Brain training – it happens all the time

At the risk of seeming untrendy, the trend to rave on about neuroplasticity can be a bit overdone.  Not, I add quickly, because it doesn’t happen, or it’s not important – in fact, quite the opposite – but because it happens all the time.  And at the back of our minds, I think we’ve known this for quite a while.  How else do you think we manage to learn new things even in our elder years?

The reason I’m raising this today is, after yesterday’s post on phantom limb pain and the parts of the brain that are active when we have pain and when hypnosis is used for pain relief, I started to mull over the range of treatments that are used in managing chronic pain.  Now, we don’t have fMRI studies for all the treatments available.  I don’t think I can recall any studies where fMRI is used to study the effects of CBT on pain, or exercise on pain.  This is, in part, an artifact of the fMRI technology – it’s impossible to be physically active while inside the scanner, and scanning occurs in a rather artificial environment that is nothing like that encountered on a daily basis.

But if we move away from any notion that psychological approaches are magical and affect the being through ‘mystical’ processes, we need to draw the conclusion that any of the standard behavioural and cognitive techniques used in pain management must influence the brain somehow.  While we don’t currently know how this occurs, there doesn’t seem to be any other plausible explanation.

Why is this important?  Well, because it means the more we know about how the brain works, and particularly those very complex forebrain processes (see Neugebauer, Galhardo, Maione, & Mackey, 2009), the more we can see how previously ‘mind not body’ processes are actually neurobiological, and how the dualist notion of a distinction between mind and body simply doesn’t work.

And this leads me to introduce a patient of mine to you (details altered for confidentiality reasons).  Let’s call him Jim.  He’s a 64 year old man who crashed his motorcycle and sustained a below knee amputation about 15 years ago.  He successfully managed this, and wore a prosthetic limb most of the time.  Five years ago he started to experience more than his usual phantom limb, he started to have severe intermittent phantom limb pain.  He was still working at the time, and told me he’d close his office door and hold his breath and brace himself every time his pain started.  The episodes were initially once or twice a day, but quickly progressed to several times an hour, and each episode lasted for around a minute.

Jim tried a range of medications, and was part-way through a systematic trial of available meds when he was referred to me because he couldn’t remain working and was highly distressed at giving up his quite responsible job.  I need to explain that Jim had always been an active amputee – he regularly cycled, swam, walked (should I say, hiked/tramped!) for miles, and his general health was excellent.  He’d never had a bout of depression, had never been an anxious man, but was quite driven to excel and very motivated to keep his job.

It’s common to find that there are no medication solutions to phantom limb pain.  Jim was ready to look at how he could regain some sense of control over his life, and most especially, a way to get through the intermittent painful ‘attacks’.

As many researchers and authors point out, knowledge about pain mechanisms, or at least a model of pain, can reduce fear.  In doing this, it can reduce distress.  While we don’t know exactly how this occurs, it’s fairly certain that those parts of the brain that are involved in self regulation, emotion, fear, and decision-making are activated.

In Jim’s case, I began by describing a model of pain – and included in that, a cognitive behavioural model as well.  This model identifies that thoughts interact with the emotional state which interact with behaviours – and all of these in a bidirectional way. 

From this model, Jim was able to identify that as soon as his pain came on, his first thought was “Oh no, not this again”, he immediately felt afraid and braced himself for the onset of pain.  He also held his breath, gripped his desk, gritted his teeth, closed his eyes – and waited.  The effect of this response, even in someone who doesn’t have pain, is exhaustion – just try it yourself!

I introduced diaphragmatic breathing as a first step, ensuring that Jim had an effective relaxation response before we started changing his behaviour at the onset of pain.  Once he’d achieved this, we started by acknowledging his automatic thought, then allowing this thought to go by and instead of bracing himself, using a long outbreath and a cue word “Relax”.  He continued then with four more long breaths out, and by then the ‘attack’ had passed.

In addition to this, we also introduced a mirror treatment.  This consisted of using an old full-length mirror he had at home, sitting with the mirror in between his legs, so he could see his ‘good’ limb.  He then initially looked at his leg in the mirror, and progressed after some time to asynchronous movement of both limbs (while wearing the prosthesis).  While Jim told me that the initial experience was ‘weird’, he was able to experience a reduction of the continuous aching pain he had, and the frequency and intensity of the intermittent ‘attacks’.  This outcome with about 20 minutes use of the mirror each day.  Unfortunately after about 3 months use, the effect faded, and we’re not sure why.  It has never returned despite increasing the novelty, and improving the ‘illusion’ of the limb being his.   Jim told me that while he was disappointed in this, he was happy that he had other ways of coping, both the breathing/acceptance process, and he had developed more confidence to have an ‘attack’ while in the presence of other people, so it became less intrusive.

Some things to note: we can see from Flor’s work (and Moseley’s too!) that this kind of experience affects the brain regions involved in the experience of pain, while the majority of medications either don’t address it at all, or simply work to damp down the overall over-excitement of the nervous system. 

We can also see that it’s important to move beyond just addressing the brain retraining via mirrorbox.  It’s also vital to engage in cognitive and behavioural approaches to counter things like Jim’s concern that other people might think he was weird or pathetic when he had an attack.  The breathing strategy was a nonintrusive strategy that he can use anywhere.

Iannetti, G., & Mouraux, A. (2010). From the neuromatrix to the pain matrix (and back) Experimental Brain Research, 205 (1), 1-12 DOI: 10.1007/s00221-010-2340-1
Neugebauer, V., Galhardo, V., Maione, S., & Mackey, S. (2009). Forebrain pain mechanisms Brain Research Reviews, 60 (1), 226-242 DOI: 10.1016/j.brainresrev.2008.12.014

Flor, H. (2008). Maladaptive plasticity, memory for pain and phantom limb pain: review and suggestions for new therapies Expert Review of Neurotherapeutics, 8 (5), 809-818 DOI: 10.1586/14737175.8.5.809

Flor, H., Nikolajsen, L., & Staehelin Jensen, T. (2006). Phantom limb pain: a case of maladaptive CNS plasticity? Nature Reviews Neuroscience, 7 (11), 873-881 DOI: 10.1038/nrn1991

A year in review

This is the third year I’ve written this blog.  As the year ends, numerous people will be reviewing the year, reflecting on the good, the bad and the indifferent, and like them, I will too.

What has been the same this year is the endless need to repeat to all and sundry the following:

  • All chronic pain starts with acute pain – maybe if we were able to effectively manage risk factors for developing chronic pain in people when they first present for help with their pain, my job would be less in demand.
  • All pain, whether acute or chronic, is a psychological experience – and can’t be understood without an appreciation of the biopsychosocial model.
  • Because pain is a psychological experience means that we can’t divide pain into nociception and the psychological response to that nociception – because the two are indivisible.  Our brains are not just ‘waiting for’ peripheral events to reach them – the brain is not a blank slate, it’s actively involved in determining which aspects of our experience ‘we’ will experience.
  • There is not a lot new under the sun in pain management really.  Not a lot of new drugs (mostly they’re derivatives of opium, or they’re old drugs that have been adopted for new uses), and not a lot of new procedures, and no, not even a lot of new psychosocial/nonpharmacological treatments.  With, perhaps, the exception of brain retraining a la Moseley, and the introduction of acceptance and mindfulness based treatments.

What has been different this year?

  • More discussion across ‘Web 2.0’, or the medium of the internet – Facebook, Twitter, blogging and email.
  • More detail of the aspects of the cognitive behavioural approach to pain management that is influential to change, and along with that, more recognition that one size does not fit all.
  • More detail of what works for whom and when.
  • More need to not only assess – but also treat people!
  • More recognition that people with pain live in a network of relationships with other people, within communities and sociopolitical systems including legislation, and that all of these have an influence on the person’s ability to cope.
  • Increasing recognition that the health provider relationship has as much influence on the individual as his or her own beliefs.  Yes folks, what we say and how we say it does have an effect! Maybe not quite what we had expected, but definitely we have an effect.
  • More awareness that it’s not so much WHO delivers self management, but that self management IS delivered that is important!

In Christchurch, we’ve had the momentous earthquake and the aftermath.  Internationally we have had wars, rumours of wars, pestilence and plague – and yes we’ve even had locusts (in parts of Australia!).  Once again I’ve made friends with people from all around the world, all sorts of professional backgrounds, all sorts of interests in pain and pain management.  And I’ve continued to learn – from fellow clinicians, colleagues, patients, the journals I’ve read, the blogs I’ve read, the discussions (and maybe even arguments!) I’ve had – all have prompted me to think and learn and question.

And once again, I reflect on the incredible nature of science and the way in which I, as a clinician, ‘stand on the shoulders of giants’ to learn more.  To know that no ‘fact’ is sacred – that if there is evidence there to challenge a ‘received’ view, even a view that I’ve cherished, then it’s my duty to look at that evidence in the face and check it out.  There is no need to resort to mysticism, nor to hold to magical beliefs, or sacred texts.  Research is there for us all to learn from, and it’s my privilege to help share it to people who may not have the time or access to the information I do, and by doing this I might have a chance to help people live lives that are a bit better in quality than if I had written nothing.  At least that’s what I hope happens!

I’m incredibly thankful to the people who take time to comment and question me.  I’m not a guru, I’m definitely blinkered in my own perception of what I see, and I admit to being somewhat biased.  That’s another reason for writing – by putting my thoughts out to the interweb, hopefully people can bounce ideas off what I write – and then ask me questions!  And in doing that, I learn too.

2011.  Who knows what it will bring.  I expect (and yes, hope) it will bring even more questions!  Do ya feel like coming along for the ride?!

Why bother with happiness? Broaden and build theory & Chronic pain

Readers may be wondering why I’ve come over all happy clappy and jolly joy germ – well, I realised I’d been writing a lot about experimental and theoretical factors found to influence vulnerability to chronic pain, but I had been writing less about ways to help people cope more effectively with chronic pain.

I do have a soft spot for positive psychology because, as we can see in most of the major journals, psychological studies have primarily been interested in what goes wrong, why people may struggle to cope with their pain, and other aspects of vulnerability. Yet more people than not live well with their chronic pain, and rarely seek help for their pain – maybe we can learn something from how these people cope, and in doing so, help people who do need treatment develop some of those skills. This is the topic of my PhD – Living well with chronic pain.

Building on yesterday’s post about ways to increase positive emotions (I talked about savouring – recalling past positive experiences; being ‘in the moment’ in present positive experiences; anticipating future positive experiences) I want to briefly discuss why on earth positive experiences might be useful. Apart from just feeling good in the moment!

The ‘broaden and build’ theory provides a framework for understanding the utility of positive experiences – especially the value of having positive emotions during tough times.  In this theory, developed by Fredrickson (2001), both positive and negative emotions have useful functional effects.  From an evolutionary viewpoint, there has to be some sort of adaptive value in having emotions and in the broaden and build theory it is posited that negative emotions help with generating “action tendencies that focus and narrow thoughts and actions (to prepare the body for fight or flight)” (and I guess we’re all pretty familiar with this response, especially in Christchurch after the quake!), while positive emotions “broaden ones thoughts and actions, and by consequence build important personal resources.”

In other words, negative emotions help us reduce the number of action options so we can active and use them quickly, while positive emotions help us generate ‘out of the box’ options, those creative, flexible, innovative ideas that can solve a problem – you know those overnight ‘aha!’ moments when the solutions just fall into place.

The empirical support for these two opposing but complementary emotion-elicited strategies is pretty good – we are familiar with the idea that by relaxing and thinking of good times, peaceful moments and happy events, autonomic arousal generated by ‘stress’ is reduced.   When there is no pressure to perform, people are often able to experiment and make mistakes and by doing so, arrive at unusual and exciting new possibilities – put a time pressure on and the options are narrowed and people revert to ‘tried and true’ behavioural repertoires.

Psychological resilience, or ‘bounce-back’ is possibly more common than not, according to Tugade and Fredrickson.  They suggest that under short-term traumatic events (perhaps the death of a loved one, or, closer to home, an earthquake with disruption to homes, services and businesses) it’s normal to temporarily experience negative emotions – but the general life trajectory continues in similar directions as before the event.  And for the majority of people in Christchurch, for example, despite the disruption we’ve experienced, life goes on.  For a smaller number – life is disrupted much more seriously.  Yet – in a couple of years, while the events of the last few months will be remembered, for more people than not, life plans and direction will be going along reasonably smoothly.

Of course this situation is different when the event is not short term, as in chronic pain.

The point that Tugade and Fredrickson make is that if resilience is commonplace, maybe it is also something individuals can learn, at least to a greater or lesser extent.

Back to the theory and how it might apply in chronic pain.  Some people seem more able to bounce back than others – and one factor in this resilience, according to Tugade and Fredrickson, is that people who are high in general or trait resilience, might be more able to draw on positive emotions than people lower in this trait.  For example, some people find it easy to use humour to cope with stressful times; some use relaxation – allowing time to interpret and assess problems before acting; some use exploration – looking at possibilities and options before taking action; and others use gratitude or hope – looking for the ‘silver lining’ or being thankful for ‘small mercies’ as my Grandmother would have said.

There is a relationship between the ability to access positive emotions through these strategies and physiological responses.  Research cited in the paper by Tugade and Fredrickson found that “although both low and high resilient individuals experienced equal levels of cardiovascular arousal and subjective negative experience in response to a stressor, high trait resilient individuals exhibited faster cardiovascular recovery from negative emotional arousal. Additionally, ‘‘bouncing back’’ to cardiovascular baseline levels was partially mediated by resilient people’s experiences of positive emotion in the midst of distress (Tugade and Fredrickson, 2004).”

What does this mean for people with chronic pain?

Well it is well known that people with chronic pain can have difficulty down-regulating autonomic arousal.  Things like heart rate and respiration rate, skin conductance and EMG can be readily increased – but people with chronic pain, even when they’re only recalling a time when their pain was high, find it reasonably difficult to reduce these readings.  There are a range of programmes for biofeedback that can help people recognise their own body responses and just by giving visual feedback, can help people develop skills to down-regulate.  Clinicians could enhance this process by helping people to remember happy times, or plan future positive events, or even simply be mindful of what is happening right now, as strategies to help people become more able to reduce their level of arousal.

What might this mean?

Well, resilient people seem to be able to recognise their own levels of arousal quite quickly – and then recruit resources to manage these situations quickly.  Tugade and Fredrickson consider that one strategy resilient people use is ” effectively harnessing positive emotions to their advantage when coping, and they do so with a seeming intuitive sensibility.” They go on to suggest that by experiencing positive emotions, the short term effect is to broaden the range of behavioural options, making it more likely that they will find a solution to a difficult situation.  They suggest that over time, and with repeated experiences of positive emotions, this broadened mindset might become habitual. Success breeding success.

So, quite apart from the need to help people in distress from their pain to generate short-term, ‘do-able’ goals to increase self efficacy, it seems that by being able to succeed and feeling good about doing so, people can develop skills over time that support resilience.  Sort of like banking a range of coping resources based on creative and positive options that can be adapted to suit changing circumstances.

What can we do to help?

Step one is to recognise that resilience could be something we learn.  Yes, some people have more innate resilience than others, but they also use skills that, over time, become more and more flexible and responsive.  To help generate this resilience, helping people become more aware of good things that generate positive experiences seems an important step. 

This might include things like scheduling pleasant events, writing down three things that have been positive each day, sitting for some peaceful time to simply appreciate something from nature, setting small goals – and achieving them, noticing unhelpful thinking and letting go of these thoughts in order to focus on what is important and valuable in the here and now.

I can see an enormous potential in helping people with chronic pain use these positive strategies – and who knows, it might even help us as clinicians?!

Tugade, M., & Fredrickson, B. (2006). Regulation of Positive Emotions: Emotion Regulation Strategies that Promote Resilience Journal of Happiness Studies, 8 (3), 311-333 DOI: 10.1007/s10902-006-9015-4

Happy happy! Joy joy! Increasing positive experiences to improve mood

I am sure there will be people who read today’s post who will feel like giving me a bit of a slapping. “How”, they will say, “Are you supposed to get happy when you’re feeling bad?” And I would have been one of these people a few years ago too, given my history of low mood and love of whining. Seriously, it’s completely counter-intuitive to think that when you’re feeling flat and low, all you need to do is get out and enjoy yourself!

It goes a bit like this, I think. When someone is feeling a bit flat, maybe having done too much and started to feel fatigued, it’s normal to stop doing quite so much and rest up. But if resting fails to increase energy – maybe because of a chronic condition like fibromyalgia, or really any of the chronic pain conditions – then the next most sensible thing to do is to keep doing less. This means there is not only less happening each day making it quite possible that life gets boring, but also reducing the opportunity for positive emotions to be generated. Where is the flush of achievement? The pride of completing something? The excitement of a new experience?

This can lead on to having less to talk about, less to get up in the morning for, and less reason to need to be energised.

“Emotion regulation refers to the attempts to influence the types of emotions people experience, when they experience these emotions, and how these emotions are expressed and experienced (Gross, 1998).”
I’ve written before about the way in which chronic pain can deplete the executive functioning that supports and maintains appropriate emotion regulation.  The process of needing to use brain circuits that were designed to regulate emotion, attention and action in order to respond to temporary situations – but use them for chronic situations – can lead to depletion of capacity to regulate, and ultimately leads to fatigue.

Most of us don’t really want to stay in a negative frame of mind.  An enormous industry exists to help people avoid negative mood and maintain or enhance positive mood.  Time for some jargon: the hedonic contingency model developed by Wegener and Petty (1994) suggests that people learn to associate benefits with positive emotional experiences over time, and as a result, they look for activities and thoughts that will allow them to maintain (or even elevate) their positive experiences.

One method of maintaining positive emotions is to savour them – think about them, either in anticipation of a good event (thinking about that birthday surprise you’re springing on your loved one maybe?), appreciating what is happening right now (sipping on that gorgeous Gisborne Gewurtztraminer?), or recalling something from the past (remember last summer’s barbecue with friends?).

Savouring seems to be quite important for feeling good and coping over the lifespan. Bryant, a researcher into positive affect found that ” savoring is positively related to favorable advantages in well-being, including self-reported optimism, internal locus of control, self-control behaviors, life satisfaction, and self-esteem; it is negatively correlated with hopelessness and depression (Bryant, 2003).” It’s probably also associated with gratitude, something I wrote about recently too, but is a little different because it’s specifically about maintaining a positive emotion.

How can we increase savouring?  Meditating specifically on enjoyable experiences or situations springs to mind.  Looking through old photographs and reminiscing.  Spending time planning pleasant events for the future.  Journalling, or making a scrapbook of events that we’ve enjoyed.  Being mindful as we eat, drink, even clean our teeth!  Really being present when we’re doing something – these can all extend and increase savouring.

Another set of strategies involves finding positive meaning in ordinary events.  Folkman and Moskowitz identified these strategies as one way to buffer the effects of stress: People find positive meaning in daily life things like  (1) positive reappraisal (i.e., finding a ‘‘silver lining’’), (2) problem-focused coping (i.e., efforts directed at solving or managing the problem
causing distress), and (3) infusing ordinary events with positive meaning (e.g., appreciating a compliment).

It looks like intentionally planning to look for positive things acts as a buffer to stress – so planning to enjoy a meal, being thankful for friendship, taking the time to smell the roses(!) all make for small oases of positivity even in everyday life.

I’ll write more tomorrow on the ways in which positive emotions can both be generated – and the effect of doing so on coping. In the meantime, enjoy this week’s picture!

Tugade, M., & Fredrickson, B. (2006). Regulation of Positive Emotions: Emotion Regulation Strategies that Promote Resilience Journal of Happiness Studies, 8 (3), 311-333 DOI: 10.1007/s10902-006-9015-4

Counting your blessings? or looking on the bright side of life [whistles]

My family were big on the Andrews Sisters. One of my strong memories as a child is listening to the song ‘count your blessings, name them one by one…’ [no, I will not sing it ok?!]. And I remember the book Pollyanna (you can read it for free here!) and the ‘Glad game’ where she looked for the positive in her rather dire situation when she went to live with her strict Aunt Polly.

And guess what?  There is something in this approach to coping that makes a difference!

While on holiday, sad person that I am, I did spend one or two days reading journal articles.  Several of them were related to the theme of positive psychology in a special issue of Clinical Psychology Review.

While research into optimism, positive affect and even psychological flexibility has been around for a long time, and even been integrated into clinical practice, gratitude has been a bit of a forgotten sister.  Maybe it’s because of the slightly naive views expressed in books and films of the 1950’s and the effect of the cynicism that increased during the swinging 60’s, but whatever reason, gratitude hasn’t had nearly as much attention paid to it as other emotions like anger or sadness or even happiness.  I certainly can’t find a single paper on gratitude in chronic pain research, so this post is a little speculative.

Onto what is not speculative, in a paper by Wood, Froh and Geraghty (2010), the authors summarise some of the most recent findings about gratitude – is it a trait? a habit? what is the effect of looking for and expressing gratitude?

Firstly, gratitude is defined as   “…involving a life orientation towards noticing and appreciating the positive in life.” While some of us probably have more of a tendency towards this than others, these authors suggest that gratitude as a trait is an overarching construct that includes things like awe and respect, appreciation for what is happening right now, and so on.  These underlying components are not exactly the same as gratitude, but together contribute towards an overall ‘life orientation’ – a bit like the role neuroticism has as an overarching construct that includes things like anxiety, hostility, depression and so on.

Gratitude is found to correlate with “traits associated with positive emotional functioning, lower dysfunction, and positive social relationships. Grateful people were less angry and hostile, depressed, and emotionally vulnerable, experienced positive emotions more frequently.” It’s not entirely clear whether these findings are cause – or effect.  Similarly, gratitude is associated with aspects of wellbeing – negatively correlated with mental health problems such as depression, anxiety, as well as positively correlated with relationships with others, emotional wellbeing (happiness), and response to adverse events.

The research base is poor, however, in terms of the relationship between gratitude and physical health.  The few studies that have been conducted suggest that there is a relationship between gratitude and experiencing the physical effects of stress – and interventions to increase gratitude have shown positive effects on sleep.

Some of the clinical interventions that have been developed have provided a degree of hope that by developing gratitude it may be helpful for promoting wellbeing.  Twelve studies are cited in this paper, with three different interventions being studied.

The first is to simply list things for which a person is grateful. This can be carried out in different ways, but a common one is to write down three things at the end of the day for which the person is grateful, directly before bed.  The outcome from this in one study was a reduction in worry comparable to the intervention used in CBT, of recording automatic thoughts and working with those thoughts.  The advantage of the gratitude intervention was that people enjoyed it, completed it, and some even continued to use it after the study was over.

Another intervention involved ‘contemplating’ gratitude – by simply thinking of, or writing about things the person is grateful for.  This is a brief intervention, maybe over 5 minutes, and appears to be useful for raising mood in the short term – and might be useful for someone who comes into a session feeling particularly flat.

The final intervention involves ‘behavioural expression of gratitude’ – maybe writing a letter expressing gratitude to someone and delivering it, or visiting and speaking with someone to express gratitude.  In the studies exploring this, long-lasting increase in positive affect was found up to two months after the activity.

There are problems with the current research into gratitude as a clinical intervention.  None of the studies examined in this paper were thought, by these authors anyway, to involve adequate control conditions, and for people reading this blog, none of them were related directly to people experiencing chronic pain.  It’s clearly the early stages of developing this construct for the people we work with.

On the other hand, and being admittedly speculative, I think the gratitude research does hold out some interesting features that can be explored in pain management.

One of the most grim aspects of experiencing chronic pain is the loss of enjoyment and motivation to do everyday activities.  Low mood and pain, along with loss of quality sleep, are commonplace.  Gratitude interventions seem to have a positive affect on mood and sleep – so it might be reasonable to consider writing daily gratitude lists just before bed to foster more restful sleep, abort or disrupt the negative rumination that often occurs as people try to go off to sleep with pain, and to focus on what has been achieved during the day rather than what has not been achieved to help reinforce goal achievement and maintain forward momentum.

There is ongoing research into growth from traumatic experiences – many people have spoken and written about the new insights they have gained from going through difficult times.  Maybe something we can encourage people we work with to do is consider what they have gained from their chronic pain.  I know this sounds challenging – what could be positive about chronic pain?

For me, having chronic pain has helped me stop and slow down, helped me remember to have balance in my life and to measure my energy so I can be consistent and persistent.  For almost every negative I can also find a positive – if I look at things in a different way.  I can think of the need to ‘pace’ and ration my energy as a ‘have to’ or a ‘must’, and an imposition.  Or I can think of it as a way to experience and choose to do each activity in a mindful way, fully being present with each activity rather than flitting off and doing things in automatic.

I’d love to hear your thoughts on this – or better still, what about trying it for a couple of days? Write down three things you are grateful for just as you go to bed, and see what it’s like.

Wood, A., Froh, J., & Geraghty, A. (2010). Gratitude and well-being: A review and theoretical integration Clinical Psychology Review, 30 (7), 890-905 DOI: 10.1016/j.cpr.2010.03.005

Clinicians and graded exposure

Some people do, and some people don’t, some of us will, and some of us won’t!
Graded exposure can be an uncomfortable experience for both the person who is learning to approach activities that don’t feel very good – and for the clinician! It goes against the grain for some of us to elicit anxiety and see distress as we work with people, after all, our job is to help people feel better isn’t it?

There are some consistent findings about clinician anxiety vs patient anxiety when it comes to pain. It seems that clinicians can often be more conservative with regard to what is OK for a person to do than the person can be. This conservatism can be related to clinician’s beliefs about hurt vs harm, clinician’s orientation to a biopsychosocial model – and possibly, although I haven’t seen any specific studies, it could be associated with clinician ability to self-regulate emotional content. This last one is a hypothesis that I’ve been considering as I watch my own responses to people who are distressed. Learning to regulate my own responses as I ‘make room for’ a person’s emotions has been an important part of learning ACT, and it has allowed me the privilege of being present with people who are processing some incredibly emotional material.

So, how do I work with my own responses while working with people to do activities that they’ve been avoiding?

It probably doesn’t surprise anyone reading these blogs to know that I tend to want to understand and apply reason to most situations. So one way I have often managed my own responses has been to know why I’m following this path – and to explain why to the people I’m seeing in therapy. This can be one way to down-regulate anxiety, simply by putting it into a bigger picture and removing that ‘unknown and scary’ aspect of the treatment.
On its own, however, this isn’t the be-all and end-all, but it is an important component of pain management (have a chat to Lorimer Moseley and David Butler if you don’t believe me!).

Another way for me has been to recognise that the short-term distress is in the aid of longer-term function, and remembering that distress doesn’t last forever. No emotion does carry on, they start low and build to a peak – then taper off. Just think of a two-year-old tantrum to remember this! And it can be worth saying this to the person you’re working with too, to remind them that emotions don’t remain forever – although it can feel like a long, long time in the middle of it!

But we need to remember these mirror neurons that start to fire up when we observe another’s behavior. Remember we can’t feel someone else’s emotion or pain – what we’re doing is observing behavior and our brains are firing up to remind us of situations where we’ve carried out those behaviors too. So what happens in empathic people, especially newbies, is that our mirror neurons fire and we start to experience some of the emotional impact these behaviors might generate in ourselves. Studies have shown that over time the amount of ‘mirror’ activity reduces as clinicians observe or carry out procedures that are known to increase pain. This is a form of down-regulation that we’re not typically aware of, and it probably works in a similar way to what occurs during graded exposure – rather than ‘turning off’ the empathy, we learn to inhibit the expression of this empathy and at least some of the power of the emotion is reduced in our consciousness.

Studies of mindfulness show that we are able to learn to be open to experiences as they are rather than judging them as either positive or negative, and by developing this skill we can be more flexible and able to cope with situations we would otherwise avoid. Maybe this is a skill clinicians should learn as part of training, to help us manage the many situations we encounter as we practise.

Shapiro, Shauna L; Carlson, Linda E. (2009). The art and science of mindfulness: Integrating mindfulness into psychology and the helping professions. (pp. 107-117). xvii, 194 pp. Washington, DC, US: American Psychological Association; US.http://dx.doi.org.cmezproxy.chmeds.ac.nz/10.1037/11885-008

Fear/Anxiety/Avoidance – treatments review!

For years, clinicians working in pain management have mixed together a rich assortment of strategies to help people function better.  But to identify the ‘active ingredients’ of multidisciplinary pain management using a cognitive behavioural approach, it’s been important to tease each element apart.  One size does not fit all – and just as a physician chooses the most effective medication for a disorder, in time I hope we will be able to choose the most effective strategy for the problems each individual experiences rather than applying our current ‘scatter-gun’ approach.

Yesterday I gave a brief overview of the three main treatments to helping people who are fearful/anxious of their pain (or harm) and avoid activities as a result. They are:

  1. Graded exposure in vivo
  2. Graded activation or reactivation
  3. Acceptance and Commitment Therapy

…and the combined or mixed sort of multi-modality approach used in most settings.

Bailey and colleagues have conducted one of the first reviews to summarise the effectiveness of these treatments.  It’s too soon to carry out a full meta-analysis because so few of the published papers are RCT’s.  After searching the various databases, and personally approaching researchers known to the authors, 17 studies were identified, made up of eight randomized clinical trials (RCTs), eight replicated single-case studies, and one case study.  Over 1200 patients have been involved in these studies, but there was a fairly high drop-out rate in both case studies and RCT’s, and while reasons for drop-out were not given in many cases, in those that were it was found participants thought the treatment was ‘too psychological’ (didn’t give enough of a biomedical explanation for their pain) or weren’t sufficiently motivated to complete.  Of course, I’d suggest that motivation is a case of readiness to engage – and that motivation can be enhanced, but nonetheless, this is what was stated in two of the papers.

The type of patients in terms of age, gender and pain duration were fairly similar in all of these studies (and very similar to the type of patient I see each day).  The participants were attending research-oriented pain management centres, so possibly look a little different from the people seen in community settings, or in primary care.  Their pain was mainly lower back, with a subset having pain from whiplash or similar.

The main treatment outcome measures used were the Tampa Kinesiophobia Scale for most of the studies with the PHODA, or photographs of daily activities being used alongside this for most of the graded exposure studies.  The Roland Disability Questionnaire was the most commonly used disability measure, Beck Depression Inventory the most common depression measure, and Pain Catastrophising Scale and Pain Anxiety Symptoms Scale used for pain-related anxiety.  Only one study used physical performance measures as part of the outcome measurement, and none used individualised or patient-specific goal achievement as a measure.

So, what did they find?

From this set of studies, graded exposure and ACT appear to have the greatest positive effect on disability and reducing fear of pain compared with waitlist groups or graded activation.  Graded exposure was also superior to graded activation for reducing fear of movement, catastrophising and perceived harm, while ACT was demonstrated as effective for reducing pain and disability in all of the studies in which it was used.  Both graded exposure and ACT appear to be effective in addition to ‘treatment as usual’ (participants weren’t asked to refrain from using other treatments), but this finding doesn’t always occur.

Unfortunately, the mixed CBT approaches don’t demonstrate such clear-cut results on catastrophising, fear of movement/reinjury, and disability.  The authors suggest that the mixed protocols probably don’t provide greater effectiveness than waiting list or a combination of cognitive therapy and ‘physical therapy’ (what ever that looks like!).

Graded exposure does seem to offer some advantages over ACT in terms of reducing pain-related catastrophising, and overall require fewer sessions than ACT (at least in these studies) – but there does appear to be a greater chance for people to drop out.

Our problems with this summary are that these are not direct RCT comparisons of different treatments, and because of differences in context, and size of the study groups and different methodology.  And an interesting feature is that most of the graded exposure studies were carried out in Netherlands, Sweden, and the United Kingdom, and only one study was conducted in North America.  This is quite at odds with the majority of studies looking at chronic pain management.  There are considerable differences between these countries and the US in terms of litigation and access to various treatment modalities (particularly psychological treatments).  As the authors say “Potentially more important is that these same countries do not rely on insurance models for psychology-augmented multidisciplinary health care.”

What can we learn from this review?

Rather than suggesting that graded activation shouldn’t be used as widely as it is, I think this review shows that there are at least two other treatment protocols that can be successfully applied to this sub-group of people who are fearful/anxious and avoid activities because of their pain.

There were no generally-applied cut-off scores on, say, TSK or PCS to help clinicians in other settings decide who would best benefit from graded exposure vs a broader approach, which makes it a little difficult to select patients – but my initial thinking is that if you have a person reporting that they avoid activities, particularly if they have specific movements they avoid (like bending or reaching), these people may be candidates for graded exposure.  For people who are basically deactivated and are not avoiding any specific movements, maybe ACT or graded activation could be a better bet.

The question to ask too is, can physiotherapists, occupational therapists and other ‘non-psychologists’ apply these treatments successfully?  My thoughts are that yes, of course – provided that clinicians take the time to learn about the approaches and theoretical basis for conducting them.

My worry is that some of the subtleties of graded exposure especially may not always be picked up by people unfamiliar with the idea of eliciting specific thoughts, beliefs or concerns about a movement – this can lead to inadvertently failing to expose the person to their fear, and potentially incorporating ‘safety behaviours’ into the treatment.  This prevents the patient from learning to manage what they are actually afraid of, and can replace complete avoidance with a set of almost ‘magical’ beliefs – such as using a specific lifting technique to ‘prevent’ damage. More about this aspect tomorrow!

Bailey, K., Carleton, R., Vlaeyen, J., & Asmundson, G. (2010). Treatments Addressing Pain-Related Fear and Anxiety in Patients with Chronic Musculoskeletal Pain: A Preliminary Review Cognitive Behaviour Therapy, 39 (1), 46-63 DOI: 10.1080/16506070902980711

Essential Skills for Living with Pain

I could actually head this post with the title ‘Essential Skills for Living’ and leave out the pain part, because as I reflect on the events over the past week, and the aftermath as residents of Christchurch start to demolish then rebuild their homes and businesses, these same skills apply.

How do people live well despite adversity? Our lives are not straightforward and both major events and daily hassles are encountered and influence thoughts, emotions and behaviour. It’s normal to have a range of emotions, abnormal to be ‘happy, happy, joy, joy’ all the time (despite the adverts!).

It has been postulated that the ability to regulate emotions is a sign of adulthood, and that being unable to regulate emotions is a contributor to much emotional ill-health. Emotion regulation is about being able to monitor, judge, and work with emotional responses in order to achieve goals. We can’t simply give up because it’s hard to learn to do something. We need to manage disappointment and develop grit and determination. Berking, Wupperman et al (2008) summarise the skills thought to be important for life – the ability to:

  1. consciously process emotions and be aware of them
  2. identify and label emotions
  3. interpret emotion-related bodily sensations
  4. understand what emotions prompt us to do
  5. support oneself when emotionally distressed
  6. actively modify negative emotions in order to feel better
  7. be resilient to or tolerate negative emotions
  8. accept emotions
  9. confront emotionally distressing situations in order to achieve important goals

Whew! That’s a bit of a list! These same authors carried out a study to establish those skills that are associated with good mental health, and to look at those that are enhanced during treatment to influence a good outcome.  What they found was that three skills in particular were associated with good mental health – the ability to modify negative emotions; the ability to be resilient to negative emotions; and acceptance of emotions.

In other words, being able to do things to lift spirits or reduce frustration, to know that negative emotions won’t last forever and won’t overwhelm, and being able to accept that emotions are present without judging them are all skills that, in particular, help people cope with adversity.

The question now is – how can these findings be transferred into what clinicians working in pain management can offer the people we see every day?

Most of us working in chronic pain management know that we can influence other people through what we say and do.  We can help the people we work with by recognising that therapy is not easy – and that it’s OK to experience disappointment, frustration, sadness and grief. We can model this by ‘making space’ for people to express these emotions during sessions without quickly moving along, making a joke, or otherwise trying to alleviate the feeling.  What we can say are things like ‘it’s OK to take some time to feel what you’re feeling’; ‘let’s just give you a moment to be with what you’re feeling right now’.

In ACT, this is called ‘being present’ – and the people we work with may themselves rush past a moment of negative emotion.  They may do this by changing the subject, turning away or making a quick quip.  We can help people experience their emotions by gently stopping them for a moment and asking them to ‘just notice what is happening’.

When we do this, we’re modelling that it’s OK to experience emotions, that it’s not going to de-rail the session, that we’re not afraid of emotions and that we’ll be there.  We’re not trying to comfort or challenge that emotional content, but instead we’re allowing it to be.

Flink, Nicholas, Boersma and Linton (2009) describe another approach – what they call ‘interoceptive exposure’.  Participants in this study were asked to “calmly focus their attention on their pain sensations, whether sitting or performing activities associated with more bothersome pain (e.g. standing, walking). They were told to expect some increase in pain initially but to keep their attention calmly focused on the pain, allowing themselves to feel it, as much as possible without thinking about it or trying to change it or block it, until it was less bothersome.”

This is a specific attentional control skill that asks the person to experience their pain, probably initially increasing their anxiety about doing so, but then, by being calm and allowing it to be present, allowing that anxiety to reduce.  It is a form of mindfulness.

I intend to look, over the next few days, at some of the other strategies that we can use during pain management to help people develop skills of emotion-regulation.  I think they’re skills everyone could learn and use – what are your thoughts?

Don’t forget that I blog most days during the week, that you can subscribe using the RSS feedlink above, or via email, and that I love comments and observations!  You can also follow me on Twitter and Facebook.  If you’re an occupational therapist and would like to look at my ‘OT Only’ section, just drop me a line via the ‘About’ page.

BERKING, M., WUPPERMAN, P., REICHARDT, A., PEJIC, T., DIPPEL, A., & ZNOJ, H. (2008). Emotion-regulation skills as a treatment target in psychotherapy☆ Behaviour Research and Therapy DOI: 10.1016/j.brat.2008.08.005

Flink, I., Nicholas, M., Boersma, K., & Linton, S. (2009). Reducing the threat value of chronic pain: A preliminary replicated single-case study of interoceptive exposure versus distraction in six individuals with chronic back pain Behaviour Research and Therapy, 47 (8), 721-728 DOI: 10.1016/j.brat.2009.05.003

On being both a scientist and a human

In some circles there is a slightly strange belief that it is not possible to both be a scientist and be empathic, warm and value the ‘human touch’.  I beg to disagree, and in this post I hope to put forward some of my thoughts about how these two ‘ways of being’ are not mutually exclusive.

I’m proud of being a scientist-practitioner.  I use this term despite having been told at one point by a senior occupational therapist that if this is the case, then I can’t be practicing occupational therapy.  Well at the time I would have quite happily given up the occupational therapy part! And now I’m tiptoeing back towards the values of my profession background while not always following the practises of my colleagues.

The term scientist-practitioner originated in the early years of clinical psychology.  In 1949 this model was “proposed as the most appropriate framework for the training and professional practice of the then emerging profession of clinical psychology (Raimy, 1950),[and]  its aim was to train psychologists to work as both practitioners and scientists.” Ever since then the debate has raged, but the original intention was to have a “partnership between science and practice [that] would ensure that psychologists achieved a rigor in their clinical work that typified the academic world”.

Critics of the scientist-practitioner model argue that the intentions have never been fulfilled, and to suggest that the ‘scientist’ aspect of the clinician is evident is almost fraudulent – after all, most clinical psychologists don’t directly contribute to research, most don’t confine their practice to strict empiricism, and while the priorities of the scientist are to identify phenomena that can be studied in order to develop generalisations, clinicians work with individuals and their unique and idiosyncratic presentations.  In fact, some critics think that the two can’t be combined at all because of the different priorities.

In clinical psychology, the debate continues and there are schools of thought suggesting that it’s sufficient to be able to know about scientific methodology in order to critically appraise the literature – but completely unnecessary to actually have to conduct scientific work as part of a course of study; while others suggest that by developing good scientific skills there is insufficient emphasis on the clinical skills required to be good therapists; some say that the way therapists/clinicians work in the ‘real world’ is so different from the scientific work that research findings and the practice of research are poles apart and can’t be applied clinically, and still others firmly hold that it’s clinicians who fail to read the scientific literature and integrate findings from research into their practice.  Does the latter sound familiar to occupational therapists and physiotherapists and others?

So, why do I uphold this as a model for my practice?  Well it’s hard to work without some sort of framework, and for me, the desire to know that what I offer as a clinician is based on an evidence base,  and to be able to critically appraise that evidence is a big part of that framework.  I also apply the ‘hypothesis-testing’ model in my clinical formulations – see my posts on case formulation for more discussion of this – and on theory generation and ultimately theory testing by studying phenomena that occur in the ‘real’ world and systematically examining them using scientific methodologies.  I particularly like a definition used by Corrie and Callanan (2001) where it was described as embodying  “a spirit of enquiry whereby psychological evidence could be used in a … holistic way, according to the needs of a given enquiry.” I’m reminded here of a quote attributed to Einstein:

“the important thing is not to stop questioning. Curiosity has its own reason for existing. One cannot help but be in awe when he contemplates the mysteries of eternity, of life, of the marvelous structure of reality. It is enough if one tries merely to comprehend a little of this mystery every day. Never lose a holy curiosity.”

Now let me turn my attention to the human part.

To be scientific seems, in some people’s opinion, to lack emotion, or the desire to have empathy or warmth.  This view seems to come about because of the need to put aside opinion and bias when drawing conclusions from scientific evidence.  It doesn’t, however, mean that when using that information, I should similarly put aside my human empathy and communication skills.  I’d argue too, that in order to be curious, scientists need to have a spark of emotion – and to have passion and commitment to carry out the work to really explore what they find!

One of the most scientific yet human approaches I know of is Acceptance and Commitment Therapy – as a clinician, to practice ACT requires active use of mindfulness, being present, cognitive defusion, values, committed action – all the facets of living fully.  At the same time this therapy is constantly generating research questions – and finding answers which subsequently generate more questions, and is based on hard, cold facts.

Being human and caring is an essential part of my clinical practice.  It’s one of my values – to be as authentic as I can be and to avoid being someone I’m not, and so if someone describes a traumatic situation, an incredibly sad situation, their anger at mistreatment, or frustration at their pain and how it has affected their goals – why shouldn’t I express my empathy for their situation?  It doesn’t mean I necessarily agree with what they do, or why they feel that way – but it doesn’t need to stop me being there.

Being human also means I have values that guide what I aim for in my personal and professional life.  My values shape what I view as important in my practice.  For me, my values began with the values of occupation – that doing and being is important to health.  That by helping people engage in the ‘occupations’ or ‘activities’ they value, they regain roles, feel positive about themselves, are able to experience a range of emotions and contribute to their community in  positive way.

Can a scientist-practitioner incorporate these values into clinical practice?  I hope so – and as the years have gone on I’ve started to see the evidence accumulate to support these values as actually contributing to human wellbeing.  Who would have thought that ‘occupational therapy’ described by O’Malley in 1924 as starting in the days of Pinel and the moral reform of lunatic asylum might one day be promoted as a ‘new’ form of therapy called behavioural activation?

It’s worth remembering that being human, showing caring, and being empathic is about how we work with people not what treatments we use.

O’Malley, M. (1924). The psychiatric approach to occupational therapy. Discussion presented at the Occupational Therapy Association, District Of Columbia, St Elizabeth’s Hospital, 1924.

Lane, D., Corrie, S. What does it mean to be a scientist-practitioner? Working towards a new vision. Retrieved from http://www.coachingmentoring.co.nz/resources/articles/204-prof-david-lane-what-does-it-mean-to-be-a-scientist-practitioner-working-towards-a-new-vision Thursday, 26 August, 2010.