It’s not always easy to work out who will make the most of a pain management programme. While some clinicians have a ‘take it or leave it’ approach, others spend a long time ‘preparing’ people for inclusion in a programme – or is there another way? We do know that not everyone who attends a programme will ‘fit in’ – some people have difficult communication skills (or lack of), some are not able to focus for the time needed for a 9 – 4 daily programme, some have ‘other issues’ that interfere with participation (like chaotic lifestyles or alcohol/drug problems), and some are simply not looking for what a programme is intended to address.
While there is no guaranteed way to accurately select who is ‘in’ and who is ‘out’, the process that I’ve used (in conjunction with the team with whom I work) follows a ‘motivational’ approach. This leaves the person in charge of whether they want to be part of the programme, but also allows the team to decide whether the person meets the criteria for entry.
This is the process…
Everyone who is referred to the programme has completed a Comprehensive Pain Assessment (CPA) consisting of a medical, psychosocial and functional assessment. All the biomedical and pain reduction recommendations from this assessment are completed before the person is able to be considered for the programme. This ensures that the person isn’t expecting these approaches to remove the need to learn how to live despite the pain. Over the years I’ve worked in pain management, I’ve found it difficult to work pain reduction efforts alongside a pain management focus – it’s hard for the person to avoid the temptation to think that pain management won’t be needed because the pain ‘will go away’.
The screening appointment is for around an hour, sometimes a little longer. Two clinicians from the pain management programme team are involved – and we try to make sure the people who are involved in the screening are not the same people as were involved in the CPA, to ensure a fresh look at the situation. We follow a semi-structured interview process, and at this point we don’t ask for further questionnaires but instead rely upon the CPA results and our discussion to make our decision.
The first part of the interview, after establishing the purpose of screening, is to find out what has changed (if anything) since the person attended the CPA. We want to know what their response is to the recommendations, whether they’ve been implemented (eg medication changes, investigations), and whether the recommendations have made any difference to the person’s pain. Often we find that medication changes that have been recommended are not implemented – maybe because of side effects, or reluctance to use medication at all, or because of miscommunication between the pain management centre and the person’s own GP. We also ask about any other or new medical problems that might have arisen, and if there have been any other life changes since the CPA.
This part is a bit like drawing a line underneath the ‘pain reduction’ aspect of managing pain, but it also helps us gauge the person’s response to the idea of their pain being ongoing, and whether they’ve started to accept the chronic pain model. Our key question is whether they’re still thinking that further investigations or treatment might ‘find the cause and fix it’, because this can make being part of a pain management approach quite difficult.
We then ask about their understanding of their pain, the effect of their pain on important parts of their life, and what they are currently doing to cope. The purpose of this part is to firstly understand where they are coming from, and secondly to come alongside them to determine whether their coping strategies are giving them the life they want. One of the key questions is ‘How well are these ways of coping working for you?’.
In the language of ACT, I suppose at this point we’re aiming to develop a sense of ‘creative hopelessness’, or a sense that maybe there needs to be a new way of doing things so they focus less on the work of getting rid of their pain (and all the associated aspects of ‘being a patient’) and more on living a good life (being a person again). We’re also asking whether they think they need to make any changes for the future – creating a discrepancy between what they’re doing now and what they really want in life.
We move on to what they think life might look like if things were different, if pain was ‘less of a problem’ for them. We’re quite explicit that we’re not aiming to reduce pain, but we also make it clear that pain can interfere less. We’re gently probing to find out what the person might want to be able to do (ie their goals) if they were to be part of a programme, so we might ask about how they would know whether a programme had been successful, what ‘living well’ might look like, what they’d like to regain from what has changed since their pain started.
At times during thist section of the screening, we may reflect on the concerns the person raised during the original CPA – things like sleep, leisure activities, family relationships, work and so on may be the sort of thing the person may want to be able to discuss. This part of the screening aims to develop a sense of hope and looking forward, and to see what sort of specific goals the person might have. We’ve found that goals that are contingent upon reducing pain are generally not helpful, and by identifying whether there are other things the person wants, we’re able to help them generate positive and personal reasons for being part of this programme.
Around this point we’ll usually ask the person about what they know about the programme, and we’ll go through a brief outline of the purpose, approach and structure of the three weeks. We’ve already pointed out at the beginning that there are no guarantees that the programme will be the right thing for this person, or that the timing of the programme will be right – it’s our aim to let the person know that the screening is a collaborative process, and if they decide it’s not the right approach, or the timing isn’t right (or we have reservations about their suitability for it), then that’s OK, the door is open for them to come back when they’re ready for it, or have made the sort of changes we require.
There can be many reasons for someone to decline being part of our pain management programme – and for us to determine that the programme’s not the right thing for that person at this time. So we make sure we’re clear about the requirements –
- it’s a group programme so how do they feel about being in a group?
- it’s all day, everyday for three weeks and missing sessions because of a flare-up isn’t OK, so how do they feel about that?
- it can be challenging, we will be asking them to do things they may be afraid of (particularly movements and activities that could increase their pain), are they up for it?
- it doesn’t involve ‘hands-on’ therapy, does this match with what they’re expecting?
We usually take some time at about this point to talk together as a screening team, and allow the person to ponder what we’ve discussed. We’re considering many things, and we’re still developing a feel for what it is that we’re using as guidelines for inclusion and exclusion. Some of the things we’re looking for are:
- a sense the person wants to make changes in life
- readiness to accept their pain as unlikely to be abolished, and readiness to stop actively seeking pain reduction
- some ideas about what life might look like if things were to change
- the absence of litigation or pending disputes/mediation (these make it difficult for the person to focus during the programme)
- mood, concentration and general ability to sustain the 6 hours each day (we don’t mind the person getting up and moving around, but sleeping half the day probably won’t be helpful!)
- any investigations or other medical things being complete
- whether a group-based approach (which is necessarily general in nature) will address the specific concerns about their pain, and whether they have the communication skills to manage a group setting
After our screening team discussion, we return to the person and ask whether they have questions about the programme. We’re most likely at this point to let them know our thoughts, and establish whether they’re ready to consider the programme – and the timing of the programme. There is little point in someone coming to a self management programme if they’re also coping with other life changing events like moving house, or the arrival of a new baby! The programme is intensive and we make that very clear, but we also let the person know they have support throughout the three weeks, and in the period up to six months after the programme.
I suppose it’s a matching process where the expectations of the person and our knowledge of the content of the programme are compared. Even if someone isn’t ready for the programme at that time, we’re able to record this and review them in the future. Our report summarises our discussion, and even if the person doesn’t attend or needs something else, we think this report is useful and can guide both the person and their health care team towards the most appropriate option for them.