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Pain Press Special Edition

Domestic Abuse & Chronic Pain
January 2021

Features

Spotlight on pain and domestic violence: there is more that we need to understand

I was delighted to take part in the recent Airing Pain podcast that explored the relationship between domestic violence and chronic pain. The podcast drew on a number of perspectives regarding the nature of pain, how it comes about, how it is experienced and what can be done to tackle the problem. The invitation to participate was, in part, because my colleagues and I have begun to investigate this issue, specifically the association between domestic violence and fibromyalgia and chronic fatigue syndrome. The podcast provided an opportunity for us to share our insights and, alongside the lived experiences of a domestic violence survivor, give airtime to this complex problem.  

The programme explored the links between domestic violence and chronic pain, illuminating particularly the human impacts. Since recording the interview, I have been reflecting on how far we have come within society in understanding the problem of domestic violence. I have asked myself critical questions regarding the many issues that remain poorly understood, and the questions that remain unanswered. I am a researcher, so the issues discussed in this editorial are through a research lens.      

I am going to begin by thinking about how far we have come. It is only in the last decade or so that domestic violence has crept from behind closed doors, out into the public domain. It is in this arena that domestic violence is discussed far more widely than it was a number of years ago. It has made its way, as a topic, into contemporary TV programmes, soap operas and coverage in newspapers. Overall, this release into public discourse is a positive move, because it provides opportunity to air the issue and to chip away at ingrained stereotypes and myths about the problem. It means that domestic violence is an issue that is discussable now; we can talk about it. This is important because it is such a significant problem that is a scourge on society. Rates of domestic violence are shockingly high. It is difficult to present an accurate picture of the extent of the problem because it is largely under-reported, but it is likely that one-in-four, or even one-in-three, women in the UK have experienced domestic violence. It is important to acknowledge that men and boys experience domestic violence, and so too those in same-sex relationships, but violence against women and girls, perpetrated by males, is the most prevalent form.  

When I first began to research the topic a number of years ago, domestic violence was very much a marginalised subject. Researchers need funding to support the research they seek to undertake, but that becomes a real problem when funding agencies fail to see it as a priority. While it is well-recognised that domestic violence can, and does, have catastrophic impacts on lives, both in terms of health and social costs, it can be remarkably tricky to secure funding to investigate the problem. My observation that domestic violence has shifted from the margins to the mainstream as regards societal discourse and awareness, is surely indicative of a positive move? I believe this to be the case. Funders are now inviting applications specifically about domestic violence, and to that end, progress has been made. I think though, that some subjects are still at the periphery and warrant far greater attention. The relationship between domestic violence and pain is at the forefront of my mind here, and this leads me to the critical reflections about what we still need to understand.  

I have been in the privileged position as a researcher on the topic of domestic violence, to interview many survivors. Real life stories of violence and abuse are powerful and distressing. They leave an enduring print on one’s memory. The reality of living with coercion, control, gas lighting and abuse in its myriad forms is a difficult reality to hear. Yet it is one that I have listened to over the years and from which, I hope, I have learned.  One thing that I have heard – repeatedly – is the story of pain. Domestic violence survivors talk of pain a great deal. For some (a minority) the pain arises as a result of physical injuries sustained as a consequence of domestic violence. For most though, the origins of the pain are not physically rooted, but tied up with complex biopsychosocial relationships that are not easily tracked, nor articulated. We know from large cohort studies, such as the one mentioned in the opening paragraph, that fibromyalgia and chronic fatigue syndrome are more common in women with domestic violence experience, than those without. Further studies are required to explore this relationship more fully, including, for example, the risk factors or how some groups may be disproportionately affected. What we need more than ever, though, are studies that focus on the lived experience of pain and domestic violence. We need studies that get right to the heart of the problem, from which we can understand not only what it is like but what can be done to better support survivors. Airing Pain, Pain Press and an emerging body of research may be indicative of the contemporary spotlight on domestic violence, but media and societal discourses peak and wane. It is important therefore to seize the opportunity now, so that we can shed far greater light on the problem of pain and how it is lived, in the context of domestic violence.

Dr Caroline Bradbury-Jones is a registered nurse, midwife and health visitor. She is Professor of Gender Based Violence and Health at the University of Birmingham.

The answer is complex, and the phenomenon which causes victims to become trapped not widely understood:  it’s called ‘traumatic bonding’. In toxic and abusive relationships the victim becomes weakened and loses perspective; instead of taking protective measures and walking away, they look to the abuser for the solution to their suffering. They may try endlessly to persuade the abuser to become, once again, the loving person they thought they had met; against clear evidence to the contrary, they persist in the irrational belief that things will turn out OK. The most tragic consequence is the loss of self-regard and self-protection, sacrificed first to the desires and then to the dominance of another.   

This is no temporary blip or aberration; often originating in past trauma, it is a deep seated and entrenched psychological process which can defy logic and cloud reasoning. The slightest indication that things may change can cause hope and expectation to re-surface, and dangers which are all too clear to outsiders are rationalised away. 

I know first-hand of the terrible imprisonment of traumatic bonding, because it happened to me. I spent my days as a senior manager in the criminal justice field, where I was dealing with the impact of violence and abuse daily. I knew well that most victims had suffered at the hands of a perpetrator who was in a relationship with them. Despite this knowledge and experience I lived in a relationship characterised by coercive control, threatening behaviour and incidents of violence. I was isolated and depressed, trying desperately to maintain an outward veneer of respectability whilst returning daily to a situation which many would have abandoned long before.  

It’s hard to leave your home and everything you’ve worked for; it’s even harder to admit to the world that yet another of your relationships has failed. These things, combined with the habitual behaviour I had acquired from many years of trying to mend relationships which were beyond repair, ensured that I stayed for far too long, when all I really needed to do was walk out through the door and ask for support. Even when I found the courage to break away I nearly didn’t make it, due to distorted thinking which re-surfaced and caused me to believe that I could return to my toxic relationship and it could all be put right. 

When other people began to notice what was happening to me, I began to recognise that I had lost the person I used to be; the vibrant, passionate and principled person who knew what she believed in and wanted in life had disappeared. I started to grieve for this person, to realise that I had lost myself and sacrificed all that was important to me on the altar of a relationship that could never work. All my energy had been spent trying to regain what was only an illusion of happiness and security. Through the kindness of others, I was reminded of what healthy relationships felt like. At times the poignancy was too much to bear.   

None of this came easily or rapidly. I explain in my book how my mental and physical health deteriorated, I was in constant pain, I developed lowered immunity and often dragged myself to work, suppressing my distress and attempting to project an image of a capable and confident professional to the world. The strain of doing this for so long eventually caught up with me. I began to be late for appointments and couldn’t concentrate or deal with simple everyday tasks. I took a severance package and walked away from the long-term career I loved. When my relationship finally ended I believed I could simply put all the pain behind me and start again; I was wrong. The road to recovery has been long and hard and, at one point, almost cost me my life when I succumbed to bacterial meningitis, which I put down to years of failing to pause and take care of myself. The answer is not to push forward relentlessly, as I often did; doing so is part of the pattern of behaviour which perpetuates abuse. It’s important to stop, acknowledge what you have experienced and do whatever feels right to help you to heal. I only learned this after many years of pain, when it was almost too late. 

There is no quick fix, or panacea. Enlightenment comes gradually, through finding your true self, treating that self as a precious child and recognising that you deserve kindness and compassion as much as anyone else. Love shouldn’t hurt.  There is no still point at which everything falls into place, there will always be challenges and it is best to take time for this healing to happen, but with the right support, and by always acting according to your cherished values and beliefs, things will improve. 

Thankfully, I’m now free and many years away from these experiences. I’m also in a happy and balanced relationship with a beloved old friend, which came into my life when I stopped trying to make things happen and expending all my energy in the wrong direction. Writing my story proved a powerful therapeutic process. I‘m now a social work lecturer and could have written an academic book on traumatic bonding, but I found that writing more freely allowed me to work through my thoughts, feelings and experiences. As I wrote, the pattern of my life emerged on the paper, and the miraculous events which set me free organised themselves into a story which seems to touch those who read it in a way that academic analysis never could. I found myself describing and processing deep emotions at the same time, subconsciously healing the patterns which had so blighted my life and reinforcing the things I had achieved.  I finally knew who I was and was proud of myself. 

Through sharing my story I have come to realise that there is much hidden abuse amongst people such as myself. People who often feel a sense of failure and isolation, believe that they should be able to cope and therefore feel ashamed to disclose their suffering and ask for help. If this is you, by understanding the origin of your life patterns, remembering the self that was lost along the way and knowing what kind of relationships you deserve, you can make safer choices and find a happier life.  

Kath Twigg is a senior lecturer in social work, trainer, mentor and writer; her book, The Hall of Mirrors, How to Change Life Patterns and Avoid Toxic Relationships, is reviewed by Paul Evans later on.

One Scottish domestic abuse survivor's experience of pain

I recently spoke to a Scottish domestic abuse survivor who wishes to remain anonymous, we’ve called her Alex. The following is an account of Alex’s experience of abuse in early life, which resulted in health problems and chronic pain that have persisted into her adult life. 

Alex details both emotional and physical abuse perpetrated by her biological father. The abuse was directed towards both her and her mother, which Alex regularly bore witness to. She recounts suffering from anxiety, sickness and pain as a result of these experiences:

‘I realised what I feel isn’t universally felt when I began reflecting on the incident and working through things in therapy now that I’m an adult.  

I feel anxiety to the point of physical pain in my chest, it aches like the way hunger makes your stomach ache, and I believe this is due to having to ‘walk on eggshells’ at such a young age.  After looking into this further with a therapist, I began to notice more specific things that also cause me pain. For example, I always thought that my head/hair was very sensitive and having others brush my hair when I was young used to send me into frenzies and make me physically sick.’

Alex elaborates upon experiencing acute scalp pain whenever somebody touches her head or her hair. This has not only caused her severe personal distress, but has posed problems when having routine haircuts: 

‘I always experience pain when I visit hair salons, to the point where I’ve had to ask them to stop. I despise people touching my head and feel happy wearing a hat. I always chalked this down to an individual quirk, something too trivial or silly to talk about. But in reality, it’s not.’ 

Having discussed her pain with a therapist in adulthood, Alex discovered that an adverse childhood experience of physical abuse was the root cause of these intense feelings of pain: 

‘When I was about seven my dad became very displeased at the mess of my room and proceeded to pin me down (his knees on my arms) and run the hoover nozzle over my skull for some time, threatening to get rid of it. I thought it was going to pull my hair out, I really believed that. I remember screaming in pain and I then froze completely in shock. It was so painful, it ached for so long after and my mum had to sit and de-tangle my hair, which ached also.  

So, I often feel the sensation of my hair being ripped out, when I’m fact it’s just the salon worker gently removing knots. This was one incident on one occasion and I feel it as if it’s happening to this day, abuse doesn’t just hurt at the time – it hurts long after too.’ 

In our Airing Pain programme on domestic violence and chronic pain, Clinical Psychologist Dr Kate Gillan discusses how abuse can cause heightened sensitivity to pain. She explains how survivors of trauma and abuse often develop a hypersensitive nervous system, which exists in a persistent state of amplified pain. They may experience pain even when somebody is only touching them lightly. The brain does not produce an appropriate, mild response to normal touch, but a heightened pain response.

Jennifer Bowey is Project Co-ordinator with Pain Concern. She has written this case study in collaboration with a Scottish domestic abuse survivor who wishes to remain anonymous. Our thanks go to our survivor for sharing their story.

Latest News

Psychosocial stress and trauma are risk factors for chronic pain  

Domestic abuse is both a humanitarian crisis and a public health issue. Researchers have previously established that prior experience of domestic violence is common among women with chronic pain conditions like fibromyalgia. 

More recently, Dr. Yavne and colleagues reviewed the evidence for this link across academic literature in the area. They concluded that experience of traumatic events, like abuse, can lead to persistent pain conditions and autoimmune conditions, along with psychological troubles including post-traumatic stress disorder (PTSD), anxiety and depression. In fact, fibromyalgia seems to occur along with PTSD a large portion of the time. 

Many possible explanations of the association between the two have been put forth. Commonly discussed is the effect of trauma on cortisol (a stress-hormone) regulation that is associated with prevalence of pain conditions and greater pain intensity. Several other mechanisms involving the brain’s processing of trauma and pain, type of abuse and timing of abuse are discussed.  

The overarching conclusion of the study is that psychological trauma caused by threatening life events such as domestic abuse, is a major risk factor for developing chronic pain conditions such as fibromyalgia, especially in women. To read the complete review, click here. 

Early-life stress is associated with chronic pain in women during adulthood

Violence against an intimate partner is seldom a stand-alone occurrence. When children are in the household, they often experience and/or witness violence, both of which have negative mental and physical health consequences. Children of couples in turbulent relationships are also often neglected. Childhood neglect has also been associated with chronic pain and emotional symptoms later in adulthood. 

Girls with a history of such childhood adversity and maltreatment are at a greater risk of long-term consequences later in adulthood. Recently, Dr Beal and colleagues found that women with negative early-life experiences report greater post-traumatic stress symptoms (PTSS), higher likelihood of pain and greater pain intensity later in life. The researchers suggest several possible explanations including impaired emotional regulation, sleep deprivation and increased bodily inflammation associated with exposure to violence and PTSS.

The findings further strengthen evidence that the consequences of violence among parents may transmit to the next generation, and can manifest as negative outcomes for those with pain. To read the full study, click here. 

Exploring treatments for those with both chronic pain and PTSD

PTSD and chronic pain may have commonalities that serve to reinforce each other. These factors include pain-related avoidance (shutting off physically and socially in an attempt to avoid overwhelming pain) and pain catastrophising (a tendency to dwell on the pain and magnify the experience) among others. Though the knowledge of these associations is still limited, it seems that one triggers the other, ensuring that neither subsides.  

Research suggests that chronic pain may make it more difficult to treat trauma. Researchers propose that coping strategies employed to manage chronic pain may hinder therapeutic progress on healing from trauma. Evidence from other trauma-exposed groups indicates that chronic pain and PTSD mutually contribute to reinforcing each other. In instances of domestic abuse, the triggering of chronic pain due to psychological trauma is a double jeopardy for those who experience it.  

Trauma-focused therapy does not always deal with trauma in the context of one’s life circumstances. Traditional modes of therapy also do not target all mechanisms of PTSD-maintenance, like chronic pain. Hence, an integrated and holistic approach is essential. Several multidisciplinary approaches requiring the collaboration of psychologists and physiotherapists are discussed in the paper. 

The article is linked here.

Approaching women's unique experiences of chronic pain

Women, in most contexts (if not all), have historically been conditioned to submit to others even when they are better informed and capable. Studies have long established that women’s expression of pain is taken far less seriously than men’s is. This is unfortunate, given that women are statistically more likely to experience chronic pain. Women are also more likely to experience mental illness and musculoskeletal pain together, than are men. 

Research is beginning to address women’s experiences of chronic pain from a gendered and socio-cultural perspective. A recent study (available here), examined the experiences of pain intertwined with other overwhelming life situations commonly experienced by women. The study conveys the importance of acknowledging women’s chronic pain in the context of their lives and widely prevalent gender roles. 

Dr. Hill and Dr. Harrell have also addressed this in their recent article highlighting the impacts of chronic pain on various life domains (family, friendships, work, finances, etc.) and interventions and therapeutic approaches to aid coping. A feminist approach to therapy is essential to approach chronic pain holistically as a part of a woman’s life, in all its complexity. The approach also emphasises an egalitarian (or equal) relationship between therapist and client. This dismantles any power differential that is otherwise apparent in other areas of a woman’s life.  

The feminist therapeutic approach aims to equip women with skills to navigate life and relationships, including medical settings. This is particularly important as doctors are more likely to dismiss women’s pain as being 'all in their heads' and guidance on standing up for oneself in medical encounters is essential. The feminist approach to therapy for chronic pain management allows the woman to be the expert on her own experience, and is suggested to be empowering for women.  

The full article is linked here.

Airing Pain

In this episode of Airing Pain, Paul Evans discusses the isolating effects of Covid-19, trauma and how this can contribute to the development of debilitating chronic illnesses such as Fibromyalgia and Chronic Fatigue Syndrome.

Available to listen to from Airing Pain 126: Domestic Violence and Chronic Pain | Pain Concern or download from wherever you get your podcasts.

Subscribe to Airing Pain via Apple Podcasts, Spotify or wherever you get your podcasts

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