Values and outcomes in pain management: occupational therapists only


Two editorials from Pain this week have me thinking about my original occupational therapy profession, and the values that I quite clearly internalised in my formative years as a therapist.  I’ve noticed recently an increase in the attention given to individual goals, values and context in studies looking at disability and pain management – for example, McCracken and Velleman (2010) looked at psychological flexibility and acceptance, mindfulness and values-based action in people in a primary care setting with chronic pain and found there were significant relationships between components of psychological flexibility and measures of emotional, physical, and social functioning as well as healthcare use.

In another study, Vowles and McCracken (2010) found that measures of acceptance, mindfulness and values-based action demonstrated greater relationships with function over those ‘traditional’ coping strategies focused on in pain management, in participants who completed pain management programmes.

Psychological flexibility is defined as one’s ability to directly and openly contact experiences in the present moment and persisting or changing behavior according to what the situation affords and one’s personal goals and values (Vowles & McCracken, 2010).

The whole thrust of this model of contextual cognitive behavioural therapy, and ACT, is that people who act according to their values, and can vary these actions depending on the context, appear less distressed and more able to manage ‘life’ than those who try hard to control or stick with rigid ‘rules’ about how to go about life.

The important thing for me from these recent findings, is that it’s vital to find out what the person believes is important, and to help them carry out daily activities in line with their own values and context.  Sounds a lot like what I first learned in occupational therapy school all those years ago!

What does this mean for occupational therapists?

A starting place for most occupational therapists when they work with someone is to determine what the person wants to be able to do.  COPM asks for ‘important’ activities in work, self care and leisure.  MOHO identifies values. Kawa looks at forward life trajectory.  Roles and values, and how to live them in daily life are the bread and butter of occupational therapy.  The context, or where the person enacts these roles is always considered – the ‘real’ world, as opposed to the person in isolation.

It feels very natural to me to ask the person I’m working with about what they want to or have to do in life, and why.  It’s also vital to know where they’re going to be doing what they believe is important – the people and the environment in which they live their lives.

So ACT and contextual CBT and even the increasing attention to goals and goal-setting processes appeal very strongly.

What I don’t want to see is an occupational therapy panic attack where therapists feel aggrieved that ‘that’s our role’ and ‘why are psychologists taking over what we do’ and ‘if physio’s start doing functional activities, aren’t they taking over our job?’.  I also don’t want to see psychology becoming the ‘representative’ voice of values and goals in health care – as unfortunately we’re seeing here in New Zealand’s compensation system where psychologists are seen as ‘the essential profession’ in pain management.

I think it’s great to see that other professions are seeing the importance of incorporating values of the individual into treatment outcomes.  I also think it’s fantastic that the science is supporting occupational therapy’s hunch that ‘doing is good’ and ‘doing what’s important is healthy’.

What I’d love to see are occupational therapists using the common language of science and in particular psychology, so that the work occupational therapists have been doing is recognised.  Part of the professions problem has always been the challenge of studying what are pretty complex therapeutic processes, in very complex therapeutic systems – and often without the knowledge of methodology that would help to explore these systematically.  We can learn a great deal from psychology in terms of the technology of science.

I’m not particularly familiar, nor entirely comfortable with the jargon that’s being adopted in occupational therapy – yes, maybe the comfort level would increase if I were more familiar with it!  But if I find it challenging, why would psychologists and other prominent scientists and clinicians bother to move from their language to another whole new language when their terminology seems, at least superficially, to describe much of what occupational therapists consider important.

Is ‘occupational behaviour’ all that different from ‘values-based committed action’?

I’m not sure, and maybe I’m a bit too immersed in psychological literature around pain management to see clearly at this point.

What I am sure about is that increasingly, the literature is starting to demonstrate that things that matter to individuals, such as values and roles and context, when they’re used therapeutically, improve function, reduce distress and make a difference.  That means I can have confidence that it’s important to acknowledge and embrace the individualised approach when I’m working with people.

Now that’s got to be good for people seeking help with their pain!

McCracken, L. M. Toward understanding acceptance and psychological flexibility in chronic pain. Pain, 149(3), 420-421.

Vowles, K. E., & McCracken, L. M. (2008). Acceptance and values-based action in chronic pain: A study of treatment effectiveness and process. Journal of Consulting and Clinical Psychology, 76(3), 397-407.

Schrooten, M. G. S., & Vlaeyen, J. W. S. Becoming active again? Further thoughts on goal pursuit in chronic pain. Pain, 149(3), 422-423.

McCracken, L. M., & Velleman, S. C. Psychological flexibility in adults with chronic pain: A study of acceptance, mindfulness, and values-based action in primary care. Pain, 148(1), 141-147.

3 comments

  1. I couldn’t have said it better myself! These kinds of discussions have come up in my OT classes, but they’re often framed as “how can we protect our profession?” rather than “how can we take advantage of the shared goals we have with other professions?” I have felt that OT’s spend too much time trying to reinvent themselves (developing new models and frames of reference) rather than learning to speak the language that is used in psychology and other fields. And, I, too, find myself more confused by the OT terminology than I ever was of the concepts in psychology.

    If psychologists are developing approaches that build on OT priniciples and vice versa, it is an exciting thing! Ultimately it means better potential for quality patient care. The implications that these shifts may have on our profession (real or imagined) should be considered secondary to the implications for advancing patient care.

    1. Thanks! It’s been one of those things on my mind forever really, but the work I’ve been doing on ACT has helped me get much more articulate about it! Glad you had some time to visit.
      cheers
      Bronnie

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