Episode 21: Partners in Pain (Part III) - Compassion Plus Boundaries

Compassion with Boundaries: Sustainable Support in Caregiving

In the final episode of the 'Partners in Pain' series, Dr. Zev Nevo explores the transformative concept of 'compassion with boundaries' as essential for sustainable caregiving. This episode highlights the role of empathy, the necessity of boundaries, and the impact of co-regulation in relationships affected by chronic pain. Dr. Nevo revisits the key points from earlier episodes, emphasizing the importance of self-care, concrete support actions, and maintaining partnership and intimacy despite the challenges of chronic pain. Practical strategies for both caregivers and chronic pain sufferers are outlined to foster connection, communication, and mutual support.

00:00 Introduction: Compassion and Boundaries

00:35 Recap of Previous Episodes

01:36 The Framework for Sustainable Support

02:28 Understanding Compassion and Boundaries

03:10 The Science Behind Boundaries

05:47 Practical Strategies for Caregivers

07:19 Empathy Misses and Effective Communication

18:49 Self-Compassion and Setting Boundaries

25:14 Support for Caregivers

30:46 Guilt and Honest Communication

31:44 Cultural Influences on Emotional Expression

32:10 The Cage of Traditional Masculinity

33:59 Boundaries and Sustainable Caregiving

36:15 Power Dynamics in Relationships

41:00 Talking to Children About Pain

46:02 Concrete Practices for Pain Management

50:18 The Power of Connection and Empathy

52:12 Final Thoughts and Takeaways

This essential pre-roll message serves as a clear disclaimer, stating that the podcast provides pain and trauma-informed psychoeducation for informational and entertainment purposes only, and does not constitute medical advice. Listeners are reminded to always consult a qualified healthcare professional for specific medical conditions or symptoms.

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LINKS:

• Body and Mind Pain Center
• Mind Body Rehabilitation
• Substack

Transcript

Episode 21 | Partners in Pain (Part III) - Compassion Plus Boundaries

[00:00:00] What if I told you that the most compassionate people aren't the ones who give endlessly until they collapse, but the ones who have boundaries of steel? What if the key to sustainable caregiving isn't about sacrificing yourself, but about knowing exactly where you end and the other person begins? What if the secret to long-term healing isn't found in a pill bottle or a treatment plan, but in the space between two people who've learned to create safety for each other?

[00:00:33] Welcome back to Mind Your Body. I'm Dr. Zev Nevo, and this is part three, the final episode of our Partners in Pain series. In part one, we explored the invisible burden, the seven layers of suffering that the person in pain carries, and the helplessness that drowns the partner.

[00:00:52] We learned that sympathy drives disconnection by creating distance and hierarchy. While empathy [00:01:00] fuels connection by climbing down into the hole and saying you are not alone. In part two, we discovered that empathy is a learnable skill with four specific attributes.

[00:01:12] Perspective taking, staying out of judgment, recognizing emotion, and communicating understanding. We learned the golden questions. What does your body need today and what can we do? And we explore the critical distinction between cognitive empathy, which is sustainable, and enmeshment, which activates your pain centers and leads to burnout.

[00:01:36] Today we're bringing it all together with the framework for sustainable support,

[00:01:41] compassion plus boundaries. We're going to learn why boundaries aren't optional. They're a prerequisite for compassion. We're going to explore the practical toolkit for both the person in pain and their partner, and we're going to discover how to preserve dignity, [00:02:00] equality, and partnership, even when chronic pain threatens to shift the power dynamics. Because here's what's at stake.

[00:02:09] Without boundaries, compassion becomes enmeshment, and enmeshment leads to burnout, resentment, and the very disconnection you're trying to prevent. But with boundaries, compassion becomes sustainable, energizing, and transformative. Let's dive in. Now we get to the heart of sustainable support: compassion. Brown defines compassion as quote, "the daily practice of recognizing and accepting our shared humanity so that we treat ourselves and others with loving kindness and we take action in the face of suffering."

[00:02:46] End quote. The most common sense distinction is this. Compassion is empathy plus action. It's not just feeling, it's doing. It's not just understanding, it's showing [00:03:00] up. Compassion literally means to suffer together. It moves from a passive state of understanding to an active state of support. But here's where Brown's research reveals something soul shaking and counterintuitive, something that changes everything for long-term caregivers.

[00:03:20] The most compassionate people are also the most boundaried. Brown's research found that boundaries are not optional for compassion. They're not something you add if you have time or energy. Boundaries are a prerequisite for compassion and empathy. Here's the verbatim quote. "We can't connect with someone unless we're clear about where we end and they begin.

[00:03:46] If there's no autonomy between people, then there's no compassion or empathy, just enmeshment. Think about that for a moment. The most compassionate people don't have weak boundaries. They [00:04:00] have boundaries of steel. Why? Because boundaries are what make compassion sustainable. Boundaries are what prevent you from drowning.

[00:04:09] Boundaries are what allow you to be an anchor instead of another person being pulled under. Prentis Hemphill quoted by Brown says it beautifully. "Boundaries are the distance at which I can love you and me simultaneously." In short, boundaried empathy is sustainable empathy. This framework provides a scientific validation for the necessity of boundaries.

[00:04:34] What's commonly called compassion fatigue is really a misnomer. It's actually empathy fatigue, and specifically it's the result of unboundaried affective enmeshed empathy. Compassion fatigue occurs when caregivers focus on their own personal distress reaction rather than on the experience of the person they're caring for.

[00:04:56] They're drowning in their own pain centers being activated. [00:05:00] Remember the neurobiology. Empathy, the enmeshed kind, activates pain centers leading to depletion, burnout and secondary trauma. But compassion, the boundaried kind, activates reward centers leading to energy, sustainability, and connection. This is a transformative revelation for caregivers.

[00:05:25] Caregiver burnout is not because you're not compassionate enough, it's because you're practicing enmeshment instead of boundaried compassion. The prescription is not to care less. The prescription is to stop absorbing, to practice cognitive empathy, the skill which fuels compassion: the rewarding action. In my clinical notes for this episode, I wrote about the importance of conceptualizing the caregiver's role as an anchor or safety net rather than a fixer.

[00:05:57] This framing is critical because it [00:06:00] acknowledges that chronic pain patients have a strong need for co-regulation to create safety. You are providing them a nurturing environment that reduces suffering, not by offering false hope or trying to cure them, but by being a stable, consistent presence.

[00:06:17] An anchor doesn't move, an anchor doesn't get pulled under. An anchor provides stability in the storm. But here's what's important. An anchor also has to be secured to something solid. If the anchor itself isn't grounded, it can't hold anything in place. That something solid is your boundaries, your self care, your own nervous system regulation.

[00:06:47] Sarah said something profound about this when I asked her what partners need to do first. She said, "I think at the end of the day you have to learn how to validate your own feelings that you're going through." She wasn't talking about the person in pain. [00:07:00] She was talking about the partner, too. Both people need to validate their own feelings.

[00:07:05] The partner's frustration, helplessness, fear, those are real. Those are valid, and if you don't acknowledge and process those feelings, they will leak out as resentment, withdrawal, or what looks like indifference. Let's talk about one of the most common empathy misses in caregiving relationships. The vague offer.

[00:07:26] Let me know if you need anything. This phrase is well-intentioned, it sounds supportive, but here's why it fails. It's too open and overwhelming. It places the entire burden of identifying a need, overcoming the vulnerability of asking, and coordinating the help onto the person who's already suffering. For someone like Sarah, who's already masking her pain to avoid being a burden, This phrase is impossible to act on. She told me, "I feel like a burden. Like, [00:08:00] oh, well, are you okay? Do you want a pillow? Do you want a drink? It's just like, well, don't treat me differently. Just be aware that this is happening." Here's what works instead. Specific concrete offers that remove the logistical and emotional burden. Instead of, let me know if you need anything.

[00:08:19] Try, I want to bring dinner Tuesday night at six. Let me know any dietary needs. Or I can take the children to the park Saturday at two, or, I'm grocery shopping this afternoon. Is there anything I can pick up for you? This is empathy plus action. It uses empathic perspective taking to identify a specific point of suffering.

[00:08:43] Like, they're probably too tired to cook and combines it with compassionate action that removes the burden from the person in pain. Sarah gave me a perfect example of this. She's a mother of three and she told me, "it doesn't have to be like a big gesture, like, oh, I'm [00:09:00] going to take the kids for the rest of the day.

[00:09:02] It's more like, can I just go to the restroom for like five minutes alone? Five minutes alone in the bathroom? That's what she needs. Not grand gestures, not expensive treatments. Just five minutes of respite. And her partner taking the kids for those five minutes without her having to ask, without her having to explain, without her having to feel guilty, that's compassionate action. Let me give you the practical strategies I outlined in my notes for this episode. These are the things that actually help. First, attend appointments together. This shows I'm in this with you. I wanna understand what you're going through. It also helps with remembering information, asking questions the person in pain might not think of, and providing emotional support in medical settings that can be triggering. Second, celebrate [00:10:00] small wins and pain-free periods. This is so critical. Sarah mentioned a dynamic where even on good days, her partner would ask, are you flared?

[00:10:10] Are you going to be able to walk up this hill? That anxiety about good days actually reinforces the pain. It keeps the person hypervigilant Instead, celebrate the good moments. Go to Disneyland, take the walk, create positive associations with movement and activity. Third, create fun experiences. Chronic pain can sure make life feel like it's only about managing symptoms.

[00:10:38] Creating moments of joy, laughter, and connection reminds the person that they're more than their pain. Fourth, focus on abilities rather than disabilities. As Sarah emphasized, she wants awareness without differential treatment. See the person, not the pain. Acknowledge what they can [00:11:00] do, not just what they can't.

[00:11:03] Fifth, protect them from external stressors. This might mean running interference with family members who don't understand handling difficult phone calls or managing household chaos so they can rest. And sixth, recognize when they fail to set boundaries for themselves. 

[00:11:23] Chronic pain patients are often people pleasers or caregivers themselves. They don't make time for self care. They push through flares to meet others' expectations.

[00:11:34] As a partner, you can gently call this out, Hey, I notice you've been pushing really hard today. What does your body need right now? You know, I asked Sarah if there's a flip side, if someone could be too clingy or try too hard. You know what she said? She said, "I think me personally, yes. 'cause I'm not like that.

[00:11:54] I like my space. With me, it's more like if I feel like I'm willing to open up to you, just listen. [00:12:00] I'm not here for a lecture." So it seems the balance is initial engagement to find out what they need, but honoring their need for space, if that's what they request. Being available without hovering and checking in without interrogating.

[00:12:19] She said, "I think there's some people that truly need their partner there every step of the way, and then there's other people that like the sense of independence, but also knowing, yeah, I can go to my partner if I really needed to." That's the sweet spot. Independence with the security of knowing support is there when needed.

[00:12:39] Let me give you the specific phrases that help build connection by practicing the four attributes of empathy. Core validating statements. You're not alone. I'm here for you. I see you. I'm with you. Curious perspective taking [00:13:00] stems. Help me understand. Can you tell me more about what that was like for you?

[00:13:07] What is that experience like for you? The golden questions, bridging empathy to compassion. What does your body need today? What can we do? And what does support for me look like right now? Why these work? They honor perspective taking, they're nonjudgmental, they acknowledge emotion and they communicate understanding, all four attributes of empathy.

[00:13:35] And they prepare for compassionate action on the person's terms, not your assumptions. Now, let me give you the language to avoid, the common empathy misses. First, have you tried? This is unsolicited advice. It implies you're not trying hard enough. It violates the attribute of staying out of judgment.

[00:13:58] Sarah's partner would say, well, you [00:14:00] know, you haven't worked out. This made her feel blamed for her pain. Second, it could be worse, or at least. This is toxic positivity. It invalidates the person's experience and communicates that their pain is an inconvenience to you. Brown explicitly addresses this.

[00:14:19] Comparative suffering doesn't create connection. It creates competition and invalidation. Third, you're so strong or you're so brave when it feels like pity. This can be genuine admiration, but it can also create distance and hierarchy. It depends on the tone and context. When it comes from pity, it says, I can never handle what you're going through, which positions you as separate and above reinforcing the person's sense of being other.

[00:14:50] Remember Sarah's concern about pity? She doesn't want to be seen as someone to feel sorry for. Fourth, I wish I could take your pain away. [00:15:00] This sounds compassionate, but it actually centers your discomfort with their pain. It can make the person in pain feel responsible for your distress.

[00:15:11] It's a form of sympathy, feeling for them rather than empathy, feeling with them. Fifth, you look great when they don't feel great. For someone with invisible pain, this is deeply invalidating. It dismisses their internal reality based on external appearance. Remember how Sarah's partner would say he doesn't know when she's in pain because she looks normal?

[00:15:35] This forced her to mask even more. Sixth, I know exactly how you feel. This is false equivalence. Even if you've experienced pain, their pain is uniquely their pain experience. This phrase can feel like you're claiming their experience rather than honoring it. Better? I don't know exactly what you're feeling, but I'm here to understand.[00:16:00] 

[00:16:00] And seventh, silence or avoidance. This is the worst response. Remember Sarah's partner's approach of not talking about it so it's not there? Silence communicates abandonment. It tells the person the reality is too uncomfortable for you to handle, so they need to hide it. Remember what Sarah said about what she actually needs.

[00:16:24] Physical touch was at the top of her list. Nonverbal communication is often more powerful than words. Here's what creates safety. First, physical touch when appropriate. Hand on the forearm for that oxytocin release. A hug without words. Sitting close without needing to fill the silence. Remember Sarah's 4-year-old son? He would touch her shoulder and check in.

[00:16:52] That's presence without agenda. Second, sit with them while they're in pain. Not trying to fix [00:17:00] or solve. Just being there. Sarah said, "I think just honestly being present, even if you can't say anything or know that you can't fix it, just being there and physically present." Third, taking action without being asked. Running a bath, taking over a household task, bringing water or a heating pad.

[00:17:22] These actions communicate, I see you. I'm paying attention. You don't have to ask. I use this analogy with patients all the time. Think of your energy like a phone battery. When it starts flashing red and goes to zero, you can will it to stay on all you want, but it won't.

[00:17:40] Fortunately or unfortunately, we as humans can push way past where our state of health and balance is. We can survive on reserves for a really long time, but that catches up to us. Down the line, you end up with flares that are more pronounced and last longer. Your net is [00:18:00] actually an increase in suffering. If we take the time more frequently to not allow ourselves to get to a place where we're depleted, we can keep ourselves on a path where we're not fighting pain all the time. This applies to both the person in pain and the partner. For the person in pain, don't push through every flare. Don't mask until you collapse. Recharge before you hit zero. And for the partner, don't give until you're empty. Don't sacrifice your own wellbeing in the name of caregiving. You can't pour from an empty cup, as they say. Remember, Sarah's request? "Can I just go to the restroom for like five minutes alone?" That's recharging. That's honoring the battery before it hits zero. Now I wanna speak directly to those of you living with chronic pain.

[00:18:53] Sarah told me something that broke my heart. She said, "I haven't told anyone. I don't want to feel pity from [00:19:00] people. I feel like people are going to treat me differently if I tell them I'm in pain. So I just mask it." She's so good at masking that even in an active flare, she appears completely normal on the outside. She's smiling, talking, functioning, while her nervous system is screaming.

[00:19:18] These are the seven layers of suffering I mentioned earlier. You're not just dealing with physical pain, you're dealing with the shame of being in pain, the guilt of feeling like a burden, the fear of being pitied or treated differently, the exhaustion of masking, the isolation of not being able to be authentic, and the resentment that builds when you can't express any of this. And here's what makes this so insidious.

[00:19:45] You don't have a place where you can authentically be yourself. Your physical boundaries are constantly interrupted by pain. Your emotional boundaries are violated by the need to protect others from your reality. Brown's research, drawing [00:20:00] heavily on Dr. Kristin Neff's work, makes a critical distinction between self-pity and self-compassion.

[00:20:06] Self-pity is linked to excessive rumination, playing the victim, feeling isolated in your suffering, and believing you're uniquely cursed. But self-compassion has three components. The first component of self-compassion is kindness. Treating yourself with the same warmth and care you would offer a good friend, rather than harsh self-criticism.

[00:20:33] Instead of, I'm so weak, I should be able to push through this, try, I'm doing the best I can with a really difficult situation. Second, common humanity. Recognizing that imperfection and suffering are part of the shared human experience, which combats isolation. Instead of, why is this happening to me? I must be cursed, try, chronic pain affects millions of [00:21:00] people. I'm not alone in this struggle. Third is mindfulness. Observing your thoughts and feelings with clarity without suppressing or exaggerating them. Instead of, I can't think about the pain, or it will get worse, which is suppression or the pain is unbearable and will never end, which is exaggeration, try, I'm noticing the pain is at a seven right now. It's uncomfortable, but I've gotten through this before. The critical distinction is accountability. Being a victim of chronic pain is a state of fact. You didn't choose this. But playing the victim is a behavioral pattern of holding others accountable for your feelings and refusing to take any agency in your healing. Self-compassion is the antidote.

[00:21:51] It allows you to move through your suffering without becoming trapped in a shame spiral. Sarah gave me the golden framework for this with [00:22:00] those body-centered questions and the what can we do? language. But here's the challenge. You have to be willing to answer those questions honestly. If you're masking, if you're people pleasing, if you're afraid of being a burden, you won't ask for what you need.

[00:22:18] You'll say, I'm fine when you're not fine. Here's what I want you to practice. First, name the need specifically. Instead of, I'm not feeling great, which is vague and easy to dismiss, try, I'm in a flare right now. My muscles are actively tensing up. I need to rest for 30 minutes. Second, make concrete requests.

[00:22:41] Instead of saying I need help, which is unclear, try, can you take the kids to the park for an hour so I can take a bath? Third, communicate your nonverbal cues. Sarah told her partner, "when I'm in pain, I tend to move a lot. I get fidgety, I go quiet. I isolate." [00:23:00] Teach your partner what to look for.

[00:23:02] Don't expect them to be mind readers. Fourth, express what helps versus what doesn't. When I say I'm in pain, what helps me is physical touch or asking what I need. What doesn't help is trying to fix me or suggesting I haven't tried hard enough. Here's something critical from my clinical notes. Chronic pain patients are often people pleasers or caregivers themselves, as we said. They don't make time for self-care. They fail to set boundaries. Sarah demonstrated this. She's a mom of three. She pushes through flares to meet everyone else's needs. She masks her pain to avoid making others uncomfortable. But here's the thing. You cannot heal in an environment where you're constantly depleting yourself to meet others' expectations.

[00:23:54] Setting boundaries is not selfish. It's self preservation. It's the only way to [00:24:00] prevent those severe flares that come from pushing past empty. Practicing, I need to rest right now. I can't do that today. I need five minutes alone. That doesn't work for me.

[00:24:15] And here's what's important. You don't have to justify or explain. Your body's needs are valid, period. The conclusion of my physical notes emphasize something critical. The importance of affirming the person's inherent value beyond their functional capabilities or what they can do for others.

[00:24:35] Sarah's core request was awareness without differential treatment. You are not your pain. You are not your productivity. You are not what you can do for others. Your worth is inherent. It doesn't fluctuate based on whether you're having a good day or a bad day. It doesn't decrease because you need help.

[00:24:58] It doesn't [00:25:00] disappear because you can't do everything you used to do. By helping restore your sense of purpose, your sense of meaning and value, independent of your pain, you create the foundation for long-term healing. 

[00:25:14] Now I wanna speak directly to the partners, the caregivers, the ones watching someone they love suffer. Sarah said something at the beginning that speaks directly to you. "I think it's also difficult for a partner to understand how difficult it is to live with pain." I also wanna remind you of her core prescription for partners.

[00:25:36] Both people in the relationship need to validate their own feelings, not just the person in pain, but the partner too. Your feelings of helplessness, fear, frustration, and exhaustion are real. They are valid. They are a natural human response to watching someone you love suffer and being unable to fix it.

[00:25:57] If you don't acknowledge them, they'll [00:26:00] come out as resentment, withdrawal, or what looks like indifference - the very thing that drives disconnection. Just as self-compassion is vital for the person in pain, it's doubly important for the caregiver. Remember Dr. Neff's three components. First is kindness.

[00:26:17] Treat your own frustration with kindness. Instead of criticizing yourself, you know, I'm a terrible partner for being frustrated, try, this is a hard situation and it's okay for me to feel helpless sometimes. Second, is common humanity. Remind yourself you are not alone. There are millions of partners dealing with chronic pain.

[00:26:39] Your struggle is part of the shared human experience. Third, mindfulness. Observe your feelings without judgment. Notice the anxiety when they mention a flare. Don't suppress it. Don't let it drive you to fix. Just notice it. We already established that boundaries are the [00:27:00] prerequisite for sustainable compassion. To maintain your ventral vagal state, your anchor status, you must protect your own energy and time. What does this look like in practice? Saying no to more, saying no to requests that will deplete your battery. Scheduling your own self care, protecting time for your own activities, hobbies, friends and therapy.

[00:27:26] This is non-negotiable anchor maintenance. Recognizing enmeshment. If you feel overwhelmed, burned out, or are experiencing secondary trauma, you've likely slipped into affective empathy or enmeshment. Take a step back and shift back to cognitive empathy, understanding their experience without absorbing it.

[00:27:49] Part of the partner's emotional landscape is dealing with grief and loss. You are grieving the loss of the relationship you had, the future you planned, the [00:28:00] activities you used to share together, and the version of your partner that was not defined by pain. Grief is not a single emotion. It's a process. It includes anger, denial, bargaining, depression, and acceptance.

[00:28:18] Allow yourself to feel these emotions. Talk to a therapist or a support group who understands caregiver grief. Sarah says something at the beginning of our conversation that I want you to really hear. "It's really easy to go down the tunnel of why is this happening to me?" She wasn't just talking about herself, she was talking about you.

[00:28:39] Your feelings are valid. Your frustration, your helplessness, your fear, your exhaustion. These are real. These are legitimate responses to watching someone you love suffer while feeling powerless to help. But the worst thing you can do is suppress those feelings or judge yourself for having them. Because when you don't acknowledge and process your [00:29:00] own emotional landscape, those feelings leak out as resentment, withdrawal, or what looks like indifference.

[00:29:07] And as Sarah said, "I think you start growing resentment without even realizing it. And that's now another battle you got to fight in addition to your pain: to make sure your relationship is stable and that you're not upsetting the other person because you are in pain."

[00:29:24] Don't make your partner fight that battle. Own your feelings. Process them, get support for them. Brene Brown talks about how vulnerability is required for empathy, but here's what people don't talk about enough. There's profound vulnerability in witnessing someone else's pain. It forces you to confront your own mortality and fragility, your lack of control, your inability to protect the people you love, and the unfairness and randomness of suffering.

[00:29:55] These are terrifying realizations, and your nervous system responds to that [00:30:00] terror with threat activation, sympathetic arousal. That's why you might find yourself offering solutions, trying to regain control, minimizing the pain, trying to reduce the threat, withdrawing, trying to protect yourself, or getting frustrated, discharging the helpless energy.

[00:30:20] None of these responses make you a bad person. They make you human, but they also don't help. So we need to find a different way. Sarah said something profound. "I would say what can help in a sense is to tell your partner, hey, it does make me a little uncomfortable when you talk about this.

[00:30:40] So that way they're not just like, oh, am I bothering this person when I mentioned that I'm in pain?" But I pushed back on this. I asked, wouldn't that make you feel guilty about bringing up your pain? Her answer really surprised me. She said, "For me, it wouldn't. For me, it makes me feel more like the guilt when there's no communication, but I [00:31:00] still feel it."

[00:31:01] She'd rather have honest communication about discomfort than silent withdrawal. So here's what I want you to practice. Name your feelings without making them your partner's responsibility. Instead of, you're always complaining about pain, which is blame, try, when you talk about your pain, I feel helpless because I want to fix and I can't.

[00:31:22] That's my struggle, not yours. I'm working on just being present with you instead. See the difference? You're owning your feelings. You're not making them wrong for having pain. You're not making their pain about you. You're just being honest about your internal experience while taking responsibility for managing it.

[00:31:44] Sarah brought up something important about her relationship. She says, "maybe it's a cultural thing too, because in my culture, the men are supposed to be very non-emotional. I've never seen my partner cry, ever. I've never [00:32:00] seen him sad. There's never that like, Hey, I'm really going through this right now, Or, I feel stressed." This is where Brene Brown's work becomes critical. She talks about how she initially geared her work toward women, and a man came up to her and said, why don't you do anything to help men? He explained that as men, they're expected to always come off strong, Showing vulnerability is seen as weakness.

[00:32:24] And he said something that stopped Brown in her tracks. Something to the effect of, my wife and children would prefer to see me die on my high horse than fall off and show vulnerability. That's the cage of traditional masculinity. You're supposed to be the protector, the provider, the strong one.

[00:32:42] You're not allowed to be scared, overwhelmed, or helpless. But here's the truth. If you can't show vulnerability, you can't practice empathy because empathy requires you to go to that place in yourself where you've felt pain, where you felt fear [00:33:00] or isolation. And if you've numbed those feelings in yourself, you can't connect with them in your partner.

[00:33:08] I want to give you explicit permission. You don't have to be strong all the time. You don't have to have all the answers. You don't have to fix everything. You don't have to be the unshakeable rock. You can say, I don't know what to do, but I'm here. This is really hard for me too. I'm scared. I feel helpless, and I hate that feeling.

[00:33:35] That's not weakness. That's authenticity. And authenticity creates connection. As human beings, we all have emotions, and if we decide that only certain ones are okay, we're going to end up numbing everything, and we just come off as robots. Don't be a robot. Be human.

[00:33:54] Be vulnerable. Be real. Here's something critical. You [00:34:00] can't be your partner's only source of support and they can't be yours. If you're experiencing compassion fatigue or burnout, resentment towards your partner, anxiety or depression, physical symptoms of stress, withdrawal from other relationships or loss of your own identity, you need support.

[00:34:20] This might look like individual therapy, a support group for caregivers, trusted friends, or family you can vent to, your own healthcare providers or respite care to give you breaks.

[00:34:33] This is not optional. This is not selfish. This is essential. Remember, you can't be an anchor if you're not secured to something solid. Your support system is that solid ground. In my clinical notes, I pose this question, how might caregivers effectively balance their own emotional needs and boundaries while serving as an anchor for someone with chronic pain?

[00:34:58] Particularly when the [00:35:00] caregiver experiences compassion fatigue or burnout. Here's the answer. Boundaries are not about doing less. They're about doing differently. Unboundaried caregiving looks like absorbing your partner's pain.

[00:35:14] That's enmeshment, sacrificing your own needs completely, feeling guilty for taking time for yourself, measuring your worth by how much you can do for them, and losing your own identity in the caregiver role. Boundaried caregiving looks like understanding their pain without absorbing it.

[00:35:32] That's cognitive empathy. Meeting your own needs so you can show up regulated. Taking time for yourself without guilt, recognizing that your worth is inherent, not earned, and maintaining your own identity, interests, and relationships. Boundaried caregiving is sustainable caregiving. It's the only way to be in this for the long haul.

[00:35:55] And here's what's so beautiful. When you practice boundaried compassion, you model for [00:36:00] your partner what self-compassion looks like. You show them that it's okay to have needs. It's okay to set limits. It's okay to prioritize wellbeing. That's a gift. 

[00:36:12] I mentioned this earlier, but I want to dive deeper. Chronic pain can fundamentally shift the power dynamics in a relationship. I see this especially in elderly couples, but it can happen at any age. One person becomes the caregiver and the other becomes the patient. What was once a partnership of equals becomes a relationship with a helper and someone who needs help.

[00:36:34] This shift affects intimacy. It's hard to maintain romantic or sexual connection when one person is in a caregiver role. It affects equality. The caregiver can develop a sense of power or control, even unintentionally.

[00:36:48] It affects autonomy. The person in pain can feel dependent, which breeds resentment. And it affects identity. Both people can lose sight of who they are outside these [00:37:00] roles. Sarah described this dynamic. "You expect your partner to be a certain way." 

[00:37:06] Her partner who's several years older than she is, expects her to be healthier because she's younger. He suggests she should work out more, implying that if she just tried harder, she wouldn't be in pain. That's a power dynamic. He's positioning himself as the one who knows better, who's healthier, who's doing it right, and she's positioned as the one who's failing, who's not trying hard enough, who's letting herself go.

[00:37:29] Codependency in chronic pain relationships look like the caregiver's identity becoming entirely about caregiving. The person in pain's identity becoming entirely about being sick. Both people losing themselves in the dynamic. Resentment building on both sides, and neither person being able to function independently.

[00:37:53] My clinical notes emphasize the importance of maintaining an equal relationship rather than shifting into a codependent [00:38:00] dynamic. This requires both people to maintain their own identities, their own interests, and their own relationships. Recognize the person in pain is still a whole person, not just their symptoms, acknowledge that the caregiver is still a whole person, not just the helper, and preserve intimacy and partnership alongside the caregiving needs. Brown's research on pity is critical here. Remember, pity involves a belief that the suffering person is inferior, a passive self-focused reaction, a desire to maintain emotional distance, and avoidance of sharing in the suffering.

[00:38:38] When caregiving slides into pity, it strips the person of their dignity and agency. Sarah's core request remains consistent. Her partner and others need to recognize what's happening without changing how they see her. She doesn't want to be seen as less than. She doesn't want to be infantalized. [00:39:00] She doesn't want her partner to take over her life.

[00:39:03] She wants partnership. She wants equality. She wants to be seen as a whole person who happens to be dealing with pain, not as a broken person who needs to be fixed. This is why that what can we do? language Sarah gave us is so powerful. Not, what can I do for you? which positions you as the helper and them as the helpless, but what can we do? which positions you as partners facing a challenge together. This language preserves equality. We're in this together. It preserves agency. You still have a say in what happens. It preserves partnership. This is our problem, not just your problem. And it preserves dignity. You're not a burden. You're my partner.

[00:39:50] First, make decisions together. Don't decide what's best for them. Ask, what do you think would help? Second, respect their [00:40:00] autonomy. If they want to try something, support them. Even if you're worried. Sarah described how her partner's anxiety on good days made her feel challenged, so she'd push herself harder just to prove she could.

[00:40:13] That's autonomy being violated. Trust them to know their own limits. Third, maintain your own life. Don't make caregiving your entire identity. Keep your hobbies, friendships and interests. This models healthy boundaries and prevents resentment. Fourth, preserve intimacy. Find ways to connect that aren't about pain or caregiving.

[00:40:37] Date nights, shared laughter, physical affection that isn't just about comfort. Fifth, celebrate their abilities. Focus on abilities rather than disabilities. What can they still do? What brings them joy? What are they good at? Celebrate that. Acknowledge that. Don't let the pain become the only thing you see. [00:41:00] Sarah's a mother of three, and this added another layer of complexity to her experience.

[00:41:05] She told me, "I feel like I have to mask for them too. I don't want to instill a fear of pain or create trauma for my children. This is a real concern. Children are incredibly perceptive. They pick up on everything. Your pain, your stress, your fear. Remember Sarah's 4-year-old son? He demonstrates this beautifully.

[00:41:25] His nervous system detects the shift in hers even when she's masking verbally. That child knows. He's reading her nervous system. He's offering comfort in the way he knows how. I asked Sarah what she thought would be helpful in terms of talking to children about pain. 

[00:41:43] She said, "I think it's easy to explain to them like, hey, you know, Mom's not feeling that great. She's taking a bath because her muscles hurt. Or maybe just simplifying a little bit more and just like, yeah, Mom's body hurts right now." This is [00:42:00] age-appropriate honesty. You're not hiding it. You're not dramatizing it.

[00:42:03] You're just naming it simply. For young children, Mommy's body hurts today, so I need to rest. My muscles are tired, so I'm going to take a bath. I'm okay. I just need some quiet time. For older children, I have a condition that causes pain sometimes. It's not dangerous, but it means I need to rest more. When I'm in pain, I might seem quiet or tired.

[00:42:28] That's not because of you. It's just my body. You can help by being patient and understanding when I need breaks. Sarah says something that really struck me.

[00:42:38] "Just even stepping in like, hey, I'm just going to take the kids for 10 minutes, and during that time, let's say I get in the bath and then all the kids come in. I don't get that. Just that little break." Partners, this is where you step in. Not by taking over parenting completely, but by creating protected space. Hey kids, Mom needs 30 minutes [00:43:00] alone, let's go to the park. Mom's resting right now, let's play quietly in the living room. I've got bedtime tonight, you go rest. These small acts of protection are compassionate action. They remove the burden of having to ask, having to explain, having to feel guilty. My notes emphasize the importance of modeling vulnerability and healthy emotional expression for children. If you, the partner, never show emotion, never acknowledge, struggle, never ask for help, you're teaching your children that those things are shameful. If you, the person in pain, always mask, always push through, always pretend you're fine, you're teaching your children that their needs don't matter. What you want to model is that it's okay to have needs. It's okay to ask for help. It's okay to set boundaries.

[00:43:53] It's okay to feel emotions. It's okay to rest. Sarah's son is already [00:44:00] learning this. He's learning that when someone is hurting, you offer comfort. You ask if they're okay. You stay with them. That's empathy in action. And he learned it by watching.

[00:44:11] Let me bring this all together. This three part series was about shifting the perspective on chronic pain from a personal struggle to a shared journey of nervous system co-regulation.

[00:44:23] We've established that the pain is a hundred percent real for the person's suffering. The exhaustion and confusion are a hundred percent real for the partner. Both experiences are valid. The goal isn't to fix the person in pain. The goal is to co-create a sanctuary of safety where both nervous systems can begin to calm and heal.

[00:44:44] We've learned from Brene Brown that sympathy drives disconnection, feeling for someone from a distance. Pity creates hierarchy, seeing someone as inferior. Empathy fuels connection, feeling with someone, climbing into [00:45:00] the hole. And compassion is sustainable. It's empathy plus action plus boundaries. 

[00:45:08] We've learned from Sarah's lived experience that masking creates seven layers of suffering. Partners' discomfort can manifest as indifference.

[00:45:17] Those golden questions about what the body needs and what we can do to create partnership.

[00:45:22] Small gestures matter more than grand solutions. And presence is more power than fixing. We've learned that enmeshed empathy activates pain centers, leading to burnout. Boundaried compassion activates reward centers, leading to sustainability. Co-regulation requires you to regulate yourself first. And your nervous system affects your partner's nervous system. Here's the ultimate take home point. You are not two separate islands. You are a single, interconnected mind-body system. You have the power to influence each other's [00:46:00] nervous systems for healing. Let me give you concrete practices you can implement immediately, whether you're the person in pain or the partner. For the person in pain, first practice self-compassion, not self-pity. Use Kristen Neff's three components: Kindness, treat yourself as you would a good friend. Common humanity, remember, you're not alone in this struggle. And mindfulness, observe your pain without suppressing or exaggerating it.

[00:46:30] When you notice self-critical thoughts like, I'm so weak, I should be able to handle this. Pause and reframe. I'm doing the best I can with a really difficult situation. Millions of people struggle with chronic pain. I'm not uniquely broken. Second, communicate your needs specifically. 

[00:46:47] Name the need. I'm in a flare. My muscles are tensing up. And make concrete requests. Can you take the kids for an hour so I can rest? Teach your partner your cues. [00:47:00] When I go quiet and fidgety, that usually means I'm in pain. Third, honor your battery before it hits zero. Don't push through every flare. Don't mask until you collapse.

[00:47:12] Rest before you're depleted. Your net suffering will actually decrease. Fourth, affirm your inherent worth. Your value is not determined by your productivity, your functionality, or what you can do for others. Practice saying, I am worthy of love and care regardless of my pain level today. For the partner or caregiver. First, regulate your own nervous system before engaging with your partner in pain, check in with yourself. Are you calm and connected? Are you anxious or frustrated? Are you shut down or numb? If you're dysregulated, take a few minutes to regulate yourself. Breathe, walk, ground yourself.

[00:47:55] Your regulated presence is the intervention. Second, use those [00:48:00] golden questions. Replace, What do you want me to do? which puts the burden back on them, with, what does your body need today? What can we do? What does support from me look like right now? Third, offer specific concrete help. Replace, let me know if you need anything, which is too vague and overwhelming with, I'm bringing dinner Tuesday at six. I'm taking the kids to the park at two, you rest. I'm running to the store. What can I grab for you? Fourth, practice presence without fixing. 

[00:48:30] When your partner expresses pain, resist the urge to solve, minimize or offer advice. Instead, offer physical touch hand on the forearm, a hug. Say, that sounds really hard. I'm here with you. Ask, what would help right now? Or just sit with them in silence. Fifth, maintain your boundaries.

[00:48:50] Remember, boundaries are a prerequisite for compassion. You cannot be an anchor if you're drowning. Keep your own hobbies and friendships. Seek your own support. Take breaks [00:49:00] without guilt. Say no when you need to. And for both of you, first, ride the wave together. On good days, celebrate them. Don't wait for the shoe to drop. Create joyful experiences. And on bad days, show up. Don't withdraw. Don't get frustrated. Just be present. Second, communicate about the meta level. Talk about how you're talking about pain. Sarah said, "I'd rather talk about it than brush it under the rug." Have the conversation about what helps versus what doesn't.

[00:49:31] What your needs are, what your fears are, and what your boundaries are. Third, preserve your partnership. Don't let pain become the only thing your relationship is about. Maintain intimacy, emotional and physical. Maintain shared interests and activities.

[00:49:48] Maintain laughter and lightness. And maintain your identity as partners, not just patient and caregiver. Fourth, focus on co-regulation. Practice creating nervous [00:50:00] system safety for each other. Soft eye contact, calm voice tones, gentle touch, regulated breathing, creating calm environments. Remember, you can't heal alone and the most powerful medicine you have is this sense of safety and validation you can offer each other.

[00:50:18] What we've been talking about throughout this series: empathy, compassion, boundaries, co-regulation. These aren't just tools for managing chronic pain. These are the foundations of any healthy relationship. Chronic pain just makes the stakes higher. It forces you to confront the dynamics that might have been lurking underneath the surface all along.

[00:50:39] Can you be vulnerable with each other? Can you ask for what you need? Can you hold space for discomfort? Can you maintain your own identity while being deeply connected? Can you love someone through their suffering without losing yourself? These are the questions that define intimacy, and here's what I've learned [00:51:00] in my years of working with patients.

[00:51:03] The couples who navigate chronic pain successfully are the ones who are already practicing these skills or who are willing to learn them now. This is hard work. It's vulnerable work. It's ongoing work, but it's also the most meaningful work you can do. I wanna close with this.

[00:51:23] Connection is possible despite pain. Intimacy is possible despite suffering. Love is possible despite limitation. "I see you. Let's work on this. We'll get through it together." That's the goal. Not to eliminate the pain, not to fix the person, not to pretend everything is fine, but to see each other, to work on it together,

[00:51:46] to get through it together. You don't have to do this perfectly. You don't have to have all the answers. You don't have to be strong all the time. You just have to show up. You just have to be present. You just have to [00:52:00] keep trying. And on the days when you can't, when you're too depleted, too frustrated, too overwhelmed, that's okay too.

[00:52:07] That's human, that's real. Give yourself grace, give your partner grace. So here's what I want you to take away from this entire series. If you're living with chronic pain, know this.

[00:52:18] Your pain is real, your struggle is valid, and you deserve support that doesn't come with judgment, pity, or the burden of having to protect everyone else from your reality. You deserve a partner who can climb down into the hole with you and say, you're not alone. And you deserve to practice self-compassion, to treat yourself with the same kindness you'd offer a dear friend going through the same thing.

[00:52:44] If you're the partner of someone with chronic pain, know this. Your feelings of helplessness and frustration are real, too. They don't make you a bad person. They make you human. But the path forward isn't to fix, minimize, or withdraw. It's to regulate your own nervous system [00:53:00] first, then offer your calm, boundaried presence.

[00:53:03] It's to ask, what can we do? instead of What do you want me to do? It's to remember, taking care of yourself isn't selfish. It's essential. And for both of you, this journey isn't about eliminating pain. It's about creating a sanctuary of safety where both of your nervous systems can begin to heal.

[00:53:22] It's about riding the wave together, celebrating the good days without waiting for the other shoe to drop, and showing up on the bad days without resentment or withdrawal. It's about remembering that empathy is a skill you can practice. Compassion requires boundaries to be sustainable, and your nervous systems are constantly influencing each other, for better or worse. The most powerful medicine you have isn't found in a pill bottle or a treatment plan. It's found in the space between you, in the moments of genuine connection, in the willingness to be vulnerable, and the courage to say, I see you, and mean [00:54:00] it. "Let's work on this. We'll get through it together." That's the invitation. That's the possibility. That's the hope. You don't have to be perfect. You don't have to get it right every time. You just have to keep showing up, keep trying, keep choosing connection over isolation. Because at the end of the day, chronic pain may be an individual experience, but healing, real lasting healing, happens in relationship. It happens when two nervous systems find safety in each other. It happens when someone says you're not alone and actually means it. Reflect on the lessons you've learned throughout this series.

[00:54:38] If this series resonated with you, please, please share it. Share it with friends, family, or your partner. Listen to it together. Use it as a starting point for the conversations you've been avoiding. And remember, this isn't quick. It isn't easy, but it's possible. You can create a sanctuary of safety in your relationship.

[00:54:59] [00:55:00] You can practice empathy without drowning. You can offer compassion without losing yourself. You can ride the wave together. 

[00:55:09] This is Dr. Zev Nevo, and you've been listening to the final episode of our Partners in Pain Series. Thank you so much for sticking with me and for being here. Thank you for doing this hard, vulnerable, beautiful work, and thank you for choosing connection. See you next time.