Where do they come from?

You know the type – emails with 1000’s of footers with various virus protection & privacy notices, the ones forwarded from public health and police and other government departments – well, they can get you into trouble, and some are downright distressing.  Others are simply silly.  Here’s a couple for Friday Funnies:

Foreign signs:

In a Tokyo Hotel:

Is forbitten to steal hotel towels please. If you are not person to do such thing is please not to read notis.

In another Japanese hotel room:

Please to bathe inside the tub.

In a Bucharest hotel lobby:

The lift is being fixed for the next day. During that time we regret that you will be unbearable.

In a Leipzig elevator:

Do not enter the lift backwards, and only when lit up.

In a Belgrade hotel elevator:

To move the cabin, push button for wishing floor. If the cabin should enter more persons, each one should press a number of wishing floor. Driving is then going alphabetically by national order.

In a Paris hotel elevator:

Please leave your values at the front desk.

In a hotel in Athens:

Visitors are expected to complain at the office between the hours of 9 and 11 A.M. daily.

In a Yugoslavian hotel:

The flattening of underwear with pleasure is the job of the chambermaid.

In a Japanese hotel:

You are invited to take advantage of the chambermaid.

In the lobby of a Moscow hotel across from a Russian Orthodox monastery:

You are welcome to visit the cemetery where famous Russian and Soviet composers, artists, and writers are buried daily except Thursday.

In an Austrian hotel catering to skiers:

Not to perambulate the corridors in the hours of repose in the boots of ascension.

On the menu of a Swiss restaurant:

Our wines leave you nothing to hope for.

On the menu of a Polish hotel:

Salad a firm’s own make; limpid red beet soup with cheesy dumplings in the form of a finger; roasted duck let loose; beef rashers beaten up in the country people’s fashion.

In a Hong Kong supermarket:

For your convenience, we recommend courageous, efficient self-service.

Outside a Hong Kong tailor shop:

Ladies may have a fit upstairs.

In a Bangkok dry cleaner’s:

Drop your trousers here for best results.

Outside a Paris dress shop:

Dresses for street walking.

In a Rhodes tailor shop:

Order your summers suit. Because is big rush we will execute customers in strict rotation.

Similarly, from the Soviet Weekly:

There will be a Moscow Exhibition of Arts by 15,000 Soviet Republic painters and sculptors. These were executed over the past two years.

In an East African newspaper:

A new swimming pool is rapidly taking shape since the contractors have thrown in the bulk of their workers.

In a Vienna hotel:

In case of fire, do your utmost to alarm the hotel porter.

A sign posted in Germany’s Black Forest:

It is strictly forbidden on our black forest camping site that people of different sex, for instance, men and women, live together in one tent unless they are married with each other for that purpose.

In a Zurich hotel:

Because of the impropriety of entertaining guests of the opposite sex in the bedroom, it is suggested that the lobby be used for this purpose.

In an advertisement by a Hong Kong dentist:

Teeth extrcted by the latest Methodists.

A translated sentence from a Russian chess book:

A lot of water has been passed under the bridge since this variation has been played.

In a Rome laundry:

Ladies, leave your clothes here and spend the afternoon having a good time.

In a Czechoslovakian tourist agency:

Take one of our horse-driven city tours—we guarantee no miscarriages.

Advertisement for donkey rides in Thailand:

Would you like to ride on your own ass?

On the faucet in a Finnish washroom:

To stop the drip, turn cock to right.

In the window of a Swedish furrier:

Fur coats made for ladies from their own skin.

On the box of a clockwork toy made in Hong Kong:

Guaranteed to work throughout its useful life.

Detour sign in Kyushi, Japan:

Stop: Drive Sideways.

In a Swiss mountain inn:

Special today—no ice cream.

In a Bangkok temple:

It is forbidden to enter a woman even a foreigner if dressed as a man.

In a Tokyo bar:

Special cocktails for the ladies with nuts.

In a Copenhagen airline ticket office:

We take your bags and send them in all directions.

On the door of a Moscow hotel room:

If this is your first visit to the USSR, you are welcome to it.

In a Norwegian cocktail lounge:

Ladies are requested not to have children in the bar.

At a Budapest zoo:

Please do not feed the animals. If you have any suitable food, give it to the guard on duty.

In the office of a Roman doctor:

Specialist in women and other diseases.

In an Acapulco hotel:

The manager has personally passed all the water served here.

In a Tokyo shop:

Our nylons cost more than common, but you’ll find they are best in the long run.

From a Japanese information booklet about using a hotel air conditioner:

Cooles and Heates: If you want just condition of warm in your room, please control yourself.

From a brochure of a car rental firm in Tokyo:

When passenger of foot heave in sight, tootle the horn. Trumpet him melodiously at first, but if he still obstacles your passage then tootle him with vigor.

Two signs from a Majorcan shop entrance:

• English well talking.

• Here speeching American.

---

Two Australian businessmen in Brisbane were sitting down for a break, in their soon-to be, new store.

As yet, the store wasn’t ready, with only a few shelves set up.

One said to the other, ‘I bet any minute now some thick tourist is going to walk by, put his face to the window and ask what we’re selling.’

No sooner were the words out of his mouth when, sure enough, a curious Kiwi walked to the window, had a peek, and in a Kiwi accent asked ‘What are you selling here?’

One of the men replied sarcastically, ‘We’re selling assholes.’

Without skipping a beat, the Kiwi said, ‘You are doing well .. Only two left!’

Australians God bless them – should not mess with New Zealanders!

Questions that worry me…
Once you’re in heaven, do you get stuck wearing the clothes you were buried in for eternity?
Why does a round pizza come in a square box?
What disease did cured ham actually have?
How is it that we put man on the moon before we figured out it would be a good idea to put wheels on luggage?
Why is it that people say they ’slept like a baby’ when babies wake up like every two hours?
If a deaf person has to go to court, is it still called a hearing?
Why do people pay to go up tall buildings and then put money in binoculars to look at things on the ground?
Why do doctors leave the room while you change?
They’re going to see you naked anyway.
Why is ‘bra’ singular and ‘panties’ plural?
Why do toasters always have a setting that burns the toast to a horrible crisp, which no decent human being would eat?
If the professor on Gilligan’s Island can make a radio out of a coconut, why can’t he fix a hole in a boat?
Why does Goofy stand erect while Pluto remains on all fours?
They’re both dogs!
If corn oil is made from corn, and vegetable oil is made from vegetables, what is baby oil made from?
If electricity comes from electrons, does morality come from morons?
Do the Alphabet song and Twinkle, Twinkle Little Star have the same tune?
Why did you just try singing the two songs above?
Why do they call it an asteroid when it’s outside the hemisphere, but call it a hemorrhoid when it’s in your butt?
Did you ever notice that when you blow in a dog’s face, he gets mad at you, but when you take him for a car ride, he sticks his head out the window?

…and why dogs bite their owners

… of course, some people would ask whether these are REAL dogs (but they’d risk someone biting them – probably Sheba!)

Pain management in groups using a CBT approach: important therapist factors

I’m going to jump ahead of myself in this discussion of pain management in groups, using a CBT approach, and cut to a description of therapist factors that can influence how well a group programme works. I should add at this stage, that I’m basing much of what I write on my own experience over …ermmm… a few years… but also from an extremely helpful book ‘Cognitive behavioral therapy in groups’ by Bieling, McCabe and Antony.  It’s published byThe  Guilford Press, New York, 2006, and is a hefty 452 pages long.  It’s a great book —- but it doesn’t have anything about chronic pain management, so I’m working on describing how the factors that are discussed in this book can apply in chronic pain management.

OK, so while I’ve been looking at group process and the benefits of conducting pain management in a group setting, one of the critical ingredients has to be the clinician or clinical team involved in the programme. Our team has six clinicians, and something we’ve worked on very hard is having a common model and developing consistent responses to various issues that different participants bring into our programme.  It only takes one clinician to say something ‘different’ for participants to become confused or worse, defensive and at times work to ’split’ a team.  Pain management often runs contrary to ‘common sense’  – chronic pain management doesn’t follow the rules of acute pain, so if someone is fearful of moving and one clinician reinforces this, however well-meaning, it can stall reconceptualisation and stop progress.

Group programmes using a CBT approach need facilitators who are not only confident in themselves (they’re ‘on show’!), but also be both confident in applying CBT in a one-to-one setting, and also work well with group facilitation (ie know how groups function).  They also need to be well-trained in chronic pain management.  Transferring generic CBT skills into chronic pain is a challenge – but transferring generic CBT skills into a group setting is impossible without some mentoring and opportunity to observe.  I’m glad to see that this point is made very strongly in the book I referenced above!

In fact, that book recommends the following:

1. Didactic coursework/training in CBT models and techniques
2. Direct (hour for hour) supervision on multiple individual cases of CBT
3. Observational participation in a CBT group led by another therapist
4. Taking on the role of a co-leader

Well I can’t quite see that being given to new people joining many public hospitals in New Zealand!

Therapists need to have some specific facilitation ’styles’ that work for group facilitation:

1. They need to model ‘active participation’ – in other words, really be involved in the processes of the group
2. They need to be tolerant and open to individual differences, there is no ‘correct’ way of responding, just varing consequences im both short and long term
3. Use collaboration and Socratic dialogue to guide participants through the process of discovery.  ‘Teaching’ doesn’t work well, ‘discovering’ works better, ‘experiencing’ works best.
4. Communicate that ‘we’ are all prone to the same thinking patterns and responses – never ever giving the impression that they ‘have it all together’ or that they wouldn’t be vulnerable to the same thoughts, feelings and behaviours that the participants have.  After all chronic pain is not choosy – it could be you, and it is me, that can have chronic pain!

I’ve not often had the opportunity to work with a cotherapist, but when I have, it’s been wonderful! A point made in many manuals for CBT in a group setting is that two therapists are preferable.  One can do the majority of the facilitation, while the second can be observing, noticing, listening and providing back-up when the primary therapist runs dry.  If two therapists are going to work together, though, they need to have some idea of who is doing what, and what the potential issues might be.  AND, more importantly, they need to debrief afterwards to see what they both saw during the session.

I’ve found that it’s great to have an email or some other system to share observations and notes from each session – especially when different therapists provide input over different sessions during the day.  And as the therapists hand over to the next person, a brief exchange of ‘what’s going on in the group’ makes a huge difference.  For example, if one person has had a flare-up and is having trouble, it’s good to know what has already been said or suggested so either the same approach is used, or the person isn’t faced with the same questions or process from the next therapist!

As the group develops, the participants can take on some of this ongoing monitoring and reminding process, but especially during the initial stages, it’s vital that therapists keep their eyes and ears open and share what they observe.

To help with learning, I’ve attended training on group facilitation (Zenergy in New Zealand is one provider I particularly respect), and I’ve also participated in personal growth courses, especially those using experiential learning methods.  I think these skills also help when facilitating group-based CBT for pain management.  One book I’ve found especially helpful is Open to Outcome which gives you five questions you can use to debrief from any experiential activity.  And of course, Thiagi has a huge resource of both brief and more complex experiential activities that you can use in groups.

Pain management in groups using a CBT approach – Why do it?

I’m spending a few days looking at practical ways for working with group CBT for chronic pain.  It’s the most researched form of CBT-based pain management, and offers some very helpful features for people with chronic pain.  I’ve looked at how groups can impart a sense of optimism and at how they help people with a sense of  inclusion (sense of commonality), and group-based learning.  Today it’s time to look at emotional processing and group cohesion.

I’m sure I’m not alone in feeling slightly awkward in some social settings.  I really hate meeting a group of people who already know each other (I’m the odd one out), or in a bar where I can’t hear well, or at times when I’m feeling less than sparkling (maybe worrying about what people might think…).  I know I’m not alone in feeling that when I’m with people I don’t know well, I am not exactly open to pouring out my woes and being emotional. It can take quite a while to feel comfortable about expressing feelings in a group setting - but at the same time there is something comforting in knowing that if I’m feeling wobbly there are probably a few other people also feeling the same way, so we may all reach for the tissues at the same time!

Processing emotional content in a group setting can be both an amazing experience and at the same time an opportunity to feel really weird.  It all depends on how the facilitator or therapist responds.  Through exposing emotional content, we have greater access to automatic thoughts, assumptions, beliefs and behaviours that are often otherwise well hidden underneath our protective cognitions.  It’s at times when we feel more emotionally vulnerable that we have access to underlying ‘rules of living’ that we may otherwise be completely oblivious to.

What should a facilitator take notice of?

- times when a participant appears disengaged, perhaps doodling, or closing the eyes, maybe rocking on the chair or fiddling with a pen.

What could a facilitator do? To illustrate one way of drawing out the emotional response and opening up an opportunity to talk about what is happening here and now, the therapist could say:

Therapist: ‘before we go on, I just want to check in with the group.  Tony I can see you’re looking a bit distracted, what’s going on for you right now?’

Tony: ‘Oh nothing’

Therapist: ‘Oh.  How does what we were talking about fit for you?’

Tony: ‘Well, I’m just thinking why do I have to be here? I mean, I don’t think my pain is really chronic, and I know I can have another injection if only I talk to the doctor again, so do I really have to do all this psychological stuff anyway?’

Therapist: ‘Does anyone else feel like it’s going to be a really difficult process to learn self management, and maybe there is an easier way other than looking at thoughts and emotions and things?’

Andrea: ‘Well, yeah.  I mean, some of the doctors have said that I can just increase my medications and then maybe my pain will go down and I’ll be doing more, but I just can’t handle the side effects any more.  Those side effects can be worse than having the pain, I think.’

Therapist: ‘Does anyone else feel like it might be easier to just carry on with a medical approach and not look at other things?’

Tessa: ‘I tried that for years, but in the end I still have my pain and my emotions go  up and down every time someone suggests another medication – but I’m still here because I am so fed up with that rollercoaster, and I want to take control again.’

Therapist: ‘ Tony, what is it like for you to hear that other people feel in two minds about doing this self management approach, and there are some appealing things about using medications, but also some not-so-good effects?’

Tony: ‘Well I guess it makes me feel more normal, after all I’ve been on that emotional rollercoaster for a long time, and I really hate the side effects from medications too.  And the doctor said that he wasn’t very keen to give me any more injections.’

This approach can feel risky if you’re not used to facilitating – it’s allowing people the space to feel ambivalent and to process that anxiety but also to recognise that others in the group have also had similar experiences and offer either the same insight (I’ve been here before…) or a new insight (She’s handling it by being open-minded) that can reassure the person.  Provided that the facilitator can trust the group that there will be someone else who has moved through this same thought and emotion before, and go with the flow (roll with resistance), it’s possible to allow people to air their worries or emotions and still be able to move towards the goal of sharing and normalising many of the experiences the group shares.

Group cohesion is that sense that the group are ‘bonded’. There has been much written about the stages of development within a group – the ‘forming, norming, storming etc’  stages amongst others.  What happens is that over time a group may move to the point where it’s OK to disagree with each other, to challenge each other and to risk being ‘real’ with each other.  This can happen quite quickly, but I find that groups often get to the ‘I feel comfortable with this group’ stage (ie they all ‘get along’) but may get stuck and don’t move to the ‘it’s OK to be honest and real and disagree with each other’ stage.  It’s only when groups move to this deeper level of cohesion, IMHO, that they start to ‘work’ each other.

The therapist or facilitator can encourage this deeper relationship and here are several strategies that can also help:

1. Choosing a group that has similar characteristics – eg stage of change or readiness to adopt self management, maybe diagnosis or pain site, perhaps compensation status or job status
2. Ensuring confidentiality and creating the group norms
3. Ensuring a climate of acceptance, empathy and promoting sharing of information
4. Connecting two or more participants experiences
5. Responding to group process as it happens

More about this last one tomorrow. Group process is all about the things I’ve raised over the last couple of days – disclosure, optimism, inclusion, group learning, shifting from self to others, and managing both emotional processing and group cohesion.

I’ll review these tomorrow and add in some specific strategies that can be helpful to elicit each one.

`Pain management in groups using a CBT approach – Why do it?

`Yesterday I started to look at why pain management using a CBT approach can work well in groups.  As I mentioned, it’s the most researched form of CBT-based pain management, and offers some very helpful features for people with chronic pain.  Yesterday I looked at how a group approach can offer participants a sense of optimism.  Today I’m looking at inclusion (sense of commonality), and group-based learning.

One of the most striking features of having an invisible health problem is that many people can be walking around in our communities with their pain without anyone being any the wiser.  The sense of isolation experienced by some of the participants in the pain management programme I work on is astonishing.  It’s as if they are living in a bubble that makes interacting with other people profoundly difficult.  Being in a group setting with other people experiencing similar problems offers some really important things:

1. a sense of belonging, to recognise that chronic pain is experienced by other people who struggle with the same issues
2. a sense of normalising – recognising that some of the experiences are not strange or a sign of some unique failing on the person’s part, but are simply part of having chronic pain
3. the opportunity to learn from others who may have faced and coped well with very similar situations and arrived at helpful solutions
4. shifting the focus off the individual and offering them the opportunity to help others.  This can be an empowering situation for individuals who can otherwise feel helpless and hopeless.

The way the therapist facilitates group members to develop the sense of safety needed to share experiences, and confidence to offer opinions (especially opinions and doubts that contradict the ‘proper’ way to manage) is crucial to the success of the experience.

I begin the group programme with a brief outline of the purpose, housekeeping, and then very briefly ask particpants to share a little about themselves.  At the very beginning of a three-week programme it’s unnecessary, I think, to start with ‘icebreakers’ and I find many people simply hate them! So it’s a very simple ‘tell me a little about yourself and why you’ve come to the programme’.  Later on in the day I use the whiteboard to brainstorm all the possible topics that people might want to have the programme cover – I use a very open approach to do this, allowing the more vocal participants to start this process off.  Once a few topics are on the board, I’ll then start to prompt ‘people who haven’t had a chance to speak’, and I also allow some periods of silence because some participants need that time to process thoughts into words.

It’s once topics are on the board I notice that participants begin to warm up to each other and start to share the ‘back story’ of why some of the topics they’ve suggested are important.  Allowing this to happen without too much direction helps set the scene for people to see that the group includes people ‘just like me’, and I find the less vocal people start to show nonverbal participation.  Sometimes at this point it can be helpful to break off into pairs to share one another’s journey to coming to the programme – having to speak to only one person can help to make speaking and feeling included easier.

At this point the therapist can facilitate slightly deeper sharing – saying something like this:

Therapist: ‘Now that we’ve spent some time hearing about what’s brought people to the programme, and what they want to learn, we can see that although each person is unique, there are some similarities that you all share.  What do people think or feel about what they’ve heard?’

Tom: ‘At last there are other people who know that I’m in pain when I say I’m in pain!’

Alison: ‘It’s really strange because I’m usually the only one in pain and feeling like I really need to stand up or jiggle, and here are a whole group of people doing the same!’

Group laughs then silence

Therapist: ‘What about for others?’

Tony: ‘I thought everyone would be ACC whiners, but you’re not.  Is anyone else on ACC here?’

Andrea: ‘Yes I am, and I’m worried that ACC is going to kick me off compensation straight after the programme, and they’ve made me come here and I can’t work like this.’

Therapist: ‘It’s really great that you’ve talked about this Andrea, because a lot of people do worry about what is going to happen after the programme.  About half of this group are on ACC compensation, and we’ll talk about how to work with your case manager and what to plan for after the programme in several sessions.  It’s also a really important point you’ve raised about ACC making you come along.  Does anyone else feel like they’ve been made to come to the programme by someone else?’

Alison: ‘Well, I thought so at first because my case manager suggested I come to Pain Management, but when you did the screening you explained that I could decide whether the programme was for me or not, so I’m feeling OK about it now.’

Therapist: ‘Thanks for saying that Alison.  You’re right, coming to the programme is absolutely your choice, and it’s important you decide to be part of it yourself, and not for anyone else.  Not a partner, or a child, a doctor or even ACC can make you come along.  If you’re here because you think someone else made you attend, I can reassure you that if you decide at the end of today that this is not the right thing for you, we will communicate this with your case manager and there will be no penalty.’

This is an important ‘doubt’ that many people can have when asked to attend a pain management programme, as many people with chronic pain have some sort of relationship with a compensation agency.  We have a policy that people must be ‘ready’ to attend a programme for themselves, because we’ve found that although it’s possible to include people who feel coerced to attend and the group process can work with this, it makes progress very difficult.  Self management is that – self management.  It’s a choice, and people do need to be ready to pursue it.

Even after selecting people carefully for inclusion, participants can continue to feel worried about the consequences of completing a programme, and this is an issue to discuss openly.  We start doing this by a process called ‘fears in a box’, where after about three days, participants are offered the opportunity to write down their concerns or doubts about the programme, and place these thoughts in a box.  The team members review the written questions and at the end of that day, directly discuss these issues with the group.  Many group members say they feel relieved because they thought they were ‘the only ones’ to have the doubts, but typically it’s something many of them feel.  Offering participants a chance to anonymously air their worries helps the whole group feel more comfortable sharing their unique worries, allowing the therapist/facilitator to work through the issues to resolve them.

Pain management in groups using a CBT approach – Why do it?

This week I’m looking a working effectively with groups for pain management using a CBT approach.  Someone said recently ‘why should six clinicians be tied up for three weeks with only six patients? there are other people who need pain management too’ - and over the past ten years I’ve seen numerous attempts to move from the group approach to individualised therapy, so some time reviewing why groups are a useful way to help people develop pain management skills might not be amiss!

Using a group approach was typical for pain management in the earlier days, say around the mid-1980’s and earlier.   It’s a convenient way to bring the specialised skills of an interdisciplinary team to people with pain, and especially within the setting often used in the beginning of CBT for chronic pain, which was an in-patient or residential setting.

Now things have changed with an increase in individual programmes, but still the majority of research is carried out on the outcomes of people attending group programmes (eg Edelman, Bell & Kidman, 1999; Thorn & Kuhajda, 2004 – this is a list that could go on!).

Why use a group?

Groups provide two main aspects that individualised therapy doesn’t, and these aspects are especially important for people with chronic pain.  The first is the opportunity for the group to broaden the range of possible concerns and issues that can be discussed. Instead of drawing only on the issues that one individual chooses to raise, group members will bring many different situations, both similar to and different from, the ones that another group member may raise.  This means many more opportunities for a person to learn how to apply cognitive behavioural strategies across different settings.  Participants in a group setting often express how alone they have felt in coping with their pain problem and how helpful it is to find a group of people who have similar concerns.

The second is the opportunity for group members to develop and demonstrate using CBT with each other. Group members become, over time, much more able to challenge each other very strongly over issues common to them all, than a group facilitator.  The multiple perspectives that individuals bring to viewing situations is very helpful when learning to challenge an assumption or belief, and the group setting provides a safer setting for developing the skills to challenge themselves.

Several other aspects support a group approach - operant conditioning occurs as group norms begin to shape behaviour.  The group can begin to initiate ‘well’ behaviour, and support each other with this.  (yes, it can go the other way – we’ll discuss this too!).  Effective communication, a skill many people with chronic pain have not developed, especially with respect to communicating about their pain, is used during a programme.   Observing others succeed or not, and the effective analysis of ‘what went well, what would you do differently’ is another aspect that is strengthened in a group setting, particularly as alternative options for ‘doing it differently’ can be suggested.

What is the difference between CBT in a group setting and CBT through a group?

I’m sure we’ve all spent time in groups where the discussion is rather stilted, directed to the ‘leader’ or facilitator, and members rarely, if ever, talk to each other. ( I can think of several staff meetings like this!)  If a CBT approach is to work well in a group, it’s not just about a facilitator using CBT with each individual in turn – that’s just CBT in a group setting.  To me it’s not nearly as effective as working through the group process using a CBT approach.  The differences appear subtle when I’m writing them, but never FEEL subtle when a group is actively processing!

It’s the way the facilitator encourages group participants to start the CBT process with each other that makes or breaks the group as an active component of a CBT approach.  I’m going to firstly discuss the group process within a CBT framework, and draw on Bieling, McCabe & Antony (2006) to do so.  Today’s theme is ‘Optimism’.

 Optimism.  Believing that treatment will help, and feeling positive towards the outcome is an aspect of group process that is strongly influenced by the group and the facilitator.  Facilitators can help group members encourage each other through modelling how they can do this.

Therapist: ‘Let’s see how you’ve planned to use activity regulation over the weekend, and let the group know what you think might get in the way of it’

Tony: ‘I’m going to work in my garden, but I’ve decided to use my phone to ring an alarm after 30 minutes so I stop before I overdo it.  Then I’ll go and stretch and get a drink of water before I get back into it.’

Therapist: ‘What’s going to be the biggest challenge to doing this on Saturday.’

Tony: ‘Probably my wife coming out to see how far I’ve got, and I’ll feel guilty that I haven’t done it all.’

Therapist: ‘Anyone else in the group have a similar worry?’

Andrea: ‘Yes, that’s me.  I’m sure that my husband will come out and take over whatever I’m doing and then I’ll feel I have to go on.  What I’ve decided to do is one part of the house that he never cleans – the toilet!’

Therapist: ‘That’s one way around it!  Justine, what do you think Tony could do?’

Justine: ‘I decided last week to tell my partner and my kids that this is my project and I want to do it myself.  I did feel worried about this but I picked up that I was listening to a ’should’ statement, and so I asked myself where it was written that I ‘had’ to get it all finished and that everyone else ‘had’ to be happy with it!’

Therapist: ‘And what happened?’

Justine: ‘The family left me alone until I went in for a coffee break, and then they said I’d done more than they expected!  So Tony could do the same thing, and maybe remind himself that doing something is better than doing nothing at all’

Therapist: ‘What do others in the group think about this suggestion?’ 

Silence

Therapist: ‘Justine, do you think you can say this directly to Tony?’

Justine: ‘Tony, do you think you can remind yourself that you’re doing more than you usually do, and breaking it up like this means you’ll be able to carry on longer in the day?’

Tony: ‘Yes, and I remember you, Graham, were saying the same thing about feeling guilty.  What do you think about this?’

Graham: ‘I do feel guilty when my family have to take over for me, but I liked what Justine had to say about doing something and it being more than nothing.  I could remind myself about this when I start worrying about what my family are going to say.’

Several things helped in this exchange – the therapist drew on the group’s common experiences, asked for specific responses (and more than one), then helped that person direct the comments to a group member rather than to the facilitator.

More on this tomorrow!  Remember you can subscribe using the RSS feed link above, or you can bookmark and come on back tomorrow! Comments and feedback welcome, just remember that comments are visible to all.  To contact me more privately, use the ‘About’ page and send me a message direct.

Bieling, McCabe & Antony, (2006). Cognitive behavioural therapy in groups. The Guilford Press: New York.

Edelman, Sarah; Bell, David R; Kidman, Antony D (1999). Group CBT Versus Supportive Therapy With Patients Who Have Primary Breast Cancer, Journal of Cognitive Psychotherapy.

THORN Beverly E; KUHAJDA Melissa C, (2006). Group cognitive therapy for chronic pain, Journal of clinical psychology , 62(11), 1355-1366.

Drool…

Friday Funnies!

Yes, I’ve been good this week, and I have given myself TWO WHOLE DAYS off work!
To reward yourself, take the following with a glass of water, and lie down.

Can you tell I have a teenager?

It’s true you know.

A model of executive functioning and stress regulation

I’m a visual kind of girl, I need to see a diagram to help me conceptualise how the things I’ve been writing about recently all fit together. I’ve been looking at the various aspects of self regulation, emotions and executive functions and how this affects and is affected by stressors, of which chronic pain is certainly one.

Drawing again from Williams, Suchy and Rau, i’m going to try to describe how I think their model of executive functioning might influence the way I look at stress regulation in people with chronic pain.

This diagram is sort of upside down to me, but anyway, this is how I interpret it.
Initially we all have a genetic inheritance, or the genotype we were born with. This influences the way our neurotransmitter systems, brain circuitry, physiology and executive functioning work – but can be influenced developmentally by factors present either before birth, or during our formative years as children. The factors that can influence how our underlying systems work include attachments to others, trauma or abuse, opportunities for learning, stressors of many kinds and drugs.
These neurophysiological functions underpin our ‘personality’. As we know, different personality traits affect how we seek out and respond to stressors in the environment, including how much risk taking and novelty we enjoy, how much we react to the environment, how well we recover, and how we restore our functioning to homeostatis.

I see that in this diagram it looks like stress exposure, reactivity, recovery and restoration are linked in a unidirectional way – but I do wonder about this. At the same time, it does seem clear that each of these aspects of how we respond to stressors in turn affects that ‘black box’ of neurophysiological functioning. And the final outcome of these responses is seen in terms of physical and mental health outcomes.

I can see from this model how an acute trauma like a fracture, will be a stressor and directly affect the stress regulation factors – and at the same time will influence the neurophysiological circuitry. So in a vulnerable person, perhaps someone who has inherited less ability to regulate stressors or who has been unable to develop the potential of their genetic inheritance, the stress of an acute trauma could compromise their ability to self regulate, and in turn have much more trouble managing their acute pain – leading to a much greater potential for longterm disability.

What does this mean for clinicians?
As we learn more about how things like heart rate variability and other forms of self regulation can be trained and actually change how genes are expressed, I think we will have more of a basis for using biofeedback at an earlier stage and perhaps even as a preventive measure.

Appraisals, or how we view stressors, are directly addressed as part of CBT and ACT. Maybe again as a preventive measure, we can help kids develop skills in being aware of their own thought patterns and how to tolerate, or ’sit with’ emotions that are usually considered unpleasant. From some of the research discussed in Willaims, Suchy and Rau, it seems that both too little stress and too much stress are not good for wellbeing – but a certain amount is helpful and can be one way to develop resilience. Helping our patients learn to tolerate negative emotions and thoughts through mindfulness has been shown to influence prefrontal cortex activation.

Fitness affects executive functioning through several pathways, so the inclusion of exercise or activity in chronic pain management has an evidence base (even if there is no evidence that any specific exercise is better than another – yay! I can justify gardening and bellydance much more happily than vacuum cleaning or going for a run!).

I hope to have tweaked your interest in both self regulation and executive functioning over the past little while, it’s been interesting to read about these areas – and to ponder about how I can use them in my practice. Let me know if you’d like to know anything more – leave a comment, or you can email me via the ‘About’ page. Don’t forget that you can subscribe using the RSS feed link at the top of the page, or you can bookmark and just visit. I write most days – and tomorrow is Friday Funnies (I can hear the groans from here!).

Williams, P., Suchy, Y., & Rau, H. (2009). Individual Differences in Executive Functioning: Implications for Stress Regulation Annals of Behavioral Medicine, 37 (2), 126-140 DOI: 10.1007/s12160-009-9100-0

Stress: The final frontier (executive functions)

It’s visceral. Stress – hits you in the guts. Some of us cope well, some of us don’t – some of our stress lingers, sometimes it’s just the little things, those ‘daily hassles’ that end up tripping the switch. And I don’t think anyone would disagree that chronic pain is an enormous stressor. Regulating that stress level, or managing it effectively, has to be the main challenge in learning to live alongside chronic pain. Today’s post discusses executive functions (the parts of the brain that carry out self regulation) and stress.

Executive function is ‘… a multifaceted construct comprising a number of basic neurocognitive processes, including working memory, cognitive flexibility, response selection, inhibition, initiation, set formation, and set maintenance.’ Williams, Suchy and Rau state that ‘these processes allow us to generate goals and plans, modify our behavior in response to changes in the environment, and follow through and execute necessary actions in order to successfully achieve the intended goals.’ These functions are different from many CNS functions in that they require ‘attention’ or ‘volition’ to initiate and maintain them, whereas many other functions such as those that maintain homeostatis are pretty well automatic.

‘The areas of the brain thought to be primarily responsible for executive functions are the dorsolateral, superomedial, orbitofrontal, and ventromedial prefrontal cortices, anterior cingulate gyrus, the basal ganglia and diencephalic structures, the cerebellum, deep white matter tracks, and some aspects of the parietal lobes – and these are linked to each other and to other structures to ensure most cognitive processes including sensory perception, memory and language are linked.  As a result of these connections, EF serves as the interface between previously acquired knowledge and newly arising information in the environment.’ (Williams, Suchy and Rau, 2009) Can you see why I used a quote? I don’t trust myself to paraphrase!! These structures also link strongly to those automatic/homeostatic areas of the brain, so can influence emotional processing, autonomic control, and appetitive functions.

Even amongst people who don’t have chronic pain (or for that matter, low mood, or a brain injury), we vary in the ways in which we deal with stress. Williams, Suchy and Rau suggest that ‘even slight declines in EF can lead to a breakdown in stress regulation that affects both mental and physical health’ and that ‘aspects of EF are heritable.’ Certain executive functions such as switching attention, inhibiting a response or updating ‘working’ memory have been shown to be inherited.

I won’t go into detail about how this is studied, because it is quite complex and involves drawing conclusions from the results of both trauma or brain injury-induced deficits and the types of pathology found when people have been exposed to significant stress.  It’s also proven to be a very difficult area to study, especially in people with only slight deficits or ‘individual variations’ in the way they respond to stress.  Most neuropsychological tests are fairly blunt instruments and don’t show subtle problems, like those that occur when we’re stressed!

Some interesting findings, however, showing that traits like conscientiousness (also called ‘constraint’) have a positive association with better stress management and better health, while neuroticism (associated with the Behavioural Inhibition System – sensitising us to avoid harm, making us more tuned to negative cues) is associated with greater stress and poorer health.   Extraversion, or the tendency to want interactions with others and to become energised by them can be associated with additional risk taking, but also with positive affect which has a positive effect on health.  Openness to experience is a trait where people are basically inquisitive (that’s me to a T!) is associated with better adaptation to chronic illness, and the last one is agreeableness, or getting along with others and to cooperate, and it is associated with better health and lower stress.

What does this mean for chronic pain and executive functions or self regulation?

Perhaps some of the vulnerability to having trouble coping with longterm pain arises from genetic tendencies in the way our executive functions operate.  Remember that chronic pain is a stressor, and that chronic pain problems can arise during periods of increased exposure to stress.  This suggests that the effect of chronic pain on executive functions, or the ability to self regulate might influence how efficiently we can cope.  It also suggests that if our self regulation skills are vulnerable, then under stress we may find it much more difficult to manage.

From my last post, it also seems that we can develop self regulation, provided we have sufficient resource in terms of energy and social support (and someone to help establish appropriate goals).  Some people may find it more challenging not because they have less inclination to cope, but simply because they have certain tendencies that are inherited to make this aspect of coping much more difficult.

If as clinicians we can identify those people who need more support, and especially if we can identify some of the ‘components’ of executive functioning such as sensitivity to activating the Behavioural Inhibition System, maybe we can help prevent some of the chronic disability arising from having chronic pain, even if we can’t prevent the pain from being present. After all, it’s not the pain itself that is problematic – it’s the disability or functional limitations arising from the pain that create problems.

Williams, P., Suchy, Y., & Rau, H. (2009). Individual Differences in Executive Functioning: Implications for Stress Regulation Annals of Behavioral Medicine, 37 (2), 126-140 DOI: 10.1007/s12160-009-9100-0

Going with the flow: emotion regulation and coping

I’m in two minds about attempting to regulate emotions. From ACT, and in particular, mindfulness, I’m learning that trying to control emotions and thoughts is darned near impossible – and unhelpful. From the research on the effect of pain on emotions and subsequently on self regulation, goals and coping, it seems that pain strongly influences emotion and that negative emotions in particular, influence the range of coping strategies and goals we choose – and success or failure in turn generates further emotion, and so on.

As Hamilton, Karoly and Kitzman say ‘the primary function of pain is to disrupt other ongoing activities and to direct attention toward the cause of injury or the extent of tissue damage’ – of course, in chronic pain, there may no longer be any injury or tissue damage, and instead we are left with the experience of disruption to activities without a purpose. Pain by definition involves negative emotions, which we have seen over these posts recently, can activate ‘harm-avoidance’ strategies. Over time, pain can reduce the attention given to, and pleasure obtained from, activities that are usually enjoyable, and can reduce how well we process normally positive information.

So, pain detracts from normally enjoyable activities and reduces the benefits we usually get from achieving goals, probably makes us less likely to choose goals that are driven by curiosity or positive benefits and instead increases the chance we’ll choose ‘harm avoidant’ goals, and when things go wrong, pain makes it much more difficult for us to look creatively at ways to cope.

Self regulation is influenced therefore by emotions – but at the same time, self regulation can influence emotions. Pain management goals in one study were not only influenced by negative emotions but also by the level of social support people had. Maybe routinely including family and social networks into pain management goal setting with people with pain would be helpful. I’m noticing that over the past 20 years, the number of people who attend assessments and pain management programmes with partners or family members has dropped considerably. It’s almost as if the person with pain is the only one who ‘has’ to cope. A couple of posts ago I discussed the need to ensure that people have adequate coping resources before setting self regulation goals, because these resources become depleted (and there is no doubt self managing pain is hard work!).

Yesterday I mentioned ‘emotional complexity’, or the ability to tolerate opposing moods. Hamilton, Karoly and Kitzman think that this ability is something that is acquired rather than a trait, and suggest that CBT and ACT may, because they help people understand the relationships between thoughts and emotions, help people develop the ability to regulate emotions. Of course, ACT suggests that rather than trying to control either thoughts or emotions, we simply acknowledge them and they will pass.

By maintaining focus on values, or what is really important, ACT suggests that we’re able to tolerate the fluctuations in emotions and thoughts and remain engaged with things that we value. ACT theory suggests that by allowing the moods or thoughts to flow, the natural ebb and flow of emotions continues rather than building up to an intolerable level, or being judged negatively.

This is a different approach to self regulation from CBT where CBT suggests that by logic we can reassess our thinking patterns and replace them with more helpful ones, and in turn these will influence emotions. I think CBT has its place, but more and more I’m finding that at least part of the time I’m encouraging people to ’sit with’ negative emotions and thoughts in order to reduce the threat value or judgements about them, and help people recognise that they will survive and can continue to do what is important even if at times they feel different feelings, including negative ones.

A good deal of pain management works on helping people cope with the stress associated with having pain. The authors suggest that it might be just as important to consider working towards approach-oriented goals, that is, doing things that have positive reward, such as social goals, because these both support self regulation, as well as generate positive emotion. ‘Therapists must emphasise to paitents that it is important to maintain focus on other goals, even during painful flare-ups…both patients and therapists [can] become focused on distress management and lose sight of goals related to an enhanced sense of wellbeing.’

The way I interpret this is that it’s just as important to help people identify social activities, leisure activities and have fun and grow as it is to persist with getting better sleep, return to work, or use relaxation to cope with a flare-up. I’ve been including scheduled pleasant events every day with patients for quite a while now – and it can be unbelievably difficult! Some people have never ‘had fun’, never had time to be sociable, never thought of relaxing or having a hobby or being creative.

I remember with one patient, we instituted a whole ‘Pyjama Day’ where she could take the phone off the hook, watch DVD’s, paint her nails, have a soak in the bath and read trashy novels! Initially it was really difficult for her to do this without feeling guilty, but later on she enjoyed it and started to look foward to it, and then started to plan self development ‘creative’ things she could do on that day. Yes, painting or photography or baking or learning a foreign language can be part of pain management!

This won’t be the last post on self regulation, coping, emotions, goals and chronic pain. It seems to neatly tie in with the focus of living a good life despite having pain, and especially of living according to values. I think self regulation is one of those ‘occupational performance components’ that might be overlooked by some occupational therapists who focus on occupational performance, or function, but might not consider the underlying skills and resources that need to be present for someone to function well. Occupational therapists have as a core philosophy that ‘doing is being’, and by doing functional activities, people become well. It looks like that assumption has some support from the literature, now it’s time to look at how to help people ‘do’.

 

Hamilton, N., Karoly, P., & Kitzman, H. (2004). Self-Regulation and Chronic Pain:The Role of Emotion Cognitive Therapy and Research, 28 (5), 559-576 DOI: 10.1023/B:COTR.0000045565.88145.76