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Occupational Therapy & the Cognitive Behavioural Approach For Pain Management – ii


ResearchBlogging.orgIn the first post on my commentary of Robinson, Kennedy and Harmon’s review of occupational therapy for chronic pain, I argued that they have misinterpreted the cognitive behavioural approach to pain management, and in particular, that they appear to hold an outmoded view of pain as either biological/organic or psychological, and refute the place of psychosocial models in occupational therapy practice.

Yesterday I distinguished between cognitive behavioural therapy and a cognitive behavioural approach - while the therapy is often primarily concerned with ‘talk’ therapy followed by behavioural changes to improve mood for example, a cognitive behavioural approach is a broader concept that is based upon the assumption that people are able to make changes in the way they understand their pain, given sufficient information and strategies to do so, and that by doing so, they’re able to re-engage in important activities.

In other words, even if chronic pain itself doesn’t change, people can think of themselves as primarily ‘well’ people who simply have pain.

Today I want to move into two points: how an interdisciplinary team works (with a specific focus on role blurring and duplication of input), and more on the way in which occupational therapists can use so-called ‘psychological’ approaches to help people engage more fully in their lives.  BTW I think maybe other disciplines can use some of this too.

Interdisciplinary and multidisciplinary are two words bandied about a lot when it comes to pain management.  Sometimes they’re used almost interchangeably – but when it comes down to it, there are important differences between the two.

In a multidisciplinary team, each team member retains an independent, usually discipline-specific, approach or model for working with the patient.  Although the team works concurrently with the person, and there may be common goals, multidisciplinary teams do not necessarily need to integrate their treatment, nor have a common over-arching treatment model or approach.  Some poorly coordinated multidisciplinary teams can actually provide serial ‘mono-therapy’ – just the same as seeing several separate clinicians one after the other.

Interdisciplinary teams work differently.  Firstly they hold a common model or understanding of the problem.  In pain management, this means the team accepts the tenets of a cognitive behavioural approach as I outlined in yesterday’s post.  Then the team works with the person/client/participant to develop a combined understanding of the person’s problems or situation, and collaborate to generate shared goals.  While a newly formed team may function somewhat like a multidisciplinary team in some respects, over time each clinician develops a shared understanding of each other’s contributions - and very often can function at a basic level within some of the domains of concern of each other’s discipline.  They continue to provide discipline-specific input, but always with a view to the overall model and the client’s goals.

For example, after 18 years, I have some knowledge of medications and their side effects, so it’s not surprising that I can talk with someone about when to take medications and what the side effects might be.  I might do this because I’m working with the person to help them get up and schedule their day, and help with a better sleep pattern.  It’s also no surprise that the physiotherapist and the clinical psychologist, nurse and social worker can be heard discussing activity management – even asking how the person is going to apply skills in daily activities!

This can at times be somewhat disturbing, especially to new clinicians.  They might ask “How can I be sure these other team members know what to do? What if they do it wrong? Why are they doing what I should be doing? What if things get left out?”

As I’ve learned, two things help to make interdisciplinary teams work well – really good induction and mentoring as the new clinician settles in, and time.  It’s during the latter that communication needs to be open and robust discussion about why various approaches are used, and who might be the best person to have the main focus on a goal.  Role contributions change over time too, as team membership changes.

Does working this way lead to duplication? Yes, to a certain degree.  Provided that team members are consistent in what they say, ensure no goals are omitted, and focus on the case formulation, I’m not so sure that duplication is always a bad thing.  Maybe it’s better described as being consistent, providing back-up to each other, and more importantly, allowing the patient/client choice about who to approach to talk about topics. Most times, in an individualised programme, teams seem to work best with a combination of clinicians who can address psychosocial aspects, functional/physical aspects, and help the person integrate what is learned into his or her life.

A proviso – team members need to be competent in the techniques they use, and they must ensure the goals they can contribute most effectively to are being addressed. As someone pointed out, an occupational therapist or physiotherapist who dabbles in ‘a bit of CBT’ on the side is not likely to be helpful if they then omit something like how to schedule or plan a day, or progress activity levels over time. At the same time, I keep on saying, when is there a better time to elicit automatic thoughts and beliefs than when engaging someone in activity? When better to discuss whether the thoughts are helpful, accurate or helping the person achieve what is important and valued in life? And carried out with competence, working with thoughts, beliefs, emotions and behaviours in this way is both effective and efficient.

Mainly for occupational therapists, I want to turn to how it’s possible to integrate so-called ‘psychological’ approaches into occupation.  Be warned now – this may be continued!

If occupational therapy is about helping people engage more fully in valued occupations, I’d argue that we need to use the most effective tools to do so.  In pain management, a cognitive behavioural approach has consistently been demonstrated as effective – and occupational therapists, while somewhat silent on the publishing front, have been involved in most of the major pain management programmes.

Occupational therapy is not a ‘talk’ therapy – it’s all about doing.  It involves identifying what is important or valued in a person’s life, and helping them engage in those occupations.  While part of this involves talking and planning and ‘educating’, the purpose and outcome is for the person to then be equipped to engage in those activities or occupations themselves.

During planning and ‘educating’, it’s common for the person to raise objections to doing things differently.  These objections are – yes really – automatic thoughts!  In other words, they’re cognitions or beliefs, or maybe even attitudes or rules about how the person thinks things ‘should’ be done.  Robinson, Kennedy and Harmon seem to construe this situation as one in which what the client believes should be accepted without question.  I argue that unless the belief supports the person engaging in occupation, it is a valid target for an occupational therapist to address. While the belief may be part of the person’s ‘lived experience’ to date, it’s amenable to revision and change so he or she can see themselves and their opportunities differently, and re-engage in what is important.

When using a problem-solving process to review how a person has managed a new set of occupations, or way of approaching an occupation, feedback and evaluation is a vital component. It’s at this point too that an occupational therapist can review how helpful thoughts and beliefs are – and help the person look at the situation (and beliefs) in the light of new evidence.  They can then be helped to generate new beliefs and change their behaviour (or engagement in occupation).

I’ve gone over the word limit again today, so yes, there will be more tomorrow on this important topic.  I hope it’s generating food for thought and that what I’m writing serves as encouragement for ‘non-psychologists’ to learn more about how to work with thoughts and beliefs as they work with people.

Robinson, K., Kennedy, N., & Harmon, D. (2011). Is Occupational Therapy Adequately Meeting the Needs of People With Chronic Pain? American Journal of Occupational Therapy, 65 (1), 106-113 DOI: 10.5014/ajot.2011.09160

“Pain Management. A Handbook of Psychological Treatment Approaches” (1986) edited by A. D. Holzman and D. C. Turk.Pergamon Press

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7 comments

  1. That’s a very good summary! Here’s an interesting question: if objections are automatic thoughts that should be challenged, how do you really know which ones support engaging in occupation, and which ones don’t? I think the distinction itself makes sense, but how do you decide in practice? I had issues with occupational therapists before who made a suggestion (e.g., stretch every 15 minutes), and then refused to take me at my word when I said that this will disrupt essential tasks at work (or that for various reason this particular form of exercise/physical activity is not practical for me on a regular basis because of external constraints). I had a strong impression that they thought they were “challenging my beliefs”, but really the only outcome was me giving up on those forms of therapy altogether, because I could not cope with the suggestions, and was not willing to keep going if I was endlessly trying to prove someone that I am not randomly stubborn.

    My best workable strategies actually came from two sources. On the one hand, a person at work who was given similar suggestions, tried to implement them, failed, gave up and eventually came up with alternative coping strategies, which worked for me, too. The other source were a couple of physios who, when I said “this won’t work for me”, offered a couple of alternative suggestions and until we hit on something that I felt I could implement. But would this fall under them accepting what I believe without questioning it?

    1. I think we need to be careful to support our recommendations with facts – where is the evidence that breaking every 15 minutes will help? I prefer to propose these recommendations as an experiment, try it, and then weigh up the benefits (or not) in the situation you describe. Clinicians do need to remember that we’re not the ones living the life!
      When I describe catching automatic thoughts in a situation like you’re describing, I’m referring to catastrophic thoughts like ‘I can’t stop or it will be a disaster’, or ‘I can never stop at all during work hours’, or ‘if I stop I’ll never be able to start up again’. These are unhelpful because they don’t promote engaging in, for example, work, and they unhelpful because they increase anxiety and sympathetic arousal. They’re also inaccurate because ‘disaster’ and ‘never’, ‘at all’ etc are global terms that simply don’t come true. There are times when a situation might feel ‘disastrous’ but when really examined, they’re actually more about feeling uncomfortable or difficult to manage given the skills for coping that you might have.
      Things like ‘I can’t exercise at X time’ (because I have other things scheduled) can be problem-solved – and it’s you as the patient’s decision as to what is and isn’t a priority – it’s mine as clinician to be clear about why I might suggest something, what it should achieve, and work with a person to decide whether this holds true for him or her. I’ll run through an example to demonstrate in a post sometime soon.
      cheers
      Bronnie

      1. Ah, thanks, that is really sensible! Once I read this, I realised that this is exactly what I looked for in the various practitioners I worked with: people whom I could ask “what is the evidence that your recommendation will help/what is the specific benefit we are trying to achieve by doing things this way”. Answers to such questions can jump-start me into problem solving alternatives. But, for reasons I never quite figured out, if I asked some questions certain therapists seemed to interpret them as me saying “no, I don’t want to take your suggestion” and immediately responded with “please just try it and see if it works” or “if you don’t do this, you will just keep having pain”, while others engaged with me trying to problem-solve. I guess this comes down to the skill of the clinician, but this is definitely made a big difference in who was effective for me and who was not.

      2. Good to hear that this is what you looked for! I think sometimes it can be difficult for health providers who can forget that people can and will make decisions based on what is important to them, not just on the basis that ‘the doctor/PT/OT knows best’. Learning to do this is something that revolutionised my practice, and it’s what I want from my health providers too. It’s not always taught (or perhaps isn’t remembered) in training, and for some of us training was a while ago…hence my writing this blog.
        thanks for sharing, it helps me check that what I’m doing is worthwhile!
        cheers
        Bronnie

  2. Ah, meant to say, this post does offer an interesting answer to my comment yesterday – I really liked how you explain the difference between “interdisciplinary” and “multidiscplinary” team.

  3. I am a pediatric OT certifed in NDT and SI as well as EEG Board Certified. Needless to say, after doing this for 32 years I believe in a wholistic approach, using evidenced based tools to increase our scope of practice with the goal of improving self regulation that leads to improved function. I have just returned from my first phase of training in CBT with an emphasis on pediatric treatment of OCD, Depression and Anxiety. I think this is an excellent approach for OT to incorporate in all areas of expertise. Mind and body are linked, we all agree on that and CBT is not just “talk” therapy as some sites have indicated. It is active problem solving involving activities and is a collaborative effort between the client and the therapist.

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