Pain Behaviour Activity

Having looked all over the place for some suitable activities for people to become aware of their own pain behaviour and then learn to change it, I decided to put together one of my own. Now, unlike the posts I’ve made recently, I have no research to determine its effectiveness, but I hope you’ll forgive me for this!

The basis for considering behaviour change in pain management is behavioural psychology – by selectively reinforcing ‘well’ behaviour, pain behaviours should reduce in frequency. And it certainly does work – by simply asking someone ‘what have you been up to recently’ rather than ‘how is your pain’, we are able to reinforce activity rather than elicit a list of woes! But because I also want people to develop their own awareness of their behaviour so they can independently choose to alter their patterns, I think it’s helpful to

  1. become aware of what may be relatively automatic patterns
  2. start to alter one behaviour at a time
  3. use behavioural principles to reward well behaviour

This is the activity I chose, and a variation.
In pairs, I asked the group to ask each other this question:
“How do you know when I’m having a bad day? What do I do?”
I also gave them a list of pain behaviours to use to help them identify specific behaviours they may do.

Then I asked them to complete their own personal ‘pain thermometer’. You know how people often say they don’t have a thermometer or a plaster cast to say they have pain – well their behaviours can certainly act as a thermometer to other people!

In this activity, the thermometer is copied onto A3 paper, and the list of words and pain faces given to them to paste onto the thermometer. In pairs, they are asked to complete a pain thermometer to reflect the pain intensity and pain behaviours that they do.

The idea is to give the participants an opportunity to reflect on the range of pain behaviours they carry out, and to consider the effect on each other.

I also asked the group to carry out one of their pain behaviours to the extreme – walking from one side of the room to the other with these exaggerated behaviours. Asking the group to discuss what it was like revealed some interesting insights like ‘I don’t know what I do when I’m really sore’ to which another participant demonstrated exactly what that person does! And another said ‘I never knew how hard it was to move and how frustrating when I do these movements’.

Then I asked the group, in pairs, to choose one behaviour and discuss the impact it has on them and others – the good things about it and the not so good. Participants identified that pain behaviours can act as a warning sign to others, that they communicate very well – but have unintended effects that are not so good, like people either avoiding them, or ‘smothering’ them!

Then they chose that one behaviour and decided to spend a day learning how often they actually do it – and because they are in a group, learning to remind each other when they inadvertently revert to old habits.

All in all, I think this was an interesting activity – and hopefully will have at least increased the awareness of pain behaviours in this group. Changing the behaviours – that will take time!
If you use this activity, let me know how it works for you – and any modifications you may.

Learning to ‘feel the fear and do it anyway’

If ever there was an over-used quote from a pop-psychology book the ‘feel the fear’ quote has to be a prime contender! However, in exposure therapy for kinesiophobia, this is exactly what we are doing. If we don’t activate the feeling of anxiety just a teeny tiny bit, then we are not going to achieve an awful lot!

So, the steps from yesterday are to identify a range of activities that the person doesn’t feel they can do (and therefore avoids doing), get the person to rank them in order from ‘least bothersome’ to ‘most bothersome’ (or whatever scale you want to call it – some people call it the ‘yukkiness’ scale!).

Then it’s time to find out exactly what the person really fears about the movement. To do this, I ask the person ‘what goes through your mind when you think of yourself doing this movement?’ – it can be an image, a phrase, or some sort of prediction. It’s this prediction, or hypothesis, that is being tested in our ‘behavioural experiments’.

By exposing the person to the opportunity to test their belief that something ‘horrible’ or ‘awful’ will happen if they carry out the movement, several things happen:

  1. their anxiety level increases initially
  2. they get the opportunity to see that their feared consequence either doesn’t happen, or if it does, it is something they can tolerate
  3. their elevated anxiety subsides (we simply can’t maintain high levels of anxiety for very long)

It’s important to work out exactly what the person is concerned about.

  • Is it that they think some damage will occur? – how will they tell it has?
  • Is it that they think their pain will inevitably increase – and more importantly, that this will be ‘horrible’? – what does ‘horrible’ look like or mean?
  • Is it that they can see themselves falling, being looked at, being laughed at? – what does this mean to them, or about them?

We can then run through several different ways of addressing their underlying beliefs.

  • We can using cognitive therapy to work with their automatic thought, and evaluate the probability that the negative event will happen.
  • We can use cognitive therapy to probe more deeply to find out what it means for this event to happen, and perhaps uncover a more significant belief or attitude that can be worked on in therapy.
  • We can also find out what the worst possible consequence could be, and why it might be so awful. Or what the most likely consequence could be, and whether they could cope with that.

Having done this, we can then start to ask the person if they’re prepared to see what happens if they try one of the movements that bothers them. This is the ‘behavioural’ part of this process and it’s critical to include this as well as the cognitive aspects indicated above.

Reassuring the person that we are certain that they can handle the situation (that they have the skills not to freak out!), or that we are clear that the harm they think will happen won’t occur gives the person a sense of your confidence in their skills. I always make sure that they do have skills to reduce their physiological arousal – usually using diaphragmatic breathing, and calming self statements – before starting this process. I also make sure that we start low enough on the hierarchy so that their anxiety is only just increased so they don’t refuse altogether.

The activities in the PHODA are daily activities that almost everyone has to do in life. For this reason it’s usually not too hard to get the person to agree that the activity is something they think is important to learn to do. If the person starts to balk, it may be because the activity isn’t that important to them, or that they really lack confidence that they can do it successfully. If this is happening, it’s time to return to exploring importance, and increasing confidence using motivational interviewing strategies. Moving down the hierarchy gives the message to the person that they don’t have the skills to cope, and that they have every right to be afraid, and that you’re not confident that it will be OK.

Then the process is reasonably straightforward.
Demonstrate the movement using efficient biomechanics. Note that I’m not suggesting ‘safe’ movements, or ‘proper’ movements – because this suggests that if and only if the person uses the right technique they will be safe. This is a form of safety behaviour that reduces the anxiety that we really want to have present. What safety behaviours do is act as a sort of lucky charm, and when the lucky charm isn’t present, the avoidance that has maintained the fear returns. Nothing is actually learned!

Then ask the person to rate how much concern they have right now about doing the movement.
Continue with asking the person to then rate how strongly they believe that their hypothesis will come true if they do the movement.

Then it’s their turn to do it. I move quite swiftly into this phase, because it’s the anticipation of doing the movement that generates the anxiety. The longer you delay, the more anxiety, the less likely they are to be able to settle their anxiety level down after the movement.

Once they’ve carried the movement out using efficient biomechanics, it’s time to ask them to re-rate their concern about doing the movement, then re-rate the probability that their feared consequence will occur if they do it again. Most times the rating has reduced, but sometimes it hasn’t gone down by much.

If their rating of the probability hasn’t changed, you can ask ‘how often do you think you need to do this to change your rating?’ You can use logic (How many times have you seen people actually fall over when they bend forward? How many times have you fallen over when you bend forward?) or you use other cognitive strategies to help them re-evaluate their belief, then re-test using the behavioural experiment again. You can also ask the person to develop a new experiment that might be a better test of their belief (to make it more likely that their feared outcome occurs).

For a really good article reviewing models of inhibitory learning in exposure therapy, Craske et al. (2008) have written ‘Optimizing inhibitory learning during exposure therapy’ for Behaviour Research and Therapy. Worth a read, even if you’re inclined to go glassy-eyed at loads of psychological stuff. But if you’re reading this, you’re probably quite happy to read psychological stuff, so head on over to it!

More tomorrow on exposure therapy – so y’all come back now!

CRASKE, M., KIRCANSKI, K., ZELIKOWSKY, M., MYSTKOWSKI, J., CHOWDHURY, N., BAKER, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46(1), 5-27. DOI: 10.1016/j.brat.2007.10.003

Cognitive behaviour for pain worksheet – client information

It’s not always easy to find freely available client worksheets that reflect ‘real life’ situations, and are written for the age and reading level of the people we often see. For example, most of the people I work with are practical ‘hands-on’ people who don’t like reading or writing, and are either very visual ‘show me what to do’, or kinesthetic ‘let me do what I need to do’. So they can find some of the materials available for cognitive behavioural therapy rather unrelated to their own situation.

I thought I’d share with you a client worksheet I recently developed for a man who has always worked in very practical metal fabricating work. Although he is very intelligent and readily learns new concepts, he is not the sort of person to read a book for leisure, and he dislikes writing.

He is happy to carry out ‘missions’ (I never use the word ‘homework’ because it reminds people too much of school!), but strongly prefers them to be action-based, and if there is any recording to be done, that it be ticking boxes rather than writing sentences. Does he sound like any of your clients?!

CBT worksheet for client handout

The worksheet attached (above) has a brief explanation of what CBT is, then three pictures of activities. The ones used in this example were relevant to the person I was working with – and it’s not terribly difficult to replace these examples with ones relevant to the individual you’re working with.

If you’re using something like Microsoft Word, you can go to the clipart section on their website and there are a lot of photographs you can find showing everyday activities. If none of these fit, very inexpensive clipart CD’s are available with literally 1000’s of different photographs of people and activities that you can use.

I used these because although I would love to have taken him to his own workplace and home, in this instance I was only able to see him at the Centre, and photographs are much more able to elicit automatic thoughts (AT’s) than just talking about a situation.

I then ask him to tell me what was going through his mind, and write this down in the speech bubble beside the relevant picture. Sometimes at this point it’s helpful to work through the AT’s so you access the underlying beliefs, attitudes, or rules that are being expressed – because often you’ll elicit an exclamation like ‘Oh no!’ or a swear word, which is ‘shorthand’ for the unstated but highly relevant belief that is being elicited. The next step is to ask about the emotion that occurs as a result of the statement – and then to write that down in the thought bubble.

This then allows you to identify three separate instances when an automatic thought can be identified, as well as recording both the thought and the emotion very briefly and with graphic illustrations rather than a whole lot of writing. Even if, in the end, there is writing, the photographs seem to help reduce the ‘brain fog’ that can get induced by seeing a lot of writing all on one page.

The final part is to work through one example of an AT and its effect, look at the pro’s and con’s, perhaps work through any thinking patterns (I use this word rather than ‘maladaptive’ or ‘errors’ because it’s less demoralising to hear that it’s a pattern than a fault or error), and replace with a more helpful but equally true statement.

See what you think – and let me know how this works for you.

be careful what you say...

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CBT Workshop!

If you’re wanting a short, practical and interactive workshop on using cognitive and behavioural approaches for managing chronic pain, book yourself in for the CBT Workshop on 2nd, 3rd, and 4th May 2008.

This workshop is an introduction to using cognitive and behavioural approaches with people experiencing chronic pain, and is designed for occupational therapists, physiotherapists, nurses, social workers and psychologists who want to learn the practicalities of integrating this approach into daily clinical practice. The workshop is run through the Otago University, Christchurch, and is on-campus at the Christchurch Clinical School.

Participants are invited to bring ‘real’ case examples to work through, and develop skills by working within small interdisciplinary teams as part of the workshop. The interdisciplinary approach is encouraged throughout, and each person is also encouraged to participate by bringing his or her own experiences to the group. A maximum of 20 participants can enrol for the workshop, and registrations (and more details) are available from Veronica McGroggan at the Department of Orthopaedic Surgery + Musculoskeletal Medicine and her contact details are at the bottom of that page.

This will be the 5th year the workshop has been run, and alongside the fun of getting together with colleagues from around New Zealand, you also get a fully referenced workbook, and the opportunity to bring complex cases to a ‘meeting of the minds’ to learn new ways of viewing their situation.

Topics include:
– assessment and case formulation
– cognitive strategies including education/information, attention management, cognitive reframing and working with automatic thoughts
– behavioural strategies including relaxation training, biofeedback, recording and graphs, reinforcement, social modelling and time is also spent on exposure therapy for pain-related anxiety and avoidance
– motivational strategies

The workshop is pitched at an introductory level, and a more advanced and applied workshop will be run in August. This usually considers more complex presentations, and further developing and refining clinical techniques of cognitive therapy.

Cognitive behaviour management resources

One website I keep returning to is this Cognitive behavior management reference holds a wealth of resources that are mainly in the public domain (provided they are attributed appropriately).
There are three main areas covered on the site:
* Cognitive Rehabilitation: This has two components, cognitive restructuring and cognitive error correction. The first deals with a much deeper structure of thought.
* Social Skill Building: The process of teaching both social [interpersonal] and thinking skills to improve perfromance.
* Culture Restructuring: The process of seeding the culture with memes [sounds like genes], artefacts, icons, and rituals of prosocial competence.

The main focus of the site is on children – but children and adults can both apply the same cognitive and behavioural principles!

It’s often difficult to find resources that are easily printed (I’m guilty of not doing this here – I haven’t learned how yet!), but this site holds a huge number of well-written ‘instructional techniques’ that are in pdf format and can be saved and printed.
Some good examples are:
Changing distressing thoughts
Testing core beliefs
Covert modelling
The mirror model

One area I spend time in is Theory in which there are 10 – 15 papers written on areas such as Consciousness, Belief Systems, Language and Thinking, and others.

As with any web-based site, view the material with a critical eye, and use with discretion. At the very least, it provides you with a model for how this type of material can be written as a relatively simple procedure, and at its best, there are some resources that can be applied right away.

Biofeedback or – things that go ‘beep’!

Biofeedback is an approach to revealing the inner states of human functioning so that people can develop control. In pain management it can take many different forms from surface electro-myography (sEMG), skin conductance (SC), blood volume pulsimetry (BVP), respiration rate, and heart rate variability. It can even be as simple as readings on two scales (left foot, right foot); video recording; a mirror; taking your pulse; temperature or weight!

I use biofeedback pretty regularly – so here’s a very quick tour through the biofeedback uses (but wait! there will be more as time goes by…)

A simplified explanation of cognitive and behavioural therapies for chronic pain

Cognitive and behavioural therapies (CBT) are not one single ‘therapy’, but a group of interventions that are combined in pain management to help the person develop ways to continue living despite their pain.

Cognitive Behaviour Therapy (CBT) is based on the idea that how we think (cognition), how we feel (emotion), and how we act (behaviour) interact together. Specifically, our thoughts determine our feelings and our behaviour. Therefore negative thoughts can cause us distress and result in problems.

CBT is based on both cognitive and behavioural therapy.
Cognitive therapy – thoughts, beliefs, attitudes and perceptual biases influence which emotions will be experienced and also the intensity of those emotions. Therapy is based on modifying thoughts and therefore emotions and behaviour.
Behavioural therapy – reinforcement and imitation teaches normal behaviour, therapy is based on learning theory. Initially cognitions were ignored as having little relevance.

CBT arose from amalgamation of behaviour therapy and cognitive therapy. These therapies were developed in contrast to psychodynamic therapy, which assumed that inner conflicts in the psyche were responsible for problematic behaviour and emotions.

Behavioural Therapy
Skinnerian behaviourist therapy (B.F. Skinner, 1904-1990) was made popular by the thought that by applying scientific principles to behaviour, years of psychotherapy could be avoided and problematic behaviour could be changed quickly. Original behaviourists ignored or downplayed the role of thoughts, beliefs and understanding of the patient. This was mainly as an over-correction from the psychodynamic approach.

Normal learning theory developed from behaviourist theory and science shows that by reinforcing specific behaviours, the frequency of those behaviours can be affected. 

What we can use from behavioural therapy is:

  • That the part of the pain experience that is directly open to change is behaviour associated with pain
  • To specify the behaviours we want to see more of, and those we want to see less of (i.e. to increase healthy behaviour and to reduce pain behaviour)
  • To specify the environment or situations in which these behaviours occur
  • To identify precursor (antecedent) factors that influence behaviour
  • To identify consequent factors that influence behaviour
    This is part of functional analysis and is part of our assessment process

Cognitive therapy
It’s easy to see that cognitive factors also play a role in attention, learning and in attribution relevant to the experience of pain. Cognitive therapists such as Aaron Beck successfully used cognitive strategies to help people recover from depression and anxiety. It’s almost impossible to work with a person without giving them some sort of rationale for why we as therapists have recommended they participate – explanation is a cognitive intervention!

Cognitive therapy is about thoughts, beliefs, attitudes – how we attribute meaning to what we do and what happens to us. It is based on the belief that emotions are influenced by our thoughts, which are often unhelpful or even erroneous. In the same way, our thoughts are influenced by our emotions, and each of these influence and influenced in turn by our actions.
Cognitive therapists likewise use practical, real situations in which new cognitive strategies can be used – in essence a behavioural strategy.

Cognitive behavioural therapy has a long history in pain management. CBT applied to pain management is well-researched, and is one of the main areas outside of mental health that research has been conducted.

What we can use from cognitive therapy is:

  • That explanation can reduce the ‘fear factor’
  • That what we think, feel and do can be influenced by each other
  • That we can learn new ways of thinking, feeling and doing
  • That sometimes our thinking and feeling occur so quickly we are not aware of what happens until after the fact
  • That some of our common sense ‘truths’ in the community are wrong – but still affect us (e.g. pain in the back is injury)

Cognitive and behavioural therapies are both used in pain management – but unlike mood or anxiety management where there are relatively established protocols, in pain management there has been less research specifying the components of therapy that are known to work, and for whom.  Because of the multidimensional nature of disability arising from chronic pain, it may well be that there is no single protocol that will work for everyone.  Instead, a clinical hypothesis-testing approach may be the most appropriate strategy (more details on this soon!). 

CBT-based therapies are a generic tool for all health providers working in the field of chronic pain management.  Relying on a single discipline (or member of the team!) to provide the ‘CBT’ is a recipe for patchy therapy, an opportunity for inadvertent splitting of the team, and more difficulty focusing on goals.