Cognitive Behavioural Therapy

It’s really all about the brain
Neuroscience is such a geeky area to study. And I have to say I didn’t really study the brain all that well in my undergraduate training all those years ago – but oh, how the worm has turned! It’s so exciting to see how basic science directly influences treatments that we can use for people who don’t have many pharmacologic options for their pain.

While I don’t have really up-to-date papers today, I think the 2008 paper by Herta Flor presages some of the approaches we’re starting to use in clinical settings now, a scant three years later. Flor’s work has always been impressive – she has often looked at what happens when brains are deprived of their normal feedback because of trauma or amputation, and (really exciting!) she is coming to Australia for NOI’s Conference 2012.
I came across this 2008 paper while compiling some readings for students enrolling in the Postgraduate papers in Musculoskeletal Medicine through University of Otago (distance taught papers for health professionals interested in pain and pain management).

BTW it’s not too late to enrol for MSMX 704 (Pain) and MSMX 708 (Pain Management) – papers suitable for medics, nurses, occupational therapists, physiotherapists, psychologists, social workers – anyone working in the area of pain.

In this paper, Flor summarises some of the changes that occur along the neuraxis following amputation, and spends time expanding on the mechanisms of maladaptive neuroplasticity and from this, discusses therapies that might directly influence this plasticity.  She notes that the majority of current therapies (particularly pharmacological) don’t address this at all.  Sadly, most of these therapies have limited effect on people, and a large number of unpleasant side effects.

Let’s take a look at some of the mechanisms thought to play a role in phantom limb (and note the similarities between phantom limb, complex regional pain syndrome and post-spinal cord injury pain).  Also please note that I’ve simply abridged notes from Flor’s paper – no reinventing the wheel!

Peripheral mechanisms

  • Structural changes in neurons and axons – terminal swelling and regenerative sprouting of the injured axon end occurs and neuromas form, giving rise to abnormal afferent input to the spinal cord with upregulation, and altered trafficking, of voltage-sensitive sodium channels and decreased potassium channel expression, as well as altered transduction molecules for mechano-, heat and cold sensitivity in the neuromas.
  • Ectopic impulses – these occur in the DRG and can summate with ectopic activity from neuromas in the stump, which can lead to the depolarization and activation of neighbouring neurons, significantly amplifying the overall ectopic barrage.
  • Ephaptic transmission – this refers to transmission of nerve impulses without the need for a neurotransmitter, developing from non-functional connections between axons.
  • Sympathetic–afferent coupling – in some patients sympathetic dysregulation in the residual limb is apparent, and spontaneous as well as triggered sympathetic discharge can elicit and exacerbate ectopic neuronal activity from neuromas as well as at the level of the DRG
  • Down- and upregulation of transmitters – novel receptors in the neuroma that are sensitive to cytokines, amines and so on, may enhance nociceptive processing, while ‘setpoints’ at which the nerve may fire are lowered, requiring less input for the nerve to respond
  • Selective loss of unmyelinated fibres – following trauma, axotomized afferent neurons show retrograde degeneration and shrinking, primarily involving unmyelinated neurons

Central changes

  • Unmasking – Inhibitory GABA(γ-aminobutyric acid)-containing and glycinergic interneurons in the spinal cord could be destroyed by rapid ectopic discharge or other effects of axotomy, or might change from having an inhibitory to an excitatory effect under the influence of brain-derived neurotrophicfactor (BDNF) released from microglia at the spinal cord level, leading to a loss of the normal inhibitory responses.  Downregulation of opioid receptors, on both primary afferent endings and intrinsic spinal neurons can add to this disinhibition due to reducing the normal inhibitory GABA and glycine activity.
  • Sprouting – nerve growth factors can be released in part because of activation of previously quiescent pathways that become functionally strengthened.
  • General disinhibition – previously quiescent, or low-threshold afferents can become functionally connected to ascending spinal projection neurons that carry nociceptive information to supraspinal centres, leading to an increase in the amount of information flowing upwards to higher centres.
  • Map remodelling – reorganization of the spinal map of the limb,could be due to the unmasking of previously silent connections, is also reflected in brainstem and cortical remapping – this is experienced as increased sensitivity in areas adjacent to the original area of damage.
  • Loss of neurons and neuronal function
  • Denervation
  • Alterations in neuronal and glial activity
  • Sensory–motor and sensory–sensory incongruence – the effect of illusions, such as the perception of body ownership of a rubber hand originally demonstrate the speed at which the SI cortex and also frontal and parietal areas respond to visual and sensory incongruence.  It’s this aspect of brain function that is particularly targeted when we start to incorporate mirrorbox or other visual feedback into treatments for phantom limb pain.

I get all excited when I read about this kind of research.  It opens up a whole range of treatment strategies that, for some clinicians, has previously been thought of as ‘purely psychological’, as if there was no ‘real’ (ie ‘organic’, ‘we can image/detect it’) effect.  As we go further into how the neuromatrix works, it starts to provide us with both new ways for treating this kind of pain – but it also goes to explain why some of our treatments work the way they do.

Let’s take, for instance, hypnosis.  One of the effects of hypnosis in chronic pain management can be to provide a person with post-hypnotic analgesia.  An interesting factoid to consider is that hypnosis can also produce post-hypnotic pain, with the right kind of  suggestion.  How can that be?

We didn’t really know how hypnosis worked until fMRI started being used in research.  When someone is given a hypnotic suggestion of analgesia, the cerebellum, anterior midcingulate cortex, anterior and posterior insula and the inferior parietal cortex are all activated to a greater extent than when a suggestion of analgesia is given without hypnosis.

Another form of so-called psychological treatment, cognitive behavioural therapy including biofeedback (EMG and temperature modalities), also activates ‘higher centres’, providing people with structured feedback on what their bodies do in response to their own coping efforts.  When these approaches are monitored with fMRI, lo and behold, once again those same areas of the cerebellum, anterior midcingulate cortex, anterior and posterior insula and the inferior parietal cortex are affected.  This applies when people use ‘coping self statements’ like “I can manage”, “I’ll be OK”, and diaphragmatic breathing as well.

Where this leads me to is that over the next 5 – 10 years, I predict that there will be increasing recognition for pain management strategies that have been demonstrated to be effective for some people, in that the neurobiological basis for this treatment response will be imaged.  It’s a shame that “seeing is believing” rather than looking at longitudinal outcome results within RCT ‘s for treatments that are not biomedical to be accepted, but there you have it.

Tomorrow – some more approaches that have been found useful for phantom limb, post spinal cord injury pain, and CRPS pain.   Not just mirrorbox!

Flor, H. (2008). Maladaptive plasticity, memory for pain and phantom limb pain: review and suggestions for new therapies Expert Review of Neurotherapeutics, 8 (5), 809-818 DOI: 10.1586/14737175.8.5.809

Flor, H., Nikolajsen, L., & Staehelin Jensen, T. (2006). Phantom limb pain: a case of maladaptive CNS plasticity? Nature Reviews Neuroscience, 7 (11), 873-881 DOI: 10.1038/nrn1991

Derbeyshire, S., Whalley, M., Oakley, D. (2009). Fibromyalgia pain and its modulation by hypnotic and non-hypnotic suggestion: An fMRI analysis. European Journal of Pain, 13(5), Pages 542-550 doi:10.1016/j.ejpain.2008.06.010

Skills, Strategies & Resources in 2010

Part of the reason for this blog is to introduce clinicians to some of the research and application of coping strategies for people with chronic pain.  While I can summarise the year’s developments in (almost) a single sentence (see below!), it’s also true that I’ve posted a lot of really interesting findings about coping over the year.  Today’s summary links to the goodies I’ve found in 2010.

Oh, my summary? There is nothing especially new under the sun in self managing pain – it’s about goals, acceptance, exercise, engaging in important activities and roles, gratitude, connecting with people…oh and mirrorbox for some lucky people for whom it works well!

Cognitive behavioural approaches to pain management

Before I post the links, a quick word to describe a CBT approach in pain management.

Many clinicians who are not psychologists, or who have primarily ‘physical’-oriented practice and training think CBT as something for health psychologists or clinical psychologists to do.  This is most emphatically not the case!

For a CBT approach to be most effective, the entire team working with a person need to adopt a CBT model as the guiding model, with individual techniques fitting into it. For people with pain, there is nothing more confusing than being given different explanations and approaches!

A CBT approach acknowledges the following:

  • That people interpret what is happening internally and externally
  • That these interpretations influence emotions and behaviours – and that relationships are reciprocal
  • That people can alter their thoughts and beliefs, and in so doing, take charge of the ways in which they respond to situations

A CBT approach assumes that:

  • People can learn to accept the chronicity of their pain
  • People can change their relationship to their pain so that instead of having an identity based on pain, symptoms, being a patient, they can become a ‘well person with pain’, or a ‘person living well with pain’
  • People can learn or re-explore skills to deal more effectively with pain

The goals of CBT are:

  • Reduce pain intensity (where this can happen)
  • Increase functional activity, including work
  • Reduce/rationalise the use of medication and healthcare resources
  • Reduce distress
  • Improve quality of life

Why use this approach?

  • Promotes reconceptualising pain as a biopsychosocial phenomenon
  • Provides for many areas of intervention
  • Effective
  • Can be conducted alongside other therapies (although combining a focus on pain reduction with pain acceptance is difficult)
  • Improves collaboration and engagement with the person who has pain
  • Promotes a common language

What comprises a CBT approach?

  • A good explanation or mental model of pain (one that includes biopsychosocial elements)
  • A collaborative approach
  • Development of active coping strategies to downregulate physiological arousal – mindfulness, diaphragmatic breathing, relaxation, hypnosis, coping statements, exercise
  • Goal setting to return to valued activities and re-engage with life
  • Problem-solving to develop alternative strategies when obstacles arise
  • Effective communication with others including intimate relationships, work, health care providers, systems
  • Linking thoughts, emotions and behaviours throughout
  • …and a few others I can’t think of right now!

(NB: the above is drawn from papers by Morley, Ecclestone & Williams, 1999; Morley & Keefe, 2007; Morley, Williams & Hussein, 2008; and lots of other assorted readings over the years!)

Can psychological management of fibromyalgia affect pain?

Developing a set-back plan

Flare-ups, breakthrough pain, or set-backs: self managing exacerbations of pain

Why bother with happiness?

Happy! Happy! Joy! Joy!

Counting your blessings

Go on, expose yourself!

Fear, anxiety and avoidance

Fear, anxiety and avoidance – reprise

Working with thoughts – habits too

What to do when feeling grumpy, low or fatigued

Essential skills for people living with pain

Graded exposure in the real world

Exercise questions

Values informing goals

Goals, outcomes, direction and values

Mindfulness and exercise

A quick (oops! long) observation on using ACT

Accepting what life throws at ya!

10 things you really oughta know about pain

Physical and organisational ergonomics

What obstacles get in the way of self managing chronic pain?

Online CALM

Links to online CBT resources

Relaxation…how, why and the evidence

Just doing it: behavioural activation

Goals – how relevant are they?

Pain and health anxiety: working with beliefs

Pain and health anxiety: working with worried people

Accepting chronic pain


Maintaining change

When in danger, when in doubt – deep breath in, deep breath out

Attention please! Attention management for chronic pain

That’s it for now – plenty more posts to organise though.

A year in review

This is the third year I’ve written this blog.  As the year ends, numerous people will be reviewing the year, reflecting on the good, the bad and the indifferent, and like them, I will too.

What has been the same this year is the endless need to repeat to all and sundry the following:

  • All chronic pain starts with acute pain – maybe if we were able to effectively manage risk factors for developing chronic pain in people when they first present for help with their pain, my job would be less in demand.
  • All pain, whether acute or chronic, is a psychological experience – and can’t be understood without an appreciation of the biopsychosocial model.
  • Because pain is a psychological experience means that we can’t divide pain into nociception and the psychological response to that nociception – because the two are indivisible.  Our brains are not just ‘waiting for’ peripheral events to reach them – the brain is not a blank slate, it’s actively involved in determining which aspects of our experience ‘we’ will experience.
  • There is not a lot new under the sun in pain management really.  Not a lot of new drugs (mostly they’re derivatives of opium, or they’re old drugs that have been adopted for new uses), and not a lot of new procedures, and no, not even a lot of new psychosocial/nonpharmacological treatments.  With, perhaps, the exception of brain retraining a la Moseley, and the introduction of acceptance and mindfulness based treatments.

What has been different this year?

  • More discussion across ‘Web 2.0’, or the medium of the internet – Facebook, Twitter, blogging and email.
  • More detail of the aspects of the cognitive behavioural approach to pain management that is influential to change, and along with that, more recognition that one size does not fit all.
  • More detail of what works for whom and when.
  • More need to not only assess – but also treat people!
  • More recognition that people with pain live in a network of relationships with other people, within communities and sociopolitical systems including legislation, and that all of these have an influence on the person’s ability to cope.
  • Increasing recognition that the health provider relationship has as much influence on the individual as his or her own beliefs.  Yes folks, what we say and how we say it does have an effect! Maybe not quite what we had expected, but definitely we have an effect.
  • More awareness that it’s not so much WHO delivers self management, but that self management IS delivered that is important!

In Christchurch, we’ve had the momentous earthquake and the aftermath.  Internationally we have had wars, rumours of wars, pestilence and plague – and yes we’ve even had locusts (in parts of Australia!).  Once again I’ve made friends with people from all around the world, all sorts of professional backgrounds, all sorts of interests in pain and pain management.  And I’ve continued to learn – from fellow clinicians, colleagues, patients, the journals I’ve read, the blogs I’ve read, the discussions (and maybe even arguments!) I’ve had – all have prompted me to think and learn and question.

And once again, I reflect on the incredible nature of science and the way in which I, as a clinician, ‘stand on the shoulders of giants’ to learn more.  To know that no ‘fact’ is sacred – that if there is evidence there to challenge a ‘received’ view, even a view that I’ve cherished, then it’s my duty to look at that evidence in the face and check it out.  There is no need to resort to mysticism, nor to hold to magical beliefs, or sacred texts.  Research is there for us all to learn from, and it’s my privilege to help share it to people who may not have the time or access to the information I do, and by doing this I might have a chance to help people live lives that are a bit better in quality than if I had written nothing.  At least that’s what I hope happens!

I’m incredibly thankful to the people who take time to comment and question me.  I’m not a guru, I’m definitely blinkered in my own perception of what I see, and I admit to being somewhat biased.  That’s another reason for writing – by putting my thoughts out to the interweb, hopefully people can bounce ideas off what I write – and then ask me questions!  And in doing that, I learn too.

2011.  Who knows what it will bring.  I expect (and yes, hope) it will bring even more questions!  Do ya feel like coming along for the ride?!

Knowing how is not equal to doing
There have been several attempts to develop a standardised approach to self management – one of the most popular in New Zealand is the Flinders Program (TM). This is a programme developed in Australia from the 1990 Australian Coordinated Care Trials. It’s based on cognitive behavioural therapy, includes problem solving and motivational interviewing techniques, and provides a set of tools and processes that clinicians can use to help people assess and then develop self management plans. The aim, as for any self management programme, is to shift the ‘balance of power’ so to speak from clinician-centred to patient or client-centred partnership, so that shared decision-making about health occurs.

It has been used in New Zealand for some years: the Arthritis New Zealand organisation conducts group programmes for members, and there has been widespread training of mainly primary health care nurses in the programme – about 500 health professionals have attended a two-day training workshop carried out by a Flinders trainer, and there are  assignments to be completed before a Certificate of Competence in Chronic Condition Self-Management is issued from Flinders University.

All very well then.  Training is available, people have completed the training – so we should be sweet? Maybe not.  This paper by a group of New Zealand researchers interested in chronic condition self-management identifies that while primary care clinicians may know what to do – in practice, they don’t actually do it.  Or at least, they weren’t at the time of this study in 2007-2008.  Thankfully, this paper identifies some of the problems – and some of the enablers too.

So what gets in the way of helping people in the community develop self management?

The main response was – lack of time.

It takes about 60 – 90 minutes to conduct an assessment and start the process of generating goals.  Follow-up appointments are estimated to take around 30 minutes.

Other problems are possibly more telling – lack of funding for providing this service, no electronic versions of the material, clients can’t/don’t want to pay for this, clients don’t want to have the long appointments, no space to do the work, resistance from GP’s (what?!!), resistance from other nurses (!), resistance from management (!), lack of mentoring.  And a few others such as not being in a Maori framework, or people not speaking the language.

Wow – 14% of respondents suggested that GP’s and 12% suggested that nurses resisted the use of this approach. I wonder what that’s about?  Resistance to a tool that has good evidence, helps patients, encourages people to get involved in their own health – but, admittedly, does take time and isn’t directly funded.  And there is that possibility that it’s a huge shift from a clinician-centred to a patient-centred approach.

Systems issues are incredibly powerful.  I’ve often pondered the fact that the greatest agent of change in health practice is not ‘evidence’, it’s not the latest workshop or the best clinical approach – it’s what is funded and how it’s funded.

Take a quick look at the impact of funding options on the delivery of physiotherapy in New Zealand.  In the early 1990’s there were physiotherapy practices all over New Zealand treating people with chronic pain using passive therapy for – well one patient proudly told me she had been to physiotherapy three times a week for hands-on therapy for the last five years.  All funded by our accident insurer.  And she also admitted that she only got short-term relief, maybe an hour or so.

In mid-2002 this all changed.  Treatments for people with persistent pain now needed to be delivered by interdisciplinary teams – rapidly a whole new set of private providers responded: occupational therapists and physiotherapists started to work together, and even the occasional clinical psychologist got in on the act.  Now, in 2010, the same programme must be staffed by clinical psychologists, while occupational therapists and physiotherapists are lumped together under the heading ‘functional’.  All changes initiated, and maintained by the way treatments are funded.

What enabled the use of the Flinders Program in New Zealand?

Strong leadership, ongoing contact with a trainer, funding for the programme, support from nurses, support from GP’s, and far behind… conferences and newsletters.

Like the people we work with, simply knowing how to do something is not enough.  We need to develop confidence and skill in a new approach, and we as clinicians certainly need to be supported and have systems that make it easy to carry on with an approach that differs from ‘standard medical practice’.

It seems to me that while there is ready acknowledgement in many circles that chronic health conditions such as chronic pain need to be self-managed, our current service delivery systems don’t support it.

Self management is not just a case of telling someone what to do – that’s the old  ‘Trust me, I’m the doctor’ approach.  Self-management requires time, engagement from both parties to see it through, and mutual trust.

The patients I work with say again and again that they just wished their doctors, specialists and other clinicians would only stop and listen to them, then give them information and options so they can choose.

This is such a different way of working from our traditional healthcare training that I’m not a bit surprised that so few of the respondents in this survey actually used all the Flinders Program tools in the way these tools were intended.  It’s not enough to know how – clinicians really do need mentoring (we could call it supervision), help to know they have time and collegial support as well as funding to change practice.

Finally, this study argues that there is limited evidence that a self-management approach is able to be adopted in New Zealand in the way it has been elsewhere in the world.  I’d say the authors need just to take a look at the three main pain management centres in New Zealand – two of whom have been operating since at least the early 1990’s – to see a group of clinicians who have been able to deliver and support self management to people who have chronic pain.  While the approaches are not the Flinders Program (TM), they are solid self-management strategies and are very effective in a patient group that can be challenging.

Maybe transplanting a ready-made programme isn’t the only way to begin a revolution in New Zealand.  Maybe it’s time to take a look at a home-grown approach.  And maybe it’s time for health systems to start with the successes we already have and learn from them.

M Horsburgh, J Bycroft, F Goodyear-Smith, D Roy, F Mahony, E Donnell, D Miller (2010). The Flinders Program of Chronic Condition Self-Management in New Zealand: Survey findings Journal of Primary Health Care, 2 (4), 288-293

Can psychological management of fibromyalgia affect pain?
When I’m working with someone who has chronic pain, from the outset I’m pretty straight-up that the treatments I offer don’t directly affect pain intensity.  It’s not my focus, and very often after the first session, I don’t even discuss pain – I’m more interested in what the person is doing! And for this focus, I sometimes get some reasonably snippy comments, none more so than a doctor (who shall remain nameless) who said to some of my students that psychological and functional approaches to pain management are, in effect, useless because they ‘can’t directly address the pain’.

Well, I beg to differ, kind sir. While pain intensity isn’t the focus of treatment, it very often is affected by the treatments offered using a cognitive behavioural approach – and here’s a lovely meta-analysis by Glombiewski and colleagues demonstrating just this.

Fibromyalgia is, arguably, the prototypical ‘central sensitivity’ pain problem.  Although the mechanisms of fibromyalgia are still somewhat unclear, it’s becoming more evident that it’s the descending inhibitory pathways that are affected in this disorder.  What this means is that more information than in ‘normal’ people reaches the higher centres of the central nervous system, resulting in the brain identifying this information as ‘dangerous’ and therefore, more painful, than for other people.  I have fibromyalgia, and for me it means aching, burning, fatiguing pain that travels around my body, as well as fatigue that can make it more difficult to cope with the pain I feel.  I reframe this as being ‘more sensitive’, so I am really a ‘sensitive soul’!

Back to a meta-analysis.  Meta-analytic studies are a great thing – they summarise and mathematically establish, across multiple studies, the effects of treatments.  What this means is that a great many studies are collected together, and the findings summarised so that it’s possible to find out the overall effectiveness of a particular treatment – provided that the studies use pretty much the same inclusion criteria, outcome measures and reporting methods.  In this case, 1530 studies met the initial inclusion criteria – but only 24 studies actually made it through to the final analysis!  One of the arguments against meta-analytic studies is that many pieces of research don’t get included because of various shortcomings in, perhaps, outcome measure methodology, treatment approach, or lack of randomisation etc.

Nevertheless, 24 studies were able to be included, and ranged across cognitive behavioural approaches (in this study, to be included as a CBT approach, the study needed to have cognitive, operant and/or respondent techniques in combination), biofeedback/relaxation training, mindfulness, educational and behavioural approaches.

What the researchers found was that a cognitive behavioural approach provided small but robust improvements in pain intensity reduction, sleep duration and low mood, and that these improvements were evident over both short and longer term.

A further finding was that there was a ‘dose-response’ effect – longer or more intense programmes provided better outcomes, while briefer input resulted in lower effects.

Now a question here  – how can a hands-off treatment change pain intensity?  This is the question that my good doctor friend doesn’t understand.  If your view of pain is that nociception is all there is to pain perception, then I guess it does make it difficult to understand how pain can be influenced by a treatment that doesn’t target the nociceptors.  (A brief refresher on nociception – this is the transmission of information from the periphery of the body to various parts of the central nervous system via a sensory receptor that responds to potentially damaging stimuli.)

I think my colleague’s misconception is that he believes that there is a dedicated system that sends ‘pain signals’ to a passively receptive brain, or more specifically, the sensory and motor cortex of the brain, to be ‘perceived’ – and that the only way to change ‘pain’ is by interrupting these signals.

If only it were so easy!  But this view is a very simplistic one, and our central nervous systems far more complex than this.  My thought is that if our ability to survive depended on a dedicated ‘pain system’ then we’d risk it being knocked out or damaged far too easily, so it’s much more likely that a ‘distributed system’ approach has evolved wherein pain is a product of a neuromatrix that has the job of detecting information about our body that is important (ie salient) and novel (ie new or changing).

I’m not alone in this view either!  A nice paper by Iannetti and Mouraux (2010) details this model of pain, developing the original idea of a multimodal neuromatrix proposed by Melzack and rebutting the concept of a ‘pain matrix’.  Well worth reading if you’re interested in neurobiological theory of pain.

As a result of acknowledging that a neuromatrix exists to process information about the body and environment and to detect important and new information that could be a threat to the individual,it makes sense to me that any effort that alters the threat value of that information about the body state is likely to – reduce distress, improve mood, improve function, reduce disability – and reduce pain intensity and even quality.

Does the converse hold true? If a signal to the brain is disrupted, without altering the threat value of that information, is it likely that the pain will reduce? Well maybe, because at least some of the information isn’t reaching those parts of the brain there to detect important information.  But on the other hand, it may also disrupt the information that the neuromatrix thinks ‘should’ be reaching it, and in so doing, maintain pain – and distress, anxiety, low mood, disability and difficulty doing what the person wants to do.

We can’t do just one thing and hope to influence such a complex phenomenon as pain.  If pain is a biopsychosocial thing, then it probably takes biopsychosocial treatment to change it.  And that, my dear medical pal, is why psychological and functional approaches can influence pain intensity – and much more beside.

Glombiewski, J., Sawyer, A., Gutermann, J., Koenig, K., Rief, W., & Hofmann, S. (2010). Psychological treatments for fibromyalgia: A meta-analysis Pain, 151 (2), 280-295 DOI: 10.1016/j.pain.2010.06.011

Iannetti, G.D., Mouraux, A. (2010).  From the neuromatrix to the pain matrix (and back). Exp. Brain Research, 205, 1-12.

Developing a set-back plan in pain management
Without a doubt, anyone reading my blog will have tried at some point to change a habit.  Maybe to stop drinking coffee (why?!), start doing more exercise, say no to new projects, eat more fibre – even when a decision to make a change is not done of a New Year’s Eve, chances are that maintaining that new habit is not entirely smooth sailing!

It’s the same for people living with chronic pain.  Maybe one change is to use relaxation more often, while another might be to exercise more – while the specific method might not be difficult to learn, dealing with the mind chatter and maintaining the new behaviour pattern can be hard.  What’s more, for most people with chronic pain it’s not just changing one aspect of their life, very often it’s a number of areas that are up for renovation.

Set-backs come in many forms.  It’s tempting to think only of flare-ups as being a set-back, but if we consider the active use of strategies to be the new behaviour (rather than pain intensity or whether a flare-up actually occurs), then a set-back can be a period of time when pain is low (why bother using relaxation, why keep up with exercise – after all, I feel fine!), or it can be a change of environment – perhaps a holiday, new job, a move to another house.

Marlatt and Gordon’s Relapse Prevention Model is a very popular way of viewing situations that may elicit lapses or relapses in behaviour change.  This model was developed in relation to problem drinking, but has been extended and applied to many problem behaviours such as gambling, quitting smoking, sex offending and so on.  And yes, it’s been applied to pain management behaviour change too.  This is a nice summary of the model as it applies to problem drinking. The key points of this model are that it distinguishes between ‘lapses’ and ‘relapses’.

You probably know from your own attempts to change your habits that it’s easy to — ooops! slip up, and do exactly what you vowed you wouldn’t.  Maybe the weather is a bit wet and chilly to get out and exercise.  Maybe it’s someone’s birthday shout at work and you have that slice of chocolate cake.  Whatever the reason, you’ll probably have thought (at least momentarily) – oh no! I’m back at square one again.  Many people with chronic pain say the same things – they’ve stopped exercising or planning their day, and oooops! Back to square one.

The difference between a lapse and a relapse is in the duration of the slip-up.  Once or twice, recognising this and returning to the new behaviour – that’s a lapse.  It happens.  Doing that for longer – maybe more likely to be a relapse or return to old habits.

A set-back plan identifies what to do when a lapse, slip-up, set-back, flare-up, whatever occurs.  It does the thinking before the event so that as soon as it’s recognised, there is a plan for returning to the new behaviour.

In the Centre where I work, two plans are developed – the main Pain Management Plan consisting of the components I discussed several days ago – but personalised and clearly listed on the “Purple Planning Sheet” (thanks Bronny!); and the set-back plan.  The PMP details the ways in which the person has decided work well for living with pain.  Our plan is quite detailed and includes areas like relationships, leisure, exercise, mood management, sleep management, work, communication and so on.  The participant lists specific actions he or she has found to be helpful for maintaining (or developing) a balanced life in which they are the drivers rather than pain.

The set-back plan sits alongside the PMP.  It includes space for the person to indicate their own ‘High Risk Situations’ – those situations in which they are less likely to use their new skills; it reminds people of the ‘Problem of Instant Gratification’ – and ‘Seemingly Irrelevant Decisions’.  These are things like deciding to do 20 lengths of the pool because it feels so good to be doing something (PIG); deciding to ask family around for dinner and then tidying the whole house and then remembering at the last minute that it’s wonderful to have flowers on the table so going into the garden to get flowers but while you’re there, doing some weeding and before you know it – being too sore to enjoy the meal (a whole chain of SIDS).

The plan itself is about developing, through problem solving, a range of options that maintain at least part of the pattern of helpful behaviours that have been established on the Pain Management Plan.  For example, if exercise is important and usually means cycling to work, when the weather is inclement it’s important to have ‘something else’ that can be done.  If being assertive and saying NO to certain activities is important, then having some ‘ways to say no’ and to bow out gracefully can be really helpful.  Prompts, reminders, alternatives, reinforcements, ways to recruit help from others, positive self statements – all of these can go onto a set-back plan.

Maintaining change is an area that I think telehealth, or support from a distance may be useful.  While the evidence for intermittent contact as a strategy for maintaining self-management isn’t very clear-cut, I think there may be merit in exploring low-level, inexpensive ways to provide prompts or refreshers/reminders as part of a structured supported self management approach.

I was interested to read the very clear description and methodology of Therapeutic Interactive Voice Response for maintaining change by Naylor and colleagues.  The idea behind this is to provide “automated access to self-monitoring, didactic review of coping skills, guided behavioral rehearsals of skills including prompts for regular practice, and personalized encouragement and reinforcement.”

In practice, what this meant was participants who had completed a fairly standard CBT approach to pain management, had access to a structured and pretty intensive telephone-based programme that asked participants to self monitor their progress through rating scales; reviewed skills; guided behavioural rehearsal of coping skills (eg mini-relaxations); and monthly therapist feedback.  In this study, access to this support was maintained for four months.

What this research found was that across a wide range of outcome measures including pain intensity, mental health, physical activity and disability, participants maintained their changes.  Not only did they maintain these changes during the four months of telephone support, they also maintained changes over a subsequent four months – to a greater extent than those who didn’t have access to this kind of support.

I think this approach is promising.  Ongoing support groups have some negative effects, particularly if they rely on volunteer or lay leaders (who may have their own issues to manage), and they can foster a degree of ongoing identification with the ‘patient’ role.  Similarly, providing intermittent refresher groups may also generate some dependency – and they can be costly in clinician time.

Perhaps a telephone or internet-based approach like this, combined with the personalised set-back plan, and pain management plan, might help people maintain their new healthy lifestyle and allow them to feel less like ‘patients’ and more like ‘people learning new habits’.  It would be even more fantastic if this was something GP’s and other primary health practitioners could direct ‘graduates’ from pain management to in the event of any kind of set-back, including flare-ups.

It looks to me like something a group of computer nuts and clinicians could work to set up – food for thought huh?

NAYLOR, M., KEEFE, F., BRIGIDI, B., NAUD, S., & HELZER, J. (2008). Therapeutic Interactive Voice Response for chronic pain reduction and relapse prevention Pain, 134 (3), 335-345 DOI: 10.1016/j.pain.2007.11.001

Flare-ups, breakthrough pain or set-backs: self managing exacerbations of pain

ResearchBlogging.orgA couple of days ago I wrote about medication and managing flare-ups, and out of that post there was a bit of discussion about what exactly I meant by flare-up, and whether it might be better defined as break-through pain.  I’ve found that there is not a lot of agreement in the literature – nor with clinicians! – in terms of distinctions between flare-up or breakthrough, so I’ve decided to redefine the problem completely. Not that I’m the first to do so, as you’ll see from the paper I’ve referred to today.  I have to admit that I like Turk’s approach to chronic pain, as it’s the way I have been trained to approach pain management.  Turk is also the author of a self-help book for chronic pain management that I still think is one of the best – The Pain Survival Guide. I intend to consider both as a form of set-back.  And I’ll refer to exacerbations of pain as flare-ups for want of a better term.

How do both flare-ups or breakthroughs affect people?

The first thing is that both represent exacerbations of pain.  Whether the exacerbation is very brief, or somewhat longer, the fundamental problem is that pain has increased from a baseline.  This is a very common situation – it’s also one of the main features of having a chronic health condition. So we can expect chronic pain to change in intensity from time to time, and learning to manage that is one of the key aspects of maintaining self management.

Flare-ups are one of the main reasons people with chronic pain who have been through pain management return to their health care providers. Some models of self management see this ongoing relationship with a clinician as an integral part of how to live with the condition.  I think it can be somewhat fraught with the potential for self management to be inadvertently undermined as I’ll discuss in a moment.

Using a cognitive behavioural approach for managing pain means recognising that how a person appraises, or evaluates a situation (including pain) influences both the emotional response, and the behavioural response.  Appraisal is also influenced by past experiences, anticipated future outcomes, underlying mood, longer term tendencies (such as negative affectivity, anxiety sensitivity and so on), and social context.

Because a flare-up is a change in the intensity of pain, a very common tendency is to catastrophise, or think the worst.  It’s a difficult situation often, because we are almost hard-wired to take notice of novel stimuli, and especially those that are particularly salient.  In other words, changes in our situation that our brains consider to be important are brought to our attention pretty rapidly.  For a nice discussion of this tendency, a recent paper by Iannetti and Mourax (2010) is a good read.  As a result, any change in pain, particularly any increase in pain, tends to catch the attention – and then a number of cognitive habits come into play.

Once a person evaluates pain intensity in a catastrophic way, emotional distress starts to increase.  People respond to emotional distress differently, depending on emotion regulation tendencies (to externalise, to suppress, to seek action and so on), and this leads to a range of often unhelpful coping strategies.

During flare-ups, escape and avoidance strategies often come into play – and this makes sense initially because it may mean a reduction in pain.  It also either means a reduction in getting involved in activities that are valued or important, and – often not recognised – it doesn’t necessarily change the pain intensity very much at all.  It may instead reduce distress.  Now that’s not always a bad thing, because heightened distress brings with it many undesirable outcomes such as additional attention from others, negative judgements about self, and a reduction in the range of options to help manage the situation (see my posts on the ‘broaden and build’ theory).  But it does mean that life can become rather less satisfying, especially over time.

Self management can be undermined

When encountering a person who is distressed it’s relatively easy for a treatment provider to address reducing the immediate distress, while omitting to look at the longer term effects of doing so.  This is especially important when a person is developing self management.

Confidence to manage pain, or self efficacy, involves successfully using active coping strategies even during difficult times

If a clinician can show the person with pain that he or she can manage with active coping, this will support self efficacy for managing pain.  If a clinician instead suggests a method that reduces distress but doesn’t support the use of self management (such as prn medication or passive treatments), this reinforces to the person with pain that the coping strategies they have to hand are insufficient.  By doing this, it effectively reinforces to the person that they shouldn’t have confidence in self managing pain.

What to do, what to do…

If I’m suggesting here that clinicians should avoid undermining self management by thinking carefully about how to respond to distress, what exactly will be useful?

Well, one thing to remember is that we, as clinicians, are susceptible to responding to distress.  It’s probably one of the reasons we choose to work in health care!  We need to be empathetic, rather than sympathetic.  By this I mean we need to come alongside the person, and acknowledge their distress, but not allow this to influence our reasoning process.

Distress often arises from catastrophic thinking – thinking things like ‘I can’t cope’, ‘This pain will never end’, ‘I shouldn’t have this pain’, ‘It’s horrible’ and so on.  When someone’s highly distressed, it’s not easy to work through a reasoning process to challenge these thoughts.  It’s helpful in the first instance to work on reducing their negative emotions through down-regulating their arousal level – and because the aim is to help the person manage by themselves, it’s useful to remind them to use diaphragmatic breathing, calming self statements, and by doing so, interrupt the distressing chain of thoughts.

Once they’re somewhat calmer, I think it’s helpful to reconceptualise a flare-up as a set-back from their usual pain management plan.  A couple of days ago I described the main components of a pain management plan – along with this plan, I think that recognising that set-backs will occur, and pre-planning for this eventuality does a couple of good things:

  • The shock value of a set-back is somewhat diminished
  • By developing a plan when emotions are neutral or even positive, creative options for coping are much more readily generated than when a person is distressed (see Broaden and Build theory again)
  • It gives everyone a set of options to support the person to get through the experience (including family, friends and health care providers)
  • It recognises that set-backs can come in many forms, and plans can counter this in many different ways

More on this tomorrow – it’s a very important area of pain management to work through.

Turk, D.C., Swanson, K.S., & Tunks, E.R. (2008). Psychological approaches in the treatment of chronic pain patients–When pills, scalpels, and needles are not enough The Canadian Journal of Psychiatry, 53 (4), 213-223

Iannetti, G., Mourax, A., (2010). From the neuromatrix to the pain matrix (and back). Exp Brain Res  205:1–12

Medication and Self Managing Chronic Pain (iii)

When discussing medication and pain reduction for chronic pain, it’s not surprising there are some very strong opinions and emotions.  After all, having pain is universally known to be unpleasant, very few people really want to have pain (except those who like the rush of acute pain – vis a vis body suspension!), and the first person many people go to discuss their pain is a medical practitioner.

The way the centre in which I work views medication is that it forms part of a toolkit for managing pain, alongside all the self management strategies that we also endorse.  So, by and large, most of the people we see are on a stable regime of medication targeting the underlying mechanisms thought to be influencing the nervous system’s sensitivity to stimuli.

A reader suggested that there is a difference between ‘breakthrough’ pain and ‘flare-up’ pain.  I had a look in the literature, and it’s very clear that the terms are not used consistently – so here is the way I use the terms.

Breakthrough pain to me is a term that has most usefulness in acute pain (eg post-operative pain), or in cancer pain.  A regular amount of analgesia is used, with additional medication available when the pain ‘breaks through’ that analgesic cover.   Most of the additional medication is short-acting, and is designed to act quickly to provide that analgesic cover.  I use the term breakthrough pain when there are regular variations of pain through a day, and the pain ‘breaks through’ because the overall level of analgesia is not quite sufficient – perhaps because of side effects being unpleasant, or because of a progressive element in the underlying disorder.  NB – this is the way I use this term, and as I’ve noted, definitions vary, but I’ve mainly found literature describing breakthrough pain in cancer pain rather than non-cancer chronic pain.  (This is one of the journal articles that discusses it quite nicely – a little old, but none-the-less explores many of the issues – Portenoy & Hagen, Breakthrough Pain: Definition, prevalence and characteristics. Pain, 1990 (41:3), pp 273-281. )

Flare-ups, on the other hand, I describe as variations from a baseline level of pain.  Flare-ups can be any length of time, short or long, and can be influenced by numerous factors, psychosocial and biophysical. Flare-ups can occur periodically, intermittently, erratically, or regularly. Flare-ups don’t represent a new ‘injury’ or disorder, or even necessarily a change in the underlying disorder. Flare-ups generally settle down, and are commonly more difficult to handle if the person experiencing them feels they have no control over duration or intensity, or no control over how to cope with them.

The basic question, I think, is whether medication is useful for managing exacerbations of pain,. whether temporary or longer term. 

Before I discuss that particularly thorny issue, I want to consider the other tools in the toolkit – and the cognitive behavioural approach within a biopsychosocial model, because without viewing pain in this way, I think it can be really difficult to consider ways to manage pain aside from reducing pain intensity.

The first tool in a pain management toolkit is understanding something about the neurophysiology of pain, or having a model or framework on which to hang various aspects of pain and how it affects people.  This helps in many ways – it makes the experience more understandable, particularly when considering the multiple body systems that get involved in pain; by making it more understandable at least part of the anxiety/fear associated with pain reduces – the threat value diminishes as the evolutionarily younger parts of the brain are able to influence the more primitive areas of the brain.  This can explain why someone can voluntarily sit through a body suspension and reinterpret the sensations as exhilarating rather than fear-provoking.  It’s important to move beyond just a neurophysiological model too, because we’re also psychosocial animals.  While I’m sure that at some stage we’ll find out how psychosocial factors directly influence neurophysiology, I don’t think the science is yet far enough advanced to be used in patient education (hey, some clinicians still don’t think psychological factors influence neurophysiology!).

The second tool is having ways to reduce physiological arousal.  To me this comes before thoughts/beliefs work, because even if someone doesn’t ‘get’ the model of pain, and can’t access their own thoughts and emotions readily, they can still use practical strategies like breathing, deliberately reducing muscle tension, relaxation and so on.

The third tool is developing an understanding of, and using, activity management.  This means understanding how to establish a baseline, how to progress a baseline, and how to use this on a daily basis to manage the physical demands of an ordinary life.  There are several tools in this part of the toolkit because activity management also involves planning, goal-setting, problem solving and working with thoughts and beliefs about what needs to get done and how it can be done.  It can even mean working on communication, self esteem and relationships because when changing behaviour, all these things are likely to be influential.

The fourth tool is developing an awareness of the influence of thoughts and emotions on behaviour, and on the experience of pain.  This is one of the critical skills for self managing chronic pain, IMHO, because it helps people develop flexible ways of coaching themselves to manage situations.  It also, when all elements line up, means the person may not need much more from health professionals and can live as a person who just happens to have pain, rather than a patient.  This aspect of the coping toolkit involves learning how we appraise situations, the effect of these appraisals on our emotions, and how this in turn can influence our actions.  And yes, recognises that each one of these factors operates on the others!

How we, as clinicians help people develop these tools is the focus of the Healthskills blog.  It’s my intention that these posts help clinicians and people with pain to learn as much as possible about the psychosocial aspects of pain and the underlying neurobiology because it’s by learning this we are able to help people live more fully in the world without experiencing overwhelming distress, despair or demoralisation.  AND without limiting their lives so that they’re able to have very little of what makes it all worthwhile to be alive.

I’ll continue this series on medication and self management over the next week – but it’s vital to me that when we’re looking at the use of medication, whether as a way to reduce some of the pain intensity, or as a way to minimise painful exacerbations, we also appreciate the need to fully use the other tools that we have to influence pain.

’nuff said – flare-ups will be on the menu next week when I start discussing set-back planning.

Rebuilding work identity

I love helping people return to work.  It’s got to be one of the most rewarding parts of pain management for me because not only is work important for health, it’s a major part of our day, and it’s a whole lot about individual identity.  So helping people reconstruct their sense of self to the point where they can go to an employer and say ‘I can do this for you’ with confidence is an enormous challenge.

To feel confident enough to put yourself on the line to an employer despite chronic pain is a challenge.  It involves at least some of the following (and yes, this is mostly from my experience on this post!):

  1. Good self efficacy for managing pain – to the point where fluctuations in pain intensity can be taken with equanimity
  2. Strong knowledge of what you can do
  3. A sense of yourself as OK despite limitations (reconstructed identity as a worker)
  4. Ability to communicate effectively, especially when it comes to doing things differently so as to accommodate functional limitations
  5. Underlying routines and habits that can maintain optimal functioning in a work environment

I’m going to put myself out here – I think that although some of this work is considered within pain management contracts for ACC (our national accident insurer), I think much is missing.

There are some assumptions held by people about work.  Sort of a Calvinist view that everyone ‘should’ work, that work ‘should’ be done dutifully albeit not really enjoyably, and that everyone ‘should’ know what kind of work they can do – or be grateful for the chance to go to work so be happy with whatever is provided.

This somewhat simplistic view of ‘work ethic’ ignores some really significant issues – and as a result, the programmes for returning to work for people with chronic pain, along with the pain management programmes, don’t seem to address them.

A couple of vignettes might help illustrate the problems:

  • Angus is 58, a truck driver, he has long-standing low back pain, what he calls a ‘crook’ heart, and a recent seriously sprained ankle that is still niggling.  He knows he can’t manage a full working day, but his job has gone and he is getting pressure from his case manager to return to work.  Functionally he is able – but he needs to change the way he does activities AND cope with ongoing pain that he gets worried about, and this is difficult for him.
  • Caroline is a very busy teacher.  She loves teaching but is finding it very difficult to communicate to the Principal that she can’t keep up with the out-of-school activities that are expected from her.  She’s struggling because she knows what she used to expect from herself is not appropriate now, but finding it difficult to negotiate changes and help people adjust their expectations.
  • Kevin is bitterly unhappy that his last employer was never prosecuted for the accident in which he hurt his hand.  He has always been a very fit person and had moved up ‘through the ranks’ at work to become a production manager, so had no paper qualifications.  Now he is not confident that he can either maintain the hours he used to do (and that he sees as normal), or that he can honestly tell an employer that he will be reliable.  He doesn’t know what kind of job to go back to because his previous work involved using both hands all the time in skilled movements (making furniture).

Each of these people has had pain management – but not specifically targeting the things that are important for them for returning to work.  While they have all been workers and obtained jobs in the past, it’s difficult doing the same thing now.  They have different work habits, restricted functional abilities, and need to change from ‘tried and true’ ways of living life and responding to pressures than they’ve needed to before.

How often are these problems directly addressed in a pain management programme?

I’m struck by the blithe way in which some people are told ‘You can’t go back to your old job, you probably need to look for something else.’  And while many vocational providers are good at eliciting transferable skills – they don’t appear to readily address altered worker identity.  Neither do they appear to recognise the need for people to both be honest with an employer and openly discuss their pain and how they manage it.  It’s not OK to tell someone to lie about their health at a job interview!

There are some fundamental factors that clinicians can ask about to help someone identify their concerns about returning to work:

How much do you believe the following statements:

  • I may do damage to my body
  • I may put other people at risk of harm because I may not do my job well
  • I am not reliable and I might let my employer down
  • My medications make it difficult for me to concentrate, or they are not allowed in my workplace
  • I need to get my pain under control before I start thinking about returning to work
  • I look as though I am well, and people may misunderstand how much I can actually do
  • I can’t return to my previous job, and I don’t know what else I can do
  • If I go to work, the rest of my life outside of work suffers
  • I don’t know how to talk about my health problems to people at work
  • While I can manage my pain at home, I don’t think I can manage it at work

If we can help people feel confident to be unconcerned about these things, we may be able to help people move from pain management at home to living life well and working.  And yes, occupational therapists (among others) can help with this!

Resilience, catastrophising and positive emotions

Catastrophising, or thinking the worst, is one of those psychological factors that we know influences distress and disability in people with chronic pain. It’s quite a common phenomenon, and sometimes can stand us in good stead – after all, if we can think of the worst things that can happen, then plan to avert those possible disasters, then life will be sweet, yes? ermmmm – no, as a matter of fact.  Catastrophising can actually function to narrow our thinking down, reducing the range of options we can come up with to manage situations, and it can also function to focus us on things that haven’t worked out while at the same time minimising our appreciation of things that are working well.

In chronic pain, catastrophising is often an outcome to measure – the thought is that if people learn to think more positively about what might happen when their pain is bad, they’ll be in a better position to cope with their pain. This is thought to reduce the level of distress by being more realistic about the potential for negative things to happen.  People who can face difficult times with a greater sense of the real level of threat can harness resources more effectively and often avert negative situations before they happen.

There are a number of interesting theories about resilience and how people cope more positively with life’s situations.  One of these theories is the ‘broaden and build’ theory first developed by Fredrickson, (2001). In the ‘broaden’ part of this theory, it’s thought that positive emotions serve to broaden what we attend to and think about, and in doing so, widen the range of things we consider and think about so that we can think of more options than we consider when we’re under stress. This is thought to help us cope better with stress because we can think of a greater range of things that might work to help us out of that particular difficulty.

Some of the other relevant discussions about resilience and positive emotions suggests that while resilience can be thought of as a trait, or a fairly stable ‘way of viewing the world’, one aspect of reslience that is important is the ability to generate and have positive emotions. Maybe having positive emotions is just a by-produce of resilience, or maybe it’s that if we can remain positive despite stressors being present, then we will be able to be resilient – but it’s certainly evident that when people are able to find something positive in a difficult situation, or if they can find something funny in their situation or even find something to comfort and therefore increase positive mood, they seem to cope better than people who ‘think the worst’ and then remain focused on these negative aspects of their situation.

How does this fit with catastrophising and chronic pain?

Well, in an interesting ‘daily process study’ by Ong, Zautra and Reid, people who were being seen for their chronic pain were asked to keep a daily diary and record catastrophising, pain intensity, and both positive and negative emotions over a period of 14 days. At the beginning of the study they were asked to complete a set of questionnaires including a measure of resilience, neuroticism, and the usual range of demographic details.

The aim of the study was to see how resilience characteristics related to catastrophising, positive and negative emotions, and pain. There were four main questions: (1) Is there a gender difference in catastrophising? (2) Is there a relationship between the level of resilience and the changes experienced in pain catastrophising? (3) Do positive emotions reduce pain catastrophising? and (4) Is the relationship between resilience and pain catastrophising influenced by positive emotion?

What did they discover?

Well, the first question about whether there is a relationship between gender and catastrophising found that yes, women in this study of 95 people, were more likely to catastrophise. Why this is, we don’t know. More research please!

The second question about resilience and catastrophising found that people who were identified as more resilient (using the scales in this study, anyway) were less likely to score as highly on the measure of catastrophising as people who were found to be less resilient. So it seems that if you have that tendency to bounce back, you’re also less likely to think the worst in a stressful situation. Which one comes first, we are not quite as certain.

The third question about whether positive emotions could influence catastrophising about pain also found that yes, if these participants felt positive on one day, they’d tend to score less on catastrophising the following day. (I guess you can see that maybe the reverse also applied – so it could easily become a downward spiral of feeling low in mood, then the next day, tending to think the worst – which is probably only going to increase the likelihood of feeling even lower that subsequent day!).

And lucky last, the question about whether positive emotions influenced the relationship between resilience and catastrophising (ie mediated that relationship) was also tested. In this rather complex set of calculations, it was found that the relationship between being generally resilient and the degree of catastrophising experienced on a daily basis was mediated by positive emotions. So if you’re generally resilient, but have a bad day, this can influence your catastrophising, but not to the same extent as if you’re generally less resilient, when it can lead to a really big increase in catastrophising.

What does this mean for us as clinicians?
The first thing that strikes me when I look at this is that if we can help people identify and pursue things that make them feel more positive, and they do this on a daily basis, it might help them be more able to think more realistically about their situation. So rather than freaking out about their pain, and being really concerned that their pain is going to overwhelm them, people who have had a couple of positive experiences through the day might be more likely to think that their pain is bothering them, but they can deal with it.

This leads me to consider the many ways in which we can help people generate positive events in their lives. Not everything we suggest to people needs to involve ‘hard work’! It’s actually OK to throw a ball for the dog and laugh at her antics. It’s fine to get out an old comedy movie and watch it for laughs. There could be merit in ‘laughing meditation’ where people are encouraged just to start laughing – it’s almost impossible to resist laughing when you see someone else chuckling away! Maybe even get people to look at my Friday Funnies? – oh, maybe not.

The next thing that comes to mind is that while women tend to be more likely to catastrophise, it was also found that positive emotions had a greater effect on catastrophising in women. The authors of this paper suggest that maybe women have more trouble regulating emotions (don’t talk to our menfolk will you? They’d only agree…sigh…), but add that perhaps a greater emphasis on using ways to increase positive emotions will pay dividends for women.

We have a long way to go to really understand what helps people look on the bright side or have bounce back when they experience life’s challenges. At least one thing we can draw from this study is that by increasing positive emotions there is a reasonable chance we can help people reduce their degree of catastrophising about their pain. I’ll post more about how to increase positive emotions shortly – but this is one area that is an especially important one for clinicians working in chronic pain, and especially for occupational therapists who are ‘expert’ in occupations that people enjoy. Having positive emotions seems to generate more options for coping, and increases the sense that life can go on – and this has got to be good for the people we work with.

Ong, A., Zautra, A., & Reid, M. (2010). Psychological resilience predicts decreases in pain catastrophizing through positive emotions. Psychology and Aging, 25 (3), 516-523 DOI: 10.1037/a0019384

Fredrickson, B. L. (2001). The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions. American Psychologist, 56, 218–226. doi:10.1037/0003-066X.56.3.218