cognitive therapy

Making an exception – one way to soften a rule


I’ve mentioned before that one of the main problems with helping people to develop new ways of managing their pain is internal rules – things that we all learned as kids probably! Things like ‘if a job is worth doing, it’s worth doing well’, ‘never leave a job unfinished’..

These are great general rules, but for people who are learning, for example, to work to a quota, or to use activity ‘chunking’, or even to use a relaxation strategy at set times during the day, they can prove to be a cruel rod for their back.

How do you know when someone is applying a rigid rule?

Using the same method as for identifying automatic thoughts, ask the person ‘what when through your mind when you started to take a short break?’

If they respond with something like ‘I just couldn’t’ or ‘It didn’t feel right’, or ‘I could never leave a job undone’ – you have an opportunity to help them soften their rule, or make an exception.

I may ask them why they couldn’t, or why didn’t it feel right – and uncover a rule then. Remember that rules are mainly beliefs that have the word ‘should’, or ‘never’, or ‘always’, or ‘must’ or similar – and there is usually a further thought about what it might be like if that rule is violated, and this is usually an attitude ‘it would be awful’, ‘I would be so ashamed’, ‘it would be horrible’, ‘I wouldn’t cope’.

The simplest way to soften this rule is to ask them to substitute that ‘rule’ word for a more gentle one, one that offers them a choice. This can be something like ‘could’, or ‘might’.

You can also ask the person whether they can make an exception to that rule – and when they might think an exception applies. I may use something like ‘what would you do if you had pneumonia or the flu and were laid up in bed?’. I then might ask them whether there are any other situations they might relax that rule. Some people then say that they know they can relax the rule, but ‘it doesn’t feel right’ – and this provides an opportunity to talk about emotional reasoning.

It’s worth also asking yourself – are there some rules you live by too? For example ‘I must make sure all patients feel good about what I do’, ‘I must never upset a patient’. Be aware that sometimes a crisis or a challenge exposes the contradiction the person faces between applying a rigid rule and still being able to carry out important things in their life. For example: having a wonderfully tidy home which interferes with being able to spend time with the children; being a very hard worker which interferes with being able to live a balanced life that promotes wellbeing.

More tomorrow!

Learning to ‘feel the fear and do it anyway’


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ResearchBlogging.org

Working with a kinesiophobic person


One of the biggest challenges when working with someone who is fearful of pain and avoids movement is that although it’s very much like any sort of phobia, it differs on one essential point: people who are spider phobic, socially phobic, fearful of flying or heights or whatever are usually aware at some level that their fear is out of proportion to the ‘real’ risk. People who are kinesiophobic (kinesio – movement, phobic – fearful) are much more likely to believe that their fear is realistic and to have their concerns about moving despite pain reinforced both inadvertently and deliberately by others (including health professionals!).

So, to introduce the idea of beginning to move despite fear of pain or harm requires a bit of a delicate touch!

Some people advocate ‘just tell them’, and spend a good deal of time going through a psychoeducational approach about the difference between hurt and harm until they believe they have convinced the person that it’s OK to move. And sometimes this does reduce the ‘threat value’ of pain.
But just as the spider phobic person (and I was one!) is not reassured by the knowledge that in New Zealand we have very few poisonous spiders, and the one or two we do have are quite rare, the person who is afraid of moving when they are sore can remain unconvinced and continue to avoid moving despite the best ‘information’ or education available.

So, what can you do?
Well, let me tell you how I’ve started working with my current client. The man I’m working with is in his late 20’s, he has a slight disc bulge in his lumbar spine, with little evidence of nerve compression, and he has a 12 month history of low back pain.

His back pain started after he lifted some timber at work, and tripped, falling onto his side with the wood on top of him. He has had a very thorough orthopaedic examination, been seen by a neurosurgeon who doesn’t want to pursue surgery because of the somewhat equivocal findings both neurologically and on imaging studies. He’s now being seen by me and a physiotherapist, and having his low mood treated with pharmacology. He uses paracetamol for pain relief but no other medications.

Functionally, he still has good power in his lower limbs, has no neurological findings, but his activity level and movement patterns are extremely limited. He sits for about 3 – 5 minutes before getting up and slowly stretching. He walks (albeit slowly) to keep comfortable, and can stand for only a few minutes before leaning or stretching.

He has completed a set of questionnaires, including the short version of the Tampa Kinesiophobia Scale, and his score on this questionnaire was well above the cut-off we use to identify those a risk of kinesiophobia.

When I completed the 99 picture PHODA with him, he indicated he would not attempt nearly 70 of the pictures, including any pictures of bending forward, twisting his trunk, jarring (eg going up and down stairs, or riding a bike over a kerb or using a mini-trampoline), carrying anything, or reaching above his head. In his daily activities, he is not working, he makes his bed (he has a duvet only), carries out his personal activities of daily living, but is otherwise either inactive (lying down to rest), or he walks.

He is living with family who are doing all of the household activities, so his responsibilities are very low. In addition, he is quite depressed although starting to look more future-oriented, he has an unsupportive family who are quite critical of his limitations despite carrying out his household responsibilities, and he has broken up from a long-term relationship about six months ago.

I started with using a motivational interviewing approach, and suggested we review some of the areas that other people often find helpful when they are thinking about managing pain. Using a menu of options, he identified sleep, medication use, relationships and work as his main concerns.

I asked him what he had found useful about previous therapies, and also what he had found not so helpful about those approaches. My aim was to help him identify that his previous attempts to control his pain by avoiding activities had not reduced his pain, and had increased the difficulties he faced living his life according to the values he holds.

I asked him whether he thought his movement patterns were helping him or whether there were some not so good features about the way he moved. He agreed that although sometimes it meant that he could avoid doing a movement that he thought increased his pain, for much of the time his pain remained and he had to keep on being ‘careful’ of any movements he did, and this was exhausting!

I then asked him how important it was to him to be able to return to normal activities even if it meant he needed to bring his pain along as well – and he indicated that it was very important. Using the ‘scaling questions’ (Why do you think it’s so important to you? Why give it a 9/10 and not a 6/10?), he told me that he thought his life was becoming very restricted, he wasn’t able to work, and he didn’t think there was going to be a medical way to reduce his pain.

I then went through his confidence that he would be able to carry out normal activities despite his pain, and he told me it was 3/10. Once again, using ‘scaling questions’, I asked him what it would take to help him move his confidence up a little, had he ever successfully made a change in his life despite it being quite hard, and he was able to talk about how he had worked his way up in the workplace despite not being a proficient reader, and that he knew he could make changes because if he took things one step at a time, he could see progress.

I then went through the PHODA pictures, and asked him which of the images he thought were most important for him to be able to do. He indicated that bending forward (eg to do dishes and clean teeth) was important, and also to put on shoes and pick things up from the floor.

I suggested to him that we weren’t sure why he thought he shouldn’t do these things, and asked him what went through his mind when he thought of himself doing these activities. He told me immediately that as he looked at photographs of people bending he could see himself falling forward and hitting the ground, or he could see his vertebrae grinding ‘bone on bone’ and see himself clutching his back because of the pain saying ‘I couldn’t cope with that sort of pain’.

Three things to note here:

  1. the catastrophic image which generates an emotional response,
  2. the misbelief that his vertebrae had no ‘padding’ so they were ‘grinding’ when he moved, and
  3. the belief that he ‘couldn’t cope’ with high levels of pain

Each of these automatic thoughts/images are open to reappraisal, but unless they’re paired with actual movement, they are not likely to help him actually do things.

So – tomorrow I’ll discuss the next step in his programme: working towards ‘exposure’