Couple Therapy and Chronic Headache: A Preliminary Outcome Study

Ranjan Roy

Professor of Social Work and Psychiatry, University of Manitoba, Winnipeg, Manitoba, R3T 2N2, Canada.

Accepted for Publication: March 3, 1989.

SYNOPSIS

This brief report examines the factors that led to successful completion of couple therapy with 8chronic headache patients and their spouses, as opposed to another 8 couples who dropped out oftreatment. Overall, the couples who successfully completed therapy were in less strifeful marriages andwere confronted with specific life change events as opposed to the couples who dropped out, who gaveevidence of chronic marital difficulties. Family and couple therapy for chronic headache sufferers isrecommended on a selective basis.

(Headache 29:455-457, 1989)

COUPLE THERAPY AND CHRONIC HEADACHE:A RETROSPECTIVE OUTCOME STUDY

Family factors have been implicated in the etiology, maintenance and perpetuation of headaches and otherchronic pain problems.1,2,3 In addition, negative consequences of chronic pain on the family system have comeunder considerable scrutiny over the past decade.4,5,6 Family treatment of chronic pain, on the other hand, hasreceived very limited attention in the literature.7,8,9 Reports of family treatment are primarily of a clinical nature andcontrol studies to test the efficacy of family therapy for chronic headache are non-existent.

The following study, which is of a very preliminary nature, was undertaken to determine retrospectively thefactors that might have contributed to a positive outcome of couple therapy for chronic headpain.

METHOD

Eight subjects with chronic headpain and their spouses who successfully completed couple therapy, werecompared with another eight chronic headache sufferers and their spouses who dropped out of treatment beforecompletion.

A retrospective clinical analysis was conducted to explain this difference. Couple functioning was assessedusing the McMaster Model of Family Functioning.9 In addition, information was obtained on recent life events, andpast psychiatric and medical history and a detailed history of the headache. The couples were treated utilizingproblem-centered family systems therapy.10 All information was obtained through clinical interviews. Outcome wasbased on self-report of improvement of headache and family functioning as wall as clinical evaluation.

RESULTS

The mean age for the successful outcome group was 36.7 years with a range of 25 to 53; and for the dropouts36.5 years with a range of 26 to 52 years. In the successful outcome group there were 3 (37.5%) males and 5(62.5%) females, as opposed to 4 (50%) males and 4 (50%) females in the dropout group. The successfuloutcome group comprised 3 (37.5%) patients with muscle tension headpain, 2 (25%) with mixed headaches and 3(37.5%) with migraine. The dropout group had 6 (75%) with muscle tension headache and 2 (25%) with mixedheadaches. The duration of marriage for the successful outcome group was 8.37 years and a range of 11 to 18years, as opposed to 11.87 years for the dropout group. As for employment status, 6 (75%) patients in thesuccessful outcome group were engaged in full-time employment and 2 (25%) were homemakers. 5 (62.5%) of thedropout subjects were in full-time employment, 2 (25%) were homemakers and 1 (12.5%) was unemployed. Themean duration of pain for the successful outcome group was 16.62 with a range of 9 to 30 years; and for thedropouts 17.75 years with a range of 1 to 25 years.

Psychiatric history for the successful outcome group was negative and there was only 1 (12.5%) subject in thedropout group with a history of psychiatric illness. As for other health problems, only 1 (12.5%) subject in thesuccessful outcome group had a history of physical illness, and there were none in the dropout group. In terms ofrecent life events, 7 (87.5%) subjects in the successful outcome group provided powerful evidence of many lifeevents as opposed to only 3 (37.5%) subjects in the dropout group. Detailed examination of the marital historyrevealed that 3 (37.5%) couples in the successful outcome group provided a history of chronic marital discord asopposed to 6 (75%) couples in the dropout group.

On the basis of the six dimensions of the McMaster Model of Family Functioning, the following facts emerged. Inthe area of problem solving 3 (37.5%) couples among the successful group provided evidence of effective problemsolving as opposed to only 1 (12.5%) couple in the dropout group. Evidence of clear and direct communication wasprovided by 4 (50%) couples in the successful outcome group and none in the dropout group; 2 (25%) couples inthe successful outcome group engaged in clear and indirect communication as opposed to 3 (37.5%) in the dropoutgroup, and masked and direct communication was absent in both groups. Masked and indirect (least effective) typeof communication was evident in 2 (25%) couples among the successful outcome group and 5 (62.5%) in thedropout group.

In relation to role functioning, 4 (50%) couples in the successful outcome group provided evidence of a nurturingand supportive type relationship as opposed to 2 (25%) in the dropout group. 5 (62.5%) couples had satisfactorymarital and sexual relationships in the successful outcome group, as opposed to none in the dropout group. 7(87.5%) patients in the successful outcome group were fulfilling their occupational roles as opposed to 5 (62.5%) inthe dropout group. All 8 (100%) couples in the successful outcome group gave evidence of effective functioning inthe area of household activity and 6 (75%) couples in the dropout group gave similar evidence.

In relation to affective responsiveness which deals with couples' and family members' ability to express a wholerange of emotions, 4 (50%) couples in the successful outcome group gave evidence of their ability to express a fullrange of emotions, as opposed to 2 (25%) in the dropout group. 4 (50%) couples in the successful outcome groupalso could only express negative emotions as did 6 (75%) couples from the dropout group. In the area of affectiveinvolvement which deals with nature of relationships 7 (87.5%) couples of the successful outcome group engagedin empathic (that is, effective relationship), as opposed to 2 (25%) couples in the dropout group. Finally, in the areaof behaviour control which deals with the rules by which families live, 3 (37.5%) couples in the successful outcomegroup gave evidence of flexible (that is, effective) behaviour control, and 2 (25%) couples in the dropout groupengaged in flexible behaviour control.

Finally, 5 (62.5%) patients in the successful outcome group reported reduction in headpain. None in the dropoutgroup did. 8 couples who completed the treatment altogether had 48 sessions between them with a mean numberof six sessions. The dropout couples had 18 sessions with a mean of 2.25 sessions per couple.

DISCUSSION

This retrospective clinical study revealed a number of interesting differences between the group we treatedsuccessfully and the group who dropped out of therapy. The following points of difference are noteworthy.

First, the successful outcome group had many more recent life events than the dropout group. This may beindicative of the fact that the successful outcome group were faced with more immediate problems, or even crises,which could have been precipitated by life change events. While the patients presented themselves to the clinic withdefinite complaints of worsening of headpain, they were unquestionably confronted with problems as aconsequence of the life change events. That fact conceivably made them more amenable to treatment.

Second, on the McMaster Model of Family Functioning, major differences emerged between the two groups.Some of the more striking differences were: (a) the successful outcome group gave evidence of more effectivecommunication between the couples; (b) in the area of sexual and marital gratification, the successful outcomegroup was most effective, whereas the dropout group was totally ineffective; (c) in relation to affectiveresponsiveness, affective involvement and behaviour control, the successful outcome group was more effectivethan the dropout group.

Overall, it would appear that the patients and spouses who completed therapy were more stable in their maritalrelationship. It may be reasonable to speculate that the problem of pain had a limited effect on their ability tofunction as couples. A combination of recent life events and pain brought these individuals for marital therapy.

In contrast, the dropout group furnished ample evidence of chronic marital strife. The strife probably predatedthe pain problem, and may have been accentuated by the problem of pain. These patients and their spouses werefirmly entrenched in the sick role and seemed determined to perpetuate that status. Finally, it should be noted thatthe couples who completed therapy not only provided evidence of improved couple functioning, but 5 (62.5%) ofthe 8 patients also reported a reduction in the frequency and intensity of headpain. This reported improvement wascorroborated by their spouses, but there was no provision within the study to independently verify the change in thelevels and frequency of headpain.

This investigation offers a very preliminary basis for exploring differential outcome in couple therapy for chronicheadpain. It points in the direction that couples who present themselves at a pain clinic with complaints ofexacerbation of pain, and who upon further exploration, reveal stressful life change events and a reasonable level ofcouple functioning, may be very amenable to couple therapy.

REFERENCES

1. Turk D, Flor A, Rudy T: Pain and families I. Etiology, maintenance and psychosocial impact. Pain 30:3-28,1987.

2. Payne B, Norfleet M: Chronic pain and the family. Pain 26:1-22, 1986.

3. Roy R: Chronic pain and family: A problem-centered perspective. New York, Human Sciences Press(in press).

4. Flor H, Turk D, Scholz D: Impact of chronic pain on the spouse: Marital, emotional and physicalconsequences. J Psychosom Res 31:63-72, 1987.

5. Hudgens A: Family-oriented treatment of chronic pain. J Marital and Family Therapy 5:58-67, 1979.

6. Roy R: Impact of chronic pain in marital partners: systems perspective. Proceedings of the Vth WorldCongress on Pain. Amsterdam, Elsevier, 1988.

7. Roy R. Couple therapy and chronic pain. In: D Tollison (Ed.). Non-surgical treatment of chronic backpain. Baltimore, Williams and Wilkins (in press).

8. Flor H, Turk D, Rudy T. Pain and Families II. Assessment and treatment. Pain 30:29-46, 1987.

9. Epstein N, Bishop D: Problem-centered systems therapy for the family. In: A Gurman and D Knisnerz(Eds.). Handbook of family therapy. New York, Brunner/Mazel pp 444-482.

10. Roy R: Problem-centered family systems approach in treating chronic pain. In: A Holzman and D Turk(Eds.). Pain Management: A handbook of psychological treatment approaches. Elmsford, NJPergamon Press, pp 113-130.