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Occupational therapy & the cognitive behavioural approach for pain management


ResearchBlogging.orgI have always resisted being labelled. I am much more than my gender, my marital status, my diagnosis, my professional background.  I also feel quite uncomfortable about being told what I may or may not do (maybe that’s where my kids get it from?!). I don’t like being told what is and isn’t ‘my role’ or someone else’s role.  I’m interested in what works and doing it well and at the right time for the right reason.  Today’s post is the first of a two-part commentary on a paper by Robinson, Kennedy and Harmon published in the American Journal of Occupational Therapy this month in which it is argued that occupational therapists who offer cognitive behavioural therapy ‘without sufficient attention to occupational therapy’s professional domain could lead to occupational therapists’ duplicating the interventions of other multidisciplinary team members.’ (Robinson, Kennedy & Harmon, 2011).

The paper also includes critiques of the ‘acceptability’ of psychological interventions, and suggests that ‘the use of CBT reflects psychosocial understandings of chronic pain that are frequently incompatible with clients’ interpretations of their experiences.’ They go on to say ‘many therapists have adopted the evidence to support psychological interventions without critical consideration of these interventions’ role within their professional domain or their acceptability to clients.’ The tone of this part of the paper strongly suggests that by using a CBT approach, occupational therapists do not directly address the occupational needs of people with chronic pain, and that if they do use it, it may not be acceptable to patients, and it could lead to duplicating service delivery.

Where do I start with this? There are several points that I think Robinson, Kennedy and Harmon may have misinterpreted about a cognitive behavioural approach to pain management and to the ways in which interdisciplinary pain management works.  I want to add here that I hope some of the funders of treatment services for people with chronic pain in New Zealand will also take a good look at their assumptions about both of these things as well.

A cognitive behavioural approach to pain management is not exactly the same as cognitive behavioural therapy for depression or anxiety.  In pain management, while cognitive behavioural therapy as used for mood management can be one of the therapeutic strategies used, the CBT approach is broader than this.  Basically, the CBT approach conceptualises the problem of disability and distress as due to inaccurate understandings about pain (such as hurt = harm, or that pain must dictate behaviour), and thus, inappropriate activity levels are maintained, and these in turn lead to negative mood states.  Of course, these relationships are usually reciprocal, and this is a very simplified version of the approach.

The aims of a CBT approach are to:

  • Help the person reconceptualise themselves as able to manage and do despite experiencing ongoing pain
  • Help the person set new behavioural goals to reduce disability (aka ‘re-engage in occupations’ to use occupational therapy jargon)
  • Reinforce progress and acknowledge achievements
  • Identify obstacles to progress
  • Help the person acquire skills to overcome these obstacles (Medical Practice Guidelines, Hunter Integrated Pain Service, Updated July 2005)

One of the main features that distinguishes a cognitive behavioural approach from the majority of other treatments for pain is the assumption that people are able to make changes in the way they understand their pain, given sufficient information and strategies to do so, and that by doing so, they’re able to re-engage in important activities.  In other words, even if chronic pain itself doesn’t change, people can think of themselves as primarily ‘well’ people who simply have pain.

Robinson, Kennedy and Harmon describe and critique ‘psychosocial understandings of chronic pain’ and to me what they say smacks of the old dualist notion that mind and body are separate.  When they say “…the clinician may discount the presence of an organic cause and interpret the person’s experience within a psychosocial model”, it suggests to me that the authors have not really come to grips with pain as a function of the brain’s interpretation of incoming information from the body (or lack of input from the body).  “Organic” factors or not, pain is an experience and is therefore ‘psychological’ – and it’s also biological because the brain is made up of cells and other ‘organic’ material.  We’re not talking here about mystical ‘energies’ or forces!

But their biggest reservation about CBT being used by occupational therapists seems to be twofold: that clients don’t like so-called ‘psychological’ approaches, and that these approaches don’t “directly address the occupational needs of people with chronic pain.”

While some people that I see don’t initially feel happy with a nonmedical approach to their pain, it doesn’t take long to establish that people are aware of their beliefs about their pain, and they can also see how their beliefs lead to emotions and behaviours – and vice versa.  The heart of the CBT approach is that it is collaborative.  By working together to identify the various factors that influence pain and disability (occupational performance limitations), people with chronic pain are readily able to apportion relevance to biophysical/biomedical, psychological and social components that affect their ability to do what they want.

While the authors don’t quite go as far as saying that therapists shouldn’t give patients accurate information about our current knowledge of pain, they do imply that by using a psychological explanation (sic),  patients are “de-legitimized by the suggestion that psychological factors are at play in the chronic pain experience…” I think that if clinicians fail to explore the relevance of thoughts and emotions and values etc, and instead support patients misunderstanding of their pain as fixed, permanent and unable to be modified, then they do their patients great harm.  And when better to explore thoughts and beliefs than when the person is getting in and out of the car or walking up and down stairs? Who better to do this than the clinician standing beside them as they do this?

One of the most important goals for pain management is to reduce disability or increase functional activity.  In fact the purpose of using a CBT approach is to increase the person’s ability to choose to engage in the things they want to do.  For this reason I strongly refute the idea that by using a CBT approach therapists may not be “critical[ly] consider[ing] these interventions’ role within their professional domain…”.  As I said before, who and when better to explore thoughts and beliefs than the clinician who is standing beside the person while they practice getting in and out of the car or walking up and down stairs?

I have reached my word limit for today – there will be more though, because there are several other points I need to make in response to this review.  Read on if you’re keen to see why I believe both occupational therapists and physiotherapists (and psychologists, nurses, social workers and other allied pain clinicians) are justified working in pain management using a cognitive behavioural approach, why I fail to see that this approach should be confined to clinical psychologists, and why I believe the CBT approach (and others aligned to a CBT approach such as ACT) should be employed at the earliest opportunity and right through until the person with pain is able to manage their situation independently.

Robinson, K., Kennedy, N., & Harmon, D. (2011). Is Occupational Therapy Adequately Meeting the Needs of People With Chronic Pain? American Journal of Occupational Therapy, 65 (1), 106-113 DOI: 10.5014/ajot.2011.09160

17 comments

  1. Great post. OT is all about helping people to function better, and if CBT is a “tool” to help them function, why not? It’s about treating the whole person. Look forward to hearing more.

    1. Read on Amy! I have struggled with reconciling my use of CBT with my professional identity. I feel very comfortable now with the thought of using various so-called ‘psychological’ tools to help people reduce disability, but it has taken a long time and a lot of debate and criticism from people who believe it’s outside of an occupational therapists’ scope of practice. Thanks for taking the time to comment, it’s very encouraging!

  2. i love spending my weekend mornings catching up with healthskills, BIM, somasimple etc

    and really value your perceptions and concur that ” I’m interested in what works and doing it well and at the right time for the right reason”.

    In the UK right now, there are now post graduate masters programmes that combine PT training with OT skills, seeking to create a generic P/O T role within the NHS.
    This overlap between the 2 professions, AKA lean thinking to save money and to refine resources, means that the PT and OT may well become one role in the near future.

    but psychological therapeutic approaches are also under valued when dealing with chronic pain,
    so i think that you should initiate an online, international psych/physio/occupational therapy course

    pretty much like reading your blog, but accredited

    that will ultimately benefit our patients in helping us help them understand and engage with their chronic pain.

    thanks for your blogging,
    it inspires little me, way over here, to try and make a significant difference to someones really big pain,

    kind regards
    neil

    1. You are so incredibly kind Neil, thank you. I am worried about any move that seeks to ‘save money’ by combining roles. I think it fails to recognise the different bodies of knowledge that the professions have, and very often generates a bland ‘one size fits all’ approach. While I’m a very strong advocate of an interdisciplinary approach, I think there is great value in recognising that each discipline brings with it a public (ie one that patients perceived) and private (often unrecognised) set of values that contribute to a team approach, so that a team is more than the sum of its parts.
      I’d love to develop some sort of accredited course for people interested in pain management – but have no idea how! The next best thing is possibly the course I’m developing through University of Otago, distance taught course on interdisciplinary pain management. Details coming soon!

  3. you really hit home with this one as I hear these comments frequently. Iy is obvious that therapists beliefs com into play as well here and how they can affect treatment. I believe all that you said and I believe we can and should use CBT in many if not all chronic pain patients to some degree, and I know i would get trouble from a lot of different therapists with their own views

    1. It’s so true that clinician’s beliefs are influential in their management of chronic pain. Some very good research suggests that fearful clinicians are more likely to prescribe or recommend less effective treatment including rest, avoidance and using pain as a guide than clinicians who have less fearful beliefs. Worth thinking about! CBT approach is akin to an underlying philosophy of treatment in some ways IMHO, in that it is based on the idea that people process what happens to them and are therefore able to change their beliefs and behaviour and in doing so, reduce their distress and disability.

  4. Robertson, Kennedy & Harmon have not considered the neurophysiology of chronic pain. Thoughts &, emotions, hence beliefs are most definitely part of the chronic pain experience; thats simply a neurophysiological fact.

    To not address thoughts & beliefs (and CBT/ACT offers so many tools to facilitate the process) while working with clients is I think negligent. OTs help peope live valued lives and will do that best by taking a holistic approach to an individual, within the personal & social contexts of their lives.

    The other issue for me is that Psychological knowledge is not limited to psychologists; many professionals use psychology from human resources, business, marketing professionals right through to health care professionals. The knowledge & skills are there to learn in a multitude of learning domains including tertiary study, not limited to psychologists. I do think its a good idea for OTs to seek ongoing training in psychological areas, so there is confidence in applying knowledge & skills; learning does not stop once we have a bach degree.

    1. Thank you so much for making those points Helen! It’s so true that if we fail to address beliefs, our clients/patients will be less able to participate in their own lives – and it’s through the ‘doing’ that thoughts and beliefs are elicited, so who better to work with them than those clinicians who know activity (occupation) best?!
      Occupational therapy ‘borrows’ fundamental knowledge from so many areas of study, to isolate the profession from anything other than ‘occupational science’ is both unhelpful and cannot be done. Where and how occupational therapy uses that knowledge is what differentiates it from other professions, not the actual knowledge itself!

  5. I see your point, but I think the journal of Occupational Therapy has a point as well. There is a real strong skill in delivering CBT appropriately, and making it a truly collaborative approach as you suggest. In my experience, therapists that tried to do “a little CBT” on top of either physical or occupational therapy got very bad results: they weren’t good enough at building the therapeutic relationship that would help on the psychological side, but so much time was wasted on talking that I could not get my goals satisfied with respect to sorting out my physical and work issues. There never seemed to be quite enough time in a session for everything. I had much better results when I dealt with a dedicated ACT therapist, and a physical therapist separately, and both them and myself were clear on what I was expecting from those encounters and how we were going to go about it.

    1. Read on and see what I say about interdisciplinary teamwork and how applied therapists can and should integrate CBT approaches into their treatment. You’ve highlighted some of the challenges that occur when clinicians dabble in multiple approaches and in poorly coordinated goal-setting and treatment planning. I think there are many ways around this, one of course is the way you’ve suggested: dedicate one person to do one aspect, and another to do a separate aspect. Another is the way I’m suggesting in my post tomorrow. And of course, there are still more! Thanks for taking the time to comment – you’ve raised some excellent points (maybe another blog post?!).

  6. Thanks for addressing this topic! I’m also an OT working with clients with chronic pain and using the cognitive behavioural approach. Everyone on the team should learn as much as possible about using CBT to help clients manage pain better. The idea of a health discipline having ownership over CBT doesn’t make sense to me in the field of pain managment. I’m looking forward to what else you have to say!

  7. Hi, I’m an OT student, I’ve found this a very interesting read. I’ve been planning on doing a study about OT’s using a cognitive-behavioural approach in people with chronic fatigue syndrome. Its interesting as you’ve presented as argument as to whether its appropriate for OT’s to use CBT as a tool in practice. Obviously in another area, but there are parallels I can take from this, I’ve found this a very good article to read to increase my own understanding. Thankyou

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