choices

Collaborating with our patients


Have you noticed how some of the literature on pain management seems to distance the therapist from the patient as if the therapist is the ‘expert’?
I’m not sure where this started – perhaps with the behavioural approach where reinforcing well behaviour is carried out alongside ignoring or not responding to sickness or pain behaviour. Or maybe it was the ‘stinking thinking’ or ‘maladaptive thoughts’ of cognitive therapy that brought about the idea that patients are ‘doing it wrong’ and therapists know all…
Or maybe it’s an impression that patients get sometimes, that therapists ‘should’ know everything, so that if they do as they are ‘told’, and it doesn’t work out, the therapist carries the responsibility.

Whatever, I think the most helpful therapy is carried out when the therapist and the patient collaborate as equals: the therapist has professional knowledge and experience that can shed light on the functions of certain beliefs and behaviours, while the patient knows about his or her own values and the effect of making changes. Together they can work out what is going on and perhaps why, and what the options might be for doing things differently.
In the end, the patient has the responsibility for actually deciding to take action – no-one else can do it!

The therapist’s role? To make the options clear, to be up-front about known outcomes or consequences of a course of action, to find out what is important to the patient – and how the patient’s actions are moving them closer or further away from what they value.

It’s a dance rather than a teacher-student process. A flow of interaction between the two, with the therapist needing to take extra care to ensure the patient’s vulnerability to differences in ‘power’ and amount of knowledge about each other is not exploited.

I feel so privileged to work with people who have chosen to share something of themselves with me. It’s a gift to treasure. And an absolute joy to see someone learning and taking steps to live the life they have chosen.

Change


This is just a quick ponder on the words we use in pain management.  Quite often we talk about ‘goals’ and ‘prioritising’ and ‘planning’ and ‘skills’ – as if it’s an event that will come to an end.

‘Oh I’ve done my planning, and achieved my goals’.

The team I work with has started to consider whether an overarching theme in our programme should be around the process of changing – a process that never stops.  In the programme maybe there will be three elements throughout the three weeks – one that focuses on skills for managing pain; another that helps develop skills for managing change; and still another that provides opportunity to consider change itself.

One of my long-term concerns about pain management programmes, and in fact any intensive programme of change, is that it’s all fine and dandy while the programme is running.  Lots of skills, lots of new things that generate energy, and lots of new plans to put in place.

But after six months, what will have actually changed?  What will remain of those skills, that energy and those plans?

When I asked people who had ‘graduated’ from a three week pain management programme what was different about their lives since they completed the programme, it was sad to hear that so little had changed.  Yes, attitudes towards pain had changed, and most talked about ‘pacing’, ‘exercise’, ‘relaxation’ – but their day to day lives didn’t look at lot different.  Their outlook and ideas for the future hadn’t changed much.

They gave lots of reasons for not implementing their skills.  Things like ‘you can’t do pacing at work’, ‘you can’t go away and do a relaxation at work’, ‘my case manager wanted me to do something else’, ‘I look stupid doing exercises’, ‘I don’t have any time to do my relaxation/exercises/social stuff/look for work’… And these comments were from people who were motivated to see me about returning to work!

Something wasn’t gelling – it’s almost like ‘lead a horse to water and watch them walk away’… Or is it?

At the time I was naive to the Prochaska and DiClemente model of stages of change – perhaps some of these people were simply not yet ready to integrate their pain management into a ‘new life’.  And some had very complex psychosocial situations with mental health problems, family problems, as well as (often) medical influences.

But as I reflect today, I wonder whether we talked about specifically planning, over time, to implement each piece of the pain management puzzle until it formed a ‘new’ life.  And I know we didn’t talk about the process of acceptance…

So, here are 10 thoughts to help people weave new habits into their lives…

1. Begin by making small changes.  Pick one or two skills to begin with each fortnight.  Get used to these before adding in some more.

2. Mentally link changes to daily routines you already do. This can make changes like taking on a new habit happen much more smoothly. For example, if you want to begin using relaxation at home, try adding it in to your bedtime routine.

3. When a change feels most stressful, it’s probably about something really important. Achieve in this area, and others will feel much easier.

4. A timetable or checklist to record progress helps maintain your motivation.  And you can show it to others to keep yourself honest!

5. Remember that all change involves a degree of learning. You don’t expect to be skillful until after you’ve practiced.

6. Remember that upheaval and confusion are often natural parts of change. Both you and other people may find it difficult to feel comfortable with new ways of doing things.  It won’t always feel great.  It will probably be ‘odd’ until you no longer have to think about it to do it.

7. Don’t feel like you have to cope with changing circumstances or the stress of making a change on your own. Talk about what’s going on for you with a friend or write about it in a journal. Sharing your feelings can give you a sense of relief while helping you find the strength to carry on.

8. No matter how large or difficult a change is, you will eventually adapt to these new circumstances. Remember that regardless of how great the change, all the new that it brings will eventually settle into the right places in your life.

9. When you feel ambivalent about ‘doing it’ pick something, anything, to do and do it right away! Don’t stop to think about it! Completing something provides impetus to keep doing.

10. If you’re trying to change a pattern of behavior or navigate your way through a life change, don’t assume that it has to be easy. Wanting to cry or being moody during a period of change is natural. Then again, don’t assume that making a change needs to be hard. Sometimes, changes are meant to be that easy.

 It takes about six to eight weeks for a new behaviour to start to feel automatic.  Some things help make it easier, I’ll be posting about these shortly!

Positive psychology – Polyanna or Promising?


holly-cherubl.jpgI was hoping to post on positive psychology and chronic pain, but have failed to find any specific references using these two headings – I then had a brain-wave and without waiting for someone reading this to locate something for me… I remembered the body of research in contextual cognitive behavioural therapy – mainly by Lance McCracken.
So this post is dedicated to CCBT, positive psychology and the season of good cheer!

Anyway, the reason for wanting to post on this aspect of psychology is that I have a hunch that resilience (my PhD topic!) and aspects of positive psychology might just be relevant for people learning to live with chronic pain.

So, what is positive psychology?
It is the ‘scientific study of the strengths and virtues that enable individuals and communities to thrive’ (Positive Psychology Centre )
It’s derived from the early humanist psychologists such as Carl Rogers, Abraham Maslow and others, and further developed by Martin Seligman, Albert Bandura and others, with the focus being on strengths, and those features of human life that promote wellbeing, resourcefulness and the ability to develop.

For a great list of resources and links relevant to positive psychology, go here: and go here for links to various questionnaires that may be useful.

Anyway, to come back to my hunches… psychological flexibility is a feature of positive psychology, and involves processes of acceptance, mindfulness, values, and cognitive defusion (for a longer explanation of these see McCracken, L. M., & Vowles, K. E. (2007)).

Positive values such as the following seem to enable people to live well despite life events around them:

  • finding good things about each event that happens in our lives,
  • having compassion for ourselves and others,
  • being creative and finding opportunities for development

When people don’t demonstrate cognitive flexibility, they can remain fixed in resentment and anger, attend to only a few things (and judge the experience negatively), and believe that what they think is so, rather than a thought that alters depending on context. What this means in pain management is that people fixate on their pain and the negative judgement of that pain and how it interferes with their activities, remaining angry and fixed in the ways that they approach life.

Using what we can learn from positive psychology, we may be able to help people in this position draw on their strengths by assessing coping strategies in terms of strengths rather than us as professionals dwelling on their vulnerabilities and problems.

For example, we may look at the values that they are using when declaring that ‘I can’t do pacing’ – does this reflect their desire to achieve and their ability to persevere despite pain? Instead of a negative feature, can we help them identify their strength with task persistence or achievement, and develop the ability to apply this value flexibly and in contexts in which this is helpful?

McCracken and others have spent a good deal of time exploring the concept of acceptance, finding strong positive relationships between acceptance and function, acceptance and positive affect, and acceptance and reduced use of avoidance (see below for references). I’m looking forward to the time when we can read of others researching this area – perhaps from the Positive Psychology Centre or similar.

In the meantime, we can learn from this research ways to encourage the people we work with to sit ‘with’ their pain, becoming aware of pain but not judging it negatively (or positively), help them to look for positives (remember the post about counting your blessings?

And in this season of good cheer, perhaps we can interpret the ways people cope with their pain in positive ways – what is adaptive about their strategies? How can they be used to help them achieve their goals in life? What features of what they currently do can be drawn upon to help them succeed?

Finally, can we as treatment providers look on the bright side too? Can we give ourselves credit for continuing to work in this complex and challenging area, often with limited idea of just how effective we are? And perhaps, by being ‘Pollyanna’ for a while, we might catch sight of the promise, possibilities and potential in our clients and ourselves – and have a Brilliant New Year!

If you’ve enjoyed this post, and others – subscribe above using the RSS feed, and leave a comment!

BTW For a great place to review positive psychology from a personal perspective, go to Authentic Happiness and spend some time mooching about the information and resources held there…

McCracken, L., & Samuel, V. (2007). The role of avoidance, pacing, and other activity patterns in chronic pain. Pain, 130(1), 119 – 125.

McCracken, L. M. (2007). A Contextual Analysis of Attention to Chronic Pain: What the Patient Does With Their Pain Might Be More Important Than Their Awareness or Vigilance Alone. Journal of Pain, 8(3), 230-236.

McCracken, L. M., Eccleston, C., & Bell, L. (2005). Clinical assessment of behavioral coping responses: Preliminary results from a brief inventory. European Journal of Pain, 9(1), 69-78.

McCracken, L. M., & Vowles, K. E. (2007). Psychological flexibility and traditional pain management strategies in relation to patient functioning with chronic pain: An examination of a revised instrument. The Journal of Pain Vol 8(9) Sep 2007, 700-707.

McCracken, L. M., & Yang, S.-Y. (2006). The role of values in a contextual cognitive-behavioral approach to chronic pain. Pain, 123(1-2), 137-145.

Motivating people to make changes (iii)


The third of a series about using values and empathy to help people make choices

The previous two installments in this series have introduced the concepts of stages of readiness for change, rapport and empathy and appreciating that the people we work with have their own values influencing the choices they make. This paper introduces two strategies that can help people directly influence the focus of therapy while at the same time enabling you as a therapist to signal areas that are important.

From the outset of a clinical encounter, you as the therapist direct the interaction. This means you have the responsibility for ensuring the person you are working with has opportunities for choice. In order for you to find out what is important to the person, you need to ask about how their health situation is affecting them. This sets the agenda for your session.

Agenda are usually set by you – so giving the patient/client the opportunity to set what that is important to them at the outset immediately establishes your credentials as someone who will take them seriously.

We often do things that have unintended consequences in the medium to long term, while satisfying immediate desires. While we don’t always like the unintentional outcomes, it can be very difficult to resist instant gratification! While we satisfy our craving for chocolate, we risk gaining weight. Our taste for chocolate might make us feel better – but our good feelings disappear when we step onto the scales in a fortnight’s time… Similarly, the person who doesn’t want to work to quota because he ‘has to mow the whole lawns – and cut the edges’ may be reducing the immediate distress of letting the family down, but ends up being unable to go to work for a day – letting his employer down.chocolate

Part of what we are doing as we establish rapport is becoming aware of what is important (therefore valuable) to the person – and from this we can develop goals with the person that (hopefully) align with their values in the medium and long term.

Read further on this topic in my Coping Skills section.
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Motivating people to make changes (ii)


The second of a series about using values and empathy to help people make choices

The first installment in this series looked at why people might not be doing what we think they ‘should’ and how they might show this. This installment looks at developing rapport and reviews the essential interpersonal skills that are needed.

Rapport – what does it really mean? Is it just making small talk so the person calms down and is ready to listen to what we want to say? Or is it something much deeper?

Superficially, rapport is really about ensuring you and the other person are on the same wavelength. It can be as simple as asking them about the weather, or did they have a good day, or ‘what can I do for you?’ Done glibly it can be shallow and forced – and you know the person will only tell you what they think you want to hear (until they are just walking out the door and say ‘oh by the way…’!)

 

To respect this person’s situation, we need to believe that they have made the best possible choices given the resources they had at that time, and that to them their choices made sense at least once. Something about their choice was important to them at the time. Their choices reflect their values – what is important to them.

 

Although there are specific skills to help develop rapport, the first and most essential element is actually an attitude: ask yourself ‘Do I really respect this person?’ Respect means accepting that although the person is different, and has made choices that are different from yours, you can honour their position and understand that they have done so to make the best possible decision at the time.

Reflective listening is a basic skill taught (usually) early on in health professional training. It’s often assumed by both ourselves and others that we know how to use reflective listening, but sometimes our skills haven’t developed since we first learned them!

For more details – click here to go to this post in my Coping Skills section!

 

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Motivating people to make changes (i)


The first of a series about using values and empathy to help people make choices

Most of our training in health care provision assumes that:

  • the people we will be working with are ready to receive our knowledge/expertise
  • we know more than they do (about what they should do)
  • their health status is the most important thing in their lives (well, we think health is important, don’t we?)
  • all they need is for us to tell them what to do and they will go away and just do it

And if they don’t – they’re ‘resistant’, ‘not motivated’, ‘noncompliant’, ‘nonadherent’.

– and we’ve always known how they show us this!!

They may

  • say ‘yes but’ to any suggestions
  • become silent
  • become angry
  • deny they have a problem
  • interrupt
  • avoid making a commitment
  • not come back to see you
  • pretend they are doing what you suggest, but actually do nothing

By taking care to really understand the good things about the way the person is currently acting, and the not so good things about changing, we can work together to help change occur out of intrinsic motivation, or values that the person holds.

Read on…!

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The gift of Fibromyalgia – one woman’s view


A quick link to a wonderful post by Moonbeammcqueen on her blog ‘FibromyOWgia’. I loved her representation of the opportunities that something like chronic pain can give – depending on one’s view of it. From adversity comes change and triumph and discovery. Not a bad way to view life I think. Thanks moonbeammcqueen – you made an impact here! and congratulations on the article being published.

Welcome to the first post! Values


You can talk to Merrolee about this blog, it was seeing hers that ‘inspired’ me to get around to starting this blog. An idea that had, I must admit, been kicking around in my brain for quite a wee while…

Finally I got around to it…

This will be a ‘from time to time’ blog, just as my photography one is. Every now and then inspiration hits and away I go!!

But for today – values in health.

Almost all health professionals have a code of ethics in which there is something about ‘respect’ for the client/patient/consumer. All throughout health care we are asked to compromise our values (How much therapy ‘should’ we offer this person? How much time can I afford to spend with that person? Should I tell this person about this therapy – when I know they won’t be offered it here…).

Personal and professional values are challenged directly and indirectly every day we work with people. If it’s about equity in funding (in New Zealand, the difference between funding for accidental injury and health conditions can be vast), about whether a person wants to engage in new behaviour, or how much we compromise our own beliefs about what is and is not important (documenting patient statistics versus spending time with a person?) we make decisions about what is important to us in our practice.

On the NZAOT Values Exchange , participants are asked whether equipment should be offered to an individual with obesity, initially described as developing before the diagnosis of osteoarthritis was made, but later described as being diagnosed at the same time (and presumably as a result of the OA). Ministry of Health determines that equipment needed because of obesity cannot be funded, while equipment needed because of disability from other health problems can be funded. A value-laden judgement suggesting that obesity is a choice, while disability from other causes is not. Perhaps not a value judgement that is explicit, but nonetheless, a judgement about what is and is not important. Is this respectful?

In cognitive behavioural therapy we are often called to ‘challenge’ the beliefs or assumptions of the person we are working with. Some cognitive therapies are very direct, calling the beliefs ‘maladaptive’ or erroneous. To the person hearing someone say ‘your thinking is wrong’, is this respectful?

Can I suggest some things to consider:

  1. Spend some time with yourself to work out what your values are both personally and professionally
  2. What are the stated and unstated values of the organisation you work for?
  3. There will be areas of compromise – have you spent time considering the effect of this compromise on you as an individual and as a professional?
  4. Think about offering choices to the people you see – what is important to you (their health status) may not be important to them (their kids schooling may be more important than their diabetes!)
  5. Drawing on motivational interviewing we can be both directive (being clear about our own position on the effects of a course of action), while being respectful of the choices that the person makes (based on what is important to the person).
  6. We can ensure we provide the person with a range of options so that they can an informed decision on what to do next (and the implications of that decision). Done sensitively the person will feel that you trust them, that they do have the resources to draw on, and that you both respect them and will welcome them back.

I hope this first post provokes thought. Comments are welcome!!