We have all had them – moments when we know what we shoulda-coulda-oughta — but didn’t. And it’s even more common when we’re trying to change a habit, or in the case of chronic pain management and healthy skills, develop a new way of responding. We can call this ‘relapse’, which works for alcohol and drug use, but in chronic pain I think it’s more helpful to refer to ‘setbacks’.
A setback can be a time when things just don’t go as planned, perhaps when unexpected or out of the ordinary events happen (like Christmas!), or when pain intensity fluctuates. Usually pain increases are called ‘flare-ups’ to avoid the possibility of people thinking they are ‘having another injury’. The point of setback planning is to avoid identifying pain intensity as the outcome of pain management, and instead focus on healthy behaviour and whether pain management strategies have been used. This helps people recognise that although pain fluctuates, in order to take control of their actions, they need to look at how they have responded to a situation, and learn from choices and consequences they’ve made.
Each person will encounter lots of situations where they slip up on using helpful strategies to cope. I’d hope that at least once during a pain management programme, they have a slip up and use it as an opportunity to learn how to review the situation to learn new ways of responding. One way of doing this is to use a daily-review worksheet, another is to use a relapse-prevention worksheet.
I like worksheets that are reasonably simple, allow for some personalising, and have room for handwriting when working with a client. I looked everywhere on the internet and then decided that ones relating to alcohol and drug use really didn’t work for chronic pain, and so although I’ve based this on Marlatt’s model of relapse prevention (read this article for a good overview), I’ve put in some factors that I think might be more applicable.
This worksheet was designed to be used toward the conclusion of pain management. The first page introduces the setback model. You can add extra factors specific to the person along the top, and ask the person if there are any specific consequences along the bottom. Usually I think I’d follow the ‘slip-up’ path first, then discuss the alternative. It’s also helpful to indicate that ‘apparently irrelevant decisions’ gradually add up to lead to a ‘high risk situation’, which is an opportunity for a slip-up.
The next worksheet works through the slip-up and personalises the details of a specific situation. I suppose you could do this in a general way, but I think it brings it to life if it’s used with a specific (and recent) situation as the focus. Themes will appear – especially when working through the responses to factors (ask the person ‘why was that a problem for you?’) – often it’ll be a consistent pattern of perhaps not being adequately assertive, or the ‘problem of immediate gratification’ which is where the immediate payoff (eg immediate reduction of anxiety) is easier to cope with than the time delay before longer term benefits pay off (eg being assertive and setting boundaries).
Personal responses can be put in the blue boxes along the bottom, to help the person really become aware of the negative consequences of unhelpful choices.
The final worksheet is an opportunity to review a more helpful way of responding, and problem solve ‘the next best step’ for the person.
I hope you find this worksheet helpful. Let me know if you use it, and if you’d like any changes to it. I have made it available free of charge because the concepts are adopted from Marlatt’s model, and it’s simply a graphic tool that might be useful.
Don’t forget that I post most days during the working week, and you can either subscribe using the RSS button above (go here for more information on RSS if you’re not familiar with it!), or bookmark my blog. I love comments and respond to what you say!