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Your patient has psychosocial risk factors: what now?


Congratulations! You’re an insightful clinician who’s offered your patient a screening assessment to find out if she or he has psychosocial risk factors – and yes! they do! Well done. Now what?

Do you…

  • send your patient to the nearest psychologist?
  • spend at least one treatment session offering pain neurobiology education?
  • scramble to find a “psychologically informed physio” to send them to, because it takes really highly trained and special clinicians to work with these people
  • give your patient the same exercise prescription you were going to anyway because, after all, they still have things going on in their tissues (or is it their nervous system? I forget – whatever, they just need to move, dammit!)
  • throw your hands up in horror and say “I never wanted to deal with people in pain anyway!”

You’d have to be hiding beneath a rock to avoid learning that people with musculoskeletal pain with psychosocial risk factors such as feeling that back pain is terrible and it isn’t going to get better, believing that it’s not safe to move or exercise with back pain, having worrying thoughts going through their mind, or not enjoying things very much should have special attention when they seek help for their pain. And we’ve all read studies showing that many of our frontline clinicians who see people with musculoskeletal pain aren’t comfortable, confident or clear about what to do with people who are, frankly, scared and distressed.

Papers like Caneiro, Bunzli & O’Sulllivan’s (2021) Masterclass clearly show that messages people with pain get told include avoiding certain movements to prevent damage, being advised that special exercises ‘protect’ the body, and that clinicians believe that certain postures and movements are inherently unsafe (bending, lifting with a rounded back). At the same time, Sajid, Parkunan & Frost (2021) found that only 11.8% of people referred by GPs for musculoskeletal MRIs had their mental health problems addressed, while only 16.7% of the MRI results were correctly interpreted by GPs and in 65.4% of cases were referred for “spurious overperception of surgical targets.”

Worse, Nicola, Correia, Ditchburn & Drummond (2021) conducted a systematic review of the effects of pain invalidation on individuals – invalidation from family, friends and healthcare individuals, and the person themselves. They found five themes: not being believed, lack of compassion, lack of pain awareness and understanding, feeling stigmatised and critical self-judgement. Perceived social unacceptability of experiencing pain was found to have an impact on the emotional state and self-image of those with persistent pain. Ya think?!

If I return to the case I presented last week, Angelina, a pretty common case of someone with a neck pain who is having trouble sleeping and generally handles her pain independently, we could assume that she doesn’t have significant psychosocial risk factors. After all, she’s managing to stay working, does a bit of self-help, and she’s not depressed though she’s a bit irritable.

What would you do?

I guess my first thought is: would Angelina even get a screening assessment to see whether she has any psychosocial risk factors? Might she present superficially well enough for her therapist to think she’s fine, let’s just treat the neck?

Of all the neck pain treatments available, what would she be given? And what might she be told about the rationale for that treatment? A recent systematic review with meta-analysis pointed out that while specific exercises helped in the short to medium term, the quality of that evidence was low (Villaneuva-Ruiz, Falla, Lascurain-Aquirrebena, 2021), while a systematic review with network meta-analysis of 40 RCTs found “There is not one superior type of physical exercise for people with chronic non-specific neck pain.
Rather, there is very low quality evidence that motor control, yoga/Pilates/Tai Chi/Qigong and strengthening exercises are equally effective.” (de Zoete, Armfield, McAuley, Chen, & Sterling, 2020).

More than this: would her sleep and relationship concerns be discussed? What about her safety while driving? How about how she manages her work, and her belief that perhaps her pain is happening because of a period at work where she wasn’t positioned “correctly”?

You see, at the moment in our musculoskeletal treatment literature, the focus has been almost entirely on grouped data. And this, folks, is where Steven Hayes points out that the ergodic theorum is violated. Ergodic theory is “…the idea that a point of a moving system, either a dynamical system or a stochastic process, will eventually visit all parts of the space that the system moves in, in a uniform and random sense. This implies that the average behavior of the system can be deduced from the trajectory of a “typical” point. Equivalently, a sufficiently large collection of random samples from a process can represent the average statistical properties of the entire process.” (I stole that from https://en.wikipedia.org/wiki/Ergodicity).

Hayes, Hofmann & Ciarrochi (2020) point out that “We cannot assume that the behavior of collectives (e.g., a volume of gas) models the behavior of an individual element (e.g., a molecule of gas) unless the material involved is “ergodic” and thus all elements are identical and are unaffected by change processes.” Humans are not ergodic (only a few noble gases are…) and what this means is that “statistical techniques based on inter-individual variation cannot properly assess the contribution of given elements to phenotypic change.” In other words: humans actively respond and change to what they’re exposed to – each of us presents to treatment with our own incredibly unique range of responses and past history, and these influence how we respond to a treatment. And perhaps this explains why most of our treatments (RCTs, using grouped data and uniformly applied and consistent treatments) particularly for persistent pain problems end up showing pretty small effect sizes. We’re violating the assumptions of the ergodic theorum. What we need are more sophisticated ways to analyse the impact of any therapy, and far fewer algorithms and cookie cutter treatments.

Where does this leave us? I have loads of ideas about where to from here, but not nearly enough space today to write about them!

My first suggestion is to avoid blindly following a treatment algorithm that fails to support YOU to sensitively and reflexively offer treatments that fit for your patient.

My second is to avoid measuring the impact of what you do only at the end of treatment (or worse, not at all!). Measure often, and measure things that matter – either to how you get to the end outcome, or that the person values. Or both.

And third: Get reading outside of your profession. Dig into psychology (I especially recommend Hayes); look at sociology (try Jutel); anthropology (try Sarah Pink’s “Sensuous futures: re-thinking the concept of trust in design anthropology”); make 2022 the year that you lean into uncertainty. I know the past two years have been incredibly unsettling – but this is the perfect time to continue on this journey into new ideas, fresh concepts, and ambiguity.

Caneiro, J. P., Bunzli, S., & O’Sullivan, P. (2021). Beliefs about the body and pain: the critical role in musculoskeletal pain management. Braz J Phys Ther, 25(1), 17-29. https://doi.org/10.1016/j.bjpt.2020.06.003

Nicola, M., Correia, H., Ditchburn, G., & Drummond, P. (2021, Mar). Invalidation of chronic pain: a thematic analysis of pain narratives. Disability and Rehabilitation, 43(6), 861-869. https://doi.org/10.1080/09638288.2019.1636888

Sarah Pink (2021) Sensuous futures: re-thinking the concept of trust in design anthropology, The Senses and Society, 16:2, 193-202, DOI: 10.1080/17458927.2020.1858655

Sajid, I. M., Parkunan, A., & Frost, K. (2021, Jul). Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care. BMJ Open Quality, 10(3). https://doi.org/10.1136/bmjoq-2020-001287

Villanueva-Ruiz, Iker, Falla, Deborah, Lascurain-Aguirrebeña, Ion. (2021) Effectiveness of Specific Neck Exercise for Nonspecific Neck Pain; Usefulness of Strategies for Patient Selection and Tailored Exercise—A Systematic Review with Meta-Analysis, Physical Therapy, 2021;, pzab259, https://doi-org.cmezproxy.chmeds.ac.nz/10.1093/ptj/pzab259

de Zoete, R. M., Armfield, N. R., McAuley, J. H., Chen, K., & Sterling, M. (2020, Nov 2). Comparative effectiveness of physical exercise interventions for chronic non-specific neck pain: a systematic review with network meta-analysis of 40 randomised controlled trials. British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2020-102664

Making first contact: What to do with all that information! Part 5


People come to see us because they have a problem. So the formulation approach I’m taking today begins from “the problem” and works back and forward. It’s called a “network” model, and is something many of us do without knowing that’s what we’re doing. The network model can also be called a functional analysis where we’re looking at what happens, and what a person does, and the ongoing consequences or loops that occur over time.

Angelina comes to see you because her neck is very sore. She’s not sure why it’s sore, or what happened to start it off, but she thinks it could be after working for a week at a new workstation where she had to look to the right to read documents, and straight ahead to work on the main monitor. It’s been there for over six months, and she’s come to see you now because she has a week of annual leave and some time to spend on herself. She’s played with changing her pillows because her neck is more uncomfortable in the morning, and it gets painful towards the end of the day just before she heads to sleep. She’s having trouble turning her head to reverse down her driveway, and looking up is almost her least favourite thing. Her sleep is OK once she’s got off to sleep, but initially it takes her a while to fall asleep because she can’t get comfortable. Her partner is getting frustrated with her because she doesn’t want to kiss him because that means she has to look up, and she doesn’t sit on the couch with him any more because he likes to rest his arm around her shoulders – and that increases her pain. She’s irritable and finds herself getting snappy at him. Angelina is in her mid-50’s, otherwise well, but has always lived with various aches and pains, most of which she ignores until they go away. She has had a painful shoulder and lateral elbow pain that lasted for over a year, but has gradually settled down – she didn’t do anything special to manage those after having only a small response to a steroid injection into her shoulder.

Angelina’s main concern is to establish whether her neck pain is anything to worry about, or whether it’s just more of the same, like her shoulder and elbow pain. Her other focus is on getting a comfortable position to go off to sleep because she thinks this is adding to her problem.

OK, so we have a lot of information about Angelina, and we can organise this information in many different ways. Given her main concern is her prognosis and then her sleep, we need to make sure the way we organise the information offers a possible explanation – a hypothesis.

Take a look at the network diagram below to see how I’ve sketched the information out – you’ll note that at this point I’m not trying to develop a diagnosis, I’m focusing on the problem as she sees it.

The matrix I’ve used here comes from Hofmann, Hayes & Lorscheid (2021) Learning Process-based Therapy, published by Context Press, New Harbinger.

What I’ve done is summarised the processes that I think might be relevant to Angelina’s presentation, and drawn the relationships between various aspects that she’s described. You might organise this information differently – and I’d usually do this in collaboration with the person.

If you look closely at the networks, you’ll see several loops that likely will continue if something doesn’t change. One to spot is this set below:

You can see that she’s worrying about her sleep, doesn’t get comfortable as she goes off to sleep, feels fed up, has changed her pillow (in line with her self-concept of someone who is a practical person), and the whole network will likely remain winding itself up unless “something” comes to disrupt this pattern.

This set of relationships raises some factors we need to consider when we’re thinking of interventions. As someone who sees herself as a practical person who doesn’t seek healthcare often, and has had previous bouts of pain that settled without specific treatment (though she sought it for her shoulder), we could interpret this as meaning she doesn’t panic about her situation too much – but we could also wonder if, because she’s seeking help now, she’s seeing her problem as different from previous pain problems and maybe this one is worrying her more than she’s ready to acknowledge. Just to the right of the loop I’ve shown above, you’ll see a box where she says “I’ll deal with it if it doesn’t get in the way of my family and relationship”. This is important – it’s an expression of how she sees herself, an important value, and her motivation for seeking help is also framed in terms of maintaining her loving relationship. For this reason, I’d be looking for interventions that either won’t intrude on her family life and routines, or I’ll be looking for ways to frame whatever treatment suggestions I make in terms of how this will support her relationship.

By drawing a network diagram showing potential processes that might be influencing Angelina’s presentation, I’m answering my question “why is she presenting in this way at this time, and what might be maintaining her predicament” – she really wants a prognosis so she can establish a strategy to maintain her relationship with her family, keeps her “practical person” view of herself alive, and in a way that she can still fulfill her desire (and others’ expectations) to be fully productive at work.

I could analyse (or organise) Angelina’s information in lots of different ways. This is just one – and in some ways, the particular model I use to assemble her information is less important than ensuring Angelina is an equal partner in sketching out these relationships. I could have drawn the Tim Sharpe CBT model or used an ACT-based model and looked for patterns of psychological flexibility. I could have used Vlaeyen’s fear-avoidance model – and I’m sure there are plenty of others that might have been useful.
Irrespective of the model, what needs to be evident is using the information the person offers us, modifying the way we approach therapy as a result, and collaborating with the person to decide treatment priorities. This means we as clinicians need to be nimble, responsive, adaptive, and stop using treatment protocols! Any approach that suggests offering the same approach irrespective of the unique things influencing a person’s presentation is doomed to do a half-arsed job. These protocols might work for some, but they won’t work for all, and they may fail to address the real reason the person came to see us in the first place.

Making first contact: What to do with all that information! Part 4


In the previous few posts on what to do with all that assessment information I’ve talked about generating a formulation to guide treatment, and a little about how teams might work together to generate one. This post is a little different because I want to situation the discussion around the ultimate aim of therapy.

I usually work with people who have long-standing pain that hasn’t changed much and doesn’t seem to be disappearing. I’m not a nihilist, but I do wonder if clinicians are trying too hard to “change pain” when the body doesn’t seem to respond all that much to whatever we offer when it comes to musculoskeletal pain! Perhaps all we do is offer support to the person as their body gets on with the job of settling down…?

Anyway, my focus is to help people respond flexibly to what life has thrown at them – because while pain poses one of the greatest problems for people, often it’s not the pain as such but what we do to avoid or control pain – or, for that matter, what we do to avoid or control the results of avoiding or controlling pain. Confused? Let me unpack it a little with an example.

About the time I started this blog wayyyyy back in 2007 I had a concussion and developed post-concussion syndrome. I found it incredibly difficult to concentrate, find words, remember things, switch my attention from one thing to the next, and to deal with sensory overload. I was advised to rest and let my brain recover in its own time – all good. BUT I never expected that recovery to take almost two years! so I returned to part-time work after two weeks. In my head I was balancing my fatigue/headache/difficulty concentrating against my need to return to work, keep my employer happy, and do things that mattered.

If I flip that motivation on its head, I wanted to control both my symptoms and my fear/guilt of failing and perhaps losing my job/fear of sitting still and doing nothing/fear of feeling useless. After all, I was the vocational rehabilitation therapist for the service I worked in!

By trying to control my fear of not doing, I created a whole bunch of trouble for myself – I failed at controlling my symptoms – they grew out of hand and I eventually had to take some time off work, got quite depressed, and achieved exactly what I’d hope to avoid – needing to stay at home doing nothing!

When we think of ACT (Acceptance and Commitment Therapy) for living with pain, we often think of the person working hard to control or avoid pain and our focus is on helping them to be willing to make room for pain and begin doing things – and yet I’ve met a great many people who have got caught up in a vicious cycle of over-doing and under-doing, or who “get on with it” with gritted teeth and sheer determination! So one thing we can be looking for in our “first contact” is to identify how workable are the ways the person is approaching this time in their life, a time when they’re dealing with pain and life restrictions, stress, balancing priorities, working, family and so on.

ACT provides a series of six processes that together offer a way to be flexible about how we handle what life throws at us, and help us do what matters in our life. In an ACT formulation, we’re looking for unhelpful patterns that constrain how flexibly we can do what matters. Some of the patterns we might see could be:

  1. Unwillingness to stop and create space for pain so the person gets stuck acting as if there is no pain, trying to do everything the same way as normal but either getting fatigued and stressed and just hanging on in there, or doing short bursts of “normal” and crashing periodically.
  2. Getting stuck with rigid beliefs about what’s going on like thinking the pain must be able to be fixed and quickly, or that the pain is the most horrible disaster ever and everything about life must be shelved until it’s fixed.
  3. Comparing what he or she can currently do against a previous level of performance and being frustrated and angry because this doesn’t fit with how they see themselves, and especially thinking that this is the way it’s going to be forever…
  4. Losing sight of important things like being with family, or seeing friends because of feeling irritable, sad, thinking they don’t want to see them like this, not being able to do the things they used to do, waiting for the pain to reduce, or looking for the fix.
  5. Anticipating calamity or remembering disasters either about “the last time I tried doing this” or “because I saw this happen to [name]” and then feeling utterly stuck.
  6. Casting about being erratic or just not sticking to a plan, getting off track maybe because results don’t happen, or maybe because it’s something new and feels unfamiliar, or perhaps because someone else suggested another option…

There are always other ways people respond to pain, not just the patterns I’ve listed here, but these are some common ones I’ve seen. In ACT we’re looking for unworkable patterns that don’t lead the person towards being the kind of person they want to be, doing the things that bring meaning in their life.

When I’m jotting these things down, I’m looking to identify the core things the person isn’t willing to experience: thoughts, emotions, memories, situations. I want to understand what the person does to avoid them – like things the person has stopped doing or deliberately avoids, the ways the person avoids or controls emotions associated with that thing (like drinking more alcohol, zoning out, lashing out), and what I observe during our initial assessment like skipping over topics that feel uncomfortable.

I want to understand the cost or “unworkability” from the person’s perspective: what’s the impact of responding in these ways. I need to understand what’s going on in the person’s context – their family life, employment situation, influence of case manager or insurance/compensation, friendships. And I want to look at the factors that might be adding to the person’s inflexible responses, and these are myriad and often include what we do as clinicians – like being told to stop doing a favourite hobby “because it might be damaging” (how many people with low back pain have been told to stop running, stop fishing, stop dancing, stop lifting, to sit in a certain way, walk in a certain way, lift in a certain way, stop slouching, walk faster, slower…?). And of course I want to understand a person’s strengths: have they had an experience like this before? Do they have strong values? Have they succeeded in some area in life? What brings them joy and takes them into the zone? How have they modified the way they do things so they can do what matters?

I like to do this in collaboration with the person (how else could I do it?!) and to look at the good and not so good of everything they’ve done along with the context. Because one thing that always resonates with me is that people do what they do because it’s worked in the past. Always. At least once.

For more on ACT, you can’t go past the Association for Contextual Behavioural Science – https://contextualscience.org/

And Chapter 2 from Lance McCracken’s book Mindfulness and Acceptance in Behavioral Medicine, 2011, Context Press, New Harbinger:

Vowles, K.E, & Thompson, M. (2011). Acceptance and Commitment Therapy for Chronic Pain, pp31 – 60.

Making first contact: what to do with all that information! Part 3


In my last post I described the “4 P” model (sometimes called the 5P!) of formulation for pain. In today’s post I want to talk about an integrated approach for a team.

Teamwork in pain management is an enormous thing – IASP (International Association for the Study of Pain) endorses multidisciplinary (I prefer interprofessional) teamwork but gives little information on how teams best work together. In fact, research exploring teamwork processes in pain management is remarkably absent, even though there’s considerable research elsewhere in healthcare showing that effective teamwork is quite distinct from being an effective solo clinician. The processes of coming together, learning about one another and what each person and profession contributes, learning how to make decisions, how to negotiate differences of opinion, to trust one another: all of these have been explored in other health settings, but not in pain management ones. This matters because of all the areas in healthcare, pain management presents us with the most complex inter-related problems where the model of pain adopted by a team must be consistent or the person with pain will likely feel utterly confused.

’nuff said. Let’s take a look at a team mental model of pain, because this is where learning from one another and across professions becomes “live”.

The basic assumption for the whole team must be that pain is a multifactorial experience, influenced by (broadly) biological, psychological and social elements. In other words, a team won’t work well if some of the members think that pain can be “fixed” by addressing only one piece of the puzzle. Even in acute pain, the team needs to recognise that what a person believes is going on, the meaning they draw from the experience, the influence of others (the family, hospital staff, community) will make a difference to the person’s distress and disability. Context always matters and people always bring their previous experiences (either personal or drawing from what they’ve seen/heard from others, including media) with them when they’re in pain.

If the team takes this idea on board, then the weight that’s placed on the various factors contributing to distress and disability should be equal, at least initially. For example, although anxiety might be a key influence in one person’s pain experience, this shouldn’t be valued above possible biological factors. Each contributing factor needs to earn its way into the overall formulation, and it’s only from reviewing the formulation as a whole that it’s possible to determine where to begin with treatment.

This sounds complicated – and it can be in some cases! But it is really a mindset rather than being horribly complex. If we hold each piece of the puzzle lightly, look to the relationships between each piece, then we can begin to see how one factor influences another. And teams can, if they share their ideas, put the pieces together much more effectively than any single person can – even the person with pain.

Yes, the person with pain IS part of the team – always. How else will the team know they’ve been effective?

Teams form a mental model of what each other knows, what the team (as a whole) thinks matters, and who in the team might offer the mix of skills the person needs. This mental model doesn’t happen instantly: you can’t put six clinicians in a room and an hour later expect them to have a common understanding of pain, each other, and what the team can do. There’s good research showing that teams need time together – even virtual teams (Maynard & Gilson, 2021) – and that frequently changing team members reduces the teams’ effectiveness (Bedwell, 2019; Williams & Potts, 2010). Mental models emerge as teams share knowledge – the problem is that group members often share knowledge that is common, rather than unique information that could be the linchpin to an effective decision (Levine, 2018).

In my experience, and reading through an enormous amount of research, the most commonly adopted model in persistent pain management is a cognitive behavioural approach. Now this is not “CBT” the therapy, but instead an approach that recognises:

People are active processors of information and not passive reactors.

Thoughts (e.g., appraisals, expectations, and beliefs) can elicit and influence mood, affect physiological processes, have social consequences, and also serve as an impetus for behavior; conversely, mood, physiology, environmental factors, and behavior can influence the nature and content of thought processes.

• Behaviour is reciprocally determined by both individual and environmental factors.

People can learn more adaptive ways of thinking, feeling, and behaving.

People should be active collaborators in changing their maladaptive thoughts, feelings, and behaviour. (Turk & Flor, 2013)

We might disagree on how these points might be operationalised, and treated, but a team should have something like this as a critical understanding of how the factors influencing a person’s distress and disability might fit together.

I’ve written plenty of times about the formulation approach that I’ve often used – here and here – and I’ll show you another ACT-based formulation next week. In the meantime, perhaps it’s time to consider how well you and your team know one another, and consider whether you have enough trust in one another to debate issues (not people), bring unique information (rather than shared), and collaborate rather than compete?

Bedwell, W. L. (2019). Adaptive Team Performance: The Influence of Membership Fluidity on Shared Team Cognition. Frontiers of Psychology, 10, 2266. https://doi.org/10.3389/fpsyg.2019.02266

Levine, J. M. (2018). Socially-shared cognition and consensus in small groups. Current Opinion in Psychology, 23, 52-56. https://doi.org/10.1016/j.copsyc.2017.12.003

Maynard, M. T., & Gilson, L. L. (2021). Getting to know you: The importance of familiarity in virtual teams. Organizational Dynamics, 50(1). https://doi.org/10.1016/j.orgdyn.2021.100844

Turk, D. C., & Flor, H. (2013). The Cognitive-Behavioral Approach to Pain Management. In S. B. McMahon, M. Koltzenburg, I. Tracey, & D. C. Turk (Eds.), Wall and Melzack’s Textbook of Pain (6 ed., pp. 592-602). Saunders. https://doi.org/10.1016/b978-0-7020-4059-7.00043-7

Williams, A. C., & Potts, H. W. (2010). Group membership and staff turnover affect outcomes in group CBT for persistent pain. Pain, 148(3), 481-486. https://doi.org/http://dx.doi.org/10.1016/j.pain.2009.12.011

Making first contact: what to do with all that information! part 1


Last post I wrote I said I’d continue with a process for structuring and synthesising the information we gather from the initial contact we make with the person. This process is integral to clinical reasoning, and somewhat surprisingly, there’s not a great deal of research to give us guidance on the best way to do this – and it’s even more challenging for those of us working in an interprofessional team setting, where different professions, personalities and assumptions are part of it.

If we work backwards from the end point, we might get some clues about what to do. Our end point is to help this person do what matters in their life. All our efforts are pitched towards this end. Because people are unique, what matters to them in their context is likely to be unique, and because pain and disability are multifactorial, there will be many paths to help that person get to where they want to be. Algorithms are designed to make the task of clinical reasoning a lot simpler, but there are some enormous assumptions associated with using an algorithmic approach: that we know the important factors associated with change; that we can address those factors successfully; that each person has the same set of factors evident in their presentation… and frankly, I don’t think I’ve seen strong evidence of any of these when it comes to pain.

Clinical reasoning is about a series of cause and effect assumptions. We have limited certainty about much of pain and the relationships between factors we think influence pain and disability. We’ve also been holding on to some outdated and inaccurate assumptions about the way grouped data applies to the one person in front of us. Prof Steven Hayes points out that as early as the 1940’s (perhaps earlier) we knew that there was no such thing as “the average man” (or woman!). This emerged in human factors/ergonomic design, where using the average/median of all the anthropomorphic measures we have does not help us design a workstation or control panel that will work for all people. Instead, we have to design to suit the minimum and maximum clearances and reach, and add adjustability so that everyone can make their workstation work for them. The assumptions used in early application of anthropometrics were that everyone is essentially similar: it’s ergodic theory (https://en.wikipedia.org/wiki/Ergodic_theory). Ergodic theory holds two assumptions that don’t work well for people: all the events in ergodic theory must be stationary, and all elements in the mathematical model must obey they same rules.

When we work with people, we know their presentation is a series of responses that continue to move over time. Their presentation is dynamic, changing all the time but exhibiting similarities in terms of processes. And we also know that different factors influencing a person’s presentation don’t always follow the same patterns. There are things like legislation, unexpected events like trauma or earthquakes, biases and stigma – and these don’t affect everyone equally.

One solution is to acknowledge this and instead look to the particular, applying to this person at this time – idiographic, or as Hayes calls it “idionomic.” A network diagram, showing the dynamic hypothesised relationships between contributing factors can help us generate ways to influence change. And the diagram should “make sense”, or explain, what’s going on to all the team members including the person with pain.

I’ve used a cognitive behavioural formulation model for many years now (see here and here – and use the search bar for “case formulation” for a list of the posts I’ve made over the years). The assumptions in this approach are that directly influencing the thoughts a person has about their pain will have flow-on effects on pain, emotions, actions and physiological arousal. And to a certain extent this is true – plus, there are some things we cannot readily change, such as family responses or previous trauma. But the flexibility of a formulation approach is that we can include anything that’s relevant including strategies the person has used in response to those things that can’t be changed.

The biggest assumption that I make is that pain on its own isn’t the main problem. It’s how we respond to pain, what we think is going on, how we react to the things we do in response to pain (or things we don’t do but think we should), and how the people around us influence us, that help determine how much pain bothers us. There is plenty of research showing that people willingly do painful things if they do so for important reasons. Some everyday examples include ritual tattoos, endurance sports, boxing and martial arts, eating very spicy chilli. Of course, these aren’t examples of persistent pain – and yet, people with persistent pain started with acute pain. There are some highly influential factors that are present from the outset and these do have an impact on how we respond to pain, especially as time goes on.

The second assumption I make is that everyone is able to learn how to do things differently, and in doing these, we can develop a different relationship with pain and become less distressed and disabled by our experience. This doesn’t mean (a) that we should just give up and be resigned to a life of pain and not seek treatment to reduce pain; or (b) that we should just ignore pain and grit teeth and bear it. It also doesn’t mean that we will feel happy about pain, or that life goes on as normal. But it does mean that we can make some room for pain to be present, and move towards doing what matters rather than having pain become some invisible barrier to a life worth living.

Exactly what we include, and how the relationships between each factor play out is the topic for next weeks’ blog – stay in touch!

Adam’s slow recovery


Not long ago I wrote about Adam Meakins back pain, and the astonishing response he’s had from fellow clinicians as he’s documented his recovery. Sadly, the polarised views of how therapists should approach a person with low back pain show me just how appallingly badly we adhere to low back pain guidelines… and worse, the kind of language and attitudes shown to a colleague who knows what he’s doing, demonstrates why change is so very slow.

What do I mean? Well, Adam has been following evidence-based low back pain guidelines that haven’t really changed a great deal since the advent of New Zealand’s “Yellow Flags” and guide to low back pain published waaaaay back in 1997. I’ve jumped to the NICE guidelines, as an example of one guideline, but you could look to many others.

NICE suggest these steps:

Assess for alternative diagnoses – in particular, “cancer, infection, trauma or inflammatory disease such as spondyloarthritis”

Risk assessment – basically, sorting people into those who are pretty OK with their pain, non-distressed and recommending those people receive “reassurance, advice to keep active and guidance on self-management.”

If Adam was distressed, or had a whole lot of risk factors for ongoing disability, then he might benefit from “more complex and intensive support for people with low back pain.” And yes, this mentions exercise programmes, manual therapy, psychological approaches.

Imaging – is not recommended, with imaging only used if the result is likely to change management.

Treatment – self-management, no orthotics or belts, no traction, and only offer manual therapy as part of an overall package that includes exercise.

No acupuncture, no electrotherapy.

Maybe use psychological therapies in conjunction with exercise.

Add in some NSAIDs

And don’t do much else…

In other words – exactly what Adam has been doing.

Why are there so many clinicians offering unsolicited opinions, without examining Adam, and without listening to his preferences, and without referring to the evidence?

What does this say about our clinical practice? What does it say about our confidence? What does it say about knowledge translation?

Most of all, what does this DO to the people we hope to help?

Seriously, folks. Watching the responses gives me nightmares.

I’ve been working in this field for 30 years now, and saying essentially the same thing about low back pain management for most of those years. I worry that an enormous business is built around scaring people, offering treatments with limited effect, for a condition that is common and responds well to doing normal movements.

In fact, one gripe I do have with the NICE guidelines is that they utterly and completely ignore daily life activities that a person needs to return to, and quickly. There’s nothing on managing sleep – and Adam’s described really rotten sleep until two days ago. There’s nothing on how to manage washing yourself, driving your car, sitting at a desk, doing the grocery shopping, preparing a meal, care for kids (or older parents) – absolutely nothing on the daily life activities that people need and want to do.

But, then again, I would say this – occupational therapists are the profession concerned about daily doing. The context of every day life. Knowledge translation from clinic/gym/exercise to what people actually do in their daily routines. It looks oh so simple – until you have to do it.

Back to Adam’s slow recovery. As I’ve watched Adam’s videos, I’m struck with the thought that many people just don’t know what to say – and so offer advice because that’s one way to deal with their own disquiet at helplessness. Clinicians, we need to develop better skills at managing our OWN emotional responses. We need to develop greater skills at sitting with our uncertainty. We need to stop leaping in with unsolicited advice that we offer just because we’re not comfortable doing nothing.

Could we just, for a moment, stop thinking about our reactions – and listen to what Adam (and I’m sure a whole bunch of our patients, too) says he wants? Listening means stopping that inner voice that’s got the “good” advice. It means really hearing what a person says. And only formulating a verbal response after we’ve digested the meaning the person is trying to convey.

Kia kaha Adam. You’re a brave man, a strong man, and I have much respect for you.

Why I don’t trust my clinical reasoning: and why this matters


“See someone experienced” I hear people with pain say. “They’ll know what’s wrong with you.”

Well, based on the research I’ve read, I wouldn’t be so sure. In fact, I’m certain my own clinical reasoning is biased, prone to errors that I don’t notice, and influenced by factors that most clinicians would be horrified to think they, too, were influenced by.

Let me give you a few to ponder:

I’m interested in women and pain – and there’s a lot of evidence showing that women’s pain doesn’t get the same kind of diagnostic and management attention as men. Now part of this is due to the inherent bias in research where experimental studies often rely on male rats, mice and undergraduates because they don’t have those pesky hormonal fluctuations each month. Even volunteering to take part in a pain study has been found to be biased – people who volunteer have been shown to be more risk-taking and more extraverted (Skinner, 1982) – though to be fair this is an old study!

But contextual factors such as gender, distress and even the supposed diagnosis do influence judgements about pain intensity (Bernardes & Lima, 2011) including potentially life-threatening chest pain (Keogh, Hamid, Hamid & Ellery, 2004). Gender bias has been identified in a large literature review of gender bias in healthcare and gendered norms towards people with chronic pain (Samulowitz, Gremyr, Eriksson & Hensing, 2018).

And if you have the misfortune to be judged to have low trustworthiness and you’re a woman, you’re more likely to be thought to have less pain and to be exaggerating your pain (Schafer, Prkachin, Kaseweter & Williams, 2016). Beware if you’re overweight and a woman because you’ll be likely judged as having less intense pain, the pain will be judged as less interfering, more exaggerated and less related to “medical” factors – women’s pain in particular is likely to be judged as “psychological” and given psychological therapy rather than other treatments (Miller, Allison, Trost, De Ruddere, Wheelis, Goubert & Hirsch, 2018).

The weird thing is that the clinicians involved in these studies were oblivious to their bias. And let’s not even go there with people of colour or so-called “minority” groups such as LGBTQI.

So as clinicians our initial impressions of a person can lead us astray – and I haven’t even started with the contribution experience has on clinical reasoning. Let me go there then!

Something that cognitive psychologists have explored for some years now, is the type of thinking that we draw on for clinical reasoning. System one is “fast reasoning” – where we rapidly, instinctively and emotionally make decisions on the fly. Kahneman (1982) first described these two processes and noted that fast thinking gets better with rehearsal and are helpful especially for skilled clinicians needing to make decisions in pressured contexts, and draw on “pattern recognition” – or to be precise, draw on deviation from a recognised pattern (Preisz, 2019). System two is “slow reasoning” where decisions are made in a considered way, are not influenced by emotional state, and can be thought of as “rational.” Slow thinking is most useful where the situation is complex, where decisions need to weigh multiple pieces of information, where the situation might be novel, or where, for persistent pain in particular, there are multiple disease processes occurring.

OK, so we should choose system two, right? Not so fast! System one is hard to switch from – it’s what underpins “intuition” or “hunches” – and it gets more entrenched the more experienced we are. According to Preisz (2019), system one “seeks to form a coherent, plausible story by relying on association, memories, pattern matching and assumption.”

Why is system one thinking not so great? Well, we’re human. We’re human in the way we respond to any reasoning situation – we anchor on the first and most “plausible” ideas, and these might be unrelated to the actual presentation we see. For example, if we’ve been reading a journal article on a new treatment and its indications, it’s amazing how many people will present with those exact same indications in the next week! This is availability bias or anchoring bias. We’re also inclined to believe our own patients and judgements are different from “those people” – especially “those people” who might respond best to clinical guidelines. This means that even in the face of clear-cut research showing the lack of effects of knee arthroscopy (Brignardello-Petersen, Guyatt, Buchbinder, Poolman et al, 2017) an orthopaedic surgeon I know argued that “we choose our patients very carefully” – essentially arguing that his patients are different, and this approach is the best one.

If experienced clinicians find it hard to “unstick” from old practice, or move quickly to “intuitive” reasoning (even if it’s called “pattern recognition”), and if we all find it hard to recognise when we’re biased, or even that we are biased, what on earth should we do? All us old hands should retire maybe? All follow algorithms and not use “clinical judgement”? Take the “human” out of clinical management and use AI?

Some of these things might work. There is evidence that algorithms and AI can offer effective and (perhaps) less biased diagnosis and management than our unaided human brain (Kadhim, 2018) but there are also studies showing that direct comparisons between decision aids and clinical judgement are rarely made, and those that have been carried out don’t show superior results (Schriger, Elder, & Cooper, 2017). But watch this space: AI is a rapidly developing area and I predict greater use of this over time.

The risk with decision aids is – garbage in, garbage out. If we look at existing research we can see that male, pale and potentially stale dominates: this doesn’t bode well for people of colour, for women, for the unique and idiosyncratic combination of diseases a person can have, or for untangling the impact of disease on the person – in other words, disability and illness.

So, to summarise. We are all biased, and it’s best to acknowledge this to ourselves upfront and personal. We can then turn to strategies that may reduce the biases. For me, the one I turn to most often is a case formulation, using information gathered from a semi-structured interview and a standard set of questionnaires. These have been developed a priori so my biases in information gathering are limited. By taking time to follow a case formulation, my thinking is slowed to that more deliberative system two. At least some of the biases I know I’m prone to are mitigated.

And yet, I know I am biased. That’s why I use a supervision relationship to help me identify those biases, to be challenged and to reflect.

Bernardes, S. F., & Lima, M. L. (2011, Dec). A contextual approach on sex-related biases in pain judgements: The moderator effects of evidence of pathology and patients’ distress cues on nurses’ judgements of chronic low-back pain. Psychology & Health, 26(12), 1642-1658.

Brignardello-Petersen, R., Guyatt, G. H., Buchbinder, R., Poolman, R. W., Schandelmaier, S., Chang, Y., Sadeghirad, B., Evaniew, N., & Vandvik, P. O. (2017, May 11). Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ Open, 7(5), e016114. https://doi.org/10.1136/bmjopen-2017-016114

Kadhim, M. A. (2018). FNDSB: A fuzzy-neuro decision support system for back pain diagnosis. Cognitive Systems Research, 52, 691-700. https://doi.org/10.1016/j.cogsys.2018.08.021

Kahneman, D., Slovic, S. P., Slovic, P., & Tversky, A. (1982). Judgment under uncertainty: Heuristics and biases. Cambridge university press.

Keogh, E., Hamid, R., Hamid, S., & Ellery, D. (2004). Investigating the effect of anxiety sensitivity, gender and negative interpretative bias on the perception of chest pain. Pain, 111(1-2), 209-217.

Miller, M. M., Allison, A., Trost, Z., De Ruddere, L., Wheelis, T., Goubert, L., & Hirsh, A. T. (2018, Jan). Differential Effect of Patient Weight on Pain-Related Judgements About Male and Female Chronic Low Back Pain Patients. J Pain, 19(1), 57-66. https://doi.org/10.1016/j.jpain.2017.09.001

Preisz, A. (2019, Jun). Fast and slow thinking; and the problem of conflating clinical reasoning and ethical deliberation in acute decision-making. Journal of Paediatric Child Health, 55(6), 621-624. https://doi.org/10.1111/jpc.14447

Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). “Brave Men” and “Emotional Women”: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain. Pain Research and Management, 2018.

Schafer, G., Prkachin, K. M., Kaseweter, K. A., & Williams, A. C. (2016, Aug). Health care providers’ judgments in chronic pain: the influence of gender and trustworthiness. Pain, 157(8), 1618-1625. https://doi.org/10.1097/j.pain.0000000000000536

Schriger, D. L., Elder, J. W., & Cooper, R. J. (2017, Sep). Structured Clinical Decision Aids Are Seldom Compared With Subjective Physician Judgment, and Are Seldom Superior. Ann Emerg Med, 70(3), 338-344 e333. https://doi.org/10.1016/j.annemergmed.2016.12.004

Skinner, N. F. (1982, 1982/12/01). Personality characteristics of volunteers for painful experiments. Bulletin of the Psychonomic Society, 20(6), 299-300. https://doi.org/10.3758/BF03330107

From the particular to the general – Clinical reasoning in the real world


From the particular to the general –
Clinical reasoning in the real world

I make no secret of my adherence to evidence-based healthcare. I think using research-based treatments, choosing from those known to be effective in a particular group of people in a specific context helps provide better healthcare. But I also recognise problems with this approach: people in clinical practice do not look like the “average” patient. That means using a cookie cutter, or algorithm as a way to reduce uncertainty in practice doesn’t, in my humble opinion, do much for the unique person in front of me.

I’ve been reading Trisha Greenhalgh’s recent paper “Of lamp posts, keys, and fabled drunkards: A perspectival tale of 4 guidelines”, where she describes her experience of receiving treatment based on the original description given for her “fall”. The “fall” was a high-impact cycle accident with subsequent limb fractures, and at age 55 years, she was offered a “falls prevention” treatment because she’d been considered “an older person with a fall”. Great guidelines practice – wrong application!

Greenhalgh goes on to say “we should avoid using evidence-based guidelines in the manner of the fabled drunkard who searched under the lamp post for his keys because that was where the light was – even though he knew he’d lost his key somewhere else”

Greenhalgh (2018), quoting Sir John Grimley Evans

When someone comes to see us in the clinic, our first step is to ask “what can I do for you?” or words to that effect. What we’re looking for is the person’s “presenting symptoms”, with some indication of the problem we’re dealing with. Depending on our clinical model, we may be looking for a diagnostic label “rheumatoid arthritis” or a problem “not sleeping until three hours after I go to bed”.

What we do next is crucial: We begin by asking more questions… but when we do, what questions do we ask?

Do we follow a linear pattern recognition path, where we hypothesise that “rheumatoid arthritis” is the problem and work to confirm our hypothesis?

Our questions might therefore be: “tell me about your hands, where do they hurt?” and we’ll be looking for bilateral swelling and perhaps fatigue and family history and any previous episodes.

Or do we expand the range of questions, and try to understand the path this person took to seek help: How did you decide to come and see me now? Why me? Why now?

Our questions might then be: “what do you think is going on? what’s bothering you so much?”

Different narratives for different purposes

Greenhalgh reminds us of Lonergan (a Canadian philosopher), as described by Engebretsen and colleagues (2015), where clinical enquiry is described as a complicated process (sure is!) of 4 overlapping, intertwined phases: (a) data collection – of self reported sensations, observations, otherwise known as “something is wrong and needs explaining”; (b) data interpreting “what might this mean?” by synthesising the data and working to recognise possible answers, or understanding; (c) weighing up alternative interpretations by judging; and (d) deciding what to do next, “what is the right thing to do”, or deliberation.

Engebretsen and colleagues emphasise the need to work from information from the individual to general models or diagnoses (I’d call this abductive reasoning), and argue that this process in the clinic should be “reflexive” and “informed by scientific evidence” but warn that scientific evidence can’t be replaced simply by reflexive approaches.

The reason for conceptualising clinical reasoning in this way is that a narrative primarily based on confirming a suspicion will likely reduce the number of options, narrow the range of options considered, and if it’s focused on diagnosis, may well over-ride the person’s main concern. A person may seek help, not because he or she wants a name or even treatment, but because of worries about work, the impact on family, or fears it could be something awful. And without directly addressing those main concerns, all the evidence-based treatments in the world will not help.

Guidelines and algorithms

Guidelines, as many people know, are an amalgamation of RCT’s and usually assembled by an esteemed group of experts in an attempt to reduce unintended consequences of following poorly reasoned treatment. They’re supposed to be used to guide treatment,  supporting clinical reasoning with options that, within a particular population, should optimise outcomes.

Algorithms are also assembled by experts and aim to provide a clinical decision-making process where, by following the decision tree, clinicians end up providing appropriate and effective treatment.

I suppose as a rather idiosyncratic and noncomformist individual, I’ve bitterly complained that algorithms fail to acknowledge the individual; they simplify the clinical reasoning process to the point where the clinician may not have to think critically about why they’re suggesting what they’re suggesting. At the same time I’ve been an advocate of guidelines – can I be this contrary?!

Here’s the thing: if we put guidelines in their rightful place, as a support or guide to help clinicians choose useful treatment options, they’re helpful. They’re not intended to be applied without first carefully assessing the person – listening to their story, following the four-step process of data collection, data interpretation, judging alternatives, and deciding on what to do.

Algorithms are also intended to support clinical decision-making, but not replace it! I think, however, that algorithms are more readily followed… it’s temptingly easy to go “yes” “no” and make a choice by following the algorithm rather than going back to the complex and messy business of obtaining, synthesising, judging and deciding.

Perhaps it’s time to replace the term “subjective” in our assessment process. Subjective has notions of “biased”, “emotional”, “irrational”; while objective implies “impartial”, “neutral”, “dispassionate”, “rational”. Perhaps if we replaced these terms with the more neutral terms “data collection” or “interview and clinical testing” we might treat what the person says as the specific – and only then move to the general to see if the general fits the specific, not the other way around.

 

Engebretsen, E., Vøllestad, N. K., Wahl, A. K., Robinson, H. S., & Heggen, K. (2015). Unpacking the process of interpretation in evidence‐based decision making. Journal of Evaluation in Clinical Practice, 21(3), 529-531.

Greenhalgh, T. (2018). Of lamp posts, keys, and fabled drunkards: A perspectival tale of 4 guidelines. Journal of Evaluation in Clinical Practice, 24(5), 1132-1138. doi:doi:10.1111/jep.12925

Each time we face our fear, we gain strength, courage, and confidence in the doing – Theodore Roosevelt


I’m not certain Theodore Roosevelt actually said that – but who cares?! It’s a great statement. For the person living with persistent pain, though, it can be the last thing you want to hear. After all, it’s tough enough getting up and just doing the normal things let alone challenge yourself! So… how can a health professional help?

Let’s briefly recap. Self efficacy is the confidence I can do something successfully if I wanted to. It’s a robust predictor of many health behaviours including exercise, stopping smoking, eating healthily and coping well with persistent pain (Jackson, Wang, Wang & Fan, 2014; Williams & Rhodes, 2016). It was first introduced as a concept by Bandura as part of his theoretical model of behaviour change, and further discussed in an experimental study in a paper investigating systematic desensitisation processes, arguing that this approach to treatment created and strengthened expectations of personal efficacy (Bandura & Adams, 1977). Bandura argued that people develop a sense (expectation) of self efficacy from their own performance, watching others succeed, being persuaded by someone that yes indeed you have the skills to achieve, and also awareness of physiological arousal from which people can judge their own level of anxiety.

Self efficacy is more than a simple “general confidence” construct, however. It’s far more selective than this. For example, although I believe I can successfully dance in my lounge with no-one there and the curtains closed, this does not translate to me dancing on a stage on my own in the spotlights with an audience watching! Self efficacy refers to confidence to succeed and produce the outcome I desire in a given context – and that’s extremely important for pain management, and in particular, exercise for people experiencing pain.

How does self efficacy improve outcomes? There are at least two ways: (1) through the actions taken to manage or control pain (for example, gradually increasing activity levels but not doing too much) and (2) managing the situations associated with pain (for example, people with low self efficacy may avoid activities that increase pain, or cope by using more medication (Jackson, Wang, Wang & Fan, 2014).

To examine how self efficacy affects outcomes, Jackson and colleagues (2014) conducted a meta-analysis of papers examining this variable along with other important outcomes. Overall effect sizes for relationships between self efficacy and all chronic pain outcomes were medium and highly significant. This is really important stuff – we don’t find all that many studies where a single variable has this much predictive power!

As a moderator, the adjusted overall effect size (r=.50) of self efficacy and impairment was larger than the average effect sizes of meta-analyses on relations between disability and fear-avoidance beliefs, and pain as a threat for future damage and challenge for future opportunities. Self efficacy has stronger links with impairment than cognitive factors such as fear-avoidance beliefs and primary appraisals of pain (Jackson, Wang, Wang & Fan, 2014).  Age and duration of pain were the strongest moderators of these associations and suggest that reduced self-efficacy can become entrenched over time. In other words – as time passes, people experience fewer opportunities for success and begin to expect they won’t ever manage their pain well.

An important point is made by these authors: how we measure self efficacy matters. They found that self efficacy measures tapping “confidence in the capacity to function despite pain” had
stronger associations with impairment than did those assessing confidence in controlling pain or managing other symptoms.

Bolstering self efficacy – not just about telling people they can do it!

Given that self efficacy is domain-specific, or a construct that refers to confidence to do actions that lead to success in specified situations, here are a few of my questions:

  • Why are most people attending pain management programmes provided with gym-based programmes that don’t look at lot like the kinds of things people have to do in daily life? It’s like there’s an expectation that “doing exercise” – any exercise – is enough to improve a person’s capabilities.

    BUT while this might increase my confidence to (a) do exercise and (b) do it in a gym – but does it mean I’ll be more confident to return to work? Or do my housework?

  • How often are people attending gyms told to “push on”, or to “stop if it hurts”? And what effect does this have on people?

If their confidence is low, being told “just do it” is NOT likely to work. People need to experience that it’s possible to do things despite pain – and I think, to be able to handle a flare-up successfully. Now this is not going to happen if we adopt the line that getting rid of all pain is the aim, and that flare-ups should be avoided. If we want people to deal successfully with the inevitable flare-ups that occur, especially with low back pain, then we need to (a) be gentle, and grade the activities in an appropriate way (b) have some “ways of coping” we can introduce to people rather than simply telling them they can cope or reducing the demands (c) have other people around them also coping well (and that includes us health professionals)

  • Ensure we attribute change to the person, not to us.

That’s right: not to our sparkling personality, not to our special exercises, not to the machines we use, not to the techniques we have – you get the drift? Progress must be attributed to the person and his or her skills and perseverance. Because, seriously, all this arguing over which exercise regime is best doesn’t stack up when it’s actually self efficacy that predicts a good outcome.

And for case managers who may read this: just because someone has successfully completed an exercise programme, or a vocational programme with exercise as a component, this does not mean the person can manage successfully at work. Well, they may manage – but they may utterly lack confidence that they can. Context matters.

 

Bandura, A., & Adams, N. E. (1977). Analysis of self-efficacy theory of behavioral change. Cognitive Therapy and Research, 1(4), 287-310.

Estlander AM, Takala EP, Viikari-Juntura E., (1998). Do psychological factors predict changes in musculoskeletal pain? A prospective, two-year follow-up study of a working population. Journal of Occupational and Environmental Medicine 40:445-453

Jackson, T., Wang, Y., Wang, Y., & Fan, H. (2014). Self-efficacy and chronic pain outcomes: A meta-analytic review. The Journal of Pain, 15(8), 800-814.

Williams, D. M., & Rhodes, R. E. (2016). The confounded self-efficacy construct: Conceptual analysis and recommendations for future research. Health Psychology Review, 10(2), 113-128.

The confidence that you’ll succeed if you try…


Self efficacy. It’s a word bandied about a lot in pain management, and for a group of clinicians in NZ, it’s been a shock to find out that – oh no! They’re not supporting self efficacy with their patients very much! It means “confidence that if I do this under these conditions, I’ll be successful”.

Self efficacy is part of Bandura’s social learning theory (click here for the Wikipedia entry) where he proposed that much of psychological treatment is driven by a common underlying mechanism: to create and strengthen expectations of personal effectiveness. Bandura recognised that we don’t always have to personally experiment through trial and error in order to learn. Self efficacy expectations were thought to develop from personal experience (let me do, and I’ll learn how); watching other people try (show me, and I’ll see if you succeed, then I’ll copy you); verbal persuasion that aims to convince that you have the capabilities to manage successfully (encourage me, let me know I can, and I’ll try); and how physiologically aroused or alert you are (if I feel confident inside, I’ll try but if I feel anxious or stressed I’m less inclined to) (Bandura, 1977).

Bandura and colleagues established that “different treatment approaches alter expectations of personal efficacy, and the more dependable the source of efficacy information, the greater are the changes in self-efficacy.” (Bandura & Adams, 1977, p. 288). The conclusions drawn from this mean that treatments where people DO and succeed are more effective at enhancing their belief in self efficacy, while watching others, or being told how to do something are far weaker at building this effect.

Bandura began working on this theory while pondering how psychological treatments, particularly for systematic desensitisation or graded exposure, generated their effects. Systematic desensitisation aimed to reduce arousal levels and thus avoidance while being in a relaxed state – therefore the person is exposed to increasingly “aversive” stimuli (stimuli you want to avoid) while remaining calm and relaxed. Bandura thought that there were other factors involved in avoidance behaviour, developing his theory that expectations of negative consequences alone can generate fear and defensive behaviour and that this isn’t necessarily reflected in autonomic arousal and actions. Bandura hypothesised that reducing physiological arousal improved performance not by eliminating a drive to escape – but instead by increasing the confidence that the person can successfully manage the situation.

For parents, the idea that if you believe you can do what you set out to do, is embodied in the little book “The Little Engine That Could” (Piper, 1930/1989). Remember? The little engine that couldn’t because all the bigger engines said so, but then tried and tried and believed he could – and he did!

So, what does this have to do with pain management?

Let’s paint a scenario. Allan comes to see a hands-on therapist because he has a sore back. He believes that hands-on therapy is the thing, because others have said it’s really good. He goes, gets his treatment and wow! Things improve! The next time he has a sore back (because, you know, it almost always comes back) what does he do? Well, on the basis of his past experience, he heads to his hands-on therapist, because he’s confident this will help his pain. The problem is, his therapist has moved town. He’s a bit stuck now because in his town there are not many therapists doing this particular kind of treatment – what does he do? He doesn’t believe that anyone else can help, and he has no belief that he can manage by himself. He has little self efficacy for managing his own back pain.

Self efficacy is not about whether a person can do certain movements, it’s about believing that the person can organise skills to achieve goals within a changing context – not just what I will do, under duress, but what I can do, what I’m capable of doing, and what I say I’ll probably do.

Self efficacy is not a belief that a specific behaviour will lead to a certain outcome in a certain situation, it’s the belief that I can perform that behaviour to produce the outcome.

So, self efficacy isn’t a generalised attitude – it’s a specific belief about certain actions, certain outcomes in certain situations. It’s not a personality trait like hardiness, or resilience, or general confidence or self-esteem, it’s about being confident that I can generate a solution to a problem in a particular part of my life.

The times when we’re least confident are often when we’re facing a new experience, or we’ve had a bad experience previously. Particularly if we’ve seen other people fail at the same thing, or succeed but do so with much fear and loathing. In the case of pain, there are ample opportunities to have a bad experience in the past, and to learn from other people around us that – oooh back pain is something to be afraid of, and you can’t manage it alone – you need to get help from someone else. Consequently, many people have very low self efficacy for successfully dealing with a bout of low back pain.

And health professionals: we can foster this.

How? By implying that success is due to what we do, rather than being a natural process of recovery. By suggesting it’s something about our “magic hands” or pills, or injections or surgery or special exercises, or “using the core correctly”. In doing so, we’re generating a belief that the person cannot manage alone. That it’s not what the person does, but the magic hands, pills, injections, surgery, special exercises or using the core…

Damush, Kroenke, Bair, Wu, Tu, Krebs and Poleshuck (2016) found that self management approaches to pain increase self efficacy, self management actions, and reduced pain intensity and depression in a group of community patients with chronic musculoskeletal pain and depression. A typically tough group to work with because confidence to succeed at anything is pretty low in depression. Self management aims to ensure the credit for recovery lies with the person doing things that help – creating and supporting a belief that the person has the capability to successfully manage their situation. The techniques? Simple strengthening and stretching exercises, progressive muscle relaxation, and visualisation, in a group setting. Strategies that typically don’t need technology, but do provide support. Information about the natural history of recovery was included – so people were given realistic and optimistic information about their recovery, whether it meant pain reduction, or not. The usual goal setting, problem-solving, and positive self talk were encouraged, and people set goals each week to achieve – maybe based on something from the session, or something the person wanted to do for themselves.

This is not a high-tech approach. This is simple, straightforward pain management as it has been done for years (right back as far as the mid-1970’s and Sternberg!). And through it, these people become increasingly confident that they could successfully manage their own mood and pain independently. As a business model it’s probably not the best for repeat business – but oh how good for those participants who could go away and live their lives without having to think of themselves as patients.

More on self efficacy in the next couple of weeks – we can help people to become confident that they can succeed at managing their pain if it should happen again.

 

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review,  84, 191-215.

Bandura, A., & Adams, N. E. (1977). Analysis of self-efficacy theory of behavioral change. Cognitive Therapy and Research, 1(4), 287-310.

Damush, T., Kroenke, K., Bair, M., Wu, J., Tu, W., Krebs, E., & Poleshuck, E. (2016). Pain self‐management training increases self‐efficacy, self‐management behaviours and pain and depression outcomes. European Journal of Pain, 20(7), 1070-1078.

Maddux, J. E. (2016). Self-efficacy Interpersonal and intrapersonal expectancies (pp. 55-60): Routledge.