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,

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

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.

Quick update from earthquake city

The aftershocks seem to have slowed a little, and they are not as powerful so hopefully things will settle down a bit. We still don’t have water, so we’re having to use our emergency stash (60 litres!) and boil it to wash, do dishes etc. Even when the water comes back on, we’ve been advised to boil the water again because there’s damage to the sewers.
I feel OK in myself, in that I’m not fearful of the quakes (a bit fatalistic really, but there is so little time to react when a quake hits, there seems little point in being afraid – you can’t do anything!), but I am very tired and not sleeping all that well.
I think the difference for people in Christchurch now, compared with the previous two big earthquakes is that the adrenaline rush that was there last time hasn’t been available this time. There’s less energy reserve to draw upon and the daily hassles of dodging potholes and cleaning up liquefaction and working out which shops are still open and where they’ve relocated to – all of that practical ‘stuff’ that is usually there in the background – these things take cognitive effort. Routines and habits make life easier, mean the brain can be freed for more important things. For me anyway, the routines and habits are disrupted and require thinking and planning and time.
I ask myself how are these changes I’m working through any different from the sort of changes in “how to do” that a person with disability needs to make? How often do clinicians forget that doing things “differently” takes mental effort – and in pain management, we’re often asking people to do almost everything in life “differently”. No wonder there are times when people who have limited resource to draw on (maybe fewer social supports, fewer original habits and routines, mental health problems, less flexibility in the ways they are able to view their world) struggle to cope with the demands of both a pain problem (which already makes demands on them) AND our suggestions for change!

I’m off to work shortly, to work with a group of people who have chronic pain and who have been incredibly courageous in wanting to keep going with the last week of their programme despite the earthquake. They were given the choice to stop, to defer the programme and return again, but they chose to stay. That is strength and resilience folks. I am so lucky to work in this field, with the team and patients I work with.

Wobbles in the Quakey Isles

By now, if you’re a regular reader of my blog, you’ll know that I’m from Christchurch, NZ, and yes, we’ve had a few earthquakes recently! I’m happy to report that while we’ve had some more damage to the surrounds of our house, and there are a few more cracks in the ceiling and bricks, we’re pretty well off. No serious damage done except a rather disrupted night!
My nerves are a bit frayed and I keep monitoring any deep rumbling sound or rattle of the windows just in case it’s the beginning of another one – and yes, it’s a bit wearing. I’ll keep blogging but will keep the number of posts down, as I have been, just to reduce some of the (internal) pressure I put on myself to post often!
It’s tempting to say something a bit trite like “we’re all tough here” or something but really, it seems to me there is little I can do to change our situation, much to be grateful for, and more reasons to be positive than not. So if being tough is equal to being occasionally grumpy, tearful for a moment or two, laughing often, taking time out, and finding good things to appreciate, then I suppose I’m being tough! This is life, and life can randomly throw challenges as well as delights. That sounds awfully philosophical, but seriously folks – that’s my way of getting through and being OK.


I had a nice email from James Hardie from Moodjuice website, an NHS Scotland site developed for both health professionals and individuals to access self help resources.

For patients, the site starts by saying “Emotional problems are often the mind and body’s way of saying that something needs to be changed in our life” – I like that!  I like the way the patient area is based on practical problems like housing, childcare, hobbies and interests, meeting people, relationships and so on.

For professionals, the feature that really appeals to me is the “build your own resource” area.  This enables you to put together the most relevant handouts for the person you’re seeing – a lovely feature! Then you can print the whole lot off, and it’s a pulled-together document that looks a far cry from some of the tatty photocopied things I’ve seen in the past.

The resources in the professional area is designed to be used alongside individualised sessions, so it’s not a “plug and play” kind of site – but it does provide a great range of tools that you can use.

My one tiny criticism? The site doesn’t clearly indicate who developed it – well, it does, but it’s buried in the menu’s right away from the front page. I’d like to see that information on the front page, along with the dates the material has last been updated (just a wee point).

Anyway, here are the pages for the Chronic Pain page

and the Problem Solving Information page

and the Challenging Thoughts page


Earthquake aftermath

Dear Readers

I have had many, many expressions of concern since the earthquake struck Christchurch again on Tuesday 22 February 2011.  I’m glad to say that me and my family have escaped relatively unscathed from this traumatic event – I can’t say how badly hit my home city has been though.  While the earthquake on 4 September last year was certainly awful, this one has been so much more devastating in terms of the physical damage, not to mention the human cost in loss of life and both physical and emotional damage.  The infrastructure in Christchurch is incredibly damaged – I live in New Brighton, and we are expected to not have power for several weeks; we have no water or sewerage; the roading is terribly broken up with huge holes and smelly, sewage-contaminated liquefaction all around. 

Luckily I am well set-up at home with camping equipment.  My partner and I were away on a camping holiday for two weeks, starting on Sunday (20th).  We were in Motueka which is well north of Christchurch when I heard about the quake.  I can’t tell you how overwhelming it felt to be up there and be unable to contact my daughter who was in town, right beside one of the worst-hit areas of the city centre.  She was safe, and made contact about five hours later, but as we heard of people being killed by falling debris, I’m sure you can imagine what it was like not to be able to hear anything.  The rest of my family are fine.

I’m currently writing from my parent’s place.  Their power and water has been restored hence my being able to write! But I will go back to my home later today because the mess inside was incredible.  Every single drawer and cupboard was open with the contents hurled on the floor.  All the TV sets (we have a few!!) hurled to the ground, all the electronic equipment similarly on the ground (and we have no way to tell if they’ll ever work again with no power!).   My precious ceramics and crystal smashed – all the foodstuffs from my pantry over the floor.  Now the contents of my fridge and freezer are rotting because there is no power.  My sewing machine, iron, all my beadwork – tossed on the floor.  My piano had a shard of glass embedded in the side about 1cm deep (glad I wasn’t standing in the way of that!).  All the bookshelves and books, all the china cabinet, – ALL THE ALCOHOL!!!! all over the floor. 

How do you clean with no water? How do you get rid of the glass shards in the carpet with no power?  What do you do with the wasted food and human waste that needs to be disposed of while keeping hands clean?  No cell phones, I have a portable radio (thankfully!) but not able to make calls for most of yesterday – we now have the telephone connected, thankfully we have an old analogue phone we keep for just these emergencies!

If you haven’t yet put together an emergency kit – please do!  Consider it to be something like camping: gas cooker (portable), water containers (20litres), toilet paper and a portaloo, hand sanitiser, foodstuffs that won’t go off or don’t need refrigerating.  I’m using ice and a chilly bin to keep food cold – you can’t keep meat, milk, cheese in a warm environment.

I know I won’t be able to maintain contact much over the coming days until we get power restored.  In the meantime, please accept my thanks for the thoughts that have been pouring in.  I know there are so many people who have given time and energy to keep the people around me well and bouyed in heart and mind.  This is why people matter.

A maori saying that always means a lot to me:

He aha te mea nui?
He tangata.
He tangata.
He tangata.

What is the most important thing?  It is people, it is people, it is people. 

Believe it.

Friday Meditation

As you know, Friday is about getting ready for the weekend.  Today I decided not to pass on some of the horrendous puns shared with me by one of my esteemed colleagues (although I may drop just one in because I can!).  Instead I thought this poem is a chance to consider being ‘in the now’, something clinicians working in pain management really need.

Salutation To The Dawn

Look to this day!

For it is life, the very life of life.

In its brief course

Lie all the verities and realities of your existence:

The bliss of growth,

The glory of action,

The splendor of achievement,

For yesterday is but a dream

And tomorrow is just a vision,

And today well lived makes every yesterday a dream of happiness

And every tomorrow a vision of hope.

Look well, therefore to this day!

Such is the salutation to the dawn.



Oh, a pun?  As you read this, remember I have to work with the person who passed it on…sigh…

She was only a whiskey maker, but he loved her still.

A rubber band pistol was confiscated from algebra class, because it
was a weapon of math disruption.

No matter how much you push the envelope, it’ll still be

A dog gave birth to puppies near the road and was arrested for

I wondered why the baseball kept getting bigger.  Then it hit me.

Two fish swim into a concrete wall.  One turns to the other and says

CBT approach in the real world


While there are many papers published about the outcomes from using a cognitive behavioural approach, there are very few describing the process ‘in the real world’. This leaves a gap for many clinicians who may read about it, maybe have training in delivering this type of intervention, or work in a team where it’s an integral part of practice – but who may not know how it ‘works’ except as it’s delivered in a pen-and-paper, sitting-in-a-clinic-room kind of way.

Today I’m describing one way I go about integrating a CBT approach into my work.    This case study is a compilation of several people I’ve worked with, in order to protect patient privacy.

Simone has neuropathic pain in her dominant hand. She’s a tough cookie who worked in a shearing gang. She’s tiny, has a command of the cussing vocabulary that has to be heard to be believed, and she’s very reluctant to use her hand although she has really good movement.

Simone’s always been a physical kind of person and loved riding motorbikes, rock climbing and gardening. She doesn’t think any of these things are manageable now, and so she spends most of the day ‘pottering’ in the garden or with friends or, as she puts it ‘death by DVD’.

Her goals are to get fit again, to decide on her ‘next best steps’ for returning to work, and to feel more confident about using her hand BUT she’s made it very clear that she’s not going to do ‘pretend’ activities like handcrafts or ‘just holding the bike throttle’ – she wants to start doing proper things again.

Oh my, where do we start!

We’ve started by reviewing what she knows about pain management – naming all the different types of strategy that can be used, and ranking them in order of priority for review. Simone said she needs to ‘get fit again’ and sees exercise as a big part of this; she also recognises that she can be quite inconsistent in her activity patterns, and although she knows about activity pacing, she doesn’t like doing it.

I asked her about her daily routine and she laughed saying that she just ‘does’ and hates planning, so instead I gave her 12 cards representing the amount of energy she has to ‘spend’ over the course of a day. I asked her to allocate her cards into three areas of living: self care, fun and work. She divided the cards quite evenly, so I then asked her whether this was how she wanted to spend her energy. She said no and that it was very different from her pre-accident pattern, so I asked her to show me what that looked like. She pushed almost all of the cards into the ‘work’ pile, and kept only one for self care and two for fun.

I asked her what was different about her self care now compared with before, and she described the process of showering – and while she talked, I was able to identify her automatic thoughts about each task. She said she always thought it should be enjoyable but now it just felt hard. She said she didn’t think she should have to ‘think’ about how she undressed, washed herself, dried herself, and got dressed again. Now she felt her body was skinny and ugly and her arms ‘wouldn’t work properly‘, and so she avoided looking at it, and didn’t use moisturizer and didn’t shave her legs any more.

She was very articulate about the automatic thoughts and images that she had while showering and we were also able to identify some of the emotions that were generated by these thoughts, and how this affected what she did.

I used a whiteboard to jot down the situation, her thoughts, linking to her feelings and on to her actions, and Simone was quick to say that these thoughts weren’t helping her.  NB all the underlined phrases above refer to automatic thoughts she was having.

We haven’t yet explored these thoughts nor tried to do anything with them (maybe we won’t do anything, just notice and do what is important?) – but part of understanding her situation is about listening to her thoughts as I’ve outlined above. This is Simone’s ‘lived experience’, but it’s absolutely possible for her to evaluate her situation differently and come to a different conclusion about them.

For a very quick example, I might ask her what does it mean to ‘have’ to think about each movement she does?  What does it say about her? What does it mean to have a rule that says showering ‘should’ be easy – when clearly, showering for her is not. If she says she feels ‘dumb’ or ‘useless’, I may explore other situations in her daily life now where she feels ‘dumb’ or ‘useless’ – and help her notice her emotional response to this.  What effect does having this emotion have on her actions? On what she does and how she goes about it?

Simone has described patterns of thoughts that are very judgmental about her capabilities.  While a psychologist may explore some of the origins of this, and the effect on her mood and especially her vulnerability to depression, what I’m inclined to explore is how her automatic thoughts and underlying ‘rules’ are affecting her willingness to engage in activities that she previously enjoyed – like having a shower – and both be aware of this vulnerability in terms of goal setting (she’s not keen on doing this!), and help her generate some more positive self statements she can make when trying a different approach. I’ll also ensure the goals are achievable but also ones she really values.  If they’re ‘too easy’, she’ll judge them as not worth the effort while if they’re too difficult and she can’t see why she should persevere (ie they’re not important to her), she may give up.

I’ve suggested already that she treat each new method as an experiment.  We don’t fail at experiments – we can learn from each attempt. When she tries a new approach, we’ll go through the things that worked well, and the things that she would do differently.  I’ll also use motivational approaches to encourage her to recall why she used to enjoy showering – she loved it because she felt energised, she could pamper herself (remember that Simone was working in a very masculine environment), and she was able to take some time out.  These are important things she can focus on as she develops strategies to return to this very important activity.

Shannon, E. (2002). Reflections on clinical practice by occupational therapists working in multidisciplinary pain management programmes in the UK and the USA Australian Occupational Therapy Journal, 49 (1), 48-52 DOI: 10.1046/j.0045-0766.2002.00291.x

Strong, J. (1998). Incorporating cognitive-behavioral therapy with occupational therapy: a comparative study with patients with low back pain. Journal of Occupational Rehabilitation, 8(1), 61-71.

Pulling it all together – biopsychosocial assessment

Over the past little while I’ve been writing about how a comprehensive pain assessment can be carried out.  Today it’s time to pull that information together to develop a formulation, or set of possible explanations for why this person presents in this way at this time – at least for one or two aspects of his presentation.

For example, if the person’s pain is low back pain, where surgery has failed to improve the person’s pain, but he has maintained working in a teaching job where physical demands are reasonably light, but is having trouble with sleep, feels irritable, can’t manage things like mowing lawns, and is very careful not to bend because he was advised after surgery to avoid bending because it may affect healing.   Limited forward flexion, side bending, back extension, cardiovascular tolerance moderate on step test, reports fatigue getting worse through course of weekGuarding noted, rubbing back, grimacing, would not complete box lift test from floor, or box to top shelf  (no weight in either situation) due to concerns about increased pain and potential harm.

Each of the underlined phrases represents a finding that needs to be put together with the information from questionnaires and clinical examination/observations from the team to form a set of hypotheses that can be tested within therapy to (a) establish whether they hold true and (b) help to ameliorate the pain, distress and/or disability the person is experiencing.

What do you think is going on for the person described above?

Remember that the people I see have chronic pain, most of them have had this for many years, and most of our treatments reduce pain by maybe 30%.

From a biomedical perspective, if it’s established that surgery has been ineffective, one of the most likely diagnoses is ‘chronic low back pain with central sensitisation’. This diagnosis can’t be confirmed with any specific test, but is most likely if the person describes multiple persistent pains, possibly migraine, often highly sensitive to side effects from medication, low mood, irritable bowel and, in women, pelvic pain especially that associated with menstruation.

The main management from a medical perspective is a tricyclic antidepressant, if that’s ineffective something like gabapentin or pregabalin, failing that, and atypical SNRI or similar, and often a combination of these medications.  In some people there is a nice response – pain is alleviated, sleep is improved, and the person feels much better.  In most people, the response is somewhat more muted, and in some there is no improvement at all.  Even the best response is not often more than a 30% reduction in pain.  At least in our experience.  At this point I’ll remind everyone that I’m not a doctor, this is not medical advice, and this is what is carried out in the center in which I work.  For more references on central sensitisation, you can’t go beyond papers by Prof Clifford Woolf, this one is from 2007 and is full text, online.

Unfortunately, having a diagnosis, as you can see, doesn’t really help us with the management of our man’s disability and distress. Even if his pain reduces by our mystical 30%, he still avoids a lot of movements, his sleep pattern is poor, and he believes his back may be damaged if he does movements that bring on his pain.

And even if we’re very good at giving him ‘education’ about his pain – as I’ve said before, quoting Bill Fordyce, ‘Information is to behaviour change as spaghetti is to a brick.’ Information or education alone is often/usually insufficient for someone who is stuck in a pattern of avoidance and disability – after all, a spider phobic in New Zealand knows there are very rarely any poisonous spiders here, but is still fearful! (I know because I was one).

Let’s take a look at one of the psychosocial and functional strengths this man brings to his situation: He’s maintained working as a teacher, despite poor sleep, and lots of functional limitations. We can ask some questions of the information we’ve assembled about how he’s able to do this – what are his values? what routines support his getting out to teach every day? what strategies does he use to maintain standing, walking, sitting – and concentrating, remaining calm despite feeling irritable – as he teaches?

At the same time, we can ask similar questions of his functional limitations: what factors contribute to his difficulty bending? What are his beliefs about bending? What maintains this behaviour – internally (he may get a stab of pain when he bends, or he may anticipate that he will get pain when he bends, or he may get pain that starts after he’s done some bending – hardly an incentive to bend!), and externally (what do people around him say when he bends and grimaces? what do important/powerful people say about bending? eg his surgeon), what muscle groups are working over-time to maintain his guarded posture – and so contribute to his pain and subsequent avoidance?

In the space of a few minutes, I’ve started to put together some areas to flesh out the simple picture we get from just knowing his diagnosis.  Now let’s start to draw in what else we know from theory and clinical experience.

Hypothesis one: because this man holds strong values about following through on a commitment, he may be mindful of his pain while teaching, but is able to put this aside in the classroom.  Theory base? If I used ACT as a framework, values are ‘chosen qualities of purposive action’, in other words, they’re what lies beneath committed actions.   One way this man could be maintaining this action could be because he has developed an awareness that his thoughts are not him.  So he can experience pain, but allow this awareness to flow past him as he continues teaching.

We could to test this hypothesis by asking him about his values and his awareness of his thoughts about pain while teaching, and we could see if he uses this same approach in another activity that he also feels is aligned to an important value.

Hypothesis two: he avoids bending because of several things – he believes he may harm himself, this was initially reinforced by advice from his surgeon post-operatively, and later by the images he has in his mind of his vertebrae ‘above and below the fusion taking more of the strain’.  Additionally, he experienced pain on several occasions when he inadvertently leaned down to pull his socks on after surgery, and he is fearful of having that pain again because it gave him a fright and reminded him of the pain he had before his surgery.  Finally, his partner reminds him to ‘be careful when you’re moving, dear’ because she’s heard him groaning when getting in and out of bed during the night.

To test this set of hypotheses we can provide him with good information about his back, we can remind him that the surgeon was talking about immediate post-operative care, we can show him his X-rays and we can tell him about the studies that show degeneration of vertebrae above and below a fusion is no worse than if his back hadn’t been fused.  If his anxiety reduces, and he is more able/ready to approach doing those movements, our hypothesis is confirmed to a degree.

Then we’ll need to use graded exposure to help him work out that bending doesn’t inevitably lead to an increase in pain – and more importantly, even if he does experience an increase in pain, this doesn’t mean he ‘can’t cope’ with it, or that he will end up needing further surgery.  We can help him deal effectively with any increase in pain by using breathing, mindfulness, positive coping statements, and ensuring our graded exposure has been developed appropriately. 

If, by following this process, he begins to reduce his avoidance and he reports that his anxiety is reduced (and we could even monitor this using biofeedback), our hypothesis is confirmed, again to a certain degree.

The final thing we might do is ensure his partner is involved in the initial explanation and reasoning for these approaches so she is reassured, and help her develop some coping strategies for her own distress at seeing her partner sore – perhaps by helping her say something encouraging like ‘good to see you have a go at that’, or breathing techniques, or a coping statement like ‘he’s learning how to do things again, this is a good part of his recovery.’

If, by his partner responding more positively to his attempts at doing things he has previously avoided, our patient starts to do more while in her presence, again our hypothesis is confirmed and we have done the right thing.

Some references for these types of approach? Your wish is my command.

Vowles, K. E., Wetherell, J. L., & Sorrell, J. T. (2009). Targeting acceptance, mindfulness, and values-based action in chronic pain: Findings of two preliminary trials of an outpatient group-based intervention. Cognitive and Behavioral Practice, 16(1), 49-58.

van Wilgen, C. P., Dijkstra, P. U., Versteegen, G. J., Fleuren, M. J., Stewart, R., van Wijhe, M., et al. (2009). Chronic pain and severe disuse syndrome: long-term outcome of an inpatient multidisciplinary cognitive behavioural programme. Journal of Rehabilitation Medicine, 41(3), 122-128.

Slade, S. C., Molloy, E., & Keating, J. L. (2009). ‘Listen to me, tell me’: a qualitative study of partnership in care for people with non-specific chronic low back pain. Clinical Rehabilitation, 23(3), 270-280.

Quartana, P. J., Campbell, C. M., Edwards, R. R., Quartana, P. J., Campbell, C. M., & Edwards, R. R. (2009). Pain catastrophizing: a critical review.  Expert Review of Neurotherapeutics, 9(5), 745-758.

de Jong, J ; Vangronsveld, K ; Peters, M ; Goossens, M ; Onghena, P ; Bulte, I ; Vlaeyen, J.  (2008) Reduction of pain-related fear and disability in post-traumatic neck pain: A replicated single-case experimental study of exposure in vivo.  The Journal of Pain. Vol.9(12), pp 1123-1134.