Go on…expose yourself!

…er, maybe not that way OK?!

Graded exposure in vivo (with response prevention) is a specific treatment for pain-related anxiety/fear and avoidance.  More specifically, it’s for people who are avoiding activities that are not going to harm them, but may increase their pain.  Their beliefs as to why they ‘shouldn’t do’ these activities or movements differ widely – some people recognise that while they’re not going to harm themselves, they don’t want to or feel overwhelmed when they experience increases in pain, while others are definitely concerned that their pain means some damage is likely to occur, or more often, ‘might’ occur.

Simple reassurance doesn’t help people in this situation.  Just telling someone that ‘it’ll be fine’ doesn’t work on its own.  After all, most people who are afraid of needles or birds realise that their belief is probably not realistic – but this doesn’t reduce their fear!  “Successful avoidance of normal activity minimises the chances of discovering that continued pain does not necessarily mean more damage and lessens the chance of disconfirming unrealistic beliefs or expectations about pain.” (Dehghani, Sharpe, Nicholas_2010) What does seem to help is being exposed to the situation and developing a new sense of confidence that the dire consequences don’t happen, and that if pain does increase, the person can cope with it.

The paper I’ve referred to today by Dehghani, Sharpe, and Nicholas (2010) reviews, using structural equation modelling, the “proposition that self-efficacy mediates the relationship between avoidance and disability.”  In other words, if people are more confident that they can engage with what they fear, then the avoidance which relates strongly to disability, is reduced.  By increasing self efficacy for doing activities despite pain, disability is reduced at least in part because even though someone may be fearful, they have confidence that they can succeed in doing activities.

One of the most effective ways to address avoidance is to help the person construct a graded hierarchy of activities and movements that they currently avoid.  Then, by starting at the least feared activity, help the person systematically do these activities both to demonstrate that the consequences they’re worried about don’t happen, and that they can cope with whatever does happen.

I’ve usually used PHODA to start this process.  PHODA is a set of photographs of people doing everyday activities.  There are several sets available, similar to the original one (An online version of the PHODA can be downloaded here (Leeuw, Goossens, vanBreukelen, Boersma, & Vlaeyen, 2007).  The way I use this clinically, is to ask the person to quickly sort the photographs into two piles – one consisting of activities the person will do, and another of the activities the person is ‘bothered about doing and would avoid’.

I use the term ‘bothered about doing’, or ‘think you shouldn’t do’ rather than saying ‘are afraid of’, because initially at least, people seldom recognise their fear of the activities.  Some of them have been advised not to do some of the movements by clinicians (or they believe that’s what they have been advised), some of them say ‘but I know it’s just going to hurt so I won’t’, and others admit they are worried about harm or damage. 

I think a refinement that hasn’t yet been explored in the literature is the need to assess avoidance and to somehow account for the fact that many people have been told they’re not ‘doing further damage’.  What I see happening is that they complete a questionnaire like the TSK, indicate that they’re not concerned about damage – but at the same time, they’re definitely not prepared to actually do the movements because ‘it will hurt’.  In this instance, although the person knows at a superficial level that they’re not harming themselves, they haven’t gained confidence that they can cope with the possibility of changed pain intensity.

Once the person has sorted the photographs into two piles, I ask him or her to rank the photographs on a 0 – 10 scale, where 0 means ‘I’ll do this, but not happily’, and 10 means ‘there is no way I’m prepared to do this’.

I then start at the least bothersome end of the hierarchy, and start to enquire about the specific concerns the person has.  I do this using a range of phrases, with my ultimate aim being to focus in on the specific beliefs or thoughts the person has about doing the movement.  I don’t stop at ‘I know it’s going to hurt’, I’m keen to look at ‘what does it mean if you have pain when you do this?’

Some questions I use are:

  • ‘What do you think is going to happen if you do this?’
  • ‘If I asked you to do this now, what would go through your mind?’
  • ‘If you had to do this, what is your main concern?’
  • ‘What do you think would be happening in your body if you tried this movement?’
  • ‘What would it mean to you if that (previous event/situation) happened?’

And I continue probing until I find out the person’s own hypothesis about what is going on in their body, what might happen, and what the pain signifies.  These thoughts or beliefs can be quite idiosyncratic – maybe it’s the slippery surface, maybe the jarring, maybe the hand position, or shape of the item being moved…

I then ask the person to rate two things: the probability that the negative event will actually occur, and the level of concern the person has if this does happen.  As a convenience I use a 0 – 10 scale, but it could be a percentage.

I demonstrate the activity, and then ask the person to do it.  The person is finally asked to re-rate both the level of concern and the probability of the negative event occurring.

Some really important things to note:

It doesn’t seem as though ‘ergonomic’ or ‘biomechanical’ movement patterns are needed.  In fact, if a ‘special’ technique is used this can offer the person a replacement ‘safety behaviour’.  Rather than completely avoiding the movement, he or she may end up doing the movement provided that a specific technique can be used.    This means the hypothesis that some dire consequence will occur if the activity is carried out is never actually tested – so beware doing things like suggesting special movements, specific gadgets, or even specific coping strategies like breathing or relaxing the shoulders etc. 

It’s also important not to make the task or activity easier in any way – in other words, don’t go down the hierarchy because the person says it’s too hard, or makes their pain worse, or they can’t cope with it.  If you do adjust your expectations it simply confirms to the person that they were completely justified in their avoidance, and strongly reinforces to them that they shouldn’t confront this activity. 

This is hard!  It’s difficult to say to a person that you know their pain has increased – but that they can cope with this.  It’s at this point, after doing the activity, that you can suggest things like relaxation, diaphragmatic breathing, positive self statements and so on. 

What you will notice is the sense of achievement that managing these exposure activities provides people.  It’s a bit like when you first learned to ride a bicycle, drive a car, speak in public – nerve-wracking, but wow! you’re flying!

Dehghani, M., Sharpe, L., & Nicholas, M. (2010). Structural Evaluation of the Contemporary Psychological Models of Chronic Pain: Does Fear of Pain Work for All? Cognitive Behaviour Therapy, 39 (3), 214-224 DOI: 10.1080/16506070903390134


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