Book reviews, site reviews

Develop your skills in CBT for chronic pain

I’ve never found one single book that covers all the areas I think are important for chronic pain management, but today I want to review one that I have found helpful – and I’ll review another tomorrow! I got this one about two years ago, and I’ve referred to it quite often, especially for worksheets.

The book is Cognitive behavioural therapy for chronic illness and disability by Renee Taylor (2006), published by Springer, New York. I got mine from University Bookshop (another wicked place…) for NZ$125 , but as you can see it’s available from Amazon as well.

Renee Taylor is a clinical psychologist, but one with a unique twist – she’s based in the Department of Occupational Therapy, University of Illinois, Chicago, and her book reflects the orientation of this department in that she incorporates the Model of Human Occupation developed by Dr Gary Kielhofner.

She uses four case examples of chronic illness throughout the book to illustrate various aspects of CBT for disability – fatigue, chronic pain from rheumatoid arthritis; sleep disturbance in a man with advanced prostate cancer, and gastrointestinal difficulties in a young man. Alongside the physical illness, each case study has varying degrees of Axis I and Axis II dysfunction to demonstrate the complexity of the biopsychosocial model as it plays out in people’s lives. While I’d probably prefer less of the ‘psychiatric’ labelling that DSM IV provides, it’s nice to see some examples that represent the type of people who do attend pain management centres.

The book is divided into three sections – Theoretical foundations and practice guidelines; Related knowledge; and Specific applications of CBT to the four different physical disorders.
Section one provides an overview of CBT as a therapeutic approach, particularly noting the relevance of CBT to disability, discussing the psychological (note that this is NOT psychosocial?!) issues often found in chronic illness, and then details assessment and sessions as well as CBT techniques used in health.
Section two introduces several concepts that I have to admit I haven’t seen discussed in most CBT texts – empathy, hope and motivation. It’s the motivation chapter that includes the Model of Human Occupation construct of volition – personal causation, values and interests – that help to shape occupational choice.
Section three provides a brief review of some of the literature on the various clinical conditions (fatigue etc), and discusses assessment and treatment options for each.

Things I like about this book – great to see MOHO used to frame motivation, and the inclusion of hope and empathy is also quite novel and positive. I like the clinical examples used throughout to illustrate how the techniques can be applied along with the clinical reasoning for their inclusion. Finally, I really do like the figures used throughout – while the graphics themselves are quite simple, the design of several forms and figures make them really usable. I have to admit I’ve copied and used the ‘Thought Reversal Record’ and the ‘Problem solving worksheet’ with patients!

Things I liked less about this book
– I found the writing style to be a bit dry, and the general layout or typesetting of the book makes it more of a textbook than a ready-reference book. I’m also bothered by the lack of attention to social factors and that the approach does not directly discuss working within a team (either interdisciplinary or multidisciplinary).

If you haven’t read a book that clearly discusses how to use CBT where people have beliefs that are true – but not helpful – this is an excellent book.  It’s really good for the worksheets and figures, and it’s great for including some positive psychology concepts along with MOHO.  A good one for your shelf – or if you’re recommending a book to a library, this one would be an excellent choice.

Facilitating a group

Group-based approaches to pain management are common. They’re used not just for cost-effectiveness (because there are some ‘hidden’ costs to groupwork such as screening participants and team meetings), but also because some processes are better conducted in a group setting – such as observing others ‘well’ behaviours, learning vicariously from others’ experiences – and because experiential learning in a group setting replicates many of the work and family settings that people who experience pain will need to function in.

I use experiential learning, that is, the idea that change and growth take place when people are actively (physically, socially, intellectually, emotionally) involved in their learning rather than just being receivers of inforamtion. It’s not new – cognitive behavioural therapy has used this philosophy since its inception, occupational therapy is based on the idea that doing invokes being. I’ve no doubt many other health professionals also consider that active involvement in processing and learning is essential to integrating new behaviours. To carry out experiential learning, facilitation skills are vital, but again not training that health professions often seriously study during undergraduate study.

Today’s book is one of several I’ve recently obtained to refresh my facilitation skills. I’ve been lucky enough to complete a five-day training several years ago on facilitation run by Zenergy. Zenergy have a distinct philosophy about the value of teamwork, the synergy that occurs when people align to a common purpose and that cooperacy will achieve much for the whole world. For a list of their training courses, go here. Some of us, however, can’t take the time to go to formal training, or want a reference book, so I was pleased to find this book at Amazon.

Now, there is a saying ‘don’t choose a book by its cover’ and I would add ‘don’t choose a book by its title’ because the title is ‘The Secrets of Facilitation’, and that just smacked to me of cheesy pop psychology – but, perhaps surprisingly, this book has some very useable, practical ways for facilitators to ‘ask questions that ignite a bonfire of responses’, ‘discover the three reasons people disagree’, ‘resolve dysfunctional behaviour in four steps’ and ‘build consensus in meetings with five strategies’…

The Secrets of Facilitation: The S.M.A.R.T. guide to getting results with groups, written by Michael Wilkinson, published by Jossey-Bass, A Wiley Imprint: San Francisco, 2004. The book provides a model of group facilitation that incorporates both the flow of a facilitated session (preparing, starting a session, focusing the group, writing down resolutions, gathering information and finally closing the session – and includes asking questions to generate effective responses throughout the process); as well as the processes involved in group dynamics (how to manage dysfunction, build consensus, keep energy levels appropriate and set the agenda).

The book is not written for pain management, indeed it’s not written for health at all – it’s a business book aimed at helping teams function effectively so that group decisions are achieved and implemented (not that health teams EVER need to work on this, do they?). Despite this, so much of the book translates directly into both team functioning and group therapy sessions that I think it’s worth thinking about for your bookshelf.

What I like about the book
is the straightforward language, the summaries at the end of each chapter, and the loads of example phrases and questions that you can immediately transfer into a clinical setting. Like many books, it includes some great tables that summarise the information – for example, a comparison of facilitator vs nonfacilitator responses listing what you might perceive (eg you don’t think what was said was correct), an example of both types of response, then a classification of the type of response that is recommended (eg Direct probe, indirect probe, leading question and so on). The diagrams have immediate appeal for me (I’m pretty visual!), and also help to give an overview of the construction of the book so you can see where each piece of the information given fits in.

What I liked less about the book is the example scenarios that relate to business or school settings, and so are not quite as easily transferred into the health setting – even though health can be considered a complex business enterprise! I also really dislike the ‘secrets’ concept. The book lists 60 so-called ‘secrets’, many of which are not exactly secret. I mean, do you think using energy-generating techniques throughout the session is a ‘secret to maintaining energy’?

Despite this somewhat tedious concept of ‘secrets’ the actual suggested strategies are effective. From the first chapter I picked up things I could use when facilitating group sessions on the pain management programme. Some good examples? Well, if someone comes up with an idea that you’re not sure about, acknowledge the contribution then ask them ‘how do you get around [X]’ and state what your concern is. He calls it ‘Building a PAC’ or listen, playback (reflect), agree (acknowledge the part/s that you can see merit in), then challenge or state your objection in the form of a question that allows the person to either solve your objection or to agree with it.
Another example is in using the whiteboard to record what participants say. The ‘secret’ is to write first (in other words, write down exactly the words the person says) then discuss what they’ve said. This ensures you as facilitator don’t imply that you know better than the participants, elicits more responses from participants who may otherwise begin to depend on you as facilitator for ‘the answers’.

If you want to help your team work together more effectively, or have a group of patients you’d like to help facilitate to achieve their goals – this book might just be what you’re looking for.

A week of book reviews

This week I’ve decided to review some of the books that I’ve recently bought for my bookshelf (not that they stay there!). Anyone who knows me will agree that I’m a bookworm, and the two most horrible websites (at least to my bank balance) are Amazonand Fishpond!

Onto today’s book – just arrived, although not a new book, published in 2006, it’s called ‘Cognitive behavioural therapy in groups’, written by Peter J. Bieling, Randi E. McCabe and Martin M. Antony. It’s published by Guilford Press, and I got mine from Fishpond at a cost of $58.25.

The reason I’m so pleased with this book is that for ages I’ve been looking for something to help with group processes and carrying out cognitive behavioural therapy. While groupwork was a core part of my training as an occupational therapist, and I’ve followed this up with facilitation training, many people working in pain management feel somewhat overwhelmed at the thought of taking a group. What can then happen is that the group sessions become almost an educational ‘lecture’ rather than a cognitive behavioural approach – which isn’t nearly as effective. We know that ‘information’ alone doesn’t necessarily change people’s beliefs or behaviour, and that people need to actively engage with and process new material to reconceptualise the implications of, for example, the fact that hurt does not equal harm.

This quite readable book has three parts – the first part is the most applicable to pain management, and covers the ‘General principles and Practice of Cognitive-Behavioural Therapy Groups’. There are six chapters that discuss why we might use a group approach rather than work individually with people; looks at how to use the inevitable group dynamics productively; then reviews cognitive strategies, behavioural strategies and a basic structure that can be used to implement CBT within a group setting. The final chapter in this section is about some of the problems and obstacles that occur in groups and how to overcome these.

The second part is much less relevant to pain management, and deals with nine mental health diagnoses and how groups have been used in these instances. It’s a shame that chronic pain groups were not included, because group therapy has been a fundamental of most cognitive behavioural approaches to pain management.

The final section looks at comorbidity and CBT groups and finally an FAQ section. There is an extensive reference list (forty pages!), and the whole book is well-indexed.

So, let’s take a quick look at the chapters in Part 1.
Chapter 1 – CBT groups – possibilities and challenges. Several reasons have been put forward for conducting CBT approaches in a group rather than individually since the early days of CBT. Of course the main reason initially given is that it is more cost-effective than working individually with people, but there are other good reasons to consider this way of delivering CBT such as the way that people learn vicariously (ie by watching and learning from what other people say and do) and the way in whcih people can feel less isolated when they meet others with similar problems. The chapter reviews several models for analysing group process from outside the CBT framework and applies these to the specific requirements of the CBT approach. It particularly defines ‘group process’ and ‘CBT technique’, with technique referring to the learning tools and methods people use to review their thoughts, beliefs, emotions and behaviours in order to make changes, while process refers to the interpersonal interactions among and between group members and facilitators.

Chapter 2 – Group process – This chapter very clearly describes a number of the group process dynamics that occur longitudinally as group members and facilitators interact. These processes may directly influence self disclosure, a sense of optimism, reduce isolation, moving from a ‘self focus’ to a focus that includes others, direct modification of behaviours (particularly applicable in relation to reducing pain behaviours), and group cohesion and emotional processing. I particularly liked a table included in this chapter that identifies the process factor, defines the factor and summarises how to positively influence and use the process for client change. Some very good dialgoues are provided to illustrate ways to attend to group process while carrying out some of the basic CBT techniques within a group setting. I’ve learned some good things about how to structure my responses to facilitate better group participation especially around home learning review. The last part of this chapter considers the longitudinal development of group development and presents another wonderful table identifying the ‘stage’ of the group and effective therapist responses to ensure the CBT approach is maintained throughout.

Chapter 3 – Cognitive strategies within a group setting.
This chapter explains the range of cognitive therapuetic techniques such as guided discovery, collaborative empiricism and Socratic dialogue, and provides an overview of how these can be applied. Once again it uses dialogue to guide through examples of how this might work in a group – and although the examples are specific to mental health issues, they can still be applied in most cases to people with chronic pain.

Chapter 4 – Behavioural techniques in a group setting.
It’s good to look at both the advantages and disadvantages of groupwork for CBT, and this chapter reviews this very briefly. Basic behaivoural approaches such as exposure therapy, behavioural self monitoring, using the group to monitor each other’s behaviour and so on are discussed in the chapter, but I have to say I think there are more aspects of behavioural therapy that can be used than are described in this chapter, as well as more challenges than are discussed.

Chapter 5 – Structre and organisational issues. Now this is one chapter everyone should read before starting to take a group CBT programme! Four aspects vital to effective group programme management are discussed: participant selection, therapist factors, between-session structure and within-session structure. The emphasis is on learning and experience both within the group, and the chapter makes it clear that balance between all aspects of both group process and CBT technique is needed throughout. A good solid read on the ‘how to’ of administering a group-based CBT programme.

Chapter 6 – Problems. Another chapter that everyone should read – or will want to read because it has answers! I can’t think of a single group where at least one of the issues that is discussed in this chapter has not occurred. From having a dominating group member to someone who speaks on behalf of the others to ‘help’ to someone who rarely turns up or appears disinterested…hmmm sound familiar? Like some of the other chapters, it has a great table describing various member behaviours and appropriate therapeutic responses to them. The final section deals with group process that derive from aspects of the CBT model such as didactic aspects of some parts of therapy, the very structured approach that CBT sessions take, the need for some ‘outside of group’ sessions in certain circumstances, and how to deal with trainees and non-group people observing.

To summarise: while the second part of this book may not necessarily directly apply to people taking pain management group sessions using a CBT approach, the first part is, I think, essential reading for anyone wanting to really apply CBT within a group setting. The writing style is straightforward, the example dialogues very helpful, and summary tables really clear. There are heaps of references (if you’ve ever had to justify having a co-therapist to your manager, you’ll appreciate some of them in particular!), and the FAQ section answers yes, some of those really frequently asked ones! This is a book I just wish had either included chronic pain groups, or was published in two volumes so the first part was available in a stand-alone edition.

Overcoming Pain – David Hall’s new book!

Every now and then you run into someone who makes a real impact on you – Dave’s one of those people.  I met him in Sydney at the International Association for the Study of Pain World Congress in 2005 (take a look here at the information on the next one), and we’ve intermittently kept in touch by email ever since.  David is one of these almost relentlessly energetic people – he looks fit, healthy and balanced.  You’d never guess that he’s experienced chronic neck pain and has had to learn how to become ‘CAPABLE’ so he can live this good life.

His book (and pain management programme by the same name) is called Overcoming Pain, and it’s available from his website at the very reasonable price of Aus$25 + postage.  It’s all about the things he’s learned as a physiotherapist, person experiencing pain, and avid reader of lots of good research, and what’s more, he’s got a refreshing and down-to-earth style that makes what he says easy to digest.

The book is a slim paperback with 157 pages of cleanly-laid out text.  It has 12 chapters covering things like Dave’s own story, understanding pain, physical recovery, psychological recovery and something that’s a bit unusual in self help books: how to use the health system effectively.  He includes a good number of excellent references, some great illustrations and another thing that I thought was a distinctive feature – case examples of people who have demonstrated how they have become CAPABLE.

What does CAPABLE mean?

C – confronting the true causes of your pain

A – acknowledging responsibility for your situation

P – problem solving your way to recovery

A – assertiveness to change your situation

B – bravery to overcome your fears

L – Look forward by setting goals

E – Enjoying the journey…

There are always aspects of a self help book that don’t fit with my views on managing pain – I’m not entirely convinced by the section on ‘core stability’, and the word ‘overcoming’ sounds a bit like the relationship between you and pain is some kind of war – BUT I think these are tiny bits of what is overall an excellent self help book that I’ll definitely recommend to people I see.  It would certainly sit nicely on a GP, physiotherapy or occupational therapy shelf, but might need to be chained down because I could see people taking off with it!

If you don’t believe my review, head over to here for some other reviews by people who’ve read Overcoming Pain.

Oh, and no you can’t have my copy, I’m going to re-read it (and that’s really unusual for me!)

maybe in an alternative universe…

I read recently that about 70% of New Zealanders use ‘alternative’ medicines (NZ Medical Journal, 2007) – more than in many countries, and very common among the people I see who have longterm pain. (As an aside, have you ever wondered at the irony of someone who refuses to put nasty chemicals into their body, prefer ‘natural’ medicine, but smoke both tobacco and marijuana?!)

Among the ‘alternative’ options, one woman I’m seeing at the moment is wearing copper bracelets, several hematite pieces of jewellery, drinks no carbonated drinks ‘because it excites the nerves’, has regular healing touch massage with aromatherapy, and ingests a variety of homeopathic concoctions. She was horrified to hear that the magnetic underlay she bought has no known effectiveness, but was still considering whether she should ask a health agency if they would buy her a massage chair…

The amount of money that is spent by people desperate to find something to fix their pain is incredible!

Which leads me to a book I’m thoroughly enjoying at the moment. It’s called ‘Trick or Treatment’ and is written by Professor Edzard Ernest, Professor of complementary medicine and Dr Simon Singh, science writer, and is published by Bantam Press.

It’s a very readable book, and the chapter I’m loving the most is actually the first – a wander through the history of the double blind, placebo-controlled, randomised clinical trial – and includes blood-letting, Florence Nightingale, scurvy and early research into smoking! The authors argue that the most significant contribution to modern medicine is evidence-based medicine (although some of my colleagues still argue that it’s all very well, but there just isn’t enough evidence yet…). One quote from Hippocrates stays in my mind “There are, in fact, two things, science and opinion; the former begets knowledge, the latter ignorance.” Oh if only more basic scientific principles were taught in schools, we would have so much less opinionated nonsense!!

Other chapters cover the evidence for acupuncture, homoeopathy, chiropractic, herbal medicine – and the final chapter ‘Does the truth matter?’. I haven’t got there yet (I’m still half-way through acupuncture!), but a quick flick right to the end Appendix ‘Rapid Guide to Alternative Therapies’ shows a long list of locally popular remedies including colonic irrigation (why would you?!), magnet therapy, orthomolecular therapy (wha..????), Reiki – well you’ve probably got the idea now!!

Recommended reading for all of us who work with patients who are likely to have thought about or tried at least some of these approaches, this book is well-written, somewhat simplistic but having said that, is attempting to summarise hundreds of studies into lay language. Enjoy.