Chronic pain and abuse: Listening for the connection

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Chronic Pain and Abuse: Listening for the Connection Claudia

Zayfert,

Lad Vi: W-, N.A. Radomsky

PhD

Chmnic

Pain,

and Abuse

Harrington Park Press, New York 1995. 169 pages, $12.95 (softcover)

-EM

Broner

TheWikHoggodah

This book interweaves educational material and social commentary with poignant clinical tales of the women it seeks to serve. The women in these stories suffer not only from chronic pain, but also from desperation, fear, isolatiorl. and a pervasive sense of powerIe+ neSS in Ilr.:ir lives. TLese stories will be all 100 familiar tc rhe seasoned clinician who tends to the n.& of wOrnen with chronic pain. For the D Gee practitioner, they may be eyeopeni,,g examples of the multitude of chronic health Lcmplaints that defy the medical Claudia Zayien. PbD. is a Research Execufive DiGion of The National Traumatic S..m Disorder, White \km.ont, US< and Ass&ant Prd&or at Ikwtnollt‘n Medical School. Harqxshlre, JSA Pn Yms-392496~155-8

Associate at the Center for PostRiver Junction, of Ps@atry Lebanon. New

model. They are well worth reading even If only for rich qualitative descriptions of contemporaneously occurring chronic pain and abuse reported by numerous empirical investigations. The true merits of this book lie. however, in the thoughtful manner in which Dr. Radomsky leads the reader to an undemanding of the utility of viewing this perplexing problem from a feminist perspective. Thejourney is both a penonal and professional one, as Radomsky shares her frusuation in attempting to apply the rigid medical model she embraced during her uaining to the plights of the women who enter her primary care office. Radomsky offen a brief introduction to the biopsycbosocial model as an alternative to uaditional medical models. She the goes a step further and implores the readers to reach beyond the limits of the biopsychosocial model and to include cultural and emotional aspects of healing in their appmach IO caring for these women. The discussion relies heavily on feminist understandings of relatioruhip as cenual to creating meaning in women’s lives. She focuses on the intimidation, repression, powerlessness. and isolation women often experience in relationships molded by patriarchal cultures. By examining the anguish of women in repress& relationships, Radomsky attempts to draw connections between interpersonal functioning and the dominance of physical complaints in patients’ l&s. She uhimateiy concludes that exacerbations of chronic pain reflect unmet needs for reU. 08853951/%/$15.%

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exercise, diet, and selfcare. In struggling to meet the demands of the roles set for them by a parriarchal society, women have been reinforced for verbalizing bodily symptoms, and punished for expression of emotions. Radomsky hypothesizes that over time, women subject to this pattern of social reinforcement learn that emotional needs can be met through communication of physical symp toms. While this argument is consistent with operant theories of pain, she surmises that through the processes that silence women’s intuitive and emotional ways of being, women lose connection with their bodies and become uruesponsive to its needs. The healing process, thus, is largely one of tuning into both bodily and emotional needs. The physician can play a key role in igniting this process by reversing the pattern of silencing so often perpetuated by doctor-patient relationships. Radomsky does an excellent job of modeling such empathic and collaborative physician-patient relationships throughout the book. She emphasizes that it is through this collaboration tbat the physician can artfully lead the patient down a patb of healing. This is a process that will restore a sense of importance, competency, and control to women immobilized by oppressive relationships; essentially, restoring their “lost voices.” An element of the book I found most refreshing w-as the discussion of sevetzl important observations that emerge from Radomsky’s self-reflection upon her professional behavior in her role as a physician. She notes that the medical model shields physicians from their own sense of powerlessness in dealing with abused women. Within this model, physicians focus on concrete causes and effects in their attempts to diagnosis, label, and fix health complaints. They cling to their role as experts, distancing themselves from the vulnerability represented by patients who do not respond tJ technological interventions. Physicians are “uncomfortable with the complexity and the messiness of emotional responses.” They prefer not to know of problems they cannot fix. In offering a pill to an abused woman, the physician avoids the confusion and complexity of the psychosocial situation, and retain? a sense of power and competency. The recipient of the pill feels silenced

Reviews

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and invalidated, and is left to cope on her own with her overwhelming predicament. I applaud Dr. Radomsky’s candor in reflecting on the damage that may be done when physicians arc unable to break out of “the expert thing” to forge collaborative relationships with patients. Attention to the role of the feminine experience in women’s health problems is long overdue. By encouraging health care providers LO examine the social context within which behavior-health relationships unfold, this book is sure to provoke scholarly discourse among researchers and clinicians alike. Dr. Radomsky provides a concise and readily digestible summary of the literature linking chronic pain and abuse that launches her quest to find meaning in thi,, association. Her analysis. while rich in valuable clinical and introspective commentary, would be strengtbened by drawing c!oser connections to existing theory and empirical literature on both chronic pain and abuse. In particular, this discussion would be enriched by forging stronger links with the literature that seeks to understand how psychological stress relates to chronic pain through an integrated model of psychological and physiological processes (for example, the diathesis stress model of illness). The field of pain management has developed an extensive literature that explores applicattons of major psyrhological theories (for example. self-efficacy theory, operant theory, uvo-factor theory) to the understanding and treatment of chronic pain (for review, see Flor I al.‘). The social function of pain expression 2nd the role of empowerment and selfcontrol are central theses of the book The utility of these discussions would be greatly enhanced by making connections with existing theoretical and empirical literature in these areas. Radomsky highlights a neglected, yet important, issue when she explores the role that devaluation and silencing experienced by women may play in their somatic symptoms. As is well known, much of tire abuse women experience in relationships is accompanied by violence or threats of violence, which can produce persistent conditioned fear responses that may effect the experience of pain. For many abuse survivors, repeated exposure to violence and threats leads to post-traumatic stress disorder (PTSD), which is associated

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whh poor long-term health.s*’ The CCV. fc9 tures of FTSD include intense anxietv, dittress, and physiological reactivity upon expos Ire to reminders of the trauma, marked efforts to avoid such reminders, and hypetarousal in both the sympathetic and central nervous systems. In recent years, considerable attention has been focused on the role of fear, avoidance, and hyperarousal in chronic pain (for example, Lethem et al.s). In cases in which pain is superimposed on traumatic experience, the impact of fear and avoidance on the pain experience may be magnified. For these reasons, a comprehensive analysis of how abuse impacts women’s physical well-being should address the role of fear conditioning within an integrated biopsychosocial model. In summary, by illuminating connections between physical and psychological pain, tbii book may help survivon of abuse to find their voices. The book does an even greater service by demonstrating for clinicians the value of listening to those voices. Radomsky opens the door for medical providen to da--!q 7 hmader and clinicdly useful model for approaching women suffering from chronic pain and abuse. Unfortunately, she f&Us short of clearly articulating a model to explain relationships between chronic pain and abuse that would generate hypotheses and guidelines for tnzaunent thal are empirically testable. Thus while the book may point researchen in the right direction, it leaves them without a road map.

1. Broner. EM. The Women’s HaggJdah. New York: Harper Collins Publishers I 994. 2. Ror H. Birbaumer N. Turk IX. The pyhobiology of chronic pain. A& Behat Res Thtr 1990,12: 47-84.

3. Houskamp BM. Fey D. The +sessmem of peattraumatic stress diwrdrr in bag d women. J Imerpen mllence 1991;6367-375. 4. Rowan AR. Fey DW. Postuamlatic stress disorder in child sexual abuse sur\.vors: a literature rcview.J Traumatic Stress 1999;63-‘29. 5. Lethem J. Slade PD. Troup JDC. b~n:!ey G. Outline of a fear avoidance model of exagbcrated pain perception--I. Behav Res Tber 1983;21:401408.

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The Missing Link: Sports Rehab Richard

B. Birrer,

MD

Edited by Ralph M. Buschbacher and Randall L. Btaddom Hanley & Belfus. Philadelphia 1994, 319 pages, S50.00 ln a market glutted with 5~1~ medicine textbooks, a wistful exclar..ation of “Where have you been?” received rids book. Primary care physicians know
Richard B. Birrer, MD, is Associate Profeoor of Medicine ac Cornell Uninniry Medical College, New York. NY and is also afRliated with Catholic Medical Center of Brooyll and Queens. Jamaica, NY, USA. III scms-3!t2q%IooIs&x