clinical communication

Modifying pain behaviour (1)


In my post last week I talked about pain behaviour and why pain behaviours are often a good treatment target in pain rehabilitation. I also talked about pain intensity rating scales and how, because rating scales are a form of communication, the numbers we obtain from them aren’t a true measure of pain: they reflect what the person wants to communicate about their pain to someone at that time and in that context.

This week I want to discuss modifying pain behaviour, and believe me, we are all in the business of modifying behaviour even if we think we’re doing something completely different!

Ethics

One of the issues about modifying behaviour is addressed right at the beginning of Fordyce’s chapter on “Techniques of behavioral analysis and behavior change” and this is the ethical issue of informed consent. It’s important because behaviour change using behaviour modification techniques can operate without the person’s awareness (and does so All The Time). As clinicians, though, we have an obligation to ensure we obtain informed consent from our patient/client before we embark on any treatment. Of course, you and I know that this doesn’t happen in the way that I’d like to see it! When I’m a patient, I’d like to have my options laid out in front of me, with the pro’s and con’s over both short and long term clearly explained. Then I can choose the option that I prefer. But actually, most of the time I’ve received treatment from any clinician, I’ve been given little or no information about alternatives – it’s been assumed that I’ll go along with what the clinician has chosen for me. How’s that for informed consent?

Back to behaviour change. Fordyce clearly details the approach he prefers which is clear discussion with the person about what is proposed – that “well” behaviour will be reinforced via social interaction and “praise”, and “unwell” behaviour will either be ignored or redirected.

Behaviour change done badly

Where I’ve seen behaviour modification done badly is where the clinician fails to indicate to the person that this is the approach being taken (ie no informed consent), where this is applied to all people irrespective of their treatment goals and without discriminating the types of behaviours to be modified, and where it’s applied without empathy or compassion. The kind of “one size fits all” approach. More about this in a minute.

Fordyce points out that “almost every behaviour change problem can be analysed into one or a combination of these three possibilities: 1) Some behaviour is not occurring often enough and needs to be increased or strengthened; 2) some behaviour is occurring too frequently and needs to be diminished in frequency or strength or eliminated; and 3) there is behaviour missing from the person’s repertoire that is needed and that therefore must be learned or acquired.”

Behavioural analysis (lite – more to come in another post!)

So we can work out which behaviours to focus on, as clinicians we need to do some behavioural analysis. This is often best carried out by observing the person – best in his or her natural environment because the contextual cues are present there – but at a pinch, in a clinic setting. I like video for analysing behaviour, particularly something like limping or guarding or compensatory movements, but larger repertoires of behaviour can be self-reported. For example, if someone recognises that they’re resting more often than they want (especially useful if the person values returning to work), then the person can time how long they rest for and work to reduce that time. Fitness trackers or movement trackers can be great for monitoring this. Other options include asking the person’s family about the particular behaviours they notice as indicators that the person is having trouble with their pain: people around the person with pain often know what’s happening well before the person has said anything!

Now this raises my earlier point about lacking empathy or compassion. It doesn’t feel normal to ignore someone who is wincing, looking “pained” or talking about how much they hurt. And this is why, I think, many clinicians don’t enjoy using behaviour modification in a deliberate way – it either feels unsympathetic, so we avoid it, or we do a 180 turn and we apply “ignore all pain behaviour” indiscriminately. Fordyce definitely did NOT suggest this!

Being human in behaviour change

So, how do we approach a person who is distressed? Do we ignore them or comfort them or what? In true time-honoured tradition, I’m going to say “It depends.”

First, we need to analyse the function of the distress in this context, and in the context of our treatment goals. Remember informed consent! We need to clearly articulate and obtain agreement for our behavioural target, and if someone is distressed and this isn’t our target, then we need to respond in an empathic and supportive way. If we’ve observed, however, that the person we’re working with is often distressed as we begin a new activity, perhaps one that pulls the person towards doing something unfamiliar or a bit scary, then we might have a conversation with the person about what we’ve seen, and with agreement, begin to modify our response.

When I describe “function” of distress in this context, I mean “what does the distress elicit from us, and for the person?” – what are the consequences of that distress for the person? If we reduce our expectations from the person, or the person avoids doing the new activity, then we can probably identify that the distress is functioning to reduce the demands we’re putting on the person. Our behaviour as a clinician is being modified by the behaviour of the person – and probably unwittingly. Reducing demands reduces anxiety, a bit, and it may be anxiety about doing that movement (or experiencing pain as a result of doing that movement) that’s eliciting distress. I wouldn’t say being distressed in this context is deliberate – but it’s functioning to draw us away from maintaining the treatment goals we developed with the person.

So what can we do? In this instance, we might remind the person of our agreement to stick to our plan of activity, we can acknowledge that they’re feeling anxious (that’s probably why we’re doing this activity in the first place!), we can reassure the person that we trust that they can do this (boosting self-efficacy via verbal encouragement), and we can maintain our treatment goal.

That’s hard!

Yep. Using this approach is not for the faint-hearted. It means we need to be observant, to always be thinking not just about the form of behaviour we’re seeing, but about its function. We need to monitor our own behaviour (verbal, facial expressions, subtle body shifts, all the non-verbal “tells” we make), and we need to change our own responses to what the person does. And often we find this self-awareness difficult to do. Most of our responses are “automatic” or habitual, and behaviour modification means we need to interrupt our habitual responses so we can help our patient/client do what matters to them.

For a brilliant description of Fordcye’s approach as applied in a case study, Fordyce, Shelton & Dundore (1982) is a great example of how a seriously disabled person was helped via this approach. Remember, this was carried out with the person’s full consent! Chapter 4 of Fordyce’s Behavioral Methods for Chronic Pain and Illness gives the best blow-by-blow description of how to go about this. And for a rebuttal to some of the criticisms of a behavioural approach to pain management, Fordyce, Roberts and Sternbach (1985) offer some very helpful points. That paper also offers some of the best analyses of pain behaviour and why it’s needed as part of pain rehabilitation.

Fordyce, W. E., Shelton, J. L., & Dundore, D. E. (1982). The modification of avoidance learning pain behaviors. Journal of behavioral medicine, 5(4), 405-414.

Fordyce, W. E., Roberts, A. H., & Sternbach, R. A. (1985). The behavioral management of chronic pain: a response to critics. Pain, 22(2), 113-125.

Tough topics to talk about


I was involved in a Facebook discussion about intimacy and sexuality and pain, and I was struck at how tough people find it to raise this kind of topic with a new person seeking help. So… I thought I’d do a series of very brief, very introductory talks on ways I’ve used to broach tough topics.

Before I begin, though, I’d like to frame my discussion by sharing my “therapy viewpoint” or the values I try to integrate in my work.

  1. People are people, so it’s OK to be a person too. What I mean by this is that therapists can sometimes feel they have to be “perfect” and know everything and say the right thing and never fumble around for words… And as therapists we can, as I’ve written recently, “other” the people we’re trying to work with. Othering is where we identify the other person we’re communicating with on the basis of their differences from us – and may inadvertently elevate the characteristics we have – while using those other characteristics to define the other person in terms of what they’re not. When I think about being a person, I mean that while I’ve learned a lot, listened a lot to stories, had my own experiences and keep learning – in the end I can’t elevate myself in my clinical interactions. I’m not the expert in this person’s life – they are – and they have had a lifetime of being them and arriving at decisions that make sense at the time, although like me they may not be aware of unintended consequences of those decisions. So, we’re equals, but with particular roles in our interactions.
  2. People usually have a few clues about what to do – but they’re ambivalent about doing them. This means that my job is to help them identify what they already know, ask to offer new ideas, and then guide them to make their own mind up about what to do next (ie, resolve their ambivalence). Sometimes I do know some things from my experience and learning and perhaps the other person hasn’t yet come across those ideas – but I need to respect their readiness to look at those options. We know that ideas a person has thought of for themselves seem to stick more than those “implanted” ones, AND the process of discovering options is a skill that will enhance self efficacy and be a lifelong skill, so the process of discovery may be more useful than any particular “answer”.
  3. Deeply personal material is rarely discussed voluntarily – people need to feel safe, not judged, and valued as people before they’re willing to share. At the same time, if we never ask about some topics, they’ll never be talked about – so as the “controller” of a clinical discussion we need to be willing to ask the tough, sensitive questions. I suspect our careful avoidance of tough topics arises from our own worries: will we get it right? will they be OK about us asking? will we know what to do if they answer? how will we deal with the emotions? is this going to take too much time out of my session? Like any clinical skill, it’s our responsibility to learn to develop self regulation so we can deal with awkward topics. Self regulation is in part about managing our personal emotional and cognitive responses to situations. Just like we had to get over ourselves when we learned examination techniques (remember your first anatomy labs?), we need to get over ourselves when we enquire about tough topics.
  4. People generally don’t make dumb decisions, they making the best decisions they can given the information at hand. Judging someone critically for having got where they have with health, pain, exercise, daily life, mood, drugs, whatever – reflects our values and our beliefs and priorities. Who says we wouldn’t make those same decisions if we’d lived the lives of the people we’re seeking? In my book, judging someone for making a different decision from me when I’m seeing them clinically suggests taking some time out and examining motives for doing this work. Nobody gets up in the morning and says “I’ll just go out and get fat today.” What happens are a series of small decisions that seem fine at the time, being either unaware of the consequences, or valuing something else. We all do this, so stop the judging!
  5. Most people with persistent pain don’t get heard. Oh they tell their story a lot – often the abbreviated one that cuts to the chase about the events leading to persistent pain and thereafter. What doesn’t get heard is what it feels like, the deepest fears, the endless questioning “am I really that bad? am I just using this to get out of doing things?” all that self-doubt, exacerbated by insensitive statements from people around them, particularly clinicians. Giving people time to talk about their main concerns, to validate that it’s OK to feel this way, that it’s common and unpleasant and real, gives people an opportunity to trust. How we let someone know we’ve heard them lies in our response to what they say: reflecting your understanding of their story, pausing to allow the person time to think and express themselves, and summarising the key points to check out that we’ve heard them accurately, these are skills we can develop.

I’m sure I have other values woven into my practice, but these are my key ones. Being real, nonjudgemental, respecting the person’s own capabilities, giving people time and bearing witness to their story, and getting good at sitting with my own discomfort – not the usual kind of skills you learn in undergrad training!

So over the next few weeks I’ll post some brief videos of some of the ways I approach tough topics.

BTW if you’re in Melbourne (or nearby) this is the course I’m running with the amazing Alison Sim – all about communication!

Seminar – “Better Communication For Better Outcomes”
Date: Sunday, 17 March 2019 from 09:00-17:00
Featuring: Bronnie Lennox Thompson and Alison Sim
On Behalf of: Beyond Mechanical Pain

“Spend a day exploring the value of communication in a clinical setting and how we can implement better ways of communicating with your clients:

◾ Motivational Interviewing 
◾ Cognitive behavioral therapy 
◾ Acceptance and Commitment Therapy (ACT) 
◾ How we define “success” in the clinic 
◾ Functional outcome measure to assess our client’s progress 
◾ Workshop style activities to practice implementing some different communication approaches “

FB Event: https://www.facebook.com/events/242714736618057/

Booking Page: 
https://www.trybooking.com/book/event…

Cost:
Students – $165
Other Practitioners – $330