Relational demand in the chronic pain experience of women veterans: a mixed methods analysis.

Social factors are critical determinants of the chronic pain experience. Despite this, psychological interventions for pain largely ignore them as meaningful therapeutic targets. Relational demand, the tendency to prioritize the needs of others over self, is a barrier to effective pain self-management, particularly among women. CONNECT, a remote reciprocal peer support pain intervention tailored for women Veterans and based on cognitive behavioral principles, was enhanced to target relational demand via psychoeducational content and self-management strategies. The additional content is not commonly addressed in behavioral pain interventions. Thus, CONNECT was designed to bolster skills related to improvements in pain (intensity, interference) and relational demand. CONNECT used ecological momentary assessment (EMA) to measure demand-pain associations before, during and after the intervention among women Veterans with back pain. A mixed method design leveraging thrice daily momentary assessments over three two-week observation periods (N = 22) was used to (a) quantify the associations between relational demand and pain relevant variables (e.g., pain intensity, pain interference and mood) (b) estimate within-time associations among demand-pain variables to determine whether CONNECT attenuates them, c), explore changes in pain and relational demand following CONNECT and d) qualitatively elucidate the implications of relational factors in the experience of women Veterans with back pain. Relational demand was significantly and moderately correlated with pain intensity (r = .41, p = .006), pain interference (r = .45, p < .001) and mood (positive affect r = − .41, p = .006; negative affect r = .48, p < .001), at baseline. There was no evidence of a statistically significant change in the strength of these associations across the three observation periods. Exploratory analyses revealed a 24% reduction in demand following intervention. Interviews revealed that guilt/shame about the impact of pain on loved ones was common. This reflected failure to fulfill internally or externally imposed expectations as well as fears of burdening loved ones. Pressure to meet the caretaking demands at the expense of self and to self-isolate—or “go it alone” emerged as a strategy to reduce guilt and the need to self-sacrifice—and to minimize burdening others. Relational demand is a relevant and potentially modifiable social construct that should be considered when treating women Veterans with chronic pain. Findings provide compelling support for the role of relational demand as a pain exacerbator and precipitator of distress in women Veterans. Incorporating strategies to target relational demand into existing behavioral pain interventions may enhance self-management efforts. Trial Registration Number and Date of Registration: NCT04229134.