Maintaining change
I’m sure we’ve all seen it. The person comes into a pain management programme, gets excited, does really well during each session, enjoys the company and makes huge gains – then the programme ends and — FIZZLE! It all stops.

Some critics suggest that any change obtained during a short-term programme (such as a three-week pain management programme) can only be short-term.  That to really make a difference to habits of a lifetime needs a therapist to carry out at least 12 weeks of individualised input.

This study by Christiansen, Oettingen, Dahme and Klinger, shows an extension of the motivational approaches based on Motivational Interviewing, integrates it with traditional problem solving, drags in a bit of goal achievement theory and ties it all together in two half hour sessions – and produces a significant change in functional outcome.  How so?

Importance and confidence

The two important drivers of action seem to be how important an activity is and how confident a person is to achieve it.  In this study, a group of patients was asked to rate the importance and confidence to ‘improve physical capacity’.  They were then asked to list four positive aspects associated with making this change – eg getting in shape, having fun, distraction from pain.  They were then asked to list four negative aspects of the reality standing in the way of exercising more (obstacles) eg not enough time, being too tired, inconvenient, increased pain.

The participants then elaborated on one positive and one negative in alternate order.  eg  ‘I will feel better if I exercise more’ because ‘I will have better muscle definition, I will lose weight, and I will feel proud of myself’, and ‘I will not have enough time’ because ‘I have a busy life, my kids will need me to do things for them, and I will have to take work home.’

The second 30 minute session involved problem solving each of the obstacles, then develop ‘if-then’ plans or implementation intentions that circumvent the obstacles.  Problem solving involved the use of cognitive behavioural strategies such as addressing unhelpful thoughts and beliefs, evidence-based models (eg pain-related anxiety and avoidance), Socratic questioning (guided discovery) to identify underlying obstacles and automatic thoughts.

Then each patient wrote out a card that summarised the two sessions so that they could refer to them during the following month when the programme had finished.

Each card had the four positive reasons for exercising, and the four obstacles listed.

Underneath this was an example of mental elaboration, or expanding on one of the positive reasons for exercising, and one of the obstacles.

CBT-oriented problem solving was completed underneath this, providing evidence for exercise such as moving doesn’t cause damage, exercise releases endorphins, not exercising leads to lack of fitness and fear of moving.

And finally, two examples of ‘if-then’ plans were included, personalised to that individual:

‘If it is Monday or Wednesday I’ll park the car a block away from work and walk from there.’

‘If my kids want me to do something for them, they’ll have to come with me to walk the dog that night.’

The results

The results from this study showed that by doing this very brief intervention, participants were able to increase their engagement in exercise, and obtain better outcomes in terms of fitness and reduction in disability.

What? CBT in two half-hour sessions?!

While I’m not sure this would work in all cases, the use of a specific strategy targeting one issue in pain management to maintain engagement in exercise seems a really effective use of clinician’s time.  I’m keen to try this approach out – it’s not a ‘new’ or untested approach, after all problem solving and motivational interviewing has been included in pain management for some time.  What is new is targeting the specific concerns that influence action rather than assuming that because the person is there and attending pain management they are able and willing to carry on with it at home.

A couple of things I really liked:

  • it’s really specific to the individual and works with their real concerns
  • it directly addresses the obstacles that we know will be there and works through ways to get around them
  • it doesn’t rely on people to remember how to problem solve, it involves writing it down and making it visible
  • it builds on positive reasons for making changes
  • it doesn’t go overboard and try to solve ‘everything’!

I’d love to hear if anyone else has given this a try.  I’m keen to use it on myself, knowing that there are days when I simply don’t want to get out there and exercise, even though I love walking the dog and dancing!  I’ll keep you updated on my progress, but drop me a line if you have a go and let me know your results.

Christiansen, S., Oettingen, G., Dahme, B., & Klinger, R. (2010). A short goal-pursuit intervention to improve physical capacity: A randomized clinical trial in chronic back pain patients Pain DOI: 10.1016/j.pain.2009.12.015


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