formulation

What should I include in my pain assessment?


With such a wide array of factors influencing a person’s pain experience, it can be difficult to decide exactly what to include in a pain assessment.

We do know that the model we use to view pain will influence the factors that are included – and although the internationally accepted model of pain is a biopsychosocial one, there are any number of versions of this model that can be adopted.

Within each domain of the biopsychosocial model the research over the past few years has exploded, meaning there are more and more factors than can be considered – and these need to be organised in a systematic way so that we can make sense of them, make good clinical decisions about interventions and then work with the person who has the pain so they can understand them and contribute.

There are a couple of fundamental things we should always have as guiding principles:

  1. No single element in the biopsychosocial model of pain is more (or less) important than any other
  2. All three domains must be assessed to fully understand the ‘four p’s’ of a pain presentation:
    1. Predisposing factors
    2. Precipitating factors
    3. Perpetuating factors
    4. Protective factors
  3. The fundamental questions to be answered through assessment are
    1. ‘What brought this person to this place with this problem today?’
    2. ‘What can be done to reduce distress and disability?’
  4. Simply asking the person with pain provides some good information, but on its own is probably inadequate.  Interviews need to be supplemented with:
    1. History – from relevant documentation (from the referrer, other health care notes, previous consultations within your facility)
    2. Observation – structured or unstructured observation from the moment the person enters your clinic, to the time they leave
    3. Clinical examination or testing – including functional performance as well as pen and paper questionnaires
    4. Other people – particularly partners or other family members
  5. Assessment only begins the process of developing a working set of hypotheses about what might be ‘true’ for this person at this time for these problems

A couple of models that can be helpful:

This one is from Robert Gatchel (Gatchel, 2004).

, American Psychologist, 59, 792–805.

Another model I like is by Tim Sharp, published in 2000, which is somewhat less complicated than Gatchel’s one, but still has a whole lot of arrows!  Dr Sharp now runs a successful consulting practice listed in my blogroll, worth a look!

Of course, no matter what model you use, under each ‘heading’ you will need to continue to update relevant research into specific factors to include (eg ‘appraisals’ would now routinely include catastrophising and pain-related anxiety, while ‘motor behaviours’ would include avoidance, safety behaviours, as well as task persistence).  And after deciding what to include, it will be just as important to determine the best way to access the information – through questionnaire, observation, history, testing or interview.

Finally, it will be important to work out a structured way to put the information collected together so it can be readily understood and used as the basis for hypothesis testing.

I’m not sure I’ve got a handle on this part yet – but I’m keen to hear what you use, or how you think this part can be structured.  I think we’ll have to draw on research from small group/teamwork literature into decision-making, and on human cognition and information processing to inform us on the best way to integrate such complex information without jumping to conclusions.

Isn’t it great the way that answering one question leads to a whole lot of new bits of research?  Can ya tell how much I love questions?!

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Gatchel, R. (2004). American Psychologist, 59, 792-805

Sharp, T. (2000). Chronic pain: A reformulation of the cognitive-behavioural model.  Behaviour Research and Therapy, 39, 787–800

Gatchel, R. J.(2004), American Psychologist, 59, 792–805

Problem solving: A practical self-help strategy


Not surprisingly, lots of people I see with chronic pain feel like they’ve landed in a hole they can’t get out of. And one of the most positive things I think I can do is show people that change is possible.
Getting out of a hole is incredibly difficult all by yourself – but oh so necessary for life to move forward again.

Problem solving is a fundamental tool for many professions – not just occupational therapists who seem to have adopted it wholesale (see this article from November 2007!), but also engineers, mechanics – oh and psychologists! But occupational therapists have books (like this one by Jeanne E. Lewin and Colleen A. Reed, and this one (parts of which you can read online to get the drift) about the use of problem solving in mental health.

My main problem with ‘the problem solving process’ is the tendency to almost immediately focus on solving the problem rather than working to identify and manage contributing factors. So when I was trying to develop a problem solving process format for the people I work with who have chronic pain, I spent a bit of time trying to come up with something that would encourage them to go beyond the immediate. Here’s what I came up with.

At the top of the page:

  1. ‘the problem’ described briefly.
  2. Then a box below that with the label ‘factors contributing to the problem’
  3. Then a second box below that labelled ‘factors contributing to these factors’
  4. Then all around the outside I ask the participants to write possible solutions for each contributing factor with an arrow leading to the relevant factor.

This way, the tendency to prematurely close in on ‘The Solution’ is halted, and a range of options are generated. At the same time, there are two levels of problem solving – the immediate, and those that are underneath the immediate. (You could do this layering of contributing factors several times, but this gives you something not too complex to work with.)

To make it even more systematic, if you have a model to work with, you could use that to organise the layers of contributing factors…as in the ‘ishikawa’ fishtail model.
Or clinically, you might use a biopsychosocial model, or for cognitive behavioural pain management, you might use one of the Main & Spanswick models of disability to help yourself work your way through the relevant areas.

The astute amongst you might have noticed that the last two bear a striking resemblance to what can otherwise be called ‘case formulation’ – problem solving and case formulation are pretty much the same thing – well at least, they’re steps along the same track.

In each case you’re developing a set of hypotheses about what might be a factor relevant to the onset and maintenance of a problem.

The next step is, of course, to pick the hypothesis or possible solutions and DO IT! Clinically we would use evidence from the scientific literature to decide which approach to use first, based on which hypothesis appears to explain the majority of problems in the simplest way, with the fewest assumptions.

With clients, we would start with preferences, use logic, or work with available resources – especially if we’re trying to help the person develop self efficacy.

When you need to change tack…


There are some times when things just don’t go the way you plan…Therapists don’t very often publicise when things don’t work out, but I think we can learn a lot from these situations – and the reflection process models one of the ways that we can help patients learn from every situation too. As one saying goes ‘it is not a failure, it’s a learning experience’!

So, with this particular client, I found myself in a ‘yes, but’ situation…this situation occurs when I’m asking the person to take action before they’re ready.
This man is a Very Busy Man – a ‘type A’ if you like. He’s a professional, in a senior position in a medium-sized organisation, and very, very busy. He works 10 hour days, rarely takes breaks (even lunch), and takes work home. He has had an exemplary work record, very few ‘sick’ days – but when he has abdominal pain, he can end up in Emergency Department. His admissions have increased in frequency over the past 12 months, and he is now asking for ‘something’ to help so he doesn’t have to be admitted to hospital, but can carry on at home.

As I assessed him, I thought the most important areas of concern were these:

  • when he experienced discomfort he tended to not notice it until it became overwhelming
  • when he became aware of his pain, he became very fearful and immediately used pain medication or sought medical care
  • he rarely communicated his pain concerns to anyone, and had been careful not to tell anyone at work
  • he had few friends and his relationships at work were somewhat distant
  • he and his wife were very worried about his health and were very keen to have his pain completely abolished
  • he was very capable of focusing and becoming completely immersed in his work
  • he had a limited range of relaxation or leisure activities

I started with offering him the menu of options, and mentioned that I had observed from the assessment he had completed with our service that he was finding it difficult to relax, and I wondered whether he would like to see how relaxation might help him.

His response?

‘Yes, but…’

And what came next was a long list of reasons why he couldn’t relax – his job was too busy, he enjoyed the ‘buzz’ of pushing himself to achieve, he was aiming for promotion, he was ‘carrying the load’ for other people at work….

I tried another tack, and reflected to him that he must find the thought of relaxing quite strange and perhaps that it felt unnecessary and a ‘time-waster’ – to which he said ‘yes’ and that what he thought he needed was to have his pain ‘properly managed’ and that ‘doctors must be able to find the cause of my pain and fix it’.

hmmmm… time for a moment of quiet reflection!

Once again I used reflective listening to let him know that I ‘heard’ what he was saying, and suggested that perhaps it might be a good idea to see if we could have a joint consultation with one of our doctors to review the medical situation, to ensure that he had the best advice available on whether a ‘fix’ was available. If there was a medical area for follow-up, that’s great, if not – the door was always open for him to come back.

Using the review process, I spent a bit of time thinking about what had happened – why had CBT and my suggestions fallen flat? What could I do differently?

I use a semi-standard set of questions (well, some of them are the same every time!):

  1. What did I do well? I think I went well with rolling with his resistance – using listening skills to demonstrate empathy and respect.
  2. What was not so good about that session? I misjudged his readiness to begin making changes and to see his pain as ongoing.
  3. What was particularly frustrating? For me it was that he wasn’t ready to move on from finding a ‘cure’ or ‘fix’.
  4. What was the most satisfying aspect about this session? That I recognised this and rolled with it instead of getting into a ‘yes, but’ situation.
  5. What skills did I use? Listening skills and a range of ‘motivational’ approaches including the menu and listening skills.
  6. What skills could I have used? Asking him what he wanted or thought was his ‘next best step’. Perhaps asked him what went through his mind when he experienced his pain at work, or started to feel pain and ‘knew’ he needed to go into hospital, or even asking him about what was important about maintaining his pace at work and establish the discrepancy between this value and what happened when he went into hospital.
  7. If I could wave a magic wand, what would I change about the situation? Spend more time listening to what he wanted before starting on a menu that assumed he was ready to make any changes at all.
  8. What extra resources could I draw on? Going through his medical file and working with his medical doctor to establish his readiness and what the options were – helping him come to a point of ‘creative helplessness’
  9. What would I do differently next time? Listen first, talk less, assume nothing.

Now I don’t use all these questions all the time, and some of them I don’t use often at all (particularly the magic wand one!! that would be too tempting…)
Is CBT the right approach? Yes – but with a tweak or two to make sure this person is at the right point of readiness before starting to introduce change.

I hope this post has helped you see some of my thinking style and that we never stop learning! By drawing on a range of different therapeutic styles that hold to a similar value base, we are able to respond with flexibility to people at different points in the change cycle.

If you want to continue reading about how I apply CBT and other therapies in chronic pain management – don’t forget you can subscribe using the RSS feed above (just click!), bookmark this blog, and comment!