Gutted…


Over the past couple of days I’ve had the need to really think hard about my practice in pain management. Some of you will know that I hail from New Zealand, and my origins are as an occupational therapist, with subsequent study in psychology, and wide-ranging readings and training and supervision and experience in a whole bunch of other areas (including case management, health and safety, policy development and so on).

Some things are really quite essential in chronic pain management especially – adopting a cognitive behavioural approach, using an interdisciplinary team, having a biopsychosocial model of pain… nothing really controversial there (unless you LOVE hands-on therapy, or think all pain can be abolished through injections/surgery/medications!).

What I’m facing right now is a really significant challenge to what I’m able to do (and be funded for) in both assessment and intervention. A new contract has been drawn up by a major health purchaser that restricts ‘psychosocial’ assessment (usually included with biomedical and functional as parts of a comprehensive assessment of the person with chronic pain) to ‘psychological’ assessments that must be carried out by psychologists. At the same time, the content of this assessment has shifted the areas to be assessed to eliminate the ‘social’ or contextual aspects of the pain presentation.

In the interventions area, the programmes that may be provided to people with pain MUST include sessions with a psychologist, and areas of coping that are often provided by occupational therapists (such as thinking about thinking, relaxation training, graded exposure and so on) are to be provided by psychologists.

Now I’m the last person to want to get involved with a turf war – I’ve always said that it’s important to ask yourself ‘what can I contribute to this team?’ rather than ‘what is my role?’ – but this really does cast doubts on my profession, and my ability to carry out what I think are fundamental skills of all therapists working in the field of pain management. I can’t see what the benefit to people experiencing pain will be to make these sorts of changes.

For me, the question is: can I ethically provide interventions to an individual withoutusing therapies that I am both competent in, are part of my professional repertoire and from the literature, have been shown to work? I don’t think so – what do you think?

4 comments

  1. Interesting post and timely too as there’s kind of the reverse going on here. Recent changes to Medicare, meaning that clinical psychologists attract a specialist rebate and all other psychologists get lumped together in a rebate category for generalist psychologist services along with OTs, nurses, counsellors (who don’t even have to be registered) and others. This has created quite a division within the various groups of psychologists, particularly those with specialist skills such as clinical health psychologists for example This has also made many a psychologist ticked off because the level of psychological training involved in getting full registration as a psychologist will far exceed any of these other practitioners. Don’t get me wrong, I’m not disparing any of the skills of these other groups. Many people like yourself have obviously done a lot of psychology training too but is the level comparable? In most cases, I would have to say not.

  2. HP
    Actually for me it’s even more gutting, as I only require a year of supervision by a psychologist to register – but there is no process for this to happen in NZ, as the only way now to register is through completing a clinical or health psych diploma. Which would be fine, but it means three more years of study… Until the Psychology Society here pulled the plug on its registration scheme I would have been able to complete the supervision without any problems… There’s no sign of a replacement scheme so far.

    For me it’s not the ‘who does it’ thing that bothers me – it’s actually whether the training and professional background really makes any difference to the delivery of cognitive behavioural therapy especially for pain management. So far I haven’t found any literature to strongly support this, and there is literature to suggest that even untrained ‘good listeners’ can make a significant difference in cases of mild to moderate mental illness. Is there evidence to suggest that developing self management of chronic pain is any different? The people who have chronic pain don’t have major mental illness, they just have pain…

    In this case, the wording of what is being assessed (psychological vs psychosocial) has a significant impact on the content and focus of a comprehensive pain assessment. Without recognition of the social interaction, there is a whole area of influence completely ignored.

    In terms of whether the training of a psychologist (in NZ) gives adequate skills for pain management, I can’t find any courses in psychology in New Zealand (apart from the Auckland Health Psych diploma) that include pain or pain management. This means many clinical psychologists without any knowledge of pain management are now thought completely competent to practice in what I think is a specialist clinical area.

    On the other hand, occupational therapists are trained in CBT, and have pain and pain management content in their undergraduate course, which means they do have clinical skills to work in the area. They may not be as au fait with CBT for mental health problems as clinical or health psychologists, but they do know how to use basic CBT – what’s more the focus is on behaviour change rather than cognitive change, and the emphasis is on applying skills to the ‘real’ world.

    Again I really want to emphasise that this is NOT for me a turf war – it’s simply saying that as professionals working in pain management, there are some generic skills that we all bring. Being able to adequately assess psychosocial factors influencing the pain experience, and use cognitive and behavioural therapy to help people develop self management has GOT to be fundamental to any practitioner working in the field, I would have thought.

    Given that the dominant model of chronic pain management is CBT, and there is a never-ending number of people really needing help to take control of their lives, can the restriction of funding really be justified? or is this just a way for one group of clinicians to make themselves a tidy income by excluding others.

    Once again, I don’t know whether there are any good studies showing that cognitive and behavioural therapy provided by clinical psychologists in chronic pain management is any more effective than cognitive behavioural therapy provided by other clinicians.
    Where has the ‘multidisciplinary’ and ‘interdisciplinary’ model gone?

  3. I just wanted to point out the similiarities in the situation you described that are occuring here, albeit from a different angle. My comments were based on a more general sense, not strictly related to pain management. To me, it doesn’t matter who provides, let’s say, the CBT or whatever other treatment, what does matter is that the person doing it has sufficient training. That’s not always the case with CBT, whatever the profession. There is a proposal here to have some kind of registration for CBT practioners and that would not be limited to psychologists but any health related professional who can demonstrate adequate training and ongoing skills development/maintenance.

    The point you raise about clinical psychologists is a good one. Most clinical programs cover elements of health psychology but not to any great degree. However, health psychology masters, do incorporate pain management training. Nonetheless, with the current situation here, most places will now only employ clinicals because they attract higher funding.

  4. Now I’m with you 100% here when you say that the person delivering the intervention MUST be trained adequately. It’s the half-trained or people who are trained but haven’t ‘got it’ that really worry me. The problem with registration as a benchmark is that registration alone doesn’t mean competence in all areas of practice or all types of therapy.

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