As time passes, therapists can form their own way of working with people – sometimes we get away with this by calling our treatment models ‘eclectic’. This can be a euphemism for ‘I’ll use whatever I think fits’, or even ‘I like doing this, so this is what I’ll do’!
While this may not be too troublesome if we’re working alone, when we work as a team, and particularly if we work in an interdisciplinary team with shared goals and common treatment approaches, it can mean we talk right past each other – especially if we use the same words, but mean totally different things!
For example, if we have team members assessing a person, unless they clearly define what they mean when they talk about assessing interpersonal/social aspects for example, they could well be looking at the situation entirely differently.
One may look at the impact of pain on the quality of relationships with others – perhaps discussing how clearly the person communicates with the other, how much satisfaction they have with their relationship, how supported they feel.
Another might look instead at the effect social interactions have on pain behaviour – what the family of origin did about pain, how responsive the partner is to reports of pain, and the effect this has on pain behaviour.
Still another might consider broader social issues such as the role of social agencies and relationships between the person and their health care team, maybe the person’s roles within the family and community, the effect of case management, issues of access to funding or treatment, or processes the person has to go through to keep getting income support and so on.
Hopefully they’ll consider all of these areas!
Similar differences exist in terms of assessing mood, anxiety, past mental health problems, current activity level, coping strategies and so on. When teams work together it’s not just about using common words – it’s also about having a common understanding of the constructs being used within a model.
There are probably several layers of model to consider too, just to complicate matters.
At the broadest level there is the biopsychosocial model – with differing emphases placed on each aspect of this model depending on training and orientation.
A model with a smaller focus might be a cognitive behavioural model of chronic pain – and there are more than one of these although they have common features.
A model with even smaller focus might be emotion regulation, which can form one of several models contributing to a cognitive behavioural model of chronic pain.
Beneath this, there could be several different approaches to emotion regulation, all of which may have something to contribute.
Each of these models has something to add to the management of chronic pain – but without careful definition and ‘translation’ from the jargon of one model to another, we can talk right past each other even within the same team.
Why bother with models at all?
Some people don’t articulate their treatment model – this doesn’t mean they don’t have one, simply that they’ve not made their model explicit.
We all have assumptions about how and why we choose certain treatment approaches. (provided of course that we use clinical reasoning and don’t just follow a recipe book!) Models provide us with the conceptual basis for clinical reasoning – although IMHO they are broad brushstrokes that can be used to generate hypotheses about what might be happening for this person to present in this way at this time. More about that later!
Models are theory – which is based on researched findings. As research continues to build a bigger and more detailed picture of how various aspects of a theory relate to each other, it can be modified – and in fact, needs to be. Evidence can support or not support tenets of a model, and the model can be revised in the light of new evidence. Which makes our clinical work both always new and always intriguing.
The patients we work with will have their own unique set of factors that inter-relate, and part of our work as clinicians is to identify the possible factors and their relationship to each other, test that out to see if the predictions from it hold true, then work with the person to modify the things that can be modified so their life changes.
If we’re working in a team, it’s important that we speak the same language AND have similar assumptions about how treatments might influence the person.
To add to this mix, we also have collected knowledge (from research) on what domains need to be considered in self management – and these are the domains we commonly work on to help a person take control of their destiny. If a team doesn’t have some common understanding of the areas necessary for self management (or doesn’t agree on what self management looks like), again members can talk past each other.
This is one reason I’ve put the poll up on ‘what is self management’ – because I have a fair idea for myself on what it looks like, but I could be quite unique in terms of how I view it.
I’ll be scouting around for various models over the next little while – and discussing how new information can be integrated into models at least until the model needs to change significantly. Kuhn called this shift a ‘paradigm shift‘, and I’m guessing that for most of us the paradigm shift in pain management was the introduction of the chronic model of pain, and integration of the biopsychosocial model.
Paradigm shift (or revolutionary science) is the term first used by Thomas Kuhn in his influential book The Structure of Scientific Revolutions (1962) to describe a change in basic assumptions within the ruling theory of science. It is in contrast to his idea of normal science. (Wikipedia)
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