Making self-help more helpful

One of the things that appeals about self-managing chronic pain is that it doesn’t require endless appointments. If life is for living, why spend it sitting in a waiting room? (they never have up-to-date magazines anyway!)

Our problem as health providers is that we don’t know whether all our great self-help recommendations actually get done by the people we see. After all, we’re not there in the morning when they get up, or late at night when they’re trying to get to sleep! Most of us simply hope that –

• the person is sufficiently motivated (thinks what we’re advising is both important and they’re confident they can do it)
• can organise themselves to ‘get around to it’ before they forget what we’ve suggested
• they’re telling us the truth when they say they’ve been doing whatever it is we’ve suggested

Quite a while ago I read about a very simple strategy to help people be more likely to carry out their exercises – and posted about it here. In that study by Christiansen,  Oettingen, Dahme, and Klinger (2010), two 30-minute sessions involving identifying the reasons for making a change (to increase physical activity), and the potential obstacles to actually doing it, were held.  For four of the obstacles identified, the participants were helped to generate solutions that would help them get around the obstacle and engage in exercise.  To do this, ‘if-then’ statements were developed.

An ‘if-then’ statement involves identifying a specific situation such as ‘when I get home from work’, then indicating the behaviour that will occur ‘I will get my running shoes out and go for a walk.’

In the study I’ve looked at today, the same strategy was applied when delivering a self-help booklet for people with anxiety. In this study, Varley, Webb and Sheeran contacted (via email) the students and staff at a university in the UK.  People who were already being treated for anxiety were excluded, and the remaining participants (251 of them) were randomised into three groups.  All of them completed baseline Hospital Anxiety and Depression Scale (HADS, developed by Zigmond and Snaith, 1983) and the state version of the State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, Lushene, Vagg, and Jacobs, 1983).

One group received no input, while the other two groups were asked to go to a web page where they downloaded a self-help booklet.  Both of the booklets were the same eight-page booklet containing psychoeducation, diary sheets for self-monitoring triggers and feelings, and two relaxation techniques – a breathing technique that could be used anywhere, and a longer relaxation exercises that could be used daily at home.

The experimental group, in addition to the booklet, were also asked to develop two ‘if-then’ plans – one that involved the participant identifying a specific anxiety-related symptom and to associate it with using their newly learned breathing technique. eg “If I feel my heart racing, then I will use my breathing technique to relax.” The second plan asked participants to identify when they might be able to do their deep relaxation technique into their daily routine. eg “when I get home at night, then I will do my deep relaxation.”

When the participants were reviewed eight weeks later, as expected, neither the control group nor the standard self-help group differed very much.  However, the self-help group that received the implementation intentions (if-then) supplement had significantly lower scores on the HADS and the STAI.

Interestingly, the experimental group also thought the booklet was more ‘user-friendly, used the relaxation techniques more frequently, were better at detecting the triggers of their anxiety, and experienced the benefits of using the relaxation techniques.’ So basically, quite an effective and yet simple strategy!

For readers with a critical eye for statistics and methodology, this study is a nice example of the use of multiple statistical methods to determine outcomes – a combination of ANOVA, Sheffe post hoc tests, multivariate analysis, correlations, and bootstrapping to test direct effects – and what’s more, they also reviewed ‘caseness’, or whether the changes that were statistically significant were also clinically significant.  This was achieved through identifying participants with scores over 11 on the HADS at pre- and post-testing.

OK, so lovely for people with anxiety: how might this apply in self-management of pain?

Well we’ve already had one demonstration of this method on exercise for people who have chronic pain (Christiansen and colleagues), and I wonder if it might not make an effective addition for people who have high pain-related anxiety.

One of the effects of anxiety about pain is to reduce how readily people can bring coping strategies to mind (go here for some of the references to the Pain Anxiety Symptoms Scale).  If we identify people who have trouble thinking straight when they’re sore, we can help them generate specific ‘if-then’ statements to help them get by.  Here’s an example:

Jenny gets worried when her pain starts to increase, especially when she’s busy at work.  Her therapist helps her identify the ‘early warning signs’ that signify the potential for difficulty coping.  These are:

• several deadlines occurring together
• jaw tightening and frowning
• multiple interruptions

She chooses one of these, and with her therapist, identifies several strategies:

• breathe and let go
• stand up and stretch
• assertively setting a limit

She then constructs an “if-then” statement like this:

• “If I have several deadlines occurring together, then I will stand up and stretch”

She writes this down and puts a copy of it beside her computer at work.

The good things about this strategy are that:

• it’s generated by the person (who therefore gets involved in identifying personally relevant cues and solutions);
• it’s brief (so easy to remember!);
• it does the thinking and problem solving beforehand (when thinking can be much more creative, and the situation may even be pre-empted);
• it involves a different behaviour (it’s an action, which is much easier than a cognitive strategy when anxiety is elevated)

Give it a go with your patients – and see whether it’s something they might find helpful.  Or even use it yourself!

Varley R, Webb TL, & Sheeran P (2011). Making self-help more helpful: a randomized controlled trial of the impact of augmenting self-help materials with implementation intentions on promoting the effective self-management of anxiety symptoms. Journal of consulting and clinical psychology, 79 (1), 123-8 PMID: 21171737