way out of these emotions?

Taking a Family Systems Approach

Describing the family as a system helps us to better understand the effects of chronic pain on the family as a whole, rather than on each member individually. In a family systems approach, what is important is looking at the family as a functioning unit, in terms of how the actions of each family member affects the rest of the family, both individually and as a whole. Thus, when _______________ developed chronic pain, that change in him or her naturally had effects on every member of the family and on the way the family operates (e.g., interacts or communicates). However, in a family systems approach, your actions and reactions will also affect the family, including _______________.

FAMILY SYSTEMS: A BRIEF INTRODUCTION

While a complete discussion of the many different family systems theories is beyond the scope of this book, a brief discussion of the central ideas common to all of them will be presented here. Reviewing this brief discussion will help you to understand what is going on in your family and how it could be changed.

From a systems perspective, a family is considered to be a system whose members are interdependent. This means that each member of the family can function independently, but they also turn to one another for support and can have effects on one another. Each family can also have several subsystems that have generational links and boundaries, communication networks, coalitions and alliances, rules, secrets, myths, and rituals.

The important or key dimensions and terms include:

1. Adaptability: whether the family is flexible, as opposed to chaotic or rigid, in its functioning and its ability to adapt in order to effectively handle problems as they arise.

2. Cohesion: to what degree the family sticks together and is interdependent, as opposed to being disengaged (i.e., too cut off) from each other or enmeshed (i.e., in each other’s business, codependent, or enabling).

3. Family Communication: how well the family communicates with each other, which can facilitate their adaptability and cohesiveness.

4. Dynamics: how the system interacts, including patterns and the effects of one’s actions on the rest of the system and individual members.

5. Interaction Patterns: related to dynamics. This is how the family members interact with each other. Boundaries, family rules and roles, and nonverbal behavior (e.g., whether closed doors are respected) are important here.

Interaction patterns can involve triangles (a third person intervening to referee a conflict), stable coalitions (two members repeatedly aligned against a third), detouring coalitions (two agree on identifying a third as the source of the problem, which can give others an impression of harmony), triangulation (two members both insist that a third member side with him or her), and splitting (playing two people against each other). In the triangulation scenario, the third member asked to be aligned with two others may develop symptomatic behavior as a result of the conflict of being pulled in two different directions. Boundaries are important here as well (as they are in cohesiveness), and can be either too rigid (blocks interaction between members) or enmeshed (overly open, in each other’s business, codependent, or enabling).

6. Homeostasis: what a family system does to keep functioning “normally”—in the same way it has always functioned, for better or worse (i.e., functional or dysfunctional). For example, dysfunctional families often work hard to keep family secrets from being revealed by creating unspoken rules such as “Don’t ask; don’t tell.”

Thus, a healthy family system is one that is flexible or adaptable, has a well-defined structure, and is cohesive. Healthy families can therefore accommodate changes in the roles and functions of individual members, family subsystems, and the entire family unit. Also, healthy families can accommodate changes within the sociocultural context. By contrast, dysfunctional families have a limited capacity to cope effectively because of rigidity or chaos in their functioning and structure, unhealthy alliances and power balances within the system, and persistent boundary problems.

Before Jim’s injury, he was the breadwinner, Mary was the mom and homemaker, and the kids were unruly teenagers. Their level of adaptability was limited, and much chaos ensued in the family system after Jim was hurt. Their communication skills were limited, so they couldn’t make sense of the enormous changes. Most of the family rules in that household were unspoken, and after a while no one talked with anyone about what was occurring. Mandi escaped from the environment with relief when she went off to college. Ross started using pot, and his grades dropped. Mary could barely keep her head above water, and just let it happen; she felt she had no choice.

As Amy became less functional, Chris became more and more isolated—from her and from others. He was terribly embarrassed by Amy’s limitations and behaviors, so he stopped calling and interacting with friends. Whereas previously they were a balanced, self-assured couple, the two of them became more enmeshed, and because of her progressive drug dependence, she became totally dependent on him for any support.

{exercise} 2.2

Identifying Effects of Chronic Pain on Your Family System ___________

1. Describe your family’s functioning in terms of the following (refer to the definitions provided in the previous section):

ADAPTABILITY

(Circle the word that best describes how adaptable your family is.)

Rigid Flexible Chaotic

COHESIVENESS

(Circle the word that best describes how well you stick together.)

Disconnected Interdependent Enmeshed/Codependent

INTERACTION PATTERNS (Are there any of the following?)

Triangles Coalitions Triangulation Splitting

BOUNDARIES (Circle the word that best describes how boundaries are within your family.)

Rigid Flexible Chaotic Nonexistent

FAMILY ROLES (Describe the roles that each of your family members plays.)

______________________________________________

FAMILY RULES

(Describe any rules that control the actions of family members. How have the rules changed?)

______________________________________________

2. Describe how the family responded when _______________ was first injured or developed pain problems.

3. As _______________’s pain became chronic or unchanging, how did the family seem to respond?

4. Comparing how things are now (refer to your answers to the first question in this exercise) to how your family functioned before the onset of _______________’s chronic pain problems, describe the most noticeable differences.

Codependent and Enabling Behaviors

Most people have heard the term “codependence.” Codependence originally referred to an addict being dependent on drugs, and the partner in the relationship being dependent on the addict, and thus codependent. However, codependency is not just a characteristic of addiction. Codependence is a cluster of behaviors that often occurs in people affected by an addicted person’s behavior. Thus, codependence occurs in relationships and can be defined as one person’s tendency to be overly focused or centered on another rather than on him- or herself. Typically, the codependent person feels compelled to meet the needs of other people, to fix or control others (e.g., the addict). Because of this unhealthy desire to meet the needs of the other person in the relationship, the codependent person can become the enabler of the other person’s addictive behavior. Additionally, the codependent person protects the other person from the natural consequences of the addictive behavior. For example, a codependent person may not mention, pretend not to notice, or make excuses (e.g., “He’s just tired.”) for obvious signs of intoxication in his or her partner, despite how angry he or she feels. This denial enables the addictive behavior, making it seem acceptable via the silence, and also protects the addict from being confronted about the behavior.

Codependence can affect any relationship, not just those involving a drug-dependent person. For people with codependent tendencies, being in a relationship that requires taking care of someone (e.g., a person with chronic pain) is a perfect scenario for codependency to flourish. For example, in relationships involving a person with chronic pain, a spouse may enable his or her spouse’s isolation and withdrawal from the family by not confronting him or her about it. As a codependent person, you may unknowingly enable and contribute to your partner’s continued imbalance (addiction, chronic pain, etc.). Enabling allows this pattern to continue in an unhealthy fashion.

It should be noted that this discussion of codependence barely scratches the surface of a very important and complicated topic. There are many good information sources available for further reading on codependence, including Choicemaking: For Spirituality Seekers, Codependents and Adult Children by Sharon Wegscheider-Cruse (HCI); Adult Children: The Secrets of Dysfunctional Families by John and Linda Friel (HCI); and Codependent No More: How to Stop Controlling Others and Start Caring for Yourself by Melody Beattie (Hazelden).

Mary enabled Jim’s isolation and withdrawal from the family by not confronting him and not communicating how upsetting his behavior was. When Amy didn’t get out of bed for a week, Chris began feeding her in bed. His intention was to take care of her and to prevent her from starving; but when he feeds her in bed, she doesn’t have to get out of bed. He is reinforcing her pain, and she has become more and more dependent on him. This contributes to his sense of powerlessness and unmanageability.

Enabling involves not being able to set appropriate boundaries. Boundaries become distorted when family members begin to take over responsibilities that the person in pain is capable of handling for him- or herself. This is usually driven by guilt and a desire to make up for the situation the person in pain is in. The enabling behavior is the natural response of the caretaker to the afflicted loved one, but instead of helping, it creates an unhealthy dependency and prevents the person in pain from maintaining self-sufficiency, which reinforces pain and helplessness. Family members often enable the person in pain to engage in victim thinking and behavior.

{exercise} 2.3

Identifying Codependency in You and _______________ ___________

This exercise will help you to identify codependent traits in yourself and in _______________. Read the following list of characteristics and indicate which apply to you, to _______________, or to both of you (check both boxes).

Self	Other Person	Characteristic
		Problems trusting others (anticipating betrayal), making true intimacy very difficult.
		“People-pleasing,” an excessive need or desire to do what other people want, often at the expense of one’s own needs.
		Covering or making excuses for behavior so as to avoid having to deal with the consequences, e.g., telling family that someone is “sick” or “tired” when he or she has taken too much pain medication or is drunk.
		A need to be in control of self.
		A need to be in control of others.
		Always depending on another for guidance.
		Discounting or doubting one’s own judgment.
		Always being worried about making the wrong decision.
		Ending up in relationships with people who need to be taken care of.
		Ending up in relationships with people who initially need help, but later take advantage or become abusive in some way.
		Fear of feeling angry (i.e., losing control), to the point of avoiding confrontation or conflict and/or denying that you are angry.
		Lying, omitting information, or exaggerating, even when it would be easier to tell the truth.
		Fearing abandonment.
		Fear of being alone.
		Tolerating hurtful behaviors.
		Guilt about not being able to take away the pain.
		Guilt for being angry.

THE SOLICITOUS SPOUSE

Research has shown that in the presence of a “solicitous spouse” (one who genuinely cares and expresses concern), pain and disability increase. Studies on chronic pain sufferers found that when their spouses focused more attention on the pain problem and engaged in overlyprotective, solicitous behaviors, their reported pain and degree of disability increased. Solicitous behaviors can include asking repeatedly if the person is in pain, suggesting that he or she lie down, or asking if the person has taken his or her pain medication. When the spouse paid less attention to the pain problem or actively tried to get the chronic pain sufferer to focus on other things, his or her reported pain and degree of disability decreased. Though this research focused on the spouse, what it illustrates is that if you reinforce pain (through codependent and enabling behaviors), the pain is maintained.

Mary’s tendency was to stroke Jim’s brow when he complained of pain. She’d coddle him and even use baby talk at times in an attempt to soothe his discomfort. This reinforcing behavior actually caused him to report and to feel more pain than when Mary was at work and he had to do for himself. He developed a lack of the ability to self-soothe. Sometimes, without realizing it, he groaned and complained to evoke a response from her. Imagine what would happen when she failed to respond the first time, being distracted, exhausted, or just annoyed. This became a source of great friction for them.

THE COMPASSIONATE BRAIN

We also know that our brains are wired to react empathetically when someone else is in pain. A study was conducted where people were shown videos of a person experiencing pain. Brain scans revealed that the same areas of the brain “light up” in the person who is watching someone in pain as in the person who is experiencing the pain. Literally, we feel another’s pain. And this empathetic reaction is much stronger when the person in pain is a family member. So it is only natural to develop enabling behaviors when a loved one is in pain. It is our innate response to feel another’s pain and to want to do something to help, but it is just those solicitous or enabling behaviors that make the pain worse.

Reinforcing pain causes more pain; reinforcing function enhances function.

When Amy cried with her pain, it would break Chris’s heart. He didn’t think he could stand it. He often gave her medication before it was due (he had confiscated her medications in an attempt to control her drug use), even though she appeared to be “loaded.” He simply couldn’t tolerate the feelings that came up when he witnessed her suffering. What would happen if he didn’t give her the meds? He didn’t want to find out.

{exercise} 2.4

Enabling Responses ___________________________________________

You may be unknowingly responding to _____________’s pain in ways that make the pain worse. This exercise will help you identify ways in which this may be occurring.

Please complete the following sentences with the first response that comes to mind.

1. I can tell when _______________ is in more pain because

2. When I know his or her pain is getting worse, I usually

3. When it’s time for _______________ to take more pain medication, I usually

4. If _______________ tells me he or she is hurting more, I tell him or her

5. If I want to go out to dinner or some other activity and _______________ says he or she is in too much pain to go, I usually

Secondary Gain: A Hidden Obstacle to Recovery

Secondary gain is a psychiatric term that means any hidden reason that is motivating a person to hold onto an undesirable condition or problematic behavior. Here it can refer to any perceived benefit _______________ receives from having pain, or it can refer to any perceived benefit you receive from _______________’s pain. If not identified, secondary gain can cause you to unconsciously hold onto unhealthy behaviors. This does not mean _______________ is pretending to hurt for these benefits, or that you want him or her to remain in pain, just that the benefits are making the pain rewarding in some ways and thus more complicated to treat.

Some examples of secondary gain that might result from having chronic pain are listed below. Check those that apply to _______________.

_____ Receiving more attention.

_____ Not having to work.

_____ Being excused from responsibilities.

_____ Being on disability—essentially, being paid to be in pain.

_____ Getting out of activities.

_____ Having an excuse to take pills.

Some examples of secondary gain that might result from caring for someone with chronic pain are listed below. Check those that apply to you.

_____ Giving you a sense of purpose and meaning in life.

_____ Being the hero/caregiver/helper/rescuer (having someone who rewards your need to be needed).

_____ Being able to “people please.”

_____ Being in more control or having more power in the household.

_____ Getting you out of the house, since you have to work to support family.

_____ Being the major breadwinner.

_____ Receiving disability benefits that help support the family.

_____ Expecting a large financial windfall from a lawsuit due to injuries.

_____ Reinforcing your sense of being a martyr/victim, fulfilling a need from early childhood.

When you become aware of them, you may view secondary gain as deserved compensation for the challenges you are experiencing. These thought processes may be conscious but are usually totally unconscious. Either way, if these beliefs remain unexamined, they will interfere with your ability to improve your situation. Taking inventory of secondary gain you and _______________ may be experiencing, and examining your attitudes about this, is an important step in moving toward balance.

{exercise} 2.5

Identifying Secondary Gain ____________________________________

List all the real and perceived benefits you have ever received from _______________ having chronic pain. Be sure to include the things you get, as well as things you were or are able to avoid. One example of each is provided for thought.

PHYSICAL {example: I do not have to be involved in activities I never really liked because _______________ can’t do them now.}

MENTAL {example: Since _______________ is out of it most of the time, I can speak my mind more freely.}

PEMOTIONAL {example: I can avoid emotional intimacy.}

FAMILIAL (Include emotional as well as specific household or practical responsibilities.) {example: I am in charge of what happens around here.}

SOCIAL/WORK LIFE {example: Just like I always wanted, I have to go to work. What a relief!}

SEXUAL {example: He’s in too much pain for physical intimacy, so I don’t have to do that anymore.}

It’s important to look closely at secondary gain, as the perceived benefits might not be as attractive as you believe. Most of the time secondary gain is not gain at all, but loss. Chronic pain sufferers and their families often inadvertently buy into the concept of secondary gain without looking at primary loss.

{exercise} 2.6

Examining Secondary Gain ____________________________________

Go over the list of examples of secondary gain you identified and take a minute to look at what is actually going on. Write about your observations.

Most people find they are just stuck and afraid to move forward. Once you walk through this fear, you will find you gain much more by a return to normalcy in your life.

Looking back, Chris couldn’t say exactly when things had changed for Amy and him, but it was probably soon after she started on Lortab and Soma for the diffuse pain all over her body that left her anxious and depressed. When she started taking the pills, everything got better for both of them for a while because Amy’s pain was reduced, but eventually the doses and strength of the pills increased. The pain doctor she found had rapidly advanced her medication intake. She became emotionally distant; she seemed to disappear into a drug haze, but when unmedicated, she was miserable with the pain. Chris called her doctor to discuss his concerns but was unable to speak with anyone because of HIPAA^* restrictions. Amy was clearly addicted to her medications, which became a complicating factor in her relationship with Chris. Chris now had to deal with his responses to chronic pain as well as her addiction.

In this chapter, we’ve discussed the many ways in which families react to the entry of chronic pain into the system and how it can upset the balance of the family system. Important in this discussion are the issues of what defines a family system and the effects that chronic pain has had on your family, as well as codependence, enabling, and secondary gain. We hope you have seen how these issues relate to you and your family. With this background, we turn now to a discussion of addiction and the effects of drugs on the family.

*The Health Insurance Portability and Accountability Act (HIPAA) provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information.

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