letting it all hang out

Taking a peek beneath the hood

What would it be like to lift the hood and take a good hard look at the skills needed to carry out various chronic pain management treatments? You know, take each profession’s jargon away and really look at what a clinician needs to know to conduct safe, effective treatment. Oh I know, this is skating on thin ice – each profession’s treatment paradigm and assumptions are incredibly important and I’m an outsider looking in, so please, before you push me under the cold, cold water, let’s think about the parts that really do the business in pain management.

The first set of skills that are crucial to effective pain management are those to do with communicating. The ability to listen carefully, reflect what’s being said, and to ask questions to genuinely understand what a person believes and feels, and how they got there.  To be able to help the person identify what’s important to them, their main concerns, their values and the direction they want to move towards. To know what to say and how to say it (Bensing & Verhuel, 2010; Hall, 2011; Hulsman, 2009; Klaber & Richardson, 1997; Oien, Steihaug, Iversen & Raheim, 2011).

These skills are generic to all health professionals, although perhaps enhanced and refined in those clinicians who are involved in talking as the therapeutic process.

The second set of skills involve being able to change behaviour. To be aware of operant conditioning, classical conditioning, and to use these principles along with those involving cognitions (eg “education” or providing information).  Interestingly, while these principles are derived from psychology, and perhaps educational research, ALL health professionals use these skills when they’re involved in asking the person to make a change outside of the treatment room.

Unless the clinician is doing something TO the patient, treatments for chronic pain typically involve asking the patient to DO something (Honicke, 2011; Persson, Rivano-Rischer & Eklun, 2004; Robinson, Kennedy & Harmon, 2011).

The third involve being able to progressively grade activities from simple to complex – modifying them so that the demands just slightly exceed the person’s capabilities or confidence.

  1. Those demands might be physical (repetitions, range of movement, loading, isolation to integrated movement),
  2. Cognitive (simple one-step directions through to complex multi-stage decision-making activities),
  3. Social (working alone, in a pair, in a small group, large group, being the follower, being the leader),
  4. Emotional (joyful flow or frustrating, touching on highly important values or those that are not especially relevant).
  5. Contextual (controlled contexts like a clinic room vs highly chaotic like a shopping mall on Christmas Eve)

It’s this latter set that I think we may forget when looking at skills and professionals. There can be an assumption that being able to do an exercise programme in a gym or clinic should lead to greater participation in life outside that setting. Exercises can be prescribed to isolate a small set of muscles, using all the usual suspects to increase strength, flexibility, speed and stamina – and the techniques to progress along this kind of training are, sorry guys, reasonably simple to learn. The challenge is for the person doing them to be able to transfer this training to the real world where movements are integrated, where the environment is complex and the demands and distractions are myriad.

Likewise with graded exposure training – beginning with the least feared movements, progressing to more and more feared situations using a graded hierarchy is something any one of us can learn provided we take the time to understand how and why this approach is used. What’s far more difficult is helping the person doing these activities in new and evolving situations so the skills generalise. Occupational therapists, for what it’s worth, are explicitly and uniquely trained to analyse occupations/activities to do precisely this kind of generalisation.

When we look at what works in chronic pain management, there are four things:

  1. Placebo or meaning effects which are strongly influenced by the way we communicate, and the person’s expectations from us and our interaction.
  2. Providing accurate information so the pain is “de-threatened” or at least loses a large degree of the threat value even if the pain doesn’t reduce as a result.
  3. Supporting the person to do more, whether that be through exercise or just doing more of what they want.
  4. Generalising those skills so that irrespective of the pain fluctuations or context, the person can remain able to participate in what’s important in their life.

And the skills needed to do these things? They’re the ones I’ve listed above.

What I think this means is the time has come to stop describing various treatments as “belonging” to any single discipline. They don’t “belong” to anyone – they’re generic skills that we ALL use. So I, as an occupational therapist warped by psychologists, will have greater technique in communicating, noticing psychosocial obstacles, and helping a person generalise skills into a range of contexts by virtue of my training. Paul, as a physiotherapist, will have greater technique in prescribing specific exercises for certain muscles, and have more confidence in exercise progression. Scott will have greater expertise in enhancing expectations and helping a person reconceptualise their pain in a way that dethreatens it. We ALL have effective skills across all of these areas, but at the same time we have particular expertise in what we originally trained in.

Finally, what I think this means is that when the call is made for clinicians to work in primary care, or alongside GPs or in ED, to help reduce healthcare use, increase participation in life and so on, it’s time we stopped saying “The (X profession) and the GP should form a team”, I think it’s time for us to say “The allied health team (made up of people with the following skills) should form a team with the person living with pain”.


Bensing, J. M., & Verheul, W. (2010). The silent healer: The role of communication in placebo effects. Patient Education and Counseling, 80(3), 293-299. doi:http://dx.doi.org/10.1016/j.pec.2010.05.033

Eakin, E., Reeves, M., Winkler, E., Lawler, S., & Owen, N. (2010). Maintenance of physical activity and dietary change following a telephone-delivered intervention. Health Psychology, 29(6), 566-573.

Hall, J. A. (2011). Clinicians’ accuracy in perceiving patients: Its relevance for clinical practice and a narrative review of methods and correlates. Patient Education & Counseling, 84(3), 319-324.

Hardcastle, S., Blake, N., & Hagger, M. S. (2012). The effectiveness of a motivational interviewing primary-care based intervention on physical activity and predictors of change in a disadvantaged community. Journal of Behavioral Medicine, 35(3), 318-333.

Honicke, M. (2011). Acceptance and commitment therapy as a challenging approach for occupational therapists in pain management. Ergotherapie und Rehabilitation, 50(7), 28-30

Hulsman, R. L. (2009). Shifting goals in medical communication. Determinants of goal detection and response formation. Patient Education & Counseling, 74(3), 302-308.

Klaber, M. J., & Richardson, P. (1997). The influence of the physiotherapist-patient relationship on pain and disability. Physiotherapy Theory and Practice, 13(1), 89-96.

Okun, M. A., & Karoly, P. (2007). Perceived goal ownership, regulatory goal cognition, and health behavior change. American Journal of Health Behavior Vol 31(1) Jan-Feb 2007, 98-109.

Oien, A. M., Steihaug, S., Iversen, S., & Raheim, M. (2011). Communication as negotiation processes in long-term physiotherapy: A qualitative study. Scandinavian Journal of Caring Sciences, 25(1), 53-6

Persson, E., Rivano-Fischer, M., & Eklun, M. (2004). Evaluation of changes in occupational performance among patients in a pain management program. Journal of Rehabilitation Medicine, 36(2), 85-91.

Robinson, K., Kennedy, N., & Harmon, D. (2011). Review of occupational therapy for people with chronic pain. Australian Occupational Therapy Journal, 58(2), 74-81.

Rosser, B. A., McCullagh, P., Davies, R., Mountain, G. A., McCracken, L., & Eccleston, C. (2011). Technology-mediated therapy for chronic pain management: The challenges of adapting behavior change interventions for delivery with pervasive communication technology. Telemedicine Journal & E-Health, 17(3), 211-216.


Connecting: A cognitive behavioural approach to initial interviews

As I’ve been reading and thinking about the ways health professionals work with people who live with pain, my mind keeps coming back to the power of human connection. Pain is ephemeral: we can’t touch it, see it or truly understand the “what it is like” for that person to experience that pain.  The only way we can get to understand even a little of another’s pain is when we take the time to hear what they’re saying. This post is about how a cognitive behavioural approach can inform our communication and build a bridge towards shared understanding. Only once this is begun can we start “treatment”.

A cognitive behavioural approach is based on the idea that people are not blank canvases, reflecting whatever is thrown at them. Instead people actively think about what is happening, seeking out information they think is relevant, depending on their past experiences, the framework they use to understand what’s going on, and to make predictions in light of what they want to do (goals).

What this means is that a conversation about pain is like dipping your toe into a stream. The stream keeps moving on, but the water gets swirled around where your toe is dipped. Whatever is upstream comes down along the waterways, where you dip your toe is here and now, and depending on the depth of your toe-dipping (and the stream’s flow) will influence the stream’s direction downstream. If your conversation is superficial and only concerned with issues the person doesn’t feel is relevant, your toe-dipping isn’t going to have much influence. But if you take the time to get into the water, immersing yourself in what the person is really saying (where they’ve been, what they’ve learned, where they want to go), you may well have a huge influence on their future directions.

What’s the focus of an initial interview?

An initial interview usually focuses on “what are the problems?” and “what can I do?” Of course, most clinicians also recognise the importance of establishing rapport, and the need to be empathic. The actual factors considered important within an initial interview vary depending on the model of health or disease adopted by the clinician. For a strongly biomechanically-oriented clinician the factors may be muscle length, strength, range of movement, loading and tolerance. For a clinician using a biopsychosocial framework, hopefully weight will also be placed on beliefs, understanding, attitudes, past experiences, emotions, predictions for the future, past treatments and what has been learned from these, existing stressors, vulnerabilities and strengths. And of course, a whole heap of family, friends, workplace and social factors should also form part of this assessment.

I’ve attached a semi-structured interview I’ve used clinically when working with people who live with chronic pain – this interview can take 60 – 90 minutes, depending on the complexity of the person’s narrative – Self Management Semistructured interview. I don’t think this is the only way to approach learning about someone else’s pain, but it provides me with a very sound basis for deciding whether I can help the person, and more importantly, I think it gives the person a chance to feel that I’m really listening.

To abbreviate this interview, I’d hone in on two main questions that I need to answer:

  1. Why is this person presenting in this way at this time?
  2. What can be done to reduce this person’s distress and disability?

All of my questions are designed to help me answer these two questions. Of course, they’re not going to work at all unless the person I’m talking with is part of this conversation. After all, they have ideas about what they want from me, why they’re looking for help, and what’s led them to come to me now rather than seeing someone else, or at another time.

There’s something missing from this interview though!

Something you can’t get from a simple list of questions is how to ask them and how to respond to the answers. I used to think the art of asking good interview questions lay with the wording, but I’m not so sure now. I think it’s about my attitude. Let me unpack this.

Socratic questioning is the main orientation I use in my initial interview. Socratic questioning is about guided discovery, or a dialogue between me and the other person in which I guide both of us towards discovering things the person knows but may not know they know. Confused? Well, here’s an explanation of the process. (BTW I follow Christine Padesky’s approach for Socratic questioning – click here for more info)

Padesky states “Socratic questioning involves asking the client questions which: a) the client has the knowledge to answer; b) draw the client’s attention to information which is relevant to the issue being discussed but which may be outside the client’s current focus; c) generally move from the concrete to the more abstract so that; d) the client can, in the end, apply the new information to either reevaluate a previous conclusion or construct a new idea.”

To begin with, we need to find out what the person knows they know – so I will ask Informational Questions.  These include things like “what do you think is going on?”; “what’s your theory about your pain?”; “why do you think your sleep is so bad right now?”.

The second and equally important part is Listening. Not only am I listening to (and then reflecting that I’ve heard), I’m listening for words or phrases that are idiosyncratic, have emotional impact, those metaphors and images the person uses, the emotional feeling tone of their account.

The third is Summarising in which I gather together several phrases or responses given by the person, and present them back to him or her to make sure I’ve heard them correctly, but also to give them a chance to hear what they’ve been saying. Sometimes it’s only by talking that a person finds out what they’ve been thinking (ever had that happen to you?!). In Motivational Interviewing this is called “giving a bouquet” of what the person has been saying. I like that image!

The final phase is Synthesising, or Analytical questions. This occurs after you’ve spent the time finding out what the person thinks, listened carefully and then reflected this, explored the unique meanings the person puts on aspects of what is going on for them, and finally you’ve summarised and reflected their narrative as a whole – synthesising questions help the person make sense of what they’ve just said, pulling it all together. I sometimes use phrases like “so where does this leave you?” or “what does all that mean now?” or “what is your next best step?” Smart readers will recognise some of the Motivational Interviewing phrases in here!

The attitude I bring to this kind of encounter is one of curiosity. I’m genuinely curious to try to understand how this person has developed his or her understanding of their situation. This helps me step away from judging their situation as “good” or “bad, and in particular helps me avoid judging them as “good” or “bad” (or “coper” or “noncoper”). I constantly remind myself and others that people generally don’t get up in the morning to do dumb things. There’s usually a reason for people being in the situation they’re in – and often it’s about lacking accurate information.

Putting it together

Having gathered information, reflected what you’ve understood and confirmed this understanding with the person – now’s your chance to help that person develop their own, personal understanding of what’s going on. I like to call this their own personal model of pain. It won’t be complete, but it’s a great beginning. Padesky suggests asking “What do you make of this? How do you put this? How do you put these ideas together?”

For more information on a strengths based approach to cognitive behavioural therapy (not the same as a cognitive behavioural approach, but very interesting to read) – go here for a full paper by Padesky and Mooney, published in 2012, and for a much more detailed discussion of Socratic questioning in a panel – go here.




What is the difference between using cognitive behavioural therapy – and using a cognitive behavioural approach?

My last post generated an enormous amount of discussion about whether clinicians who are not psychologically trained, or who haven’t completed a psychology degree, or indeed, should carry out treatments using a cognitive behavioural approach. This is my answer! But note well, these are not my words, but drawn from two of the most eminent researchers and clinicians I know. And yes, I think you can ALWAYS learn more skills – and apply them within your practice with an eye to optimising the quality of your interactions and outcomes.

The first is from Professor Turk:


This excerpt is from Turk (2003). Cognitive-behavioral approach to the treatment of chronic pain patients. Regional Anesthesia and Pain Medicine, 28(6), p 573-579.

In this paper, Turk identifies the many influences on our experience of pain, and on subsequent disability, that are amenable to “top down” approaches. As he points out in this excerpt, a cognitive behavioural approach is a way to conceptualise the person and his or her experience. The perspective is as important as the content of therapy. The best way I can put this is to show the following clip from this paper – and ask readers if they agree, based on the findings from pain science research.

assumptions of CBT approach















So, it’s clear to me anyway, that our modern view of pain as an experience that people go through in the context of their life implies that tissues and nociception are only part of the picture. Along with this is the recognition that our treatments exert their influence not just through the so-called “active ingredients” of whatever modality we choose to use. At the same time as we “treat”, the people coming to see us interpret and place expectations on what will happen in that “third space”. Their understanding of what could and should happen influences their response – and even if we don’t recognise this! What this means to me is that we have a responsibility to be mindful and thoughtful about everything that goes on between the person “treating” and the person “seeking”, because these influences are always happening. For more information on the neurobiology of treatment seeking and relief, Benedetti’s book on The Patient’s Brain should be a mandatory reference, though there are others.

Turning to whether those clinicians who primarily touch people, or advise on movements and bodies (ie physiotherapists) should adopt a cognitive behavioural approach, I’m going to snip from a paper by Harding and Williams (1995). What’s scary is that this paper was written waaaay back then, but some clinicians in this area of practice STILL don’t recognise that this is a legitimate approach for them to take. Back to the snip:


Here’s a further snip from that same paper, explaining how and why providing accurate information, and helping people identify unhelpful ways of thinking is an important component, especially within a team environment.

“The cognitive component of a CP management programme involves teaching patients to identify thoughts and beliefs which underpin maladaptive behaviours and which adversely affect mood. There is a particular focus on anxiety and depression. Once patients can identify the very disabling cognitions, they try to use cognitive restructuring to identify and challenge longstanding beliefs and immediate judgements (Turk et al, 1983), with resultant improvement in mood and in practical coping with the pain.
Cognitive restructuring is a task that varies in complexity. Although this complexity sometimes requires the specialised skills of clinical psychologists or others with appropriate training, there are many occasions when less experienced professionals may help patients apply the principles to great effect.
One of the more disabling habits of thinking identified in many CP patients is catastrophising: expecting only the worst to happen and feeling
unable to cope with it. Research shows that patients who use catastrophising frequently cope poorly with CP (Jensen et al, 1991; Keefe et al,
1992). Team members are therefore taught to recognise catastrophising and to help patients to challenge it when it occurs, such as during exercises,
practical activities or planning.”

I know we can argue about the language used here (remember when this was published), but here’s my rationale for physically-oriented clinicians to actively use cognitive and behavioural approaches. When do you think people are likely to think those unhelpful thoughts? When is it most likely they will recall those scary images and immediately experience distress – and then avoid? Is it likely to be sitting quietly in a clinic room where the only expectation is to talk? Or is it more likely to happen when engaged in doing something that represents the thing the person is afraid of? When do you think emotions are most likely to be present? And when do you think it’s most likely that an experiment disproving the unhelpful assumption might best be carried out? I think it’s likely to be when you and the person are beginning to do some movements.

Along with cognitive aspects, there are also behavioural ones. “Changing Behavior: Providing positive consequences for learning a new behaviour such as a previously feared exercise is likely to reinforce it, particularly when the reinforcements are provided immediately and frequently for small achievements in the early stages. The focus is moved away from unhelpful behaviours, and shaping (Becker, 1989) rather than criticism is used to achieve the finally desired exercise or posture. Pain is not denied, only the pain behaviour is not reinforced.”

And further: “Goal Setting: Exercises are seen as part of the ‘building blocks’ to achieve a range of patient goals, so although they may improve local biomechanics, they constitute steps to  achieving activity goals and general fitness, rather than being prescriptive on the basis of the assessment.”–  yet more“Pacing: Since patients’ exercises are learnt with pacing on a quota not pain basis, practices like ’no pain, no gain’ and ‘pushing through the pain barrier‘ are discouraged. They learn to set exercise baselines at what can easily be managed rather than the most they or the therapists think they can do. Patients are thus enabled to challenge and resolve fears (such as bending the back, or weight bearing through a chronically painful knee) rather than to be precipitated into anxiety and avoidance.”

Still more “Education: Patients need information with written back-up to make choices and help them bring about behaviour change…Education is interactive and involves practical experience, not just discussion.”

“Recording Progress: Charts and exercise sheets are used to demonstrate and reinforce a behaviour change (such as regular and increasing exercise rather than pain determined exercise). They are filled in by patients, not therapists, to reinforce patients’ improvement.”

“Challenging Thoughts and Feelings: Physiotherapists who can help patients capture and challenge unhelpful cognitions, when they are confronted with feared situations such as physical activity, are likely to catalyse big improvements in function and mood. Unhelpful cognitions about exercise may be challenged on the basis of realistic estimates of physical capacity and of risk of harm.”

Finally, “Maintenance and Self-attribution: If improvement is seen as the patient’s achievement – ‘I did it’ – right from the start, rather than ‘the physiotherapist cured/fixed me up’, they will have a greater sense of future self-management.”

Further to my post about interdisciplinary working: An inter-disciplinary team is not hierarchical but involves sharing of skills, and it is quite usual, for example, for the psychologist to address the psychological implications of the physiotherapist‘s initiatives and vice versa. The physiotherapist has a lot of patient contact, so mutual feedback with other members of the team is important both in timetabled team meetings and informally. Good team integration helps patients understand how to tackle the complex experience of CP using the techniques, and prevents mixed messages from the staff which may confuse and discourage patients. Where integration is achieved, differences apparent to patients are easily resolved.” So much for concern about scope.

While these papers are old and the language reflects this, the cognitive behavioural approach is now firmly established as a helpful way to conceptualise the experience and problems of people living with pain. As Vlaeyen and colleagues indicated in their recent book “Pain-related Fear”, the skills rather than the professional discipline is what is important. Turk and others say that by using a cognitive behavioural approach, people are able to attribute change to themselves, rather than on any mythical theory about application of hands.

As Harding and Williams state: “When improvement occurs, it is important that it is credited to patients, both my themselves and by staff. Hands-on physiotherapy is tremendously rewarding, and rapid dramatic results produce in therapists quite a buzz of pride in their skills. Patients sense this and physiotherapists will remember being told: “Oh you are wonderful, no one else has been able to help me, such healing hands…etc”. However this is not helpful to patients. The unspoken message is: “I couldn’t do without you”. Physiotherapists guidance can be acknowledged but it is patient’s hard work and the renegerative capacity of their bodies which bring about change, catalysed by professional help” (p. 686).

So, to conclude, I think clinicians of all colours and stripes should be ready to adopt a cognitive behavioural approach. It is a perspective about a person experiencing pain, not a therapeutic procedure or set of actions. It’s a way of seeing people from within a biopsychosocial perspective. All the actions you then take as a professional will naturally reflect your unique clinical scope – but as far as I know, using effective communication (eliciting a person’s understanding of their pain and situation, and reflecting what you’ve heard) and being able to think of people as active participants in their own health doesn’t constitute stepping out of anyone’s scope.

cb perspective


Harding, V., Williams, A., (1995). Extending physiotherapy skills using a psychological approach: Cognitive behavioural management of chronic pain. Physiotherapy, 81(11), p681 – 688.

Turk (2003). Cognitive-behavioral approach to the treatment of chronic pain patients. Regional Anesthesia and Pain Medicine, 28(6), p 573-579.

Vlaeyen, J., Morley, S., Linton, S., Boersma, K., & de Jong, J. (2012). Pain-related fear. Seattle: IASP Press.


Scopes, roles, boundaries, contributions: who does what in a brave new healthcare world?

I have been meaning to write a post like this for some time now, but prompted to today by two things: one is an ongoing debate about non-psychologists using “CBT” with people who are experiencing pain, and the other is a conversation with Chai Chuah, Director General of the Ministry of Health in New Zealand. Let me set the scene:

We know there are a lot of people in our communities who have relatively simple pain problems – a temporarily painful knee after walking up hills for the first time in ages, a painful back that “just happened” overnight, a rotator cuff problem that makes it difficult to get dressed or hang out washing. We know that there are some pretty simple things that will help in these situations: some reassurance that the awful thing the person is worried about isn’t likely to happen (no, you won’t end up in a wheelchair because of your back pain, and no it’s not cancer); some pain relief to help with sleeping more soundly and so we can keep doing things; and gradually returning to normal occupations including work even if the pain hasn’t completely gone.

We also know that approximately 8% of people with low back pain will ultimately end up contributing to the most enormous spend in healthcare that we know about – their pain continues, their distress increases, their disability is profound.

BUT before we put all our attention on to this small group of people, I think it’s worthwhile remembering that people in this group are also more likely to have other health conditions, they’re more likely to smoke, to be overweight, to have mental health problems; they also probably come from lower socioeconomic groups, groups including people from minority ethnicities, people who find it much harder to get work, to remain in education and perhaps even people who typically use healthcare more often than the people who get back on their feet more quickly. Data for these statements comes from the 2006 Health and Disability Survey in New Zealand and numerous studies by epidemiologists around the world  –  back pain is only one of a number of problems people in this group have to deal with. I’m also not saying everyone who gets back pain that lingers has all of these additional concerns – but there is a greater prevalence.

What does this mean?

Well, for a while I’ve been saying that people working in this area of health (musculoskeletal pain) seem to be developed a set of common skills. That is, there is more in common between me and Jason Silvernail, Mike Stewart, Paul Lagerman, Alison Sim, Lars Avemarie, Rajam Roose and many others around the world from many different health professions, than there is between me and a good chunk of people from my own profession of occupational therapy. And I don’t think I’m alone in noticing this. (ps please don’t be offended if I’ve left your name out – you KNOW I’m including you too!)

What’s common amongst us? The ability to see and work with complex, ambiguous, messy and multifactorial situations. Recognising that along with all of our individual professional skills, we also need to have

  • effective communication skills,
  • patient/person-centredness,
  • critical thinking,
  • generating a framework to work from,
  • identifying and solving the unique goals and situations the people we work with have,
  • ability to step beyond “this is my role” and into “what can be done to reduce this person’s distress and disability?”
  • And possibly the most important skill is being able to tolerate not knowing without freaking out.

That ongoing cycle of assess -> hypothesise -> test -> review -> reassess -> hypothesise -> test -> reassess ->  review

This is important because when people come to see us with a complex problem (and increasingly this seems to happen), the simple models break down. The tissue-based, the germ-based, the simple single-factor approaches do not fully explain what’s going on, and don’t provide adequate solutions.

What this means is we, ALL health professionals, will need to think about where our skills lie. Are we people who enjoy pumping through a big number of relatively simple problems? If so, that’s great! Your contribution is clear-cut, you know what you need to do, and you refine and practice your skill-set until you’re expert. I think this is awesome. Or, are we people who relish complex, who look at situations and see that it’s messy and complicated but don’t get put off? In this group we probably use skills for researching and planning, operationalising or getting things started, and we’re often the people who network furiously. We do this not because we’re social butterflies (me being the ultimate introvert), but because we know WE CAN’T DO THIS WORK ALONE!

What about clinical skills and scopes and boundaries?

You know, I am not entirely sure that anyone except the health professional him or herself cares who does what they do to help someone get better. It’s not whether a nurse or a speech language therapist or a podiatrist or a medical practitioner, it’s whether the person (or people) treats each person as unique, listens carefully, is honest and straightforward about what can and can’t be done, and knows when his or her skills are not sufficient so calls in the rest of a team for help. There is a time for working beyond your scope, and a time for calling in an expert – but to recognise when an expert is needed requires knowing enough about the problem to know that an expert might be helpful.

What this means in healthcare, I think, is adopting a framework that works across diagnosis and into the idea that people actively process what happens to them, they make their minds up about what’s needed, and they can learn to do things differently. I’d call this self-management, but I could equally call it a cognitive behavioural approach, or behaviour change, or motivational approaches or even patient-centred or person-centred care. The idea that people understand more than we often give credit, that they make sense from what happens to and around them, and that this knowledge influences what they do comes from a cognitive behavioural model of people, and fits beautifully within a biopsychosocial framework.

So, when I advocate getting skilled at cognitive behavioural skills, I could equally use the term “person-centred” or “self-management” – whatever the label, the contributions from each professional involved will ultimately influence the health experience and actions of the person we’re seeing.

Isn’t it time to be excited about opportunities to develop and to extend our skills? And if this doesn’t excite you, isn’t it great that there are a group of people who will respond to the simple and straightforward – but let’s not confuse the two situations.


Brandywine Falls

Who can do Cognitive Behavioural Therapy for Rehabilitation?

I have heard many discussions about scopes of practice: the main concern as far as I can see is of people who are trained to work mainly with the body perhaps stepping out of scope to work with thoughts, beliefs, and emotions. There are risks from stepping too far away from what you’re trained to do, I acknowledge this, though I think health professionals who see people are probably exerting greater influence over thoughts, beliefs and emotions than many of us acknowledge.  And given that’s the case, I think it’s only ethical to learn to craft that influence in ways that are positive rather than inadvertently doing harm because of ignorance.

When I read about a post-surgical rehabilitation approach for people who had spine surgery, I was immediately interested and not because of the surgery! This study compared “cognitive-behavioural based physical therapy” with an education programme six weeks after laminectomy for a lumbar degenerative condition. People were included in the study if they reported high fear of movement using the Tampa Scale for Kinesiophobia. Assessments were completed before treatment, after treatment and at a 3 month follow-up, and included the Brief Pain Inventory, Oswestry Disability Index, SF-12, and three performance tests (5-chair stand, timed up and go, and 10 metre walk).

There was no discussion about the physical rehabilitation, but the CBT and education sessions were conducted by phone and participants also received a workbook to take home and follow. Sessions took 30 minutes, except the first session which was for one hour. The main components of the programme are reported as education on the mind-body connection, activity levels, graded activity plan (graded hierarchy) and weekly activity and walking goals. A cognitive or behavioural strategy was introduced in each session, with the therapist helping patients identify enjoyable activities, replace negative thinking with positive thoughts, find a balance between rest and activity, and manage setbacks by recognising high-risk situations and negative thoughts.

The education sessions included the usual contents delivered by a physiotherapist, and featured biomechanics, daily exercise, and ways to promote healing. Information on stress reduction, sleep hygiene, energy management, communicating with health providers and preventing future injury were also provided.

What did they find?

Firstly, only 68% of those eligible for the study agreed to take part, which in itself is interesting. A number of other factors influenced the total number of people entered into the programme – not being treated for a degenerative lumbar condition, not having high enough scores on the TSK were the main reasons. Dropout rates for both programmes were quite low – 7 – 5%, and both programmes had good follow-up outcomes (not too many people missed the follow-up).

Now here’s a thing: 91% of participants also received clinic-based physiotherapy during the treatment phase (roughly 8 visits), and right up until the three-month follow-up (about 6 – 7 visits). No real difference between the groups here.

What did differ was the long-term improvement in the cognitive behavioural group – in terms of back and leg pain, pain interference and disability. The education group still improved in their leg pain and disability, but back pain and pain interference stayed the same. Similarly, the CBT group continued to improve on measures of physical and mental health over time, while the education group’s physical scores improved but mental health scores stayed pretty much the same. The CBT group’s scores improved more than the education group on almost all the measures including the physical performance tests.

What does this mean?

Well, interestingly, the authors of this study suggest that they obtained large and clinically relevant changes because of the specific focus they had on decreasing barriers to functional activity and walking rather than focusing solely on resolving pain symptoms. I think this is very interesting indeed. Although this study used physiotherapists, the clinician was naive to using CBT and was trained specifically for this study. Participants received concurrent physiotherapy in a clinic – the CBT (and education sessions) were additional to what was delivered in the clinic setting. To me the results suggest that the occupational therapy focus on creating opportunities for people to do more within their own environment might be a potent tool in post-operative rehabilitation.

Once again, it also suggests that the professional discipline of the clinician delivering a CBT approach is far less important than the fact that the CBT approach is tailored to the concerns of the patient, and that the treatment targets factors within the real-world context.

Important points to note: these patients were selected on the basis of high levels of pain-related fear and avoidance. I don’t think the outcomes would be nearly as fabulous in a general or undifferentiated group. This approach, while relatively inexpensive to implement, is an added cost – though if we look at the effect on patient outcomes, I would argue that the financial cost is far outweighed by the positive human results.

Finally, I think this study also shows that addressing thoughts, beliefs and emotions is a part of what every health professional should be doing: it’s unethical not to learn to do this well.

Archer KR, Devin CJ, Vanston SW, Koyama T, Phillips S, George SZ, McGirt ML, Spengler DM, Aaronson OS, Cheng JS, Wegener ST, Cognitive-behavioral based physical therapy
for patients with chronic pain undergoing lumbar spine surgery: a randomized controlled trial, Journal of Pain (2015), doi: 10.1016/j.jpain.2015.09.013.


Pain Acceptance rather than Catastrophising influences work goal pursuit & achievement

We all know that having pain can act as a disincentive to doing things. What’s less clear is how, when a person is in chronic pain, life can continue. After all, life doesn’t stop just because pain is a daily companion. I’ve been interested in how people maintain living well despite their pain, because I think if we can work this out, some of the ongoing distress and despair experienced by people living with pain might be alleviated (while we wait for cures to appear).

The problem with studying daily life is that it’s complicated. What happened yesterday can influence what we do today. How well we sleep can make a difference to pain and fatigue. Over time, these changes influences can blur and for people living with pain it begins to be difficult to work out which came first: the pain, or the life disruption. Sophisticated mathematical procedures can now be used to model the effects of variations in individual’s experiences on factors that are important to an overall group. For example, if we track pain, fatigue and goals in a group of people, we can see that each person’s responses vary around their own personal “normal”. If we then add some additional factors, let’s say pain acceptance, or catastrophising, and look to see firstly how each individual’s “normal” varies with their own acceptance or catastrophising, then look at how overall grouped norms vary with these factors while controlling for the violation of usual assumptions in this kind of statistical analysis (like independence of each sample, for example), we can begin to examine the ways that pain, or goal pursuit vary depending on acceptance or catastrophising across time.

In the study I’m looking at today, this kind of multilevel modelling was used to examine the variability between pain intensity and positive and negative feelings and pain interference with goal pursuit and progress, as well as looking to see whether pain acceptance or catastrophising mediated the same outcomes.

variationsThe researchers found that pain intensity interfered with goal progress, but it didn’t do this directly. Instead, it did this via the individual’s perception of how much pain interfered with goal pursuit. In other words, when a person thinks that pain gets in the way of them doing things, this happens when they experience higher pain intensity that makes them feel that it’s hard to keep going with goals. Even if people feel OK in themselves, pain intensity makes it feel like it’s much harder to keep going.

But, what’s really interesting about this study is that pain acceptance exerts an independent influence on the strength of this relationship, far more than pain catastrophising (or thinking the worst). What this means is that even if pain intensity gets in the way of wanting to do things, people who accept their pain as part of themselves are more able to keep going.

The authors of this study point out that “not all individuals experience pain’s interference with goal pursuit to the same extent because interference is likely to depend on pain attitudes” (Mun, Karoly & Okun, 2015), and accepting pain seems to be one of the important factors that allow people to keep going. Catastrophising, as measured in this study, didn’t feature as a moderator, which is quite unusual, and the authors suggest that perhaps their using “trait” catastrophising instead of “state” catastrophising might have fuzzed this relationship, and that both forms of catastrophising should be measured in future.

An important point when interpreting this study: acceptance does not mean “OMG I’m just going to ignore my pain” or “OMG I’m just going to distract myself”. Instead, acceptance means reducing unhelpful brooding on pain, or trying to control pain (which just doesn’t really work, does it). Acceptance also means “I’m going to get on with what makes me feel like me” even if my pain goes up because I do. The authors suggest that acceptance might reduce pain’s disruptive influence on cognitive processes, meaning there’s more brain space to focus on moving towards important goals.

In addition to the cool finding that acceptance influences how much pain interferes with moving towards important goals, this study also found that being positive, or feeling good also reduced pain interference. Now this is really cool because I’ve been arguing that having fun is one of the first things that people living with chronic pain lose. And it’s rarely, if ever, included in pain management or rehabilitation approaches. Maybe it’s time to recognise that people doing important and fun things that they value might actually be a motivating approach that could instill confidence and “stickability” when developing rehabilitation programmes.

Mun CJ, Karoly P, & Okun MA (2015). Effects of daily pain intensity, positive affect, and individual differences in pain acceptance on work goal interference and progress. Pain, 156 (11), 2276-85 PMID: 26469319

Podcast from Karen Litzy (Healthy, Wealthy and Wise) – and me!

I haven’t done a lot of interviews, but even if I had, this one is very special. Karen is a warm, funny and very human interviewer who isn’t afraid to show who she is – even if I made her cry! (well, I didn’t actually make her cry, but she did need to wipe a tear or two away!).

Listen to this and then go off to iTunes to rate it (I hope you’ll give it a good one!)


before the nor'wester

“Them” and “us”

The governing principles and purposes of International Association for the Study of Pain (and thus NZ Pain Society) are clear that “IASP brings together scientists, clinicians, health-care providers, and policymakers to stimulate and support the study of pain and to translate that knowledge into improved pain relief worldwide.”
There is no mention in this purpose of the people who experience pain. I think this is an omission.

Pain is a subjective experience. This means we can only be informed about pain when people communicate about it. So many aspects of pain have not been explored in a great deal of detail: things like gender, the lived experience of “good” outcomes vs “bad” outcomes, the use of labels like “failed back syndrome”, the “what it is like to be” a person receiving types of treatments, even determining whether a treatment is acceptable in the context of the real world – or not.

If we want to reduce the burden of pain within our population, shouldn’t we be incorporating the views of people living with pain? so the aims and priorities of those living with pain are included, increasing public awareness of pain and what it means to counter the prevailing attitudes towards people living with pain?

There is, however, a divide between “us” and “them”. “Us” being privileged to know about pain, to develop research agendas, to study pain and translate into improved pain relief, while “them” are passive recipients of such efforts.  This doesn’t fit with my views of the reducing gap between treatment provider and recipient, or of the relationship of collaboration that must exist between a person wanting help and those giving it. And it doesn’t afford a strong voice to people living with pain who have as valid a view as those who do not live with pain.

Is there room for a person-focused approach in pain research? And can people living with pain have a voice?

I’ve been reading some of the very old medical journals, ones like the New England Journal of Medicine from 1812. In this article, J. G. Coffin expounds on the use of cold bathing saying “For several years past from May to November, I have been in the habit of walking or riding on horseback freely til 12 or 1 o’clock of the day, hastening to the water’s edge, and plunging in with the least possible delay; and in no instance have I regretted the habit, but on the contrary have found it alike grateful and invigorating.” Now I’m not about to suggest we all begin cold bathing, but what I want to point out is the very personal nature of this account.

Compare this with an excerpt from Martel, Finan, Dolman, Subramanian et al (2015) discussing self-reports of medication side effects and pain-related activity interference: “Despite the potential benefits of each of these medications for the management of patients with pain, it is well known that the combination of a wide range of medications may lead to a number of adverse side effects, including nausea, dizziness, headaches, constipation, and weakness. These medication side effects are frequently observed in clinical settings and represent a complex pain management issue.” (p. 1092).

Patients,  not people, are discussed in the latter paper, even though the subject of this study is the experience of people taking medication for their pain. Numbers of side effects. Self-reports of pain intensity, reduced to a 0 – 10 scale. “Negative affect” reduced to numbers.  Interference in three areas of activity rated using the same scale.

While I applaud the need to measure variables of importance, I find it interesting that articles about subjective experiences of people feature far less prominently in our esteemed journals of pain research than those presenting a one-step-removed depersonalised view of what is a human experience.

In recent months I have been reading about the space that occurs between a clinician and patient. Benedetti’s writings on The Patient’s Brain (which, incidentally, also and equally discusses the clinician’s brain) help unpack that special place in which ritualised relationships including power and plea are played out every day. What I draw from Benedetti’s book is that while people seeking treatment appear the supplicants, in fact it is they who determine (to a great degree) whether a treatment will be helpful or not. The meanings ascribed to the interaction are formed by the person seeking help. Clinicians play out a role according to the “rules” of this interaction.

In a treatment setting we are but two humans meeting in a shared space. The quality of that interaction, and indeed the benefit experienced by the recipient of treatment, is strongly influenced not only by that person’s expectations, but also by the degree of empathy expressed by the treatment provider.  As Garden (2008) states “The biomedical approach to medicine all too often overrides concern about patients’ psychological and social experiences of illness” (Garden, 2008, p. 122).  She points out some of the factors that lead to difficulty with empathy in clinical encounters are often about social and cultural issues – too little time, sleep deprivation, a clinical culture that neglects clinician’s personal identity and physical experience (p. 122).

We should also know that downregulating empathy for people in clinical encounters can be a self-care strategy, as Reiss indicates in a brief paper in 2010 (Reiss, 2010). Downregulating the “pain empathy” response involves inhibiting neural circuits such as the somatosensory cortex, insula, anterior cingulate cortex, and periaqueductal gray. Downregulating these areas also “dampen[s] negative arousal in response to the pain of others”. She goes on to say “without emotion regulation skills, constant exposure to others’ pain and distress may be associated with personal distress and burnout” (p. 1605).  However, the harm caused by dehumanising, and unempathic healthcare results in focusing on organs and tests and poorer outcomes, as well as greater burnout, increased substance abuse and more patient complaints (p. 1605).

Cohen, Quintner, Buchanan, Nielson & Guy (2011) writing movingly of the potential role health professionals have in stigmatising those experiencing chronic pain. I wonder if the very way we investigate pain, the scientific model so often used to examine aspects of pain and pain management that works by compartmentalising people into “them” (usually people with pain) and “us” (usually researchers and clinicians) also leads to a sense that “we” are different somehow from people who experience pain. And hence from there to organisations established to study the pain of “them” without actually including “them”.

I wonder how many people working in the field of pain and pain management experience pain. Hopefully ALL of them sorry, US. And that means we need to begin thinking about how easily any one of us could become a person living with pain, and perhaps begin considering how we could work together to shift the societal belief that there is a “them” and “us.

Cohen, Milton, Quintner, John, Buchanan, David, Nielsen, Mandy, & Guy, Lynette. (2011). Stigmatization of patients with chronic pain: The extinction of empathy. Pain Medicine, 12(11), 1637-1643.

Garden, Rebecca. (2009). Expanding clinical empathy: an activist perspective. Journal of General Internal Medicine, 24(1), 122-125.

Martel, Marc O. , Finan, Patrick H. , Dolman, Andrew J. , Subramanian, Subu , Edwards, Robert R. , Wasan, Ajay D. , & Jamison, Robert N. . (2015). Self-reports of medication side effects and pain-related activity interference in patients with chronic pain: a longitudinal cohort study. Pain, 156(6), 1092-1100.

Riess, Helen. (2010). Empathy in medicine–a neurobiological perspective. JAMA, 304(14), 1604-1605. doi: dx.doi.org/10.1001/jama.2010.1455

river gliding  by

Five critical skills for pain clinicians

I could be wrong: it might be seven or ten, but five is a good start. What do people working with those who have pain really need to know/do? What makes them effective? What keeps them positive in the face of what can be an extraordinarily demanding work?

  1. Effective listening skills, along with the ability to communicate that you’re listening. One of the most common complaints about health professionals made by people living with pain is that they don’t listen (Allegretti, Borkan, Reis & Griffiths, 2010; Stenberg, Fjellman-Wiklund & ahlgren, 2012).  While I’m sure there are some clinicians who deliberately protect themselves from engaging in a patient’s distress, I think there’s probably a more insidious version of this – some research shows that when patients report pain, physicians spend more time on technical tasks and less time helping the person actively participate in their own care (Bertakis, Azari & Callahan, 2003).  There’s also some research showing that when clinicians are trained in specific techniques for expressing empathy, patients believe they are more caring (Bonvicini, Perlin, Bylund, Carroll, Rouse & Goldstein, 2009). Physicians were trained to use “The 4 E’s” (engage, empathise, educate and enlist), with a particular focus on communicating that they had heard what was said. Techniques included rephrasing what a patient said; asking a question to elicit more detail; acknowledging or confirming that the person’s emotions are valid/legitimate; and expressing that he or she had experienced a similar feeling. Maybe it’s time for greater training in these skills for all clinicians working with those who have pain.
  2. Mindfulness skills to help deal with emotions during sessions. I hope I’m not just jumping on the mindfulness bandwagon, but I do think being able to be fully present but not caught up in judging or evaluating your own feelings is a critical skill to maintain openness in a clinical situation. A definition of mindfulness that I quite like is “a process of regulating attention in order to bring a quality of non-elaborative awareness to current experience and a quality of relating to one’s experience within an orientation of curiousity, experiential openness, and acceptance” (Bishop, Lau, Shapiro et al, 2004). Being mindful and open allows you to be there for your patient while also making space for yourself. There’s good evidence that mindfulness improves psychological health (Keng, Smoski, & Robins, 2011), and some studies also show that it improves your own communication skills and improves patient satisfaction (Beach, Roter, Kortuis, Epstein et al, 2013).
  3. Case formulation skills. These skills are about pulling your assessment information together in a coherent way so you can generate some testable hypotheses to explain why your patient is presenting in the way they are at this time. To me it’s a waste to conduct assessments and then fail to use that information when you’re developing your treatment plan. And it’s even more of a shame to fail to share that information with your patient. The thing is, there’s often little training given to how to generate a case formulation: it’s got to be based on broad theoretical knowledge fleshed out with the specific information you’ve gathered from your patient. This makes a formulation a unique ideographic set of hypotheses about your patient. I’ve written about case formulations here and here and here.
  4. Superb research reading skills. I don’t think it’s enough to say you’re evidence-based if you’re only using clinical guidelines. I think clinicians need to be critical readers of both qualitative and quantitative research. And I think it’s a crying shame that so much research is hidden behind paywalls. That’s one reason I write so often – I can access research and make it accessible. Of course I’d prefer it if everyone took to reading research, but the cost of doing so is atrocious! And we know that getting into print isn’t always easy, and with the current funding models in tertiary education institutes I think the range and depth of research being published is likely to stay a bit skinny. And until research is widely available for free (remember, authors write for free, reviewers review for free, and much research is published electronically, so where’s the money being spent?) I think it’s going to be tough for clinicians working in private practice. Having said that, even when I was a private practitioner, I always had a subscription to the local medical library – it’s a valid deductible expense.
  5. Effective social media skills. Really? Social media? isn’t that just for people who want to share their food pix? Uh, no. I’ve had the best CPD experiences via Twitter, Facebook, and blogging. Some of the most challenging and thought-provoking discussions occur every day on Twitter. Links to new and emerging research. Links to opinions that make you think. Apps that help you be there for your patients, even when you’re not. Ways to remain in touch with people working in your field from around the world. Is it really a healthcare skill? I think so. Social media allows me to connect directly with researchers, other educators, clinicians, people working in niche fields, people living with chronic pain (the very people I so want to know about). Social media gives people living with pain a voice that can be heard. It allows my niche field to be visible. It has an impact on the general public. If we want chronic pain to be taken seriously by policy developers, and if we want to influence how people living with chronic pain can be heard, then social media is, I think, the way forward. It’s not just me – here’s paper reviewing and with tutorials of applications in medicine and healthcare (Grajales, Sheps, Ho, Novak-Lauscher & Eysenbach, 2014).

This list isn’t exhaustive: what else do you see as critical skills for clinicians working with people who experience pain? Add your thoughts to the list below!

Allegretti, Andrew, Borkan, Jeffrey, Reis, Shmuel, & Griffiths, Frances. (2010). Paired interviews of shared experiences around chronic low back pain: Classic mismatch between patients and their doctors. Family Practice, 27(6), 676-683. doi: http://dx.doi.org/10.1093/fampra/cmq063

Beach, Mary Catherine, Roter, Debra, Korthuis, P. Todd, Epstein, Ronald M., Sharp, Victoria, Ratanawongsa, Neda, . . . Saha, Somnath. (2013). A Multicenter Study of Physician Mindfulness and Health Care Quality. The Annals of Family Medicine, 11(5), 421-428. doi: 10.1370/afm.1507

Bertakis, K, Azari, R, & Callahan, E. (2003). Patient Pain: Its Influence on Primary Care Physician-Patient Interaction. Family Medicine Journal, 35(2), 119-123.

Bishop, Scott R., Lau, Mark, Shapiro, Shauna, Carlson, Linda, Anderson, Nicole D., Carmody, James, . . . Devins, Gerald. (2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11(3), 230-241. doi: dx.doi.org/10.1093/clipsy.bph077

Bonvicini, K.A., Perlin, M.J., Bylund, C.L., Carroll, G., Rouse, R.A., & Goldstein, M.G. (2009). Impact of communication training on physician expression of empathy in patient encounters. Patient Education and Counseling, 75(1), 3-10. doi: dx.doi.org/10.1016/j.pec.2008.09.007

Grajales, Francisco Jose, III, Sheps, Samuel, Ho, Kendall, Novak-Lauscher, Helen, & Eysenbach, Gunther. (2014). Social media: A review and tutorial of applications in medicine and health care. Journal of Medical Internet Research, 16(2), 452-474.

Keng, Shian-Ling, Smoski, Moria J., & Robins, Clive J. (2011). Effects of mindfulness on psychological health: A review of empirical studies. Clinical Psychology Review, 31(6), 1041-1056.

Stenberg, G., Fjellman-Wiklund, A., & Ahlgren, C. (2012). “Getting confirmation”: gender in expectations and experiences of healthcare for neck or back patients. J Rehabil Med, 44(2), 163-171. doi: 10.2340/16501977-0912


Faking pain – Is there a test for it?

One of the weird things about pain is that no-one knows if you’re faking. To date there hasn’t been a test that can tell whether you’re really in pain, or just faking it. Well, that’s about to change according to researchers in Israel and Canada.

While there have been a whole range of approaches to checking out faking such as facial expression, responses to questionnaires, physical testing and physical examinations, none of these have been without serious criticism. And the implications are pretty important to the person being tested – if you’re sincere, but someone says you’re not, how on earth do you prove that you’re really in pain? For clinicians, the problem is very troubling because allegations of faking can strain a working relationship with a person, and hardly lead to a sense of trust. Yet insurance companies routinely ask clinicians to make determinations about fraudulent access to insurance money – and worst of all, clinicians often feel they have little choice other than to participate.

In this study by Kucyi, Sheinman and Defrin, three hypotheses were tested: 1) Whether feigned performance could be detected using warmth and pain threshold measurements; 2) whether there were changes in the statistical properties of performance when participants were faking; and 3) whether an “interference” or distractor presented during testing interferes with the ability to fake and therefore provide a clue to when someone is being sincere or not.

Using university students (I hope they got course credits for participating!) who were not health science students, and were otherwise healthy, the investigators gave very little information about the procedure or hypotheses to minimise expectancy bias. Participants were then tested using a thermal stimulator to obtain “warmth sensation threshold” and “heat-pain thresholds” – this is a form of quantitative sensory testing (QST). TENS was used as a distractor in the experimental case, applied for 2 minutes before measuring the pain threshold, and during the heat pain threshold test. This was repeated with first the threshold test, then TENS. Participants were asked to pretend they were in an insurance office, being tested to establish whether they were experiencing genuine pain, after being told the test would be able to tell whether their pain was real.

What did they find out?

Well in situation one, where both threshold and warmth detection were used, and participants were asked to fake the pain intensity, respondents gave higher warmth detection ratings than normal. Not only this, but the ability to repeat the same response with the same temperature was poorer.  Heat pain threshold was also consistently different between the sincere and faked conditions, with heat pain threshold lower when people were faking (to around 3 degrees).

When the second testing option was carried out (using TENS to distract), heat pain threshold was significant lower when participants were faking, and the variance of the feigned + interference condition was three times that of the sincere condition, and the CV of the feigned + interference condition was twice that of the sincere condition.

What does this mean?

Well first of all, it means there are some consistent effects of faking in response to tests of warmth and heat-pain threshold when a distractor like TENS is used. Increased reports of warmth threshold and reduced heat pain threshold were observed, and where statistically significant. Interestingly, it was only when a distractor was used that the variability of reports were found – these authors suggest that people are pretty skilled at giving consistent reports when they’re not being distracted by an additional sensory stimulus.

Now here’s where I begin to pull this apart from a clinical and practical perspective. The authors, to give them credit, indicate that the research is both new and that it may identify some people who do have pain as malingerers. My concerns are that people with chronic pain may not look at all like healthy young university students.

We know very little about the responses to QST by people with different forms of chronic pain. We already know that people with impaired descending noxious inhibitory control respond differently to some forms of QST. We also know that contextual factors including motivation can influence how nervous systems respond to input. But my concerns are far more about the potential harm to those who are tested and found to be malingering when they’re not.

What do you do if you think a person is faking? How do you deal with this? What good does it do to suggest to someone their pain is not real, or isn’t nearly as bad as they make out? Once the words are out of your mouth (or written in a report) any chance of a therapeutic relationship has just flown right out the door. And you’re still left with a person who says they’re having trouble – but now you have an angry, resentful person who has a strong need to prove that they DO have pain.

You see, I think it might be more fruitful to ask why is this person faking pain? If it’s simply for money, surely there are far easier ways to get money than pretending to be disabled by pain? If it’s the case that a person is off out fishing or playing golf or living it up when “supposed” to be in pain, wouldn’t it make more sense to reframe their response as either recovering well (doing what’s healthy) and therefore get on with returning to work; or use a private investigator to demonstrate that he or she is actually capable of doing more than they indicate?

The presence or absence of pain is not really the problem, IMHO. To me we need to address the degree of disability that’s being attributed to pain and work on that. Maybe a greater focus on reducing disability rather than on expensive procedures to remove pain or otherwise get rid of pain is in order?

Kucyi, A., Sheinman, A., Defrin, R. (in press). Distinguishing feigned from sincere performance in psychophysical pain testing. The Journal of Pain.