I promised there would be more on this topic – it’s a popular one and full of vexing questions. I left off yesterday, after making four points that IMHO might help incorporate some of the psychosocial management to a nonpsychological practice. They were:
Give precise advice about what to do.
Give reasons for your advice.
Ask the person about their understanding of their pain.
Make sure you give clear timeframes for any activity restrictions.
The underlying rationale for each of these is to counter two main problems that appear to underpin the development of longterm disability associated with pain: catastrophising, or ‘thinking the worst’, and avoidance.
This point is really important, so listen up!
It’s not the presence of pain alone that is the problem. It’s negative thoughts or judgements about pain, and behaviours that people do to avoid exacerbating the pain.
Combine both of these with low mood, and we have a witches brew that can lead to longterm disability. And it’s disability associated with pain that really is the problem because it’s about not being able to do the things that people want or need to do.
OK, ’nuff said. While I appreciate that pain by definition is a negative emotional experience, it’s these two additional components that need to be addressed as early as possible. And yes, that’s pretty much what Linton and colleagues found (and recommend) in the paper I’ve referred to.
Their point is that we don’t know very much about the best ways to target the tendency to catastrophise, and while our focus is often on low mood and low mood certainly has a major impact on longterm outcome, we also need to directly address catastrophising and develop targeted treatments for this.
The quote I gave yesterday from Linton et al., was incomplete – here’s the rest: “Clearly, encouragement to upgrade activities and exercises, as well as education and attempted reassurance about pain may be sufficient to achieve meaningful changes in many, but they appear to be insufficient to overcome strongly-held catastrophic beliefs by a proportion of people.” Something else needs to be added, and I think it might be doing things differently. With the emphasis on doing. Education/information alone doesn’t necessarily change behaviour…
At this point, I’m leaping off the solid ground of evidence, and into some clinical conjecture, but hopefully based on what we currently know about helping people make changes. So please, bear this in mind when you read on…
- Check with the patient to find out what they think they’ve heard. What does the person hear when you give an explanation? What do they think you mean? How does your explanation fit in with their personal theory of what is going on?
- A picture or diagram is worth a thousand words. I find myself drawing diagrams linking the person’s thoughts, their responses in both emotions and behaviours, and I add in alternative paths and extra information that I can give to them to take away. Personalising this information and using what the person already knows to show them that their reasoning might ‘make sense’ but has unintended consequences, or their reasoning is based on inadequate knowledge helps to make your advice on ‘doing it differently’ much more acceptable. This is a joint discovery you and the person are making.
- Setting goals always needs to start where the person is at. If you want the person to start doing things for themselves, being active in their own treatment, they need to feel that those actions are both important and that they can do them successfully. If the person doesn’t think they can walk to the letterbox every day, even though you think that’s barely sufficient, then start with something they think they can do – and do consistently.
- When the person comes back to see you – check with how they’ve carried out the goals you set. If you don’t check in on them, they’ll see the goals as unimportant. Even if they haven’t done the goals, you can continue with your treatment – just ask what happened? What got in the way of doing the goal? What went through their mind? What external obstacles got in the way? This is where you’re starting to use psychological ‘stuff’ because often what you’ll find is that it’s thoughts/beliefs about the pain, emotions related to those thoughts about pain, and/or the influence of other things (people, events) that will directly influence recovery.
More on this stuff tomorrow – but let me know, does what I’ve written ring true? Can you do this? Does it make sense to you as a clinician? I’m looking forward to hearing your comments.
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