Interdisciplinary? Or serial monotherapy?

Teamwork can be a mixed blessing. Knowing that other members of the team are working alongside you is wonderful but a team that’s not functioning well can be a destructive animal that can tear itself apart.

I’ll begin with some definitions:

Monotherapy means having a single type of intervention. This is useful for acute problems, or very simple problems. For example, if I sprain my ankle, I might need to see a physiotherapist to improve my mobility. In New Zealand, the ACC-funded Psychological Pain Management sessions are a good example.

Multidisciplinary means more than one discipline working with an individual, but not necessarily working with one another. This is useful where coordination is difficult, such as in a busy Emergency Department, or where the problem doesn’t need collaboration, for example possible neuropathic pain post-deQuervains release where the patient needs physiotherapy, medication and help to return to work. In New Zealand, a good number of the ACC-funded Activity Focused Programmes run this way.

There may be a physiotherapist, occupational therapist and psychologist working with the same patient, and although they may share notes their interventions remain focused on their individual disciplinary contributions. The way the disciplines conceptualise the patient’s problems remains within the individual professional’s model. So the physiotherapist might focus on biomechanics and strength, the occupational therapist may consider how the individual manages his or her driving and work tasks, while the psychologist may consider the person’s thoughts and beliefs about pain. Although the disciplines acknowledge one another’s contribution, clinicians focus on their own intervention and clinical reasoning with little reference in their own sessions to anything another clinician has looked at.

Interdisciplinary means professionals from a variety of disciplines working together in an integrated way with joint goals and ongoing communication. A common model is used, joint goals developed, clinicians contribute in the area/s most needed by the patient/client, share session content and communicate regularly so other team members can provide the same message in their sessions. This might mean the physiotherapist uses cognitive reframing during exercises, the occupational therapist discusses medications and side-effects during activity planning sessions, the psychologist talks about exercise timing and intensity during a session using biofeedback.

The popularity of interdisciplinary pain management has waned somewhat since the days of the mid-1980’s to late 1990’s. Health administrators look askance at large teams because they seem expensive, time is tied up in meetings, there are turf wars, people talk about role conflict and role confusion, time is needed for induction, and there’s always a suspicion that having a team leads to over-servicing and too many cooks spoiling the broth. I’ve watched the integrated interdisciplinary approach gradually being replaced by a multidisciplinary approach, although the language may not have caught up with this!

Teams are a complex beast. To understand teams we need to draw on cognitive psychology, social psychology, rehabilitation research, general systems theory and, dare I say it, management theory.  Not only do clinicians in an interdisciplinary team need to know their profession’s contributions, they must also communicate effectively as individuals, have learned how to collaborate, and the team must be supported in a structural way to do its job well.

What does this mean in practical terms?

There must be effective selection and induction process for new team members – members need to be chosen for teams on the basis not only of their proficiency in their individual discipline, but also on what they can contribute individually to a team. Personally I don’t think a decision to appoint an individual to a team should occur without the team being involved in the selection process.  Induction needs to involve not only where the first aid kit is, but more importantly, the team’s philosophy and clinical model, sharing what each individual member can contribute to the team – especially when a new member is appointed, how decisions are made, how disputes are resolved, and the team’s values.

Time must be set aside for team development and that hackneyed term “team building”. This is an ongoing need – because trusting one another is critical to effective teamwork. This means learning about other clinician’s contributions – enough to be able to provide the same kind of input within your own clinical session, so a consistent message reaches the patient.

Communication must be pretty robust at times! What I mean by this is that it’s vital to be able to disagree, challenge one another’s viewpoint and take the time to reach alignment, if not agreement. A team that can’t or won’t openly disagree with one another is likely to hold onto disputes, souring the relationships and creating distrust. Over time, the team’s effectiveness is lost as patients/clients can tell where the weakest links lie.

Develop a structure for presenting information
–Optimum amount of information – 3-7 from each person
–Most likely to be forgotten – presented first
–Lowest prestige – presented early
–Share unique information rather than shared
–Use a timer to limit discussion – egg timer?
–Consider using delphi, or other structured decision process (nominal group technique, SWOT, decisional balance, cognitive mapping)
Identify functional roles as well as clinical roles in a team, support these roles – this means some people are the “organisers” in the team, some are the “comforters”, some are “rule makers”, some are “enforcers”. These interpersonal roles are as important as clinical roles because they facilitate team functioning. And the professions traditionally expected to “lead” or “organise” may not be the best individuals to do so in a particular team.
Develop a process for resolving differences – this might mean sitting and thrashing a problem out in discussion, or it might mean bringing another person in to mediate/arbitrate, or it could mean giving a decision-making role to one individual within the team, though this can mean developing a hierarchy and this is less positive within an interdisciplinary team.
Managers must recognise that interdisciplinary teams need time to learn to work together, that teams are less effective when team membership changes, that members of teams often know what they need and who they need as members and that external managers or even clinicians working outside a team may have little knowledge either of how the team works, or of what the team needs to be effective.
Are interdisciplinary teams effective?
This is a slightly difficult question to answer, but overall the indications are that interdisciplinary teams are effective in terms of patient outcomes, and they are also better for the individuals involved in them. This report, somewhat old now but still relevant, found that IDTs are better for mental health of members and there is lower staff turnover.  This report, from 2013, finds that the data are not yet clear about cost effectiveness.
What seems evident is that the more complex a patient’s problems, and the more chronic, the greater the need for interdisciplinary teams, and the more cost effective the outcomes.
Human Resources for Health provides this summary – 10 Principles of Good Interdisciplinary Team Work
I love working in a team. I love being able to trust the other members of the team to provide seamless integration of the things I contribute, and I love being able to support the other clinicians in their approach. I know it’s not easy to develop good teamwork, but there’s enough information available from research to know what can help. What I definitely know is that defining what one profession will do without also considering both the other professional’s contribution AND the personal strengths and vulnerabilities of the individuals involved is likely to lead to subversive behaviour, dissention and ultimately failure for the person at the centre of it: the client/patient.

The complexities of interdisciplinary teams
Pain management, especially chronic pain management, is characterised by using an interdisciplinary approach rather than a multidisciplinary one. Distinguishing between the two can be a case of splitting hairs at times, but the fundamental difference is that in multidisciplinary teams, treatment is carried out by different team members who may work with the patient concurrently, but not necessarily using the same underlying model or framework for treatment. In an interdisciplinary team, treatment is carried out by different team members using a common model to address common goals – working collaboratively and in close communication with each other.

Interdisciplinary teams take time to develop. The members of the team learn more about each other’s professional roles the longer they work together. They become familiar with, and trust each other to support the common messages such as ‘don’t use pain as your guide’, or ‘do no less on a bad day, do no more on a good day’. Interdisciplinary teams rely on each other to help the person with pain move forward towards the life they want to live.  To become effective, interdisciplinary team members need to learn to trust each others practice, to have confidence in their own practice, and to develop a common language and approach to clinical situations they encounter.

The problem with these teams is that much of the ‘work’ of a team occurs during meetings, and meetings of groups of health professionals look costly. Five or more therapists sitting together for a couple of hours seems to be an inordinate waste of productivity when you think of the number of patients they could be seeing during that time! Not only that, but developing effective team processes including good induction and dispute resolution also takes time. And it’s invisible input with little visible output. No wonder managers think teams like this could surely be done differently.

The research on effectiveness of interdisciplinary pain management continues to support this model, despite erosion of it in some countries (notably North America). I’m not going to review the literature here, but a couple of good references (and yes, these are old ones, but still relevant) are Turk and Okifuji (1998), and Okifuji, Turk & Kalauokalani (1999), and of course, Main and Spanswick who wrote the book Pain Management: An interdisciplinary approach (2000). A more recent edition of this book has been published, further extending the application of the biopsychosocial model in pain management.

When we’re trying to identify what constitutes an effective interdisciplinary team so we can perhaps develop it more quickly, or refine it, the elements that make up a good team become incredibly complex.  The individuals themselves, the communication style, the procedures that structure their work, the roles people play within the team – all of these elements need to be understood to work out how a good team becomes more than the sum of its parts.

Humphrey, Morgeson and Mannor (2009) produced a paper outlining a theory that considers not just the individuals and the roles they play within a team, but also the composition of the roles.  Recognising that not all roles are made equal, in this paper they look at what they call ‘strategic roles’ – those roles that either encounter more problems, or are more involved in critical activities, or are in a central position in the workflow of a team.  This definition describes strategic roles according to the structure of a team rather than the performance of a team.

They then looked at a number of teams (OK, they used sports teams, but the model can apply to health teams too), and identified that it is not the individuals within a team, but the roles they fulfil in a team that make a difference to the effectiveness of a team.  Some roles are more important to the outcome than others.  They then suggest that by investing more heavily in the ‘core roles’ of a team, overall performance increases – this investment could be in terms of resources available for the people fulfilling these roles, or rewards for those individuals in this role, or time available to the people fulfilling those core roles.

Another facet to this study looked at the place of experience and skill on team performance – it matters who has experience depending on the roles that person fulfils.  This suggests that investing time, training and possibly even monetary reward for those people who fulfil important or core roles could pay dividends in terms of output or outcome of the entire team.

Interdisciplinary teams are complex beasts.  While most of us work within some sort of team, many of us don’t know what our contribution actually does within the team.  And most of us haven’t been trained in how to work effectively in teams – after all, our training has been primarily to develop our individual professional skills, rather than to recognise the strengths of a collective.  Perhaps this is an area for us to explore in more detail – and maybe managers can learn from research such as Humphrey, Morgenson & Mannor’s team roles theory, and look at how to resource team members to enhance their work.

If you’ve enjoyed this post, and want to read more, you can subscribe using the RSS feed link above.  Or you can bookmark and come back again! I post most days during the week (look out for Friday Funnies!), and love comments.  Drop me a line if you want to introduce yourself, or just leave a comment and I’ll be sure to reply.

Humphrey, S., Morgeson, F., & Mannor, M. (2009). Developing a theory of the strategic core of teams: A role composition model of team performance. Journal of Applied Psychology, 94 (1), 48-61 DOI: 10.1037/a0012997

Okifuji AA, Turk DC, Kalauokalani D. Clinical outcomes and economic evaluation of the Multidisciplinary Pain Centers. In: Block A, Kremer EE, Fernandez E, editors. Handbook of Pain Syndromes. Mahwah, NJ: Lawrence Erlbaum Publishers; 1999. pp. 77–97.

Turk DC, Okifuji A. Treatment of chronic pain patients: clinical outcomes, cost-effectiveness, and cost-benefits of multidisciplinary pain centers. Critical Reviews in Physical and Rehabilitation Medicine. 1998;10:181–208.

Talking about roles in pain management

If you’ve missed it before, you won’t in the future: I don’t like turf protection in pain management!  If there is one thing people experiencing pain really need, it’s consistency from all the people working with them – and the second thing they need is more people doing good pain management.  So IMHO there is no room for health professionals staking out an area and saying ‘its mine all mine’.

Nevertheless, there are certain areas of greater or lesser specialisation, and I’m not suggesting pain management becomes an area like many mental health ones, of generic ‘case management’.

What I am suggesting is elimination of the phrase ‘the [insert professional title here] role in pain management is…’ What I’d like to suggest is a new way of looking at what each professional does, and the phrase ‘what [insert professional title here] can offer a team is…’ (more…)

Why CBT? How do patients feel about it?

There are many different therapies out there – why is CBT (or one of the newer variants) the Chosen One?
I gave a few reasons yesterday –
* that people are capable of change,
* can accept self responsibility for their actions,
* that what we think and believe about a situation can affect our emotions and responses, and
* that we can implement a whole range of strategies that can make a difference to life
Here are a few more…

  • help people become more likely to stick to ‘other’ interventions
  • provide opportunities for people to reflect on the choices they make, especially the choices about healthy behaviour
  • help people recognise their own power and role within their own health care team, and their responsibilities
  • help people develop a sense of control over their own health
  • reduce the effects of stressors
  • reduce the misleading effects of anxiety and concern (e.g. reduce the search for a ‘cure’ or ‘another diagnostic investigation’

In chronic pain management there is plenty of research-based evidence that programmes building on these principles help people recover to a more normal life, and especially, return to normal life roles. CBT-based programme are not, however, very specifically prescribed – researchers still don’t know how much or what constitutes ‘necessary’ and ‘sufficient’ elements in a programme.

One of the main problems with initiating CBT-oriented therapy is that people with a health problem, especially pain, really DON’T want the slightest hint that their pain could be ‘imaginary’, ‘psychological’, ‘malingering’, ‘in my head’, nor about them being ‘unable to cope’. Introducing the idea of CBT initially can be quite challenging if it’s carried out as if it’s separate from any other aspect of the person’s health care. This is another strong reason for it to be integrated and conducted by any and all members of the team.

Introducing CBT

A lot of CBT books suggest ‘socialising’ the person to CBT – I’m not entirely comfortable with this idea myself! It sounds a lot like the demand characteristics of a therapeutic setting are being used to ‘make’ the person ‘conform’ to how I as a therapist want sessions to be run. My preference is to use the menu approach, as I think I’ve mentioned before. menu I’ve attached one for you to download if you want.

Once the person’s identified what they see as their concerns, I can start talking about some of the ways other people have worked through or solved their problems. This can often mean the person comes up with their own solutions – and my job is to then, with their permission, help them put that solution into a framework that can help them understand how or why it might work.

An example? One of the people I’m seeing currently has difficulty sleeping. She’s fine getting off to sleep, but just can’t stay asleep. She has worked out that she finds it really difficult to get comfortable again once she’s woken up, and then her mind becomes very busy.

Her thought for a good way to manage this was to work out how she could get comfortable more quickly – and she knew from the menu I’d used that learning how to relax might be helpful. We’ve started developing her skills in relaxation – but I’ve added in the following cognitive model to help her understand why it might work.

  1. She’s quite a busy person and doesn’t relax readily. She goes off to sleep very quickly because she’s very fatigued, but waits to go to bed when she’s really exhausted. As a result, she doesn’t allow herself to experience that relaxed dosiness that most of us get.
  2. When she wakes in the middle of the night, she’s recovered from some of her fatigue, so because she doesn’t know how to fall asleep again, she starts to become anxious – especially when she thinks of the coming day, and how much she needs to have good sleep!
  3. As she starts to worry, her body starts to respond to the increased anxiety, and she becomes more aroused physiologically – this increases her general anxiety and she becomes more aware of (and hypervigilant to) her back pain. She also has less to distract her from her worries and her pain because it’s quiet and she is alone.

I also took the time to discuss the stress response – and she was able to identify a number of factors that are increasing her anxiety at present, and how this is experienced in her body. She arrived at the conclusion that prior to her back pain, she was able to ‘work off’ some of her ‘stress’ by keeping very busy and by carrying out fitness activities also. Without her usual outlets for ‘stress’ she reflected to me that she has been finding it harder to wind down.

At the same time as identifying the stress, pain, arousal, sleep problems – this woman has also identified that she’s not sure why she keeps so busy all the time. She’s pondering this and it may be something she discusses with the psychologist on our team. And next time we meet, she intends to see how the relaxation process we went through has worked – and she’s also been given some other information on sleep hygiene to review.

Without even attempting to ‘socialise’ her to CBT, a common structure for CBT sessions is developing – starting each session with an ‘agenda’ or menu, reviewing her past learning (‘homework’ -ugh! missions if you please – you do have a choice about whether you want to accept them or not!), identifying the elements that have worked well, those that haven’t, and reviewing new pieces of information as we go.

For my next post, I’ll describe a situation that hasn’t moved so smoothly so you can see that it doesn’t always work out exactly as I want! But in this case, I think I’ve been able to start where she is at, give her the responsibility to identify what is important to her, and the solutions she has identified (which demonstrates my belief that she has the resources to cope and increases her confidence in herself), help her fit the solutions she has come up with into a framework that makes sense and opens up an opportunity for more factors to be added in for future exploration.

Group facilitation

I love working in groups! I love the diversity, and the way that learning occurs, and the challenges of energising and focusing groups. For me groupwork is one of the most demanding and yet rewarding aspects of my work.

There are many many sites on the internet that have a range of activities for groups – a good number of them are free. What they don’t seem to do is help with how to integrate the activities so they not only energise and warm a group up, but also provide a venue for serious learning.

I’m going to describe two activities that I’ve enjoyed using with groups who are developing pain management skills.

The first is used within the first week (often the second or third day), and the second is best used towards the end of a programme. The purpose of each activity is to allow the group to focus on the activity while forgetting about their pain, so that they can develop awareness of what their ‘high risk’ behaviours are with regard to learning new activities, integrating pain management strategies, and in a sense, how they live their life. I subscribe to the idea that ‘how you do anything is how you do everything’ – so how people participate in these activities is probably how they will respond to situations in the real world.

There are some common tasks as facilitator for both activities, and I’ll describe these as a preamble to the specific activities.

The purpose: to enable the group members to respond naturally to a ‘demand’ situation, to assist them to reflect on the way they approach activities (‘life’)

My role: facilitate, set task parameters, enforce ‘rules’ or boundaries, assist the group to reflect and generate their own learning, ensure the equipment and environment is established for mental and physical health

Pre-activity: set up environment, ensure the instructions are printed and clear, ensure all equipment is available, have stop-watch or timer set up, and that adequate time for both briefing and debriefing has been allowed for.

Post-activity: ensure all participants have had time to reflect, all have been facilitated to hear what you as facilitator think is important, and that group process has been allowed to flow, the participants have written down ‘key learnings’ from the session, and you have been able to clean up.

Group size: 4 – 9 participants

Activity one – ‘Crossing croc-infested waters’

Materials: 5 A4 sheets of paper, tape to mark floor

Preparation: tape a ‘river’ across the floor – the ‘river’ should be at least 3 m wide, and about the same deep (or as wide as your room!)

Instructions: Tell the group that they are required to cross the river which is full of crocodiles. They have five stepping planks that they can use to cross the river with, but because they’re made of wood and float, once they are placed down in the water, they must be held down with a foot at all times or they will be swept away! The group must rely on each other, and work out how to get all members of the group across the river safely using only the five pieces of paper. They must not allow anyone to ‘die’, neither can any part of their body touch the ‘river’ or it will be ‘eaten’. They have 10 minutes to complete this activity.

Facilitator role: It is very important to enforce that the pieces of paper must be held down at all times. This is often forgotten unless the group have rehearsed the activity on ‘dry land’, and learning to rely on each other and work together as a team, watching out for each other and coordinating their movements. The facilitator must also urge speed and maintain a watch on time, particularly as the activity nears the end. To make the task more difficult, the time can be made shorter, or a piece of paper can be removed. It’s also important that no-one puts their foot in the ‘water’ (or they may not put that foot down again – it’s been bitten off!)

At the end, the facilitator must conduct the debrief – see attached pdf doc.

Activity two – Radioactive Rice

Materials: two cups, one filled with uncooked rice, various items from around the room including sheets of paper, tape, spoon, icecream sticks, pottles, string, bluetac, chalk, instruction sheet

Preparation: draw a circle with chalk on the table (circle is usually about 1m radius). Place one cup filled with rice in the centre of the circle. Collect other assorted items around the table.

Instructions: Tell the group that this is a heavily disguised cup of radioactive rice that will blow up in 30 minutes, creating a huge crater of radioactivity and killing all within a 2km radius of the area. Inside the chalk circle is an invisible containment field shaped like a cylinder, going from ceiling through the table to ground level. This is currently holding the radioactivity inside it. The rules are:

  • No body parts are allowed to enter the containment area
  • No-one is allowed to commit suicide and sacrifice themselves to remove the rice
  • No items that are outside the room are allowed to be used
  • Anyone who breaks the rule is ruled out and cannot be physically involved from then on (not the word physically involved! it’s OK to talk…!)
  • As much or as little rice can be transferred at any one time
  • The group has 30 minutes to transfer the rice from one cup to the other, then to remove the second cup to the ‘safety zone’ before the whole area will blow up

I usually allow 5 minutes question time then I will stop answering any questions and allow the group to get to work.

After 30 minutes, time is up and it’s debriefing time.

Facilitator role: It’s very important to stick to the rules at all times, maintain a very close watch on the participants and firmly tell them they are out if they break the rules. Every 5 minutes for the first 15, count time, thereafter every one minute, and in the last two minutes, every several seconds. Ensure people who are ‘out’ don’t get physically involved – but remember they are allowed to remain in verbal participation! Managing the debrief is essential.

Debriefing: for both of these activities, debriefing is essential!

In each case, these activities represent ‘life’ – and how people go about managing their participation is very similar to how they will participate in ‘real life’. So, some people will work together with others, think and plan, and manage both themselves and their pain using a wide range of skills. Others will completely forget to manage their pain, jump right in and break the rules very quickly.

This document (activity-review-jan-2008.doc) can be used for individual review.

As well, the group can be facilitated to provide review to each other – this is a very powerful way for people to develop knowledge of each other, and to learn to give and receive feedback (positive and negative). I usually start with asking the group ‘what did you do well?’, and ‘what would you do differently?’, then I ask the group to contribute both types of feedback, and finally, ask the person ‘what will you take away from this experience today?’.

Often it’s helpful to reflect on ‘what happened when I was counting the time down?’ – it’s adding pressure, and mimics a working situation.

Asking ‘and what happened to your pain during the task?’ reminds people of the usefulness of distraction, and that it can be a trap because pain becomes more problematic afterwards. Most people forget to use pain management strategies, so it can be a potent learning tool to remind them that they need to integrate pain management strategies even during activities like this that are involving and distracting. I also like to remind people that they always had a choice – they could have told me that this activity was silly, not real, and chosen not to participate! But they may have missed an opportunity to learn something – which is pretty much what life is like!

Reflecting on ‘What did it feel like when you were told you were out?’ is a powerful experience – many people say that they felt gutted, stunned, angry, and some argue against the rule. It’s useful to draw the parallel with the experience of suddenly having pain, when all the physical things they used to do were restricted (but equally powerful to emphasise that people were still able to contribute verbally – many people don’t remember this, and it can be both humbling and empowering for people to realise that they self-limited their involvement by not clarifying their position).

At the completion it’s important that participants write down their take-home messages – it’s impressive how many are aware even at the beginning of a programme, exactly what their particular pain management ‘trip-ups’ will be, but equally impressive to notice that even by the end of the programme, they will still fail to integrate their skills.

I hope you enjoyed this introduction to two activities I’ve used with people to help them learn experientially.

Professional maturity

What constitutes a mature profession?

  • One that calmly does what it does without constantly being fearful that someone is ‘poaching’ the role
  • One that is self reflective, and challenges itself to become more and better
  • One that knows its core purpose and uses whatever scientifically proven strategies support that purpose
  • One that has ‘jargon’ but doesn’t need to tout it about like a shiny new ring ‘Seen my occupational performance recently? Look how shiny it is!!’
  • One that takes a broader perspective on issues other than those immediately relevant to its core practice
  • One that can see there are other issues to comment on other than those immediately relevant to its core practice

Probably a heap of other things too – but those are some of my pet peeves.

There are times I feel like one of the first feminists – ‘Oooh! look, a woman can drive a car!’, ‘Oooh! Look an OT can teach doctors!’ It seems a bit of a novelty that an occupational therapist should educate people from outside the profession – and debate issues across professional boundaries as well! I ask – why not? The information is available in the scientific literature, and it’s up to each one of us to critically examine both our own and our team’s way of working to ensure the very best outcomes for our clients. Sometimes this means being critical of another’s practice – more often it means being critical of our own. It also relies on us as professionals being confident about our own skills – professional, scientific, interpersonal.

What do I do as an occupational therapist that defines my practice? I help people live their lives despite limitations so they achieve their potential in the real world.

In simple words, I help people ‘feel it, think it, do it, be it’.

Health professionals of every stripe have some core skills – common to anyone who works with people. In pain management, more probably than any other area of health care, interdisciplinary team work relies on professionals being comfortable enough within their own skin to allow another to do things that would normally be the province of a single discipline, and at the same time, be willing and able to pick up on skills that aren’t normally used by his or her own profession.

We can’t afford to be precious about what we offer – we really need to question, explore, examine and test our practice because so much of what we do in the name of therapy has been assumed to work, but doesn’t, or works in a different way from what we assumed. Why is this important? So we can refine it, learn more about mechanisms, and hopefully even prevent some of the disability occurring.

Rock on 2008 – it’s got to be a good one!

If you’re an occupational therapist, and want to debate professionalism and occupational therapy – head on over to the occupational therapists only section, get the password by emailing me, and join in!

Pain management can’t be cloned

I’ve had occasion over the past few weeks to think about service delivery and teamwork and how to provide really good pain management programmes in a group context.

A problem with any interdisciplinary team is that the members of the team may change as staff leave, or are unwell, or even have annual leave(yes! we like to take a break too!). At the same time, programmes for people with pain need to be provided consistently and often enough to break even financially.

The economic viability of interdisciplinary group pain management has been established (see these papers by Gatchel & Okifuji (2006), Goossens, Rutten-Van Molken, Kole-Snijders, Vlaeyen, Van Breukelen, & Leidl (1998), Turk & Burwinkle (2005) for discussion), and we know the effectiveness of this approach on individuals from too many studies to list here. Often however these outcomes can be overlooked in the face of the need to resource a programme with professional staff members, facilities, administration, outcome measurement, and ongoing review and development. So managers sometimes think of ways to reduce the cost in the most expensive resource – the staff members and the time spent on reviewing and developing programme content.

The argument seems to be one of two:

  1. That once a programme has been developed, there is little need to review it, and a ‘cloning’ approach can be used (similar to a franchise strategy!)
  2. That once the programme has been developed, the professional involved in the programme can simply ‘teach’ the contents – and perhaps ‘any’ professional can do this…

Let’s take a look at the first argument – that programmes can remain essentially the same once they’ve been set up. I’d argue that because pain management is continuing to evolve and develop, it becomes foolhardy not to include the findings and ‘technology’ based on new research findings. For example, in the last 5 years the literature on the pain-related anxiety and avoidance model (Vlaeyen & Linton (2006) has rapidly established the place of behaviour change and exposure-based therapy for people who are fearful of movement or pain. Programmes ignore pain-related anxiety and activity avoidance at their peril. Review and update are necessary in all areas of health care – no less so in pain management.

The second reason, that therapists can be slotted in and out of programmes as required – provided that they can ‘teach’ the content, suggests that the technical needs of cognitive behavioural therapy have been misunderstood. CBT is not simply providing information to people – it is a process of reconceptualising concepts, developing and rehearsing new skills, and reviewing situations to problem-solve and develop strategies so that the next encounter can be successfully managed.

As I’ve written about before, interdisciplinary teams need certain things to be effective – these include

  • a common model that all members of the team are well-versed in
  • technical skills in providing cognitive behavioural therapy
  • group facilitation skills
  • knowledge and trust in each other as professionals
  • ability to work across professional boundaries as necessary so as to reinforce the common model

To achieve this state, I think these things are essential

  • really good induction
  • time together as a team
  • agreement to adhere to the programme process
  • systems and structures to support decision-making
  • opportunity to observe the team members and programme

It is simplistic to think that the best way to ensure an economically viable programme is to reduce costs in the areas in which the ‘technology’ resides – the therapists and their skill, and ongoing review and development of the programme.  Not to mention time and processes to develop teamwork.   Although it’s expensive up-front, this time and effort is recouped in the quality of the programme and the outcomes it achieves.

On a slight tangent – can a successful programme from one country be transplanted holus-bolus into another country across the other side of the globe?

Some things concern me about this – the ‘franchise’ approach which prizes adherence to a manualised approach and can prevent ongoing development; the belief that professionals in one country have the same background and training as in another country (especially with respect to occupational therapy training!); the thought that patients can be cloned and ‘one size fits all’; and finally the suggestion that the active ingredients in the programme will ‘fit’ with the social, economic and political climate in another country.  I don’t know that this is achievable in chronic pain management…and wait to see with a good deal of interest whether it can happen here in New Zealand.

Let me know what you think about this post – agree? disagree? want to point out arguments for and against? Bring those comments on!!

Gatchel, R. J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain.[see comment]. Journal of Pain, 7(11), 779-793.

Goossens, M. E., Rutten-Van Molken, M. P., Kole-Snijders, A. M., Vlaeyen, J. W., Van Breukelen, G., & Leidl, R. (1998). Health economic assessment of behavioural rehabilitation in chronic low back pain: a randomised clinical trial. Health Economics., 7(1), 39-51.

Turk, D. C., & Burwinkle, T. M. (2005). Clinical Outcomes, Cost-Effectiveness, and the Role of Psychology in Treatments for Chronic Pain Sufferers. Professional Psychology: Research and Practice, 36(6), 602-610.


Vlaeyen, J. W., & Linton, S. J. (2006). Are we “fear-avoidant?” Pain Vol 124(3) Oct 2006, 240-241.


Postgraduate distance-taught papers in pain and pain management

If you haven’t started planning 2008 postgraduate study yet – there are a couple of ‘down-under’ papers that you can choose from.

University of Otago, Christchurch has the Postgraduate Diploma in Musculoskeletal Medicine (for medical practitioners), which includes a number of papers that can be credited to Masters of Health Sciences. These papers cover a broad range of musculoskeletal topics but the two I want to highlight are Pain and Pain Management.

All papers are distance-taught, using a combination of comprehensive readings (provided), online discussion and fortnightly teleconference calls. Pain and Pain Management are taught in the first semester, and enrolments are being called for now! Students come from around New Zealand, Australia, HongKong, Singapore, UK. A unique feature of these papers is the very strong interdisciplinary approach – students come with backgrounds of medicine, psychology, occupational therapy, physiotherapy, nursing, osteopathy, chiropractic, acupuncture, podiatry… Another strong feature is the emphasis on the biopsychosocial model throughout the papers.

Paper MSMX 704 – Pain

The aim of the paper is to provide an understanding of the broad range of clinical techniques used for the assessment, treatment and management of musculoskeletal pain. The paper is designed to complement MSMX 708 Pain Management.

  1. Biopsychosocial model of pain.
  2. Pain mechanisms.
  3. Neuropathic and spinal cord injury pain and central pain syndromes.
  4. Tissue specific pain entities.
  5. Psychology of pain.
  6. Behavioural aspects of pain
  7. Cognitive aspects of pain.
  8. Pain related fear and avoidance in pain – a model of disability.

Assessment is by completion of a case study of a person experiencing pain and a two hour written examination.

Paper MSMX 708 – Pain Management

The aim of this paper is to provide an understanding of the broad range of clinical techniques used for the assessment, treatment and management of musculoskeletal pain. The paper is designed to complement MSMX 704 Pain.

  1. Pain assessment and outcome
  2. Treatment effects and placebo
  3. Cognitive behavioural treatment – theoretical
  4. a – Clinical intervention – Clinical Techniques.
    b – Multi-disciplinary and interdisciplinary treatment for chronic pain.
  5. Interventional pain management
  6. Primary and secondary analgesia.
  7. Neuromodulation
  8. Psychopathology and chronic pain – assessment and management

Assessment is by completion of a case study applying an evidence-based pain management approach, that is also based on case formulation. A two hour written examination is also required.

For busy clinicians, these papers are a relatively heavy workload – but at the end of the papers most students say they have developed a new awareness of pain as a biopsychosocial phenomenon.

For occupational therapists there is another option – through the Otago Polytechnic Occupational Therapy School, in the second semester, a distance-taught paper in Pain and Pain Management will be offered. This paper can also be credited to Masters of Health Science, and Postgraduate Diploma in Occupational Therapy. More details about this occupational therapy specific paper will come later!

A simplified explanation of cognitive and behavioural therapies for chronic pain

Cognitive and behavioural therapies (CBT) are not one single ‘therapy’, but a group of interventions that are combined in pain management to help the person develop ways to continue living despite their pain.

Cognitive Behaviour Therapy (CBT) is based on the idea that how we think (cognition), how we feel (emotion), and how we act (behaviour) interact together. Specifically, our thoughts determine our feelings and our behaviour. Therefore negative thoughts can cause us distress and result in problems.

CBT is based on both cognitive and behavioural therapy.
Cognitive therapy – thoughts, beliefs, attitudes and perceptual biases influence which emotions will be experienced and also the intensity of those emotions. Therapy is based on modifying thoughts and therefore emotions and behaviour.
Behavioural therapy – reinforcement and imitation teaches normal behaviour, therapy is based on learning theory. Initially cognitions were ignored as having little relevance.

CBT arose from amalgamation of behaviour therapy and cognitive therapy. These therapies were developed in contrast to psychodynamic therapy, which assumed that inner conflicts in the psyche were responsible for problematic behaviour and emotions.

Behavioural Therapy
Skinnerian behaviourist therapy (B.F. Skinner, 1904-1990) was made popular by the thought that by applying scientific principles to behaviour, years of psychotherapy could be avoided and problematic behaviour could be changed quickly. Original behaviourists ignored or downplayed the role of thoughts, beliefs and understanding of the patient. This was mainly as an over-correction from the psychodynamic approach.

Normal learning theory developed from behaviourist theory and science shows that by reinforcing specific behaviours, the frequency of those behaviours can be affected. 

What we can use from behavioural therapy is:

  • That the part of the pain experience that is directly open to change is behaviour associated with pain
  • To specify the behaviours we want to see more of, and those we want to see less of (i.e. to increase healthy behaviour and to reduce pain behaviour)
  • To specify the environment or situations in which these behaviours occur
  • To identify precursor (antecedent) factors that influence behaviour
  • To identify consequent factors that influence behaviour
    This is part of functional analysis and is part of our assessment process

Cognitive therapy
It’s easy to see that cognitive factors also play a role in attention, learning and in attribution relevant to the experience of pain. Cognitive therapists such as Aaron Beck successfully used cognitive strategies to help people recover from depression and anxiety. It’s almost impossible to work with a person without giving them some sort of rationale for why we as therapists have recommended they participate – explanation is a cognitive intervention!

Cognitive therapy is about thoughts, beliefs, attitudes – how we attribute meaning to what we do and what happens to us. It is based on the belief that emotions are influenced by our thoughts, which are often unhelpful or even erroneous. In the same way, our thoughts are influenced by our emotions, and each of these influence and influenced in turn by our actions.
Cognitive therapists likewise use practical, real situations in which new cognitive strategies can be used – in essence a behavioural strategy.

Cognitive behavioural therapy has a long history in pain management. CBT applied to pain management is well-researched, and is one of the main areas outside of mental health that research has been conducted.

What we can use from cognitive therapy is:

  • That explanation can reduce the ‘fear factor’
  • That what we think, feel and do can be influenced by each other
  • That we can learn new ways of thinking, feeling and doing
  • That sometimes our thinking and feeling occur so quickly we are not aware of what happens until after the fact
  • That some of our common sense ‘truths’ in the community are wrong – but still affect us (e.g. pain in the back is injury)

Cognitive and behavioural therapies are both used in pain management – but unlike mood or anxiety management where there are relatively established protocols, in pain management there has been less research specifying the components of therapy that are known to work, and for whom.  Because of the multidimensional nature of disability arising from chronic pain, it may well be that there is no single protocol that will work for everyone.  Instead, a clinical hypothesis-testing approach may be the most appropriate strategy (more details on this soon!). 

CBT-based therapies are a generic tool for all health providers working in the field of chronic pain management.  Relying on a single discipline (or member of the team!) to provide the ‘CBT’ is a recipe for patchy therapy, an opportunity for inadvertent splitting of the team, and more difficulty focusing on goals.

Chronic Pain’s Favourite Tools

Teamwork and working with thoughts and beliefs.

Some therapists believe cognitive behavioural therapy (CBT) is ‘only’ for psychologists. Well, I’m not one of them. Frankly, if you are hoping to change ‘what people do’, you are using CBT…whether you’re doing it well or not – that’s another thing! (uhh.. that proviso holds for psychologists also)

What does it involve? It primarily involves identifying thoughts and beliefs, checking out the consequences of holding those beliefs, and providing the person you are working with some information about the implications of those beliefs. After this – it’s about doing something different to cement any belief change into place.

So, how does it all fit together? Well, in chronic pain it could work something like this…Anna attends her pain service. At intake, she is seen by three professionals – medical, functional and psychosocial (including work). She completes a set of questionnaires. At the end of the assessment, all her team sit together to discuss the aspects of her presentation that they feel are important. Using a common model of pain (biopsychosocial), her team review her questionnaires and develop a preliminary explanation (or hypothesis) for the development and maintenance of her current problems with pain. The team explains this model to Anna, who is able to confirm whether their findings ‘fit’ with her experience. She and the team agree that her main concerns are

  • poor sleep,
  • avoiding certain activities
  • low activity level

She starts with the medical person to begin new medications, and then returns to see whether these have helped.

On this occasion she also sees the occupational therapist and psychologist to review (together) a model of chronic pain, and the impact on her life. Anna specifies her main concerns about her sleep, and it is hypothesised that she is not doing very much during the day, and she is very worried about her future. Her general fitness level is low and she is fearful of increasing her activity level.

The working hypothesis for the team is: Anna has chronic pain, she has developed anxiety about her pain, and is avoiding activities that she believes will increase her pain. As a result of this she is not doing very much, and her body is quite ‘wound up’. She is both deactivated (and has lost fitness), and has poor sleep (because she has not exercise much, and lies awake worrying).

Once her medications have been stabilised, Anna starts to see the occupational therapist, psychologist and physiotherapist to begin working on her functional goals.

The occupational therapist is interested in Anna’s daily activity pattern and the activities she most wants to pursue, including work; the physiotherapist is keen to establish a fitness programme to increase her cardiovascular fitness; while the psychologist intends to help Anna become aware of how her worrying has become a habit prior to going to sleep.

As a team they all agree that Anna is anxious about experiencing pain, is worried that when she has pain she ‘won’t cope’ (but is not fully aware of what she means by not coping), and has developed avoidance patterns and engages in safety behaviours that she has inadvertently developed to ‘keep herself safe’.

The physiotherapist encounters Anna’s automatic thought that ‘this is going to be too much for me’ when she starts to get on the bicycle. The physio gently encourages Anna to define what ‘too much’ would be – and reassures her that Anna has the skills to cope even when she is sore. At the same time, the physio starts teaching Anna diaphragmatic breathing, using a the word ‘relax’ as a cue word on the out breath. After the session the physio talks to the occupational therapist who sees Anna next about Anna’s concerns about coping.

The OT starts the session by developing a hierarchy of activities that Anna has been avoiding, going from ‘least concerned about’ to ‘most concerned about’. While doing this, she encourages Anna to identify what her automatic thoughts are, and what she thinks those thoughts mean. She encourages Anna to continue with a daily walk or cycle, and ends the session with a few minutes of diaphragmatic breathing using the cue word ‘relax’, and a posture-based relaxation. She gives Anna a notebook to record her walking or cycling, relaxation, and a copy of the posture-based relaxation.

Anna sees the psychologist last, and discusses the goals for the week. She and the psychologist talk through the meaning of anxiety and stress, and discuss the fight/flight/freeze response. The psychologist gives Anna a worksheet containing sentence stems about chronic pain, advises Anna on basic sleep hygiene and asks her to record her sleep in the diary. The psychologist also enquires about Anna’s exercise plan, and encourages Anna to work to get her heart rate to the target level.
In this example it’s hard to work out where the ‘psychology’ part begins and ends – and similarly where the OT and physio aspects begin and end.

This is teamwork, this is interdisciplinary, this is trust – and this is seamless service delivery.

Who benefits? Anna.