mindfulness

Empathy and catastrophising influence pain inhibition


When I went to occupational therapy school I was introduced to nociception and the biological underpinnings of pain. I wasn’t, at that time, taught anything about the brain, attention, emotions or any social responses to pain behaviour. Like most health professionals educated in the early 1980’s, pain was a biological and physical phenomenon. I suppose that’s why it can be so hard for some of my colleagues to unlearn the things they learned way back then, and begin to integrate what we know about psychological and social aspects of our pain experience. Because pain is a truly biopsychosocial experience. Those pesky psychosocial factors aren’t just present in people who have difficulty recovering from pain, they’re actually integral to the entire experience.

Anyway, ’nuff said.

Today I stumbled across a cool study exploring two of the psychosocial phenomena that we’ve learned are involved in pain. The first is catastrophising. And if you haven’t got your head around catastrophising it’s probably time to do so. It’s one of the strongest predictors of disability (Edwards, Dworkin, Sullivan, Turk & Wasan, 2016). Catastrophising is the tendency to “think the worst” and consists of ruminating (brooding on), magnifying (over-estimating the negative impact) and helplessness (feeling as if there’s nothing you can do).  The second is empathy, or the ability to sense other people’s emotions, coupled with the ability to imagine what someone else might be thinking or feeling. Empathy is not the same as sympathy which seems to be about the emotions a person experiences while observing another’s emotional state. In fact, separate parts of the brain are involved in the two experiences (Cuff, Brown, Taylor & Howat, 2014).

Back to the study. This study examined conditioned pain modulation in partners observing their partner undergoing a painful experience. It was carried out by Gougeon, Gaumond, Goffaux, Potvin and Marchand (2016) in an attempt to understand what happens to the pain experience of people watching their loved ones in pain. The experimental protocol was (1) baseline; (2) assessing pain VAS 50; (3) pre-CPT heat pain testing (thermode preimmersion at a fixed temperature); (4) CPT (either at 201Cor71C); and (5) post-CPT heat testing (thermode postimmersion at the same fixed temperature). What they did was ask the participants to submerge their right hand in a freezing cold waterbath while video recording them. They then asked their partners to place their right hand in lukewarm water while watching the video recording. Participants were asked to rate their pain intensity.

What they found was the higher the catastrophizing score was, stronger was their descending pain inhibition when they were watching either themselves or their spouse in pain. In women, the more empathic the women were, the better was their descending pain inhibition when they observed their spouse in pain.

This is extraordinary. Firstly, the finding that there was a correlation between catastrophising score and descending inhibition contradicts other research studies – Gougeon, Gaumond, Goffaux, Potvin and Marchand suggest that although cognitive and emotional processes underlying catastrophising increase pain perception and decrease inhibition, their experimental design may have increased pain perception during the conditioned stimulus which may have triggered more conditioned pain modulation. They also suggest that the catastrophising level of participants increases their perceived pain, explaining why it correlates with conditioned pain modulation efficiency.

Secondly, women were more distraught than men by observing pain in others. Adopting the perspective of a loved-one elicited stronger activation in regions involved in the “pain” matrix than adopting the stranger’s perspective (Cheng et al), and the authors suggest that empathy is a powerful factor involved in pain modulation while observing someone in pain. This shows that descending inhibition is influenced by physical stimulus characteristics (such as intensity or location), as well as personal cognitive dimensions. A far cry from the notion that psychosocial factors play little part in modulating our pain experience.

What does this actually mean for us?

Well, to me it suggests that we need to be aware of our own empathic response to observing someone else who is experiencing pain. Let’s put it this way: if I’m an especially empathic person (and especially if I tend to catastrophise) and I see people who are experiencing pain in my clinical practice, my own emotional and cognitive response to seeing people may influence my behaviour and practice. For example, I might be less willing to tell people that I don’t have a way to reduce their pain. I might pursue more “heroic” healthcare – send people off for more treatments, try for longer with unsuccessful treatments “just in case”, I might even send people away from my care because I find it hard to tolerate being around someone who “doesn’t respond”.

You see, being empathic and catastrophising tends to elevate feelings of distress in the presence of pain. If we don’t have effective ways to manage our own distress when we are in the presence of someone who is indicating they’re sore, we’re at greater risk of developing burnout and of feeling frustrated (Gleichgerrcht & Decety, 2014).

For this reason I’m a fan of using mindfulness because it does help people to step back from the emotional judgements of experience, and in particular the negative impact such judgements have on both interactions and emotions (Dobkin, Bernardi & Bagnis, 2016).

 

Cheng Y, Chen C, Lin CP, et al. Love hurts: an fMRI study. Neuroimage. 2010;51:923–929.

Cuff, B. M. P., Brown, S. J., Taylor, L., & Howat, D. J. (2014). Empathy: A review of the concept. Emotion Review, 8(2), 144-153. doi:10.1177/1754073914558466

Decety, J., Yang, C.-Y., & Cheng, Y. (2010). Physicians down-regulate their pain empathy response: An event-related brain potential study. Neuroimage, 50(4), 1676-1682.

Dobkin, P. L., Bernardi, N. F., & Bagnis, C. I. (2016). Enhancing clinicians’ well-being and patient-centered care through mindfulness. Journal of Continuing Education in the Health Professions, 36(1), 11-16.

Edwards, R. R., Dworkin, R. H., Sullivan, M. D., Turk, D. C., & Wasan, A. D. (2016). The role of psychosocial processes in the development and maintenance of chronic pain. The Journal of Pain, 17(9, Suppl), T70-T92.

Gleichgerrcht, E., & Decety, J. (2014). The relationship between different facets of empathy, pain perception and compassion fatigue among physicians. Frontiers in behavioral neuroscience, 8, 243.

Gougeon, V. M., Gaumond, I. P., Goffaux, P. P., Potvin, S. P., & Marchand, S. P. (2016). Triggering descending pain inhibition by observing ourselves or a loved-one in pain. Clinical Journal of Pain, 32(3), 238-245.

Dealing with distress


From time to time anyone who works with people trying to help them make changes in their lives will encounter someone who is overwhelmed, distressed and generally not willing to (or able to) take even a tiny step forward. It’s hard for us as therapists because, after all, we want to help people – but hey! This person in front of us just isn’t up to it!

I think many of us who weren’t trained in psychology can find it really hard to know what to do, and like all humans, we deal with feeling helpless by hoping to avoid it.

Some of us will tell people what to do – this is the way most of us were trained, so it’s what we do when under threat. We might couch this advice in fancy words, but essentially we try to get the person to make a change on the basis of our expertise and superior position. After all, the person came to us for help, right?

Some of us will feel stuck ourselves. Perhaps we’ll give up, or blame the person we’re sitting in front of. They’re not motivated/willing/ready so we stop trying and back off.

In both of these situations, the person’s actual needs at the time can be inadvertently ignored. They’re distressed and we either ignore and advise, or back off – when perhaps what they’re really wanting is someone to be present with them and offer them time to work together on the next best step they can take.

Here’s one way I’ve used to help people who are stuck, distressed and not certain.

  1. Be fully present and let them express what’s going on. This means listening, perhaps asking “can you tell me more about that?” or “it’s tough but are you willing to talk me through what’s going on for you right now?” or “what’s your theory on why you are feeling what you’re feeling?”
  2. Listen with an open and enquiring mind and heart. That means absorbing what they’re saying without trying to respond to it. At the most, you can reflect what you hear, perhaps saying things like “I think I understand that you’re feeling [sad, afraid, overwhelmed], do I have this right?”, or “From what you’re saying, you’re not sure [what’s going on with your rehab] and this is incredibly hard”, “if I’ve heard what you’re saying… is that what you mean?”
  3. Breathe and be mindful of your own response before charging on with the session. It’s OK to tear up if someone is saying something that would make you feel sad. It’s OK to feel aghast that this terrible thing is happening. It’s OK to notice your own body tighten up, your breathing change, not to know what to say. Just notice this in yourself BEFORE you respond. If you do feel something, respond naturally – normalise the experience described by the person as being something anyone in their shoes would feel, and reflect your own response to it. You can say things like “Oh that sounds like such a tough situation” or “I feel a bit tearful myself when I listen to what you’ve been through”, or “I really don’t know how to respond to what you’ve said, I’m lost for words, it’s really hard”.  The purpose behind doing this is to acknowledge that we’re human too, and get affected by what we hear. To be transparent and real so that the person is aware of your own readiness to “show up” and be fully present alongside them.  If you need a moment to catch your breath after they’ve told you something emotionally charged, say so.
  4. When you do respond, summarise what you’ve heard and ask them if that’s what they intended to mean. In motivational interviewing terms this can be called “giving a bouquet” – collecting together a summary of what the person has said, then offering it back to them to check you’ve understood (and it also shows them you’ve been listening).
  5. Before doing anything else, ask them “where does this leave you?” or “what do you think you should do right now?” or “what’s the next step for you now?” People have ideas about what to do next, most times, and we work more effectively with those ideas than if we try to bolt on some piece of advice without recognising their thoughts.

A couple of nice tools to use at this point are the choice point  , and the matrix by Dr Kevin Polk.

The hardest part of responding this way is often our own response. Because we feel uncomfortable, and we’re aware of timeframes, expectations, and because we probably don’t enjoy people crying or being angry in our sessions, we often don’t want to take the few moments needed to be present with someone who is in the middle of it all. Being present is about being there and not trying to change the situation, or rush away from it, or fix the problem – it’s about being willing to bear witness and honour the vulnerability that person has shown us. What a privilege!

It can be emotionally tough after a day of seeing people who are feeling distressed. I think this is where using mindfulness as I’ve described above can be really worthwhile. Noticing what our body is doing when someone is distressed can help us notice the work we do (and help explain why some of us don’t want to talk to anyone at the end of a hard day!). The odd thing is, that when we honour someone by being present and not trying to change their situation at the time, we often find the person is ready to move on and engage in therapy far more quickly than if we’d tried to “make” it happen. At least, that’s my experience!

A good clinician once told me “never be afraid of allowing someone to have a crisis, because after a crisis, shift happens”. I’ve found that to be true.

I’d love to know your thoughts on this post – I don’t have loads of references for it, but a couple that come to mind are:

Beach, Mary Catherine, Roter, Debra, Korthuis, P. Todd, Epstein, Ronald M., Sharp, Victoria, Ratanawongsa, Neda, . . . Saha, Somnath. (2013). A Multicenter Study of Physician Mindfulness and Health Care Quality. The Annals of Family Medicine, 11(5), 421-428. doi: 10.1370/afm.1507

Goubert, Liesbet, Craig, K., Vervoort, Tine, Morley, S., Sullivan, M., Williams, A., . . . Crombez, G. (2005). Facing others in pain: The effects of empathy. Pain, 118(3), 285-288. doi: dx.doi.org/10.1016/j.pain.2005.10.025

Five critical skills for pain clinicians


I could be wrong: it might be seven or ten, but five is a good start. What do people working with those who have pain really need to know/do? What makes them effective? What keeps them positive in the face of what can be an extraordinarily demanding work?

  1. Effective listening skills, along with the ability to communicate that you’re listening. One of the most common complaints about health professionals made by people living with pain is that they don’t listen (Allegretti, Borkan, Reis & Griffiths, 2010; Stenberg, Fjellman-Wiklund & ahlgren, 2012).  While I’m sure there are some clinicians who deliberately protect themselves from engaging in a patient’s distress, I think there’s probably a more insidious version of this – some research shows that when patients report pain, physicians spend more time on technical tasks and less time helping the person actively participate in their own care (Bertakis, Azari & Callahan, 2003).  There’s also some research showing that when clinicians are trained in specific techniques for expressing empathy, patients believe they are more caring (Bonvicini, Perlin, Bylund, Carroll, Rouse & Goldstein, 2009). Physicians were trained to use “The 4 E’s” (engage, empathise, educate and enlist), with a particular focus on communicating that they had heard what was said. Techniques included rephrasing what a patient said; asking a question to elicit more detail; acknowledging or confirming that the person’s emotions are valid/legitimate; and expressing that he or she had experienced a similar feeling. Maybe it’s time for greater training in these skills for all clinicians working with those who have pain.
  2. Mindfulness skills to help deal with emotions during sessions. I hope I’m not just jumping on the mindfulness bandwagon, but I do think being able to be fully present but not caught up in judging or evaluating your own feelings is a critical skill to maintain openness in a clinical situation. A definition of mindfulness that I quite like is “a process of regulating attention in order to bring a quality of non-elaborative awareness to current experience and a quality of relating to one’s experience within an orientation of curiousity, experiential openness, and acceptance” (Bishop, Lau, Shapiro et al, 2004). Being mindful and open allows you to be there for your patient while also making space for yourself. There’s good evidence that mindfulness improves psychological health (Keng, Smoski, & Robins, 2011), and some studies also show that it improves your own communication skills and improves patient satisfaction (Beach, Roter, Kortuis, Epstein et al, 2013).
  3. Case formulation skills. These skills are about pulling your assessment information together in a coherent way so you can generate some testable hypotheses to explain why your patient is presenting in the way they are at this time. To me it’s a waste to conduct assessments and then fail to use that information when you’re developing your treatment plan. And it’s even more of a shame to fail to share that information with your patient. The thing is, there’s often little training given to how to generate a case formulation: it’s got to be based on broad theoretical knowledge fleshed out with the specific information you’ve gathered from your patient. This makes a formulation a unique ideographic set of hypotheses about your patient. I’ve written about case formulations here and here and here.
  4. Superb research reading skills. I don’t think it’s enough to say you’re evidence-based if you’re only using clinical guidelines. I think clinicians need to be critical readers of both qualitative and quantitative research. And I think it’s a crying shame that so much research is hidden behind paywalls. That’s one reason I write so often – I can access research and make it accessible. Of course I’d prefer it if everyone took to reading research, but the cost of doing so is atrocious! And we know that getting into print isn’t always easy, and with the current funding models in tertiary education institutes I think the range and depth of research being published is likely to stay a bit skinny. And until research is widely available for free (remember, authors write for free, reviewers review for free, and much research is published electronically, so where’s the money being spent?) I think it’s going to be tough for clinicians working in private practice. Having said that, even when I was a private practitioner, I always had a subscription to the local medical library – it’s a valid deductible expense.
  5. Effective social media skills. Really? Social media? isn’t that just for people who want to share their food pix? Uh, no. I’ve had the best CPD experiences via Twitter, Facebook, and blogging. Some of the most challenging and thought-provoking discussions occur every day on Twitter. Links to new and emerging research. Links to opinions that make you think. Apps that help you be there for your patients, even when you’re not. Ways to remain in touch with people working in your field from around the world. Is it really a healthcare skill? I think so. Social media allows me to connect directly with researchers, other educators, clinicians, people working in niche fields, people living with chronic pain (the very people I so want to know about). Social media gives people living with pain a voice that can be heard. It allows my niche field to be visible. It has an impact on the general public. If we want chronic pain to be taken seriously by policy developers, and if we want to influence how people living with chronic pain can be heard, then social media is, I think, the way forward. It’s not just me – here’s paper reviewing and with tutorials of applications in medicine and healthcare (Grajales, Sheps, Ho, Novak-Lauscher & Eysenbach, 2014).

This list isn’t exhaustive: what else do you see as critical skills for clinicians working with people who experience pain? Add your thoughts to the list below!

Allegretti, Andrew, Borkan, Jeffrey, Reis, Shmuel, & Griffiths, Frances. (2010). Paired interviews of shared experiences around chronic low back pain: Classic mismatch between patients and their doctors. Family Practice, 27(6), 676-683. doi: http://dx.doi.org/10.1093/fampra/cmq063

Beach, Mary Catherine, Roter, Debra, Korthuis, P. Todd, Epstein, Ronald M., Sharp, Victoria, Ratanawongsa, Neda, . . . Saha, Somnath. (2013). A Multicenter Study of Physician Mindfulness and Health Care Quality. The Annals of Family Medicine, 11(5), 421-428. doi: 10.1370/afm.1507

Bertakis, K, Azari, R, & Callahan, E. (2003). Patient Pain: Its Influence on Primary Care Physician-Patient Interaction. Family Medicine Journal, 35(2), 119-123.

Bishop, Scott R., Lau, Mark, Shapiro, Shauna, Carlson, Linda, Anderson, Nicole D., Carmody, James, . . . Devins, Gerald. (2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11(3), 230-241. doi: dx.doi.org/10.1093/clipsy.bph077

Bonvicini, K.A., Perlin, M.J., Bylund, C.L., Carroll, G., Rouse, R.A., & Goldstein, M.G. (2009). Impact of communication training on physician expression of empathy in patient encounters. Patient Education and Counseling, 75(1), 3-10. doi: dx.doi.org/10.1016/j.pec.2008.09.007

Grajales, Francisco Jose, III, Sheps, Samuel, Ho, Kendall, Novak-Lauscher, Helen, & Eysenbach, Gunther. (2014). Social media: A review and tutorial of applications in medicine and health care. Journal of Medical Internet Research, 16(2), 452-474.

Keng, Shian-Ling, Smoski, Moria J., & Robins, Clive J. (2011). Effects of mindfulness on psychological health: A review of empirical studies. Clinical Psychology Review, 31(6), 1041-1056.

Stenberg, G., Fjellman-Wiklund, A., & Ahlgren, C. (2012). “Getting confirmation”: gender in expectations and experiences of healthcare for neck or back patients. J Rehabil Med, 44(2), 163-171. doi: 10.2340/16501977-0912

Talking past each other: Secret conversations, hidden realities


Take a look at what is written about pain and people living with pain. Look at it with a critical eye. What do you see?

We have descriptions of battling, winning, losing, overcoming, finding a way, getting through, controlling, removing, reducing. Pain is the invader, the alien, something against which we must prevail. And we may prevail using the tools of modern science: we diagnose, we identify, we label and we explain. We treat, we medicate, we use novel movements, graded activity, we avoid sensitising a sensitised nervous system.

The results of this discourse are that when pain does not reduce, is not overcome, cannot be controlled, does not respond to treatment or explanation, we as treatment providers have lost.

Cognitive dissonance is the mental stress or discomfort experienced by an individual who holds two or more contradictory beliefs, ideas, or values. When faced with the situation in which pain “should” have reduced but hasn’t, treatment providers explain away this uncomfortable fact by suggesting that the person hasn’t been following instructions, the treatment wasn’t carried out properly or wasn’t the right treatment, the real cause wasn’t found, the explanation wasn’t thorough enough, the person wasn’t convinced, the treatment wasn’t carried out for long enough, or even that there was a change but the person didn’t recognise it, didn’t make the most of it, expected more.

How often do people living with pain fudge the outcome to avoid displeasing the person treating them? Fail to let the clinician know that yes, there’s still an impact on life despite pain being explained or managed?

Words, or discourse, are as John Shotter put it, “prostheses for moving about through our world’s physicality” (Shotter, 1993). By conversing, clinicians are given a glimpse into a client’s world, but at the same time, clinicians shape that conversation, guiding and leading it in directions that suit the clinician’s purpose. The words used by the client are translated into technical jargon, one prosthesis replaced with another, more “correct” one. Much of the “what it is like” to live with pain is never spoken of, perhaps never verbalised and never made tangible.

Let’s examine some of the expectations we as clinicians might hold about pain (taken from Strong, 1999):

  1. Pain is personal and individual. This means that outward demonstrations of pain are discouraged – those who do are labelled negatively and called “distressed”, “disabled”, their behaviour called “maladaptive”, and in some cases even called “histrionic”, “malingering”, or simply “wallowing”.
  2. Pain is valid only if “we” all agree on it. Although this discourse is slowly changing there’s a hint still present that if the person doesn’t “recover” the way they’re expected to, there’s something wrong with them – it’s those “psychosocial factors”, not the real pain mechanisms.
  3. Suffering, or the loss of self, is some sort of moral or physical failing of the person.  They haven’t “accepted” it, they have ongoing litigation or compensation, they must be getting secondary gain.

I am guilty of these kinds of attitudes. I have been guilty of projecting my own frustration at people who haven’t responded the way I think they ought to. I’ve held beliefs that people should get better because I’ve conducted good therapy and if they haven’t made changes it can’t possibly be my fault, it must be “them”.

In a conversation over the weekend I was reminded that despite generally being someone who deals with my pain (and depression) reasonably well, there is a whole hidden conversation that I rarely engage in, and in failing to acknowledge that part of the “what it is like” to live with pain I’ve missed being compassionate towards myself – and probably others.  That conversation for me was about the never-ending presence of pain at all times somewhere in my body. There is never a time when I’m not sore somewhere. I ache in my lower back, I burn between my shoulder blades, my neck is tight, my MCPs feel hot and bruised, my toes are tingling and sensitive.  I have heaviness behind my eyes. My belly hurts.

The point behind posting this is not that I seek comfort or support or anything from anyone else, but simply to acknowledge that although I know my pain is meaningless, it doesn’t reflect harm or damage and doesn’t pose a threat – it is still present. And in being present, in order to do what is good and enriching and valuable, I must use energy to put that pain experience to one side. I need to accommodate that pain, and take account of it at all times.  And that is tiring. It can be more than tiring, it can be exhausting.

In his article, Strong describes a practice that I guess today would be called mindfulness. He describes “listening for, and working within, the language of visceral experience” to help people transform the quality from one of rejection or judgement, into an “authenticating or welcoming stance”.  He suggests beginning by actively focusing in a relaxed manner on the area which most feels pained, using breathing and concentration. Using this focusing to explore the sensory quality of that area anew – a gentle curiosity. To stay “with” the area – and if working with a therapist, the therapist must “stay with” their client by using “clean language” or the client’s actual words to reflect that the experience has been “authenticated”, or verified by co-construction.

Hidden or secret experiences continue to have an impact although they are rarely discussed. While my experience of pain is certainly personal, the impact it has on me and what I do (and even on what I allow myself to acknowledge) is public. Or it can be if I allow it to be so. By hiding my experience from others I show a public face of energy and effervescence that isn’t complete. It’s not authentic. It suggests to others that I may not have this experience. I wonder how often I/we as clinicians make our therapeutic space safe and nonjudgmental enough for the people we work with to get in touch with those aspects of “what it is like” to live with pain that are hidden, are buried beneath the facade of winning, overcoming, battling, being explained away.

And here’s a final kicker: having been open to being vulnerable, how many of you find it hard to read this honesty? What’s your initial response? Do you want to fix it? Find a solution? Offer me something? Do something for me, to me? What would it be like to simply be present and experience the “what it is like” to be utterly fatigued by ever-present pain? Would you be willing to stay with that experience? And what would it mean to you? Your response will, if you let it, tell you a secret.

 

Shotter, J. (1993). The cultural politics of everyday understanding. London: Basil Blackwell.

Strong, Tom. (1999). Macro- and micro-conversation in conspiring with chronic pain. Journal of Systemic Therapies, 18(3), 37-50.

Being: or doing?


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Interrupted by Pain


If there’s one thing I loathe, it’s being interrupted when I’m in the middle of something. There I am, working away at something, in the flow, knowing where I’m going and what I’m doing then BANG! something gets in the way!

I wasn’t aware, but there is a science of interruptions – mainly studied within ergonomics or human factors research (the study of work and humans) – and this science has begun to unravel some of the issues associated with interruptions. Interruptions are not only annoying, they’re also a good way to provoke mistakes!

Pain is, as Geert Crombez and others have shown, a stimulus we find difficult to ignore. It interrupts what we have planned, and orients us towards finding ways to escape the stimulus. Of course, when pain doesn’t stop, as in chronic pain, people learn to deal with the interruptive effect of pain so they can get on and do things that are important – but at the same time, because part of our brains must deal with the pain in some way, our performance can be degraded.  Essentially, to continue doing something important when pain is also present requires us to deal with goal conflict. 

What happens when a person becomes aware of his or her pain while working on another goal?

Well, initially, the goal pursuit remains strong – our brains are very good at prioritising what we want to do, except when the new stimulus is salient (relevant), novel (new) and intense. Pain is (usually) relevant (it’s a threat!), is experienced as something new or different about our bodily status, and varies in intensity. So in the context of a task, people may remain focused on the task until the pain is intense enough, or meaningful enough, or new for it to capture the attention.

So, pain gets in the way, and we attend to the threat and the threat reduces.

After some time, we return to what we were doing – but the time that it takes to get back to what we were doing differs depending on a bunch of things.

Those things include

  • the threat value of the pain,
  • how readily it resolved,
  • how close to the end of the original activity we were,
  • how quickly we oriented towards the pain (the more quickly we do, the less easily we return to doing what we were originally doing, perhaps because we don’t have time to code the need to return to it into our memory before we move on to address the pain),
  • whether there are cues in the environment that help us remember to get back to the original activity

and a bunch of other things as well.

Some interesting facts have emerged about interruptions – if we have many interruptions, it’s easier to adapt to them and get back to the original task (which is possibly why mothers are known to be good at multi-tasking!); unpredictible interruptions are more difficult to recover from, they’re more disruptive; interruptions that last a long time make it more difficult to return to the original task.

In the case of chronic pain, pain is usually present to at least a certain degree all the time. It’s when it is intense, or the character changes, or it is particularly salient, or perhaps our overall coping is less, that pain interrupts more. So, for some people, it’s possible to delay being taken off task to attend to pain because these people might have learned that it’s “nothing unusual”, it isn’t a threat, it will subside of its own accord, or it’s just less important than the goal they’re working on.

For those of us who do deal with chronic pain, the aspect that may still trip us up is getting back to the activity we were working on before we needed to take a break because of our pain. If we need to take a long break, if we stop the original activity without having clearly planned to stop, if we don’t give ourselves cues to return to the activity, we might find it more difficult to remember (a) where we were in the activity, and (b) that we actually were working on something!

The relevance of interruptions becomes very important when, as therapists, we suggest to people that they consider using activity pacing.

While the definitions of pacing are not clear and still being debates, essentially it means interrupting what a person is doing to take a break, regain energy or maintain pain at a reasonable level. I’m sure many of you will remember the old-fashioned programmes on the computer that used to flash up a screen telling you to STOP! and do a break or stretch. You could “ignore” it a few times, but eventually it would lock your computer so you couldn’t use it until you’d taken the predetermined break. I LOATHED it! I’d be halfway through writing something and it would stop me and get in the way. So I deleted the programme.

That’s one of the problems of these kinds of approaches to activity management – they may stop you “overdoing” something, but they often stop you from completing a task, and completely disrupt your thinking!

My preferred way of helping people to use “pacing” was to suggest “activity chunking” where, at the completion of some chunk of an activity, the person could take a quick break to do a body scan or stretch or something. I found that people used this strategy more often, complained less often, and consequently relaxed a lot more!

After reading about pain and interruptions, I can now understand why this strategy was a little more effective – because at the end of a chunk of activity there are cues established in the memory to remind us that we’ve got a task to complete. These breaks were planned and expected, so they were easier to anticipate, and therefore accommodate.  Eventually, as people got good at them, they become habitual and no longer seem to get in the way of doing the original task.

Pacing, interruptions and pain. People with chronic pain are chronic multi-taskers. We know multi-tasking isn’t good for cognitive efficiency, accuracy or even energy (see the references below), so quite apart from the added burdens we as clinicians might give to people with chronic pain by suggesting “pacing”, people who have chronic pain are chronically stretched cognitively.

My suggestion for managing the demands of pacing and pain is to use planned breaks, preferably using chunks – or, as I’ve been doing recently, using Pomodoro technique to plan and schedule my activities and breaks. I also use mindfulness when my pain begins to get noticeable. By doing this I can remain “on task” rather than distracted.

Conard, M.A., & Marsh, R.F. (2014). Interest level improves learning but does not moderate the effects of interruptions: An experiment using simultaneous multitasking. Learning and Individual Differences, 30, 112-117.
Finley, J.R., Benjamin, A.S., & McCarley, J.S. (2014). Metacognition of multitasking: How well do we predict the costs of divided attention? Journal of Experimental Psychology: Applied, 20(2), 158-165.
Gatzounis, R., Schrooten, M. G. S., Crombez, G., & Vlaeyen, J. W. S. (2014). Interrupted by pain: An anatomy of pain-contingent activity interruptions. PAIN®, 155(7), 1192-1195. doi: http://dx.doi.org/10.1016/j.pain.2014.03.017

Katidioti, I., & Taatgen, N.A. (2014). Choice in multitasking: How delays in the primary task turn a rational into an irrational multitasker. Human Factors, 56(4), 728-736.
Munneke, J., Fait, E., & Mazza, V. (2013). Attentional processing of multiple targets and distractors. Psychophysiology, 50(11), 1104-1108.
Sanjram, P.K. (2013). Attention and intended action in multitasking: An understanding of cognitive workload. Displays, 34(4), 283-291.

 

Mindfulness, catastrophising and disability


ResearchBlogging.org

Readers of Healthskills will know I have a fascination for mindfulness as an intervention for people who have ongoing pain.  Mindfulness is relatively easy to learn, is portable – is free, and has no calories! Seriously, as a seemingly simple intervention, it has appeal not only because it is readily used, but also because so many studies have found that it is effective for reducing distress and disability.

What is it?

Mindfulness is “moment-by-moment attention and observation of external and internal stimuli (eg, thoughts, feelings, bodily sensations) in a nonjudgemental and nonreactive way” (Cassidy, Atherton, Robertson, Walsh & Gillett, 2012).  It’s thought to be the opposite of catastrophising, which is the tendency to interpret those same experiences as an indication of harm or damage.

Learning mindfulness is relatively simple – but hard to maintain, practice is everything. This is my process, developed from multiple readings over the years so I am completely unable to identify where I got it from!  Readers keen to learn more about how to teach mindfulness should head to the Center for Mindfulness in Medicine, Healthcare and Society based in the University of Massachusetts, alternatively, read anything by Jon Kabat-Zinn.

I begin with asking the person to become aware of their breathing. Not changing it, not trying to breath more slowly or deeply or anything – just become aware of it.  I might guide the person to

  • become aware of cool air as it enters the nostrils and flows down the back of the throat;
  • to notice the warmth of the air that passes back out;
  • to be aware of the rise and fall of the abdomen or chest;
  • to become aware of what it feels like when the chest expands

…and so on.  I often extend this awareness to notice the body sensations of contact with the support, or the warmth of the hands as they rest on the lap – for as long as I think the person is remaining aware and not drifting into other thoughts.  I know I can’t really be aware of the person’s thoughts, but I watch very carefully to see whether the person’s eyes are moving (usually they’re closed during this session) and whether they’re fidgeting or shifting in the chair. This initial introduction is usually quite brief – only a few minutes – to give the person a taste of what it might feel like to experience without naming or judging or labelling.

Debriefing at the conclusion of this brief session is essential, IMHO.  This is where therapist’s personal use of mindfulness is important – whatever the person experiences is OK.  I ask about what they noticed during this experience, mainly to identify whether they’re labelling the experience as “good”, or “bad”, or shades in between.  Essentially I’m hoping for the person to simply list the sensations rather than indicating whether they are judged as something.  An example might help: if the person said “I was surprised at how warm my hands were” is a judgement – the word “surprised” suggests a judgement about what is usually experienced.  My response might be “So you noticed your warm hands” rather than probing as to what the “normal” state is, or reflecting that the person was surprised.

For home-based learning, I suggest doing this same breathing exercise at least three times a day.  Or I might suggest being mindful while cleaning the teeth, noticing the sensations of brushing and the taste of toothpaste.  It’s a simple activity that is done regularly and is usually not interrupted!

Why focus on mindfulness?

There are a couple of reasons I like mindfulness.  I indicated earlier that it’s a portable, relatively simple strategy that can be used anywhere – and that it’s the opposite of catastrophising.  Delving into the mechanics of how mindfulness works is beyond the scope of a post like this, but it does seem that observing without judgement reduces the automatic evaluation of a body sensation as “something really bad”, ie catastrophising.  We know that catastrophising is associated with increased disability, anxiety, low mood and can serve to maintain behavioural avoidance.

The study by Cassidy and colleagues found that “greater mindfulness was predictive of lower levels of disability, anxiety, depression and catastrophizing, even when pain severity was controlled” in the context of delivering a multidisciplinary pain management programme.  We can’t determine from the design of this study whether the practice of mindfulness influenced catastrophising, but some statistical analysis of the relationships between mindfulness, catastrophising and disability found that the degree to which mindfulness influenced disability was itself influenced by catastrophising, and that mindfulness had a direct relationship with catastrophising, and in turn had a relationship with disability.

What this means is that increased mindfulness appeared to reduce catastrophising, which in turn reduced disability.

The explanation given is that mindfulness involves greater use of nonjudgemental awareness of events, experiences, sensations around an individual, and that by doing this, the tendency to jump to a negative conclusion about the meaning of that experience is reduced.

It’s worth considering how mindfulness can be integrated into daily clinical practice – for both the practitioner and the client.  It’s certainly easier to teach something that has been personally experienced, and it is likely to help maintain that broad awareness that is needed when observing what is going on with a patient.  It does mean giving oneself space to later recall and interpret what is being observed, but I find it’s a whole lot easier to do so than if I’ve been trying to interpret at the same time.  This, of course, will depend on the content of a treatment session.

Cassidy, E., Atherton, R., Robertson, N., Walsh, D., & Gillett, R. (2012). Mindfulness, functioning and catastrophizing after multidisciplinary pain management for chronic low back pain PAIN, 153 (3), 644-650 DOI: 10.1016/j.pain.2011.11.027

Gratitude when you’re in pain? You’ve got to be kidding!


ResearchBlogging.orgOr – introducing the “parent of all virtues” (Wood, Joseph & Linley, 2007).

For some time now I’ve been exploring the contribution of positive psychology on wellbeing in people with chronic pain.  Positive psychology is the ” scientific study of the strengths and virtues that enable individuals and communities to thrive”. (Seligman, ND). It strikes me that in chronic pain management, we’ve responded to the issues raised by people who don’t “live well” with their pain, leaving the group of people who do cope well largely ignored. We have much to learn, I believe, from those who have faced their situation and either been stoic – or in a surprising number, grown from their experiences.  Some excellent resources in the field of positive psychology in general can be found at The Positive Psychology Center and Authentic Happiness, and for Kiwi’s, the New Zealand Association of Positive Psychology.

Gratitude is an emotion that most people feel frequently and strongly (McCullough et al., 2002).  Most people say that feeling grateful makes them feel happy. And oddly enough, gratitude seems to emerge despite difficult circumstances – with some research suggesting that it is in times of intense personal challenge that gratitude is most prominent (Peterson & Seligman, 2003). Immediately after the earthquakes in Christchurch nearly a year ago, people frequently expressed gratitude for one another, for the workers who kept the city running, and for the simple things in life like water, shelter and social support.

The question then arises – is experiencing gratitude empirically related to psychological wellbeing? And the answer is, not unexpectedly, yes! One study showed that gratitude was associated with wellbeing more than the “big five” personality model (Wood, Joseph and Maltby, 2009). It appears that gratitude influences wellbeing in two ways: “directly, as a causal agent of well-being; and indirectly, as a means of buffering against negative states and emotions.” (Nelson, 2009).

The next question is – can we influence wellbeing by increasing gratitude? And so far, research seems to support it.  For instance, in Catherine Nelson’s 2009 review of gratitude interventions, she cites studies in which one group of participants were asked to write down five things they were grateful for each week over 10 weeks, while two other groups were asked to carry this out daily either for two weeks or three weeks. At the completion of the study, it was found that positive affect was increased, and that there appeared to be a dose-response effect. In other words, the more often gratitude was expressed, and the longer this was carried out, the more positively people felt (Emmons & McCullough,
2003).

Interestingly, although we think of gratitude as having an effect on emotion, expressing gratitude can have a direct influence on “physiological coherence”.  This is “increased synchronization between the two branches of the ANS, a shift in autonomic balance toward increased parasympathetic activity, increased heart-brain synchronization, increased vascular resonance, and entrainment between diverse physiological oscillatory systems. The coherent mode is reflected by a smooth, sine wave-like pattern in the heart rhythms (heart rhythm coherence) and a narrow-band, high-amplitude peak in the low frequency range of the HRV power spectrum, at a frequency of about 0.1 hertz.”(McCraty & Atkinson, 2003). What this means is that by expressing gratitude, we may be improving our physiological response to life events.

How do we introduce the idea of expressing gratitude when life is difficult? – for this part of my post today, I’m using my approach, because I haven’t yet found research that identifies “the best way” to do it!

My way is to begin with some mindfulness. Sitting with the person and asking them to be present with what is happening right now. This can be done through focusing the mind on breathing, really experiencing the sensations that occur while breathing – the rise and fall of the abdomen, the cool air in the nostrils when breathing in, the warmer air when breathing out, the heart beat, the weight of the body pressing against the surface of the chair or support, the warmth of hands on lap.

I then ask the person to think of something that they appreciate right then and there. I might say “What comes to mind when you think of something you’re grateful for right now.” If they seem stumped, I might suggest that they express appreciation for being able to breathe; or being able to hear – and I might guide them to sounds of nature; or having a chair to sit on – and I might guide them to experience the sensation of being supported by the chair.

I try to guide the person to identify at least four or five things they appreciate then and there, so they can experience what it feels like to mindfully notice the good that is around them, and to notice the emotions that arise from doing so.

Ongoing practice I then give people is to write down three things they appreciate or are grateful for at the end of each day just before going to sleep.  Research has shown that doing this can influence sleep quality (Wood, Joseph, Lloyd & Atkins, 2009).

So, here’s a thought: what about trying this strategy out for yourself? It’s easy, quick and has some surprising results. Let me know how it works for you.

Emmons, R.A. & McCullough, M.E. (2003). Counting blessings versus burdens: An experimental investigation of gratitude and subjective well-being in daily life. Journal of Personality and Social Psychology, 84(2), 377–389.

McCraty, R. & Atkinson, M. (2003). Psychophysiological coherence. Boulder Creek, CA: HeartMath Research Center, Institude of HeartMath, Publication No. 03-016.

Nelson, C. (2009). Appreciating gratitude: Can gratitude be used as a psychological intervention to improve individual well-being? Counselling Psychology Review, 24(3-4), 38-50.

Wood, A., Joseph, S., & Linley, A. (2007). Gratitude – Parent of all virtues. The Psychologist, 20(1), 18-21.

Wood, A. M., Joseph, S., Lloyd, J., & Atkins, S. (2009). Gratitude influences sleep through the mechanism of pre-sleep cognitions. Journal of Psychosomatic Research, 66(1), 43-48.

Wood, A. M., Joseph, S., & Maltby, J. (2009). Gratitude predicts psychological well-being above the Big Five facets. Personality and Individual Differences, 46(4), 443-447.
A Wood,, S Joseph, & A. Linley (2007). Gratitude – Parent of all virtues The Psychologist, 20 (1), 18-21

Empathy, distress and mindfulness


ResearchBlogging.org
One of the main thrusts of the paper by Hadjistavropoulos, Craig, Duck, Cano, Goubert, Jackson, et al., is that pain communication can serve several functions – it can be an action where a message is sent or received; it can be an interaction where the message is sent, received and interpreted; or it can be a transaction where the messages are exchanged but something other than the messages exchanged actually occurs such as a verbal exchange that results in a contractual agreement.

Communication as action can be something like when a person groans, rates their pain as “really bad”, or goes to a clinic.  Communication as interaction can be when a person is able to communicate their distress to their partner so the partner can understand how the person is feeling.  And when that person sees a doctor, tells him or her about the pain and the doctor makes a diagnosis and then starts treatment, communication as transaction has occurred.

It’s the communication as interaction that I want to talk about today, and particularly in the case of someone in distress – because that interaction can move from simply an interaction to a transaction depending on how the communication is interpreted.  Let me explain.

A person I’ve been seeing (and don’t forget, details are modified to protect confidentiality) has low back pain.  She has completed her pain management programme but every now and then makes contact.  Yesterday I had a message given to me by our receptionist saying that Andrea had phoned, sounded really upset and could I call back as soon as possible.  This is communication as transaction – the receptionist had made a commitment to do something.

Anyway, I phoned Andrea and she did sound incredibly distressed.  Her voice wobbled and I could hear her breathing in short gasps.

“I’ve hurt my back again”, she said. “I can’t move my neck, my shoulder, and I can’t lie down, I don’t know what to do!  My doctor wants to send me to hospital. I’ve taken all the meds I’m allowed to, and they’re not working. I haven’t slept. What do I do?”

Well, to me she sounded pretty unhappy! My interpretation of her tone of voice, the panting and gasping I could hear and the words she used was that she was scared, she was struggling to maintain control, and she wanted rescuing.  This is communication as interaction.

I had a choice. I could tell her what to do. Take control of the situation and “do something” just as her doctor had.  But what would my doing so communicate to her?  Where was my belief that she had skills, she knew what to do?  And, more importantly, was this what she really wanted from our interaction?

Another option was to try to soothe her, talk her through her distress and ease her fears, to settle her down. What would my doing this communicate to her? Would it teach her that she had every right to feel upset and out of control, to fear this flare-up of pain, to avoid experiencing it?  And would I be doing this out of my concern for her, or to reduce my own distress at the rawness of her emotions?

I learned, way back in my early training, that empathy can be defined as “being able to walk an another person’s moccasins”.  Apparently this was a Native American saying to show that to really know where someone is coming from means to feel the blisters their shoes make on your feet.  Being empathic is an important part of clinical work.  But there are drawbacks – standing with another’s emotions can expose your own vulnerability, and it involves effort. It can be fatiguing.

For many clinicians, I think it’s difficult to allow someone else to feel their own feelings without wanting to “take the pain away”.  I wonder whether this is (a) what the person wants, someone to “fix the problem” and (b) teaching the person that these emotions are bad, wrong or to be feared.  And I wonder whether this response says more about the clinician’s own ability to be present with distress.

Mindfulness is about “making room for” the wide range of human emotion, in a nonjudgemental way.  Mindfulness acknowledges the presence of sadness, fear, anger, joy, desire, and allows it to pass.

My choice with Andrea was to ask her if she was prepared to sit with her feelings with me. I asked her to just breathe, to feel the flow of air in and out of her body, to feel the contact of her body on the chair, the sensation of warmth where her fingers lay on her leg, the rise and fall of her emotions as we made room for them to be present.

I asked her to be present with her pain too, to feel the sensations and to allow them to be experienced as they are instead of what she feared they represented. Because it wasn’t the actual sensations that Andrea was worried about – it was her fears that the pain wouldn’t ever go away, that she’d never be able to sleep properly again, that they’d escalate, that the pain would spread, that all the things she’d learned wouldn’t work, and she was remembering how she’d felt right back before we’d started to work on her pain management.

And together we made it through and Andrea said, with some surprise, that she felt the pain but it wasn’t bothering her as much.

Hadjistavropoulos, T., Craig, K., Duck, S., Cano, A., Goubert, L., Jackson, P., Mogil, J., Rainville, P., Sullivan, M., de C. Williams, A., Vervoort, T., & Fitzgerald, T. (2011). A biopsychosocial formulation of pain communication. Psychological Bulletin DOI: 10.1037/a0023876

Which comes first: Doing or knowing?


ResearchBlogging.orgReceived wisdom in cognitive behavioural therapy says that to change behaviour, a person must first change his or her thinking.  This has created a tension between those clinicians who emphasise the cognitive aspects of pain management – and those who focus on helping people with pain do more.  Should we educate and target cognitions, particularly those sticky core beliefs – or can we use behaviour change as a way to help the person make gains?

The answer is, as you’d have guessed, not black and white.  In fact, as several authors and researchers have pointed out (see the references below for just two), not only is the cognitive behavioural approach to chronic pain management a mixed bag of strategies, there is very little information on the process of change that occurs during treatment.

Here’s what I’ve seen clinically – while some people are ready to change, others are not.  I need to work with this second group using motivational interviewing approaches to help them identify their own reasons for doing things differently.

This might mean creating a sense of dilemma – identifying where they are now in terms of goals and satisfaction with life, and creating awareness both of the possibility that life might be different, and what that might look like.  This helps people recognise their “stuckness” and creates momentum for change.  From there, it’s far easier to help them develop goals and start to problem-solve what needs to happen to reach them.

Another group of people are those who are relatively inflexible in their thinking and behaviour – they’re stuck not because of a dilemma, but because they’re continuing to use strategies that have worked for them in the past, but are not working now.  It’s like they have trouble working out another way of approaching problems.

A good example of this is a man who has always been fit and before his pain began was a representative sportsman. His approach was always to do more than what was required. He was stuck because doing this when he had pain created a “boom and bust” approach to activity.   For this kind of person, I like to use what Steven Hayes (ACT) likes to call “creative hopelessness” – pointing out that it’s not the methods the person is using, but their purpose. I use experiential methods to do this – gettng the person to monitor what has happened over the week, and asking him to establish what he believes: his mind and what it tells him? or his experience and whether it works.

Cognitive change doesn’t necessarily occur before behaviour change
It’s strange, but true, that despite our best efforts, twelve months after people have completed a pain management programme, few are still using the strategies we help them develop.  While some are goal setting, or using relaxation, or exercising, or even checking in with their thinking – the majority are simply getting on with life (Curran, Williams  & Potts,  2009 – doi: 10.1016/j.pain.2005.09.004). And even more strange – people who start making behavioural changes early in a pain management programme seem to do best, while those who actually complete between-session activities also seem to do best (Heapy, Otis, Marcus, et al., 2005).

Persuasion, challenging core beliefs, and education have their place – for the right reasons, at the right time, for the right person – but they don’t alter the fundamental issue alone. 

 What is that issue? It’s about an attitude shift towards “sitting with” uncomfortable thoughts and sensations, and working towards valued goals despite those thoughts and sensations.  It’s about a spirit of gentleness and willingness to recognise those thoughts and sensations as the mind’s way of solving problems – and at the same time, accepting that it’s entirely possible to do what is important despite the presence of these thoughts and sensations.

Morley, S., & Keefe, F. (2007). Getting a handle on process and change in CBT for chronic pain Pain, 127 (3), 197-198 DOI: 10.1016/j.pain.2006.10.025
Morley, S. (2004). Process and change in cognitive behaviour therapy for chronic pain Pain, 109 (3), 205-206 DOI: 10.1016/j.pain.2004.02.008

Curran, C., Williams, A. C. d. C., & Potts, H. W. W. (2009). Cognitive-behavioral therapy for persistent pain: Does adherence after treatment affect outcome? European Journal of Pain, 13(2), 178-188.