Wouldn’t it be wonderful if everyone we saw was ready for self management and committed to putting everything in place? Wouldn’t it be even better if we could tell who was and who wasn’t going to drop out? Then we could focus treatment on people who were ready for treatment, and help those who are not ready prepare to get ready (or manage their situation differently). Unfortunately, it’s one of those areas that is not well-researched, even though it’s a very important part of our clinical planning and can affect up to 60% of people initially enrolled in a cognitive behavioural approach to pain management.
Over the years I’ve worked in pain management, I’ve seen several different approaches for establishing whether people should be included or not.
One approach is to use profiles from a pen and paper assessment like the Westhaven Yale Multidimensional Pain Inventory. This instrument provides three main profiles – interpersonally distressed, adaptive coper and dysfunctional. Each profile appears to have characteristics that mean different treatment options work more effectively – such as an increased emphasis on communication and interpersonal relationship for the ‘interpersonally distressed’ group, ‘pain management light’ for people in the ‘adaptive coper’ group, and the full interdisciplinary approach for people falling into the ‘dysfunctional’ group. Unfortunately this doesn’t provide any information on how ready the person is to embark on any of these treatment approaches!
Another strategy, and the one that I use routinely now, is to follow a ‘stages of change’ model, assessing the person’s readiness to adopt a self management approach. This model is based on Prochaska and DiClemente’s work on the Transtheoretical Model, and draws on Motivational Interviewing to help the person identify and resolve their ambivalence about taking on self management. Currently I do this by following a semi-structured interview, carried out with another clinician, and after a comprehensive pain assessment has been completed. This makes sure any pain reduction input is complete before we start on a self management approach.
I’m sure there are other ways to do this – and I was glad to read this timely paper by three researchers from the German Philipps-University of Marburg. They start by citing the evidence-base for a cognitive behavioural approach to pain management – which is strong. But at the same time, the high drop-out rate has limited the clinical application because it’s a bit difficult to have a programme with only a few participants who actually complete it! As these researchers point out “From a research viewpoint, attrition limits the interpretability of outcome research data.” I’d add that adherence to treatment recommendations also complicates outcome research and we also see little research into this aspect.
These researchers decided to look at drop out rates from initial screening, waiting list, and throughout the duration of the programme to establish whether there were any systematic factors that could identify why people dropped out. The programme they followed was an individualised one-to-one programme of weekly sessions for up to 25 sessions, carried out by one experienced CBT therapist, and three PhD students with advanced training in CBT. (This differs from the multi- or inter-disciplinary approach favoured by the chronic pain management literature).
So, what did they find? Well, cutting to the chase, they found that about 18% of the participants enrolled into this programme dropped out – and about 9% dropped out during the waiting list period. The average number of sessions completed by people who dropped out was eight, but people dropped out at different points throughout the therapy programme. When the researchers interviewed these people, they found many different reasons were given for not completing the programme:
- feelings that treatment was ‘‘ineffective’’ or ‘‘not necessary’’ (n=7; 30.4%),
- conflict with work or other time schedule (n=7; 30.4%),
- regarding pain as a medical and not a psychologic illness (n=3; 13%),
- wishing for or needing other treatment (n=3, 13%),
- feeling too physically impaired to attend treatment (n=2, 8.7%),
- and reluctance to deal with questionnaires (n=1, 4.3%) (I do understand this aversion!)
Being good psychologists, the authors of this paper looked at predictor variables to see whether there would have been any way to identify those who dropped out before the treatment started. Younger people were more likely to drop out; people who were less depressed, and had fewer ‘psychological’ symptoms were more likely to drop out – but pain intensity, disability and use of health care wasn’t associated with dropping out. After some statistical work it was found that dropouts reported fewer psychologic symptoms and took fewer drugs than completers, despite comparable self-reported pain duration, pain intensity, and pain disability.
Interestingly, it looks like the level of satisfaction with treatment at around about three sessions can predict who will stay and who will leave – low treatment satisfaction in session
3 predicted independently treatment dropout and accounted for 21% of the total variance.
“Eighteen percent of patients attending an outpatient individualised CBT for CBP dropped out of treatment, 65% of them within first 8 sessions. This dropout rate was slightly higher than average dropout rate from other studies on CBT in CBP patients, which was 13.46%.”
Now this is actually pretty good – 25% to 60% are the rates in CBT programmes for other disorders such as depression and anxiety. And it’s a wee bit odd too – given that this programme was a psychological programme, not an interdisciplinary one, and that many people with chronic pain resist any suggestion that their pain needs a psychological approach (no, it’s not in my mind, I’m not nuts!). On the other hand, one strong feature of a cognitive behavioural approach is reconceptualising pain from something unpredictable and unmanageable and a sign of harm to something that is able to be managed and that thoughts, emotions, beliefs, and behaviours can all influence not just the experience of pain, but also the experience of life.
I think this study, while not answering the questions we’d like to have answered ‘who should be in, who should be out’, does start the long process of collecting information and putting together an explanation for why some people do ‘get it’ while others find it much more difficult to stick with the programme. I think it’s worth considering routinely collecting the kind of data that these authors have in clinical practice – at the very least each of us will learn more about the characteristics of those within our own pain programmes, but more than this, we might be able to contribute ‘real world’ information to this area of research.
Glombiewski, J A, Hartwich-Tersek, J, & Rief,W (2010). Attrition in Cognitive-behavioral Treatment of Chronic Back Pain Clinical Journal of Pain, 26 (7), 593-601