Using cognitive behavioral therapies in pain management isn’t really rocket science, it’s simply being aware of the principles of learning from both a cognitive (thinking) point of view and a behavioural point of view. It is, however, complex – by that I mean, there are many threads to systematically follow and actively manage.
There does need to be a fairly large emphasis on assessing or understanding (or formulating, if you prefer psychological language) the factors that are working together to influence the person’s presentation. A formulation is simply a set of premises or hypotheses that, if they are tested and found to hold true, help to explain why this person is presenting the way they are, and to predict how they might respond in certain situations.
In chronic pain management, this means incorporating biophysical or biomedical elements, along with psychological and social elements. The complex blending of all these factors is what gives each individual a unique presentation and a unique set of concerns. And this is why it’s important never to think there is a ‘standard’ or routine way to help people with chronic pain develop ways to cope and move forward. ‘Cookie cutter’ or ‘recipe’ methods simply won’t work as effectively as an individualised approach.
My main concern currently is that the biomedical/biophysical and psychological aspects of assessment are fairly well covered in many settings – the aspect that is least well assessed and addressed is the social. ‘Social’ covers an area of influence that begins with interactions between the individual and his or her family, through to the influence of mass media and systems of governance and policy within a society. I think in New Zealand anyway, the psychological assessments are becoming over-emphasised, and the lack of emphasis on roles, function, interactions
Today let’s look at the words of people experiencing chronic pain – a great reading is Mandy Corbett, Nadine E. Foster, Bie Nio Ong’s paper ‘Living with low back pain—Stories of hope and despair’.
It incorporates the narratives of six people experiencing chronic pain, and themes that emerge include the fluctuating emotions of hope and despair. A number of linked themes emerged which influenced the extent to which people oscillate between hope and despair, the most salient of which were ‘uncertainty’, ‘impact on self’, ‘social context of living with pain’, and ‘worry and fear of the future’. It is clear from the narrative accounts that it is not only just physical pain that the back pain sufferer must endure, but also that the psychosocial implications pose an added and often complicated challenge.
‘They [others with back pain] go through what
I’ve been through. They’ve got to come through
it all: the stress, the anger, er…the feeling of
..er.. uselessness, and it can take a toll on a
marriage and a family so bad, to the point that,
that person may not have a family in 18 months,
‘You know, I can’t have one
day a week off. I’ve got to do full-time and I’m
finding it very hard and I’m frightened that I’m
going to do it because I have to, but then I end up
getting worse and I just can’t cope. What do I
do? Because that worries me. I can’t go off sick. I
can’t afford to go on half pay. So .. so that’s a
‘He positions himself as a social persona
who contributes both to his family and to the
community, and re-affirming himself in this way
forms the foundation for a generalised hope where
he can have faith in the future’
Can we spend a while listening to the social context of the people we work with? Considering both the impact and the influence of the wider social factors that abound when an individual experiences their personal pain.
More tomorrow on the social context of pain.
Corbett, M., et al. Living with low back pain—Stories of hope and despair. Social Science & Medicine (2007), doi:10.1016/j.socscimed.2007.06.008