Chronic Pain Explained w/ Dr. Dean Tripp

This week on The Caregivers Podcast, Dr. Mark sits down with returning guest Dr. Dean Tripp, a professor of Psychology, Anesthesiology, and Urology at Queens University.

Together, they pull back the curtain on the neuroscience of chronic pain, explaining how it physically alters the brain and why the traditional medical model often fails those in pain. Dr. Tripp introduces the C.A.R.E. Method, a practical framework for caregivers to provide empathy without burning out, and tackles the taboo topic of caregiver resentment.

Whether you are living with pain or caring for someone who is, this episode offers a roadmap for moving from a state of learned helplessness back into a loving partnership.

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What is The Caregivers Podcast?

The cost & courage of caring - stories that spark resilience.

Welcome to the Caregiver's

Podcast.

I'm your host, Dr.

Mark Ropolesky, and our guest

today

is a returning guest from Season

1, Dr.

Dean Tripp.

He's a professor in the

Departments

of Psychology, Anesthesiology, and

Urology at Queen's University in

Kingston, Ontario,

Canada, and he studies chronic

pain.

Chronic pain is one of the most

misunderstood kinds

of suffering, especially when

tests look normal.

Today, we're going to explain what

chronic

pain is, what it feels like from

the inside, and what caring for

someone in pain does to

the caregiver.

Dean, thank you for being here.

Welcome back.

Dr.

Dean Tripp, welcome back

to the Caregiver's Podcast, a

returning guest.

So happy you're back here, and

boy, do we have

some questions for you today.

Thank you.

Let's just start off and hit the

road running.

Chronic

pain is not just pain that lasts

longer.

So in plain language, can you just

tell us, what

is chronic pain, and why do people

misunderstand it so often?

That's a great question, Mark.

I mean, you know, chronic pain, I

guess, frequently is misunderstood

because it lacks visible evidence,

or markers, whatever language you

want to use.

And it also

tends to clash with traditional

medical models on how we think our

bodies should be behaving.

Pain is one of those interesting

things where it's like, when

you're in acute pain, like, you

know,

I stub my toe, I break a finger,

I, you know, depending on the

level of acute pain you want to be

in,

you know, we have full expectation

that it's going to stop.

Like, you know, I take a Tylenol,

I'll take an Advil, you know, I do

some kind of medical thing, and,

you know, I'm usually fine.

But chronic

pain is not like that.

It's when a system is broken into

a chronic state of alarm.

And some of the key,

sort of reasons, I think, from my

perspective, you know, over the

years, some of the key reasons

from

this misunderstanding really is

about the invisible nature.

Like I said, unlike acute

injuries, you can't

really see them.

You don't see tissue damage, you

don't see a broken bone.

So chronic pain often

doesn't have traceable tissue

damage that shows up on even

standard medical tests, works or

scans.

So

there's no way, like, it'd be

great if we had a pain thermometer

in our forehead, and this

thermometer

would glow red when we were in

pain, people would know.

So there are physical signs of

pain, but

there's no standard testing that

we can use to show us that you are

in that pain.

So pain is subjective.

And that's one thing that's, that

makes it personal, makes it

private.

And I can be in a lot of pain,

and you don't know unless you ask

me.

And that, that is hard to measure.

Because when you're trying

to do this objectively, and then

you're taking a subjective report,

as a physician, as a psychologist,

as a healthcare provider, and as a

caregiver, how do you know without

asking how much pain someone's in?

You can look at body behavior, you

can look at different ways to kind

of help code it, you can

look at the changes in the human

that you're dealing with, the

changes in personality, the

changes that we

might, we call it personality, but

I really don't think I should call

it personality.

We might talk

about that later.

But I think the thing that's

important to understand is there

are these thoughts,

it's like chronic pain is to me,

like a false alarm mechanism.

Like in what I mean by that is in

chronic

conditions, the nervous system can

become quite hypersensitive.

And these pain signals that we

have

in our body, like if I smash my

fist with a hammer, I'm going to

have pain signaling from this

point of

injury up my arm to my spinal cord

to my brain where it gets

interpreted.

So this kind of pain signaling

system is often a false alarm or

broken on, like a fire alarm that

continues to ring when there's no

fire.

And it's not like it's imaginary,

but there's no more physical

trauma that's happening, but the

pain

signaling is still there.

That is a really hard thing for

people to get their head around.

And I think

that's one of the biggest

differences between thinking of

pain being acute and thinking

about pain

being chronic.

I mean, there's other things I

could mention about it, like the

diagnostic uncertainty.

It's interesting.

I'm just going to stop you there

because it just really resonates.

It's not the nature of the

injury, but the nature of the

alarm.

And the alarm is probably, there

are a lot of inputs into that

alarm, which I think

we might be getting into a little

bit later, but that's, I think

that really seals it the

conceptually

for me.

And I think that that's a key

point for our listeners.

It's not the nature of the harm.

It's the

nature of the alarm.

So that's a great way to say that

people get told that, you know,

your tests are all

normal.

And in a blanket statement, you're

fine.

Yeah.

But how can pain be real if all

the tests and scans are

normal?

Yeah.

I mean, well, first of all, like I

said earlier, tests and scans are

limited in what

they're designed to do and how

they're supposed to measure an

event, if we want to call it an

event.

Because pain is an event.

Pain is not like, how can I say, a

static experience.

It's an event because

pain affects you as a person.

Pain affects your physiology.

Pain affects how we breathe.

Pain

affects respiration rate.

Pain affects, you know, the amount

of oxygen, fresh oxygen we get to

our brain,

our ability to think concretely.

It provides confusion, delirium.

Pain is like more than just a

single act.

So it's an ongoing experience.

And some of the things that are

really important to understand,

like societal and medical impacts

of pain, and chronic pain in

particular.

So we know stigma.

And one of the big stigmas we have

in chronic pain, and I'm quick to

say this, is in how we

approach people, how we treat

people, how we care for people.

And this includes medicine,

psychology, OT.

This includes physiotherapy,

includes all the helping

professionals.

And because

we sometimes think of people who

have chronic pain as exaggerators.

You know what I mean?

Like they're exaggerating their

pain.

It's not an exaggeration.

And the thing

about remembering, pain is the

fifth vital sign.

And the most important thing about

pain is what I tell

you it is.

Now, there are times when you can

be stressed, and that stress can

elevate your pain.

So does that mean it's you're

exaggerating it?

No, it means that your system is

amped up, and you're more

vulnerable to that pain sensation

than you may have been if you're

relaxed.

So that's not an exaggeration.

That's a cause and effect model

inside of pain experience.

Caregiver is professional and the

like, and allied health caregivers

need to be taught more about

pain.

Maybe the lecture needs to be more

than an hour.

Maybe we need to understand the

physiology of

pain a lot better before we go

trying to treat it.

And maybe we need to make room for

that.

What do you

think?

Well, I think there definitely is

space that we're walking into

medical programs, at least the

ones I'm

aware of in Canada and the ones I,

you know, my colleagues in the

States and some of my colleagues

over in Germany and the UK.

In particular, there is changes in

curriculum around pain education

for

physicians and surgeons.

I mean, you know, people who do a

lot of these interventions.

And I think that

that's a good, that's a good

movement and it's still in the

right direction.

But I think importantly,

one of the things we have to

remember about chronic pain is

that there's always diagnostic

uncertainty.

And that's the thing that I think

ruffles feathers in medicine with

pain and in

caregiving because it's, it's

uncertain.

There's an uncertainty to it.

Because you don't want to miss the

new acute thing that's happening,

making the pain worse,

or because you don't understand

the patterning mechanism.

Yeah.

Well, exactly.

So because pain is complicated, we

see between, oh, I think if I

remember the numbers correctly,

between 40 and 80%, pretty big gap

of chronic pain patients are

estimated to be misdiagnosed due

to the reliance of improper tests

and or the failure to take a

comprehensive pain history.

So when we're thinking about

whether the pain is acute, what's

the patterning

of the pain?

You know, did, is there acute pain

inside the chronic pain situation?

Like you can

still get hurt and have chronic

pain and have more pain.

People think if you have chronic

pain, you're

just at a level.

That's not true.

So these myths, these

misunderstandings, if you don't

have dialogue,

you don't have discussion, if you

don't talk to the patient about

their experiences, you're then

going to go

where you're going to go to

stigmas and biases or limited

understanding of what their

experience is.

So I always say there's no easy

way except to start communication

on it.

That's the smartest way

to move, I think.

You know, we've spoken a lot on

the podcast to different

individuals when we've looked at

the,

you know, the range of

availability of comprehensive

primary health care in Canada, and

it applies to

numerous parts of the world.

If your only recourse to present

with an exacerbation of chronic

pain is

the emergency room, you're, the

intake of data about you and your

pain experience is going to be

biased by the nature of the

environment by which you're

actually presenting.

And that's got to be

huge, right?

Because that's not the place to

take a chronic pain inventory

effectively.

The time just may

not be there.

Yeah.

And again, it, see, here's the

issue with chronic pain.

Well, there's a bunch of them, but

here's

one that pops out when you talk

like that is, is first of all, the

education, which we talked about,

like, what do you know about the

pain and what type of place are

you being evaluated in?

And is it

appropriate?

So it may not be the first time

that you get looked at, but I can

tell you, uh, from

personal experience and seeing the

ER work, there've been times when

I've seen ER docs do very

comprehensive

and very empathic, um, and, and

relatively quick, uh, kind of pain

assessments, including for

patients

in chronic pain.

Cause you'll see that if you talk

to your ER buddies, you know, uh,

in college around

the world, you'll hear people say

that, look, I've got a chronic

pain patient come in and they

exacerbated their pain from this

injury.

And I have to detangle where their

pain is based on

the composite of how they

experienced their pain to date.

And that's complicated, you know,

but I mean, so I guess the bottom

line is if you don't start asking

the questions, if you don't ask

broad based questions and get an

understanding of, you know, kind

of baseline, if I can use that

expression and then kind of

current kind of promoters of more

pain or antagonizes of more pain,

then you're going to miss, I think

you're going to miss it.

So you have to be careful to not

miss

that kind of relationship.

Well, shout out to our medical

colleagues across North America

and the

world who are manning small

hospital emergency rooms that are

full and also being first call

coverage to the ICU and the ward

admitted patients where, and you

can be pretty sure that you're not

going to get a comprehensive pain

history in that case.

So Dean, for someone who's never

lived with

chronic pain, what does it feel

like day to day and not just the

body, but in the mind of the

person

suffering of chronic pain with

chronic pain?

Yeah, boy, that's, that's a tough

one.

I mean,

you know, I've, I personally have

had pain experiences that have

lasted beyond three, four weeks.

I've had

surgeries.

Um, but the patients I've been

lucky enough to share, share time

with, um, I've, I've never had

that experience.

And part of what I gather from

talking to, to folks and over the

years and, and my own

experiences and my research, um,

in combination is that it can be

an empty, empty place.

And there's two

major things that I keep hearing

again and again is number one,

that you become a burden, uh, to

others.

And that is, uh, that, that sense

of being a burden is connected to

a whole hosts of other spinoff

problems that people face, but it

keeps coming back to burden and,

you know, hopelessness.

And I think

that's what we hear.

The reasons for those things are

complicated, but they're not,

they're not a rocket

science.

Like if you feel rejected by your,

let's say your medical

practitioner and, and they say,

look, there's nothing I can do for

you.

Uh, this, the way this is working,

you need to go practice

relaxation.

And, and, and if you get that

sense of being dismissed and I'm

not, I'm not saying that

this is, uh, that happens every

day, but I'm saying if you get

that sense of being dismissed by

your

medical practitioner and by other

people in your life, that they

just can't help you, can't get you

going, can't understand you, don't

have the empathy for you, don't

have the sympathy for you.

Um, you

know, that, that's where I start

to hear that word burden.

So in terms of the experience of

chronic pain,

many patients I've talked to,

cause I've seen chronic, chronic

pain, uh, and chronic, uh,

unremitting pain.

Uh, so when you talk about

defining what the day's like for

some of those people,

those days feel like that I'm a

burden and it's hopeless and it's

never going to get any better.

And that is a dark place to be for

others in chronic pain that I've

talked to.

Um, you know,

and I've seen a variety of people

who are post-treatment, um,

whether it's physiological

treatment or psychological

treatments.

And what they, what they try to do

is they just try to position

living their life in spite of

their chronic pain.

And there's a, there's a

difference between people

who I find that are in a dark

place with their pain versus

people who have maybe touched that

space

and then moved out of it a bit,

other by things that they've been

able to manifest or the

environment

or combination of these things.

So the day-to-day existence

inside, inside of chronic pain can

be

varied.

It can be very different.

So I think again, how do we find

out?

We talk to the individual

that's in pain.

We ask questions about their day.

We are open to kind of hearing

their experience.

And I think that's, that is a, as

a good way to try to anchor the

day-to-day experience for the

person you're caring about or the

patient you're seeing.

So I think it's a good lesson to

know

that there's so many different

places people can be that you have

to kind of lean into that and be a

bit inquisitive.

You got to show the support, ask

the questions and provide some of

that empathy

and sympathy.

I think it would certainly go to

say that life experiences leading

up to the initial trigger event

that led to a chronic pain state

probably have a way in shaping how

comfortable and or how able an

individual with chronic pain is

able to step in and step out of

that chronic pain experience and

then

enter that phase of, well, I'm

living the best I can with it as

opposed to that feeling of

hopelessness.

You know, they say that chronic

pain changes the brain over time.

And if you imagine the pain

patient

in their environment with people

who care for them, their families,

their caregivers, what are some of

the

what are some of the most common,

you know, changes that actually

occur but that would have families

otherwise would mistake as, you

know, the character of my loved

ones changing, the attitude of my

loved ones changing.

There's, you know, there's, you

know, how do we sort that out or

what can we teach individuals to,

to understand

better about that effect of

chronic pain on the brain on

day-to-day activities?

-That's a great question.

Um, I think it's a two-part

response.

The, the first, the first thing

that I heard you

say, Mark, was like, you know,

can, can, can pain, uh, change

your brain?

Like, you know, and this is, goes

back to the physiological talk

we're having at the beginning,

talking about, you know, that pain

is a

physiological experience.

It's not just a psychological

experience.

It is also a physiological

experience.

And one of the things that's

interesting is there is research

that talks about how, you know,

the brain can

actually visibly be changed under

assessment, uh, through chronic

pain.

We can say that's the mechanism

that changes the brain.

Now, I'm not gonna, you know,

there are, uh, different studies

out there that talk

about, you know, gray matter

volume and, and different indices

of the brain, um, that go on, the

activities

ongoing and really will stay

unaltered under chronic

neuropathic pain, say, for

example.

Um,

but what we do see is we do see

some subtle anatomical changes.

And some of these places,

they're like, it's called the

prefrontal cortex or the medial

prefrontal cortex, the interior

cingulate cortex.

You'll hear a lot about that, uh,

in the neuroscience talk.

And sometimes like the

thalamus or, or the, I think it's

the medial dorsal part of the

thalamus gets kind of altered

in structure.

So it looks, and what's really

interesting is it's like, you see

these changes,

especially like in the prefrontal

cortex and patients with pain.

And it's, it's really,

we think about what that area of

the brain is connected to.

That's when we start to talk

about,

Oh, personality changes or, Oh,

uh, attitude changes or, Oh,

there's different changes in

the individual.

And one of the things that I hear

a lot about is this idea of

novelty seeking,

because that is a, is sort of a,

if I can say an area of behavior

associated with that area of the

brain.

And if there's changes there, we

can see even subtle changes in

that activity or anatomy

can result in a change in an

individual's way of behaving.

So reduced novelty seeking,

if, if, if people aren't familiar

with that term, um, is basically

an interesting way of saying

you're

actively, you, you act and you're

less likely to actively avoid

monotony or potential punishment,

which I guess is a way of saying

you're less sensitive to future

consequences,

or you can seem dulled.

I've heard people say this.

I feel like I'm dulled.

It's like

my, my individual personality is

effectively altered.

Um, and that may need some

consideration.

And, and people will say that I

feel dull.

I feel like I am not motivated.

I'm disengaged.

I,

you know, so the, you can mistake

that first or rightly claim that

as a symptom of depression,

if it's also deep enough.

So to the answer to the question,

uh, of does physiological changes

happen

in the brain?

The answer I think is resoundingly

yes.

Um, do we know exactly what does

exactly what?

Uh, no.

Do we have some ideas that these

changes may show up in behaviors?

Yes.

There's correlations

there.

There may be some other

relationships inside of that that

we don't know yet, but I would say

that

these can change.

Yeah.

There's a lot of popular talk

these days about neuroplasticity

and new

connections and the ability of the

brain to form new connections

during, you know, habit formation

and

other things.

But from what we know, is this

chronic pain state and the

variable adaptation to it, does

that

reflect it in deconstruction of

preexisting neuronal connections

or is it new connections that are

forming?

Is it like, that's a, that's a

great question.

I don't, I don't really have a

solid

answer for that.

I can say that when we talk about

flexibility and we talk about

brain learning and we

talk about changes in, you know,

pathology, there's a wrong word,

but anatomy and function,

we do see changes under extreme

levels of stress as well.

It doesn't have to be chronic

pain.

Um, and we do see, uh, you know,

if we think about chronic stress,

uh, as something,

you know, as opposed to chronic

pain, and I think it's equatable,

uh, in my mind, but when we think

about chronic stress, we see

physiological changes in the body

also.

So we know they happen, um, in

terms of,

you know, whether it's a

degradation or there's a regrowth

or I wouldn't be able to answer

that

question, but I think, uh, there

must be, there, there has to be

play in that area.

I think for us,

one of the most important things I

want to highlight is yes, you

know, you can have, uh, sort of

changes

in your, in your person.

And I think personality is part of

that, but you can also have

changes that are

pretty profound in your

relationships.

And that's where some of these

changes in behaviors show up.

And I think that that's also very

important to anchor those

anatomical, maybe changes are

seeing

to a behavior that manifests in

the relationship.

I think that's a, that's a key to

make.

And then secondarily yet reinforce

again, new behaviors or altered

behaviors.

So when pain

in its chronic form becomes not

just permanent in the patient, but

permanent in the home,

how does it sort of quietly change

dynamics and roles and power in a

relationship at home?

Oh boy.

That's a great question.

Um, I, you know, from my

perspective,

there's a couple of things that

happen.

I think one of the things that,

you know, when, when I think

about caregivers and I think about

the home environment, you know, I

start to think about

the spouse, obviously, and the

spouse or the partner or the

individual responsible for caring

for this

person, um, or that, that find

themselves in that role.

And when a spouse, I'm just going

to use the

word spouse, uh, for my, myself to

anchor this, when the spouse

shifts into a caregiver role, the

first

thing to break is usually that

emotional or physical intimacy of

the relationship.

So it changes,

right?

Like when chronic pain becomes

into the relationship, it changes.

And there's often what

often follows that when that, you

know, that emotional and physical

intimacy gets a bit ruptured,

you often see a rapid breakdown in

communication.

And, you know, this, this kind of

potentially

emergence of, of resentment.

So this shift from, you know, uh,

this patient provider, uh, role,

this spousal caregiver role,

these, these roads of, you know,

role adjustments, they break down

in a,

in a relatively common way, uh, a

different, several different

aspects of the relationships.

And I think when I, when you, when

you make me think about spousal

changes and changes in the house,

I just go to that immediately

because they're, the literature is

clear.

Patients feel that first,

yeah, it's pretty significant, uh,

in regards to how that stuff

changes.

I'm sure it happens over a period

of time and it's not just

instantaneous.

And there are

plenty of opportunities with

greater understanding where you

can actually intervene.

So, you know,

patients with chronic pain in the

absence of a new acute injury can

have flare ups of their chronic

pain.

We've touched on that previously

when we spoke about some days are

two on 10, some days are seven

on 10.

But flare ups can be

unpredictable.

And in the middle of a chronic

pain flare up on a really bad

day, is there any advice that you

would give caregivers in terms of

what they should do,

but also what they shouldn't do in

trying to engage the chronic pain

patient in a flare up?

Yeah, I, I think, you know, uh,

one of the things I mentioned

earlier is this, this concept of

empathy and,

and, and, and sympathy and, and

understanding how to, you know,

not be a rescuer all the time.

And what I mean by that is the

practice of empathy.

Um, when someone is in a situation

of distress and I'm

going to equate significant new

acute pain on top of it in

existing, uh, chronic pain, um,

let's call

that significant distress.

You, you can't underestimate the

power of just being.

And what I mean by that is just

not trying to solve the problem

or, or, or maybe you'd start off

in solving mode.

Like,

can I get medication for this?

Can we do some kind of like, um,

uh, heat treatment?

Can we do a massage?

Can we do a hot tub?

Can we do some kind of meditation?

Can you do your breathing

exercises?

As partners, as partners, can we

do this?

And that like, that's a, that's an

action event.

Like,

those are all things that you

could pull out of your kit bag to

say, these are options.

Like,

these are things that I can try to

do for you.

Right.

But I think, uh, when, when, when

that kind of fails,

and this is, this is, uh, I think

an important point from my

perspective, when those, uh, quick

hits fail, what are you left with?

And I, our, our discussion at this

point makes me worry that

people are gonna, uh, you know,

forget that it's normal to be

panicked at that stage.

As a caregiver.

Yeah.

As a caregiver.

If I feel I can't help you and you

look like you need help,

I can't give something to you to

fix it.

Now I'm going to really be in over

my head.

Right.

Because

I feel now I feel helpless.

Now I feel hopeless.

Now I feel like, you know, I can't

do anything,

but you always can do something.

And, and it is, you can offer your

ear, you can offer empathy.

And I

talk about this, this acronym I

have called care.

And you know, the first stage in

care is C it's C A R E.

And the first stage in care is

like concentrate.

So when you start to feel panicked

as a caregiver,

um, you know, part of the things I

want you to do is just to

concentrate on what's in front of

you,

which is the person, you know,

stop the noise in your head to

worry about, I can't fix this.

I can't,

you know, just stop and just zone

in on the person and think about

the person you love and think

about what

they're saying, like, just

concentrate on what they're

saying, not whether it's right,

not whether

you can fix it, but what you think

you're hearing, what are they

saying?

Think about that.

That's step

one.

Two is to, two is really to attend

to it.

So now that you're kind of hearing

it, now let's start

to attend to it.

What does it mean?

So let's, what are they saying?

And have I seen this before and

give it

some context or attend to it.

And then third is to reflect it.

So now that I've, I've, I've

stopped

the noise, I've attended to you.

I'm focused on you and your

situation, which is difficult

enough.

Now I'm going to reflect it.

I'm going to, I'm going to reflect

it back to you because I'm trying

to give you empathy.

And the reflection of what you

said often leads to empathy

because now you think

I'm hearing you as opposed to me

having some wish like, Oh no, no,

just do that.

It'll go away.

I need it to go away.

I want it to go away.

Instead of that, you're saying

how, you know,

in this situation, I think what I

hear you say to me is this.

And then the person gets to

correct you

either.

No, that's not what I mean.

I, I, it's not about that.

I'm just really frustrated right

now.

I get it.

So you're not just telling them,

Oh, you're just having a bad day.

No,

you're actually reflecting.

You're saying, I hear you.

This is what I'm processing from

what

you're telling me.

And the key, tell me if I'm

correct or not.

Yes.

Am I hearing you right?

And that kind of discussion and

that kind of refocus of what the

issue is then leads to what I, you

know, so that's like the reflect,

right?

And then I think there's

E, which is expand.

So once we know this, once we've

done these two little steps and

we've reflected,

now we can expand on it.

Cause now I know maybe by asking

you another question, you know,

I can get to the root of where

you're at, where your pain is, is

your pain more psychological at

this moment than physical?

Because you're stressed out and

you think there's no control here.

Can I

help you with your feelings of

helplessness?

And that is an important place

that people can think.

Cause remember, I just said, you

did everything you're supposed to

be able to do.

You tried all your toolkit, you

know, all your items in your

toolkit, but you can always do

what

I just said.

You can always care.

And that care is an act of empathy

because I'm listening to you.

I'm, I'm slowing down.

I'm not jumping in and replacing

your words.

And then I'm coming to the

next, the expand.

Like, so what do you think, you

know, when we think about you

being in situations

like this before, you know, what

have we done before?

Where have we been successful?

What have

we tried?

And again, it's like this kind of

idea, depending on the situation,

right?

Of course,

um, where you're just trying to

sit with them and help them look

at where they are.

That is an

empathy.

And sometimes you just need to

shut up.

You need to hold them.

You need to put your arm around

them.

You need to hold their hands and

look in their eyes and say, you're

going to get through

this.

I'm here.

And sometimes that is helpful

because not everybody is looking

for a solution.

There's one thing I've learned in

the years of my life is being

directional all the time,

looking for a solution all the

time.

When someone wants to be heard,

can be abrasive, not

what they need at the moment.

So I think the care thing fits

into that idea of what can you do

when

you feel like you've run out of

things to do.

I could see on bad days when

someone says, just leave me alone.

You could have a cohort of

caregivers who find themselves

just walking on eggshells and

trying to avoid conflict and

potentially

making the pain worse.

What are the long-term

consequences when the partnership

has the

caregiver walking on eggshells?

Yeah.

What does it manifest to?

Right?

That's the real question.

Like you are going to be on

eggshells because if you care for

the person, and like I said, we

have an acute fix model in

our head about how life should

happen.

Like for many people, if I come in

and I complain

about a problem, they go, oh,

well, there's these things to do.

Like, let's have these solutions.

People by nature are solution

finders.

Most people.

People pleasers, yeah.

Yeah.

And you want to help somebody be

better.

I get it.

And if you like that person, love

that

person, you're more likely to be

the rescuer.

I get it.

I feel that role in different

roles in my life

all the time.

Like I want to rescue the person.

But when you start to feel,

eggshells to me sounds like

I don't know what I'm doing.

Like I don't have a cure.

I don't have the way.

And now I feel that

hopelessness and the helplessness.

So when someone is really upset

and I can't fix that,

I might shrink away.

And it may be from an aggressive

response.

Like you said, if someone

says you or get out of my face or,

you know, they're really

aggressive in that way, excuse my

language.

But if that's the aggression that

you face, that that's a push

because you can't solve

that.

That's a hard push.

That's a hard push.

And you know, when you get those,

when you get those

pushes, you have to make a

decision.

Like sometimes people will just go

to the other side of the room

and sit down.

Like you're not physically taking

off, but you're physically giving

space.

Like one of the things I've talked

about forever in terms of

psychotherapy and intimate moments

in

psychotherapy, when a patient gets

visibly upset, would I sitting

across from them in a chair come

closer and closer and closer to

them?

Or would I sitting in this chair,

which has a standard distance,

would I sit back in my chair a

little bit, but stay engaged with

my eyes, stay present, but act

behaviorally give them a little

space.

So sometimes people in these

situations give space,

right?

But it depends on your person.

Sometimes that outburst is

expected because you're used to

it.

Sometimes that outburst, they need

a minute and then they feel bad

for it.

And now you're into

the second phase, which is they're

more ready to talk about how they

feel.

Sometimes the outburst

leads to another outburst leads to

another outburst and you do need

to get distance.

So depending on the

outcomes from what you get, those

pushes, right?

Sometimes those pushes follow a

little bit of

a pull.

I need you.

Sometimes those pushes are

followed by pushes and pushes and

pushes.

And that

indicates, okay, let's take a

break.

Let's take a break, you know, and

that might be a distance break.

Does chronic pain affect a pain

patient's ability to show empathy

or does it deplete their empathy

bank

if the reaction of their

caregiving partner is to distance,

sit in a chair and burst into

tears?

I like the words empathy bank.

There's no standard answer to

that.

I mean, I think the standard

response for me on that question

would be, you know, try to do your

best as a caregiver.

Like,

try to do your best.

Will you make a mistake?

For sure.

Will you misinterpret the cues?

More than

likely.

But the thing about it is, the

beautiful thing about the

relationship is it's not going to

be over.

Unless you say, okay, it's over.

You pack your bags, you get on a

train and you actually

physically leave the relationship.

That doesn't happen.

Let's say that doesn't happen.

I mean,

it could happen, but let's say it

doesn't happen.

Just sometimes feeling awkward as

a caregiver or a

provider, I think is par for the

course.

When it gets rocky and you feel

like you want to leave,

I don't have any more empathy, or

they're feeling like you're not

providing empathy or whatever the

experience is, that's just the

next phase of work.

And that's how I like to think

about it.

It's not like,

you know, it's like, it's a movie.

It's not a picture.

It's not a snapshot.

So the event happened,

yes, but it's what you do with

that event in the next little bit.

That's the important thing.

The

event is an important signal, but

from that signal, what does that

create in the short term?

Like

immediate?

What does it create in the

midterm, which is two hours from

now?

What does that create

tomorrow?

And I think that's the important

thing for caregivers to remember

is that events are powerful.

events can be stressful, but they

are useful as signals to what you

might do in the future.

It's an analytical approach.

I get it.

And maybe, you know, the stress

that the caregiver is under is

too much and you can't put your

head in that space.

That's why I say to caregivers,

think about the CARE

acronym.

Have it written down somewhere,

you know, something like that.

Some, you know,

We're going to put that in the

show notes today so people can

actually see it and we'll make

sure

your acronyms out there because I

think it just frames things so

nicely, but

you can see how space can somehow

be created for pain to become the

third person in the couple's

relationship.

Yeah.

What are the most unhealthy

patterns that sort of couples will

fall into that

That's a good question.

Um, I like that you call it the

third person because it, in

effect, that's

actually a very smart way to think

about pain, right?

Because if you think about the

third person,

the, if you give pain, uh, it's,

it's person, right?

It's not, it's not Mark.

Like we know who Mark is.

And if pain is a third person,

that person has influence on Mark,

but it's not Mark, right?

It changes the

way Mark might behave, but you

know, perhaps it's not Mark.

So this idea that, you know,

there's a third

person, um, kind of perspective on

this is important.

I like, I like, it made me think

about a thousand

things about how to position that,

that, that language.

But, uh, to your question, when we

think

about the impact on relationships,

when pain becomes that dynamic,

that what, what happens to the

trajectory, there are things that

we have to worry about, obviously

impact on the relationship.

Number

one, I think when I start to think

about impact on relationship, I'm

thinking about strain.

I'm

thinking about role reversal.

I'm thinking about the non-pained

partner who assumes more household

financial caretaking duties, um,

which can lead to a shift, uh,

from, I don't know, say a lover to

a

caregiver or nurse.

So this role reversal and this

strain is a significant impact on

relationship.

And I think when we see pain

become chronic and fundamentally,

we get so like when patients,

I say they have their, their

chronic pain career, right, is the

way I try to think about it.

Sometimes

this third person gets introduced

into the relationship.

We have to worry about that.

Number

one, number two, because of stuff

like that, communication

breakdowns.

Number three, I think,

um, like I mentioned this earlier,

but erosion of intimacy and what,

you know, physical pain,

medical side effects from

medications, uh, diminished sort

of self-interest or self-esteem,

what that does, like even to

handholding.

Because if people go to that place

where they feel they're

a burden and they feel they're

unlovable, these are the things

that pay the price.

Like the erosion

of intimacy, I think is very

important to mention.

Social isolation.

Again, couple doesn't go out.

They don't do things anymore as a

group, as a couple.

They don't enjoy things even

together

anymore.

They don't look at each other.

Yeah.

And I think it's, when I talk,

when you make me think

about a third person in the

relationship, there is this, uh,

what's collateral damage to, I

think,

the, the relationship.

And I think we can, we can work on

that though.

There are things that people

can do, you know, to, to manage

this damage.

Um, and I think acting early

probably helps counteract

the ingrainment or even the, you

know, the neuroplasticity that

occurs in each member of the

couple's brains in facing these

recurring challenges and the

behavioral reinforcement.

Yeah.

And when I think, when I think in

particular about the caregiver and

I think about, you know,

how can they avoid this damage?

If we, I call the collateral

damage from, you know, what

chronic

pain does to us.

I think there has to be spaces

and, and time like rest flight

zones, for example,

where, you know, you create an

actual physical space or a

dedicated time where the caregiver

gets

to go away from this third person,

this experience.

So maybe it's one hour a week

where they go play

bridge.

I actually don't play bridge, so I

don't know how long it takes, but

let's say it's one hour

a week where they go to a book

club or there's one hour a week

where they do a hobby or something

for

themselves.

Just when you think about trying

to prevent the effects of that

collateral damage,

I think that those types of things

are very important for us to

emphasize that, you know,

setting realistic boundaries on

what you will do and won't do.

Like, you know, personal care

and, and cleaning and things like

that.

If that's a personal boundary

setting, then you have to

negotiate, negotiate that,

navigate that, you know, as best

you can.

So I think those are part of what

I'm thinking about when I think

about how caregivers can try to

control some of that relationship

damage.

being present, communicating, and

saying, I'm here.

We're going to take a break.

In the tradition

of our show, we'd like to welcome

the production team.

Fred, Graham, do you guys have any

questions?

So Dean, I'm wondering, like, most

of us have been through a rough

breakup, maybe a friendship

falling

apart.

I'm wondering, because a lot of

the conversation is sort of

focused on the physical

roots of pain.

I'm wondering if emotional pain or

psychological pain can be

considered chronic,

or if that's something that's

completely different.

No, it's not completely different.

I mean, you know, what we're

talking about, and what I think

is important to emphasize here,

that chronic pain is emotional

pain.

Like, it's inevitable.

Because you can imagine all the

things that we've spoken about,

you know, to this point.

The loneliness,

the burden, the depressive

symptomatology, the, you know, the

anatomical changes in your

biology,

your energy levels, your ability

to do things, you know, activities

of daily living, all of that has

emotional weight.

And this is one of the things that

I think goes most misunderstood,

is that pain,

and I made this point earlier, but

I'll do it again.

Pain is a physiological

experience,

but it carries emotional weight.

So, they are equatable.

Now, they're different.

Like, the pain of a breakup,

the pain of a dilution, you know,

a diluted marriage, the pain of a

death, like someone you love,

these are

real things.

You feel them also physically, by

the way.

And, you know, you often hear

about people,

you see people in mourning, you

see people in grief, like hard

grief, and you see the physical

changes in them.

Now, that may be mediated by lack

of sleep, poor nutrition, drug

use, and or a variety

of other things that you gave up,

like going to the gym, or trying

to be healthier, you know, all of

the, but you see it physically,

and that's mediated by emotion.

So, it's, it's, I beg for people

to

understand that chronic pain is

emotional.

It's not like it's divorced or

separable.

And I think

when I talked earlier about

medical models, this is what I'm

getting at.

Like, for years and years,

centuries, we thought that

physical situations were not

emotional.

And we know better than that now.

Science is very clear.

So, I want to, I love your

question because it is emotional.

It is a combined

event for anyone who's

experiencing chronic pain.

Makes sense.

Thanks.

You're welcome.

Well, that's pretty foundational

to the biopsychosocial model of

medicine, or maybe we can even say

the

biopsychosocial model of

caregiving.

Yes.

Yeah, I think that's a, that's a

fantastic way to say that.

Dean, if you love someone in

chronic pain, why is the

development of resentment

not uncommon?

And what do caregivers actually

feel guilty for, or what are the

thoughts that

they feel guilty for having when

resentment appears?

What a word.

What a word.

Resentment in, in psychology is

probably one of the most

interesting words that you can,

you can bring up when you talk

about relationships.

Tell us your definition and how

you position it for this

conversation.

Cause I think are,

are there a lot of listeners out

there who, regardless of chronic

pain, or maybe in other

forms of caregiving, develop

resentment.

So what's your operating

definition?

All right.

So, you know, I, I first will

start with the, I think the

question to myself, which

is, um, is resentment normal in

chronic pain caregiving?

And I would say, uh, yes, the

research

would say that it is quite normal.

It's, it's very normal and it's

common.

And I would think

that it is an expected reaction in

chronic pain caregiving.

And what I mean by that is it's

resentment

is often considered a taboo

emotion that I think caregivers

are reluctant to admit they

have.

So I'm glad you're speaking about

the way you're betraying their

loved one, right?

Or the person they're caring for.

So I'm glad you're, you're,

you're, you're talking about the

way you're talking about it

and you're bringing it up, but

it's a natural response.

Like it's a natural response.

It's

a human response to long-term

overwhelming and often the

thankless nature of caring for

someone

who is with persistent, uh,

unseen, uh, pain, like we

mentioned earlier, invisible.

So why

is resentment normal?

Um, a couple of things.

One, first of all, I think that

unpredictable,

consistent or persistent demands

of pain, it is important.

It wears people down.

Like you've

changed your role.

You're in a new space.

You didn't study this in

university.

You didn't study

this in grammar school.

You didn't study this when you're

a child.

No one gave you a book on how to

be

this person, right?

So you're thrust into this role

and you have chronic pain, which

is not a temporary

illness.

It involves sometimes 24 seven

care.

It disrupts your life, disrupts

your sleep and your

schedule, right?

So when we think about that,

that's one reason why resentment

would be normal.

Cause that's what happens.

Number two, we mentioned this

already loss of personal freedom

and

identity.

You, you like, I guess you, you

might feel, um, forced, you might

feel, uh, forced to

sacrifice things, hobbies,

careers, uh, social life,

intimacy.

That's, and that was your partner.

That part of your life with your

partner can be truncated, can be

shortened.

It can be wiped to the

side.

Again, you're, it's, you're losing

something.

And then, uh, isolation, lack of

support.

Like

thank God for your, your podcast.

Like, I mean, you know, and, and

the people who do work in the

caregiving area, because without

that work, people will surely feel

abandoned by family members, by

friends who, who, who don't help,

who don't know how to help.

Or, you know, that, that can lead

to

resentment, right?

Uh, the effort you're putting in

doesn't get appreciated by maybe

the person you're

working with or the people around

you that are blind to what you're

doing.

And then we mentioned

the visible nature of pain.

Uh, you know, I could go on and

on, but I think resentment is

normal for

these reasons because these, these

events lead to signs of resentment

and the signs are I'm irritable.

I'm angry.

I withdraw from my partner.

We mentioned that earlier.

I feel like I'm being trapped.

I'm a,

I'm a burden to myself.

I have guilt.

You mentioned guilt.

I feel guilty for having these

negative emotions

problems.

And guilt will put you in a grave.

Guilt will aid you.

Guilt will put you in a hospital.

Like guilt is such a powerful

poison.

We need to not swallow that pill.

And that leads to physical

symptoms of resentment, headaches,

chronic fatigue, feeling burnt

out.

So, I mean, when we think about

why resentment is normal, I think

we talked about that, what it

looks like.

We talked about that,

but I think more importantly for

me, it's like, what do we do about

it?

Right.

I mean, you know,

I don't know if you were going to

go there with your next question.

Well, I mean, I, one thing that

stands out is this word

invisibility and so many

caregivers

on their journey feel invisible.

They're providing the invisible

care that the system is not

holding itself accountable to

their feeling invisible in the

process.

Mm-hmm.

And now in this scenario, they're

treating a symptom that's

invisible.

Yep.

You can see where it becomes

almost the perfect storm and how

the invisibility amplifies itself

in so many ways.

Yeah.

So how, that's just, it almost

seems insurmountable, but yet we

need to move on.

The caregiving relationship

needs to survive so much is at

stake.

Yep.

How do we overcome the challenges

of that path to resentment and how

do we turn it around?

Mm.

Good question.

Um, I think in, in managing

resentment, there's a lot of work,

uh, that has

been done with resentment as a

term outside of chronic pain or

whatever, but in relationships

and, and, you know, that work has

really looked at kind of different

pathways.

And I have a couple

I can suggest.

Number one is with any emotional

experience, you have to

acknowledge the emotion.

Like, and again, you have to kind

of quiet the noise down and

acknowledge how you feel.

Accepting

that you feel resentment is always

a first step in managing it.

So naming it.

I think, yeah, yeah, it's kind of

like some people say own it,

right?

And I think you have

to understand as a first step, it

under, you're still, you might

feel like a bad person.

You might

feel that way, but you got to own

it.

You're not a bad person.

You're in a normal experience.

I just described how normal it is

to go to resentment, right?

So you're not alone.

You're

not an outlier.

You, you are part of the many

people that find themselves in

this particular

hard situation with that outcome.

So acknowledging is number one.

Number two, and I mentioned this a

little bit, setting firm

boundaries in your caregiving is

going to be really important.

So it, it, it may

be necessary from time to time to

say no to demands that either are

too much

too much for you physically or too

much for you emotionally on that

day.

So there

has to be something, some

recognition of what is burning me

out.

What is creating this

resentment?

What do I, where do I feel that

resentment most?

So anchoring that and looking

to set boundaries around those

hard places is going to be

important.

To do this, you need

to step out.

And what I mean by that is you can

emotionally step out, you know,

physically

step out.

And, and what I mean by that is

seek support.

And, and we, I, I, I'm sure I've,

I've

watched your other episodes in

this podcast.

You've talked a lot about respite

care.

You've talked

about, you know, actively, I think

trying to find people who get it.

Like people who get

what resentment and, and caregiver

burnout might feel like, look like

people who've been

there.

Right.

So if you talk about support

groups, therapists, you know, even

taking break

with respite care to recharge

yourself physically, being able to

go out and walk in

nature for 30 minutes

uninterrupted, turn your phone

off, go to the park, sit on the

bench, contemplate life, take some

deep breath, do something that

gives you a clear break.

And

then on top of all that, I mean, I

think we're mentioning this, but

it's, it's obvious to say

communicate, communication needs

to be clear.

Explicitly tell people, family

members, what help

you might need.

Talk to therapists about what help

you might need.

People, I think get stuck

in that place that we talked about

earlier, where they feel they

can't do any more.

You

can always ask for help.

You can always sit with the person

and be there present with them.

These

two things never go away.

They never run out of energy.

Can always do this, but they're

hard

because you have to go through

these stages of trying to manage

resentment before you can

communicate

what you need.

And from a place of accuracy of,

of caring versus of anger.

And I think that's

really important.

So prioritizing self-care.

Um, you know, someone said to me

once, you can't

pour any liquid from an empty cup.

And that just makes a lot of

sense.

Self-care is essential

to avoiding burnout.

Then it's essential to kind of

managing resentment.

So acknowledging, setting

boundaries, getting help,

practicing self-care, and trying

to get to a place with your

communication

that's clear in your head and with

the other people around you, that

is how you can help fight

back resentment.

It's not the answer, but I'm, I'm

hopeful that people can find

pieces of that

that might work for them.

Absolutely.

Just a follow-up to that, I was

thinking as, as I was listening to

you, we never

know when we're going to enter a

stage of our life where we become

a caregiver.

Correct.

But are there certain individuals

whose prior life experiences set

the stage that they're just

unable to participate in

self-care?

Oh, yeah.

Yeah, yeah.

I mean, I've heard you mention

this before, uh, and discussed

this

on your podcast.

We've talked about it before.

You know, there, you know, this,

this idea that

you, like everyone, I was talking

to my wife about this the other

night.

She's also a psychologist,

a pediatric health psychologist,

uh, works in the school boards.

And we're talking about how

much you have to give.

And, and, and, and I said, you

know, she said, we've talked about

a battery

analogy.

Like we have a battery.

Like, I think we have a battery

that allows us to kind of give

ourselves to other people.

And if we don't recharge that

battery, right?

If we don't have time to kind

of replenish that source, if we

don't put cup, you know, liquid

back in the cup, we've got nothing

to

poor.

Right.

And, and one of the things I asked

her, I said, you work with so many

children that

are in difficult situations facing

difficult educational situations.

I said, how do you keep

doing that?

And she said, it, she said, it's

like, I do, I do self-care.

She practices self-care,

but she also says, I have a

special battery.

And I, I loved it when she said

that I have a special

battery for that.

She said, now I said, where's my

special battery?

When I get a cold, you don't have

that same battery for me.

And if I'm, you know, doing my,

uh, my usual whining about being

sick

that you don't have the same

battery for me.

And she goes, no, I don't.

And, you know, she says,

get better, get moving, get going.

But there's truth in that.

Like you, you know, some people

have

a way that they are, that they

have a larger battery and ability

to kind of be with people in

distress.

They have a larger battery to

practice, you know, the, the

self-care routines that allow

them to have a larger reservoir

for people that need it.

So there is something about our

dispositions,

about the way we see our roles in

life and the role we're in at that

point when we are tasked with

that, that ask.

So I think it's a combination of

things.

There's no pointing at someone

saying

you're wrong or it's broken or

it's bad.

I think we just have to accept

that some people bring different

skills and talents to the table on

this.

And because of their own life,

their caregiving battery

might be small.

And so they have limited resources

in that way.

Yeah.

Probably shaped in big part by how

they've been able to be with

themselves in their own states

of distress long before they

became caregivers.

So, you know, even the most loving

of caregivers

might sometimes doubt the pain

that's reported or even be numb to

the whole pain narrative in their

their loved one.

Hmm.

Why does, why does it get to that

point?

And how do you recover and repair

that

trust if the patient or the person

being cared for feels that they're

not believed?

Yeah.

That's a good question.

Well, I, the way I see it is, is,

is like this, it's kind of like,

how do we go from

like pain management to back, back

to kind of like partnership,

right?

You know, that's kind

of where my brain's going when I

hear you say that.

Is that, is that resonating?

Mm-hmm.

Okay.

Um, so I just want to follow in on

that cause I didn't want to,

didn't want to be too

far out in left field.

So when I think about moving from

caregiving pain management to a

partnership, I think, I think you

can make, I know you can make

changes and I, and there

are exercises that couples can do

to help promote that feeling of

engagement again, to perhaps

rekindle some of that spark, that

love that that's been buried under

distress.

And I'll

name a couple that come to my

mind.

Um, number one, I call it the,

well, I don't call it, I

didn't make it out, but I mean, I

call it this 10 minute daily check

it.

It could be five minute

daily check it, but it's like,

I've said this to people before,

uh, set a timer.

It's a five

minute check it.

And each person shares what went

well, what was stressful.

And one specific

thing may be that they, they need

from their partner that night.

And that's a, that's a,

you know, it's like, I'm going to

program.

Um, if you do that, I'm going to

program healthy

exchanges on needs and that little

check-in and that little thing

about, you know, what went

well today?

You know, what was stressful?

Uh, cause it's not just about

hearing what's

wrong.

I think if you ask somebody, and,

and this was one of the things I,

I, when I was,

uh, far more active clinically, I

used to ask people this all the

time.

Um, what went well

today?

And I would always start with

that.

And you'd be surprised how many

people had to

work so hard to find something

that went well that day, something

that was good in their day.

And in fact, Mark, I had people

who would be stuck there and I

would just wait.

And then I'd get to

about two or three minutes of kind

of just uncomfortable waiting.

And I would say, okay,

so what this tells us is what, if

you're taking this long to perhaps

find something that went well

or was good today, then we're not

thinking of it and we're not

seeing it.

So we're going to change

that.

So the exercise is, yeah, we're

going to do this every day.

So, because what happens when you

get

stuck between fence posts is you

only see that much of the world.

You don't see the bookcase.

You just,

you just see this head and it's

like that you want to see more.

So perspective taking.

So asking

what went well is super important.

What went wrong is easy, right?

But that five minute check-in,

I think 10 minute check-in,

whatever you want to call it, I

would highly recommend that.

Another thing that you hear people

talk about is I feel and I need

statements.

This is, you know,

psychotherapy 101, which is

basically, you know, you want to

replace blame and vulnerability

using the script, like a script.

And I'll put it in air quotes.

I feel, and then name some

emotion,

like distressed or upset or angry

when a situation happens.

Like when you come home and you

just put

down your suitcase and you don't

look at me and you don't talk to

me.

Right?

When you think about that,

then you, then you, then you need

to say, and I need a specific

request.

So this, I feel I need

script is one way to kind of do

that.

I feel I need, and the request

could be, uh, hopefully

reasonable.

Like I would, I need you to kind

of, you know, just come in the

house, spend the five minutes with

me and

do blah, blah, blah, blah.

That checks into the five minute

check-in.

So these are kind of connectable.

You can use them in different

places, but that I feel I need is

important.

Yeah.

And that another

thing you can do is take turns

listening and speaking because

often, I mean, like, like you do

with me

here, like you're, you're listing,

you're, you're querying, we're

going back and forth.

I love the flow.

It feels comfortable.

Um, you're allowing me to talk.

Patients often don't have that

opportunity

because if I come home and I see

you and I've had a rough day and

my battery that we talked about is

low

and you come at me with, this was

wrong.

That was wrong.

This was wrong.

This was wrong.

It's sometimes difficult for me to

be quiet in hearing that because I

want to fix it and I want

to move on.

So again, that care kind of

acronym is important to consider

at that place.

So basically,

if I can boil it down, take time

listening and then take times

without interrupting and then take

time

to reflect.

That's the key of the care

process.

So that technique, again, you can

call it speaker,

listener, whatever.

There's a variety of different

ways, but that process of

listening and speaking

and listening and reflecting

really, really important.

I mean, there's probably, you

know,

those are the major that come to

my head at this point.

Um, but I'm sure there's more that

you can do.

Um, but those are the major ones

that I think I would suggest are

important.

And again, looking for

local respite and support

resources, super important because

you know, they may be available in

different

ways in the area of, of the world

that you find yourself in.

Well, in hearing what you're

saying,

I think of the three R's.

So that's relational rejuvenation

routine.

And, um, it really hits home

and it's what everybody needs to

do.

But in the setting of caregiving

and chronic pain,

maybe we need to do that even more

or make sure that as we're

thinking about all the habits we

need

to incorporate into our daily

lives, that we make that one a

priority.

Speaking of R's, I could think

of big R resentment and little R

resentment.

So normal frustration, which is

the little R and dangerous

resentment in a, in a care

partnership.

What's, what's the difference and

what's the first warning sign that

a

caregiver is like reached that

crossing over point or crossing

that line into like dangerous

resentment?

I think, I think a lot of people

feel it physically before they

recognize it emotionally.

And I think I would start there.

I would say, you know,

It's that chest tightness in the

situation.

Yeah.

Like, you know, you walk in the

room, you, you, you see the person

and you, you kind of in your

head, you're just like, instead of

like love or compassion, there's

this kind of like dread.

There's

this kind of like hate might be a

strong word, but it could be, you

know, hate.

It, it, it depends on

where you are with this.

But I mean, I think big R is, is

palpable.

Like you, you know it, uh, because

it destroys relationships, you

know?

And I think you feel it

physically.

I, I think that's why I was

talking about trying to slow down

and trying to kind of capture the

thinking, like capture the

emotion,

because if you just allow it to,

to, to wash over you and you don't

try to capture it, you won't know

what you're dealing with.

But I think people feel it.

I think they feel it.

And when you feel that way,

fatigue, um, stress, chest

tightness, yeah, the whole anxious

experience.

Yeah.

Cramps.

I mean,

you know, I think that that's a

real tell.

And unattended to, I could see it

amplifying and

amplifying exponentially.

So what, once you start feeling

those physical symptoms and the

big R is

an evolution, what's, what's

someone to do?

What's the action plan in that

moment?

I think there's a couple of

things.

And, and again, like big R's or

small R's, I, you know,

I think big R's obviously, uh,

requires us to, to really think

because big R's or act urgently.

Yeah.

Yeah.

Big R's, big R's break things.

Right.

So I'm a little bit more worried

about that.

But I think

this idea again of validating

feelings, you know, like if we

want to alleviate this, like, you

know,

I think validating your feelings,

validating the other person's

feelings, very important.

Acknowledging that you can love

someone, that you can love someone

and feel deep resentment for them.

That you can do that at the same

time.

I think, yeah, I think that's a,

you know, if I could think about a

way that that makes the most sense

to me, I think that's how I, I

would move with that.

That you can feel resentment and

you can feel love at, for the same

person.

It's just, they're going to be at

different ends of the spectrum on

any one day.

And again, just seeking care,

support, um, professional

counseling.

When we're talking big R

resentment, uh, a lot of times

that, that festers sticks and

breaks because it's above your pay

grade.

Like you just, you know, mentally

you're not, you, you, you don't

deal with that well.

It's like not something you have

training in, like put it in the

hands of the professionals.

And I say, when you feel big R

resentment, you need professional

help.

I think that that's very clear to

me.

So feeling that build from small R

to big R, like, I think just being

aware that it's okay to be angry.

It's okay to feel put out.

It's okay to have that sense of

burden hurt you too.

Like it's okay.

But it's what you do with that

that's important.

So, you know, when I start to hear

big R, I start to hear help,

support groups, professional help.

That would be for me the number

one thing to do.

When it's smaller, it's like

caregiving in a sense for

yourself, you know, recharging

your batteries, going outside,

getting your exercise, sticking to

somewhat of a normal routine for

you as well.

I think that's part of that

smaller R resentment approach.

A lot of our listeners may not be

able to afford professional care.

Are there any authors and experts

in the field whose work you'd

recommend a caregiver in a couple

situation to turn to, or that

couple to turn to, to get the

process rolling when they've

identified that resentment's crept

in?

Well, like I mentioned earlier,

John Gottman and his work, Dr.

Gottman's work, and he's decades

deep in work and relationships.

And we were talking, you and I had

spoken before about Gottman

previously, and just about some of

his work.

Like, he talks about resentment

when it's toxic as this

destructive emotion kind of born

out of like an unhealed

relationship and wounds.

Like he's really quite poetic.

But his years and years of

research talk about working on

things like criticism, the

feelings of contempt that's big

for him, defensiveness,

stonewalling, which is another

word which means kind of like,

how can I say stepping out, like

disconnecting yourself from the

person, not allowing yourself to

feel and being involved.

So I would think that a lot of

work and a lot of his work has

been put into readable self-help

books as well.

I don't have one off the top of my

head, but they're definitely

searchable and findable online.

And I think, you know, that might

be a useful, I would suggest that

reading.

Like, I think that would be a good

place to go.

But I would also say, you know,

professional help can, and I

mentioned support groups.

A lot of support groups are free.

And virtual.

Yeah, yeah.

So you could step into stuff like

that, right?

And virtual, like you said.

You can step into stuff like that.

And again, the key that I talked

about the first time I was on the

podcast with you,

taking that first step.

Like stepping into it, leaning

into the next phase of getting

better.

Because if you don't take that

first step, if you don't try to

find a support group,

if you don't, like you said, even

virtual, if you don't try to get a

book that might, but maybe you're

not a book reader, right?

If you don't reach out to a

friend, a confidant, or somebody

that you'd be surprised where

support can come from.

But if you don't allow yourself to

kind of first recognize this, and

then move in on it, then you're

just, you're not going to get it

done.

So just try to be brave.

Try to take the step.

Try to take the step.

And maybe you don't get it done on

Monday.

Maybe you don't get it done on

Wednesday.

Maybe it takes you two weeks to

take the first step.

But it's in the back of your head.

And don't beat yourself up for not

having done it Monday and

Wednesday, right?

Oh, good Lord.

No.

Good Lord, no.

I mean, if you look at behavior

change, and you look at people

trying to quit smoking,

or, you know, and I know this is,

seems like a left field topic, but

if you look at people trying to

change behavior,

it doesn't happen overnight.

And it only, it only starts to

really happen after many attempts.

For many people, it's multiple

serious attempts to change

behavior before it takes effect.

So, you're, you're, again, you're

normal.

This is hard.

So, just even thinking about it as

a victory today.

Mm-hmm.

And that can be the thing that

spurns on the action.

Just try not to let it go out.

Try to keep that pilot light kind

of lit up.

Long, long before we get to that

stage of resentment, we may be

experiencing symptoms of burnout.

So, you know, initially maybe

starting subtly and gently, but

then amplifying.

And we may still be functioning at

a high level.

Are there any warning signs for

caregivers of patients of chronic

pain that might be a bit more

specific

when it comes to just wearing

people down before it actually

raises its head in crisis?

Oh, boy.

It would be so variable.

I think the thing...

I expect it would be.

Yeah, yeah.

It's hard for me to say it's this.

I couldn't say it.

I couldn't say it's this.

I think it's a combination of just

kind of understanding, you know,

that you're going to be under a

tremendous load.

And that making decisions, moving

forward on how to manage that is

not a laid out path.

That's going to be, you know, the

reason you usually understand

you've made a mistake is when

there's some distress attached to

it.

Like, if you make a mistake in

your life and there's no

repercussion, there's no emotion,

there's no payback, there's no

kind of like someone giving you

grief,

there's no feedback, then you're

not going to make any changes.

So, I think my advice would be

watch for change.

Watch for those feelings.

Understand that when you are a

caregiver, if you're just starting

to be a caregiver, understand, if

you watch these podcasts,

understand that it's going to be

challenging, that it's not going

to be easy, and things are going

to change.

And human beings predominantly

don't do well with change.

We don't like sudden changes.

We love routine, and we build

towards that.

So, change is something that's

difficult for people.

And when you feel that change, and

you feel that distress around

these change issues, that's when

you need the outreach start.

You can start support programs

quicker.

You don't have to wait until

you're on the big R with

resentment, as we talked about

earlier.

You could start these things

proactively.

Like, you know, once you're at the

stage where it's like your pain is

not manageable acutely,

and you've been managing this for

like four months, six months, that

is chronic pain.

Some people argue it's three

months.

I mean, if your partner is in pain

for that long, and the

interventions might make a little

dent,

but it doesn't change their life

experience, understand where you

are.

That you're in a spot that you're

going to need help eventually.

So, I think you start looking

early.

That is also, you know, a word to

the wise.

Look early, and try to be honest

and communicate what you're not

good at with people who might be

able to help you.

So, I'm assuming that we may have

some listeners here today.

We're actually listening as

couples, caregivers, and the

person they care for who has

chronic pain.

I hope so.

Can you tell me, as a caregiver

who knows that they can't fix it,

but they believe in the pain

experience of the person they

love,

what does good validation, in real

words, sound like in the ears of

someone with chronic pain, hearing

those words from their caregiver?

I think the most significant

change that I've seen in

relationships where chronic pain

has upended the apple cart,

you know, it created all these

problems we're talking about.

I think it's when I see two

patients come in, and they're

holding a hand, and they weren't

before.

Or when I see two people talking,

and it's not pressured, and it's

not venomous.

There's like a genuine interest in

who they are.

I think these scenarios push you

away from the people, from the

person you love, the person that

you gave yourself to.

And I, you know, and I said

earlier, or, you know, at least I

hope I said this earlier, that

that person's still in there.

You know, that person you fell in

love with doesn't have to be dead.

That person that you appreciate,

that, you know, was with you in

years of marriage, if that's what

your situation is.

That person who you had children

with.

That person who you had your, you

know, first kiss with, if that's

what the situation is.

That person's not dead, and

sometimes to look for that person,

through all these things we've

talked about in terms of changing,

and looking at resentment, and the

care process, and, you know,

listening and reflecting, that

says, that's love.

That's love.

Respect is love.

The opposite of resentment, in my

opinion, is respect.

Right?

Let's go to another R.

A good R.

And respecting somebody means that

you appreciate, in my opinion,

what they do.

I respect you for your ability to

kind of have a smile in a hard

day.

I respect you for those small

things that you do, did do, and

still have in you, but have been

buried.

And this is why I say, often, I

talk about people, live your life

in spite of chronic pain.

Don't live your life under chronic

pain.

Yes, it's a big road.

If you're willing to kind of be

vulnerable, and try to find that

person again, I think that is the

outcome, that's the process.

Couples who are in love, couples

who are in love, can always stay

in love.

But you've got to work for it.

And that's the difference.

To paraphrase something I read

recently, and I can't quote you

from where, but it resonated.

You know, the opposite of love

isn't resentment.

The opposite of love, in this

context, is not hate.

The true opposite is indifference.

Bingo.

Because all those words you just

mentioned, kind of indifference,

resentment, it's a cascading, it's

a big bingo ball tumbler full of

garbage.

And, you know, resentment probably

is the ball that pops out that

day.

You know, it's like, you know,

this kind of indifference is

resentment, it's contempt at its

worst.

And that's why I say to people,

try to find that love.

Like, I know it gets buried.

I know that it gets lost.

It kind of gets put under.

But if I was giving advice to any

couple about how to try to be

happy in your relationship, it is

about finding that love.

You just have this blanket of

chronic pain and all that crap

that it can bring to you to try to

navigate.

But I think when you start trying

to navigate that, and you stay

open to finding love, you're my

love.

Start with simple statements.

You're my love.

I mean, you know, you're still my

love.

You're my love.

And get away from you're still to

you're my love.

Right?

Those types of statements can also

be helpful.

You know, you're just doubling

down on that feeling.

You know, what I'm hearing here,

although we've gravitated a little

bit to, you know, spousal, if you

will, partnership, caregiving.

But I think that some of these

important lessons can apply if

you're a child looking after a

parent in chronic pain, or a

parent looking after a child in

chronic pain.

There's a lot of overlap here, so

let's not put the blinders on, or

as you said, not see the bookcase

behind you and just your face.

But there's a lot of adaptability

here.

You know, as a caregiver taking

the initiative, we might want to

micromanage so many elements with

a focus on preservation and

positivity, but you could

paradoxically make life that much

smaller by micromanaging the

caregiving environment and

everything.

Like, where's that sort of fine

line, or is there boundaries that

we still need to respect in the

relationship so that love can

actually be nurtured?

Yeah.

Yeah.

That's a really good question.

I was thinking about something

like that earlier.

And one of the things that is a

killer in, at least in the chronic

pain literature, and we look at

relationships, and we look at kind

of like caregiving behaviors, like

spousal interactions.

And we've done a bunch of work

with this in, you know, abdominal

pain conditions.

And one of the things that's come

back in our research and other

research as well is this idea of

solicitous responses or doing a

lot for, so much for the other

individual that you create a

vacuum for greater disability in

that person.

So, one of the things that I think

is really important to understand,

when I talked about boundaries,

right, is like, the expectation is

that, you know, you're going to do

stuff.

Like, you know, I think one of the

things that hurts, you know,

caregivers the most is when an

individual completely rolls over.

Like, they give up to that burden

feeling they have.

They give up to those dark

thoughts.

They give up to kind of that

fatigue on that day, every day.

They, you know, they don't fight

for who they are in that day.

And I want to make sure that our

listeners understand that that is

okay if that happens, right?

But if it becomes a bit of a

pattern, one of the ways that we

see helping to prevent that is

that the individual in pain has

duties.

The individual in pain and a lot

of chronic treatment programs will

look for activation in the

patients as much as humanly

possible.

So, I'm not saying that if you're

out with a chronic low back injury

and lifting a two-pound or

five-pound sack of potatoes is out

of the question, that that's your

job for the day.

That's not, that doesn't make any

sense.

But if there's something that you

can accomplish in that day and you

have to navigate and negotiate

these things, if there's a

behavioral task that you can get

done that day.

Like one couple comes to mind,

she, um, uh, this lady was like, I

love doing laundry, but I can't do

laundry because I can't get the

clothes, the wet clothes out of a

low washing machine and put them

in a high dryer.

And she was destroyed by this and,

and depressed, like feeling very

upset about herself, the burden.

She always, you know, said that,

you know, uh, he, the husband at

the time in this relationship

doesn't understand how to do

laundry.

I feel again, like another

failure.

So this was a big point.

So what we did was we talked

about, well, what can you do?

If you can't execute that, are

there alternatives or occupational

therapy comes in?

I'm, you know, what are things

that you can do to manage this

because of this back pain?

So one of the things that was, it

was actually very interesting was

that she eventually said, or

learned to get to a place where

she could go down on one knee to

relieve some of her back pain,

reach into the, the washing

machine with an extender, like a

grabber, like one of those.

It's like a, it's like a rod and

you pull in a little hand and

grabs things and pull out laundry

and then into a little bucket and

then transfer that little bucket,

uh, onto a little platform and a

little platform, a little

platform.

So it took her a lot longer to do

it, but through these adjustments

that she would never have

contemplated, she was able to get

it done.

And she felt like, how did she

describe it?

Uh, success.

Now that took a lot of work.

That was for her a done deal.

Never able to do it.

I'm a failure.

I can't even do this.

And through those efforts of being

aware, facing the emotions,

talking about what the task was,

looking at, do you, you know, you

want to have tasks in your day,

make you feel better.

Let's get to those tasks.

That whole process changed the way

she felt on a daily basis because

she did little loads of laundry

now.

So she did laundry every single

day, small loads.

Everything had to change.

But boy, that, that led to kind of

an unburdening of kind of that

feeling of loss.

So I hope that's a, yeah, I hope

that's an example of a process.

Yeah.

A process that could be applied to

so many, so many situations, so

many challenges and you, the way

you break it down and then

systematically rebuild it to

achieve what relieves that sense

with nothing worse than a sense of

failure.

Yeah.

I hear in this case that as a

patient with chronic pain, you

don't want to fall in the trap of

learned helplessness where

everything gets made smaller.

But at the same time, you don't

want to be reductionist as a

caregiver and making everything so

much smaller for the person you

care for so they don't have the

opportunity to overcome that

challenge that you outlined.

You know, I always say this, let,

let them go.

What I mean by that, let them have

a voice in what they think they

can do.

What's your ceiling?

What can you push into?

Like, what, what can you get done?

And then, you know, where do you

want to, where do you want to go?

Do you want to get better at this?

And if you hit a ceiling that you

can't do something functionally

better, then how can you change to

get to a different place where you

want to be?

That's, that's process.

That's change.

And that change makes huge

differences in attitudes.

And those attitude changes help

with deepening relationships like

I talked about.

It's so rewarding for a partner to

see somebody smile in a task that

used to cripple them mentally.

That, that, that, that moment is

priceless.

Absolutely.

That's love.

So, Dean, thanks so much for being

here today.

One last question.

If there's a caregiver listening

today who feels totally trapped,

what's the first practical thing

to implement change that can help

them this week?

Oh boy, totally trapped.

Uh, get outside.

Like, get outside.

Breathe.

Get some fresh air.

You know, try, if you're able, try

to, to just give yourself some

space and take some deep breaths

and know that even by taking that

little piece of time, you could be

stepping into a process.

Of thinking about how to move

forward.

So, any small act like that is an

act I want you to, to think is

something that's moving you.

That, that, that is, I'm trying to

build hope.

Create space for those moments,

eh?

Creates a little bit of space.

Where sky meets tree.

Thanks so much for being here.

Thank you.

It's, uh, you've offered us so

much practical advice and I'm sure

everyone listening, uh, is better

off.

For you having been with us today.

Thanks for coming back.

No guarantees when you invite

someone, they'll let her come

back.

But we're thrilled to have you

here.

And, um, thanks for helping us

take this places.

Folks, that wraps up another

episode of the Caregivers Podcast.

I'm your host, Dr.

Mark.

We're so happy you're here.

Share your comments.

Send a review.

Tell us how we're doing.

We're really trying to make this

something about you.

We'll see you next week.

Before we wrap up, I wanted to

remind you of something important.

The conversations you hear on this

podcast are here to inform, to

support, to spark reflection.

We're not a substitute for

professional medical advice, care,

therapy, or crisis services.

Listening to this podcast does not

create a doctor-patient or

caregiver-client relationship

between us.

If you're facing a medical

concern, health challenge, a

mental health challenge,

or a caregiving situation that

needs guidance,

I encourage you to reach out to a

qualified professional who knows

your story.

If you're ever in crisis, please

don't wait.

Call your local emergency number

or recognize crisis hotline right

away.

You deserve real-time help and

support.

The views you hear on this show,

whether from me or my guests, are

our own.

They don't necessarily reflect any

organizations we work with, are

part of, or have worked with, or

been part of in the past.

This podcast is an independent

production.

It's not tied to any hospital,

university, or healthcare system.

Thank you for being here, for

listening, and most of all, for

taking the time to care for

yourself while you continue to

care for others.

I look forward to hearing from

you.