I’ve recently read a couple of studies of group-based CBT for chronic pain showing that outcomes are both durable and cost effective – and I started to ponder a little, as I do.
So far, it seems that no-one can identify the vital ingredients in a CBT approach that ‘do the work’ or create the greatest change. Despite the various studies that have been done, most of them treat the contents of a programme as some sort of ‘black box’ into which people are taken, emerging some weeks later having made changes that then last. But some studies have found that 12 months later the specific ‘skills’ that individuals were shown during a programme (and carried on using 1 – 6 months later) have been dropped, but the positive changes in terms of disability and distress have persisted.
Other studies have shown that unless a specific goal to address return to work is clear in a programme, participants may not start the process of returning to work. And many programmes require participants to start reducing their use of medication before attending, completing withdrawal by the end of the programme and an outcome that is monitored is whether the participants remain off medication.
Which lead me to wonder whether an ingredient that is needed in CBT pain management programmes might be to target specific outcomes. That is, if we are very clear about what we expect to change as a result of the programme, and ensure this is both addressed during the programme and measured as an outcome in the long term, we might see change primarily in those areas that are identified.
Stands to reason, in a way, that if we make goals explicit, they might be the ones participants start to work on.
Now I haven’t taken a stroll through the literature on this yet – and if there are some good studies on this, I’ll be really keen to read up on them, because it could be one of those vital elements that gets forgotten in the rush to include specific techniques or therapeutic approaches.
The general focus of CBT approaches to pain management is on:
- Reducing pain intensity (not always the primary focus)
- Increasing self efficacy
- Internalising locus of control
- Reducing disability and increasing function
- Reducing distress
- Rationalise medication use
- Improve quality of life
These are pretty broad goals, and might be different for different people. I wonder what would happen if we worked with each participant to make each of these goals really specific.
What would it look like if this person developed an internal locus of control? Would that mean he or she wouldn’t go to the GP during a pain flare-up? Would it means he or she would choose to use breathing/relaxation and activity management during a flare-up? Would it mean he or she would gradually reduce medication use?
What would it look like if this person’s disability reduced? Would that mean he or she would choose to mow the lawns? Would that mean he or she would walk around the block, or catch a bus, or drive a car?
What would it look like if this person was less distressed? Would he or she change the way they walk when they’re having a bad day? Would he or she remain around people more?
Time for a spot of self reflection here. I know we’re patient-centred and goals must be something the person wants – but often it’s a case of not knowing what is possible, especially at the beginning of a programme. As clinicians, we can assume that the person in front of us is clear about what they want, but we have the benefit of having seen many different people take many different paths and choose different goals, so we have an opportunity to help shape or develop the goals and actions participants choose. We’ve also got to be aware that within a group programme, the group itself helps to shape and develop the goals that participants adopt.
I wonder what would happen if we were clearer about what we think participating in a programme might achieve?
What influence might we have on the actions that participants take after a programme if we as clinicians establish positive expectations about the specific outcomes we think are important? What if we established the expectation that remaining on a benefit or compensation is not a positive choice? Or continuing with home help wasn’t a good idea? Or that remaining on medication could be really unhelpful?
I don’t know the answers, but given how subtle some of the influences are that we know about (eg placebo, expectations, nonverbal communication, word selection, social norms) I wonder if we were very clear about what we expected from our input, would we achieve more specific outcomes? Just askin’