In my post last week I talked about pain behaviour and why pain behaviours are often a good treatment target in pain rehabilitation. I also talked about pain intensity rating scales and how, because rating scales are a form of communication, the numbers we obtain from them aren’t a true measure of pain: they reflect what the person wants to communicate about their pain to someone at that time and in that context.
This week I want to discuss modifying pain behaviour, and believe me, we are all in the business of modifying behaviour even if we think we’re doing something completely different!
One of the issues about modifying behaviour is addressed right at the beginning of Fordyce’s chapter on “Techniques of behavioral analysis and behavior change” and this is the ethical issue of informed consent. It’s important because behaviour change using behaviour modification techniques can operate without the person’s awareness (and does so All The Time). As clinicians, though, we have an obligation to ensure we obtain informed consent from our patient/client before we embark on any treatment. Of course, you and I know that this doesn’t happen in the way that I’d like to see it! When I’m a patient, I’d like to have my options laid out in front of me, with the pro’s and con’s over both short and long term clearly explained. Then I can choose the option that I prefer. But actually, most of the time I’ve received treatment from any clinician, I’ve been given little or no information about alternatives – it’s been assumed that I’ll go along with what the clinician has chosen for me. How’s that for informed consent?
Back to behaviour change. Fordyce clearly details the approach he prefers which is clear discussion with the person about what is proposed – that “well” behaviour will be reinforced via social interaction and “praise”, and “unwell” behaviour will either be ignored or redirected.
Behaviour change done badly
Where I’ve seen behaviour modification done badly is where the clinician fails to indicate to the person that this is the approach being taken (ie no informed consent), where this is applied to all people irrespective of their treatment goals and without discriminating the types of behaviours to be modified, and where it’s applied without empathy or compassion. The kind of “one size fits all” approach. More about this in a minute.
Fordyce points out that “almost every behaviour change problem can be analysed into one or a combination of these three possibilities: 1) Some behaviour is not occurring often enough and needs to be increased or strengthened; 2) some behaviour is occurring too frequently and needs to be diminished in frequency or strength or eliminated; and 3) there is behaviour missing from the person’s repertoire that is needed and that therefore must be learned or acquired.”
Behavioural analysis (lite – more to come in another post!)
So we can work out which behaviours to focus on, as clinicians we need to do some behavioural analysis. This is often best carried out by observing the person – best in his or her natural environment because the contextual cues are present there – but at a pinch, in a clinic setting. I like video for analysing behaviour, particularly something like limping or guarding or compensatory movements, but larger repertoires of behaviour can be self-reported. For example, if someone recognises that they’re resting more often than they want (especially useful if the person values returning to work), then the person can time how long they rest for and work to reduce that time. Fitness trackers or movement trackers can be great for monitoring this. Other options include asking the person’s family about the particular behaviours they notice as indicators that the person is having trouble with their pain: people around the person with pain often know what’s happening well before the person has said anything!
Now this raises my earlier point about lacking empathy or compassion. It doesn’t feel normal to ignore someone who is wincing, looking “pained” or talking about how much they hurt. And this is why, I think, many clinicians don’t enjoy using behaviour modification in a deliberate way – it either feels unsympathetic, so we avoid it, or we do a 180 turn and we apply “ignore all pain behaviour” indiscriminately. Fordyce definitely did NOT suggest this!
Being human in behaviour change
So, how do we approach a person who is distressed? Do we ignore them or comfort them or what? In true time-honoured tradition, I’m going to say “It depends.”
First, we need to analyse the function of the distress in this context, and in the context of our treatment goals. Remember informed consent! We need to clearly articulate and obtain agreement for our behavioural target, and if someone is distressed and this isn’t our target, then we need to respond in an empathic and supportive way. If we’ve observed, however, that the person we’re working with is often distressed as we begin a new activity, perhaps one that pulls the person towards doing something unfamiliar or a bit scary, then we might have a conversation with the person about what we’ve seen, and with agreement, begin to modify our response.
When I describe “function” of distress in this context, I mean “what does the distress elicit from us, and for the person?” – what are the consequences of that distress for the person? If we reduce our expectations from the person, or the person avoids doing the new activity, then we can probably identify that the distress is functioning to reduce the demands we’re putting on the person. Our behaviour as a clinician is being modified by the behaviour of the person – and probably unwittingly. Reducing demands reduces anxiety, a bit, and it may be anxiety about doing that movement (or experiencing pain as a result of doing that movement) that’s eliciting distress. I wouldn’t say being distressed in this context is deliberate – but it’s functioning to draw us away from maintaining the treatment goals we developed with the person.
So what can we do? In this instance, we might remind the person of our agreement to stick to our plan of activity, we can acknowledge that they’re feeling anxious (that’s probably why we’re doing this activity in the first place!), we can reassure the person that we trust that they can do this (boosting self-efficacy via verbal encouragement), and we can maintain our treatment goal.
Yep. Using this approach is not for the faint-hearted. It means we need to be observant, to always be thinking not just about the form of behaviour we’re seeing, but about its function. We need to monitor our own behaviour (verbal, facial expressions, subtle body shifts, all the non-verbal “tells” we make), and we need to change our own responses to what the person does. And often we find this self-awareness difficult to do. Most of our responses are “automatic” or habitual, and behaviour modification means we need to interrupt our habitual responses so we can help our patient/client do what matters to them.
For a brilliant description of Fordcye’s approach as applied in a case study, Fordyce, Shelton & Dundore (1982) is a great example of how a seriously disabled person was helped via this approach. Remember, this was carried out with the person’s full consent! Chapter 4 of Fordyce’s Behavioral Methods for Chronic Pain and Illness gives the best blow-by-blow description of how to go about this. And for a rebuttal to some of the criticisms of a behavioural approach to pain management, Fordyce, Roberts and Sternbach (1985) offer some very helpful points. That paper also offers some of the best analyses of pain behaviour and why it’s needed as part of pain rehabilitation.
Fordyce, W. E., Shelton, J. L., & Dundore, D. E. (1982). The modification of avoidance learning pain behaviors. Journal of behavioral medicine, 5(4), 405-414.
Fordyce, W. E., Roberts, A. H., & Sternbach, R. A. (1985). The behavioral management of chronic pain: a response to critics. Pain, 22(2), 113-125.
This is a dangerous approach for many chronic pain patients because our Doctors do not take the time to get to know us. They rarely have time to listen at all. So, may patients have undiagnosed conditions that are continuously blow-off by Doctors. The idea that these Doctors then use behavioral modification techniques, such as ignoring, is damaging. We need to take patients & pain seriously.
Hi gaiamom, the day a medical practitioner actually does any behavioural work with someone living with pain is probably the day I will go to heaven! Your point is taken, and believe me as a person living with pain myself, I totally understand your frustration with not being believed, not being investigated, not being taken seriously, and I agree. Though most of my interactions with people living with pain, and medical practitioners, shows that Docs are inclined to go down the investigation route over and over and over again before they’ll be even the slightest bit willing to acknowledge that persistent pain is a thing. Partly it’s because of their need for certainty (we all need that, THB), but also because of the worry that they’ll have missed something. The time when Docs fail to listen to people with pain is when we don’t respond to the treatments they offer – mostly medications which really don’t work very well (certainly not for me!). Then I’m afraid it’s very common for people with pain to be thought to have “failed” the treatment, when actually it’s that the treatment wasn’t the right one and who chose the treatment? Oh yep, the Doc.
FWIW most of the readers of my blog are allied health – physiotherapists, occupational therapists, nurses, osteopaths, chiropractors, massage therapists and so on. I take it for granted that these clinicians will stop, LISTEN to the person, find out what their main concern is and address that before beginning a behavioural approach, though the behavioural approach will probably begin before any medical treatments are initiated.
You might also note that I discussed ethics and informed consent – before any behavioural approaches are used, people must be informed about the approach being taken. To simply ignore someone is unethical and inhumane. That’s not what I’m proposing here.
After 15-years, my docs are far: more interested in tapering my pain meds than finding answers. However, I love the idea of additional behavioral options for patients, in the right hands.
I’m currently seeing a Polyvagal Therapist and the behavioral changes have been powerful.
That push to wean people off medications has resulted in some really nasty behaviour from Drs who are pretty scared of pushback from their regulators. We don’t have as much of that in NZ, but far fewer resources for people with pain too. So pleased the polyvagal therapy is helping! I use ACT mostly, which offers a lot of mindfulness, values-based action, and tools for recognising when my bossy mind gets too uppity! Pity my pain hasn’t changed, but I can generally do what I need to as long as I get reasonable sleep. Good luck!
In MN the state is threatening our Doctors with being removed from the rolls for Medicaid if they treat with opioids. I’m being tapered off the one medication that has worked for me for the last 15-years. It isn’t pretty.
hiBronnie, any suggestions as to how to access those fordyce articles. Cant seem to get through Openathens
They are a bit hard to locate! The best way I’ve found is to use Google Scholar and your library networks. The PAIN journal was through Elsevier I think.
Otherwise I often ask on Facebook to see if anyone has them. Sci-Hub is a possibility too, though I have doubts about the ethics of breaching copyright in this way.