Cognitive Behavioural Therapy

e-Therapy: online CBT programmes for people with chronic pain


There are many problems with helping people access timely and appropriate chronic pain management programmes. In the US, comprehensive multi or inter-disciplinary programmes have been decreasingly funded compared with single discipline approaches. In New Zealand, the chance of being accepted into a Pain Management Centre in some cities is 1:10 if you’re not covered by ACC. Finding, resourcing and keeping clinicians in this specialist area is challenging.

So…many people have looked for alternative ways to deliver this vital and effective management approach, and with increasing use of the interwebs and smartphone apps for health information, it’s not surprising there have been some attempts to develop online pain management programmes, usually following a broadly cognitive behavioural approach.

How well do they work?

Good question. And one that needs to be answered before rushing out to set them up.  The first caveat, though, needs to be a reminder that when we look at comparing online programmes with face-to-face, we may not be comparing apples with apples. Here are the differences I’ve identified:

  • Group process in face-to-face approaches is different from online versions. This is because so much of our communication relies on visual feedback, and even with video/web cams we’re not getting the rich information we rely on in face-to-face discussions.
  • Many online programmes don’t use group approaches at all. Treatment can be carried out individually, and even in face-to-face approaches, treatments can be conducted with individual people rather than in groups. I personally think this is only more useful than group approaches for the small number of people who find it hard to be in a group: distractible, angry, dominant people, and those who don’t speak the language or can’t hear what’s going on. There’s a lot to be said for being able to watch other people and learn vicariously from them. But online programmes typically don’t have the capacity for group discussions in real time, except perhaps for moderated chat rooms.
  • Behaviour change is less likely with online approaches. The group process directly influences what people do, and without that face-to-face contact, it’s much easier for people to talk the talk while not walking the walk. Even if the behaviour change only occurs during the face-to-face sessions, that’s more than nothing at all!

Just as face-to-face cognitive behaviourally-based pain management programmes differ in content, form and duration, so do online versions. This makes comparing the approaches challenging. We also need to remember that most of the research showing that pain management programmes are effective do so when comparing the programme against a waiting list, or a non-treatment or placebo control. When the comparison is between a pain management programme and another active treatment, the results are less stunning. We should also remember that the outcomes being measured are important: is it pain reduction (not so likely, but possible)? Is it increased function (likely)? Reduced distress (probable)? Increased confidence (generally yes, at least for a while)?

To the studies:

I’m going to draw from three recent studies published by the same group, all three studies vary slightly in their scope, and were conducted in Sweden. Participants were recruited from the University-based Pain Centre, and had received a medical examination but no multidisciplinary treatment.  Participants were screened over the phone, and randomly allocated to one of two groups. In the first study, the two groups were the control group which was an online discussion group, with the second group an online ACT-based programme consisting of seven sections (Buhrman, Skoglund, Husell, Bergstrom, Gordh, Hursti et al, 2013).

The second study was an online “refresher” programme for people who had previously attended the Uppsala University chronic pain programme. Participants were invited if they had completed their programme 1 – 5 years before, had been recently screened medically, and were interviewed/screened to ensure their eligibility.  Participants were also randomised into two groups: the control group as above, and the treatment group which had eight sessions incorporating action planning, exercise, applied relaxation, cognitive restructuring, mindfulness and sleep and stress (Buhrman, Fredriksson, Edstrom, Shafiei, Tarnquvist, Ljotsson et al, 2013).

The final study by this group has yet to be published, and is a similar programme to that in the second one, and again the research design was as above. Participants in this study were those with depression and anxiety, and treatment was tailored to directly address these problems, drawing from the content above, but tailored to meet the individual needs as assessed in the screening interview (Buhrman, Syk, Burvall, Hartig, Gordh, & Andersson, in press).

What happened?

For all three programmes, outcomes showed improvement in the areas we want to see (reduced distress, anxiety, depression, increased activity engagement and willingness). This was maintained for six – twelve months. All well and good, the programmes are useful.

The questions that arise for me are whether some of the steps required for a research project might influence programme usefulness – and even participation. The authors of the in press article acknowledge this, finding that they did not provide telephone support for this last group, and therefore had more drop-outs. But of course this could happen if participants don’t think they’re getting any new information, so we’re not sure if this is important. But there is information suggesting that personal phone contact, the interview process and follow-ups by clinicians form an important part of helping people maintain interest and engagement in a programme. Could this be a potential barrier to “real world” success for internet-based programmes?

Other issues have been identified in other studies of self-management, such as the need for GP’s to actively endorse these programmes, giving authoritative sanction for them so people participating are encouraged to use them. Where this isn’t carried out the programmes don’t seem to have as much uptake.

There’s also the “I’m in a research study” effect. Simply by being in a research project people can be more enthusiastic about participating, and completing all those questionnaires. There’s the emailed reminders, the “specialness” of having your opinion valued, the enthusiasm of the researchers themselves.

What do I conclude?

By comparison with pain-related apps for smart phones (Lalloo, Jibb, Rivera, Agarwal & Stinson, in press), internet-based cognitive behaviourally-based programmes for chronic pain are broad in scope, usually based on some theoretical position, and some have been scientifically studied. In fact, Lalloo and colleagues point out that many apps don’t have health professional input, and haven’t been tested for effectiveness. While apps may offer some support for self-management, they are probably not your best choice for e-therapy.

CBT-based programmes, on the other hand, seem to have some effectiveness at least on some parameters, and within the constraints of a research format.

I’d like to see a programme developed for people in the community without requiring medical assessment, and based on a model of how people move from “Limbo Land” where pain doesn’t make any sense, through to “Living well with chronic pain” where a range of ways of getting on with life are used in a flexible and persistent way. I’d love to see this kind of programme operating without obstacles to getting involved like being screened, or medically assessed, and where participants can choose the elements that interest them. People with pain might just choose what they’re ready for more effectively than if a professional gets in on the act – what do you think?

 

Buhrman, Monica, Skoglund, Astrid, Husell, Josefin, Bergström, Kristina, Gordh, Torsten, Hursti, Timo, . . . Andersson, Gerhard. (2013). Guided internet-delivered acceptance and commitment therapy for chronic pain patients: A randomized controlled trial. Behaviour Research and Therapy, 51(6), 307-315. doi: http://dx.doi.org/10.1016/j.brat.2013.02.010

Buhrman, M., Fredriksson, A., Edström, G., Shafiei, D., Tärnqvist, C., Ljótsson, B., . . . Andersson, G. (2013). Guided Internet-delivered cognitive behavioural therapy for chronic pain patients who have residual symptoms after rehabilitation treatment: Randomized controlled trial. European Journal of Pain, 17(5), 753-765. doi: 10.1002/j.1532-2149.2012.00244.x

Buhrman, Monica PhD, Syk, Martin, Burvall, Olle, Hartig, Terry, Gordh, Torsten, & Andersson, Gerhard. Individualized Guided Internet-delivered Cognitive Behaviour Therapy for Chronic Pain Patients with Comorbid Depression and Anxiety: A Randomized Controlled Trial. Clinical Journal of Pain. in press

Lalloo, Chitra, Jibb, Lindsay A. , Rivera, Jordan , Agarwal, Arnav , & Stinson, Jennifer N. . “There’s a Pain App for That”: Review of Patient-Targeted Smartphone Applications for Pain Management. Clinical Journal of Pain. in press

Routines, habits, boredom & variety: Life skills for living with chronic pain?


I’ve just had a wonderful week on holiday. I escaped the internet, social media, telephones, power, flushing toilets, running water… and it was awesome! There’s something good about taking a break from my usual world to do things completely differently. Now that I’m back I’m reflecting on routines and habits, and how they form an important part of my life.

Routines are sets of behaviours (occupations if you know occupational science) that regularly occur in a certain sequence. Habits are behaviours or occupations we do without needing to directly think about them – maybe because we’ve done them so often they’ve become semi-automatic. Both routines and habits are useful because they reduce the demand on our attention and therefore draw less on our cognitive resources.

This can be a good thing – who would want to have to think about every single thing we have to do to get up and off to work each day?

One of the things people working in chronic pain management often discuss with those they see is how to manage activity levels so that important things can get done without leaving the person feeling exhausted, flaring up their pain, or omitting to do things they value. Activity pacing is one of the main strategies discussed, and although the evidence base for this strategy is skinny, it’s a very common approach. BUT, and it’s a big BUT, it requires people to plan and organise both what they want to do, and how and when they do them.

Many people would think this is pretty self-explanatory. Who doesn’t sort out a To Do list and prioritise what needs doing in a day or week?

Ermmm – actually, there are plenty of people who don’t do this regularly. That’s why one of the most common tools in business is time management! Remember the Day Runner Diary? The Four Quadrants (Steven Covey) Approach? The ABC of prioritising? All tools used to organise what does and doesn’t need to be done.

While these tools are readily used in business, it’s rather less often that we think about helping people organise their lives outside of the workplace. I guess this is because most of us think this just happens naturally – intuitively, if you will. Intuition, though, can be defined as “over-learned habits” that we have learned so well we’ve forgotten we ever needed to learn them in the beginning.

The field of habits and routines is part of self-regulation. Self-regulation includes these components, but also incorporates the ways we raise our energy, calm ourselves down, maintain time awareness, set our sleep/wake cycle, and manage emotions.  Self-regulation theory has been proposed as a model for helping people with some forms of chronic pain cope more effectively with their pain and fatigue (Sauer, Burris,  & Carlson, 2010). There’s some neurobiological evidence to show that some forms of chronic pain, notably fibromyalgia, have greater connectivity and baseline activity between regions of the brain involved in self-regulation including the really important parts involved in executive functioning. This means things like switching attention from one thing to another, or responding to threat appropriately (then settling down afterwards) are more difficult.

And some people are born with, or perhaps develop, less effective self-regulatory neural processes – these are perhaps the people who seem to forget deadlines, arrive late, don’t take medications at the right time, perhaps don’t have regular meals, maybe run out of ingredients (or clean clothes!), and generally find it more difficult to get their life together.

Self-regulation treatments are often concerned with ways to down-regulate breathing, heart rate, and to manage attention. Habits and routines, on the other hand, are larger chunks of behaviour that might not be addressed. Maybe this is why some people forget to do their CBT thought records and don’t do the exercises they’re meant to do. As clinicians, we can think these “forgettories” are a sign of noncompliance, lack of motivation, or not really understanding the importance of the things we ask them to do. I suggest that maybe, for some people, it’s more about failing to have some of the foundational skills needed to get organised into a routine so that there’s enough brain space for people to add new tasks into their day.

What to do about this?

I think we can draw from three main sources of literature here. The first is self-regulation theory where people like Nes, Roach, & Segerstrom (2009), Sauer, Burris & Carlson (2010) are looking at some really useful models. By helping people develop mindfulness, relaxation skills, and awareness of internal physiological states, greater ability to self-regulate is developed. But this only addresses the internal states – what about the bigger chunks?

The next source of literature is probably that from mTBI, or post-concussion rehabilitation. One of the features of post-concussion syndrome is difficulty switching attention, becoming fatigued, recognising when and how to stop or slow down. There are plenty of fun games (yes, even Lumosity!) that can be used to help people develop greater cognitive flexibility, memory, and to improve concentration, attention and so on.

But this still doesn’t address the bigger chunks of activity we need to do. So here’s where I think occupational science and occupational therapy might be really useful: all the tools of time management, cognitive props like using a cellphone alarm to remind you to take medications, daily planners, post-it notes, identifying values and using these to prioritise tasks, having a diary, writing lists – all of these can help, provided they’re tailored to the individual’s needs and lifestyle.

So, before you think that habits and routine are boring, and that planning removes variety – or that the person you’re working with who just doesn’t do those exercises is really Just. Not. That. Motivated. Maybe it’s to do with not being all that great at habits and routines or self-regulation, and maybe you can help them get better at these foundation skills.

 

Clark, F. (2000). The concepts of habit and routine: a preliminary theoretical synthesis. Occupational Therapy Journal of Research, 20(Sup 1), 123S-137S.

Nes, Lise Solberg, Roach, Abbey R., & Segerstrom, Suzanne C. (2009). Executive functions, self-regulation, and chronic pain: A review. Annals of Behavioral Medicine, 37(2), 173-183. doi: http://dx.doi.org/10.1007/s12160-009-9096-5

Sauer, Shannon E., Burris, Jessica L., & Carlson, Charles R. (2010). New directions in the management of chronic pain: Self-regulation theory as a model for integrative clinical psychology practice. Clinical Psychology Review, 30(6), 805-814. doi: http://dx.doi.org/10.1016/j.cpr.2010.06.008

Whiteford, G. (2007). Artistry of the everyday: connection, continuity and the context. Journal of Occupational Science, 14(2), 77-81.

Wiese, Dunn W. (2000). Habit: What’s the brain got to do with it? Occupational Therapy Journal of Research, 20(Sup 1), 6S-20S.

How does chronic pain management work? A hypothesis to ponder


There have been increasing calls for clinicians and researchers to move away from using grouped results from randomised controlled studies because these fail to distinguish between those people who do really well and those who do not. Eminent researchers like Amanda Williams, Chris Eccleston and Steven Morley have said it’s time to move away from “black box” RCTs in chronic pain, and begin to use more sophisticated methodologies to examine not only outcomes but processes during therapy (Williams, Eccleston & Morley, 2012).  While early studies comparing CBT-approaches to chronic pain vs waiting list controls demonstrated moderate to large effects, over time the results have shown smaller effects as these approaches are compared with other active treatments.

The magic ingredients in an effective CBT-approach to self managing chronic pain are not all that clear. There are some people suggesting that it’s all about providing good neurophysiology information about pain mechanisms to people with chronic pain (Moseley, Nicholas & Hodges, 2004; Louw, Diener, Butler & Puentedura, 2013) and this does seem to be part of the picture – but is it enough? Education doesn’t have the greatest of effects on behaviour in any other area of health (think of diets, smoking, exercise, immunisation), and while there’s no doubt we need to reduce the threat value of pain by helping people understand the old message “hurt does not equal harm” (a message I know has been around since the early days of Fordyce and Sternbach), this doesn’t always produce results.

There are other people who argue that it’s all about exercise and that exercise is not only good for people with chronic pain, but also as a “preventative” for those with acute pain who are at risk of develop chronic pain (for example in early whiplash) but this has recently been challenged by the findings from PROMISE, a study by Michaleff, Maher, Lin, Rebbeck, Jull, Latimer et al, (2014).  Nevertheless, exercise does seem to be a common ingredient in most self management programmes.

Pacing, as I indicated a couple of posts ago, has been included in many pain management programmes, but has not been examined in-depth – and even defining pacing has been pretty difficult.

Similarly for most of the approaches included in chronic pain self management: lots of “logical” reasons to include components, but when we take a closer look at them, there’s either very little information on the coping strategy itself, or the effect sizes are equivocal.

Nevertheless, for people with chronic pain who haven’t responded to any other form of treatment, these programmes are a life-line. Remember, that for many people it has taken 4 years to get referred to a pain management programme, and the chances of finding good medication options (or interventional procedures) that abolish pain are pretty slim.

“ Of all treatment modalities reviewed, the best evidence for pain reduction averages roughly 30% in about half of treated patients … do not always occur with concurrent improvement in function … These results suggest that none of the most commonly prescribed treatment regimens are, by themselves, sufficient to eliminate pain & to have a major effect on physical & emotional function in most patients with chronic pain.”Turk DC, Wilson HD, Cahana A: “Treatment of Chronic Non-Cancer Pain”, The Lancet 2011; 377: 2226–35 (25.6.11)

So, we have programmes that are offered to people who have reached the end of their treatment line, but we don’t really know much about what works and for whom. Yet there is an effect on people, small though it may be, and there’s some evidence that people who do what the programmes suggest do better than those who don’t (Nicholas, Asghari, Corbett, Smeets, Wood, Overton et al, 2012).

Two things occur to me:

  1. We need to use more sophisticated ways to study process and subgroup analysis of people in chronic pain self management programmes. I think this might include using single subject experimental design. This design was used in some of the early work by Vlaeyen and colleagues looking at response to graded exposure for pain-related fear and avoidance (Vlaeyen, de Jong, Geilen, Heuts and van Breukelen, (2001), and Asenlof, Denison & Lindberg (2005). It allows clinicians and patients to really monitor the effect of various parts of treatment, and can be a very sophisticated way for “real life” clinical work to be evaluated.  Another option is the kind of analysis conducted by Burns, Nielson, Jensen, Heapy et al (2014) where subgroups were evaluated over the course of a pain management programme to identify the programme elements that might be most effective. Their findings suggest that there are two mechanisms: one directly relevant to the components of the programme such as relaxation or exercise, and another that they call “general mechanisms”. It’s this latter one that interests me.
  2. The way in which a programme might work may not be associated with the components. Like Burns and colleagues, I’ve thought that perhaps there is something within group process, or therapeutic process that is the “active ingredient” for change. Let me quickly unpack this.

Some people do quickly adopt what a programme suggests is useful – or at least they complete recording sheets to suggest they have. Others might still use the strategies, but perhaps in a different way from that originally intended (think of pacing as a good example: lots of patients I’ve seen who have been through a chronic pain management programme think that it’s all about “stopping before your pain gets out of control”, and rather than maintaining a consistent level of activity over time, their function gradually reduces as they do less and less. Their interpretation of pacing is that it’s about using your pain as a guide.

And still others pick and choose elements of what is covered in a programme – and use the strategies flexibly within the context of their daily lives. So on one day they may boom and bust, while on other days they chunk their activities into smaller bits. One day they’ll arrange their environment to suit them, another day they’ll ask other people to give them a hand. Their coping skill use depends on their goals and priorities at the time.

What DOES change is their self efficacy or belief that they CAN do what’s important in their lives – by hook or by crook. And even more importantly, they have something to DO that’s important to them. Maybe something that hasn’t been studied in sufficient detail is what a person wants to be able to do, what’s their motivation, what are their valued occupations? That’s a hypothesis about therapeutic change I think we need to ponder.

 

Asenlof, P., Denison, E., & Lindberg, P. (2005 ). Individually tailored treatment targeting motor behavior, cognition, and disability: 2 experimental single-case studies of patients with recurrent and persistent musculoskeletal pain in primary health care. Physical Therapy, 85(10), 1061-1077.

Burns, J., Nielson, W., Jensen, M., Heapy, A., Czlapinski, R., & Kerns, R. (2014). Does Change Occur for the Reasons We Think It Does? A Test of Specific Therapeutic Operations During Cognitive-Behavioral Treatment of Chronic Pain The Clinical Journal of Pain DOI: 10.1097/ajp.0000000000000141

Louw, Adriaan, Diener, Ina, Butler, David S, & Puentedura, Emilio J. (2013). Preoperative education addressing postoperative pain in total joint arthroplasty: Review of content and educational delivery methods. Physiotherapy theory and practice, 29(3), 175-194.

Moseley, G., Nicholas, Michael K., & Hodges, Paul W. (2004). A randomized controlled trial of intensive neurophysiology education in chronic low back pain. The Clinical Journal of Pain, 20(5), 324-330. doi: http://dx.doi.org/10.1097/00002508-200409000-00007

Michaleff, Zoe A., Maher, Chris G., Lin, Chung-Wei Christine, Rebbeck, Trudy, Jull, Gwendolen, Latimer, Jane, . . . Sterling, Michele. (2014). Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial. The Lancet, 384(9938), 133-141.

Nicholas, M., Asghari, A., Corbett, M., Smeets, R., Wood, B., Overton, S., . . . Beeston, L. (2012). Is adherence to pain self-management strategies associated with improved pain, depression and disability in those with disabling chronic pain? European Journal of Pain, 16(1), 93-104.

Vlaeyen, J. W., de Jong, J., Geilen, M., Heuts, P. H., & van Breukelen, G. (2001). Graded exposure in vivo in the treatment of pain-related fear: a replicated single-case experimental design in four patients with chronic low back pain. Behaviour Research & Therapy., 39(2), 151-166.

Williams, Amanda C. de C., Eccleston, Christopher, & Morley, Stephen. (2012). Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews, (11). http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007407.pub3/abstract doi:10.1002/14651858.CD007407.pub3

Coalface conversations


Knowing about something doesn’t hit the heart or mind nearly as well as doing it. As regular readers of my blog will know, I teach various aspects of pain management to postgraduate health professionals who come from a wide range of disciplines. Hopefully I can guide people towards thinking about the range of factors that can influence what goes on between delivering a treatment and the eventual outcome. It’s difficult, though, because much of what I need to do is based on giving access to information rather than opportunities to practice and then integrate this material.

I thought about this the other day when I met with a new patient. He comes to me with a history of seeing lots of health professionals, and learning lots of skills, but still essentially having the same struggle as he’s had throughout his lifetime. What can I possibly add to his ability to cope when he’s already had such a lot?

One of the conversations I often have with new patients is the relevance of psychosocial factors in their situation. It’s a conversation many health professionals fear – and then avoid. I’ve heard people say that they’re worried that their patient will think they’re saying “it’s all in your head”, or that their problem isn’t taken seriously. That comment is certainly something I’ve heard from patients as well.

So, when I met with this patient I decided to use what he had already learned to find out what he thought was going on, and to help us both discover more about what I could offer. This is essentially Socratic Questioning. Socratic questioning is styled after the teaching approach of Socrates and written about mainly by Plato.  It’s an approach where questions are asked after each answer, and through doing this, people discover the underlying beliefs or “truths” for themselves, rather than being told what to think. It’s a process of discovery – and when I use it with a patient or client, I use it so we can BOTH discover something.

It’s not easy to describe how to use Socratic questioning without coming up with a pat series of responses, but I’ll have a go. In reality, Socratic questioning is a subtle series of responses that can summarise, clarify and then probe behind the superficial to access deeper insights for both parties. If the clinician “knows” what the answers are, and uses this line of questioning to simply show the client something, it can end up being a process to show off how brilliant he or she is, subsequently missing the point of this approach.

Here’s an excerpt (as far as I can remember it):

B:       Tell me what’s been going on since we last caught up.

P:       Well, I’ve had a few flare-ups and I’m struggling a lot with the effort it takes to keep going even on a bad day.

B:       You look defeated when you say that. Do you feel defeated?

P:       Yes. I’m no good. I haven’t got what it takes.

B:      What do you mean “I haven’t got what it takes?”

P:       I haven’t got the strength, or the commitment to keep going. I’m just not good enough.

B:       Has something happened to lead you to this conclusion, or have you felt this way for a long time?

P:        It’s just got clear to me this last week.

B:        So this is a change in your thinking?

P:         Yes. I spent the weekend with my family and saw how happy they all are, and here am I doing nothing and sitting on the sidelines. If my kids were with my brother, they’d be so much better off.

B:        So…because you care about your kids, you decided you’ve let them down, you haven’t got what it takes.

P:        That’s it. If I didn’t have this pain, if I could fight it more, I wouldn’t let them down and they’d be happier.

B:        You said this was a change in your thinking. You’ve had your back pain for quite a while now, and you’ve been around your family lots of times. What did you think about yourself in the past?

P:        I think I was feeling better about myself because at least I was trying and my pain wasn’t in the way as much. Trying hard isn’t enough.

B:        I don’t think I quite follow. Why is trying not enough?

P:       Because no matter how hard I try, I can’t get around my back pain and my kids aren’t getting what they should from me.

B:       Is that what they say to you?

P:       No, but I can see my brother’s kids are so happy.

B:       And you’d like your kids to be happier.

P:       Yes.

B:        What things would you do differently if your pain wasn’t such a problem?

P:       I’d talk with them more, I’d encourage them, I’d play ball with them, I’d be there more for them.

B:       Are these things you could do even though your back pain is more than normal?

P:        Well… I couldn’t play ball with them.

B:       What about talking, encouraging them?

P:       Well, I suppose I could, but I’m scared I’ll just get angry with them.

B:       How would it feel just to try some new things anyway, even if you get irritable by the end?

P:       I suppose it would be a start, and they would at least see I tried. But I am still worried I’ll let them down.

B:      If you did let them down, would it negate having tried encouraging them at first?

P:      No, I guess it would give them a bit of the old me for a while.

There are roughly three steps in this exchange: (1) collecting information together; (2) examining this information together; (3)  inviting the patient to develop his own plans for doing something with that information. You’ll see that I didn’t attend to his pain, but instead focused on what he was afraid of – that his pain would make him grumpy, and that this would make his kids sad.  The conversation is all about discovering together, being curious and trying to learn about his experience from his perspective. By doing this together, we make long term changes because our clients learn how to discover what they’re thinking and doing, explore their thoughts and actions from a variety of perspectives, and generate their own answers.

Simply giving my patient/client the task to “do things differently” with his kids might have given him some homework, but it doesn’t help him learn about himself, nor about his main concern which is the effect of his back pain on his relationship with his children. This is definitely a psychosocial issue, but my patient didn’t reject what I had to say because we discovered it together and he gave me the information himself. It’s a very rewarding way to collaborate with someone.

Here’s a handout swiped from www.thebeckinitiative.org

A more in-depth web page of info on Socractic questioning and cognitive therapy is here

Non-drug approaches for people with fibromyalgia


ResearchBlogging.org
No-one wants to be told their pain is “in your head”. But given our increasingly sophisticated understanding of pain neurobiology, there’s plenty of reason to agree that thinking, feeling and doing things differently makes life far more rewarding and rich than feeling helpless, fatigued and sore. Some proponents of purely biomedical interventions argue that if only the “source of the nociception” was found, the nerve “zapped” or anaesthetised, then all this psychosocial claptrap could be safely ignored because people “return to normal”. I think this belief shows ignorance and perhaps even arrogance because people process and attribute meaning to everything that happens to them.

I originally entitled this post as “psychological” approaches for people with fibromyalgia, but I’ve changed it after reflecting that we actually do not know which of the various parts of non-drug therapy are most useful for people. There are some core components in self-management approaches, these include explanations (or reconceptualising pain), graded return to life’s activities or occupations, exercise (again, graded), and often some work around thoughts/beliefs/emotions that might get in the way of returning to activities, and some practical problem-solving and goal-setting to help people work out how they’re going to “get on with it”.

While the assumptions are cognitive behavioural in origin – that is, people can take control of what is happening around them, and respond differently even if the pain doesn’t change – most of what happens involves doing things differently in order to bring more of what the person values back into their life, rather than having life dominated by pain.

I’ve written before about ACT, Acceptance and Commitment Therapy, and I find it quite appealing. The ACT approach involves developing skills to be fully present, work towards living a life aligned with your personal values, being mindful of what is (rather than worry about what was, or what might be), being committed to taking action even if the process isn’t always happy-happy, joy-joy. I like it, and in my research it seems to fit quite nicely with what people naturally do. In ACT the coping strategies used don’t fall into “good” or “bad” dichotomies, instead they’re evaluated according to how well they’re working in light of each individual’s values. I like the respectful attitude towards people’s personal values and beliefs, and the flexibility of using “what works” and experiential therapy rather than sitting in a clinic room talking.

The question is whether ACT is any better or worse than any other psychological treatment – such as “traditional” cognitive behavioural therapy.

The jury is out. Frankly I am not sure it’s as much about the particular model or type of therapy used as it is about the way in which it’s introduced to the person. There are CBT clinicians who seem to be able to come alongside a person, help them work out for themselves whether their thinking is helpful or not, and help them shift their perspective nicely. Then there are CBT clinicians who leave people feeling as if they have “stinking thinking” or “maladaptive thoughts”, who “have” to change their way of life, who “must” do therapy “homework” – and blame the patient for failing to do “homework” or being “noncompliant”.  I can, of course, say the same about ACT clinicians and indeed any other form of clinician!

Where does this leave us?

Well, I’m not sure that much has changed in the 20 or so years I’ve been working in this field. What has happened is stronger evidence to show that thoughts, beliefs, emotions and behaviour are linked, and directly influence our experience of pain. People still need to understand, or make sense, of what’s happening to them, get more active and have more of what they want in their lives rather than feeling controlled by pain.

How we achieve this probably depends as much on the person who has pain as the clinician.

We also know that fruitlessly seeking pain reduction leads to demoralisation, frustration and increasing disability.

While I’ve put “fibromyalgia” as the type of chronic pain two of the papers I’ve cited refer to, really I’m not convinced that the problems people experience from their pain differs terribly much depending on the diagnosis. The effect of pain that goes on is the same – a diminishing sense of self identity, increased sense of helplessness and overall difficulty doing and being well. Addressing these effects is far more worthwhile in people’s lives than trying to control, avoid or abolish pain – because some pains just don’t go away.

Luciano, J., Guallar, J., Aguado, J., López-del-Hoyo, Y., Olivan, B., Magallón, R., Alda, M., Serrano-Blanco, A., Gili, M., & Garcia-Campayo, J. (2014). Effectiveness of group acceptance and commitment therapy for fibromyalgia: A 6-month randomized controlled trial (EFFIGACT study) PAIN®, 155 (4), 693-702 DOI: 10.1016/j.pain.2013.12.029
BERNARDY, K., FUBER, N., KOLLNER, V., & HAUSER, W. (2010). Efficacy of Cognitive-Behavioral Therapies in Fibromyalgia Syndrome — A Systematic Review and Metaanalysis of Randomized Controlled Trials The Journal of Rheumatology, 37 (10), 1991-2005 DOI: 10.3899/jrheum.100104
Williams ACDC,, Eccleston C,, & Morley S (2012). Psychological therapies for the management of chronic pain (excluding headache)in adults. Cochrane Database of Systematic Reviews (11) DOI: 10.1002/14651858.CD007407.pub3

 

NB: I have amended the first paragraph because it may have been viewed as unnecessarily pejorative towards a single type of clinician. The truth is, I point the finger at any clinician from any background or discipline if I think what is being done is harmful, illogical or maintains distress and disability, including my original profession of occupational therapy.  I was being simplistic to suggest a single profession is at fault. It’s not the profession per se, it’s the attitude that I strongly object to.  To those who were upset by my original wording, here’s an invitation: if you’re able to demonstrate HOW you integrate biopsychosocial approaches in your practice, I’ll publish it. That’s the beauty of dialogue, and particularly social media.

Mindfulness, catastrophising and disability


ResearchBlogging.org

Readers of Healthskills will know I have a fascination for mindfulness as an intervention for people who have ongoing pain.  Mindfulness is relatively easy to learn, is portable – is free, and has no calories! Seriously, as a seemingly simple intervention, it has appeal not only because it is readily used, but also because so many studies have found that it is effective for reducing distress and disability.

What is it?

Mindfulness is “moment-by-moment attention and observation of external and internal stimuli (eg, thoughts, feelings, bodily sensations) in a nonjudgemental and nonreactive way” (Cassidy, Atherton, Robertson, Walsh & Gillett, 2012).  It’s thought to be the opposite of catastrophising, which is the tendency to interpret those same experiences as an indication of harm or damage.

Learning mindfulness is relatively simple – but hard to maintain, practice is everything. This is my process, developed from multiple readings over the years so I am completely unable to identify where I got it from!  Readers keen to learn more about how to teach mindfulness should head to the Center for Mindfulness in Medicine, Healthcare and Society based in the University of Massachusetts, alternatively, read anything by Jon Kabat-Zinn.

I begin with asking the person to become aware of their breathing. Not changing it, not trying to breath more slowly or deeply or anything – just become aware of it.  I might guide the person to

  • become aware of cool air as it enters the nostrils and flows down the back of the throat;
  • to notice the warmth of the air that passes back out;
  • to be aware of the rise and fall of the abdomen or chest;
  • to become aware of what it feels like when the chest expands

…and so on.  I often extend this awareness to notice the body sensations of contact with the support, or the warmth of the hands as they rest on the lap – for as long as I think the person is remaining aware and not drifting into other thoughts.  I know I can’t really be aware of the person’s thoughts, but I watch very carefully to see whether the person’s eyes are moving (usually they’re closed during this session) and whether they’re fidgeting or shifting in the chair. This initial introduction is usually quite brief – only a few minutes – to give the person a taste of what it might feel like to experience without naming or judging or labelling.

Debriefing at the conclusion of this brief session is essential, IMHO.  This is where therapist’s personal use of mindfulness is important – whatever the person experiences is OK.  I ask about what they noticed during this experience, mainly to identify whether they’re labelling the experience as “good”, or “bad”, or shades in between.  Essentially I’m hoping for the person to simply list the sensations rather than indicating whether they are judged as something.  An example might help: if the person said “I was surprised at how warm my hands were” is a judgement – the word “surprised” suggests a judgement about what is usually experienced.  My response might be “So you noticed your warm hands” rather than probing as to what the “normal” state is, or reflecting that the person was surprised.

For home-based learning, I suggest doing this same breathing exercise at least three times a day.  Or I might suggest being mindful while cleaning the teeth, noticing the sensations of brushing and the taste of toothpaste.  It’s a simple activity that is done regularly and is usually not interrupted!

Why focus on mindfulness?

There are a couple of reasons I like mindfulness.  I indicated earlier that it’s a portable, relatively simple strategy that can be used anywhere – and that it’s the opposite of catastrophising.  Delving into the mechanics of how mindfulness works is beyond the scope of a post like this, but it does seem that observing without judgement reduces the automatic evaluation of a body sensation as “something really bad”, ie catastrophising.  We know that catastrophising is associated with increased disability, anxiety, low mood and can serve to maintain behavioural avoidance.

The study by Cassidy and colleagues found that “greater mindfulness was predictive of lower levels of disability, anxiety, depression and catastrophizing, even when pain severity was controlled” in the context of delivering a multidisciplinary pain management programme.  We can’t determine from the design of this study whether the practice of mindfulness influenced catastrophising, but some statistical analysis of the relationships between mindfulness, catastrophising and disability found that the degree to which mindfulness influenced disability was itself influenced by catastrophising, and that mindfulness had a direct relationship with catastrophising, and in turn had a relationship with disability.

What this means is that increased mindfulness appeared to reduce catastrophising, which in turn reduced disability.

The explanation given is that mindfulness involves greater use of nonjudgemental awareness of events, experiences, sensations around an individual, and that by doing this, the tendency to jump to a negative conclusion about the meaning of that experience is reduced.

It’s worth considering how mindfulness can be integrated into daily clinical practice – for both the practitioner and the client.  It’s certainly easier to teach something that has been personally experienced, and it is likely to help maintain that broad awareness that is needed when observing what is going on with a patient.  It does mean giving oneself space to later recall and interpret what is being observed, but I find it’s a whole lot easier to do so than if I’ve been trying to interpret at the same time.  This, of course, will depend on the content of a treatment session.

Cassidy, E., Atherton, R., Robertson, N., Walsh, D., & Gillett, R. (2012). Mindfulness, functioning and catastrophizing after multidisciplinary pain management for chronic low back pain PAIN, 153 (3), 644-650 DOI: 10.1016/j.pain.2011.11.027

Pain reduction doesn’t (always) reduce disability


ResearchBlogging.org

The relationship between pain and disability is a particularly vexing one in primary care. It would be great if it was possible to get rid of pain and be assured that any lingering effects on function would be similarly abolished, but it just doesn’t seem to be quite that simple.

Many different approaches to managing this situation have been suggested. One is to argue that people should be referred for a quick pain reduction injection – for those who have pain that is thought to respond to this approach. Another is to just “reassure” and review often. And still another is to provide a cognitive behavioural approach usually reserved for those referred to a secondary or tertiary treatment centre.

For several reasons I find the first and second options above not particularly satisfying. 

For the avoidance of doubt, I want to make sure readers are aware that I am not agin pain reduction techniques. In fact, they’re a very good thing because, and this is the important point, they allow people to get back doing what is important to them. There are a few “provided that’s” to this because, as I’m going to show, people who have had a bout of pain don’t always “get back doing what is important to them”.

The second option of providing reassurance is also less than satisfactory because despite this approach being endorsed in numerous guidelines for managing acute musculoskeletal pain, very few specific recommendations as to how to provide reassurance have been given. Reassurance can be both unsatisfying to the person on the receiving end, and in some cases, increase the likelihood that the person remains fearful of moving and continues to look for more reassurance (Linton, McCracken & Vlaeyen, 2008).

Why doesn’t “taking the pain away” just return the person to the way they were?

Good question, glad you asked it!  While abolishing the pain does, in many cases, return the peripheral nervous system and tissues to normal, this situation doesn’t apply to the central nervous system – and most particularly, those parts of the brain concerned with appraisals and judgements, anxiety and emotion, and memory.  Let me explain.

When we are born, we arrive in the world with a functioning set of reflexes that respond quickly to input that startles the nervous system out of “comfort”. Loud noises, textures against the skin, new tastes – all of these provoke a startle response and we cry in protest. Thankfully most of these responses settle down as the nervous system habituates to those features of the environment that reoccur, but our responses are shaped by how adults around us respond to the same events, and how they respond to our behaviour.  This is the effect of social and cultural influences.  At the same time, we begin to develop preferences – some genetically shaped, others from what we observe and imagine about other people, and some from our own processing of the external and internal world.

It’s these factors that influence our responses to sensations that our brains ultimately determine are harmful or potentially harmful – and our brains let “us” know about this in the form of our experience of pain.
We develop tolerances to experiences as we’re exposed to them over time. Think of the sensation of biting into a

HOT CHILLI PEPPER.

Some of you will be thinking “Ouch! No way I’d do that!”, while others of you will be thinking “Yeah baby! Bring it on!”
The way we appraise, or think about/judge a situation influences our emotional response to it.  This in turn influences what we are prepared to do about it.

Returning to the chilli pepper, even the next day after having had the HOT CHILLI PEPPER, you can remember the experience. (As an aside, this ability to remember what has happened – and then predict what might happen in the future – is what I drew on when I suggested that you think about it. ) You also made some decisions in your mind when I asked you to think of it, based on your appraisal of the sensation, and your emotional response to it.

When we experience pain, even if that pain goes after a while, we judge it and we have feelings about it, and we make decisions about what we will – or won’t – do if that situation arises again.

And this is why reducing pain but failing to also address thoughts and beliefs about what has happened and the possibility of it happening again does not always give the outcome we are hoping for.

The papers by Lamb and colleagues demonstrate that group CBT for low-back pain can be delivered in a cost-effective way in primary care, with good long-term effectiveness.   Isn’t it time this approach was seriously implemented?

Sarah E Lamb, Zara Hansen, Ranjit Lall, Emanuela Castelnuovo, Emma J Withers, Vivien Nichols, Rachel Potter, Martin R Underwood (2010). Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-eff ectiveness analysis Lancet, 375 (9718), 916-923 : DOI:10.1016/S0140- 6736(09)62164-4

Lamb, S., Mistry, D., Lall, R., Hansen, Z., Evans, D., Withers, E., & Underwood, M. (2012). Group cognitive behavioural interventions for low back pain in primary care: Extended follow-up of the Back Skills Training Trial (ISRCTN54717854) PAIN DOI: 10.1016/j.pain.2011.11.016

Linton, S. J., McCracken, L. M., & Vlaeyen, J. W. (2008). Reassurance: Help or hinder in the treatment of pain. Pain, 134(1-2), 5-8.

Which comes first: Doing or knowing?


ResearchBlogging.orgReceived wisdom in cognitive behavioural therapy says that to change behaviour, a person must first change his or her thinking.  This has created a tension between those clinicians who emphasise the cognitive aspects of pain management – and those who focus on helping people with pain do more.  Should we educate and target cognitions, particularly those sticky core beliefs – or can we use behaviour change as a way to help the person make gains?

The answer is, as you’d have guessed, not black and white.  In fact, as several authors and researchers have pointed out (see the references below for just two), not only is the cognitive behavioural approach to chronic pain management a mixed bag of strategies, there is very little information on the process of change that occurs during treatment.

Here’s what I’ve seen clinically – while some people are ready to change, others are not.  I need to work with this second group using motivational interviewing approaches to help them identify their own reasons for doing things differently.

This might mean creating a sense of dilemma – identifying where they are now in terms of goals and satisfaction with life, and creating awareness both of the possibility that life might be different, and what that might look like.  This helps people recognise their “stuckness” and creates momentum for change.  From there, it’s far easier to help them develop goals and start to problem-solve what needs to happen to reach them.

Another group of people are those who are relatively inflexible in their thinking and behaviour – they’re stuck not because of a dilemma, but because they’re continuing to use strategies that have worked for them in the past, but are not working now.  It’s like they have trouble working out another way of approaching problems.

A good example of this is a man who has always been fit and before his pain began was a representative sportsman. His approach was always to do more than what was required. He was stuck because doing this when he had pain created a “boom and bust” approach to activity.   For this kind of person, I like to use what Steven Hayes (ACT) likes to call “creative hopelessness” – pointing out that it’s not the methods the person is using, but their purpose. I use experiential methods to do this – gettng the person to monitor what has happened over the week, and asking him to establish what he believes: his mind and what it tells him? or his experience and whether it works.

Cognitive change doesn’t necessarily occur before behaviour change
It’s strange, but true, that despite our best efforts, twelve months after people have completed a pain management programme, few are still using the strategies we help them develop.  While some are goal setting, or using relaxation, or exercising, or even checking in with their thinking – the majority are simply getting on with life (Curran, Williams  & Potts,  2009 – doi: 10.1016/j.pain.2005.09.004). And even more strange – people who start making behavioural changes early in a pain management programme seem to do best, while those who actually complete between-session activities also seem to do best (Heapy, Otis, Marcus, et al., 2005).

Persuasion, challenging core beliefs, and education have their place – for the right reasons, at the right time, for the right person – but they don’t alter the fundamental issue alone. 

 What is that issue? It’s about an attitude shift towards “sitting with” uncomfortable thoughts and sensations, and working towards valued goals despite those thoughts and sensations.  It’s about a spirit of gentleness and willingness to recognise those thoughts and sensations as the mind’s way of solving problems – and at the same time, accepting that it’s entirely possible to do what is important despite the presence of these thoughts and sensations.

Morley, S., & Keefe, F. (2007). Getting a handle on process and change in CBT for chronic pain Pain, 127 (3), 197-198 DOI: 10.1016/j.pain.2006.10.025
Morley, S. (2004). Process and change in cognitive behaviour therapy for chronic pain Pain, 109 (3), 205-206 DOI: 10.1016/j.pain.2004.02.008

Curran, C., Williams, A. C. d. C., & Potts, H. W. W. (2009). Cognitive-behavioral therapy for persistent pain: Does adherence after treatment affect outcome? European Journal of Pain, 13(2), 178-188.

Self management – a very vexing definition


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Self management is one of those terms that is used to describe the aim of cognitive behavioural programmes for chronic pain. It’s even in my description of this blog! At the same time, it’s difficult to arrive at a definition of self management that “everyone” agrees upon.

Self management can mean helping people to be “actively involved in their health care and to provide a variety of creative and individualized strategies to deal with their health problem in their daily life and ultimately to live as normally as possible despite their symptoms” (Zuffery & Schulz, 2009) – but the Devil is in the details!

What exactly does being “actively involved” mean?  Can it mean accessing treatments like massage, injections, acupuncture “as needed”? Or does it mean exclusively managing pain without recourse to so-called “passive” treatments?  And what are the implications of either of these two options (and yes, shades in between)?

Let’s take the most extreme option, that of having a chronic pain problem like fibromyalgia where there is no definitive treatment and no structural deficit that can be “fixed”, and learning to manage this problem without accessing any treatments.  Self management, in this case, might mean:

  • knowing as much about the diagnosis and underlying neurobiology as possible;
  • being “health literate” and able to negotiate through health care systems;
  • knowing how to select the appropriate coping strategy or strategies to achieve a specific goal; and
  • maintaining a healthy and active lifestyle, with full participation in occupations, activities and roles within the family and community

Alternatively, at the other end of the spectrum, for someone with a recurrent structural change (say low back pain that responds to medial branch blocks), self management might look like:

  • knowing as much about the diagnosis and underlying neurobiology as possible;
  • recognising the “early warning signs” indicating that either a flare-up is happening, or the medical procedure is starting to ‘wear off”;
  • being “health literate” and knowing how to access this help as needed;
  • knowing how to select the appropriate coping strategy or strategies to achieve a specific goal;
  • maintaining participation in occupations, activities and roles within the family and community, while living a healthy life

There’s not a lot of difference between the two – one doesn’t access treatment, the other does.  However – and here’s my take on self management – there is a great deal of difference in terms of managing fluctuations in pain, and in the focus on symptoms.

One of the predictors of coping well with a chronic health problem is self efficacy.  Self efficacy is confidence that you can manage a situation yourself.  At least within North American and possibly a majority of New Zealanders, self efficacy is influenced by having an internal locus of control – this means recognising that the efforts the person does make a difference, rather than expecting or hoping that someone or something outside of themself will be effective. (There are differences in cultural expectancies, hence localising my description).

Typically, it seems that people who can make a difference to their own health through their own efforts, feel more confident to manage fluctuations in pain – which, it has to be said, occur with all chronically painful conditions.  Those that are hoping for something to “take the pain away”, or who try to rid themselves of the pain through avoiding activities when they’re sore, or increasing their medication intake or access treatments to reduce their pain, seem to be less confident to weather these fluctuations, and can become distressed when their efforts don’t work, or their pain doesn’t settle, or they’re asked to do things even when they’re sore.

Where’s the evidence for this? Well, Blyth and colleagues carried out a very large study of non-treatment-seeking people in Australia who had chronic pain.  Their findings showed that “use of active strategies was associated with lower levels of disability, less distress, less reliance on medication, and less use of formal health care” – although combinations of what we might call “passive” coping such as rest and heat/cold were often used with active coping strategies such as exercise, changing position and so on.

Now I’m not comfortable with classifying various strategies as passive=bad, active=good.  I think it’s more complex than that because my taking on coping and self management is that we don’t use strategies without some sort of goal in mind.  That goal might be to reduce distress so the kids don’t see Mum crying; it might be to remain standing so Dad can watch the rugby; it could be to keep going so the housework gets done; or it might be to be productive at work. I think we need to be cautious about simplistic classifications unless we also take into account the end goal, or the “what is important to the person” aspect of the coping strategy.

I have a sneaking suspicion, though, that it’s not so much the skills used in the process of living everyday life that promotes self management and self efficacy – I think it may be an “attitude”.  In other words, it’s not what you do, but the way that you do it (or the spirit that you do it in).

My rationale for this is the growing evidence that greater pain acceptance is associated with less distress and disability (see for example, Wright, Wren, Somers, et al; 2011).  They looked at pain acceptance and hope and optimism in a group of obese patients with musculoskeletal pain.  Using the Chronic Pain Acceptance Questionnaire which divides pain acceptance into  pain willingness (or how willing a person is to experience increases in pain during the pursuit of something important), and activity engagement (or how involved in everyday living a person is). They found that “pain acceptance remained a significant predictor of psychological distress and pain disability” even after controlling for optimism, demographic, and medical variables.

This is important stuff – along with the strategies, which have always been the focus of pain management, these attitudinal changes seem to be important in self managing pain.  Now: how do we influence this attitude?

One final question: do people who have greater pain acceptance also need health literacy skills to manage the tendency of our health systems to want to offer a fix or a cure to people with chronic health problems? Because while our views have mainly about the person with pain and what he or she does, I don’t think we’re nearly as aware of, nor focus on, the influence of social forces like family, healthcare system, community attitudes and so on.  More on this later folks!

Wright, M., Wren, A., Somers, T., Goetz, M., Fras, A., Huh, B., Rogers, L., & Keefe, F. (2011). Pain Acceptance, Hope, and Optimism: Relationships to Pain and Adjustment in Patients With Chronic Musculoskeletal Pain The Journal of Pain DOI: 10.1016/j.jpain.2011.06.002
BLYTH, F., MARCH, L., NICHOLAS, M., & COUSINS, M. (2005). Self-management of chronic pain: a population-based study Pain, 113 (3), 285-292 DOI: 10.1016/j.pain.2004.12.004

Caiata Zufferey, M., & Schulz, P. (2009). Self-management of chronic low back pain: An exploration of the impact of a patient-centered website Patient Education and Counseling, 77 (1), 27-32 DOI: 10.1016/j.pec.2009.01.016

Education or a cognitive behavioural approach?


ResearchBlogging.orgThere is a reasonable amount of evidence suggesting that self management of chronic pain is only moderately effective.  Some of the factors thought to influence outcomes include the “one size fits all” approach – people with chronic pain may not all equally benefit from the same aspects of a programme; that programmes are usually delivered within a university-based, middle-class, North American setting and that there may be moderating or mediating factors that influence the who and what actually works within a programme.

I was interested to read about an RCT of “education” and “cognitive behavioural approach” conducted by Day, Thorn and Kapoor.   Dr Bev Thorn has written many books and research papers on a structured cognitive behavioural approach for pain that specifically addresses the appraisals people make of their pain.   In this approach, people are taken through a process of firstly identifying their appraisals, then learning how to challenge and restructure their thoughts about pain, while at the same time learning to do activities that they may have avoided for some time.  One feature of a CBT approach is using  “home learning” activities to bridge between sessions and help generalise the learning.

By comparison, an educational approach provides accurate information on aspects of pain and coping strategies, but doesn’t include the “home learning” and doesn’t directly address ways to identify and restructure thinking about pain.

One of the problems with many cognitive behavioural programmes for pain management is that they demand a lot from their participants – and particularly, they require literacy.  There can be, if not carefully structured, a lot of writing.  For people who don’t do writing or pen and paper activities, this can be really off-putting.  The sessions are also somewhat “talky” – again, this can be off-putting for people who prefer action and doing.

In this study by Day, Thorn & Kapoor, the two approaches were used with a group of people from a rural area, with relatively low socio-economic status, and a reading grade level of about 8.  Both groups received a group-based programme of 10 sessions of 90 minutes.  They both received a workbook and additional reading material.  The CBT group had home-learning and also participated in behavioural activities such as relaxation in-session, while the education group did not.

Interestingly, this study presents qualitative information on how participants experienced the sessions, rather than outcomes measures, so it’s difficult to establish whether pain, disability, mood or acceptance were influenced.  Instead it presents thematic analysis from in-depth interviews of the participants.

What this analysis found was that while the CBT group participants initially found it difficult to “get into” the process, they spontaneously identified many of the CBT elements that were meaningful to them such as intermediate beliefs, the ability to “redirect” thinking, and integrating activity management strategies such as pacing and task perseverance.

Fewer of these themes emerged from the education group, although group process factors similar to that identified in the CBT group were found.  Both groups identified that it was good to know they weren’t alone and that they learned from other members in the group.  Both groups also identified that they felt more confident and in control of their situation, that they could “rise above” their pain.

Where the groups also differed was in their engagement in preferred life activities (occupations).  Participants in the CBT group indicated that they were returning to preferred social activities, sports and leisure activities and that they believed they were able to persist with these despite an increase in pain.  This didn’t occur in participants involved in the education group.

What does this tell me?

Well, a couple of really important things.  While we don’t know which parts of the self management programmes do the hard work for people with chronic pain, it seems that a group approach has some unique benefits irrespective of the type of programme offered.  People with chronic pain often feel isolated and very alone, as if they are the only people with their specific problems.  A group approach provides an opportunity to normalise these experiences.

I also take the idea that information alone doesn’t necessarily initiate change – structured goals seem to help, setting an expectation that learning and engaging in activities between sessions may help, the feedback and problem-solving may help too.  It could also be the process of cognitive therapy – learning to identify thoughts and beliefs, and restructure these may be helpful.

We can’t, from this study at least, determine which of these ‘active ingredients’ is doing the trick.  I rather fancy that although the cognitive aspects certainly play a part, it could be these other aspects – setting expectations, supporting change, problem solving – these could actually be the parts that get people started on doing things differently in their own environment.

Is it time for a different take on self management? Maybe it’s time to embark on a less educational, more occupation-focused approach that incorporates cognitive restructuring in an active and “doing” way as part of problem solving – what do you think?

Day, M., Thorn, B., & Kapoor, S. (2011). A Qualitative Analysis of a Randomized Controlled Trial Comparing a Cognitive-Behavioral Treatment With Education The Journal of Pain DOI: 10.1016/j.jpain.2011.02.354
Miles, C., Pincus, T., Carnes, D., Homer, K., Taylor, S., Bremner, S., Rahman, A., & Underwood, M. (2011). Can we identify how programmes aimed at promoting self-management in musculoskeletal pain work and who benefits? A systematic review of sub-group analysis within RCTs European Journal of Pain DOI: 10.1016/j.ejpain.2011.01.016