As I review the last few people I’ve had the privilege to assess, I can see numerous factors that have lead them down the road to chronic disability from their persistent pain. One of the most common would have to be multiple medical assessments with medical management that has failed to address the person’s disability, while in some cases actually increasing the person’s beliefs that they are not in control of their lives. An example? A man I saw who, four years after the initial event firmly believes the annular tears must ‘heal’ before he can return to work. Two orthopaedic surgeons indicated to him that surgery wasn’t an option (and he didn’t want it anyway) but also advised him ‘these things take time to heal’ – or at least that’s what he heard.
Another reason for ongoing disability is the failure of pain management programmes to address the person’s beliefs about pain. As Bill Fordyce is reported to have said ‘Information is to behaviour change as spaghetti is to a brick’ – hence my concern when I read a very authoritative book written by three highly respected clinicians and researchers where ‘education’ is the term used for the process of helping the participants develop a new understanding of their pain and their role in managing it.
Education, information and teaching are often words used around the concept of helping people reconceptualise their pain. Sadly, without very good skills by the clinician, this can turn into an ‘information dump’ and leave the participants only slightly less confused than before! The processes that seem to work better involve ‘guided discovery’ or Socratic learning, and experiential learning with the opportunity to reflect.
There are arguably four broad groups of techniques for helping people to understand their pain and their role in pain management for themselves.
- Learning the various connections between thoughts, situations, and emotions
- Gathering evidence from their own experience, and becoming more objective about the patterns of thinking that each person has
- Using mini experiments to try different approaches out
- Exploring underlying beliefs and assumptions
This process is collectively called ‘collaborative empiricism’ where the participants and the facilitator join together to explore experiences and understand what is going on. In a group setting this becomes a process where the participants both become exposed to their own processes, but also the processes of others – and by the end of the programme, become adept at being therapists for one another, asking questions rather than giving advice or feedback.
The process of helping participants become their own therapists is not easy. It requires the facilitator to be very knowledgeable about pain in order to correct myths, and it also requires the facilitator to be very adept both with Socratic questioning and guided discovery as well as group facilitation. No wonder facilitators get tired after a group session!
Often, clinicians who get involved in pain management group programmes come from a background of clinical psychology or occupational therapy. Unfortunately, having professional registration does not mean that the clinician has specific skills or training in pain management or group facilitation. It does take time to develop these skills. Unfortunately in the literature on pain management within groups, there is a real dearth of research looking at the necessary skills clinicians require to help develop effective group therapy. Instead, the majority of research into cognitive behavioural approaches for pain management is carried out by psychologists, with the assumption that this training is sufficient. It’s great to read in Main, Sullivan and Watson’s book Pain Management 2nd edition (2008) that the skills required are emphasised rather than the professional discipline. Certainly many other health professionals have specific training and skill in group therapy, amongst them social workers and occupational therapists.
Something that has been investigated very recently is the stabiliy of membership within a clinical team working in group pain management. Interdisciplinary teamwork has been identified as a strength in pain management – it requires that each profession become very familiar with a common model (cognitive behavioural approach within a biopsychosocial model), with each other’s strengths, and ultimately, to be able to work almost across disciplines to support each other’s interventions. This takes time. The communication between team members must be very strong, and decision making processes including conflict resolution need to be well-established.
A paper recently available by Amanda Williams and Henry Potts looked at two factors that they thought may affect outcomes achieved after group CBT for persistent pain. Both group membership (who the participants were in the programme) and staff turnover were examined. The data was collected over 16 years (3050 participants), and included pre- and 1-month post-programme questionnaires.
Their findings? ‘Linear regression showed that high periods of staff turnover were significantly
related to poorer outcomes on self-efficacy and distance walked at end of treatment, with the
effect on self-efficacy persisting to 1 month follow-up.’
I’ll discuss the group membership findings in another post, but it’s interesting to see the areas that were directly influenced by staff turnover.
Membership of the teams were ‘… multidisciplinary teams of psychologists, physiotherapists, occupational therapists and nurses, with doctors working across teams. This meant that patients usually related mainly to a core team of four staff members, but up to seven if staff were part-time. The inpatient treatment programme remained largely consistent in content and process over the years covered by this study.’
One of the psychologists, one of the physiotherapists and one doctor remained constant throughout the study period. New staff were usually less experienced than those who had left, and worked under supervision for several weeks before commencing with the programme.
The results showed ‘for each change in staffing, patients on average had a PSEQ score that was 1.2 points lower, a Normalized catastrophizing score that was 0.04 standard deviations higher, and walked 4.6 m less at the end of treatment.’
Some very useful ‘managerial’ aspects are considered in this paper: Therapist emotional wellbeing has been reasonably consistently related to better outcomes. The treatment unit had periods of strengthened institutional support and growth and others when its future was uncertain. It is likely that these difficult periods were reflected in poorer team cohesion as well as in turnover, and that staff who were expending energies on the unit’s survival had less to offer patients.
I wonder what steps organisations take to address these issues, particularly when calls to ‘be efficient’ often demand therapists see more patients in less time. In the end, outcomes are what matters – what is the point of seeing a large volume of patients, only to have them return as re-referrals later?
It’s clear that a combination of the right treatment for the right patient is important – but it seems equally clear that the role team members play, the level of skill, the level of support and the team processes are also important.
Williams, A., & Potts, H. (2010). Group membership and staff turnover affect outcomes in group CBT for persistent pain Pain DOI: 10.1016/j.pain.2009.12.011