Without a doubt, anyone reading my blog will have tried at some point to change a habit. Maybe to stop drinking coffee (why?!), start doing more exercise, say no to new projects, eat more fibre – even when a decision to make a change is not done of a New Year’s Eve, chances are that maintaining that new habit is not entirely smooth sailing!
It’s the same for people living with chronic pain. Maybe one change is to use relaxation more often, while another might be to exercise more – while the specific method might not be difficult to learn, dealing with the mind chatter and maintaining the new behaviour pattern can be hard. What’s more, for most people with chronic pain it’s not just changing one aspect of their life, very often it’s a number of areas that are up for renovation.
Set-backs come in many forms. It’s tempting to think only of flare-ups as being a set-back, but if we consider the active use of strategies to be the new behaviour (rather than pain intensity or whether a flare-up actually occurs), then a set-back can be a period of time when pain is low (why bother using relaxation, why keep up with exercise – after all, I feel fine!), or it can be a change of environment – perhaps a holiday, new job, a move to another house.
Marlatt and Gordon’s Relapse Prevention Model is a very popular way of viewing situations that may elicit lapses or relapses in behaviour change. This model was developed in relation to problem drinking, but has been extended and applied to many problem behaviours such as gambling, quitting smoking, sex offending and so on. And yes, it’s been applied to pain management behaviour change too. This is a nice summary of the model as it applies to problem drinking. The key points of this model are that it distinguishes between ‘lapses’ and ‘relapses’.
You probably know from your own attempts to change your habits that it’s easy to — ooops! slip up, and do exactly what you vowed you wouldn’t. Maybe the weather is a bit wet and chilly to get out and exercise. Maybe it’s someone’s birthday shout at work and you have that slice of chocolate cake. Whatever the reason, you’ll probably have thought (at least momentarily) – oh no! I’m back at square one again. Many people with chronic pain say the same things – they’ve stopped exercising or planning their day, and oooops! Back to square one.
The difference between a lapse and a relapse is in the duration of the slip-up. Once or twice, recognising this and returning to the new behaviour – that’s a lapse. It happens. Doing that for longer – maybe more likely to be a relapse or return to old habits.
A set-back plan identifies what to do when a lapse, slip-up, set-back, flare-up, whatever occurs. It does the thinking before the event so that as soon as it’s recognised, there is a plan for returning to the new behaviour.
In the Centre where I work, two plans are developed – the main Pain Management Plan consisting of the components I discussed several days ago – but personalised and clearly listed on the “Purple Planning Sheet” (thanks Bronny!); and the set-back plan. The PMP details the ways in which the person has decided work well for living with pain. Our plan is quite detailed and includes areas like relationships, leisure, exercise, mood management, sleep management, work, communication and so on. The participant lists specific actions he or she has found to be helpful for maintaining (or developing) a balanced life in which they are the drivers rather than pain.
The set-back plan sits alongside the PMP. It includes space for the person to indicate their own ‘High Risk Situations’ – those situations in which they are less likely to use their new skills; it reminds people of the ‘Problem of Instant Gratification’ – and ‘Seemingly Irrelevant Decisions’. These are things like deciding to do 20 lengths of the pool because it feels so good to be doing something (PIG); deciding to ask family around for dinner and then tidying the whole house and then remembering at the last minute that it’s wonderful to have flowers on the table so going into the garden to get flowers but while you’re there, doing some weeding and before you know it – being too sore to enjoy the meal (a whole chain of SIDS).
The plan itself is about developing, through problem solving, a range of options that maintain at least part of the pattern of helpful behaviours that have been established on the Pain Management Plan. For example, if exercise is important and usually means cycling to work, when the weather is inclement it’s important to have ‘something else’ that can be done. If being assertive and saying NO to certain activities is important, then having some ‘ways to say no’ and to bow out gracefully can be really helpful. Prompts, reminders, alternatives, reinforcements, ways to recruit help from others, positive self statements – all of these can go onto a set-back plan.
Maintaining change is an area that I think telehealth, or support from a distance may be useful. While the evidence for intermittent contact as a strategy for maintaining self-management isn’t very clear-cut, I think there may be merit in exploring low-level, inexpensive ways to provide prompts or refreshers/reminders as part of a structured supported self management approach.
I was interested to read the very clear description and methodology of Therapeutic Interactive Voice Response for maintaining change by Naylor and colleagues. The idea behind this is to provide “automated access to self-monitoring, didactic review of coping skills, guided behavioral rehearsals of skills including prompts for regular practice, and personalized encouragement and reinforcement.”
In practice, what this meant was participants who had completed a fairly standard CBT approach to pain management, had access to a structured and pretty intensive telephone-based programme that asked participants to self monitor their progress through rating scales; reviewed skills; guided behavioural rehearsal of coping skills (eg mini-relaxations); and monthly therapist feedback. In this study, access to this support was maintained for four months.
What this research found was that across a wide range of outcome measures including pain intensity, mental health, physical activity and disability, participants maintained their changes. Not only did they maintain these changes during the four months of telephone support, they also maintained changes over a subsequent four months – to a greater extent than those who didn’t have access to this kind of support.
I think this approach is promising. Ongoing support groups have some negative effects, particularly if they rely on volunteer or lay leaders (who may have their own issues to manage), and they can foster a degree of ongoing identification with the ‘patient’ role. Similarly, providing intermittent refresher groups may also generate some dependency – and they can be costly in clinician time.
Perhaps a telephone or internet-based approach like this, combined with the personalised set-back plan, and pain management plan, might help people maintain their new healthy lifestyle and allow them to feel less like ‘patients’ and more like ‘people learning new habits’. It would be even more fantastic if this was something GP’s and other primary health practitioners could direct ‘graduates’ from pain management to in the event of any kind of set-back, including flare-ups.
It looks to me like something a group of computer nuts and clinicians could work to set up – food for thought huh?
NAYLOR, M., KEEFE, F., BRIGIDI, B., NAUD, S., & HELZER, J. (2008). Therapeutic Interactive Voice Response for chronic pain reduction and relapse prevention Pain, 134 (3), 335-345 DOI: 10.1016/j.pain.2007.11.001