Encouraging couples to change: a motivational assessment to promote well-being in people with chronic pain and their partners.

OBJECTIVE
Motivating people with chronic pain to engage in therapy can be difficult, especially when individuals have not experienced adequate pain management. Therefore, it may be useful for clinicians to use a motivational assessment as a part of treatment to help patients achieve immediate benefits. Additionally, because the social context impacts chronic illness, the significant other should be included in the assessment. This article describes a motivational assessment that was developed for people with chronic pain and their partners.


INTERVENTION
The motivational assessment begins with gathering information from questionnaires that each partner completes, conducting a semi-structured interview about the couples' relationship and pain history, and observing the couples converse about pain coping. Next, tailored feedback is provided to each couple regarding their strengths and weaknesses with suggestions for how to improve their relationship and pain coping skills. This tailored feedback engages the couple in this conversation by adhering to the principles of motivational interviewing.


CASE EXAMPLE
A case example of a couple who completed this motivational assessment is described. This assessment resulted in immediate improvements in marital satisfaction, pain severity, and mood for the couple.


CONCLUSIONS
This article provides a guide to clinicians for using a motivational assessment to help patients with a chronic illness achieve immediate benefits.

People with chronic illnesses, such as chronic pain, who are undergoing treatment may benefit from immediate change given the persistent, seemingly unchangeable nature of their conditions. Therapeutic assessment, a type of assessment that provides patients with feedback about their strengths and weaknesses, with the intent of beginning to intervene, has yielded immediate benefits for a host of patient populations [1]. While the idea of therapeutic assessment is not new in the psychotherapeutic literature [2], it is novel with respect to chronic illness or chronic pain. However, there is an another therapeutic strategy that involves feedback that has been advocated for in the pain literature: motivational interviewing (MI) [3]. MI is a therapeutic approach composed of asking open-ended questions and eliciting change talk. It is intended to encourage people to increase their intrinsic motivation to work toward change. Although MI was originally developed for substance abuse [4], it has been applied to a multitude of issues, including improving pain [3] and adjustment in cancer patients [5]. Specifically, MI techniques have been helpful for improving pain-related interference as well as physical and mental health [5]. These techniques have also been useful for improving marital relationships [6][7][8]. MI can be used in conjunction with therapeutic assessment so that patients not only experience benefit from the feedback given but that they also begin to develop hope that continued treatment can produce even better outcomes. The purpose of this article is to describe a motivational assessment that is therapeutic and can be applied in conjunction with behavioral treatments for chronic pain.
Given that an individual is only as healthy as his or her social environment [9], enlisting the active support of loved ones is likely to provide additional benefits. Indeed, research has shown that marital satisfaction and spousal behaviors have an impact on physical, psychological, and relationship adjustment in those with pain [10]. Although several studies have shown the benefits of including the spouse in the treatment [11][12][13][14], there is also evidence to suggest that using couple-based treatments may not offer benefits that exceed those from individual treatment [11,15,16]. Perhaps the reason that couple-based treatments do not have substantial effects is because important aspects have not been targeted in these types of treatment. Based on findings from the pain empathy literature [17], newer models of interaction in pain [18], and Integrative Behavioral Couple Therapy [15,19,20], there may be a subsample of couples that have greater difficulties with relationships skills like empathy and emotional acceptance that are not typically addressed by pain management programs [15]. MI is one way of promoting empathy within a relationship while also getting the partner involved in treatment. Thus, the motivational assessment described here was designed to be used with couples.
The motivational assessment described here resulted in immediate benefits for couples facing chronic pain [21]. Specifically, couples reported decreases in pain severity and negative mood, and increases in marital satisfaction and positive mood from baseline to postmotivational assessment. The purpose of this article is to provide a more detailed description of this motivational assessment that is needed for clinicians to put this assessment in practice. This description is illustrated with a case example so that the actual steps of the motivational assessment are demonstrated clearly. In addition, this article explains how using this motivational assessment might enhance current psychosocial interventions for chronic pain.

The Motivational Assessment
Couples who completed a motivational assessment for pain attended an appointment with the understanding that they were participating in a study about relationships and pain [21]. The motivational assessment occurred during one session, lasting about 2.5-3 hours, and consisted of two parts: gathering information and the tailored feedback. To gather information, the couples completed questionnaires assessing the relationship and pain, a semi-structured interview of the couple's relationship and pain history, and an interaction regarding coping with pain. Each couple was then provided with tailored feedback based on information gathered from the previous tasks.

Questionnaires
Couples completed multiple questionnaires at home and then brought them to their assessment appointment. These questionnaires included measures of marital satisfaction (Dyadic Adjustment Scale [22]), depression (Center for Epidemiologic Studies Depression Scale [23]), perceived partner responsiveness [24], and pain catastrophizing [25,26]. Mindfulness (Toronto Mindfulness Scale [27]) was also assessed because this concept of nonjudgmental, present moment awareness has increasingly been shown to be linked to better pain adjustment [28][29][30]. Couples also completed a second set of brief measures after arriving to their appointment to assess variables in that moment. These included a global question assessing general marital satisfaction (item number 31 from the Dyadic Adjustment Scale [22]), a 0-10 rating of the patient's current pain, a measure of current positive and negative mood [31], and a measure of current empathy and personal distress [32]. The therapist calculated scores from these measures for each partner and entered them onto a written feedback form. The second set of brief measures was repeated following the assessment and at a 1-month follow-up.

Interview
The therapist also conducted a 20-to 40-minute semistructured interview with the couple to obtain additional information about the couple's history and the manner in which they coped with the illness. This interview was an adapted version of the Oral History Interview [33], which asks about the history of the couple's relationship. Five questions from the Oral History Interview were paired with an additional five questions regarding pain that were relevant for this population. See Appendix I for these questions.

Interaction
Following the interview, the couples engaged in a 10-minute conversation about how they would like to cope with pain together in the future. This conversation was prompted by the therapist stating that, "There are many ways to deal with pain, some of which you have discussed today. For 10 minutes, I would like you to discuss as a couple how you would like to cope with pain together in the future." The therapist also elicited some ideas from the couple prior to the conversation to ensure that the couple understood the purpose and had material to discuss by asking "What ways would you like to try to cope with the pain?" This conversation was videotaped, and the therapist observed the interaction from another room to assess general functioning in overall communication skills, empathy, and pain coping skills. Specifically, the therapist counted the number of validating vs invalidating comments, adaptive vs maladaptive pain coping techniques, and recorded helpful vs unhelpful communication skills. A similar interaction has previously been used with other couples facing chronic pain [34,35].

Tailored Feedback
After couples completed the questionnaires, interview, and interaction, the therapist composed a tailored feedback form for the couple with the information that was gathered throughout the assessment. The couple waited while the therapist composed this document. The therapist provided the tailored feedback in oral and written format. The oral feedback was a collaborative effort, and the therapist encouraged the couples to participate by using MI strategies, including open-ended questioning (e.g., "What do you think are your strengths as a couple?"), reflections (e.g., "You don't see this as a problem for you"), rolling with resistance (e.g., "That might be too difficult to try right now"), empathic statements (e.g., "Sometimes it's hard to listen to your partner"), eliciting and affirming change talk (e.g., "What might be good about changing this behavior?"; "You want to change this"), asking permission to share information (e.g., "I have some suggestions on ways you can try to improve communication. Would it be okay if I shared these with you?"), and summarizing responses (e.g., "You agree that communicating has been difficult for you over time, and you were not sure how to do this differently. It now seems that you think if you try some of these techniques, you may have more success"). Couples were also provided with this information on a written feedback form that also included their individual scores prior to the intervention. This form also listed average scores on these measures as obtained from the research literature so that the participants can compare their scores with the average. See Appendix II for an example of a written feedback form.
During the motivational assessment, the therapist provided one to three strengths and one to three weaknesses to the couple from information that was gathered from the questionnaires, interview, and interaction. Common strengths and weaknesses that were reported to these couples included areas regarding marital satisfaction, communication skills, pain coping skills, empathy, and mindfulness. With the couple's permission, the therapist described research on the benefits and consequences of performance in these areas.
In addition, the therapist also included two to four strategies to assist couples in improving their relationship and pain coping. These strategies were chosen based on the couples' areas of weakness. Common strategies included relationship building techniques (e.g., marital counseling, date nights, behavior exchange), communication skills (e.g., empathic training, using "I" statements), and pain coping skills (e.g., relaxation techniques, cognitive reframing of catastrophic thoughts).
Interested clinicians can contact the corresponding author for form templates and other questions concerning the protocol.

A Case Example
To illustrate the motivational assessment, a case example is described, with details modified to preserve anonymity, drawn from a motivational assessment study [21]. This couple, "Bill" and "Sue," had been married for about 30 years. Both self-identified as Caucasian. Bill was 58 years old and Sue was 51 years old. Sue had experienced fibromyalgia for 12 years. When the couple first arrived to the lab, they completed a consent form to be in the study, which was approved by the university's IRB. They then completed questionnaires, the scores of which were used to help construct the feedback form that the couple received (see Appendix II).
Next, the couple engaged in the oral history interview. During the oral history interview, the couple reported that they met at a singles event. Sue reported that she was immediately attracted to him, and together, they excitedly told the story of how they met, finishing each other's statements. Sue also reported that the couple loved each other deeply even during the hard times in their marriage. In talking about how the pain had affected their marriage, they agreed it had a large impact and that they talk about the pain and the negative consequences frequently. They also shared that it often affected sexual intimacy. During the interview, Bill and Sue were consistently warm toward each other and expressed understanding of their partner's view.
The couple then engaged in the video-recorded interaction about how they could cope with pain together in the future. The couple discussed how the things they tried in the past (e.g., medications, sauna treatments) only worked temporarily. Bill showed great empathy for Sue, suggesting alternatives for how she could manage her pain while stating he understood how difficult it was for her to carry out activities she would like to engage in. During the interaction, there was also a large focus on the things that she was not able to do because of the pain and that Sue was "in bed all of the time." Sue became defensive about this, arguing why she needs to be in bed; however, Bill consoled her by making eye contact with her and sincerely stating that he did not blame her for her pain.
Next, the couple actively participated in the oral and written feedback portion of the assessment. See Appendix II for the written information the couple was given to take home with them. The therapist led this part of the assessment and regularly used MI strategies. Following guidelines in MI, the therapist first asked permission to discuss their results, which they agreed to. When first discussing their strengths, Bill and Sue exhibited excitement and believed that the suggested strengths were accurate. Using an MI strategy, the therapist reflected their statements and acknowledged that the pain helped them grow as a couple.
The therapist then described the couple's weaknesses. For Bill and Sue, these included 1) difficulty focusing on the present and 2) catastrophizing thoughts about the pain. The therapist continued to use several MI techniques during discussion about the couple's weaknesses. For instance, when discussing how the couple tends to plan things rather than focus on the present, Bill stated that acting in the moment can be difficult when Sue has pain, to which Sue concurred. The therapist rolled with this resistance by reflecting and empathizing that planning ahead often benefited them. Bill then realized that being spontaneous when Sue did not have pain could allow them to engage in more activities together. The therapist affirmed this change talk, "You see ways that you can improve and how you might be better able to adapt to this as well." The therapist also asked permission to share strategies to improve their areas of weakness, which is an important component of therapeutic assessment: "I think that you have the capacity to really improve upon some of these things. I would like to discuss some strategies with you on potential ways you can do this. Would this be okay?" The couple first had the opportunity to develop their own ideas, but did not have any, and agreed to have the therapist share strategies. Sue liked the first suggestion that was presented, which was while spending time together, to share the details of what they are experiencing with each other. The therapist encouraged her by stating "This is something you feel like you could try." Bill responded that he also would like to do this more. The therapist affirmed his change talk as well.
Finally, the couple completed measures after receiving the feedback. Both partners reported increased marital satisfaction, positive mood, and empathy after the motivational assessment (see Table 1). They also rated Sue's pain as being lower after completing the motivational assessment postassessment as well as lower negative mood and personal distress (see Table 1). The same questionnaires were repeated 1 month after the motivational assessment. For Bill and Sue, it appears that some of the effects were maintained over time (see Table 1).

Conclusions
Couples who participated in this motivational assessment for chronic pain had significantly more favorable outcomes than those who participated in a control group [21]. The couple described here, Bill and Sue, appeared to experience many benefits immediately after participating in the motivational assessment, including improved marital satisfaction, pain ratings, positive mood, negative mood, personal distress, and empathy. This suggests that the combination of therapeutic assessment and MI strategies is useful in providing benefits to patients and their spouses. MI and therapeutic assessment have been thought to instill the belief that changes can occur [36], and so, it is likely that these same mechanisms were at work here. This might be especially true given the improvements in pain, mood, and relationship quality that occurred over the course of the assessment period. Yet additional research is needed to determine if these are the mechanisms responsible for the immediate benefits to the patients and spouses.
Although this motivational assessment appears to be useful, there are practical issues that could interfere with implementation. For example, it is possible that some spouses may not want to participate in the treatment of the patients' illness. Some spouses may misunderstand their roles in treatment or may underestimate the impact of their own behaviors on illness coping. The MI technique of rolling with resistance could be utilized in these cases to try to engage the spouse in treatment. Providing psychoeducation regarding the effects of the spouse on the patient may also be useful. Additionally, patients without a romantic partner may not be appropriate for this assessment in its current form. It may be possible to use another significant person in the patient's life, such as a child or friend, in place of the romantic partner; however, work must be done to amend the interview appropriately. Alternatively, a version of this motivational assessment could be tailored to individuals rather than couples, focusing more on pain coping skills rather than relationship building.
Another practical issue is that this motivational assessment takes longer than a traditional assessment. It is estimated that couples spent up to 3 hours completing the entire motivational assessment. To save approximately 20 minutes, the initial questionnaires could be sent to the couple's home to be completed prior to the appointment. Another 20 minutes could be saved by asking couples to mail the questionnaires to the clinician prior to the appointment to allow the clinician sufficient time to review the questionnaires before completing the remainder of the motivational assessment. The clinician may also choose to complete the feedback portion at a separate appointment after gathering information to have additional time to consolidate and integrate the assessment materials. However, it is possible that some couples may then not return for the feedback portion as premature termination is common [37].
One of the benefits of this motivational assessment was that it assessed two people in a dyadic framework and was able to determine how the partners were functioning independently and within their relationship. Given the association between relationships and pain functioning [10], it is important to consider the relationship, and this intervention is able to target both the individual and the relationship simultaneously. This motivational assessment may be beneficial to both clinicians and their patients to use in conjunction with behavioral chronic pain treatment. Strategies from this motivational assessment could be used by any clinician who is familiar with therapeutic assessment and MI skills. Although the example described above occurred prior to any other behavioral pain treatments, motivational assessment strategies could be used at the beginning, middle, or end of treatment. For example, techniques from this motivational assessment could be used together with other evidenced-based interventions for pain management, such as spouse-assisted coping strategies [11][12][13]. The motivational assessment techniques may be useful for the clinician to use with all couples at the beginning of treatment because the assessment provides a great deal of information regarding the couple's relationship and pain status, including their strengths and weaknesses. For the couples, this motivational assessment can provide immediate benefits to the couples at the beginning of the treatment and may help motivate them throughout treatment as well. Additionally, using this assessment helps the couples recognize and identify their own strengths and weaknesses and develop their own strategies to improve. The couples may be more likely to adhere to a behavioral pain management treatment when they are involved in the development of treatment [37]. Using these strategies may foster the couple's optimism for the future as well as empower couples to develop their own self-management plans for continued improvement. Although, race, gender, education, pain duration, spouse pain status, and marriage duration were not found to be significant moderators of positive intervention outcomes, future research should continue to test whether certain couples may benefit more from this intervention. For instance, it is possible that couples who are already motivated to engage in self-management may be more likely to benefit from the intervention. Additionally, future research could also investigate whether using these strategies at different time points during a behavioral pain treatment improves outcomes at different stages.
partner may feel more understood, which could improve the satisfaction in your relationship as well as how you deal with pain and how it interferes with your life together.

Areas for Potential Change
Every couple has areas in which they can improve upon.
Here are some areas that you may want to consider working on: 1. Focusing on present issues rather than past or future issues.

Thoughts about pain.
Reasons for the Areas of Potential Change 1. Bringing up previous situations that are not relevant to a current one may increase anger or resentment and not allow for effective communication. Focusing on the present can lead to better problem solving on current issues like pain and may provide you with more reflection and enjoyment during positive times. 2. Certain thoughts about pain can affect the pain that you feel. For example, those who catastrophize about pain often rate their pain as higher than those who do not catastrophize.

Strategies
If you would like to consider working on areas for potential change in your relationship, here are some strategies that you can use to help you do so.