Deliberately using imagery, attention diversion and mindfulness to cope with pain is not something new. It’s great though, to find that it has some very positive results when studied in a formal clinical research setting.
Elomaa, Williams and Kalso use a fairly straightforward research design to examine the effects, in a clinical population, of systematic training in the ‘limitation of the impact of pain either by switching attention to another stimulus or retuning attention to pain so that aspects are attended to which are less distressing and interruptive’. They followed the treatment manual developed by Morley, Shapiro And Briggs in which six 90 minute cognitive behavioural group sessions are conducted, training up to 7 participants in each group how to use strategies such as:
- basic attention management – brief relaxation, internal and external attention focus
- attention diversion and mindfuless – Focus on the details of experience, mindfulness breathing exercises, integrating mindfulness in everyday activities, external, mental and somatic focus of attention
- use of imagery and mindfulness – Creating vivid and pleasant images to concentrate on
- pain transformation images – Creating images to transform pain
- intense pain and flare-ups – Identifying responses to pain and vicious cycles in thoughts, images and behaviour, defusing catastrophizing and breaking vicious cycles
- pain coping strategies – Coping self-statements, signal-breathing, discussion on dealing with pain and relationship to pain and its chronic nature, discussion of all sessions and the use of skills
The results of this study were assessed by changes in several questionnaire scores from pre-treatment to three and six months following the intervention. I’m not going to detail the questionnaires, but instead move straight to the results.
In the first time period until 3 month follow-up, pain intensity reduced significantly – this is interesting given that these patients were advised that pain intensity was not the focus per se, but instead participants were told ‘while pain intensity was not likely to diminish in the long term, techniques might produce a short-term reduction in pain intensity’, and the strategies were designed to address anxieties about experiencing pain. This pain reduction was maintained at 6 month follow-up, but to a lesser degree – which isn’t surprising given that this is a skill that people need to practice (rather than a pill to swallow or a procedure to undergo).
Fear avoidance scores, and vigilance to pain reduced over time, while anxiety and functional abilities didn’t really change much. There was a difference in effect size between those who attended both the 3 and 6 months follow-up, with those attending both demonstrating a better effect.
Participants reported they used brief relaxation, use of imagery, and distraction towards external objects most regularly, and reported these benefits:
- skills to deal with pain (n = 9),
- altered attitudes to pain (n = 10),
- improved sleep (n = 8),
- peer support (n = 7),
- stress reduction (n = 4)
Some points to think about
It’s rare to offer a single form of coping strategy like attention management in isolation from other aspects of a cognitive behavioural approach to pain management. In this study, it was great to see that a single element was the focus – but this could have reduced the overall effect size that could be achieved in a more common pain management setting where multiple modalities are used.
I wonder what the results would have looked like had the participants also been undergoing exercise or activities of daily living reactivation at the same time – this would have combined both the cognitive and the behavioural components of most pain management programmes, and could have demonstrated a greater (and more realistic) effect. However that would have reduced the purity of the study design, and now that we have a reasonable level of evidence for a cognitive behavioural approach to pain management, it is time to establish the specific elements that are helpful.
This programme was delivered by a clinical psychologist. I’m not sure that the professional background of the person delivering the programme is as essential as having good experience with facilitating group programmes, and having sound knowledge and practice at delivering attention management skills using a cognitive behavioural model.
Patients selected for this study may well represent a sub-group of especially compliant or motivated people – and this is acknowledged in the discussion section of the paper. This type of coping strategy takes both practice on a regular basis, and readiness and ability to actively use this coping instead of reaching for more passive options such as medications or injections. In many practice settings the level of persistence in patients who may be very anxious, somewhat depressed – and often being seen by medical practitioners who don’t necessarily appreciate the way that medication use can interfere with active coping – can be quite low. It really is easier to take a pill.
I’m hopeful that studies like this might encourage therapists of many persuasions to develop their skills in providing these strategies to complement their usual treatment. This might flow through to increase the acceptance and effectiveness of ‘mind stuff’ by medical practitioners who might then be able to review their own actions with respect to prescribing or injecting.
ELOMAA, M., DECWILLIAMS, A., & KALSO, E. (2009). Attention management as a treatment for chronic pain European Journal of Pain DOI: 10.1016/j.ejpain.2008.12.002
Morley S, Shapiro D, Biggs J. Developing a treatment manual for attention
management in chronic pain. Cognitive Behav Ther 2004;33:1–11.