If you were designing a pain management programme from scratch…


… what would you include?

I’m a fan of using a group approach for pain management. Lots of reasons, but several that really spring to mind right now.

  1. Groups offer participants a chance to learn from each other – this can be both good and not so good!  Provided the group is managed well, and both CBT techniques and the group process are attended to, participants become their own (and other’s) therapists. Participants often challenge each other far more strongly than clinicians, because they already have ‘face validity’ – in other words, they’re all on an equal ‘I’m in it with you’ level.
  2. Groups enable each participant to be exposed to a broader range of issues and situations than individual therapy – as each participant discusses their own situation, it will be unique to them, but give an opportunity for the others to learn vicariously (by watching).  As each participant follows the process of identifying unhelpful thoughts and behaviours, becomes aware of different ways of viewing the situation and responding to it, they too learn how that might apply to their own situation (either now, or in the future).
  3. Groups reduce the social isolation experienced by many people with chronic pain – by learning that their experience is not peculiar, that some people manage better while others struggle more, participants in a group can reality-test their beliefs about their own situation.  Courage can develop by watching others who cope well, and by helping others who are not managing so well, those who are managing develop more confidence in their own coping.
  4. The therapist can use the group to generate coping alternatives, broadening out the range of options the group participants can consider.  Not all the options will be feasible, or helpful, but these can be examined in terms of the various outcomes, allowing the participants to arrive at their own solutions.
  5. Groups provide opportunities for people to role play a range of different situations, and obtain feedback from a range of different people. This makes the learning opportunities afforded by groups broader than individual therapy.

Now, to be Devil’s advocate, there are good reasons for individual therapy too.  Some people don’t work well in a group setting, either because of difficulty communicating (hearing impairment, not speaking the language, or personality characteristics that make it difficult for a person to follow the normal ‘rules’ of social interaction), or perhaps because of cognitive or emotional problems.  Some people have very unique presentations, perhaps requiring specific therapy such as mirrorbox or exposure-based functional rehabilitation that most group participants might not need.  Others may have specific needs that others don’t, such as relationship problems or work problems.

What would it be like to combine both the best parts of group programmes with the best of individual sessions? In this case I’d like to set some assumptions about size of group and number of sessions/days a week.  I’d love to have a group of a maximum of 7 participants, meeting twice a week for about two and a half hours each time.  Two extra individual sessions of an hour for each participant, with input from therapists with both psychosocial and functional biases.  I’d like about 6 weeks to work with the participants, plus a couple of follow-up sessions one month and three months later.  And of course participants would also need to carry out ‘experiments’ where they use the skills in-between sessions.

Enough about format.  Onto content and approach.

Content is always contentious, but I’m sure there are at least four or five topics that just can’t be missed.

  1. Goals and aims or purpose of pain management. Why participants are there, what they really want out of it.  Where the focus needs to be.  Most importantly, the functional activities the person wants to return to.
  2. Helping people develop a personalised model of their pain, whether it be chronic or sub-acute/acute.  The various contributions of biology, psychology and sociology to that ‘unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.’ (IASP, 1979).  Working out the factors that particularly influence their pain and disability.
  3. Activity regulation, or working out the optimal level of activity the person needs and helping them develop a plan for changing their activity pattern to achieve it.  This can mean increasing activity, or maybe reducing it, or even simply maintaining a consistent level of activity.
  4. Working with resultant thoughts, beliefs, attitudes, behaviours and contingencies that affect how easily the person can make changes, and maintain them.

There will also be other common topics like:

  • medication and how to use it well
  • sleep and how to achieve it
  • relaxation, breathing and mindfulness
  • problem solving and goal setting
  • communicating effectively about pain, including pain behaviour, assertiveness, intimacy
  • working and returning to work

I think the main thing about pain management programmes is that they need to be applied. Either applied within the programme setting, or applied in everyday life.  As soon as people start to DO activities differently, the opportunity to observe how they work out, and to problem solve issues that come up as a result.  This will mean working with thoughts, beliefs and behaviours, and the responses of others (and other contingencies that operate on behaviour).

Applying pain management can be done is many different ways, I don’t think there is much agreement however, on exactly how this should be done.

Many programmes use exercise both as a pain management approach (yes, exercise helps reduce pain!) but also as a way for people to apply coping strategies.  The way people go about exercising offers a great opportunity to ‘catch’ thoughts as they occur, particularly fears about flare-ups of pain.

Exercising also offers a chance to use activity regulation – things like exercising to time rather than quantity, or to exercise consistently rather than according to pain levels – and doing these things almost always generates responses that need to be discussed so they don’t interfere with making changes in life.

But, doing exercise only and making no changes to how the rest of a person’s life is lived is just not worth it.  A person who goes to the gym or swims every day but is too scared to bend down to put on socks and shoes, or sit for more than 3 minutes, or pick up a pingpong ball when playing with the kids isn’t really managing pain and living life.  People can be very fit but still ‘disabled’.  So IMHO it’s really important to work on a daily routine that starts to include activities the person wants to do – AND needs to do.

Tomorrow I’ll add to this wish list for a pain management programme – and later in the week I’ll add in the literature to support my choices.

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