When you are assessing your clients with persistent pain, how good are you at asking clients about how pain is affecting sex and intimacy?
If the client doesn’t bring it up, do you?
Are we sometimes a bit British about this, thinking it is impolite or nosy? Perhaps the gender, race or cultural background of the client or clinician may also play a part.
I must admit I have sometimes omitted to ask for fear of being intrusive, particularly in an assessment when there is such a lot to cover and we are often working hard to build a relationship with the client.
When I worked in the NHS and we ran pain management programmes, we had a session on ‘relationships and communication’. It depended on the confidence of the facilitators and what was brought up in group discussions whether intimacy ever got a mention.
Or sometimes it gets discussed in an assessment, but there are so many other treatment goals and priorities that it is only later, perhaps when trauma symptoms settle, pain feels more manageable or low mood has improved that it feels ok to come back to the topic.
It is not uncommon, perhaps even the norm, that persistent pain will have affected a person’s relationships. This may be due to dynamics of friendships (no one calls me anymore, they are sick of me not getting better) or withdrawal from social situations (I can’t bear people to see who I am now); loss of connection from old hobbies or workplaces; a change of role within the family (feeling a burden, for example). And then, there are the closest relationships, perhaps with the people you live with, or a partner. People with pain often describe their intimate partner’s role changing from one of romantic partner to more of a carer role.
Perhaps a life changing injury has changed that person’s perception of how attractive they feel. They may be experiencing anxiety, depression, or symptoms of Post Traumatic Stress Disorder (PTSD). They may be fearfully avoidant of movement, associate sex or intimacy with flare ups of pain, or simply not have a clue how to adapt difficulties with mobility to an intimate situation. Medication side effects can often play a part, and even with a long term partner, people describe struggling to communicate or articulate how they feel about the loss of an intimate relationship and what they would like to do about it.
In my early career I spent a few years working in palliative care settings, where the priority was for all team members to play a part in assessing biological, psychological, social and spiritual needs. Here, I learnt about the PLISSIT model (Annon, 1976). This has helped guide me through some of these conversations, particularly the first step, which is asking Permission to talk about intimacy and giving the client permission to discuss matters which they may otherwise feel too embarrassed to discuss.
The second part of the model is Limited Information. This might be normalising the issues discussed and reassuring the client that it is ok to prioritise these alongside their other difficulties with pain or long term health problems. We might give some self help information for clients to read, and an invitation to revisit the topic with any feedback or questions. This can be enough for many people.
The third part is Specific Suggestions. This is where all members of the MDT may play a part. Are there psychological barriers, such as flashbacks, or anxiety? Is the difficulty more mobility or fatigue related? We often direct clients to resources outlined at the end of this blogpost. We do not have special skills in psychosexual therapy, so would be cautious of stepping outside of our area of expertise.
The fourth and final level is Intensive Therapy. If the level of difficulties are more extensive, referring on for relationship counselling, or to a psychosexual therapist, may be appropriate if the client would value that. I have certainly seen this recommended in expert witness reports where difficulties in the relationship have been significant following an accident or injury, and it is refreshing to see these recommendations being made as part of a treatment plan.
So, let’s keep talking to our clients about how pain or other health problems may be affecting their close relationships. If we don’t ask, they may never feel they can tell.
If you would like to discuss how to help clients further with persistent pain, say hello at email@example.com
Annon, Jack S. (1975) The Behavioral Treatment of Sexual Problems. Vol 1: Brief Therapy. Harper & Row
Chapter 13 ‘Pain, Communication and Relationships’ Overcoming Chronic Pain – Cole, Macdonald, Carus and Howden-Leach (2010).