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“Psychological stuff isn’t in my scope of practice” so what can I do?


ResearchBlogging.org
A common cry from various clinicians who work in the field of pain management but who are not psychologists is “but now what?” when they recognise that a key factor in recovery is something psychosocial. The answer is not, I suspect, heading off to become a psychologist!

For several reasons, I think it’s critical for non-psychologists to get comfortable with psychosocial language and principles.

  1. All clinicians use psychological principles in their interactions with patients.  Like it or not, when we give advice or encouragement we’re using knowledge gleaned from psychological study.  We might call it something like “developing rapport”, but no matter what we call it, these interpersonal skills are psychosocial in nature.  If we use these approaches, it’s pretty important to make sure we’re doing it effectively.
  2. If the patient is being seen within an interdisciplinary or multidisciplinary team setting, being consistent in the use and management of psychosocial factors is critical for treatment success (IMHO).  There’s nothing quite like working in an interdisciplinary team that has coordinated and synthesised the model they’re working with so that the patient hears the same messages from everyone.  Conversely, imagine what it’s like for a patient to hear different things from different clinicians working in a team.  Especially for a patient who needs to feel confident that the team working with him or her know what they’re doing.
  3. Psychosocial factors consistently present as the most potent variables in recovery.  And even though we may not yet know the most effective ways to manage psychosocial factors, every clinician needs to be open to identifying them and beginning to work with them because the factors are so incredibly pervasive.

It’s this last one that I want to briefly mention today.  Sub-acute low back pain is probably one of the most common pain presentations for which people seek treatment.  While most acute low back pain can get better quite quickly without too much interference from health providers, for people with sub-acute low back pain, getting treatment is a major step.  Sub-acute low back pain is pain that has persisted for a couple of weeks (give or take!) maybe up to six weeks, and doesn’t appear to be getting any better.  It’s at this six week point that many authorities and clinical guidelines suggest that additional assessment and targeted intervention should occur.

Assessment at this point seems to need to include psychosocial factors so that they can be identified and managed as soon as practicable.  The tools that seem to have the most support are below, and are all open for use by health practitioners with training in basic statistics, and who READ the original research so are able to interpret the findings.  (Anyone who uses an assessment without doing so should be ashamed.)

The Orebro Musculoskeletal Questionnaire is a common measure used to identify risk of ongoing disability, and it’s been shown to have good predictive validity (as well as other good psychometric properties).  But there are three other measures that are also often used as ‘early’ screening instruments – the Pain Catastrophising Scale (scoring and interpretation here), and a depression or mood/anxiety measure such as the Hospital Anxiety and Depression Scale (here’s a nice brief summary of interpretation).  And of course, there is the Tampa Kinesiophobia Scale.

Once a person is identified as having an elevated score, or one in the ‘clinical’ range, what then?

“The patient’s beliefs, especially any alarmist or catastrophic beliefs, about their pain should be sought. “ is the advice given by Linton, Nicholas, MacDonald et al., (2011).  It’s these catastrophic beliefs about pain, combined with low mood (particularly thinking patterns that involve ruminating on, or brooding about how bad the pain is and the negative implications of having pain).

Then, “encouragement to upgrade activities and exercises, as well as education and attempted reassurance about pain may be sufficient to achieve meaningful changes in many”, as these authors say.  It’s part of everyone’s role to be cautious about the words we use and the advice we may give.

Here’s the HealthSkills advice for nonpsychologists:

  1. Give precise advice about what to do.  State these in positive language “Sit for five minutes, then stand up and stretch” rather than “Don’t sit for too long.”
  2. Give reasons for your advice. This makes you think about why you’re giving advice!  If you can’t think why the person should do as you suggest, or you can’t find an evidence-based rationale, then don’t give it out!
  3. Ask the person about their understanding of their pain.  Gently give them an accurate explanation if what they believe differs from reality –  show them their records, even phone their original clinician up in the patient’s presence to discuss the findings if you need to, use illustrations and diagrams.  But at the same time, encourage them to ‘test’ the helpfulness and/or accuracy of these beliefs by carrying out mini experiments within daily life.
  4. Make sure you give clear timeframes for any activity restrictions.  Review restrictions regularly and give the ‘green light’ for getting back to normal.  Don’t just leave this as being ‘common sense’ – you have no idea how often patients carry on with activity restrictions long after any physiological need to do so has passed.

Wait, there’s more – but that’s for tomorrow!

Linton, S., Nicholas, M., MacDonald, S., Boersma, K., Bergbom, S., Maher, C., & Refshauge, K. (2011). The role of depression and catastrophizing in musculoskeletal pain European Journal of Pain, 15 (4), 416-422 DOI: 10.1016/j.ejpain.2010.08.009

7 comments

  1. I think this is excellent advice! And not just to physicians who work with chronic pain… One of my more frustrating episodes involved surgery. I had a surgery to remove adhesions. I knew from my own research that it was important to get moving early, because inactivity was likely to cause the adhesions to return. But when I asked the nurse about appropriate activity levels and re-starting my exercise program, the only answer I could get was “just listen to your own body and use common sense”. I ended up in a frustrating “boom-bust” cycle, where I think I avoided too much at first, then pushed myself into way too much, then was unable to cope with resulting pain, and so on… And all this despite knowing, at least in theory, about this from my chronic pain management. I would have really, really appreciated having some concrete guidelines there, along the lines you describe.

    A friend also described recovery from back pain when she was told to do exercises “as much as she can”. She ended up not doing them much at all, because she didn’t have a specific goal to work to, and there were too many other competing priorities. She was of the opinion that if her therapist gave her more explicit recommendations, she would have been able to stick to the program better.

    1. Mary, that’s exactly my experience after surgery – not just about movements, but also timing of medication. Giving explicit instructions seems such a simple step, but I think because it’s so commonplace to the surgeon, they forget this might be the first time for anyone having the surgery, so don’t consider the need to make it clear.

    1. OOOoooh Neil, that’s spooky! I hope I can maintain the standard. Let me know if there is anything specific you’d like me to discuss on here too, I find it helps with the accuracy of my ESP!
      cheers
      Bronnie

  2. It’s okay to give advice, but physicians tend to be very directive in their communication style. If, for some reason, the person finds it difficult to follow the advice, experiences a cost to doing it, or doesn’t really believe in the rationale (or if, as you say, the provider doesn’t even give one) that is likely to be counterproductive. Physicians have a righting reflex — they know what’s best for people so they will correct us if they thing we’re behaving wrongly. This leads to push back, or to just not speaking up at all because who wants to be scolded or criticized? Patients will almost always appear to accept physicians’ advice, but half the time, they don’t follow it.

    Providers need to learn some principles of motivational interviewing if they want to deal successfully with psychosocial issues — ask open questions, get the person talking and be nonjudgmental so they will tell you more of the truth, resist the righting reflex, help the person find his or her own way to a desirable conclusion, and state in her own words what she is planning to do. That works much better than telling people what to do.

    1. Absolutely right about the use of motivational interviewing. I think if a patient/person is ‘ready’ then giving specific advice is OK, but when a person isn’t ready, then it’s so much more important to listen to them, and help them view their situation as a dilemma in which the role of the professional is to provide information (when requested) and help the person sift through and look at the consequences of each course of action. I train doctors on pain and pain management – and at the core of my teaching is the need to start where the patient is at, listen to them and their concerns, and then work with them to help them understand why something is important. Thanks for taking the time to comment, it’s so nice to know people read this!

    2. I think it needs to be both, really – giving instructions, but listening to the patient as well. I have dealt with doctors who gave fixed advice that I believed I could not implement, and yes, this was frustrating and completely unproductive. I think the doctors who work best for me are those who start by giving specific instructions and rationales for them, but who are ready to say “OK, you think you cannot do that. Why? Can we either find an alternative solution that works for you, or remove some obstacles to getting this done?”. Either extreme – being very prescriptive and inflexible, or being unprepared to give specifics, causes trouble.

      This is just my uninformed opinion, but I got an impression that the “just listen to your body” is the overreaction of doctors who were originally taught the highly directive communication, and are now told that they have to work collaboratively with patients, but are not taught how to do it properly, and are struggling to find a way. In some sense, this is a basic communication skill. At work I lead small teams of people at work. I went to too many “how to manage people” classes that focused on a single thing: “don’t give instructions, get people to cooperate to make them creative”. As a result, for a while I believed that giving *any* specific instructions is a problem. Took me a while to realise that people appreciate someone giving specific suggestions in areas they are not familiar with, and don’t necessarily want to find a new independent solution to every single problem they face. I eventually found a balance between saying “I think you should do it this way because of X” and letting people find their own solutions. Some of the communication I had with doctors/physical therapists really reminds me of myself in “never give directions” stage, unwilling to give instructions for fear that people will not like it and indeed push back.

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