The gap between pain management – and returning to work

One of the most satisfying experiences I have in my job is seeing someone who has been off work for ages finally return to work.  It’s like seeing the person open up and bloom again. 

I often see people who have been off work for several years – most of them don’t have jobs to return to, and most of them have experienced a couple of attempts to return to work that have, for some reason or another, failed.  Often pain is given the blame for this, and the remedy is thought to be ‘develop pain management skills’ – and I guess in part that’s true.  But not completely.

There is a difference between using pain management skills at home, where for the most part, activities can be picked up and put down as needed, and at work where other demands are present.  There’s an element of discretion about when and how things are done at home.  People can, if they want to, take it a bit quietly on days when their pain is worse, and fit things in more readily on days when they’re feeling better.  Not so at work!  At work we have to do things to fit into an external timetable – deadlines exist! There are jobs we have to do that are not so forgiving – we have to do them in a certain way, or at a certain time whether we’re feeling great or not.

And therein lies the one of the reasons I think there is a gap between pain management and returning to work.  There’s a whole lot more riding on being able to keep going at work.

Let’s take a case like Allan.  Allan has been off work for three years now.  Before his accident he’d been working for two years as a night supervisor in a food production factory, and before that he’d been the primary caregiver for his wee girl who is now 8 years old.  And before that he’d been a professional athlete.

When he hurt his back he thought it would resolve quickly – but after a series of unsuccessful nerve blocks attempting to ‘find and obliterate the cause’ of his pain, and after two multidisciplinary physical rehabilitation programmes, he finally had to accept that his back pain wasn’t going to just go away.

He lost his job after he tried to return to work for about six weeks on a graduated return to work programme.  Allan had an occupational therapist visit his work place and was advised that he could do X, Y and Z tasks – but this wasn’t practical given the nature of the work, not even as a supernumerary.  Like many employers, his employer didn’t have any ‘selected duties’, and needed to employ someone else to cover Allan’s shift, and eventually told Allan that he couldn’t come back to work until he could manage certain tasks.  Allan’s employer terminated his employment after both of them decided that he wasn’t going to make it back in the next two or three months.

Allan was finally referred for pain management, and attended a three week interdisciplinary pain management programme.  He struggled with many of the concepts, particularly activity regulation (pacing was his least favourite word!), and he experienced panic when trying to use relaxation techniques.  He had been using a walking stick, and although he tried to stop using it during the programme, shortly afterwards he fell, and the stick became an ongoing fixture.  Allan was trying very hard to learn how to do things differently – but needed another twelve week programme of pain management using a cognitive behavioural approach before he could consistently maintain even his normal home activities.

Work was out of the question initially.  Allan’s confidence was shot – he knew he could do ‘some’ pain management, but much of what he did involved minimising fluctuations in pain, and when he did have an increase in pain he’d either push himself very hard to ‘get the job done’, or he’d use medications or rest to get through the tough patch.

Let’s make one thing clear, Allan really wanted to go back to work.  He told me he felt worthless, not a ‘real man’ because he wasn’t providing for his family and he felt trapped in his own home.  His confidence though, was at rock bottom.

The specific issues he saw as obstacles to going back to work were:

1. Managing his pain without resorting to prn medication
2. Coping with the side effects of his medication
3. Confidence to tell an employer that he would be reliable
4. Confidence he could be reliable and work consistently
5. Confidence to be assertive and let others know what he could and could not do
6. Worry that he would increase his pain and the other important aspects of his life would be under strain
7. Feeling out of touch with the technology and specific skills in the workplace
8. Not knowing how to present himself positively in a job interview – how would he answer those tricky questions about the time he’s had off work and about his health?
9. Knowing his own functional abilities – he knew what he couldn’t do, but not what he could rely on doing consistently
10. Identifying specific job options now that he couldn’t work the way he used to

You can see that the gap is not just about job seeking skills, although that’s certainly a part of it, but it’s also about how to use his skills to be reliable at work – to experience pain but persist and be consistent with his output.

How confusing it would be for Allan to be seen by a vocational provider who had a limited knowledge of chronic pain management.  How scary would it be for Allan to start to return to work after having failed in the past.  How demeaning to feel inadequate about his own skills and lack confidence to ask for help not only with every day work technology, but also with his pain (after all, that’s what lead to his loss of job early on).

The literature on returning to work after illness or injury is clear.  It’s not simply about coping with pain, it’s not simply about coping with disability, it’s not just about finding work, it’s not just about the person with the pain problem.  Vocational management is anything that helps a person remain at work or return to work – and it includes all of us on the team, including the employer.

For the most extensive review on vocational management that has been published recently, go to here for the executive summary of the report into vocational rehabilitation ‘What works for Whom’ by Waddell, Burton & Kendall (2008). 

Go here for a great set of downloadable documents about work and health (Working for Health, UK government)

And of course, RTW Matters  (Australasian) and ACC (New Zealand) Return to Work search page

Goals or actions?

Goals seem to work best when they’re important to the person, and the person has sufficient confidence that they’re going to be achieved. But…’there is many a slip betwixt cup and lip’ – while the goal might be set, actually getting there depends on many things. I wonder whether we can inadvertently slip up when we’re working to help someone set goals by focusing on outcome goals rather than process actions.

Let me clarify. Outcome goals are things like ‘sleep for 8 hours a night’. That’s what the person wants to achieve – but sleep might be disrupted by a child crying, a storm outside, or even a partner snoring! Sometimes the goal isn’t achievable not for lack of trying but because external factors intervene.

Process actions, on the other hand, are the particular actions the person does in order to work towards the desired goal. Actions are things like going to bed at a regular hour, keeping the bed for sleep and sex NOT worrying, arguing or being awake. Actions are specific behaviours the person can do, and are able to be achieved provided the person actually does them. Actions should lead toward the outcome.

I started to mull over the difference between goals and actions after reading through some of the ACT therapy manuals. In ACT, it’s important to identify the ‘why’ a particular action is being taken. The underlying reasons for an action are like a compass – they are the values that are important to the person, and guide the direction in which the person lives life. They’re never ‘completed’ or ‘achieved’, they can’t be ticked off a list and then dropped. Values can be eroded when actions that used to fulfil them stop being carried out. This can lead to a life full of actions to reduce negative experiences, but that inadvertently get in the way of actions that embody other important values.

When I look at the Stages of Change model and motivational interviewing, an important aspect of readiness to take action is to identify how important the change is, and how confident the person is to make that change.  Reviewing the importance of a change uncovers the values that the new behaviour is intended to fulfil. Without being really clear about why a new behaviour might be carried out can lead to weak engagement in the goal.  Importance is the aspect that MI identifies should be strengthened and clarified before starting to increase confidence.

Coming back to actions or goals.  If a goal is the end point and the outcome varies because of something unforeseen,  then the chances of the person becoming confident that it’s worthwhile persevering will be quite low.  After all, if my goal is to be first in a race, and I see that everyone else lining up for it has a personal best far better than mine, I’m not likely to want to even begin the race!

It’s important to distinguish between actions that the person can take, and be in control of, and goals that may not be achieved because of other things.  And the actions must tie in with underlying values or the person isn’t likely to find them important, even if they are certain they can do them.

This suggests a couple of preliminary steps before developing action plans or goals in therapy.

1. Establishing what is important, or the values that a person has might be a necessary first step in developing a therapy plan.
2. Values often tie in with roles that the person fulfils, but roles might be undertaken for different reasons – so we can’t make assumptions about why an activity is important to someone simply on the basis of our reasons for doing a similar activity.
3. Sometimes people don’t know why an action is important, and we might need to spend some time working through this with the person – and in the end, may not pursue that action at all!
4. Once the important values are identified, finding out what that value might look like in this person’s life may help to define the actions the person can take to live.
5. These actions, and working towards being able to carry out these actions then become the basis of therapy.

Actions can be specified, measured, counted, tied to place and time and person – and they’re about what this person chooses to do (or not do).  Achieving them helps the person live what they value, even though this may look different from what we might do to live that value.

I wonder if, instead of developing ‘goals’, we started to use the words ‘action plans’.  This might help us as therapists focus on things the person can do in the process of living a life aligned with personal values.  And isn’t that what we’re really trying to do in our own lives?

I hope you’ve enjoyed this tour through some goal setting literature.  If you want to keep reading, you can subscribe using the RSS feed above left, or you can bookmark and just visit.  I write most days during the working week, love comments and respond to questions!  Don’t forget you can introduce yourself via the ‘About’ page, and if you’re an occupational therapist, there is the private section just for you.  Email me for the password via the ‘About’ page.

“I thought if I held out long enough, someone would find a cure”

I’ve written about acceptance before (here) , (here) oh and (here) – it’s one of those topics that seems to come up again and again (or is that ‘cos I’m looking for it?!).

I have been reading about self efficacy beliefs especially relating to beliefs about returning to work, and the thought crossed my mind that people can hold contradictory beliefs about their condition and their confidence to do things despite pain, but that it probably has some sort of emotional cost. Not sure that I’ve found any specific literature to support that, but hold the thought in your mind!

Anyway, today I was reading an article by Busch, Goransson & Melin (2007) about self-efficacy beliefs predicting sustained long-term sick absenteeism in individuals with chronic musculoskeletal pain. In it they describe the results of a survey of 233 people with chronic pain, aged under 60, who had jobs to return to and had not taken early retirement – the long-term sick leave people. The group were divided into those who had been considered ‘work capable’ (they had been removed from the sick leave register in Sweden in the previous 6 months), or currently sick listed. All participants were given an initial questionnaire which included questions on:
(1) demographics
(2) perceived physical and psychological health
(3) working conditions
(4) involvement in rehabilitation
(5) individual factors including beliefs and mastery
(6) perceived consequences of long-term sick leave

The specific questions and questionnaires used are described in the actual article, so I’ll cut to the chase and get on with the results…
After this initial survey, four follow-up surveys were conducted 6 – 12 months after the initial one. The outcome measures of interest at these follow-ups were sick leave days.

Using regression analyses, five significant predictors were found:

• psychological health,
• mastery,
• mental demands at work,
• recovery beliefs, and
• sick absenteeism earlier in life.

The strongest predictor was beliefs about recovery, and the next strongest was a sense of mastery.

Once again, it seems that the physical characteristics of work and the physical capacities of individuals are less useful for predicting return to work than whether the person thinks they will recover. The actual question used was ‘A year from now, do you think your health will be better or worse?’

I’m not entirely sure that this is a question of self-efficacy, however that aside, it seems that the person’s own opinion of whether they are ‘well’ or not has an incredibly powerful effect on whether an individual will or won’t meet the challenge of the workplace.

As the authors in this paper say ‘beliefs about one’s recovery can be interpreted in different ways. They can reflect medical ‘facts’ about one’s disorder, communicated by medical staff or others.’

The person I quoted in the headline today said to me, ‘I thought I shouldn’t go back to work because then they wouldn’t think I needed to have my hand fixed, and if I held out long enough, someone would find a cure’.

He had been told that he shouldn’t risk his hand in a work situation because ‘it might make your recovery slower’.

If only someone had said to him that staying off work would likely mean he would lose his job and make eventual return to work much more difficult!

How does this fit with acceptance? The man I’m working with is slowly moving to a place where he accepts that his hand doesn’t perform exactly the way it used to – and that this doesn’t mean an absolute disaster for him.  Neither does it mean he needs to give up hope that things will be different in the future.  Or that someone might find a ‘cure’.

In the meantime he has a life to live, and he is gaining confidence (self-efficacy) that if he starts to take steps to regain control in his life, he’ll begin to ‘live’ a fuller, more ‘normal’ life.

Self efficacy is about being confident that one can achieve success in a given situation. Acceptance is about giving up a resentful struggle against things being the way they are, and getting on with life – I think they may be linked. It’s very hard to feel confident if you are struggling against the reality of life being different from the way you want it to be.

As for our role as health providers? Well it seems to me, if we instill in people the belief that they shouldn’t return to work in case they delay their recovery, or that we don’t believe they can cope with hearing that their problem may be chronic, we’re undoubtedly contributing to the negative effects of low self-efficacy. If instead we work hard to instill in our patients that we believe they have the ability to do ‘normal’ things in life, like return to work, and that recovery is more than pain reduction, we may contribute to their confidence. I hope we do this!

If you’ve enjoyed this post, and want to read more you can subscribe to my blog using the RSS feed link above left. Or you can simply bookmark my blog and come back for more! And yes, I do love comments – keep ’em coming!

Busch, H., Göransson, S., Melin, B. (2007). Self-Efficacy Beliefs Predict Sustained Long-Term Sick Absenteeism in Individuals With Chronic Musculoskeletal Pain. Pain Practice, 7(3), 234-240. DOI: 10.1111/j.1533-2500.2007.00134.x

Self efficacy for returning to work

Of the two dimensions I usually assess with people not working because of chronic pain, lack of importance given to returning to work is often identified by ‘onlookers’ as the main reason someone hasn’t yet returned. I don’t know how many times I’ve heard about ‘secondary gain’ getting in the way of people making progress – and yet when I look in to research into returning to work, it’s self efficacy, or confidence to successfully return to work, that has more press than any other aspect (oh, apart from physical ability vs job demands).

I’ve blogged about self efficacy several times now because it seems to be one of those factors that pops up all over the place – as Bandura himself puts it ‘Self-efficacy beliefs determine how people feel, think, motivate themselves and behave.’

I mainly look at self efficacy in terms of confidence to achieve a desired result. When I’m looking at the process of returning to work with someone, the two facets I review first-off are importance and confidence. Using the Prochaska and DiClemente transtheoretical model, both of these elements can be used to determine the stage that someone might be in terms of their readiness to take action.

Let me unpack that a little. If you recall the stages of change model, there are several stages before someone is ready to actually do something to achieve a goal. At these pre-action stages (Precontemplation, Contemplation, and Preparation), people have yet to decide whether action is the right thing to do, let alone work out how to do it.

At the Precontemplation stage, action is nowhere on the scene.
At both Contemplation and Preparation, the person is often ambivalent and maybe not yet ready to even learn what to do.

To help people work out whether they want to take action, it’s worth exploring these questions:
(1) Have they thought about returning to work at all? (Precontemplation)
(2) How important is returning to work at this stage in the person’s rehabilitation? (Contemplation)
(3) How confident is the person about actually returning to work at this point? (Contemplation)
(4) If importance is high, but confidence is not, what things are concerning the person about returning to work? (Factors that influence Preparation)

A study by Shaw & Huang (2005) showed that the areas that people are concerned about (ie, the things that reduce confidence) are divided into two main areas –

• concern about resuming physical activity, and
• concerns about resuming work.

The concerns about resuming work were divided into three main areas –

• meeting job demands,
• obtaining help, and
• coping with pain.

In fact, out of 348 statements that were coded in this study, 253 were about self efficacy, while the remaining 95 were expectations about returning to work. Expectations were around financial security, re-injury, workplace support and self-image.

So, some of the areas that may be contributing to low confidence for returning to work may be:
– can I do what I have been employed to do at work?
– can I do these tasks to the standard that my employer wants?
– can I do them as well as I want to?
– can I be reliable at work?
– can I (or do I want to) ask for, and get, help?
– can I change the physical environment at work so I can do the job?
– can I cope with the pain?
– can I prevent the pain from taking over?
– can I avoid injuring myself?

This list isn’t exhaustive, but based on Shaw & Huang’s work, covers many of the factors that people think about when they are concerned about going back to work.

Once the areas of low confidence, or concern, are identified, our job is about helping people develop confidence in those areas.

Often it is simply problem-solving ways around their concerns. Things like ensuring there is a clear description of the task demands (especially during any work trial or gradual return to work), clarifying quality requirements, ensuring reporting lines are clear, and arranging for physical environment alterations and any adaptive equipment to be available from the outset.

Other times it’s much more difficult – especially where there is a mismatch between what the client has been able to achieve in the past and what he or she can do now (this especially holds for people who push themselves to achieve well, or previously worked at 110% and now can ‘only’ manage 98%).

This may mean working through some cognitive therapy to reframe or challenge automatic thoughts, (eg ‘I’m working at this level because it’s part of my rehabilitation’ rather than ‘I must always work incredibly hard’, or ‘Most people work at 90%, and that’s all I need to achieve’, or ‘It’s OK to work at 90%, it means I can keep going for longer and be reliable the next day’).

The process of building confidence through cognitive therapy can be very challenging, especially if the person hasn’t had any exposure to CBT during their pain management rehabilitation. In fact, I often find that people may have had some CBT-based pain management, but until they reach the work environment, the real objections or core beliefs haven’t been explored, and the real ‘work’ of cognitive therapy begins only once those objections are raised.

Shaw, W., Huang, Y. (2005). Concerns and expectations about returning to work with low back pain: Identifying themes from focus groups and semi-structured interviews. Disability & Rehabilitation, 27(21), 1269-1281. DOI: 10.1080/09638280500076269

Flexible goals and distress: a research study

As I mentioned yesterday, finding research articles on goal-setting in chronic pain is not easy – there are not many out there! So this article is reasonably old, but an interesting one because it deals with something I’ve wondered about for a while: flexibility. To be flexible doesn’t just mean being able to touch your toes! it does mean being able to change tactics, direction and even focus in order to achieve fulfilment in life.

This study looks at the difference between assimilative coping: ‘active attempts to alter unsatisfactory life circumstances and situational constraints in accordance with personal preferences’ and accommodative coping: ‘revising self-evaluative and personal goal standards in accordance with perceived deficits and losses’.

We have a good body of research that suggests ‘active coping’ is better for people seeking treatment for chronic pain (e.g. Jensen et al., 1991), but coping isn’t well defined, and there doesn’t seem to be a good theoretical model that most people can agree on.  Coping strategies haven’t been derived from people who don’t seek treatment (and therefore cope well) use for their pain, and most coping assessment measures don’t recognise that what may be helpful in one situation may not be in another.

So this study was based instead on Brandtstadter’s (from the University of Trier) work on developmental problems and role transitions in adult life, where he studied assimilative and accommodative modes of coping.
As I described yesterday, goals are developed from a discrepancy between what is and what the individual would like to see happen. These discrepancies are often instigated by the individual, but can also be triggered by a change in the context, environment or demands from another person. Coping refers to efforts an individual takes to achieve – neutralise a threat or avoid loss, or perhaps achieve a success.

Brandtstadter identified that assimilative coping strategies involve altering the situation – for example, asking another person to help, using gadgets, or developing new skills based on feedback, changing the way an activity is done. Accommodative coping strategies involve altering expectations – changing desires or preferences, perhaps changing the expected outcome, giving up ideals (working to 100% for example), or even comparing how the person is going with other people who are more disabled.

The researchers in this paper identified that a ‘healthy pain patient’ is someone who is managing their pain in a way that ensures he or she has good quality of life, and feels well, and this probably requires the person to make ‘accommodative adjustments’ to existing goals and standards.

The recruits in this study were 120 people receiving inpatient treatment at a facility in Germany. More women than men were recruited, and most were married. The average pain duration was 11 years, and half of the participants had been away from work, and of that group, 40% had been so for at least 6 months. Most of the patients had headache (40%) while the remainder had low back pain, whole body pain, or pain in other sites as well as headahce.

The participants were assessed using the Pain Disablity Index (Tait et al, 1990), and the mean score in this study was 31.67 (SD=15.71). Psychological distress was measured using the CES-D, with a mean of 19.65 (SD=10.60), meaning that 53% of this group scored at or above the cut-off score usually used in the German version of this questionnaire. 24% of the respondents were diagnosed with an affective disorder using the Structured Clinical Interview for Diagnosis (SCID).

In terms of pain coping, three cognitive and three behavioural aspects of coping were assessed using likert-type scales from 1 (not at all true) to 6 (absolutely true). Finally, ‘dispositional coping tendencies’ following the Brandtstadter model were assessed using a questionnaire developed by Brandtstadter & Renner (1990). Two scales are formed by the questionnaire: ‘flexible goal adjustment’ such as ‘I adapt quite easily to changes in plans’ and ‘I find it easy to see something positive even in a serious event’; and ‘tenacious goal pursuit’, such as ‘when faced with obstacles, I usually double my efforts’, and ‘even when things seem hopeless, I keep on fighting to reach my goals’.

What did they find out?
Coping and pain intensity weren’t correlated, but a negative relationship was found between disability and distraction. Cognitive restructuring and self-efficacy were strongly associated with less depression. Both ‘flexible goal adjustment’ and ‘tenacious goal pursuit’ were negatively correlated with depression, although flexible goal adjustment had a stronger relationship than tenacious goal pursuit.

With further multiple regression analyses, it was found that flexible goals adjustment played a protective role when pain intensity and disability were high – that is, the ability to adjust goals flexibly seems to be a resource which ‘buffers the negative effect of chronic pain on psychological well-being’. This same positive relationship wasn’t found for people who continued to pursue their original goals by working harder.

The authors finally conclude that pain-related coping is only adaptive (that is, reduces pain severity or perceived disability) when the person has both ‘an accepting attitude’ towards chronic pain and uses positive coping strategies. In saying this, Schmitz, Saile & Nilges make a point that today has been empirically studied by researchers such as Lance McCracken and Kevin Vowles at Bath University: accepting chronic pain makes a difference to how well a person copes with ongoing disability.

A final point to make about this study – of the cognitive coping strategies, cognitive restructuring was the only strategy that moderated the relationship between depression and disability. Cognitive restructuring involves things like positively reinterpreting pain, reducing pain’s significance, or directly accepting pain.

Some cautions to consider when interpreting this study: it is a correlational study, so can’t demonstrate cause and effect. It’s also in a small group of people presenting to a specialised pain management centre. To date, it seems to be only study on this type of coping in people with chronic pain.

Food for thought from this study, however. Goals are all about achieving things. For some people, as I mentioned yesterday, having high goals and feeling dissatisfied with the ‘way things are’ can be a way of life that has helped them succeed. When chronic pain is present, this style of coping can become unhelpful – and it will be important to identify other ways for the person to retain their sense of self efficacy and achievement.

I think that identifying ‘different’ ways to act according to values that are important is one way to help someone live well despite their disability. This suggests that Acceptance and Commitment Therapy (ACT) may be an appropriate approach especially for people who have previously been high achievers. On the other hand, helping people who have lowered their expectations to re-set their ‘satisfaction’ set-point might involve helping them recruit new and different strategies to improve their ability to commit to ‘tenacious goal pursuit’.

Next post: another study on goals in chronic pain, and (with any luck) a worksheet!
Have a great day – and leave a comment if you’ve enjoyed this series, or have any questions.

Jensen, M., Turner, J., Romano, J., & Karoly, P. (1991). Coping with chronic pain: a critical review of the literature. Pain, 47, 249-283.

Schmitz, U., Saile, H., Nilges, P. (1996). Coping with chronic pain: flexible goal adjustment as an interactio buffer against pain-related distress. Pain, 67, 41-51.

Feedback, difficulty and satisfaction: goals!

To summarise yesterday’s post, this quote from Latham & Locke (2007):
The theory of goal setting states that there is a positive
linear relationship between a specific high goal and task
performance. Thus, the theory makes explicit that a specific
high goal leads to even higher performance than urging
people to do their best. A goal also affects satisfaction
in that it serves as the standard for evaluating one’s own
performance. A higher goal requires higher performance
for a person to experience positive affect than does commitment
to a lower goal. Two factors affect the goals that
a person chooses: the importance of the goal to the individual
and self-efficacy, namely, self-confidence that the
goal for a specific task is, indeed, attainable. The mediators
of goal setting are choice, effort, persistence, and
strategy. Goals are moderated by ability, goal commitment,
feedback in relation to goal pursuit, the complexity
of the task for an individual or group, and situational factors
(e.g., presence of needed resources).

Today we’ll look at feedback, goal complexity, the relationship between personal goals and incentives, and satisfaction with performance.

Feedback: Without some sort of indication of the difference between where the person is performing currently and where they need to be, it seems that people have trouble working out exactly how much effort they need to put in to achieve. Usually, people who find out they’re performing below the level expected will increase their effort – or seek an alternative strategy to use. The combination of goals plus providing feedback is more effective than just setting goals.

What this means for pain management is that

• if the individual is just given tasks such as ‘do this set of exercises’, but no target is ever specified, they probably won’t persist with the exercises.
• if they are given an exercise target, eg walk for 20 minutes once a day, but it is never reviewed with them, they’ll find it more difficult to persist.
• if, however, they work together to set an exercise programme, establish how often they need to do it, and it’s reviewed periodically, then the chances of the person persisting increase.

Difficulty: It seems paradoxical that people who have achieved a difficult goal will, next time they set a goal, set a more difficult one. From the research that Locke & Latham reviewed, it seems that Bandura’s observation that ‘goal setting is first and foremost a discrepancy-creating process’ holds true. We’re not machines, simply responding to situations in our environment (discrepancies), we actively search out and create situations that demand persistence and the development of skills.

This suggests that, with encouragement, people who start to develop new skills will find ways to extend themselves by setting themselves new goals – depending upon, however, their level of self efficacy and the times they find themselves able to succeed. As the saying goes, ‘success breeds success’.

• People with pain often find themselves in an ongoing cycle of failure, as their efforts to cope using skills they’ve found helpful in the past fail to support them in their goals, and their self efficacy drops.

As I mentioned yesterday, people begin facing challenges (goals) by using skills they already have, if they don’t have those skills, they try to find skills they’ve used elsewhere to help them manage. When they find themselves without the necessary skills, they seek help from others – but if those others (especially important people, such as health care providers) cannot provide them with appropriate skills and encouragement, their self efficacy drops and they begin to withdraw from what they perceive as unsatisfying and unachievable goals.

Complexity: Most of the goals that we encourage people to develop in pain management are quite complex. They involve multiple changes across a range of thoughts and behaviours. Locke & Latham (2002) found that ‘as the complexity of the task increases and higher level skills and strategies have yet to become automatized, goal effects are dependent on the ability to discover appropriate task strategies’.

It seems that the availability of different strategies to choose from can influence how readily a complex goal can be achieved. This effect is influenced by the type of goal being demanded: performance-outcome goals can interfere with learning and integrating new strategies.

For example, a goal like ‘move all these boxes within 20 minutes’ demands speed and as a result newly acquired skills such as pacing may be forgotten. If instead, a specific difficult learning goal is required, for example ‘use your pacing skills to help you move these boxes within 20 minutes’ is given, high goals lead to better performance as compared with a general request to ‘do your best to move these boxes’.

Proximate goals: To make these complex goals more easily achieved, research suggests that it’s better to develop smaller ‘proximate’ goals. Locke & Latham found that poor performance (or errors) may be due to poorly constructed proximate goals – that is, these smaller goals may not actually directly contribute to the longer-term goals. The benefit of smaller sub-goals is probably due to the feedback from errors in the performance of these goals giving an individual a picture of how realistic their longer-term goal may be.

Goals have an influence on the level of satisfaction an individual feels. To set a goal says that the person is not satisfied with their current level of performance, and their ‘satisfaction level’ drops. As a goal is achieved, people feel more satisfied. But paradoxically, people who achieve the highest goals are the least satisfied with the present situation. They do more because they’re dissatisfied with less. Their ‘satisfaction set-point’ is set very high – and so they work very hard to achieve.

In pain management this may work against some of our patients. For example, the person who typically strives to do well may find developing ‘working to quota’ or activity regulation very hard to do, because their satisfaction comes from having achieved a very high standard. For these people specific and difficult learning goals may be more helpful than performance goals.

The above model shows what Latham & Locke (2007) describe as the ‘high performance cycle’. Although, as for all of the information I’ve review so far, it’s about organizational performance, there are many similarities between this cycle and what we observe in the performance of pain management goals.

What I’ve discovered as I’ve worked my way through the literature on goal-setting, is that while we talk about goal-setting within pain management settings, there is very little empirical research on it with patient groups. Tomorrow I’ll review one of the few papers I’ve seen – so y’all come back now!

Latham, G.P., Locke, E.A. (2007). New Developments in and Directions for Goal-Setting Research. European Psychologist, 12(4), 290-300. DOI: 10.1027/1016-9040.12.4.290

Practical and useful goal-setting theory?

Some people doubt the existance of a theory that happens to be either practical or useful, but perhaps this review (which is now relatively old, but still good!) will prove the rule. While this review covers goal-setting within an industrial/organisational context, it still offers some helpful advice and findings from both experimental and ‘field’ research. I’ll comment, of course, in terms of how this may fit within a clinical pain management context!

So, what is a goal? Locke and Latham (2002) define goals as ‘the object or aim of an action, for example, to attain a specific standard of proficiency, usually within a specified time limit.’ Their definition refers to performance of work-related tasks rather than ‘discrete intentions to take specific actions’ (and they give the example of applying to graduate school, to get a medical examination). Their definition relates quite well to those in chronic pain management, where the goals referred to are often ‘to increase sitting tolerance to 20 minutes’, or ‘to be able to take a shower safely’.

How difficult should a goal be? Although during the 1950’s it had been found there was a curvilinear inverse relationship between difficulty and performance, (that is, a goal shouldn’t be too low, nor too high, or performance was affected), Locke and Latham proposed there was a positive, linear relationship between difficulty and level of performance. They found that performance levelled off only once the limits of ability were reached, or when commitment to that goal lapsed.

Additionally, Locke and Latham found that specific, difficult goals consistently lead to better performance than just telling people to ‘do their best’. Having a target seems to work better because people have something to aim for, and are clear on what needs to be done.

What this implies for pain management, is that without a specific target to achieve, people have trouble knowing whether they’re ‘doing enough’. It seems to be important to have goals that the person feels are ‘just out of reach’ but are actually within their ability, and to be very specific about how often, how much, or exactly what they have to do, in order for them to be committed to making it happen. This suggests that a vague goal to ‘try using relaxation during the next week’ probably will work less effectively than identifying exactly how often, what time of day, and what type of relaxation should be attempted.

Social cognitive theory (I’ve posted on this before! Remember Bandura?) suggests that self-efficacy, or confidence that the individual can successfully achieve his or her goals plays an important part in goal-setting. Latham and Locke state that ‘when goals are self-set, people with high self-efficacy set higher goals than do people with lower self-efficacy’.

We know that self-efficacy for many activities can be affected by pain – the Pain Self Efficacy Questionnaire (Nicholas, 1989) measures self-efficacy to participate in a range of daily activities such as work, future goals, social activities and leisure despite pain using a 1 – 10 Likert-type scale, and although the maximum score is 60, most of the people we see at Pain Management Centre will achieve less than 20.

Goals appear to affect performance through four mechanisms, according to Locke and Latham (2002).
They are directive – that is, they ‘direct attention and effort toward goal-relevant activities and away from irrelevant activities’.
They energise – high goals lead to greater effort than low goals. This has been demonstrated with goals that require physical effort, repeated performance of cognitive tasks, subjective effort as well as physiological indicators of effort.
They affect persistence – when people can control how long they spend on tasks, hard goals elicit more time being spent on them. But what often happens is that people increase their work pace in order to achieve a goal rather than work more slowly but less intensely over a longer period of time.
They affect action indirectly by leading people to discover relevant information and strategies that they can use to achieve the goal. So it seems that people actively seek and use the information they have around them to solve problems in order to achieve goals – without them, the information they have may never be integrated.

There seems to be a hierarchy of ways that people search for, and use information relevant to the task:
1. People automatically use knowledge and skills they already have to achieve a goal.
2. If already existing knowledge and skills don’t quite cut it, people draw from related skills they may have used elsewhere.
3. If the task is actually new, they will deliberately plan to develop the skills necessary to achieve the goal.
4. People with high self-efficacy are more likely than those with low self-efficacy to develop effective task strategies. People may take some time to look for ways to achieve goals they are set.
5. When people are asked to address a complex task, sometimes encouraging them to do their best can work more effectively than the usual specific performance goal because anxiety to succeed can make them look for strategies to deliver in an unsystematic way and fail to learn what actually works.
6. When people are, instead, trained to use systematic strategies, people who are given specific high-demand goals are more likely to use those strategies than people who are given either nonspecific goals, or goals that don’t really demand high performance.

Commitment to goals moderates, or changes the goal and performance relationship. This is most important when goals are difficult because they require persistence. As I mentioned yesterday, importance and confidence drive commitment to goals.

Some things seem, from Locke and Latham’s research, to increase commitment – being public about a goal can increase importance and therefore commitment (maybe because of a desire to maintain integrity in other’s eyes), others inspiring action and being supportive can create demand characteristics that can enhance commitment. Goals that are imposed on people may or may not influence commitment – it seems to be more about the way in which the purpose of the goal is given than whether the person participates in the goal setting process.

Self-efficacy or confidence is influenced by ensuring adequate training is available (so the person knows what to do, especially if that training leads to a successful experience prior to the goal), role models that demonstrate success, and through verbal communication that expresses confidence that the person can achieveit, including information about ways that goals can be achieved.

For more information on feedback, complexity and other factors known to influence goal-setting – come on back tomorrow!

For today, here is a specific goal – read one of the goals you have written with or for a client with chronic pain before tomorrow.
Check these four things:
1. Does your goal have specific actions that the client needs to do?
2. Does your goal include a timeframe?
3. Does your client think this goal is important?
4. Does your client believe he or she can successfully achieve this goal?

If you can answer these four questions, and feel like stretching yourself – check these things:
1. Does your client know exactly how to do the goal?
2. If this goals requires using skills that are new to the client, have they had a successful attempt with your support?
3. Has your client had an opportunity to see anyone else achieve this goal?
4. Has your client been given the opportunity to make his or her goal public? Have they told anyone?

Let me know in the comments section if you’ve been able to achieve these goals. More tomorrow!

Locke, E.A., Latham, G.P. (2002). Building a practically useful theory of goal setting and task motivation: A 35-year odyssey.. American Psychologist, 57(9), 705-717. DOI: 10.1037/0003-066X.57.9.705

Goal setting: A critical skill for change

Pain management is many things to many people, but most of us would agree that if life hasn’t changed in some way after pain management, then it hasn’t really been effective.  For change to actually happen and be maintained, Prochaska and DiClemente and others (eg Miller, Rollnick and colleagues) identify that people must believe the change to be important, and that they have the ability to make it happen successfully.

I’ve posted earlier on self regulation (eg this reading, and this post), making the point that it is made up of several components, one of which is goal setting.

When I went to Google to search the words ‘goal setting’, 13,200,000 hits came up in 0.16 seconds, so goal setting seems to be rather popular – and yet it’s often the most difficult session to facilitate in the three week pain management programme I work in, and some of the ‘goals’ I’ve seen written for patients just don’t look anything like the kind of goals that can actually be measured! So perhaps goal setting is both popular but not easily carried out in ‘real life’.

So, how do we set goals? It sounds easy if you’ve learned to set goals early in life, but for so many of the people I see it’s not a familiar activity. The research literature in psychology abounds with various models and influences on goal setting and achievement, which doesn’t really help a busy practitioner who may well be drawing on knowledge from first year professional training! And unfortunately, the information readily available online is often of variable quality.

I’m going to start with some random thoughts, mainly based on conclusions drawn from a motivational approach – tomorrow I’ll fill in with some literature!

Firstly, goals need to be relevant to the person. That means that the person believes that the goal is important. Importance is predicated upon things that the person values (see the New Zealand School Curriculum definition here)- these are usually abstract beliefs that, through action, become evident. The same action can represent many values (eg daily exercise can represent ‘time out’, ‘commitment to my wellbeing’, ‘a way to keep my partner/husband/dog happy’). And similarly, values can be fulfilled or operationalised in many different ways (eg ‘caring for my family’ can be achieved by ‘being in a high paid job’, ‘being home when they get home after school’, ‘always going to sports activities with the kids’).

Sometimes, the values appear to conflict with each other – it’s quite common for someone (perhaps yourself?) to value ‘being healthy’ while at the same time valuing ‘relaxing’ – how those values are played out in the real world may mean the person eating healthily in one part of the day, then drinking alcohol as a primary way to relax! I’ve seen this in people who say on the one hand that they’d like to return to work, but on the other, they don’t think they can – because they can’t continue working in the way that they’re used to. There is a conflict between two different values: the values that constitute ‘being a good worker’ (which is operationalised as ‘always doing a job at 120%’) and ‘being able to cope’ (which is operationalised as ‘never allowing my pain to fluctuate’).

The second is that goals need to be achievable. That is, the person needs to feel confident enough that they can actually succeed in making the goal happen. When pain becomes chronic, confidence to achieve goals can often be eroded, especially if pain is feared or avoided. Successive failures to achieve goals only serve to confirm that taking a risk by setting a goal should be avoided. And this seems to be much more the case if the goal is particularly important – and of course, if it’s not important at all, it just won’t happen!

It almost goes without saying that goals need to be specific and measurable – exactly what is it that the person has to do, and how will they know they’ve achieved. This is much more difficult if the area of goal development is complex, or requires sub-goals to be achieved in order to attain a longer-term goal.

Tomorrow: some readings on goal and goal-setting, and over this week – tools to use to help people set and maintain goal-directed behaviour.

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Work is the context

For many years I’ve worked in pain management and tried to help people return to work as the completion of their rehabilitation. Why? Well, apart from it being a great thing from an insurer or funder’s point of view, it’s actually what people want.

Having been through my own return to work rehabilitation after my concussion, I can personally describe some of the effects of return to work efforts – and the fears and concerns I had (and still have to some extent). However, as you know I don’t like to rely on my own personal opinion, so I thought today I’d describe the comments of participants in the pain management programme I work in.

The question participants are asked is ‘What does work mean to you?’

And their responses?
The first group of comments is that ‘work is necessary for money’, and the second ‘to get case managers off my back’ – and then some more thoughtful responses.

Here people say very clearly that work is about meaning and purpose in life, the activity that organises the day, the topic of conversation, the social interaction, the belongingness to a community, contributing to society, identity and self worth and competence.

For some interesting snapshots of what workers say (at least a group of them in the US), listen to this series of podcasts on ‘Meaning of work’. And for a slightly different take on the meaning and value of work, this community arts project by Lara Lepionka provides a wonderful doorway into the meaning of work to ‘ordinary people’.

When they are not working, participants agree that it may be fine initially, but rapidly becomes a much less positive experience. Some health researchers state that stopping work hastens ill health and death. At the very least, participants in the pain management programme agree that they don’t want to remain off work – but they lack confidence to actually return to employment.

When I read assessments of workplaces carried out by various therapists, something is missing. Each assessment covers the physical activities, the equipment, the tasks, the physical environment – but given the amount of time we typically spend in a workplace, I see very little description of some of the fundamental aspects of the culture of a workplace. More importantly, the relationships between people in the workplace are rarely mentioned.

If we return to social learning theory (remember Bandura?), and our behavioural fundamentals, we can see that responses from people within an environment are a particularly potent influence on both behaviour and belief. It’s surprising then, that assessments of the workplace, particularly when an individual is having trouble returning to work, don’t even mention attitudes, beliefs, or behaviours of the other people in the workplace. Workers spend roughly 8 or more hours in a work environment, have strong opinions about their workplace (whether they like it or lump it!), and among some of the so-called ‘black flags’ and ‘blue flags’ (see this 2002 BMJ article), the individual’s perceptions of the workplace and the organisational and task demands of the workplace feature as risk factors for people to fail to return to work.

Even in comprehensive pain assessments, although mention is made of work and past working history, mention is rarely made of the person’s belief about whether they will return to work (which is probably one of the most predictive questions for RTW I know of!), and even less of the employer-employee relationship or the social-cultural and organisational factors in the workplace.

There are multiple reasons for people having difficulty returning to work. One of the most commonly cited reasons, given by case managers, employers, and treating clinicians is ‘lack of motivation’.
It’s time to deconstruct ‘motivation’ and explore what motivation consists of – if we follow Prochaska and DiClemente’s Transtheoretical Model of Change, it’s made up of two major components: importance and confidence.

People are ambivalent about moving forward because the ‘good things’ about change are balanced by the ‘not so good things’. In returning to work, the ‘good things’ are all those reasons given by the participants in the pain management programme. The ‘not so good things’ are much more varied, and require individual assessment and problem-solving.
Most of the ‘good things’ about returning to work are things that make up the ‘importance’ dimension – things that people value.
Many of the ‘not so good things’ are about confidence to achieve those valued goals.

Motivation is therefore much less about lack of ‘importance’ of returning to work – in fact, for some people I would think that it’s precisely because work is so important that they are stuck. Why risk failure for something that is so important? Motivation in the case of people returning to work involves confidence that the individual can achieve within a workplace to the desired and required standard of performance.

What is all this commentary leading to?

1. Pain assessments for people experiencing work disability simply must assess the social and cultural aspects of the workplace – both past workplace and present (especially if the person still has a job)
2. Workplace assessments can’t just consider the physical, but also organisational, interpersonal and ‘cultural’
3. When someone is having trouble returning to work at least one question should be asked: ‘do you think you will return to work?’
4. When someone is having trouble returning to work, ‘motivation’ needs to be deconstructed: it’s more complex than simply the presence of secondary gain, laziness, lack of desire.  The importance and confidence an individual has for returning to work must be assessed, and the process of (often) building confidence initiated.

Pain may well be the cited reason for someone not being able to return to work – is it the real reason?  Disability from pain is a very complicated beast, pain intensity is not, by itself, the major factor.  When we start to look at it in more detail (which we will do tomorrow!), it could be any number of things.  If we fail to clearly identify the specific factors in any one individual, we run the risk of prolonged absence from work which is not desireable for anyone.  At the same time, what we know from motivational interviewing is the more we push against resistance the more defended that position will be.  Simply implying to someone that they are ‘not motivated’ will not achieve the desired goal if it is actually about confidence to manage the barriers around working.

Have a great day – sorry there are no specific references today, but I will make up for that very soon indeed!

In the meantime, you can’t really go past Chris Main and Chris Spanswick’s book ‘Chronic Pain: An Interdisciplinary Approach’ for a good description of the process of disability, incorporating the ‘blue and black’ flags.

A brief ponder

Complete opinion today…!
I’m pondering why we as clinicians can be so scared about increasing our patient’s pain levels. And why patients are so fearful of increases in pain.

I spoke with a new group of people starting a pain management programme yesterday. I told them, as I tell all the new groups, that their pain would probably increase during their time on the programme – and that if we hadn’t managed a flare-up at least once, we had failed our job! The participants looked uneasy at this, and laughed nervously. One brave chap said to me ‘but our pain is always high, you can’t make it worse!’

I stopped and thought for a while – and you can see I’m still thinking about it – but at the time I asked the group if they had noticed fluctuations in their pain. Does their pain ever stay at one level all the time? Do they ever notice times when it gets worse? Do they notice times when it goes back to ‘normal’?

The truth is, pain like almost everything, does fluctuate. As humans I’m not sure that we can sustain a steady state in any emotionally-charged experience. Think of anger…it ebbs away after time; peace…it becomes energised shortly; joy turns into contentment; irritation turns into grumpy…
You know what I mean? We don’t seem to be able to maintain a peak or trough for very long, especially if we acknowledge that we’re feeling a feeling and then carry on with life.

Something about acknowledging (rather than trying to ignore) and accepting (rather than trying to control) means that this process of returning to a baseline level of euthymia happens more readily. Fear of experiencing that feeling seems to make it much more difficult to allow it to dissipate.

In case of pain, because it is so influenced by emotion and thought, readily fluctuates – but patients and clinicians alike are fearful of increases, perhaps forgetting that if it goes up, it goes down also.  Perhaps part of therapy is for us to instil confidence in our patients that they can live rich lives despite fluctuations in pain – this means they need to have increases in pain while they are having therapy with us, so we can demonstrate our confidence in their ability to cope.

Do I embrace pain? Not likely! I don’t enjoy having chronic pain, but I can remind myself that by acknowledging that I have it, not judging it, but allowing it to pass on, it can and will reduce again. And even if it doesn’t reduce, I can still live my life, doing things that I feel are important, feeling confident that all things pass. Can we believe that on behalf of our patients? They can and do survive (more than survive) with pain that goes up, that goes down. This is the nature of pain.

Today, pause for a moment and do a Body Scan (mentally go through your body from head to toe and identify the sensations you are experiencing). Just note the sensations – don’t name them, don’t judge them, just be aware of them. Spend the space of 10 slow out-breaths to do this. If you’re completely painfree, I’ll be surprised. Just experience what you do experience, and allow space for it to happen – whatever it is. Then move on to live your life, in the moment.