What to do about catastrophising even when you’re not a psychologist

OK, it’s time I stopped the suspense.  This post is about what to do about catastrophising even when you’re a physiotherapist, massage therapist, acupuncturist, nurse, occupational therapist, social worker – oh just about anyone working with people who have pain!

Catastrophising is “an exaggerated negative “mental set” brought to bear during actual or anticipated pain experience” (Sullivan, Thorn, Haythornthwaite, Keefe, Martin, Bradley and Lefebvre, 2001).  It’s demonstrated when people describe their pain in highly vivid and negative terms “My muscles feel like they are tearing away from the bone”, “I can’t cope with this any more”, “I keep on thinking about the pain all the time” and so on.  Catastrophising is associated with greater distress, lower mood, greater disability and poorer prognosis (Sullivan MJ, Thorn B, Haythornthwaite JA, Keefe F, Martin M, Bradley LA, & Lefebvre JC, 2001).

A recent study of army troops found that catastrophising is present even in young, healthy people (Ciccon, Chandler and Kline, 2010).  In this study, 25.9% of those reporting acute pain, and 51.3% of those reporting chronic pain endorsed catastrophising beliefs.  And this group of people were not seeking treatment (as an aside, this is one of few studies to look at non-treatment-seeking people)!  The study also found that in those with high levels of catastrophising, mental health problems were more prevalent, and that catastrophising explained a good proportion of work disability.  In other words, even in this very healthy group of people, catastrophising was associated with greater vulnerability to having difficult managing pain and keeping mentally healthy.  If this finding is identified in other non-treatment-seeking people, I think we can confidently draw the conclusion that catastrophising may be one of the more prevalent unhelpful cognitive biases around.

Hopefully I’ve made the point that catastrophising is something that needs to be identified because of the profound effect it has on how people can live well despite having pain.  The argument is that by addressing catastrophising, people will be more able to cope with their pain, feel less helpless and distressed, and live lives less hampered by their pain.

What do we do about catastrophising?

I think (watch out – soapbox time!) that anyone who works with people who have pain and tend to catastrophise must help those people develop coping strategies to help them cope effectively.   It’s not enough to think that psychologists alone need to do this job.  This is because, as the Ciccone and colleagues study shows, catastrophising is very prevalent even in those people who are relatively well.  The people in that study weren’t likely to seek treatment from a psychologist for their pain – they’re far more likely to see a physiotherapist, an osteopath or chiropractor, an acupuncturist, a massage therapist.

Furthermore, in groups of people who do see a psychologist about their pain, at least in New Zealand, they’ll also most commonly be seeing other clinicians such as physiotherapists or occupational therapists – and a consistent approach is vital.  It only takes one clinician to reinforce an unhelpful belief for the work of the team to be undermined.

I also argue that the best time and place to work on reality testing unhelpful thoughts and beliefs is when people are doing things they’re worried about – in other words, when they’re working on movements, discussing work, developing an exercise programme, working on how they might do household activities, sports and so on.

Yes, psychologists have specialist training in working with thoughts, beliefs and emotions.  Occupational therapists, physiotherapists and other allied health clinicians are always influencing thoughts, beliefs and emotions.  To think we don’t is to ignore the incredibly powerful influence we wield almost because we tend to do it indirectly.

I argue that if we have an influence on people, we need to develop that skill so we can influence positively and helpfully.  In the case of catastrophising, I don’t think we need to become psychologists – that would devalue the other aspects of our various professions.  I do think we need to look at what we say, how we say it, and how we work with people within our professional scopes to maximise the benefit of our input.

What can we do to influence catastrophising?

Here’s another Healthskills Advice for Non-Psychologists working with people who tend to catastrophise!

  1. Find out what the person thinks is going on, and how they’ve arrived at this belief – listen well and with empathy.
  2. Empathise – say something like “It sounds like this is really scary/worrying/hard to handle.”
  3. Ask if it’s OK to give them your perspective – most of the time people will say yes, but asking gives you their permission to provide new information, and they’ll be more willing to listen.
  4. Use calm, neutral language to give an evidence-based explanation – keep it simple, and beware technical language that can be misinterpreted!  For example, an “unstable back” might be your technojargon for poor recruitment of muscles, but your patient may well have an image of their back breaking or collapsing if they move. Don’t you DARE give them a theoretical explanation that has no evidence in the peer-reviewed literature. EVER.
  5. Check out what they’ve heard.  You can ask them “Can you tell me how what I’ve just gone through might mean to you?” or “Can you let me know how that might apply to you?”.
  6. Listen to their response.  Reflect back to them your understanding of their interpretation.  This may seem repetitive, but it’s so important for people to know that you’re listening to them.
  7. Check if they have questions or doubts.  Listen to these without interrupting or saying they’re wrong.  These are their beliefs!
  8. Ask them if they’re willing to test your interpretation out, or how they might test their own interpretation.  You can ask them “how likely is it that this is true?”, “what makes you think this will happen?”, “what’s the most likely thing that will happen?”, “what does it mean if this happens?”.
  9. Set up an opportunity to test their interpretation (or your new one, if they’re prepared to).  This is in the nature of a mini-experiment – so if they think they will get stuck on the ground if they try to get down, see if they’ll do so while you’re there.  Be prepared for qualifiers – “oh but it didn’t happen because you were there”, so make sure you point out what they did to manage.
  10. Finally, make sure you convey confidence that, even though they are worried about “the worse thing happening” – you know they will get by.  They’re not asked to enjoy the process of getting by – but they can manage, and the catastrophe is averted. If pain increase is their personal catastrophe, it’s likely the belief that they “can’t cope”, or not liking the negative consequences of having an increase in pain (feeling irritable, wanting to rest, having to work with pain the rest of the day) that is the problem.  And managing that is for my next post!

It’s worth remembering Mark Twain’s comment: “I’ve had a lot of problems in my life and most of them never happened.”

Ciccone DS, Chandler HK, & Kline A (2010). Catastrophic appraisal of acute and chronic pain in a population sample of new jersey national guard troops. The Clinical journal of pain, 26 (8), 712-21 PMID: 20664336


    1. I’m glad you think it will be helpful. I was imagining that some people with chronic pain might not be quite as comfortable with some of my suggestions for clinicians – there is some worry amongst people with pain that by asking people to check in with their thinking, I might be suggesting their feelings are wrong. I hope I havent’ given that impression! It’s more a case of wondering if catastrophising is helping people reach their goals, is all.

  1. Thanks Bronnie,

    This article comes at a time when I have a number of clients who are at high risk for catastrophising.

    Best regards from Victoria, BC.

  2. Abolutely on target. I am of the opinion with you that one therapist reinforcing the catastrophizing has incredible weight for the client and defeats much of the rest of the team’s work. We need to help one another to realize this all around here in the US where our soldiers are returning more damaged than we actually know how to treat reliably.

    1. Thanks Esther! You’re right – it’s not that the person with pain is actually looking for someone to confirm their fears, but that it only takes one person to inadvertently reinforce their fears for the human cognitive bias to look for confirmation of things they believe to kick in. I hope the military has really effective screening and treatment available for people returning from the violence of warzones so they don’t have to wait and suffer the shame of “not coping” that some of previous war veterans around the world have had to.

  3. In between #1 and #2, I would add something to the effect of, “Repeat back to the client what they said word for word to make sure you have it right – clinicians have filters, too, so we need to make sure that we heard what the client/patient actually said before we can empathize with it. For example, “So what I heard you say is…” “Is that correct?” If it is, they can say yes, and if its not, you can course correct until you are certain you are on the same page before you continue on with the rest of the process. Thanks for the post!

    1. Good thinking. Yes it’s really important that we let people know what we hear – because so many times people with chronic pain seem to be misheard, or not even heard at all! – and before we can “tell” we need to know what the other person wants!

  4. Great post!

    What do you think about using a pain catastrophizing scale to identify who is at greater risk? It’s getting to be more common in pain clinics, but do you think physiotherapists and acupuncturists, etc, should be going into that too?

    1. I think it’s really helpful – provided that you know what it is intended to measure, how to interpret the scores, and can refer on if the person presents with very high levels of catastrophising. Given the influence that catastrophising can have on an individual’s response to therapy, I think if we ignore it, we could either limit the effectiveness of our treatment or, in the worst case, unintentionally reinforce catastrophising by giving messages that can be misinterpreted.

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