Education or a cognitive behavioural approach?
There is a reasonable amount of evidence suggesting that self management of chronic pain is only moderately effective. Some of the factors thought to influence outcomes include the “one size fits all” approach – people with chronic pain may not all equally benefit from the same aspects of a programme; that programmes are usually delivered within a university-based, middle-class, North American setting and that there may be moderating or mediating factors that influence the who and what actually works within a programme.
I was interested to read about an RCT of “education” and “cognitive behavioural approach” conducted by Day, Thorn and Kapoor. Dr Bev Thorn has written many books and research papers on a structured cognitive behavioural approach for pain that specifically addresses the appraisals people make of their pain. In this approach, people are taken through a process of firstly identifying their appraisals, then learning how to challenge and restructure their thoughts about pain, while at the same time learning to do activities that they may have avoided for some time. One feature of a CBT approach is using “home learning” activities to bridge between sessions and help generalise the learning.
By comparison, an educational approach provides accurate information on aspects of pain and coping strategies, but doesn’t include the “home learning” and doesn’t directly address ways to identify and restructure thinking about pain.
One of the problems with many cognitive behavioural programmes for pain management is that they demand a lot from their participants – and particularly, they require literacy. There can be, if not carefully structured, a lot of writing. For people who don’t do writing or pen and paper activities, this can be really off-putting. The sessions are also somewhat “talky” – again, this can be off-putting for people who prefer action and doing.
In this study by Day, Thorn & Kapoor, the two approaches were used with a group of people from a rural area, with relatively low socio-economic status, and a reading grade level of about 8. Both groups received a group-based programme of 10 sessions of 90 minutes. They both received a workbook and additional reading material. The CBT group had home-learning and also participated in behavioural activities such as relaxation in-session, while the education group did not.
Interestingly, this study presents qualitative information on how participants experienced the sessions, rather than outcomes measures, so it’s difficult to establish whether pain, disability, mood or acceptance were influenced. Instead it presents thematic analysis from in-depth interviews of the participants.
What this analysis found was that while the CBT group participants initially found it difficult to “get into” the process, they spontaneously identified many of the CBT elements that were meaningful to them such as intermediate beliefs, the ability to “redirect” thinking, and integrating activity management strategies such as pacing and task perseverance.
Fewer of these themes emerged from the education group, although group process factors similar to that identified in the CBT group were found. Both groups identified that it was good to know they weren’t alone and that they learned from other members in the group. Both groups also identified that they felt more confident and in control of their situation, that they could “rise above” their pain.
Where the groups also differed was in their engagement in preferred life activities (occupations). Participants in the CBT group indicated that they were returning to preferred social activities, sports and leisure activities and that they believed they were able to persist with these despite an increase in pain. This didn’t occur in participants involved in the education group.
What does this tell me?
Well, a couple of really important things. While we don’t know which parts of the self management programmes do the hard work for people with chronic pain, it seems that a group approach has some unique benefits irrespective of the type of programme offered. People with chronic pain often feel isolated and very alone, as if they are the only people with their specific problems. A group approach provides an opportunity to normalise these experiences.
I also take the idea that information alone doesn’t necessarily initiate change – structured goals seem to help, setting an expectation that learning and engaging in activities between sessions may help, the feedback and problem-solving may help too. It could also be the process of cognitive therapy – learning to identify thoughts and beliefs, and restructure these may be helpful.
We can’t, from this study at least, determine which of these ‘active ingredients’ is doing the trick. I rather fancy that although the cognitive aspects certainly play a part, it could be these other aspects – setting expectations, supporting change, problem solving – these could actually be the parts that get people started on doing things differently in their own environment.
Is it time for a different take on self management? Maybe it’s time to embark on a less educational, more occupation-focused approach that incorporates cognitive restructuring in an active and “doing” way as part of problem solving – what do you think?
Day, M., Thorn, B., & Kapoor, S. (2011). A Qualitative Analysis of a Randomized Controlled Trial Comparing a Cognitive-Behavioral Treatment With Education The Journal of Pain DOI: 10.1016/j.jpain.2011.02.354
Miles, C., Pincus, T., Carnes, D., Homer, K., Taylor, S., Bremner, S., Rahman, A., & Underwood, M. (2011). Can we identify how programmes aimed at promoting self-management in musculoskeletal pain work and who benefits? A systematic review of sub-group analysis within RCTs European Journal of Pain DOI: 10.1016/j.ejpain.2011.01.016