Pain Acceptance rather than Catastrophising influences work goal pursuit & achievement

We all know that having pain can act as a disincentive to doing things. What’s less clear is how, when a person is in chronic pain, life can continue. After all, life doesn’t stop just because pain is a daily companion. I’ve been interested in how people maintain living well despite their pain, because I think if we can work this out, some of the ongoing distress and despair experienced by people living with pain might be alleviated (while we wait for cures to appear).

The problem with studying daily life is that it’s complicated. What happened yesterday can influence what we do today. How well we sleep can make a difference to pain and fatigue. Over time, these changes influences can blur and for people living with pain it begins to be difficult to work out which came first: the pain, or the life disruption. Sophisticated mathematical procedures can now be used to model the effects of variations in individual’s experiences on factors that are important to an overall group. For example, if we track pain, fatigue and goals in a group of people, we can see that each person’s responses vary around their own personal “normal”. If we then add some additional factors, let’s say pain acceptance, or catastrophising, and look to see firstly how each individual’s “normal” varies with their own acceptance or catastrophising, then look at how overall grouped norms vary with these factors while controlling for the violation of usual assumptions in this kind of statistical analysis (like independence of each sample, for example), we can begin to examine the ways that pain, or goal pursuit vary depending on acceptance or catastrophising across time.

In the study I’m looking at today, this kind of multilevel modelling was used to examine the variability between pain intensity and positive and negative feelings and pain interference with goal pursuit and progress, as well as looking to see whether pain acceptance or catastrophising mediated the same outcomes.

variationsThe researchers found that pain intensity interfered with goal progress, but it didn’t do this directly. Instead, it did this via the individual’s perception of how much pain interfered with goal pursuit. In other words, when a person thinks that pain gets in the way of them doing things, this happens when they experience higher pain intensity that makes them feel that it’s hard to keep going with goals. Even if people feel OK in themselves, pain intensity makes it feel like it’s much harder to keep going.

But, what’s really interesting about this study is that pain acceptance exerts an independent influence on the strength of this relationship, far more than pain catastrophising (or thinking the worst). What this means is that even if pain intensity gets in the way of wanting to do things, people who accept their pain as part of themselves are more able to keep going.

The authors of this study point out that “not all individuals experience pain’s interference with goal pursuit to the same extent because interference is likely to depend on pain attitudes” (Mun, Karoly & Okun, 2015), and accepting pain seems to be one of the important factors that allow people to keep going. Catastrophising, as measured in this study, didn’t feature as a moderator, which is quite unusual, and the authors suggest that perhaps their using “trait” catastrophising instead of “state” catastrophising might have fuzzed this relationship, and that both forms of catastrophising should be measured in future.

An important point when interpreting this study: acceptance does not mean “OMG I’m just going to ignore my pain” or “OMG I’m just going to distract myself”. Instead, acceptance means reducing unhelpful brooding on pain, or trying to control pain (which just doesn’t really work, does it). Acceptance also means “I’m going to get on with what makes me feel like me” even if my pain goes up because I do. The authors suggest that acceptance might reduce pain’s disruptive influence on cognitive processes, meaning there’s more brain space to focus on moving towards important goals.

In addition to the cool finding that acceptance influences how much pain interferes with moving towards important goals, this study also found that being positive, or feeling good also reduced pain interference. Now this is really cool because I’ve been arguing that having fun is one of the first things that people living with chronic pain lose. And it’s rarely, if ever, included in pain management or rehabilitation approaches. Maybe it’s time to recognise that people doing important and fun things that they value might actually be a motivating approach that could instill confidence and “stickability” when developing rehabilitation programmes.

Mun CJ, Karoly P, & Okun MA (2015). Effects of daily pain intensity, positive affect, and individual differences in pain acceptance on work goal interference and progress. Pain, 156 (11), 2276-85 PMID: 26469319

Sunday alone time

Developing a shared plan

Last week I introduced you to one way I use to develop a shared understanding of the many factors influencing how and why a person seeks help for their pain.  The person and I work together to understand his or her perspective. I use a range of open-ended questions and reflective listening to guide our discovery of how his/her pain affects life and emotions.

Some points to note:

  • I don’t try to give explanations at this point – explanations will influence what the person says to me, and may inadvertently shape or change what he or she says without necessarily changing his or her beliefs.
  • I’m not trying to make any diagnoses either. A diagnosis is just a short-hand way of lumping a bunch of symptoms together. Great for research, and great for when we have a clear treatment, but a diagnosis tells us nothing about how the problem is affecting this person at this time. And in pain we’re always looking at the person and his or her experience, because even if we successfully get rid of the pain, the person will have learned something through the experience and this will influence the person in the future.
  • I’m informed by what we know about pain from research, so I’m constantly probing and looking for the relationships between factors we know will affect the person. Note that I’m not looking for tissue-level influences, but rather I’m investigating at a “person” level. This means I’m looking at psychological and sociological processes. I’m not ignoring those tissue-level factors, but I’m placing those off to one side for the moment. There are a couple of reasons for this: the first is that I’m probably not going to directly influence tissue-level factors. I don’t lay hands on people. I don’t give drugs. The second is that the person isn’t likely to be aware of those factors. They know much of their own experience (not all – but we’ll come to that), and experience and perception are the most potent drivers of what a person believes and therefore does.
  • I try wherever possible to flesh out my interview with additional information. This might be from questionnaires, or observing, or clinical notes from other people. And yes, I incorporate this information with the full knowledge of the person – in fact, they’re part of the process of integrating this information.

What do I end up with?

A spaghetti junction! A diagram that looks a lot like this:

formulationThis diagram is a pretty simple one, when you think of all the factors that could be involved – and in this case, I’ve made it much clearer than my usual scribble!

At this point I have a series of hypotheses to explain why Gerald is in this state. Together with Gerald, we’ve established that there could be some fear of pain, and in particular, fear that Gerald won’t be able to cope if his pain goes up and doesn’t settle. Gerald has also identified that he can feel helpless at these times, because he doesn’t know what else to do to manage his pain. He believes he’s getting unfit, and that’s adding to his feelings of frustration. He doesn’t want to go out with his mates because he’s irritable. He tries not to let his wife know how he’s feeling to protect her, but this adds to him feeling isolated. He doesn’t want to go back to work, not because he’s not motivated, but because he’s afraid he’ll let them down and this will add to his guilt. He doesn’t think his case manager understands this.

I could ask Gerald to list his main concerns and use these as a guide for my treatment outcomes, but I’ve recently started using a different approach. I’ll ask Gerald what he would be doing differently if his pain wasn’t such a problem to him.

Bronnie: Let’s imagine for a minute, what would you be doing differently if your pain wasn’t such a problem?

Gerald: Well, I’d be back at work, for one thing.

Bronnie: OK, and would you think you’d be back at work full time, or ease your way back in?

Gerald: Well, I think it would be sensible to ease myself back in because it’s been a while and I’m out of shape. Better to know I can do it than have a go and fail.

Bronnie: Great idea. What else would you be doing differently if your pain wasn’t such a problem?

Gerald: I’d take my wife out for dinner, it’s been hard on her while I’m so laid up and grumpy.

Bronnie: What’s your main concern about going out to dinner with your wife right now?

Gerald: I can’t sit long enough to enjoy a meal out. It all seems so hard, to get into a car, and drive to a restaurant, and sit there for three courses. I’m just too sore to do it.

Bronnie: So going to a restaurant and sitting to get there and while you’re there is going to increase your pain?

Gerald: Yeah. Is it worth it? What if it doesn’t settle? I can’t sleep and then the next day I’m shattered. I don’t think it’s worth it.

Bronnie: OK. Is there anything else you’d be doing if your pain wasn’t such a problem for you?

Gerald: I’d be going out and seeing my mates, going fishing and 4 wheel driving. I miss that. There’s no way I could do that right now.

Bronnie: What’s your main concern about going fishing, and seeing your mates at the moment?

Gerald: I’d be ready to go home before they’d even started. They’d get fed up with me slowing them down. And casting is really hard on my neck.

Bronnie: So to sum up then, it seems like there are some things you’d love to be doing, but reasons you think it would be better not to be doing them right now. If we go through them, you’d love to go back to work, but you’d like to do it gradually so you can get in shape again, and so you know you’ll succeed. You’d love to take your wife out for dinner, but the whole dinner thing feels too hard, and you’re worried that your pain will get out of hand and you won’t be able to sleep. And you’d really love to get back out with your mates again, and go fishing, but right now you think your mates would get fed up with you because you’d want to leave too early, and you wouldn’t be able to cast without setting your pain off. Does that sound about right?

Gerald: Yeah.

Bronnie: I think there are some things we could begin to work on so you feel more confident you can handle it when your pain levels go up and down. And I think we could work on some physical things that could help you feel a bit fitter, more able to do things for longer. And finally, I think it would be great if we could help you and your wife connect a bit more, perhaps not yet at a sit-down restaurant, but perhaps there are other ways this could happen. What are your thoughts? Is there anything you’d especially like to look at?

What I’ve tried to do here is identify the underlying reasons Gerald isn’t doing things. While pain appears to be the problem, it’s not the pain it self but the fear of possible effects of pain that haven’t even happened yet that are really stopping him from doing things. And this is adding to the misery of having neck pain.

By giving Gerald the chance to tell me his dreams, we’re going beyond “I need to get rid of my pain” and into the reasons for living in the first place. People don’t just live to get rid of pain, they live to have lives full of meaning, let’s not ever forget that.

Ryton Station Valley

Being: or doing?

I’ve posted a couple of times on goal-setting here and here and here.

You might get the message that I spend my time bimbling along without focusing on anything in particular. That’s just so not true! I definitely have things I want to achieve – and I achieve them (mostly – I never did learn German except to decipher my Burda pattern instructions!). It’s just that I think health professionals can use goals to clobber people with, and I don’t think that helps anyone, least of all the person in the middle.

Here are some more good reasons not to focus on goals:

  1. Goals can make all our efforts focused on the goal, and when the goal’s complete the actions stop. Goals can make daily actions things we do as a means to an end rather than something we do because we think they have value. Goals can make those actions temporary, a chore.
  2. Goals are external outcomes we want to achieve. That means achieving them is often out of our control. If I want to get a new job there are things I can do but in the end an employer must want to hire me. There’s nothing I can do to get a particular job if the employer just doesn’t want to employ me.
  3. When a goal takes a long time to reach, we can lose interest and give up. Then all that work is lost.

So, if I don’t just bimble along, randomly doing whatever takes my fancy, and I don’t set goals, what do I do?

I read a fabulous post by Nadira Jamal, The Belly Dance Geek

In it she’s looking at building a daily dance practice. Dancers need to practice, but many amateur dancers do a boom and bust approach to dance practice. “There’s a performance coming up – must practice! must practice!” Then once that performance is over, dance practice stops. Only to begin again once there’s another performance! No wonder some of us never get beyond struggling with hip drops. Nadira’s reasoning is that when we focus on “achieving the goal”, practice is a means to an end, not a means in itself.  Now the reason I want to dance is that it’s part of who I am, an expression of myself. So, you might wonder, why on earth don’t I practice as often as I can?  Well, it seems too hard to fit it in, I get bored, there are other people around, it’s too hot, it’s too cold, I’m still in my pj’s, I’ve had my shower already and don’t want to get all sticky…

People we work with have similarly good reasons for not doing those exercises we’ve recommended.

Instead, Nadira recommends using themes in dance practice. Picking some areas of dance to work on and working on them – selecting from a theme gives more variety for practice, they become a focus but not a prescription, and we choose them. A theme might be arms – and thinking of all the different ways I could improve my arms in dance. Pick a couple of activities, use these as a “menu”, then when you begin to practice, choose the one or ones that appeal that day.

Translating this into pain management, a theme might be “ways to down-regulate my sensitive nervous system”. The are a heap of ways to do this: mindfulness, yoga, walking in the garden, reading a good book, stretching, self-hypnosis. What a range of things I can choose from each day! I can write them all down, then depending on how I’m feeling that day I can choose the one that suits me the most.

I think it’s good to begin the day by reviewing my diary – and that when I plan my actions. I’ve decided, after listening to Nadira, to practice every morning. It’s easy because I just have to get out of bed five minutes earlier than normal. And yes, I’m only doing 5 minutes at the moment. For those who don’t know, I am NOT a morning person. And 5 minutes means I KNOW I can do it, even when I’m feeling sluggish. And it’s tied to getting up – usually I read, so I just finish reading 5 minutes early. I know the things that are likely to derail me from doing the practice, so I have my music ready, stay in my pj’s to do it (a vision that is not a sight for sore eyes), and go straight to the shower after. I’ve chosen themes for practice, and I focus on those.

With a client, I might look at “exercise” and consider all the activities that could be included in “exercise”. Not just the gym, but also gardening, vacuum-cleaning, dancing, walking along the beach, taking Sheba-the-wonderdog for a walk, throwing a stick for her. So flexible I can pick something to do each day.

The key, I think, is looking at why we think someone “should” do whatever it is we want them to do. Why should someone do exercises? Is it to be able to do something else? Yes? Then choose a number of activities that will contribute to doing that thing. Let the person decide exactly what to do each day.

Here’s an example: if we want someone to get fitter because this will help them return to work, list all the ways we (and the person) can think to get a bit of exercise into their day.

  1. Park the car a bit further away from home today, and walk to the park.
  2. Use the stairs instead of the lift.
  3. Take a bike ride around the blog.
  4. Take the dog for a walk.
  5. Walk along the beach with your partner.
  6. Build 5 minute exercise “snacks” throughout the day (I use Pomodoro technique to do this)

While these aren’t earth-shattering in intensity, for someone who is just not that into exercising, this might be a good beginning. And it allows for variety, builds on existing habits (daisy-chaining) Beginning where we are, allowing for variety and interest, and focusing on actions rather than goals gives us pleasure in the doing.

If we can’t say why we think they need to, for example, increase single leg standing balance, then seriously folks, why are we getting them to do it? If we don’t know why someone should sweat it out on a bike at a gym, then why do we think it’s a good thing? Is a spin class just for the thrill of the spin? If so, does the person enjoy it? Yes? Then fine, go for it. No? If it’s to be fit enough for something else – what other ways could that person “get fit enough”?

There is always more than one way to skin a cat, as they say. Don’t get trapped into getting your patients hooked into doing The One Exercise just because you think it’s a good thing. I’m pretty confident that this is the best way to lose people. Let’s instead focus on being, and the doing will happen in a myriad different ways.

in a blue mood

Goals? I loathe them: What to do instead

I dislike that acronym “SMART” goals. I can never decide whether it’s meant to mean “Specific, measurable, achievable, realistic and time-bound” or “specific, manageable, active, realistic and timed” And if it’s either of those, what’s the difference between achievable and realistic? Or is it meant to be “relevant”?

In previous posts I’ve established good reasons to have a focus for therapy. Unless the focus is something valued by the client, it’s either unlikely to get done or it’s not their goal and they’re going along with it to keep you happy. Goals, targets or focus are useful, and the logic goes that unless you have them you won’t know where you’re going or when you’ve got there.

I’m not going to argue against the idea of having a focus to therapy. I just think there are risks in having goals, like some sort of checklist that says “If you achieve this, you’re all good”.

Seriously, that doesn’t work in real life. That’s the same kind of logic that says “if I just buy enough things I’ll be happy”, “if I just earn a bit more I’ll be happy”. While there’s a bottom line below which it’s hard to think beyond survival, above that line, having stuff, and even doing things as an end in themselves doesn’t fulfill for long.

What gives forward momentum, enrichment, fulfillment and can’t be ticked off like some shopping list is recognising that life is actually a whole series of actions and events that, when we think back on them, make up a good life. The richer events and experiences and actions feel good and fulfilling. The empty routine and humdrum things feel deadly dull and empty.

When I think about the purpose of therapy my focus is helping people to live the kind of life they value, doing the things they believe are important. Given I don’t want to be a long-term feature in a client’s life (for all I love them, I’d rather they were doing it themselves), my focus is on helping them work out what makes a rich, fulfilled life they can look back on and feel satisfied. My job is to help them develop skills and strategies to carry out the actions needed to live a life aligned with what they value.

Let me unpack this a little.

Many people I see place value on being a good parent, a loving partner, a reliable employee. When I see them, their pain has interfered with doing the things they believe demonstrate “being a good parent” or “being reliable”. Pain has moved in to their lives, and come and sat on their laps right in front of their face so that all they can see is pain.  If I ask someone in this state to “set goals” they laugh, rather sarcastically sometimes, and say they don’t have goals, they can’t think of anything and what’s the point anyway. Perhaps not in those words, but the meaning is clear.

Instead, I ask them “what would you be doing if your pain was less of a problem for you?” Sometimes I’ll even hand over a plastic fairy wand I have, and suggest they dream a little. It’s then that the passion takes over – they’ll say “I’d be out working, having fun with my friends, caring for my family” – and the list goes on! If I stopped there, though, I’d be holding a tantalising dream just out of reach, which is cruel, so I don’t. Instead I ask why these things are important.

That’s how I find out that “family is everything”, “I just love creating”, “I need my friends”.

Then I switch tack for a moment and ask them “How well is what you’re doing to deal with your pain right now working to help you be the kind of person for whom family is everything? How well is what you’re doing with you pain helping you create?”

The reason for this tactic is to help generate what Acceptance and Commitment therapists (ACT) call “creative hopelessness“. Because motivation to change comes from inside – that it’s important enough, and the person is confident that change can happen.

I then suggest two things: 

  1. Is keeping pain happy more important than family ?(and yes, I know I’m personalising and objectifying pain here, and yes it’s an experience not a thing, but it works OK!)
  2. What would happen if you made a little room for pain to be there while you’re doing things that contribute to you being the kind of parent you want to be?

What I mean by this last statement is that pain can interfere with doing that things that help you feel you’re being a good parent. And that can lead to either completely abandoning those activities, or doing them while clutching resentfully to “the pain that interferes”. What if you attended to the value or importance of being the kind of person who is a good parent instead of focusing on the irritation, frustration and anger of having to bring pain along for the ride?

  • For many people, the things they believe contribute to “being a good parent” far exceed what they can currently achieve. So they give up and get demoralised. They both have their pain AND they don’t manage the very things they most value.

Now it’s here that I could begin to “set goals” and suggest we work towards them using all the traditional elements of goal setting. And that probably has excellent value. But here’s the catch: often we hold very strong internal rules about how these things should be done so that unless we can do them exactly the way we think they should be done, we’re not satisfied. And for many people this fails to recognise that as time goes on, life too goes on, and we change the way we do things to accommodate new habits or capabilities. So I try to begin a process of developing flexibility – and using the values a person identifies as a compass rather than a checklist.

What would happen if we thought a little about the range of things people might do to convey “being a good parent”? Maybe it would mean going to the children’s sports games and being a spectator. Maybe it would mean making lunches, helping to do homework. Maybe it would include listening while a kid tells you about his or her day. Many of these things can be done with pain present. Many might require altering how they’re done to accommodate having pain present but provided that they express the underlying value of being a good parent, can be fulfilling.

What’s important is less about the what a person does, and a whole lot more about why and how they do it.  When “being a good parent” becomes the direction we live (because we can never tick the box that says “being a good parent” is complete), then we focus on why and how we do it. Attention goes away from “but pain stops me”, and towards discovering all the ways “being a good parent” can be lived.

Often it’s through doing this that people seek new coping strategies so they can extend what they do. People may “set goals” or future actions they want to take but instead of feeling frustrated and dissatisfied, they begin to to take actions that bring them closer and closer to living the life they want to live. And that, my friends, is what I think “goal setting” is about.

This festive season is a good time to consider what’s important in your life. What actions are you taking to live a value-filled life?

tiny explosions of delight

“I don’t know what I want to do” – Silent copers?

One of my friends on Facebook said it’s difficult working with someone who doesn’t come up with a goal, or a new direction in pain management, even when they accept that their pain isn’t a threat (it’s hurt, not harm). It sure is! So I thought today I’d review some of the factors that might maintain someone in this “limbo land” where, as a therapist, it feels like you’re doing all the work.

Firstly, let’s distinguish between having pain and being disabled by it. Pain is an experience that people have. It doesn’t live outside a person’s narrative of their life. It always has some meaning in some way, and this meaning makes it pain rather than any other experience.  To quote Joanna Bourke “Being-in-pain is a multifaceted sensory, cognitive, affective, motivational, and temporal phenomenon… people perceive pain through the prism of the entirety of their lived experiences, including their sensual physiologies, emotional states, cognitive beliefs and relational standing in various communities.” (Bourke, 2014, p. 13).

Being disabled by pain involves being unable to do things as a result of pain; the experience and meaning of that experience interfering with participating in daily life. Being disabled can emerge from physiological responses to pain, cognitions about the meaning of pain, reinforcement for behaviour arising from contextual features, and emotional responses to all of the above. In chronic pain, where pain intensity is difficult to reduce (if it can be at all), my main focus is on how I can help a person be less disabled by their experience of pain.

When someone looks for help for their pain, Ferreira, Machado, Latimer, Maher, Ferreira and Smeets (2010) found that the primary reason was associated with how much pain interfered with life. Disability rather than pain intensity is a strong motivator for help-seeking. This suggests to me that we should be able to identify what it is that a person can’t do and use this as a motivating factor for change. But of course it’s not quite as simple as that.

Reasons for not having goals

  • One reason is that people coming for help with chronic pain may have been waiting a very long time to be seen. For example, in Christchurch, last time I reviewed the data around referrals to the tertiary pain management service, the average pain duration before being referred (not even being seen) was four years. Imagine how that might affect someone. Four years of “I don’t know what’s wrong with you”, or “I’m sorry but you don’t seem to be responding well”, or “The surgery went well, I don’t understand why you’re still feeling pain” – it might make you feel slightly demoralised, perhaps a little hopeless. Remember that most people with chronic pain don’t know the point at which they shift from an acute pain problem which should resolve, to a chronic pain problem that, by definition almost, is going to persist. Pain like that just doesn’t make sense. It can be very frightening.

As a result, some people lose hope and feel that they must live very, very carefully in case they do something to increase their pain, or make their problem worse.

  • Another reason can be because of the messages people can be given. Mixed messages usually, and by anyone  – “Be careful, you don’t want to overdo it”, “last time you did that, it took you days to get over it”, “You have wear and tear in your joint [oh, does that mean I should stop so I don’t wear the joint away completely?]”, “don’t have flare-ups”, “you need to let your body/brain settle down”, “pace yourself”.

Some of these messages are ones we give – even enlightened people coming from a Therapeutic Neuroscience (TNE) perspective can inadvertently suggest a person should “take it easy” and “be kind to your sensitive nervous system” – which is all very well, except when the “take it easy” message is never reviewed, and the person learns that a painful flare-up means they’ve been “too hard” on their nervous system. Like the paced activity approach, both of these messages need to be reviewed so the person learns how to deal with a flare-up then resumes gradual increases in activity level. Erroneous messages from the media (yes! that “text-neck” meme that’s going around!), medical professionals, family and friends can all maintain avoidance, even in the face of TNE that reaches the head but not the heart.

  • Some people can find it very hard to think of goals because they’ve never learned about goal-setting. Goal-setting is a learned behaviour, something that health professionals learn how to do, business people learn how to do – but it doesn’t always transfer into daily life. Some people live in the flow of life, going with whatever happens, responding to situations rather than setting out with a purpose. Sometimes this happens because they live in poverty and can’t think beyond today. Sometimes it arises because they’ve had so many negative experiences when they have tried to move in a particular direction that they’ve given up. Sometimes it’s part of a family context, perhaps a cultural context. I suspect goals and achievement are a very eurocentric phenomenon, and if you’re from a different culture, perhaps this doesn’t make sense – because family or group goals are far more meaningful.
  • Some people may have contexts in which making change is extraordinarily difficult. A scenario I’ve met before: the person with pain who hasn’t worked for some years; the two parents – one has a long-term disability, the other is unemployed, the sibling who is on a sickness benefit. No-one gets up before 11.00, no-one works, and there’s little or no support for the person with pain to make any changes within the situation. Even if pain is reduced, it’s going to be difficult for a person to do anything differently because others in the family are also stuck.
  • Some contexts are actively punitive when a person begins to make changes. When another family member needs the person to “be cared for” because it meets his or her needs, it’s going to be hard for anyone to make a change.
  • Some people hold strong ideas about their performance, perhaps holding up an idealised vision of who they were before this all happened – now, even beginning to think about making a change highlights the discrepancy between who they are now and who they used to be, not exactly a great way to encourage change.

I haven’t started looking at what you can do to help someone step out of the glue that these factors can be. Don’t worry – that’s next week’s post! But in the meantime, here are some of my older posts that might be useful:

Individualising explanations with case formulation Coping with pain: A motivational perspective goals-values-and-motivation

Bourke, Joanna. (2014). The story of pain: from prayer to painkillers: Oxford University Press.

Ferreira, Manuela L., Machado, Gustavo, Latimer, Jane, Maher, Christopher, Ferreira, Paulo H., & Smeets, Rob J. (2010). Factors defining care-seeking in low back pain–A meta-analysis of population based surveys. European Journal of Pain, 14(7), e1-e7. doi: http://dx.doi.org/10.1016/j.ejpain.2009.11.005


How occupational engagement might work in pain management

Intuitively, most of us know that when we’re actively involved in doing something we either enjoy or is sufficiently complex enough to need attention, we can lose awareness of things like hunger, thirst – or pain.  In the very early years of occupational therapy, this “distracting” factor of occupation was employed to good effect to while away the time needed to recover from serious trauma following the World Wars.  Over the years following, the positive effects of being involved in occupation were somehow overlo0ked in the desire to get scientific about the serious business of rehabilitation. Frivolous things like occupation for occupation’s sake was often left behind.

More recently we’ve begun to learn more about how occupation might be a good thing.  First came the cumulative findings that being in work was not only economically healthy, but also maintained physical and mental wellbeing.

Then we found that through positive psychology studies that the state of  “flow” popularised by Mihaly Csikszentmihalyi could bring about not only positive emotions (afterwards, not specifically during because during flow the focus is almost entirely on the doing rather than any emotion) but also greater creativity and integrated physical/emotional/mental performance.

Now studies are emerging to demonstrate how occupational engagement (not necessarily even flow experiences) may work in pain management.  This is interesting to me for several reasons – firstly there have been some inconsistent findings with respect to the usefulness of distraction per se, where in one study people experienced an increase in pain after being engaged in a distraction activity (Goubert, Crombez, Eccleston & Devulder, 2004).  Secondly, most of the research into coping with chronic pain has occurred without specific attention to the valued goals of the individual.

Let me explain: usually it’s recommended to maintain a consistent level of activity.  Sometimes this is called activity pacing.  Yet there are times when it’s appropriate to suspend the use of pacing – when there is a special event like Christmas, or when dealing with an important deadline (writing an exam over two hours).  We accommodate these events by varying the kind of strategy employed, maybe drawing on the use of additional relaxation in the day following Christmas, or using coping self statements during the exam.

Schrooten, VanDamme, Crombez, Peters, Vogt and Vlaeyen explored whether bias to attend to pain is impaired when an individual is engaged in a competing activity.  Participants in this experimental study with people who do not usually have pain, were given a spatial cueing task with pain cues and neutral cues.  Their attention bias towards pain was measured in terms of the speed with which they were able to identify whether a cue matched a stimulus.  Two different colours were used, one of which had been associated with a painful stimulus.  Usually, people respond more quickly to the stimulus that has been associated with pain than to a neutral stimulus because pain is a threat and our brains work hard to make sure we notice anything that might threaten our wellbeing.

To make this a little more exciting (well, for the researchers anyway!), half of the participants were also presented with a letter in the middle of the screen (the cues were randomly placed to either left or right of the screen) and asked to say the letter out loud.  If they got the letter correct, they were told they would be rewarded with money depending on the number of correct responses they made.  This was the “nonpain task goal”, or activity/occupation.

The results showed that when participants were distracted by the activity that might earn them money, they were slower at responding to the painful cue than when they were not distracted.  In other words, they were not as quick to respond to things that they had previously viewed as a potential threat.

This is a really interesting finding – while it’s a far cry from the kind of naturally rewarding activity we usually engage in when in the real world, the very structured and controlled nature of this experiment was able to demonstrate that there are measurable effects on how quickly our brains attend to things that we have learned might be a threat.

Another similar study using a different experimental study is by Bradshaw, Chapman, Jacobson and Donaldson (2012) in which music was used.  Their findings were that “engaging activities may prevent pain by creating competing constructions of reality that draw on the same processing resources as pain. ”

It looks like occupational therapists need to seriously get involved in the psychophysiological studies of why and how occupational engagement might work in pain management.

Schrooten, M., Van Damme, S., Crombez, G., Peters, M., Vogt, J., & Vlaeyen, J. (2012). Nonpain goal pursuit inhibits attentional bias to pain PAIN DOI: 10.1016/j.pain.2012.01.025

Goubert, L., Crombez, G., Eccleston, C., & Devulder, J. (2004). Distraction from chronic pain during a pain-inducing activity is associated with greater post-activity pain. Pain, 110(1-2), 220-227.

Bradshaw, D.,Chapman, CR., Jacobson, RC.,  and Donaldson, G. (epub ahead of print). Effects of Music Engagement on Responses to Painful Stimulation. Clinical Journal of Pain.


More “Psychological stuff isn’t in my scope of practice” so what can I do?

ResearchBlogging.orgI promised there would be more on this topic – it’s a popular one and full of vexing questions.  I left off yesterday, after making four points that IMHO might help incorporate some of the psychosocial management to a nonpsychological practice.  They were:

Give precise advice about what to do.

Give reasons for your advice.

Ask the person about their understanding of their pain.

Make sure you give clear timeframes for any activity restrictions.

The underlying rationale for each of these is to counter two main problems that appear to underpin the development of longterm disability associated with pain: catastrophising, or ‘thinking the worst’, and avoidance.

This point is really important, so listen up!

It’s not the presence of pain alone that is the problem.  It’s negative thoughts or judgements about pain, and behaviours that people do to avoid exacerbating the pain. 

Combine both of these with low mood, and we have a witches brew that can lead to longterm disability.  And it’s disability associated with pain that really is the problem because it’s about not being able to do the things that people want or need to do. 

OK, ’nuff said. While I appreciate that pain by definition is a negative emotional experience, it’s these two additional components that need to be addressed as early as possible.  And yes, that’s pretty much what Linton and colleagues found (and recommend) in the paper I’ve referred to.

Their point is that we don’t know very much about the best ways to target the tendency to catastrophise, and while our focus is often on low mood and low mood certainly has a major impact on longterm outcome, we also need to directly address catastrophising and develop targeted treatments for this.

The quote I gave yesterday from Linton et al., was incomplete – here’s the rest: “Clearly, encouragement to upgrade activities and exercises, as well as education and attempted reassurance about pain may be sufficient to achieve meaningful changes in many, but they appear to be insufficient to overcome strongly-held catastrophic beliefs by a proportion of people.” Something else needs to be added, and I think it might be doing things differently. With the emphasis on doing. Education/information alone doesn’t necessarily change behaviour…

At this point, I’m leaping off the solid ground of evidence, and into some clinical conjecture, but hopefully based on what we currently know about helping people make changes.  So please, bear this in mind when you read on…

  1. Check with the patient to find out what they think they’ve heard.  What does the person hear when you give an explanation?  What do they think you mean?  How does your explanation fit in with their personal theory of what is going on?
  2. A picture or diagram is worth a thousand words.  I find myself drawing diagrams linking the person’s thoughts, their responses in both emotions and behaviours, and I add in alternative paths and extra information that I can give to them to take away.  Personalising this information and using what the person already knows to show them that their reasoning might ‘make sense’ but has unintended consequences, or their reasoning is based on inadequate knowledge helps to make your advice on ‘doing it differently’ much more acceptable.  This is a joint discovery you and the person are making.
  3. Setting goals always needs to start where the person is at.  If you want the person to start doing things for themselves, being active in their own treatment, they need to feel that those actions are both important and that they can do them successfully.  If the person doesn’t think they can walk to the letterbox every day, even though you think that’s barely sufficient, then start with something they think they can do – and do consistently.
  4. When the person comes back to see you – check with how they’ve carried out the goals you set.  If you don’t check in on them, they’ll see the goals as unimportant.  Even if they haven’t done the goals, you can continue with your treatment – just ask what happened? What got in the way of doing the goal? What went through their mind? What external obstacles got in the way? This is where you’re starting to use psychological ‘stuff’ because often what you’ll find is that it’s thoughts/beliefs about the pain, emotions related to those thoughts about pain, and/or the influence of other things (people, events) that will directly influence recovery.

More on this stuff tomorrow – but let me know, does what I’ve written ring true? Can you do this? Does it make sense to you as a clinician? I’m looking forward to hearing your comments.

Linton, S., Nicholas, M., MacDonald, S., Boersma, K., Bergbom, S., Maher, C., & Refshauge, K. (2011). The role of depression and catastrophizing in musculoskeletal pain European Journal of Pain, 15 (4), 416-422 DOI: 10.1016/j.ejpain.2010.08.009


A new way of looking at coping, maybe?

One half of knowing what you want is knowing what you must give up before you get it. ~Sidney Howard

Many are stubborn in pursuit of the path they have chosen, few in pursuit of the goal. ~Friedrich Wilhelm Nietzsche

There are few topics closer to my heart than goals.  This is partly because of my background in occupational therapy, where goals are seen as part of how we live purposeful, meaningful lives – but it’s also because they’re incredibly difficult to help others to do, yet goal setting is seen as integral to therapy.

I’ve also been considering the whole topic of coping recently.  What is coping? Which coping strategies are helpful? Is it possible to view coping efforts without also looking at the context in which they’re being used? My current conclusion is that, at least in pain management, coping is a concept that we really haven’t come to grips with.  Even the term ‘coping’ isn’t well-defined: is it the process of adapting to a situation? the outcome? or the strategy employed?

Karsdorp and Vlaeyen, in this pre-print article, consider the pursuit of goals as part of the problem of disability associated with chronic pain.  What? you say – how can going after a goal be part of the problem?  Let me explain.

For some time, we’ve recognised that along with the people who avoid activity and become deactivated and highly disabled, there is a somewhat smaller number of people who superficially seem to be coping well – they’re active, maintain going to work, keep the family going and so on, but at the same time can be highly distressed by their pain.  Their pain represents a roadblock that gets in the way of getting things done, but unlike the first group who stop doing and avoid experiencing pain, this group of people seem to almost redouble their efforts.  They just keep going.

One model looking at mood and the motivational effects of mood is the “mood as input” model.  This model proposes that “the motivational effect of goal pursuit on behavior is moderated by mood”.  It suggests there are two types of goal – short-term ‘hedonistic’ goals, and long-term ‘achievement’ goals.  Hedonistic goals are all about pleasure in the ‘now’ – that taste of chocolate, the joy of running and so on.  Achievement goals require a longer-term focus and may involve some hard work in the short-term – learning to ride a bicycle, drive a car, win a race.

In this model, the degree to which a person tends towards either type of goal is thought to be influenced by mood.  In other words, negative mood suggests to the individual trying to achieve a goal that they haven’t got there yet – leading to task persistence.  In other individuals, negative mood suggests that they’re not enjoying the goal any more, so they should stop.  Of course, most of us have a mixture of goals, both hedonistic and achievement, but there does seem to be a tendency towards one type or another in some individuals, and in this study by Karsdorp and Vlaeyen, it was hypothesised that those with a strong preference towards one or the other, would present with the most disability and pain, dependent on their level of negative affect.

Nearly 300 people with current pain present in any part of the body and with various diagnoses were recruited by newspaper for this study.  A large battery of questionnaires were completed including some related to goals, affect, catastrophising, perfectionism and pain-related disability.  Using exploratory factor analysis, a two-factor structure was obtained from the data – one factor related to pain, and ‘the rest’.  With the pain factor excluded, a further two factors were obtained – one related to a pain avoidance goal, and the other to a mood management goal.

After completing further analyses, mainly multiple regressions,  a nonlinear, U-shaped association was found between
pain-avoidance and pain and disability.  What this means is that a stronger endorsement of either pain-avoidance goals or achievement goals was related to greater pain and disability while controlling for other factors.

The other main finding from this study is to confirm previous research that has found an association between high “sense of responsibility” and achievement goals and between pain catastrophizing and the “hedonic” goal to find a solution for pain.  In other words, there are some people who push themselves to complete goals because of a high sense of responsibility and the negative emotions they experience when they don’t complete things to their satisfaction – and in this group, disability and distress is increased when their pain ‘gets in the way of’ achieving these goals.  Then there are other people who tend towards primarily trying to manage their mood, who are likely to catastrophise more about pain, and are more inclined to avoid activities that exacerbate their pain.

Now here is where I think we need to do more research.  Rather than classifying coping strategies according to ’emotion-focused’ or ‘solution-focused’, or ‘active’ vs ‘passive’, I think we need to look at the function of coping strategies as they are conducted in the pursuit of things people want to do.  It’s not helpful to see people as separate from the context of what they want to do, and where they want to do it.

This model is in its early stages, the findings were relatively weak, and there is clearly much more to be done to explore the idea of goal pursuit and coping strategies, but it is nice to see that at least one group of researchers is concerned about “why” people do things as much as “what” they do.

Karsdorp, P., & Vlaeyen, J. (2011). Goals matter: Both achievement and pain-avoidance goals are associated with pain severity and disability in patients with low back and upper extremity pain PAIN DOI: 10.1016/j.pain.2011.02.018


Establishing routines and baselines: Baseline recording

One of the problems novice clinicians often complain about is that journals and research papers rarely examine or provide practical approaches to daily problems that are encountered when working with people who have chronic pain.

It can take a lot of work to locate suitable approaches to things like:

  • ways to help a person who is not accepting that a cure for chronic pain is unavailable
  • ‘motivating’ a person to engage in activities that are anticipated to increase pain
  • how to develop a baseline and establish an appropriate rate of progression
  • how to establish a daily routine

It’s tempting to think that in the absence of evidence-based approaches, the clinical skills are artistic rather than scientific, but I’m not so sure about that.  Maybe it’s more a case of lack of systematic documentation about methods used, or lack of systematic examination of the ways in which these often non-sexy and very practical strategies might be improved (subtle hint to clinical researchers here!).

Anyway, there are a few approaches that I’ve collected for developing a daily routine and baseline.  To date I don’t have publications to cite in their defense, so you’ll need to join me in exploring how and whether these work to help people with chronic pain become aware of their activity patterns.  First up: Baselines

There is good evidence that simply by recording what happens on a daily basis, positive changes can begin to occur.   This is a basic behavioural approach that has been used in eating disorders, smoking cessation, exercise, diabetes blood sugar monitoring and treatments for OCD.  It’s the principle that by having feedback available about often habitual activities, we’re more aware of them, and can begin to recognise antecedents and consequences of the behaviours in question.

The process of recording what happens, when it happens, and what comes after is often called ‘establishing a baseline’.  Clinicians unfamiliar with psychological use of baselines use the term without realising that, for behaviour change, the natural variations in behaviour need to settle into some sort of pattern in order for it to be called a ‘baseline’.

Variations in activity levels, for example, may not occur over the course of a single day or even over the course of a week.   If we don’t spend the time exploring variations over time until they’ve settled into a recognisable pattern, it can seem as if there are no patterns and fluctuations occur in a totally random way.

Once a baseline is recorded, we can start to analyse the antecedent triggers or events might be (ie the things that come before a behaviour), and the consequences of each type of behaviour.  This can help us identify the type of situation the person has trouble managing effectively (or in a way that is aligned with the person’s values in the long term).

For example, we might notice that it’s often after a period of feeling relatively comfortable that the person suddenly starts increasing his/her exercise demands.  After a few days of increased exercise, he/she might suddenly stop.  It’s important to explore the reasons the person felt it was important to increase exercising – automatic thoughts about being ‘lazy’ for feeling OK but not making the most of it? or automatic thoughts that the pain has ‘gone’ and ‘I’m cured’ so it’s time to start doing things normally again? or did the person get ‘bored’ of doing the same old thing and seek something more stimulating and blow their energy budget?

There are loads of ways to record baseline activity – diaries similar to an appointment diary; recording sheets that have several things to track such as sitting time, distance walked, thoughts about situations – and for people with high-tech backgrounds, electronic diaries that ask the person to note their activity as they go just by clicking on a button on a phone or PDA or iPad.

There is some research on whether there are differences in the quality of information collected via pen and paper through the day, or whether an ‘end of day’ record is sufficient.  I think it depends on the purpose of your assessment, and it also depends on the ‘pen-and-paper-ness’ of the person you’re working with!  In other words, it’s going to be difficult for a heavy labourer with limited access to pen and paper and low literacy to complete a detailed activity diary throughout the day, but if you’re asking a busy executive who is used to carrying a PDA or iPad around with them to do the same activity electronically, it’ll probably happen.

One simple electronic method of recording ‘up-time’ is a simple pedometer.  Taped up so it can’t be opened, it can be worn for three or four days, then opened, the total number of steps recorded, divided by the number of days, and there is a rough measure of general activity level.  This can help when developing and monitoring activity level over a longer period, such as when you’re helping someone begin a walking programme, or to maintain an even level of activity each day.  Just by recording the number of steps over a fortnight or so, with a target of maintaining the same number of steps each day, the person has a target to aim for and it can act as feedback on their overall activity level and help shape their activity behaviour.

More on ways to establish routines next time!  If you find this interesting and want to know more, or have questions, don’t forget you can post a comment below, and I’ll do my best to help.  I’m also collecting some diary and other recording formats that I’ll post in my next post.


What do people expect when they get referred to a pain management centre?

It can take years for someone to be referred to a pain management service. In fact, in a study of patients accepted into the three week pain management programme at Burwood Pain Management Centre, the average duration of pain was 4 years, give or take some months. No wonder then, that when people in a study by Allcock, Elkan and Williams (2007) were asked what they felt when they were referred to pain management, they said things like “…they’ve given up on us. Because anything that would have been cured, spinally or orthopaedically, has gone by the wayside.”

What’s so important about expectations before treatment? Well, expectations make an enormous difference to how satisfied people are with treatment, and the outcomes they achieve (Main, Foster & Buchbinder, 2010); Myers, Phillips, Davis, Cherkin, et al., 2007). Mismatches between what the person being referred expects, and what the clinician can (or wants to) provide needs to be carefully managed so as not to end in a frustrated consultation, or a patient who feels unheard, misunderstood or fobbed off.

Last week, a person who had just finished our three week pain management programme said that even though we had been really clear that the programme wouldn’t change his pain, secretly he and the other participants had hoped that ‘this might be the one that would take the pain away.’ This isn’t an uncommon thing for us to hear. In fact, although we haven’t studied it, I’d hazard a guess that for much of the first week of the programme, participants are struggling with the idea that we’re probably not going to fix their pain – and worse, their pain might actually become more intense as we help them start doing things again.

What might make this a process that moves along, hopefully, to some resolution or acceptance, is that we’re working with the participants in a group setting, with an interdisciplinary team approach, and consistently for three weeks. They’re hearing the same message, and they’re hearing it from many different people, and it’s for long enough that they can move through some of those phases of ‘readiness to change’ of Prochaska and DiClemente’s.

What else do people expect when they’re referred for pain management?

Allcock, Elkan and Williams (2007) point out that most people in their study expected the pain management centre to be based on a medical model of pain. They concluded that “what [patients] have learned to expect from professionals treating them prior to being referred has not prepared them for the approach to care of staff at specialist pain clinics.” That’s probably pretty accurate. And that belief is probably mirrored by their referrers!

This study also found that many people didn’t feel they had been heard, or taken seriously prior to being referred. Participants in their study “needed to feel legitimated in the sick role, and part of the reason for wanting to know the cause of the pain was a desire to seek legitimacy in the eyes of others.” They made an interesting observation in that participants ranked the statement “I would like to have a better understanding of my pain” fifth on the list of 10 statements, and in the focus group discussion, identified having a diagnostic label as something different from having a better understanding. Allcock, Elkan and Williams suggest that “It was not so much personal understanding of their pain that they needed to legitimise it, as a diagnostic label.”

I found it interesting that, both in this study, and in a review I’ve made of the goals identified by people before they attend their first assessment, doing things again is important – provided that the pain is reduced or removed. There is an expectation that life may only be lived well without having pain. I don’t think this belief is limited to the people being referred to our service – in fact, I’d go so far as to say that it’s a belief that many treatment providers also hold: that returning to the things we love to do can only be done while pain free. This attitude may well drive much of the somewhat futile search for the treatment that will abolish pain.

The problem is that for so many of the people I see, removing or reducing pain intensity is quite limited. Medications not only have unpleasant side effects, they’re also not terribly effective. Even with medications on board, many people find they continue to experience quite an unpleasant level of pain. This is in part because pain intensity is something we can’t directly measure. The level of pain intensity has to be measured through what the person says – and this is a pain behavior. Any report of pain intensity is also filtered through what the person believes is occurring, the meaning of the pain to them and the person’s coping resources.

If pain can’t be removed, am I suggesting that people stoically “soldier on”? Well, not quite. Soldiering on suggests gritting the teeth and pushing through the pain until the job is done. I guess I’m advocating a more flexible approach – recalibrating, perhaps, some of the expectations about what must be done (note the word ‘must’ – changing it to ‘could’ might help); choosing when and how to carry out important activities; maintaining a balance in daily living; having moments of daily pleasure (or taking pleasure in moments every day!); establishing challenges that keep body and mind engaged; taking time to be close to, and trust another person (at least one!).
These are the things that make life worth living.

How do we handle the mismatch between what a person (and the person who referred them) expects from coming to a pain management centre, and what pain management can achieve?
While that’s a topic for another whole post, I think we can start with taking the time to do some of the things that people do expect: listen to their concerns, and I mean really listen. We can take them seriously. We can let them know that their pain is, itself, a disorder – not an indication of something else that needs to be, or can be, fixed. To let people know that chronic pain, in many cases, is a nervous system disorder provides them with a name for what’s wrong, enables them to realize that it’s not their ‘lack of coping’ or a personal weakness, and may allow them to start to accept that it’s not necessary to look for ‘the cause’.

Then maybe we can allow people the time to work through what this means to them – just as we would do if we were telling someone they had another long-term disorder (like diabetes). Being there to listen is maybe the first and most important treatment we can give.

Then we need to instill hope – not that the pain will go, but that the problems it causes can be mitigated, and that it’s possible to live well despite having chronic pain. Of course, first that means that we as treatment providers can believe that it’s possible to live well – and that is the topic of another post!

Allcock N, Elkan R, & Williams J (2007). Patients referred to a pain management clinic: beliefs, expectations and priorities. Journal of advanced nursing, 60 (3), 248-56 PMID: 17908123
Main, C., Foster, N., & Buchbinder, R. (2010). How important are back pain beliefs and expectations for satisfactory recovery from back pain? Best Practice & Research Clinical Rheumatology, 24 (2), 205-217 DOI: 10.1016/j.berh.2009.12.012

Myers, S., Phillips, R., Davis, R., Cherkin, D., Legedza, A., Kaptchuk, T., Hrbek, A., Buring, J., Post, D., Connelly, M., & Eisenberg, D. (2007). Patient Expectations as Predictors of Outcome In Patients with Acute Low Back Pain Journal of General Internal Medicine, 23 (2), 148-153 DOI: 10.1007/s11606-007-0460-5