Pain management is replete with assessment measures. There is even a handbook dedicated to pain assessment. I’m sure that every clinician has their favourite assessment tools and process. But there seems to be a gap in terms of how to use the findings from all this assessment: how to put it all together to make some sort of sense.
Chronic pain and disability is a multifactorial problem. There are contributions from biological processes, from psychological mechanisms, and from the social environments in which we live. I think only die-hard types would argue that thinking about pain from a purely biological perspective in any but the most simple presentations makes any sense at all. But how do you put the information together to arrive at a reasonable set of hypotheses about what is going on? I think it helps to have some sort of framework, because this simplifies the way information can be presented. I also think it’s useful to work from the patient’s perspective first, before integrating any contributing factors that don’t feature in the patient’s narrative.
I usually sit down with a large piece of paper or a whiteboard, and a pen, and begin assembling a kind of story.
Bronnie: “You’ve said that it’s hard to know when your pain is going to bother you, and you’re not sure how to make sense of it. Let’s see what we do know already. Tell me your theory of why your pain is still going on.”
Gerald: “Okay… Well one doctor said it was because I’d had a car accident and I’d strained my neck muscles when I got shunted from behind. I know I started to get sore the day after that accident.”
Bronnie: “Let’s put down “got shunted from behind – neck strain”.
Bronnie: “And has anyone else given you an explanation that makes sense?”
Gerald: “Well, this one guy said that because my head got knocked around I might have had a concussion, and that might be why I have these headaches.”
Bronnie: “Does that make sense to you? Should I put that down?”
Gerald: “Yes, put that down, because I’ve had headaches ever since, and I know I really got a shake-up.”
Bronnie: “So, we have a shunt from behind, and a concussion. Is there anything else to explain why you’ve been having such trouble?”
Gerald: “Well one doctor said I was, what did he call it, kinesiophobic. That means I’m afraid to move. Well of course I’m afraid to move – it hurts! But it’s not like I’m a mental case.”
Bronnie: “What do you think he meant by that term?”
Gerald: “I think it was a way he could say that it wasn’t his fault I wasn’t getting any better. That I need to pull myself together and start doing things.”
Bronnie: “What would you like me to put down on this diagram then? What do you think, are you afraid to move?”
Gerald: “Yes, I don’t want to hurt, so I don’t move. Every time I do move, I get a headache and feel awful.”
Bronnie: “I’ll add that in, then. It makes sense that if you hurt when you move, you stop moving. What we call it doesn’t really matter.”
Gerald: “It’s horrible. My life has closed in on me, and I’m not doing very much at all. I feel pretty down some days, but mostly I feel frustrated.”
Bronnie: “We could say then that being afraid to move has meant you’ve stopped doing a lot of things. And as a result you’re feeling down and frustrated.”
Gerald: “You can say that again.”
Bronnie: “And what about the people around you? What’s it been like at home?”
Gerald: “The kids couldn’t care less. They’re just grumpy because I’m not taking them to places like a taxi driver. I’m not driving because I really don’t want to get back into that car, even though it’s been fixed.”
Bronnie: “And what about your partner? How are things with her?”
Gerald: “I think she’s really concerned about me, but doesn’t know what to do. Sometimes I know she’s really angry with me, like it was my fault I got hit, other times she’s really supportive, and wants me to get some treatment to fix it so I can get back to normal again.”
Gerald: “Well, I can’t go back yet because I don’t want to drive. And I keep getting these headaches, so I don’t think I could even think about going back. My boss, he’s been ringing me to see if there’s anything he can do – he’s a good sort, and I want to go back, but what can I do when I’m like this?”
Bronnie: “And how are you doing for income at the moment?”
Gerald: “I’m on compensation, but my case manager keeps pressuring me to go back to work. She doesn’t seem to realise that I can’t do anything, I’d just be a liability. I think she needs to stop hassling me until I’ve got things sorted out a bit more. If only I could get rid of these headaches, and move my neck a bit more, but I can’t even look down to pick things up even if I could carry them.”
Bronnie: “To sum up, it looks to me like right now you’re feeling pretty stuck. There are lots of different explanations for your headaches and neck pain, but no matter what we call it, you’ve stopped doing things and as a result you’re feeling fed up and down. And your family aren’t really helping though they’re doing their best. Your employer is keeping in touch and that’s great but you don’t think you’re reliable enough to go back to work, even though your case manager keeps pushing for you to try. How does that sound?”
Gerald: “Pretty right to me.”
At this point, Gerald and I have developed rapport, and a shared understanding of his perspective on his pain. You’ll note that I haven’t started “educating” him, or trying to change his understanding. I haven’t done this because I want to be certain I’ve started to understand where he’s coming from. People don’t develop weird beliefs for no reason – these beliefs usually begin from a misunderstanding, or perhaps faulty logic that hasn’t accounted for some of the factors, and they usually make sense once you take the time to listen to the person.
I will also often add some questions about treatments he’s tried, and what he’s learned from them. I’ll usually ask about his family and colleagues beliefs about pain and what he should or shouldn’t be doing. I’ll ask about other times he’s had pain and what he’s done to recover, and what he might have learned about his resourcefulness and coping from these times (or his vulnerabilities and challenges).
I will usually then ask him what his main concern is, and what he thinks the “next best step” might be. The answers to these questions will often help guide the first therapeutic steps we take. I also incorporate his responses to a set of questionnaires I usually administer before seeing him. These include the Pain Catastrophising Scale, Chronic Pain Acceptance Questionnaire, Chronic Pain Coping Inventory, and Pain Anxiety Symptoms Scale, plus a measure of general function or disability such as the Pain Disability Index, or the Multidimensional Pain Inventory. By reflecting on the findings from these questionnaires, together we can factor those aspects of his understanding into the formulation diagram.
If I’m working within a team, I like to bring the team into the formulation process – but not until after the client/patient and I have developed our understanding first. This makes it much easier to generate a collaborative approach to learning about the many factors influencing the person’s presentation.
I’ll continue with this formulation in next week’s post….
A couple of good readings:
Asmundson, Gordon J., & Hadjistavropolous, Heather D. (2006). Addressing Shared Vulnerability for Comorbid PTSD and Chronic Pain: A Cognitive-Behavioral Perspective. Cognitive and Behavioral Practice, 13(1), 8-16.
Thompson, B. (2012). Abductive reasoning and case formulation in complex cases. In L. Robertson (Ed.), Clinical Reasoning in Occupational Therapy: Controversies in practice (1st ed., pp. 15-30). Oxford: Wiley-Blackwell.
Tompkins, Michael A. (1999). Using a case formulation to manage treatment nonresponse. Journal of Cognitive Psychotherapy, 13(4), 317-330.
Vertue, F.M., & Haig, B. D. (2008). An abductive perspective on clinical reasoning and case formulation. Journal of Clinical Psychology, 64(9), 1046 – 1068. doi: http://dx.doi.org/10.1002/jclp.20504