behaviour

Curiousities


A couple of interesting sites to drop into over the weekend – I took a look at PsyBlog and what a wonderful video I found there! This one is about the Psychology of Magic – three critical techniques that good magicians use to trick the audience.  Makes me wonder whether people that believe in psychics should read it and be just a teeny bit more critical of their performances…

Ever wondered what type of person bothers to write a blog?

Well, wait no longer – there’s an answer for you!  Clinical Cases and Images posts about Who Blogs – Personality Characteristics.  What did they decide? ‘According to the … studies … people who are high in openness to new experience (both men and women) and high in neuroticism (women) are likely to be bloggers.  Women who are high in neuroticism are more likely to be bloggers as compared to those low in neuroticism. There was no such difference for men.’

Hmmm, not so sure about the neuroticism (Who me? Neurotic? No way!!) – I wonder if anyone has evern checked out the characteristics of people who READ blogs?!!  And of course I wonder whether there’s a difference between this type of blog, and the blog of those who write about everyday life?

Now, settle down for a bit of news about pseques.  (Written like that to avoid the net detector treating this blog as something to block!).  Great post from one of my favourite sites, MindHacks – which was itself blocked at my workplace the other day for ‘criminal and undesireable’ information!  It’s about the medicalisation of normal human sexuality – some great information on how certain normal variances in human behaviour are pathologised by stretching the diagnostic criteria for one disorder to include behaviours in an entirely different area – and not always sensibly either!

Finally today, some people get just a wee bit titchy on Monday mornings, while others are bright and breezy.  This post from Positive Psychology News Daily talks about team energy – and suggests that emotions are contagious, especially if you’re the boss.  Well, I’m not the boss, but I can tell you this: NEVER get between me and my coffee cup!

Some theory – and how we can put it into practice


Before we start on cognitive behavioural therapy, we need to know what we’re on about – for me in pain management, CBT assumes:

  • that people are capable of change,
  • can accept self responsibility for their actions,
  • that what we think and believe about a situation can affect our emotions and responses, and
  • that we can implement a whole range of strategies that can make a difference to life

We may not make a huge difference in terms of the actual medical condition – but as we know, the diagnosis is not the same as the health condition! And it’s health status on which CBT really has an impact in chronic health conditions.

Although it’s similar to the way CBT is applied in mental health situations in terms of looking at thoughts, beliefs, rules, attitudes, emotions and behaviours – it’s much more about the helpfulness of these things than the ‘accuracy’ of them. In mental health, often the thoughts are inaccurate – ‘other people think I’m bad’ or ‘I must keep my hands clean or else it will be a disaster’ or ‘I’m totally inadequate and nothing I do is good enough’.

In chronic health it may be more like ‘I can’t trust medicine to fix me’, or ‘If I keep bending, my pain will get worse’, or ‘I should be able to cope with this’. Some of these thoughts are accurate, some are inaccurate – and some may be accurate but are unhelpful.

So, as therapists, we are concerned with helping people become aware of usually hidden thoughts and beliefs. We then help the person identify whether these beliefs help them achieve their life goals (or valued/important activities), then alter them or work to establish ‘exceptions’ that may help them rather than hinder them.

At the same time, we’re working with the person to achieve personally relevant goals – things like achieving refreshing sleep, being able to return to paid employment, communicating well with their families, having invigorating leisure time. These activities require planning, monitoring achievement, altering behaviours and recruiting support in order to achieve them. And yes, these are all legitimate areas for input by an interdisciplinary health care team.

The process for me is to start with really good assessment across the domains that are relevant for the health condition in question. In pain management, I’m interested in attitudes, behaviours, compensation, diagnostic beliefs, emotions, family and friend interactions, and work – amongst a lot of other things. From this I want to add in – what does this person want to be able to do? What does the person referring him or her want them to do (why did they refer this person?).

Then I want to work with the person to help them achieve their goals – this means developing some ‘working’ explanations for how they’ve arrived at having the problems they are experiencing. Because I use a biopsychosocial model, I try to put together the information from all three domains – biophysical, psychological and social. This process can take quite a while, and doesn’t need to be complete – and for me, has to be shared with the person.

Most of the time the person is quite clear about how well this explanation ‘fits’ for them – and it’s not so unfamiliar for many of us who work as therapists. We usually give an explanation for the treatment we are giving – the main difference is that we work collaboratively with the person and recognise that we actually don’t know whether what we are suggesting is the ‘correct’ answer. This is because in most chronic health management situations, it’s not a simple 1+1 – it’s more a case of multiple factors interacting in a bunch of ways!

Applying CBT isn’t confined to cognitive theories, or behavioural theories, it’s much more about values – and readiness to act, based on importance and confidence – as well as allowing people the opportunity to choose.

How does this differ from normal therapy? Not a lot really – it’s simply expanding our treatment model to include factors that we know influence whether a person will or won’t change their behaviour. And this should apply to any health professional – physiotherapists need to know that people will carry on with their exercises, occupational therapists need to know what stops someone incorporating working to quota, social workers need to know how to help people approach anxiety-provoking activities, and nurses need to help people complete daily recordings!

But – more tomorrow!

Motivational Interviewing in Health Care – book review


For me, motivational interviewing to help people change behaviour has been a great approach. The first book on using motivational interviewing for health conditions ‘Health behaviour change: A guide for practitioners’ by Rollnick, Mason and Butler (1999), is a wonderfully readable book, and inspired me to learn how to apply this non-confrontational approach to helping ambivalent people change their actions.

This book, Motivational interviewing in health care provides a more focused approach to using motivational interviewing in the health care setting. It uses the results of research to provide clear instruction on ways to help clinicians who aren’t setting out to be counsellors to help their patients.

The book divides the core skills into three main areas: asking, listening and informing. It uses these heading to break down much of the jargon of motivational interviewing, and instead focuses on ways to imbue a brief consultation with the spirit of motivational interviewing. This spirit is to trust the person making the choices to put his or her own values first. This may mean actions other than healthy choices are taken – and its the therapist/health practitioner’s job to ensure the person hears that the door is always open for support to make healthy change, and to know the consequences of any choices.

Throughout the book, example conversations are provided – this brings the book to life for me! It also helps me think of how I might integrate the specific phrases into my work. At the same time, the book always encourages practitioners to think of the spirit behind motivational interviewing rather than merely adopting a ‘recipe’.

An extensive bibliography is included in the book, providing topics in which MI has been researched. The book also recognises that it can be difficult to find ways to learn more about MI, especially MI specifically relevant to health behaviour. It therefore iincludes some suggestions for how MI can be learned and practiced without necessarily attending a course.

So, all up – recommended? Yup, you bet. Not for the in-depth ‘counsellor’, but great for people who are in contact with people who are involved in the process of changing their health behaviour. This of course includes people working in the pain management area – definitely recommended. (oh, and BTW – it’s not too difficult to read either!)

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Diaries


For the longest time I wasn’t in favour of pain diaries, but I’m starting to revise my thinking.  No real ‘evidence’ per se to support this, more of a sense that it can be a useful tool for self regulation.

What are they?

Pain diaries can be used in a variety of ways, but major similarities are:

  • days of the week are recorded
  • time blocks or actual times are also recorded
  • activities are typically recorded
  • and some sort of monitor – enjoyment, thoughts, anxiety, mood – whatever

Once a baseline is recorded, then often an intervention is started, and the individual monitors progress using the diary.  It can be used for diagnostic purposes – to identify activity patterns, use of time, engagement in enjoyed activities, fulfilment of roles, interaction patterns, unintended or unrecognised relationships between activities and pain/mood/anxiety/thoughts etc.  It can also be used to monitor progress and even adherence to therapy.

An exciting way to use diaries is through the use of intermittent recording in an electronic diary.  This has been used in several research studies on ‘real-time’ thoughts throughout the day. In this, the individual is contacted or alerted at various times of the day, and then records whatever is being monitored at that time.  This avoids some of the problems with activity diaries which can be cumbersome, easy to forget, and interfere with normal activity.   Recordings from these diaries can be entered into spreadsheets and analysed automatically rather than manually, saving a heap of headaches!

For a couple of good studies demonstrating the utility of diaries for research, take a look at Buck & Morley (2006), Litt, Shafer & Napolitano (2004), and Roelofs, Peters, Patijn, Schouten & Vlaeyen (2006).  For a thoughtful review of the value of ‘process’ research, especially for coping, the paper by Tennen, Affleck, Armeli & Carney (2000), is great.

Buck, R., & Morley, S. (2006). A daily process design study of attentional pain control strategies in the self-management of cancer pain. European Journal of Pain, 10(5), 385-398.

Litt, M. D., Shafer, D., & Napolitano, C. (2004). Momentary Mood and Coping Processes in TMD Pain. Health Psychology Vol 23(4) Jul 2004, 354-362.

 

Roelofs, J., Peters, M. L., Patijn, J., Schouten, E. G., & Vlaeyen, J. W. (2006). An electronic diary assessment of the effects of distraction and attentional focusing on pain intensity in chronic low back pain patients. British Journal of Health Psychology, 11(4), 595-606.

Tennen, H., Affleck, G., Armeli, S., & Carney, M. A. (2000). A daily process approach to coping: Linking theory, research, and practice. American Psychologist, 55(6), 626-636.